Social anxiety disorder , treatment

Of the three disorders that make up Cluster C, only APD has received much attention in medication treatment studies. In addition, much of this has been an extraction of the results of social anxiety disorder treatment studies. 

The acute phase of panic disorder treatment lasts about 12 weeks and should result in marked reduction in panic attacks, ideally total elimination, and minimal anticipatory anxiety and social anxiety avoidance. Treatment should be continued to prevent relapse for an additional 12 to 18 months before attempting discontinuation. 

The onset of response to antidepressants in social anxiety disorder is delayed and may be as long as 8 to 12 weeks. Patients responding to medication should be continued on treatment for at least 1 year. 

Another study with citalopram evaluated its efficacy in the treatment of social anxiety disorder along with co-morbid major depression (Schneier etal., 2003). The outpatients (n= 21) were predominantly Hispanic (76%) and from New York. Response rates for the intent-to-treat sample were 66.7% for social anxiety disorder and 76.2% for major depression. Only one subject was known to have withdrawn secondary to severe side effects. The mean dose of the medication was 37.6 mg/day and there was no placebo control. The depressive symptoms tended to improve... 

Schneier, F. R., Blanco, C., Campeas, R., Lewis-Fernandez, R. el al. (2003). Citalopram treatment of social anxiety disorder with comorbid major depression. Depress. Anxiety, 17, 191-6. 

Drugs Used in the Treatment of Generalized Social Anxiety Disorder... 

Historically, few people with social anxiety disorder have sought treatment. Because the symptoms of the disorder can be confused with normal shyness, many could simply be unaware of the presence of the disorder. Others might recognize that they have the disorder but remain reluctant to seek treatment because that would require them to endure an anxiety-provoking social encounter with a health care professional. 

Poorer responses to psychotherapy can be expected for those with more severe symptoms or the generalized subtype of social anxiety disorder, those who are poorly compliant with homework assignments, and those who enter therapy with little expectation of benefit. Furthermore, psychotherapy may not be readily available for all patients. Consequently, treatment with medications is commonly recommended. 

Benzodiazepines. The best studied of the benzodiazepines for social anxiety disorder, clonazepam has been demonstrated in controlled trials to be effective during both acute treatment (at an average dose of 2.4mg/day) and long-term maintenance therapy lasting up to 2 years. A controlled study of another high potency benzodiazepine, alprazolam, also proved effective, though it was outperformed by the MAOI antidepressant phenelzine and exhibited response rates lower than those reported with clonazepam. 

Monoamine Oxidase inhibitors (MAOis). Many, though not all, antidepressants are effective treatments for social anxiety disorder. Although they do not provide rapid symptom relief and may even transiently worsen anxiety symptoms during the first 1-2 weeks of treatment, antidepressants have the advantage of treating comorbid depression. 

Early controlled studies demonstrated the effectiveness of irreversible MAOIs, particularly phenelzine and tranylcypromine, for generalized social anxiety disorder. Prior to the advent of the SSRIs, MAOis were considered the gold standard treatment for social anxiety disorder. The best studied of the MAOis, phenelzine, has proved snperior to both beta blockers and the benzodiazepine alprazolam in treating generalized social anxiety disorder. 

The so-called reversible MAOis, moclobemide and brofaromine, appear to obviate these problematic interactions, though the latter was never approved and the former is not available in the United States. Controlled studies of these agents in the treatment of social anxiety disorder have produced mixed results. 

Tricyciic Antidepressants (TCAs). There has been surprisingly little study of TCAs in the treatment of social anxiety disorder. Early trials with imipramine and clomipramine suggested they might be beneficial however, subsequent controlled studies indicate that TCAs are no more effective than placebo. Consequently, they are not used to treat social anxiety disorder. 

SSRis and SNRis. The introduction of the SSRIs and SNRIs has provided treatments for social anxiety disorder that are not only equally effective but safer and... 

Buspirone. Although initial open label results were promising, a controlled study of buspirone, approved by the FDA for treatment of GAD, failed to demonstrate any effectiveness in the treatment of social anxiety disorder. However, a subsequent controlled study indicated that buspirone administered at 30-60 mg/day is an effective augmentation strategy for patients with social anxiety disorder who have only experienced a partial response to SSRI therapy. 

Psychosurgery. Case series have been reported of patients with severe treatment resistant social anxiety disorder undergoing surgical procedures including capsu-lotomy and endoscopic transthoracic sympathectomy. Given the limited evidence... 

Specific Sociai Anxiety Disorder, Acute Phase Treatment. Different strategies have evolved for treating specific social anxiety disorder versus generalized social anxiety disorder. Less complicated is the management of the specific subtype. Exposure-based psychotherapy is a mainstay of treatment, and as-needed medication doses prior to scheduled performances are also widely used. Preferred agents for performance anxiety are alprazolam or propranolol. 

There has been little formal study of maintenance therapy for social anxiety disorder. Limited data indicates that continued pharmacotherapy provides significant prophylactic protection against relapse. Furthermore, growing evidence indicates that patients with social anxiety disorder experience a high rate of relapse after treatment discontinuation. CBT, however, may afford continued prophylactic benefit long after conclusion of the therapy, though the data to support this contention is limited. 

Serotonin-Boosting Antidepressants. The SSRIs have also been studied in the treatment of generalized social anxiety disorder, and paroxetine, sertraline, and venlafaxine are effective. Preliminary data suggests that the serotonin-boosting atypical antidepressants (mirtazapine and nefazodone) may also be helpful. Like the MAOIs, they appear to be effective at doses comparable to those used to treat depression. They may help avoidant patients to gradually increase their social interaction and become more assertive. 

Benzodiazepines. Longer-acting clonazepam and shorter-acting alprazolam have also been used in the treatment of social anxiety disorder, and controlled trials have shown them to be quite effective. In our experience, alprazolam is best suited for discrete periods of intermittent anxiety, though both clonazepam and the new long-acting alprazolam (Xanax XR) are likely effective for long-term treatment. 

Avoidant Personality Disorder (APD). We generally recommend following the same pharmacological treatments for APD that are nsed for the generalized subtype of social anxiety disorder. Because APD is so pervasive, medications should be used on a daily basis as opposed to as-needed dosing. 

Anxiety Treatment of generalized anxiety disorder (GAD) and social anxiety disorder (SAD) (extended-release [ER] only). 

Panic disorder is comorbid with episodes of depression at some stage in the majority of cases (Stein et al. 1990), with social anxiety disorder and to a lesser extent GAD and PTSD, and with alcohol dependence and personality disorder. Comorbidity results in increased severity and poor response to treatment. Panic disorder is associated with a significantly increased risk of suicide, and this is increased further by the presence of comorbid depression (Lepine et al. 1993). 

Barnett SD, Kramer ML, Casat CD, Connor KM, Davidson JR (2002) Efficacy of olanzapine in social anxiety disorder a pilot study. J Psychopharmacol 16 365-368 Beauclair L, Fontaine R, Annable L, Holobow N, Chouinard G (1994) Clonazepam in the treatment of panic disorder a double-blind, placebo-controlled trial investigating the correlation between clonazepam concentrations in plasma and clinical response. J Clin Psychopharmacol 14 111-118... 

The treatment of social anxiety disorder is less established than that for other anxiety disorders. Different reports present conflicting findings about the effectiveness of the drugs... 

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