SSRIs social anxiety disorder

Selective serotonin reuptake inhibitors (SSRIs) are considered the drugs of choice based on their tolerability and efficacy for social anxiety disorder as well as comorbid disorders. 

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. 

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. 

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. 

SSRI/SNRI GAD OCD Panic disorder PTSD Social anxiety disorder Onset worsening side-effects on initiation few long-term effects Relatively safe in overdose (venlafaxine possibly less safe) Well-described more common with paroxetine uncommon with fiuoxetine... 

Also, a malfunction in the dopamine system has been shown to make it more likely for a person to have a detached personality, which is a characteristic of patients with social anxiety disorder. Serotonin systems are thought to be involved because SSRIs are effective in treating this form of the disorder. Although these systems have been implicated, little is known about how they are malfunctioning to produce the symptoms that characterize this problem. 

In the case of social anxiety disorder, research suggests that some of the antidepressants that are effective in other anxiety disorders do not work to ease the symptoms of social anxiety disorder. This is true of the tricyclic antidepressant imipramine and fluoxetine (Prozac). The first line of treatment for the generalized form of social anxiety disorder is an SSRI such as paroxetine or sertraline. 

Social anxiety disorder is an uncommonly diagnosed but a fairly common condition in which the patient experiences severe anxiety in social interactions. This anxiety may limit their ability to function adequately in their jobs or interpersonal relationships. Several SSRIs and venlafaxine are approved for the treatment of social anxiety. The efficacy of the SSRIs in the treatment of social anxiety is greater in some studies than their efficacy in the treatment of MDD. 

Clinicians will readily recognize in Table 3.7 the experiences reported by many of their patients when receiving treatment for depression or other related psychiatric disorders. By looking at the Function affected column, it is possible to understand why some medications (say, SSRIs) are effective in variable degrees in several conditions associated with serotonin dysfunction (depression, OCD, social anxiety disorder, posttraumatic stress disorder, generalized anxiety disorder, panic disorder, and bulimia nervosa). 

Cluster C patients may indeed present for psychotherapy and may improve with that treatment modality alone. However, the therapist should carefully consider the differential diagnosis between avoidant personality disorder and panic disorder or social anxiety disorder, for example, which responds well to SSRI therapy. And the therapist should particularly evaluate the Cluster C patient for obsessional signs and symptoms that may respond well to antiobsessional medication. 

Stein MB, Seedat S, Gelernter J. Serotonin transporter gene promoter polymorphism predicts SSRI response in generalized social anxiety disorder. Psy chopharmacol 2006 187 68-72. 

FIGURE 69-3. Algorithm for the pharmacotherapy of social anxiety disorder. SSRI = selective serotonin reuptake inhibitor, BZ = benzodiazepine. (Compiled from Ballenger et al, Van Amerigen and Mancini, and Blanco... 

However, it must be noted that most of Effexor s reported side effects are much less severe than those associated with SSRIs. Indeed, Effexor s popularity has increased following FDA approval of the drug as a treatment for such syndromes as social anxiety disorder (SAD) and generalized anxiety disorder (GAD). Social anxiety disorder is not simply shyness, but a paralyzing inability to interact with people, such as casual acquaintances or even friends. Generalized anxiety disorder is the clinical term for a personality marked by a chronic state of worry. People afflicted with GAD often feel so overwhelmed with real or imagined problems that they have trou-... 

Sertraline hydrochloride was introduced to the market by Pfizer and known under the brand names Zoloft and Lustral. Sertraline is an antidepressant " " of the selective serotonin reuptake inhibitor (SSRI) class and is primarily used to treat major depression, highly effective for the treatment of panic and social anxiety disorders. ... 

Sertraline hydrochloride (known under the trade names Zoloft and Lustral, both from Pfizer) is an antidepressant chiral drug acting as a selective serotonin reuptake inhibitor (SSRI). It is primarily used in major depression treatment and as obsessive/compulsive, panic, and social anxiety disorders. Ir-Catalyzed enantioselective hydrogenation of C=N bond can be employed to install a second stereogenic... 

Another example of a dual SSRI/NARI is venlafaxine (Fig. 18.27), which one can view as a N,N-dimethylated and para-methoxy-phenylethylamine derivative, substituted with cyclohexanol at the (3-position. It only weakly inhibits dopamine transport and is commonly prescribed for depression but also for general and social anxiety disorder. 

Indeed, 5-HT is also a substrate for the 5-HT transporter, itself an important player in the treatment of depression, and more recently for the whole range of anxiety disorders spectrum (GAD, OCD, social and other phobias, panic and post-traumatic stress disorders). It is the target for SSRIs (selective serotonin reuptake inhibitors) such as fluoxetine, paroxetine, fluvoxamine, and citalopram or the more recent dual reuptake inhibitors (for 5-HT and noradrenaline, also known as SNRIs) such as venlafaxine. Currently, there are efforts to develop triple uptake inhibitors (5-HT, NE, and DA). Further combinations are possible, e.g. SB-649915, a combined 5-HTia, 5-HT1b, 5-HT1d inhibitor/selective serotonin reuptake inhibitor (SSRI), is investigated for the treatment of major depressive disorder. 

In recent years many of these primary care cases that would formerly have been seen as anxiety disorders have been portrayed as anxious-depressives and have led to treatment with antidepressants, in particular the more recent serotonin reuptake inhibitors. As part of this rebranding a variety of states such as panic disorder, post-traumatic stress disorder, social phobia and generalized anxiety disorder have appeared, along with more traditional disorders such as obsessive compulsive disorder (OCD). Many of these diagnoses are likely to lead to prescriptions of an SSRI although the evidence for benefit from SSRIs is poor except for OCD. 

The selective serotonin reuptake inhibitors (SSRI) have been used in adults for a wide variety of disorders, including major depression, social anxiety (social phobia), generalized anxiety disorder (GAD), eating disorders, premenstrual dysphoric disorder (PMDD), post-traumatic stress disorder (PTSD), panic, obsessive-compulsive disorder (OCD), trichotillomania, and migraine headaches. Some of the specific SSRI agents have an approved indication in adults for some of these disorders, as reviewed later in this chapter. The SSRIs have also been tried in children and in adults for symptomatic treatment of pain syndromes, aggressive or irritable ( short fuse ) behavior, and for self-injurious and repetitive behaviors. This chapter will review general aspects of the SSRIs and discuss their approved indications in children and adolescents. 

Of the SSRIs, fluoxetine has been studied most extensively. Birmaher et al. (1994) and Fairbanks et al. (1997) both found significant improvement in various anxiety disorder symptoms in typically developing children. Fluoxetine was also found to be effective in the treatment of selective mutism (Black and Udhe, 1994 Dummit et ah, 1996). Fluoxetine has also been studied in individuals with MR and autistic disorder. In an open trial. Cook et al (1992) found that fluoxetine was associated with significant improvement in the Clinical Global Impression (CGI) severity ratings in 15 of 23 individuals (65%) with autistic disorder and in 10 of 16 individuals (62%) with MR. All of the SSRIs appear to have similar properties and have been approved for panic disorder, phobias, OCD, and anxiety disorder. Sertraline has been approved for treatment of PTSD, and paroxetine, for social phobia. 

Few trials have tested the potential efficacy of SSRIs to treat anxiety disorders other than OCD in children and adolescents. Black and colleagues ( 162) found a significant difference between fluoxetine and placebo in four of six children with selective mutism (believed to be a variant of social phobia) but only on the global rating of change and parent s rating of mutism change. In another small open-trial study, fluoxetine (10 to 60 mg per day) reduced anxiety and increased speech in 76% of children (age 5 to 14 years) with selective mutism (163). 

By the 1990s antidepressants from the serotonin selective reuptake inhibitor (SSRI) class became recognized as preferred first-line treatments for anxiety disorder subtypes, ranging from obsessive-compulsive disorder, to panic disorder, and now to social phobia and posttraumatic stress disorder (Fig. 8—9). Not all antidepressants, however, are afficacious anxiolytics. For example, desipramine and bupropion seem to be of little help in several anxiety disorder subtypes. Documentation of efficacy... 

SSRIs show efficacy in social phobia, and combined serotonin and norepinephrine uptake inhibitors are effective in generalized anxiety disorder. 

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