AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Social phobia (social anxiety disorder) is the third most common mental health disorder after major depression and substance abuse, affecting approximately 10 million Americans, including children and adults. This disorder is defined by marked and persistent fear of social or performance situations in which embarrassment may occur; exposure to the social or performance situation almost always causes an anxiety reaction such as a situationally bound or situationally predisposed panic attack.

The anxiety reaction is not due to psychosis; individuals are able to recognize their fears as excessive and unreasonable. However, the ability to fully comprehend that the reaction is out of proportion to the precipitant may be less complete in children and may depend on their cognitive-developmental level of functioning.

The person's level of functioning (eg, ability to complete required educational, social, or family tasks) is significantly impaired, and the person may experience significant emotional distress (eg, dread, avoidance) as a response to social or performance situations. By definition, social phobia must persist for at least 6 months (in persons <18 y), must not be due to the direct physiological effects of a substance (eg, caffeine) or a general medical condition, and must not be better accounted for by another mental health disorder.

Often, social phobia can coexist with, or be the precursor to, agoraphobia. Agoraphobia is a specific phobia in which the individual fears being in crowded places. People with agoraphobia often become homebound.

Selective mutism is a disorder primarily affecting children, with some adolescents and adults who continue to experience an inability to speak in public. This inability is generally most disabling at school, as the child cannot be assertive and speak when called on by teachers. In adults, functional impairment occurs when public speaking or lecturing are required in one's vocation.

Formerly, selective mutism was called elective mutism in the Diagnostic and Statistical Manual of Mental Health Disorders, Third Edition (DSM-III), which was reflective of a previous view that the child intentionally refused to speak with others who are outside of the immediate family group. Often, the child with selective mutism designates a friend or close family member to serve as an interpreter of communication and whispers in that person's ear, so that communication occurs with the designated person as intermediary.

Pathophysiology

Serotonin pathways may be involved in the mediation of the anxious and obsessive qualities of both social phobia and selective mutism. This theory is reinforced by animal models of phobic behavior and by response to commonly prescribed medications such as selective serotonin reuptake inhibitors (SSRIs), such as paroxetine, sertraline, or older heterocyclic-type antidepressants, such as Anafranil (clomipramine).

Frequency

United States

Social phobia is the third most common mental health disorder after depression. Lifetime prevalence ranges from 3-13%. Selective mutism is seen in fewer than 1% of children observed in mental health settings.

Mortality/Morbidity

No mortality occurs except with associated major depression resulting in suicide or reaction to medication treatment (sudden cardiac death with imipramine or clonidine) or adverse reaction such as newly onset suicidality to SSRIs or other antidepressants. A high morbidity rate is observed, with many missed school or workdays; the child often develops associated school refusal because of the anxiety associated with being asked to speak in class.

Age

Onset of social phobia may occur as early as school age but generally occurs by mid adolescence following a childhood history of social inhibition or excessive shyness. Often, onset is abrupt, occurring after a stressor or humiliating social experience.

Onset of selective mutism is typically when a child first attends school (either kindergarten or preschool) and, like social phobia, is often associated with an initial negative school experience, such as a stressor or humiliating social experience.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Careful attention to a history of caffeine overuse can be helpful, as caffeinism commonly mimics symptoms of anxiety. Family history often includes anxiety disorders (both social phobia and selective mutism). Selective mutism may frequently coexist with other speech and language disorders (eg, expressive-receptive language disorder, expressive writing disorder). Social or performance situations (eg, public speaking, performing in a school play) are typically avoided (or barely endured) by persons with social phobia and those with selective mutism.

DSM-IV diagnostic criteria for persons younger than 18 years state that symptoms must persist for at least 6 months, must not be due to the direct physiological effects of a substance (eg, caffeine) or to a general medical condition, and must not be better accounted for by another mental health disorder (eg, depression, acute psychosis).¹

Causes

No specific genetic locus has been found; however, genetic factors may eventually be identified because a higher incidence of social phobia and selective mutism occurs in families with first- and second-degree family members with a history of panic disorder or other anxiety disorders.

• Children with selective mutism are at higher risk for developing other developmental disorders, such as enuresis, encopresis, and abnormal EEG (because of immaturity), as well as developmental speech and language disorders. These disorders are also associated with increased incidence among first- or second-degree relatives.
• No association with mitral valve prolapse has been found for anxiety disorders in general and social (anxiety) phobia specifically.
• A cross-cultural perspective is essential. In Japan and Korea, what persons living in the West classify as social phobia may manifest as persistent and excessive fears of offending others in social situations instead of embarrassment (ie, taijin kyofusho), including fears that blushing, eye-to-eye contact, or one's body odor could be offensive to others.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Difficulties with language acquisition (English as a second language)
Expressive-receptive language disorder
Mental retardation
Childhood-acquired aphasia
Apraxia due to head trauma
Cerebral palsy
Panic disorder with or without agoraphobia
Mood disorder
Substance-related disorder
Kleffner-Landau syndrome

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• If indicated by history and physical examination, perform the following tests to rule out other medical problems or to assess baseline function prior to starting medication:
• • CBC count - To exclude anemia or another blood dyscrasia as a preexisting condition or contraindication to the use of psychotropic medication
  • Triiodothyronine (T3), thyroxine (T4), and thyroid-stimulating hormone (TSH) - To exclude hypothyroidism as a cause of a tongue motor problem (eg, articulation difficulty causing language disfluency)
  • BUN and creatinine - To exclude kidney problems as a contraindication to medication treatment
  • Serum glutamic oxaloacetic transaminase and serum glutamic pyruvic transaminase - To exclude liver problems as a contraindication to medication treatment (prior to initiation)
  • Lead level - To exclude language delay (as evidenced by cognitive delay) due to elevated lead level
• The patient should be carefully monitored (weekly at first, then every other week, then monthly) for newly onset suicidality or agitation or for an adverse reaction if any antidepressants are prescribed. Rule out Landau-Kleffner syndrome (LKS), especially in a child with seizure disorder with a history of loss of previously acquired skills such as toileting, social interaction, or language.

Imaging Studies

• Brain MRI: This is generally performed if an acute or chronic brain abnormality is suspected as a cause of language delay. For example, in a child with an acute change of mental status or functioning, MRI would be used to rule out a brain tumor, especially of the fourth ventricle, which rarely manifests as a this type of change.
• EEG: This can be helpful to diagnose Landau-Kleffner syndrome.

Other Tests

• Physical screening examination, including neurologic examination - To exclude tumor or other disorder (eg, aphasia)
• ECG - To exclude any cardiac contraindication to medication treatment, such as conduction abnormality or arrhythmia
• EEG with neurology consultation - To evaluate for seizures as a cause of the problem, which can be a contraindication to medication treatment, but may also be a sign of Kleffner-Landau syndrome.
• Structured or semistructured interview - To query about history of self-harm or potentially suicidal behavior in the patient or a family history of suicidality
• Psychometric screening
• • Instruments such as those below are primarily used in research studies.
  • The following specific anxiety inventories are useful in following response to treatment that may be slow and initially subtle:
  • • The Multidimensional Anxiety Scale for Children (MASC) is a specific screening test for anxiety and related disorders that was developed by March and colleagues at Duke University.²
    • The Schedule for Affective Disorders and Schizophrenia for School-Age Children (K-SADS) is a semistructured diagnostic interview for children aged 6-17 years. It was developed as a screening instrument for use by clinically sophisticated (ie, mental health) interviewers. The K-SADS inventory was originally developed by Orvaschel, Puig-Antich, and Chambers to screen for affective disorders, anxiety disorders, schizophrenia, and schizophreniform disorders. K-SADS has been revised and updated by Kaufman, Birmaher, and Brent at Western Pennsylvania Psychiatric Institute.³
    • Screen for Child Anxiety Related Emotional Disorders (SCARED) is a specific screening test for anxiety and phobic disorders. It was developed by Birmaher et al at Western Pennsylvania Psychiatric Institute and is helpful in confirming the clinical diagnosis of anxiety disorders.⁴
    • The Connors' Parent-Teacher Questionnaire is designed as a checklist. It is generally more accurate in providing corroborating evidence for externalizing disorders such as conduct problems or attention deficit/hyperactivity disorder (ADHD). The questionnaire may be used when an anxiety disorder and an externalizing disorder such as ADHD or conduct disorder are comorbid. The instrument does not, however, clarify the diagnosis when an anxious child is being oppositional in the face of being forced into new situations.
• Projective testing (eg, Rorschach, Children's Apperception Test) - Should only be performed by a licensed clinical psychologist; not to be substituted for a careful clinical interview by a skilled clinician

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Prevention of complications such as school phobia or academic failure because of poor attendance can be achieved by family, school, and physician reinforcement of how important attending school is despite the child's desire to stay home and to avoid social events in order to reduce anxiety.

SSRIs are effective in treating patients with social phobia and the related disorder, selective mutism. The doses used in both children and adults are frequently much higher than those used for affective disorders.

Cognitive-behavioral therapy may be extremely helpful to improve the level of the child's autonomous functioning and should be performed by a clinician experienced in such therapy (eg, psychologist, psychiatrist, behavioral/developmental pediatrician). Cognitive approaches to both social phobia and selective mutism may be grouped into the below 5 major types.

• Positive reinforcers: Use of positive reinforcers such as a token economy or reward system for perfect attendance at school and special treats, such as a favorite book or movie for attending social events, may be successful.
• Systematic desensitization: The child or adolescent relearns how not to be upset or anxious when in the social situation. Instead of feeling uncomfortable in the situation, the child connects feelings of calm with the previously anxiety-provoking social situation. Instead of automatically reacting to the anxiety-provoking situation with autonomic nervous system activation, the behavioral response is reconditioned to that of relative autonomic nervous system deactivation.
• Modeling: The child or adolescent learns from a peer or adult therapist how to react in a calmer manner to the stressful situation. Research studies support the efficacy of using audio tapes or videotapes in treating selective mutism.
• In vitro graded exposure: The child or adolescent imagines the stressful situation starting with the least stressful aspects, learning how to deal with these, and then following up with more stress-provoking aspects. This could include the use of scripted play therapy using real-life stressful situations with targeted responses for learning and incorporation.
• In vivo exposure: The situation becomes less tension-provoking with repeated graded exposures as the situation becomes less new and more predictable. Careful real-life exposure (from less-threatening to more-threatening) to anxiety-provoking situations with postexposure discussion may be helpful as actual experience of real-life situations determines whether resolution of the abnormal emotional response has taken place.

Consultations

• To exclude hearing loss or other language disorder with selective mutism, obtain both a speech and language evaluation and an audiology evaluation.
• If a suspicion of a more serious problem with interpersonal relatedness exists, then the Childhood Autism Rating Scale (CARS) or other standardized tests may be administered by a licensed clinical psychologist to exclude childhood autism, pervasive developmental disorder, or reactive-attachment disorder. Autism and pervasive developmental disorders are behavioral diagnoses that can also be appropriately diagnosed by a pediatrician, behavioral/developmental pediatrician, pediatric neurologist, or, most appropriately, a multidisciplinary team.
• Exclude suicidal behavior, self-harm, and a strong family history of suicide before treatment with paroxetine.

Diet

No specific dietary recommendations have proven efficacy.

Activity

Encouragement of continued normal activity is important to prevent behavioral and physical regression in skill levels.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

SSRIs have demonstrated effectiveness for disabling social anxiety disorder and selective mutism. Experts postulate that SSRIs modulate anxiety symptoms both in the brain and peripherally in the gastrointestinal/autonomic nervous system. Peripheral gastrointestinal and autonomic nervous system activation account for the usual anxiety symptoms experienced (ie, cramping, dry mouth, tightness of the chest, palpitations, lightheadedness, dizziness). Drugs should be used only when symptoms significantly affect a patient's daily activities. Many people are mildly socially anxious, and only a small percentage need medication. Before treatment with SSRIs and when increasing or decreasing dosage, query about a history of self-harm and potentially suicidal behavior, as these are potential contraindications to treatment with fluoxetine (or other SSRIs or serotonin and norepinephrine reuptake inhibitors [SNRIs]).

Drug Category: Selective serotonin reuptake inhibitors

These antidepressant agents are chemically unrelated to tricyclic, tetracyclic, or other available antidepressants. They inhibit CNS neuronal uptake of serotonin (5HT) and may have a weak effect on norepinephrine and dopamine neuronal reuptake. They have been used to treat anxiety, phobias, and obsessive-compulsive disorders.

These agents potentiate serotonergic activity in the CNS that results from inhibition of neuronal reuptake of serotonin and also block the influx of serotonin into platelets. Receptor and neurohistochemical changes result in changes in modulation of emotions.

SSRIs are greatly preferred over the other classes of antidepressants because of their increased tolerability, which tends to lead to improved compliance. Recent studies by the US Food and Drug Administration (FDA) have shown an association of increased risk of suicidal ideation or attempts with SSRIs. SSRIs do not have the cardiac arrhythmia risk associated with tricyclic antidepressants. Arrhythmia risk is especially pertinent in overdose, and suicide risk must always be considered when treating a child or adolescent with a mood disorder.

Physicians are advised to be aware of the following information and to use appropriate caution when considering treatment with SSRIs in the pediatric population.

In December 2003, the UK Medicines and Healthcare Products Regulatory Agency (MHRA) issued an advisory that most SSRIs are not suitable for use by persons younger than 18 years for treatment of "depressive illness." After review, this agency decided that the risks to pediatric patients outweigh the benefits of treatment with SSRIs, except fluoxetine (Prozac), which appears to have a positive risk-benefit ratio in the treatment of depressive illness in patients younger than 18 years.

In October 2003, the FDA issued a public health advisory regarding reports of suicidality in pediatric patients treated with antidepressant medications for major depressive disorder. This advisory reported suicidality (both ideation and attempts) in clinical trials of various antidepressant drugs in pediatric patients. The FDA has asked that additional studies be performed because suicidality occurred in both treated and untreated patients with major depression and thus could not be definitively linked to drug treatment.

However, a recent study of more than 65,000 children and adults treated for depression between 1992 and 2002 by the Group Health Cooperative in Seattle found that suicide risk declines, not rises, with the use of antidepressants.⁵ This is the largest study to date to address this issue.

Currently, evidence does not associate obsessive-compulsive disorder and other anxiety disorders treated with SSRIs with an increased risk of suicide.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Further inpatient care is generally not needed.

Further Outpatient Care

• Concrete depictions that relaxation is occurring may facilitate relaxation training; for example, the use of a biofeedback apparatus including a computer screen that changes color or graphically depicts an increase in the height of a bar graph when a relaxation response occurs (and is measured by objective measurements such as skin conductance, pulse, or blood pressure) may be helpful.
• Weekly individual cognitive-behavioral therapy and/or group therapy sessions for at least 1 hour per week with appropriate parental involvement are recommended.
• Additional helpful items may include the following:
• • Supportive educational environment to guard against further additional anxiety or stressors, which worsen the patient's emotional state
  • Close collaboration among school, home, and community personnel (eg, athletic, music, art, religious personnel) and any therapy providers to reinforce prevention of loss of skills in other areas
  • Medication management (at least initially) by a child psychiatrist or pharmacologically knowledgeable behavioral-developmental pediatrician after appropriate screening, medical examination, and testing results are obtained (weekly or every other week visits until the patient is stabilized and monthly thereafter)
  • Group therapy (more appropriate for older children and adolescents to provide an in vivo experience but may benefit younger children if they are able to participate appropriately in a group)

In/Out Patient Meds

• Adjunctive treatment with a low-dose SSRI is indicated if no improvement is observed or if the person's level of functioning deteriorates to the point of not being able to maintain at least 50% level of functioning (ie, missing 50% of days of school or work) after 2 months of cognitive-behavioral therapy.

Deterrence/Prevention

• Intensive intervention with children or adolescents at high risk for anxiety disorders (eg, parent with anxiety disorder) to prevent development of phobias after traumatic experiences (eg, anesthesia) and encouragement of both the child and family to work through their emotional reactions to stressors soon after the stressor occurs may be needed.

Complications

Interestingly, children and adolescents with social phobia are less likely to develop a panic attack in response to an infusion of sodium lactate or CO₂ than persons with panic disorder.

• Panic disorder with and without agoraphobia
• Separation anxiety disorder
• Generalized anxiety disorder

Prognosis

• Prognosis is fair-to-good, depending on the severity of impairment of functioning associated with avoidance of social situations and public speaking and depending on the presence or absence of secondary gain factors that tend to discourage persons from changing their adaptation to anxiety.
• Perhaps related to the higher incidence of associated speech and language disorders, children who have social phobia when they are younger than 10 years have a better long-term prognosis. Prognosis is poorer in children older than 12 years who have social phobia than in younger children. Long-term prognosis is perhaps related to the implications of having fewer overall communication skills in social settings or with peers for long-term social skills and language skills development. Also, the baseline problems that provoke the adolescent have the potential to be more long-standing and more serious.

Patient Education

• Mild heart rate increases and subjective sensations of a lump in the throat or abdominal discomfort are physiological reactions to stress and are to be expected. These must be differentiated from disabling panic attacks in which simple reassurance does not help. Reactions can decrease as the child or adolescent learns to relax instead of tense up when stressful situations occur.
• For excellent patient education resources, visit eMedicine's Anxiety Center. Also, see eMedicine's patient education articles Anxiety, Panic Attacks, and Hyperventilation.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to screen for hearing loss in selective mutism is a possible pitfall.
• Failure to ask about contributory factors, such as marital stress or discord and peer rejection, in social phobia is a possible pitfall.
• Polypharmacy or drug interactions are more likely if the patient or family feels that the somatic symptoms are not being adequately managed; therefore, explaining to the patient and family that the somatic symptoms are uncomfortable, that psychotropic medication is intended to improve those symptoms, and that the symptoms are truly experienced and bothersome is important. Do not tell the patient or family that the symptoms are imagined; instead, empathically reflect to the child and family understanding and compassion toward the very real suffering, which is an abnormal response to the anxiety-provoking situation.
• Failure to closely monitor the patient when medications are started, increased, or lowered can lead to medical or legal pitfalls.

Special Concerns

• Medication treatment is generally contraindicated in the first trimester of pregnancy and should be used very cautiously in the last trimester.
• Unnecessary medical procedures (especially invasive) should be avoided, and the patient and family should, therefore, be encouraged to remain with the same primary care physician to prevent iatrogenically induced complications.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Nov 27, 2007