Connor, MD, Box 3812, Duke University Medical Center, Durham, NC. 27710, U.S.A. ..... (IVR) form of the scale now exists, enabling individuals to call a toll-free number and complete the scale on the basis of a guided telephone interview (51).
Epilepsia, 4O(Suppl. 6):S60-S65, 1999 Lippincott Williams & Wilkins, Philadelphia
0 International League Against Epilepsy
Social Phobia: Issues in Assessment and Management Kathryn M. Connor, Jonathan R. T. Davidson, Suzanne Sutherland, and “Richard Weisler Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina, and *Private Practice, Raleigh, North Carolina, U.S.A.
Summary: Social phobia was initially classified with phobic anxiety states and was believed to be quite rare, but it is now gaining due recognition as a widespread and often crippling disorder. The boundaries of social phobia merge into traits of shyness and universal performance anxiety, with symptoms commonly appearing in the teenage years. If left untreated, social phobia is a remarkably persistent condition, leading to potentially lifelong impairment in social development and occupational functioning. It may also give rise to other co-morbid disorders, particularly dysthymia, depression, obsessivexompulsive disorder, other phobic disorders, and substance abuse. Over the years, social phobia has been all too frequently viewed as a somewhat trivial, minor form of psychiatric illness and has
received little clinical attention. This erroneous perception is now giving way under the mounting evidence in support of the extensive morbidity and disability associated with social phobia and the probable role of genetic and environmental influences. Furthermore, data from multiple controlled clinical trials reveal that this is a treatable condition, responding to both psychosocial and pharmacologic interventions. Here we examine issues to consider in the differential diagnosis of social phobia, review the goals of treatment, and summarize evidence in support of the effectiveness of individual pharmacologic treatments. Key Words: Social phobia-Anxiety-Pharmacotherapy.
Social phobia has emerged as one of the most common of all Akis I psychiatric disorders, having a lifetime prevalence rate of approximately 13% based on data from the National Comorbidity Survey (1). Social phobia tends to arise early in life, with a mean age of onset in the teenage years (2). Left untreated, social phobia is a remarkably persistent disorder and may give rise to a variety of co-morbid disorders, particularly dysthymia, depression, obsessive-compulsive disorder, other phobic disorders, and substance abuse ( 2 ) .There is evidence for strong genetic determinants for the diagnosis (3) and for the behavioral traits that characterize the disorder (4). First described by Marks in 1970 (3,social phobia was grouped nosologically with other phobic anxiety states and was for a long time regarded as quite rare, with its treatment poorly understood. Worse yet, it did not generally arouse a great deal of interest in either the clinical or the research community. Social phobia has tended to be seen as a somewhat trivial, minor form of psychiatric illness because its boundaries merge into traits of shyness and universal performance anxiety. This is an erroneous perception, as there is now mounting evidence for extensive morbidity
and impairment associated with this condition (6), and a biologic foundation is becoming increasingly well established (7,8). One of the rather unusual characteristics of social phobia, in contrast to many other chronic psychiatric disorders, is the comparatively high response rate to psychotropic drugs but remarkably low response rate to placebo. These characteristics are inconsistent with the responses typically seen for an “unimportant” variation of normal population characteristics. Recent clinical trials make. it clear that social phobia is now a very treatable condition. This article reviews a number of issues relevant to social phobia; differential diagnosis, treatment goals, and evidence for the effectiveness of specific forms of pharmacotherapy. DIFFERENTIAL DIAGNOSIS Social phobia is characterized by fear of humiliation, embarrassment, or scrutiny by other people. These fears may be manifested either in the setting of large groups, where some performance task is to be undertaken, or in smaller and even more intimate gatherings of people, such as in the workplace, in community or social activities, with strangers or authority figures. Typically, feared situations are avoided or endured with intense distress. Social phobia is distinguished from nonpathologic shy-
Address correspondence and reprint requests to Dr. Kathryn M. Connor, MD, Box 3812, Duke University Medical Center, Durham, NC 27710, U.S.A.
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SOCIAL PHOBIA ness or social fear by the following characteristics: an awareness that the fears are excessive; some degree of impairment or disability; and considerable psychic and/ or physiological distress. Exposure to the aforementioned situations invariably leads to increases in symptoms and anxiety. Social phobia can easily be mistaken for several other psychiatric disorders, such as agoraphobia, panic disorder, depression, and body dysmorphic disorder (BDD). This confusion further complicates appropriate diagnosis and treatment implementation. Although an attempt should always be made to determine whether or not the individual diagnosis is present in relation to a neighboring disorder, two or more disorders may also coexist. Therefore, it is possible to have co-morbid disorders, e.g., social phobia and panic disorder. In agoraphobia, the sufferer is afraid of public or crowded situations from which escape would be difficult in the event of some form of catastrophic event, e.g., a panic attack. Similarly, the fear may also be generated if there is no feeling of immediate access to help in the event of such a circumstance. A person with agoraphobia is comforted if there are one or two support people available. Social phobia, on the other hand, is apparent in situations in which the individual is preoccupied with fears of embarrassment, scrutiny, or humiliation. Moreover, the individual feels better if other people are absent. Social phobia may often be confused with panic disorder, in part because panic attacks can occur as presenting and troublesome aspects of social phobia. Once again, it is important to establish if the panic symptoms are conditional on situations in which the individual is preoccupied with likely embarrassment, exposure to humiliation, or scrutiny. Fear of embarrassment, because of the attendant loss of control after spontaneous or other forms of panic attack, is not regarded as primary social phobia but as a form of social fear secondary to, for example, panic disorder. Furthermore, in panic disorder, the attacks at some point occurred spontaneously, and there has usually been a sustained period of time in which the individual was preoccupied with the consequences of such an attack. The two conditions can be distinguished by the symptom of blushing, which is often quite characteristic of social phobia but is rarely seen in panic disorder. Depression can result in social withdrawal, loss of confidence, and increased awareness of inadequacies in front of other people. It may superficially appear similar to social phobia. If the history indicates that such patterns were absent before the depression, there would be no need to posit the additional diagnosis of social phobia. Equally, depression can be the result of unmitigated social phobia, and it is always important to ascertain in any depressed patient whether or not there has been a
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preexisting morbid social anxiety. Schneier et al. (2) have also revealed a substantially increased rate of suicidal ideation in association with social phobia and other co-morbid states. Therefore, the clinician should always keep in mind the possibility of suicidal behavior in a person with the disorder. BDD is frequently co-morbid with social phobia in patients with anxiety disorders (9), and may appear to be closely related to social phobia. Individuals with BDD experience a preoccupation with an imagined defect in appearance or, if a slight physical anomaly is present, markedly excessive concern. This preoccupation causes clinically significant distress or impairment in social, occupational, and other important areas of functioning. In contrast, in social phobia, although the individual may worry about being embarrassed by real defects in appearance, this concern is usually not prominent, persistent, distressing, time-consuming, or impairing. There are also conditions in which social phobia or extreme concern about embarrassment is a clinical problem that arises from some other disorder. Examples include parkinsonism, obsessivexompulsive disorder, or status post cerebral vascular accident, conditions that often give rise to undue and excessive concern over fear of humiliation or embarrassment. The term “secondary” social phobia has been applied to such situations (lo).
COMPLICATING DISORDERS SECONDARY TO SOCIAL PHOBIA In addition to differential diagnosis, there are “masks” of social phobia in which the individual presents for treatment because of a complicating state. Most typically, this is alcohol or other substance abuse, major depression, or dysthymic disorder. We have no idea how many such people have been missed because the clinician or counselor simply focused on the complicating state, but it can be safely assumed that, until recently, social phobia was almost always thus overlooked. Consequently, the disorder has been woefully underrecognized and undertreated. This point is illustrated by a finding from the Piedmont Health Survey in conjunction with the Epidemiologic Catchment Area Study, which noted that only 3% of social phobia sufferers received medical treatment for their disorder in the prior 12 months. Moreover, only 10% of all individuals with social phobia who presented for psychological treatment were diagnosed as having the disorder ( 1 1). A second study conducted in France by Weiller et al. (12) found the current prevalence rate of social phobia in general practice to be 5%. The authors observed that treating physicians would recognize social phobia more often if there was a co-morbid problem such as depression but that uncomplicated social phobia was not often recognized. It is therefore evident that social phobia continues Epilepsia, Voi. 40, Suppl. 6, I999
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to be poorly recognized and that there is a great need to increase educational efforts directed at the medical community and the general public. One of the particular problems that hinders people with social phobia from obtaining optimal help is their own tendency to be avoidant and ashamed. The act of going to the doctor and meeting in close quarters to disclose aspects of oneself about which there is embarrassment may well lead to nondisclosure of distressing events. Indeed, avoidance of doctors may at times result in nontreatment of other medically important problems.
TREATMENT Treatment of social phobia can be accomplished with either psychosocial or psychopharmacologic interventions. Psychosocial treatments are effective (13,14) and may be appropriate for individuals who specifically prefer this approach and/or for those who have failed to respond adequately to a medication. Pharmacologic treatments proven to be effective in social phobia include the P-blockers, monoamine oxidase (MAO) inhibitors, reversible inhibitors of M A 0 type A (RIMAs), benzodiazepines, and selective serotonin reuptake inhibitors (SSRIs). More recently, promising evidence has emerged indicating that the antiepileptic drug (AED) gabapentin is also effective. Data supporting the use of these pharmacologic modalities are briefly reviewed below. In addition, because it is now possible to conveniently measure symptom severity in social phobia, including assessment of change over time during treatment, information is also provided about available rating scales. Social phobia presents with three major symptom clusters, each of which must be adequately addressed: fear, avoidance, and physiologic symptoms. The fear of social phobia is centered around cognitions pertinent to shame, humiliation, scrutiny, and possibly rejection and criticism. This fear frequently leads to marked anticipatory anxiety, which in extreme cases can occur weeks ahead of an event and be fully preoccupying such that the individual is unable to sleep. Avoidance, which is expressed either in behavioral terms or in more subtle ways, such as not properly paying attention (mental avoidance), can result in significant impairment and may be the primary reason for seeking treatment. Physiologic symptoms, especially blushing, sweating, trembling, and palpitations, also cause great personal distress, particularly because these symptoms are often evident to other people. This awareness in itself becomes a source of much distress for the sufferer, who is then doubly burdened both with the problem and with the reactions of others. In some cases, sweating or trembling serves as the presenting feature of social phobia, particularly in a primary care setting. Epilepsia, Vol. 40, Suppl. 6, 1999
PHARMACOTHERAPY P-Blockers P-Blockers have been used in the treatment of social phobia for over 20 years and were originally prescribed for public speaking-related types of performance fear. This class of drugs is of some use in situations where the symptoms are discrete, confined to one or two clearly specified situations, and accompanied by marked autonomic distress. By dampening these physiologic reactions, @-blockersenable the patient to go ahead with the task at hand, free from the distractions of an “out of control” physiologic state. However, @-blockersare ineffective in the treatment of generalized social anxiety and may not help with anticipatory anxiety, distorted cognitions, and the co-morbidity that is often present. Two clinical trials (13,15) have shown atenolol to be somewhat less successful than both cognitive behavior therapy and to phenelzine, respectively, in generalized social phobia. Unfortunately, the medical practitioner’s view of social phobia tends to be equated with this form of performance fear, for which P-blockers are often helpful. Consequently, there is the mistaken belief that all social phobia should be treated with this group of drugs. Their ineffectiveness, along with physicians’ underappreciation of the benefits of other drugs, means that social phobia often remains largely unresponsive to treatment. Monoamine oxidase inhibitors A series of studies conducted with phenelzine (15-17) have shown unequivocal benefits for this drug. In one study by Liebowitz et al. (15), phenelzine led to a marked reduction in avoidant personality disorder symptoms, indicating that this so-called personality disorder can respond to effective drug therapy in the short term. We tend to view avoidant personality disorder more as an early and very pervasive manifestation of social phobia, with the addition of very shaky self-esteem, excessive sensitivity to rejection, general timidity, and fear of undertaking novel or potentially risky activities. The moniker “personality disorder” is a poor choice and will deter many people from thinking of the disorder as a pharmacoresponsive state. Phenelzine, although consistently effective, carries a high rate of intolerable side effects and risks due to interactions with drugs or certain foods. By and large, phenelzine and other M A 0 inhibitors are best reserved for treatment-resistant cases, especially those with multiple and persisting co-morbid states. Reversible inhibitors of M A 0 type A Studies with moclobemide and brofaromine initially were greeted with much enthusiasm (17-19), because these drugs opened up the prospect of safe treatment with MAO-inhibiting agents and were without dietary precau-
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tions. Although it is true that moclobemide is safe and well tolerated, the clinical data with respect to social phobia are somewhat equivocal. One modestly positive European controlled study (20) and one extremely positive study from Brazil (21) have been followed by two negative studies (22,23). Two controlled studies of brofaromine have also demonstrated efficacy (24,25) and a third, although also supporting efficacy, reported substantial rates of discontinuation due to poor tolerance (26). Although unavailable in the United States, these medications have received an indication for social phobia in a number of countries where they are available and used. Benzodiazepines One study with alprazolam by Gelernter et al. (16) showed alprazolam to be a little better than either placebo or cognitive behavior therapy but markedly inferior to phenelzine. On the other hand, a larger study with clonazepam in generalized social phobia (7) found a 78% response rate to clonazepam compared to only 20% on placebo. Early and robust effects were seen with this drug. In a long-term discontinuation study with clonazepam, patients who received maintenance therapy with the drug for 12 months did better than those who went into a slow discontinuation at 6 months (27). These findings demonstrate that benzodiazepines can clearly be useful, particularly clonazepam. A number of advantages and disadvantages of benzodiazepines should be noted. Onset of substantial therapeutic efficacy occurs quickly, and many people are able to tolerate benzodiazepines well. They can also be used on a pm basis for episodic performance fears. However, the disadvantages of using benzodiazepines include their tendency to sedate, depress, induce hostility, and produce physiologic dependence, tolerance, and withdrawal symptoms if stopped abruptly. They do not usually help co-morbid major depression or obsessive-compulsive disorder, although they might be helpful in an individual who has co-morbid panic disorder or generalized anxiety. They are also inadvisable for most social phobia patients who have a recent history of alcohol or other substance abuse. Antidepressants Findings from open-label studies of fluoxetine (28,29), sertraline (30-33), and paroxetine (34) have suggested a role for SSRIs in treating social phobia. Providing further support to data, three double-blind, placebocontrolled trials have been published showing effects for fluvoxamine and sertraline relative to placebo (35-37). Until recently, these medications have received little attention, although a number of studies are now under way. Stein et al. (38) treated 36 patients with generalized social phobia for 11 weeks with open-label paroxetine, followed by 3 months of double-blind treat-
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ment with either continued paroxetine or placebo. The drug was apparently tapered rapidly, so it is unclear to what extent subsequent findings reflected withdrawal or relapse. Nevertheless, the authors found a relapse rate of 62% with placebo and 12% with paroxetine, suggesting the benefit of maintenance treatment. An interesting report by Miner et al. (39) found that the clinical effects of fluoxetine in social phobia were directly related to brain levels of the drug as measured by magnetic resonance spectroscopy. The application of this technique to fluorinated drugs is one of considerable promise . Until recently, tricyclic drugs have received no systematic attention because it has widely been believed that they are not effective for social phobia. A recent openlabel study of imipramine by Simpson and colleagues (40) confirms this belief, finding no clinically or statistically significant difference between the two treatments. Very few data are available on the role of the newer antidepressants in treating social phobia. In a retrospective chart review of venlafaxine in patients with social phobia (41), venlafaxine was effective and generally well tolerated when started at lower doses and titrated to the dose level recommended for depression. An SSRI recently available in Europe for the treatment of depression, citalopram, may also have a role in the treatment of social phobia (42), and further investigation is needed. Azapirones Busiprone, as an established anxiolytic drug, has understandably been applied to social phobia. There have been two double-blind, controlled trials, both of which showed a marked lack of effect (43,44). Interestingly, one study was conducted in musicians with performance anxiety, whereas the other was conducted in a mixed clinical sample of generalized and performance social phobia subtypes. The role of this drug in social phobia remains unclear. In the single study to find some suggested benefit, an open-label trial by Schneier et al. ( 4 3 , the response was modest and was noted only among those few patients who were able to tolerate high doses of the drug. Antiepileptic drugs After clinical observations that gabapentin enabled patients with epilepsy to feel much less embarrassed about themselves and their neurologic condition, and to generally feel more comfortable with themselves, a two-center trial was conducted that assessed gabapentin vs. placebo (46). In this study, 82 outpatients with DSM-IV-determined social phobia were treated for 14 weeks with either gabapentin 900-3600 mg daily or placebo. Various rating scales were used, including the Liebowitz Social Anxiety Scale (LSAS) (47), the Brief Social Phobia Scale (BSPS) (48), and the Social Phobia Inventory (SPIN). In addition, clinical global impressions of both Epilepsia, Vol. 40, Suppl. 6, 1999
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severity and improvement were made, and assessments taken with the Marks Fear Questionnaire and the Hamilton Depression and Anxiety Scales. Sixty-nine subjects were randomized to double-blind treatment, and 79% of the sample received doses of gabapentin of at least 2100 mg per day. As with most clinical trials of social phobia, subjects had reported symptoms of very long duration, in this case 25 years before study entry, with a mean age of onset at 12-13 years. Response rates with active drug were 39% compared to only 19% with placebo. Statistically significant differences were noted in favor of gabapentin on all the major social phobia scales. In addition, the benefits of gabapentin were most apparent in those patients who had more severe forms of social phobia, with a greater degree of physiologic symptomatology and agoraphobic features. Gabapentin was well tolerated, and similar rates of mild and moderate intensity side effects were observed in both the gabapentin and the placebo group. This study showed that the AED gabapentin can now be extended in its therapeutic scope and demonstrated for the first time an anxiolytic affect of a nonbenzodiazepine AED relative to placebo in social phobia. Gabapentin acts at neither the benzodiazepine nor the GABA receptor site. It is not known to directly modulate the synthesis, release, or reuptake of serotonin and, although some decrease has been noted in the release of M A 0 (49), this mechanism is not likely to explain the drug’s action in social phobia. Its mechanism of action is therefore unknown, but the demonstration of its benefit in social phobia suggests that it is possible to ameliorate symptoms of the disorder in ways other than those that have hitherto served as the principal focus of investigation, i.e., serotonin, norepinephrine, and benzodiazepine receptors.
MEASUREMENTS A variety of scales exist for measurement of symptom severity and treatment response in social phobia. Perhaps the most satisfactory self-rating is the Social Phobia Inventory (SPIN) (50). This 17-item self-rating scale consists of questions reflecting the symptom domains of fear, avoidance, and physiologic distress and can be completed in 2 or 3 min. Data from use of this scale now exist that indicate defined threshold scores by which one can separate social phobia from other psychiatric states, and social phobia from nonpsychiatric controls. The SPIN is also sensitive to the effects of treatment across time, and is able to distinguish between an active treatment and a placebo. The Brief Social Phobia Scale (BSPS) is an observerrated scale that is structured in a comparable way to that of the SPIN. The BSPS takes perhaps 10 min to complete and serves as a very satisfactory measure of treatment Epilepsia, Vol. 40, Suppl. 6, 1999
response (48). Moreover, an interactive voice response (IVR) form of the scale now exists, enabling individuals to call a toll-free number and complete the scale on the basis of a guided telephone interview (51). An additional observer-rated scale, the Liebowitz Social Anxiety Scale (LSAS) (47), has been widely used in clinical trials and is well able to separate the effects of active treatment from placebo. However, the LSAS does not contain any items pertaining to the physiologic symptoms that are often clinically important aspects of the disorder. Thus far, although the scale has good face validity, psychometric properties of the LSAS have not been comprehensively presented.
CONCLUSION Social phobia has emerged from the diagnostic shadows and must now be viewed as both a common and a costly disorder. It is easy to recognize, provided one asks the right questions. Unlike other common conditions, it is less likely for a sufferer to spontaneously seek help for the core fears and avoidance than for co-morbidity or physiologic manifestations that are more difficult to hide. The onus must therefore be on public education to raise everyone’s awareness and for physicians to learn to identify the situations in which asking a few pertinent questions is likely to reveal the “disorder.” A screening tool such as the SPIN could also be very helpful in the clinical setting. Treatment of social phobia can now be accomplished effectively and comparatively simply with drugs such as the AED gabapentin and other alternatives such as benzodiazepine, or SSRI and MAO-inhibiting antidepressants. A more limited role for P-blockers exists, but it is important to point out that they are ineffective for social phobia as usually appears in the clinical setting.
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