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Social Anxiety Disorder Franklin R. Schneier, M.D.

From the Anxiety Disorders Clinic, New York State Psychiatric Institute; and the Department of Psychiatry, Columbia Uni- versity College of Physicians and Sur- geons — both in New York. Address re- print requests to Dr. Schneier at the Anxiety Disorders Clinic, New York State Psychiatric Institute, 1051 Riverside Dr., Unit 69, New York, NY 10032, or at frs1@ columbia.edu.

A 28-year-old man reports feeling anxious and self-conscious around people in school, work, and social situations since his early teens. He appears shy and, on ques- tioning, describes avoidance of speaking up in work meetings, attending social gath- erings, and dating. He desperately wants to be more socially active but fears he will appear nervous and embarrass himself. How should he be evaluated and treated?

T h e C l i n i c a l P r o b l e m

Social anxiety disorder, also known as social phobia, is one of the most common psychiatric disorders, with a lifetime prevalence of 12%.1 About half that prevalence represents persons who have the generalized type of the disorder, with fear or avoid- ance encompassing most social situations.2 The remainder report fear and avoidance mainly limited to public speaking or other performance situations, representing the type of this disorder sometimes referred to as nongeneralized or performance- type social anxiety disorder. Table 1 summarizes the diagnostic criteria of the Di- agnostic and Statistical Manual of Mental Disorders, 4th edition, text revision.3

Social anxiety disorder typically begins during the early teenage years1,4 and is chronic. Although social anxiety disorder is more common among women than among men, approximately equal numbers of men and women seek treatment for it. Persons seeking treatment often have had symptoms for 10 years or more, and coexisting psychiatric disorders are common. Among such persons, the lifetime rate of phobias is greater than 50%; major depression and alcohol abuse occur in 15 to 20% of cases.4

Social anxiety disorder differs from shyness and performance anxiety in its great- er severity, pervasiveness, and resultant distress and impairment.5 Persons with social anxiety disorder may avoid important activities, such as attending classes and meetings, or attend but avoid active participation. They achieve less in school and work and are less likely to marry than people who do not have the disorder.6 In primary care settings, social anxiety disorder contributes to poor functioning and missed work,7 yet most cases go untreated.8

Both heredity and environment contribute to the development of social anxiety disorder.9 Toddlers who appear to be shy and have inhibited temperament are at in- creased risk for the development of social anxiety disorder by the time they reach their teens, although the disorder does not develop in most shy children.10 Overpro- tective and hypercritical parenting has been associated with social anxiety disorder, although the extent to which such parenting is a contributing cause, as compared with a response to a child with social anxiety, is unclear.11 Neuroimaging studies in affected persons have shown increased reactivity in the amygdala to social cues, such as faces.12 Other studies have shown abnormalities in serotonin and dopamine

This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines,

when they exist. The article ends with the author’s clinical recommendations.

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systems.13 Performance-type social anxiety disor- der is associated with increased reactivity in the autonomic nervous system in feared situations.14

S t r a t e g i e s a n d E v i d e n c e

Evaluation

People who have social anxiety disorder often have anxiety in the presence of authority figures and are self-conscious when undergoing a physical examination. They may avoid mentioning their social anxiety because of shame or fear that it will not be taken seriously. A set of three screen- ing questions regarding avoidance of embarrass- ment, avoidance of being the center of attention, and fear of being embarrassed or looking stupid have high sensitivity (89%) and specificity (90%) for the generalized type of social anxiety disorder, and responses indicating fear and avoidance (pos- itive responses) should be followed by further in- quiry (Table 2).15

The diagnosis of social anxiety disorder is made on the basis of the clinical presentation. Patients

often report fear of embarrassment as well as more general fear of being evaluated negatively by others.16 Many fear that others will notice their physical manifestations of anxiety, such as sweat- ing, trembling, and blushing, and they overesti- mate the visibility of these features. Panic attacks may occur in social anxiety disorder, but unlike those in panic disorder, these attacks occur only in relation to current or anticipated social situ- ations. Whereas worry and symptoms of anxiety are also characteristic of generalized anxiety dis- order, in social anxiety disorder these features are associated predominantly with social situa- tions.

In major depressive disorder, the coexistence of social anxiety disorder may increase the risk of suicide.17 Patients with alcoholism and social anxiety disorder may particularly avoid group- based treatments, such as Alcoholics Anonymous, and may be more likely to have a relapse than those who do not have these two disorders con- comitantly.18

In persons whose social anxiety and avoidance of social situations appear to be completely sec- ondary to embarrassing symptoms of another medical condition such as essential tremor, stut- tering, or obesity, the condition does not techni- cally meet the diagnostic criteria for social anxi- ety disorder.3 Nevertheless, persons with clinically significant secondary social anxiety may benefit from therapies used in the treatment of primary social anxiety disorder.19

Treatment

Established treatments for social anxiety disorder include cognitive–behavioral therapy and pharma- cotherapy.20,21 The primary goal of treatment is to reduce social anxiety to manageable levels, but even modest reductions in avoidance and discom- fort may be highly valued by affected persons.

Cognitive–Behavioral Therapy Cognitive–behavioral therapy for social anxiety dis- order addresses the vicious cycle of anticipatory negative thoughts (“My voice will shake and the audience will think I’m crazy”) and behaviors (e.g., avoiding practicing before speaking in public), leading to increased situational anxiety and mal- adaptive behavior (e.g., cutting the speech short) and to negative self-appraisals (“My speech was a disaster”) and further avoidance behavior. Tech- niques for cognitive restructuring help the pa-

Table 1. Diagnostic Criteria for Social Anxiety Disorder.*

A marked and persistent fear of one or more social or performance situations involving exposure to unfamiliar people or possible scrutiny by others. The person fears that he or she will act in a way (or show symptoms of anxiety) that will be humiliating or embarrassing.†

Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a panic attack.†

The person recognizes that the fear is excessive or unreasonable.†

The feared social or performance situations are avoided or endured with in- tense anxiety or distress.

The condition interferes significantly with the person’s normal routine, occu- pational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

The fear or avoidance is not due to the direct physiological effects of a sub- stance or a general medical condition and is not better accounted for by another mental disorder.

If a general medical condition or another mental disorder is present, the so- cial or performance fear is unrelated to it (e.g., the fear is not of trembling in Parkinson’s disease).

Specify the disorder as “generalized” if fears include most social situations.

* These criteria were adapted from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision, of the American Psychiatric Association.3 All these criteria are required for the diagnosis.

† In children, there must be evidence of the capacity for age-appropriate social relationships, and the anxiety must occur in peer settings. The anxiety may be expressed as crying, tantrums, freezing, or shrinking from social situations. Children may not recognize that their fear is excessive. The duration of the condition must be at least 6 months.

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tient identify and question maladaptive thoughts and then develop alternative perspectives. Behav- ioral techniques known as therapeutic exposure introduce the patient to feared situations in a grad- uated fashion while the patient learns to use cog- nitive strategies, sometimes augmented by relax- ation techniques, to manage anxiety.

Cognitive–behavioral therapy has been studied in individual and group formats and typically con- sists of 12 to 16 weekly sessions, each lasting 60 to 90 minutes. A workbook can provide supple- mentary educational materials and homework ex- ercises.22 The therapist and the patient devise a hierarchy of feared situations, which serves as a template for exposure exercises. The therapist trains the patient in cognitive restructuring. For example, persons who are fearful of speaking to others are helped to recognize that, even if they speak in a voice that shakes, others are unlikely to notice or care, and they can still get the point across. Patients also learn methods to use to re- place unhelpful expectations (“I shouldn’t be anx- ious at a party”) with constructive behavioral goals (“I’ll start two conversations at the party”). They practice using these methods while being exposed to feared situations in role-playing with the thera- pist and in homework assignments.

Numerous open and controlled trials involving patients who have generalized or performance- type social anxiety disorder have provided evidence of the efficacy of this approach, as compared with no treatment, educational support groups, and placebo.20,22-31 Clinical improvement typically be- comes apparent after 6 to 12 weeks of therapy and may progress over several months. In clini- cal trials, one half to two thirds of patients have been considered to have a response at 12 weeks (on the basis of global assessments that incorpo- rate clinically meaningful improvements in so- cial anxiety, avoidance of feared situations, and associated impairment in functioning).23,24 In one study, at the 5-year follow-up, 89% of patients who had completed a course of cognitive–behav- ioral therapy were considered to have clinical improvement, as compared with 44% of control subjects who had completed a course of educa- tional therapy.32

Pharmacotherapy Placebo-controlled, randomized trials have dem- onstrated the efficacy of several classes of medi- cation for the treatment of social anxiety disorder

(Table 3). Most clinical trials have involved pre- dominantly or exclusively patients with the gen- eralized type of social anxiety disorder, in whom the high frequency and unpredictability of anxi- ety-provoking situations warrant standing daily doses of medication, rather than as-needed use of medication.

Selective Serotonin-Reuptake Inhibitors The selective serotonin-reuptake inhibitors (SSRIs) and the serotonin–norepinephrine–reuptake inhib- itor (SNRI) venlafaxine (Effexor, Wyeth–Ayerst) have emerged as first-line pharmacotherapy for the generalized type of social anxiety disorder. The ef- ficacy and safety of these medications in the treat- ment of social anxiety disorder have been estab- lished in more than 20 randomized, controlled trials.21,33 Response rates typically range from 50% to 80% after 8 to 12 weeks of treatment. How- ever, studies of fluoxetine (Prozac, Lilly) in social anxiety disorder have had inconsistent results (one of three controlled trials showed efficacy).25,27,34 Head-to-head trials comparing SSRIs with one an- other or with an SNRI have not demonstrated that any one medication is superior to the others in the treatment of social anxiety disorder.35,36

Treatment with an SSRI or an SNRI is com- monly initiated at half the usual effective dose, and the dose is increased after 1 week (Table 3). The dose–response curve for these agents is relatively flat in social anxiety disorder,37 but because some patients may benefit from higher doses, clinicians commonly increase the dose as tolerated in those who have no response after 4 weeks of the thera- py. Although many patients report improvement during the first few weeks of treatment, more than

Table 2. Self-Administered Screening Questions for Generalized Social Anxiety Disorder.*

Rate each item according to the following scale:

0 = Not at all, 1 = A little bit, 2 = Somewhat, 3 = Very much, 4 = Extremely

1. ___ Fear of embarrassment causes me to avoid doing things or speaking to people.

2. ___ I avoid activities in which I am the center of attention.

3. ___ Being embarrassed or looking stupid is among my worst fears.

___ Total

* A total score of 6 or higher (positive predictive value, 52.6%; negative predic- tive value, 98.5%) suggests the need for further assessment of symptoms, as- sociated distress, and impairment as the basis for a diagnosis of generalized social anxiety disorder. Questions are from the 17-item Social Phobia Inventory (SPIN).15

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a quarter of those who do not have a response at week 8 may have a response during an additional 4 weeks of treatment at the same dose,38 suggest- ing that an initial trial should last 12 weeks. Pa- tients who have a response during those 12 weeks should receive maintenance treatment to minimize the risk of relapse. The usefulness of these medi-

cations during longer periods of treatment is lim- ited in some cases by adverse effects, including sexual dysfunction and weight gain (Table 3).

Benzodiazepines Although evidence of the efficacy of benzodiaz- epines in social anxiety disorder is more limited

Table 3. Medications Used in the Treatment of Social Anxiety Disorder.*

Disorder and Medication Initial Dose Target Dose Common Side Effects

mg/day

Generalized social anxiety disorder

Selective serotonin-reuptake inhibitors (SSRIs) Sexual dysfunction, headache, nausea, sedation, insomnia, sweating, withdrawal syn- drome

Sertraline (Zoloft, Pfizer)† 50 50–200

Paroxetine (Paxil, GlaxoSmithKline)† 10 10–60

Paroxetine CR (Paxil CR, GlaxoSmithKline)† 12.5 12.5–75.0

Escitalopram (Lexapro, Forest) 5 5–20

Fluvoxamine (Luvox, Solvay) 50 50–300

Serotonin and norepinephrine-reuptake inhibitors (SNRIs) Same as for SSRIs; also hyperten- sion

Venlafaxine XR (Effexor XR, Wyeth–Ayerst)† 75 75–375

Monoamine oxidase inhibitors Sedation, insomnia, hypotension, weight gain; low-tyramine diet required to prevent hyperten- sive reaction

Phenelzine (Nardil, Parke-Davis) 15 30–90

Other antidepressants Sedation, weight gain, dry mouth

Mirtazapine (Remeron, Organon)‡ 15–30 30–60

Benzodiazepines Sedation, cognitive impairment, ataxia, withdrawal syndrome

Clonazepam (Klonopin, Roche)‡ 0.25 0.50–4.00

Other anticonvulsants Sedation, ataxia, dizziness, dry mouth, nausea, asthenia, flat- ulence, decreased libido

Gabapentin (Neurontin, Pfizer)‡ 600 900–3600

Pregabalin (Lyrica, Pfizer)‡ 300 600

Nongeneralized social anxiety disorder (performance-type social anxiety disorder)

mg as needed§

Beta-blockers Hypotension, bradycardia

Propranolol (Inderal, Wyeth–Ayerst) 10 10–40

Benzodiazepines Sedation, cognitive impairment, ataxia

Alprazolam (Xanax, Pharmacia and Upjohn)¶ 0.25 0.25–1.00

Lorazepam (Ativan, Wyeth–Ayerst)¶ 0.5 0.5–2.0

* This list is not exhaustive, but it includes all medications approved by the Food and Drug Administration (FDA) for the treatment of social anxiety disorder and selected others for which there is evidence of efficacy in social anxiety disorder. Venlafaxine, phenelzine, mirtazapine, gabapentin, pregabalin, clonazepam, propranolol, and all the SSRIs other than paroxetine are classified by the FDA as Category C. Paroxetine, lorazepam, and alprazolam are Category D. CR denotes controlled release, and XR extended release.

† This drug is approved by the FDA for social anxiety disorder. ‡ Evidence for the efficacy of this medication in social anxiety disorder includes a single randomized, controlled trial. § Evidence for the efficacy of this medication in nongeneralized social anxiety disorder is inferred from randomized, con-

trolled trials involving persons with undiagnosed performance anxiety. ¶ This drug is approved by the FDA for anxiety.

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than that for SSRIs and SNRIs, benzodiazepines are commonly used in the treatment of patients who cannot tolerate or do not have an adequate response to SSRIs or venlafaxine. The relatively long-acting benzodiazepine clonazepam (Klono- pin, Roche), given daily in divided doses, appeared to be highly effective in generalized social anxi- ety disorder in a controlled trial (response rate, 80%) and in several open trials.39 A single con- trolled trial of alprazolam (Xanax, Pharmacia and Upjohn) was inconclusive.28 In most patients, tol- erance rapidly develops to the sedative effects of benzodiazepines, but not to the anxiolytic effects. Long-term use (more than 2 weeks) may result in physical dependence, and abrupt discontinuation of the medication should be avoided because of the risk of rebound anxiety and withdrawal symptoms (including tremor, insomnia, and in rare cases, sei- zures). A gradual tapering of the dose of clonaz- epam (a decrease of 0.25 mg every 2 weeks), how- ever, has been shown to be well tolerated by patients with social anxiety disorder.40 Benzodiazepines are not recommended as monotherapy for pa- tients who have major depression in addition to social anxiety disorder and should be avoided in patients with a history of substance abuse.

Other Medications Gabapentin (Neurontin, Pfizer) and pregabalin (Lyrica, Pfizer) are structurally related anticonvul- sants that have been reported to be significantly superior to placebo in reducing symptoms of gen- eralized social anxiety disorder in single controlled trials, although response rates for each were less than 45%.41,42 In a recent small, placebo-controlled trial, mirtazapine (Remeron, Organon), an antide- pressant with a mechanism of action different from that of other available antidepressants, was shown to be effective at a fixed dose of 30 mg per day in women with social anxiety disorder.43 The mono- amine oxidase inhibitor (MAOI) phenelzine (Nardil, Parke-Davis) has been shown to be effective in so- cial anxiety disorder in randomized clinical tri- als,21,28,44 but it is generally reserved for the treat- ment of refractory disease because of the risk of severe hypertensive reaction to dietary tyramine or sympathomimetic medication. Moclobemide, a re- versible inhibitor of monoamine oxidase A, appears to be safer than standard MAOIs, although meta- analyses have found it less effective in social anxi- ety disorder than the SSRIs21; it is not available in the United States.

Maintenance Therapy

Several controlled studies have shown that the initial clinical improvement seen with pharmaco- logic treatment generally persists during up to 12 months of maintenance treatment.21,45,46 Discon- tinuation of pharmacotherapy after 5 to 12 months of treatment has resulted in relapse rates of 20% to 60% during follow-up periods of 3 to 6 months; discontinuation of therapy after only 2 to 3 months appears to result in higher rates of relapse than when therapy is continued for a longer period. Al- though more data are needed, these findings sug- gest that continuing medication for 6 to 12 months, followed by tapering and discontinuation, and then follow-up for relapse, is reasonable.

Randomized trials directly comparing cogni- tive–behavioral therapy with pharmacotherapy in populations with predominantly generalized so- cial anxiety disorder have not demonstrated con- sistently greater efficacy for either approach,24-28 although one meta-analysis of trials of 6 to 16 weeks’ duration suggested that pharmacotherapy is superior in the short term.23 Trials comparing the outcomes of these two approaches at 6 to 12 months after discontinuation of the therapy, how- ever, have suggested that cognitive–behavioral therapy has more durable benefit.24,45 Studies of combined cognitive–behavioral and pharmacolog- ic treatment24,25 have not demonstrated efficacy superior to that of either approach alone, although the combined treatment may be helpful for some patients.

Nongeneralized Social Anxiety Medication may be useful on an as-needed basis in the treatment of patients with nongeneralized (performance-type) social anxiety disorder, whose feared situations (such as public speaking) occur predictably and with less than daily frequency (Table 3). Data to guide treatment in this setting are derived primarily from controlled trials in- volving persons with performance anxiety, rather than those who have received a formal diagnosis of performance-type social anxiety disorder.

Several studies suggest that beta-blockers such as propranolol (Inderal, Wyeth–Ayerst), taken as needed about an hour before a performance, may be helpful in performance-type social anxiety dis- order.47-49 Benzodiazepines may also be useful.47 These are typically taken at least 30 minutes before a performance, and the effect of a single dose may last up to several hours. Although tolerance and

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physical dependence are unlikely to develop when benzodiazepines are used less than daily, psycho- logical dependence may occur, and the immediate side effects of sedation and cognitive dulling some- times outweigh the anxiolytic benefits. With either beta-blockers or benzodiazepines, patients may benefit from being given a trial dose outside their feared situation to confirm tolerability.

A r e a s o f U n c e r t a i n t y

Resistance

Data from controlled studies are lacking to guide the optimal treatment of patients who do not have a response to an initial course of pharmacother- apy, and clinically useful predictors of response to particular therapies are also lacking. Clinical experience suggests that patients who do not have a response to one medication may have a response to another of the same or a different class or may benefit from cognitive–behavioral therapy. Clini- cal experience also suggests that a partial response to an SSRI or SNRI may be augmented by cogni- tive–behavioral therapy or by use of a benzodiaz- epine, gabapentin, or pregabalin. A MAOI is con- traindicated in combination with an SSRI or SNRI because of the risk of the serotonin syndrome, which is characterized by neuromuscular and au- tonomic hyperactivity and agitation.

Treatment of Children and Adolescents

Social anxiety disorder in children and adolescents may sometimes be difficult to differentiate from age-appropriate social awkwardness, but treatment of persistent and impairing symptoms holds prom- ise for restoring normal social development and preventing further impairment. Although the treat- ment of children has been studied less than the treatment of adults, cognitive–behavioral therapy appears to be effective in children and adolescents with social anxiety disorder.50 Several placebo-con- trolled trials have also provided evidence of the efficacy of pharmacotherapy with an SSRI or SNRI for social anxiety disorder in children 6 to 17 years of age.50 A recent report51 of the increased risk of suicidal ideation among adolescents receiving SSRIs or SNRIs, although derived primarily from studies of depression in adolescence, suggests that

youths prescribed these medications for social anx- iety disorder must be closely monitored.

G u i d e l i n e s

No formal guidelines for the management of so- cial anxiety disorder have been issued by U.S. or European professional societies.

S u m m a r y a n d R e c o m m e n d a t i o n s

Social anxiety disorder is common, impairing, and responsive to treatment, yet it remains underrecog- nized. Randomized, controlled trials support the use of either cognitive–behavioral therapy or phar- macotherapy. For most patients, such as the one described in the vignette, I would initiate treatment with cognitive–behavioral therapy, given the data supporting its potential long-term benefit. SSRIs or venlafaxine are alternative first-line treatments for patients who prefer medication, have prominent coexisting depression, or lack access to a trained therapist. I would start with a low dose for 1 week, to minimize initial side effects, then increase it to the usual effective dose for several weeks, and if the response is incomplete, gradually increase to the maximal dose, as tolerated. Patients should be en- couraged to try to increase their social activities gradually, and they may benefit from adjunctive use of self-help literature oriented toward a cognitive– behavioral approach. Because the data suggest a higher rate of relapse with a shorter duration of therapy, I would recommend that when medication is used it be continued for 6 to 12 months, followed by an attempt to taper and discontinue the medica- tion, although the risk of relapse must be recog- nized. In patients with recurrent symptoms, treat- ment may be reinstituted for a longer period.

The Anxiety Disorders Association of America (www.adaa.org) and the National Institute of Men- tal Health (www.nimh.nih.gov) are good sources of information for patients. The site of the Anxiety Disorders Association of America includes listings of clinicians with expertise in the treatment of social anxiety disorder.

Dr. Schneier reports having received grants from Eli Lilly and Forest. No other potential conflict of interest relevant to this article was reported.

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