Treatment of Social Anxiety Disorder

By | March 23, 2015

Current recommended treatment options for social anxiety disorder include pharmacotherapy and cognitive behavioural therapy (CBT). Although several randomised controlled trials (RCTs) have failed to show efficacy for beta-adrenoceptor antagonists in generalised social anxiety disorder (SAD), it has been suggested that these agents may be useful in non-generalised social anxiety disorder (SAD), patients with performance anxiety only. Efficacy in the treatment of generalised social anxiety disorder has been demonstrated for a number of interventions, including SSRIs, high potency benzodiazepines (e.g. clonazepam), MAOIs (e.g. phenelzine), reversible inhibitors of monoamine oxidase A (MAO-A) [RIMAs, e.g. moclobemide], certain antiepileptics (e.g. gabapentin, pregabalin), serotonin-noradrenaline reuptake inhibitors (venlafaxine) and cognitive behavioural therapy.

Nonpharmacological treatments

These treatments include exposure, cognitive re-structuring, relaxation techniques and social skills training, often used in combination. Literature have concluded that cognitive behavioral therapy (CBT) is often effective for treating social anxiety disorder. The goal of cognitive behavioral therapy (CBT) is to provide techniques and practice to patients with social anxiety disorder, so they can learn to change how they think about and behave in situations that terrify them. cognitive behavioural therapy may be offered individually or as part of group therapy. There is continued interest in the question of whether group or individual treatment is more effective. Early studies suggested some superiority for group treatment, and arguments were raised that the group setting would provide a richness of exposure experiences not easily replicated in individual treatment; by the late 1990s the weight of evidence suggested that there was no clear superiority between group and individual treatment.

Meta-analyses of the efficacy of cognitive behavioural therapy for social anxiety disorder that have compared various types of cognitive behavioural therapy with each other and with control conditions have yielded the highest effect sizes for exposure-based interventions. In exposure therapy, the type of cognitive behavioural therapy most often used and studied for social anxiety disorder, therapists gradually expose patients to the dreaded situation and suggest ways to manage fear. The exposure-based extinction of fear is now thought to involve new learning that actively inhibits the fear reaction to a given cue. In other variations of CBT— not as well studied as exposure therapy— patients learn and practice social skills and relaxation techniques.

Pharmacological treatments

SSRIs; evidence from RCTs supports that the efficacy and tolerability of almost all SSRIs (escitalopram, fluvoxamine, paroxetine, sertraline, fluoxetin, citalopram in the treatment of social anxiety disorder (SAD), so SSRIs can be regarded as first-line treatment in social anxiety disorder (SAD). These agents have the additional benefit of treating comorbid conditions commonly seen with social anxiety disorder. Fluoxetine, fluvoxamine and sertraline have been the most studied SSRIs in socially phobic children and adolescents and have shown good efficacy and tolerability in this group. Venlafaxine; has shown promising results in open-label and controlled trials in the treatment of social anxiety disorder (SAD). Venlafaxine is an effective treatment option for generalised social anxiety disorder but has no superiority from paroxetine in clinical trials. While venlafaxine is an effective treatment, this may be related to its serotonergic profile, and the authors are unimpressed with response to the specific noradrenergic agent reboxetine from both the literature and clinical experience. Venlafaxine is associated with significant side effects and discontinuation syndrome and described as second-line treatments of social anxiety in most settings. MAOIs; Phenelzine was one of the first established treatments for social anxiety disorder with several early double-blind, placebo-controlled trials demonstrating efficacy in this disorder. In light of their adverse effect profiles and the dietary restrictions associated with use of these agents, together with the availability of alternative treatments, MAOIs are currently not considered to be a first-line treatment for social anxiety disorder (SAD). RIMAs; reversible inhibitors of monoamine oxidase A, appears inferior to that of phenelzine in efficacy but the main advantages of moclobemide over phenelzine are superior tolerability and no concern about dietary restrictions at the standart dosage of 600 mg/day moclobemide. This may be a particularly important consideration in the long-term treatment of social anxiety disorder.

Benzodizepines, despite the positive results, the adverse effect profile, the potential for dependence, the possibility of rebound anxiety, the possible negative consequences of state-dependent learning and their ineffectiveness in the treatment of depression shows that these agents should not be considered as first-line monotherapy for social anxiety disorder.

Beta Blockers; Beta-blockers are effective at blocking peripheral autonomic symptoms such as tachycardia, tremor, sweating, blushing and dry mouth and thus have a potential role as anxiolytics. They are effectively used in the treatment of performance anxiety but there is substantial evidence that beta-blockers are not effective in social phobia and that better options are available. A limited role in performance anxiety is indicated.

Gabapentine, Pregabalin and Levetirasetam; Some anticonvulsants trials suggest that gabapentin, pregabalin and levetirasetam could be alternative agents for patients who are nonresponsive to SSRIs and SNRIs. However these agents need further studies about the safety and efficacy in social anxiety disorder (SAD). Other pharmacological agents for treatment of SAD; Tricyclic antidepressants have been used but failed to be an effective treatment choice for social anxiety disorder. There are trials with buspirone in literature but these trials have both negative and positive outcomes in social anxiety disorder. So that buspirone may be a useful agent for augmentation in social anxiety disorder. There is a little evidence for bupropion efficacy in social phobia. There are trials that have found mirtazapine as an effective treatment option for social anxiety disorder. However in a recent study mirtazapine showed no superiority to placebo for treatment of social anxiety disorder.

Atypical antipsychotics have been shown to have anxioloytic properties in the literature. Olanzapine and quetiapine have been found effective as monotherapy in the treatment of social anxiety disorder (SAD). In another study switchover to aripiprazole effectively improved social anxiety in patiets with schizophrenia.

Inadequate response to pharmacotherapy and augmentation strategies

Criteria for remission of social anxiety disorder proposed by Ballenger include absence of core symptoms of social anxiety disorder (SAD), no or minimal anxiety (e.g. in anticipation of social interaction) as rated by rating scales such as the Hamilton Rating Scale for Anxiety, no functional impairment (the Sheehan Disability Scale may be used to evaluate this), and remission of course of action when first-line treatment with a co-morbid depression as reflected by the Hamilton Rating Scale for Depression. It should, however, be noted that the mean reduction in Liebowitz Social Anxiety Scale scores was <50% in a review of 19 double-blind, placebo-controlled trials involving patients with social anxiety disorder (SAD). Switching to another SSRIs, venlafaxine or MAOIs has been suggested in non responders or patients with adverse event. Augmentation strategies that may prove useful in partial treatment responders include buspirone, clonazepam, gabapentin, bupropion or new generation antipsychotics, although empirical data are lacking.

In case of comorbidity moclobemide was found to be effective and well-tolerated in the social anxiety disorder patients with anxiety disorders as well as SSRIs. In the presence of co-morbid alcohol abuse, MAOIs and benzodiazepines can complicate the treatment, SSRIs have usefulness in reducing the alcohol consumption. cognitive behavioural therapy may be the treatment of choice during pregnancy and lactation.