Social Anxiety DIsorder

SAD

- marked fear about social situations

- exposure to feared circumstance --> panic attacks

SAD: Clinical Presentation

- fears: scrutiny by others, negatively evaluated

- physical: blushing, diarrhea, stumbling over words, sweating, tachycardia, trembling

- specifier: performance (fear of public speaking)

SAD: DSM-5 Criteria

- intense, irrational & persistent fear of being scrutinized in at least one social or performance situation

- exposure to fear initiates attack

- blushing is the principal physical indicator

- recognize fear is excessive & unreasonable, but unable to overcome w/o tx

SAD: Goals of Therapy

- acute phase: reduce sx of anxiety, social anxiety, & phobic avoidance

- continuation phase: extend therapeutic benefits, reduce sx, improve QoL

- maintenance: maintain improvement, decr rate of relapse

SAD: Non-pharm Therapy

- support groups

- CBT: exposure therapy, social skills training, relaxing training techniques

Pharmacologic Tx 1st line

- SSRIs

- venlafaxine XR

Pharmacologic Tx 2nd line

- clonazepam

- buspirone

Pharmacologic Alternatives

- gabapentin

- phenelzine

- pregabalin

First Line Agents

- paroxetine (prevents relapse)

- sertraline (FDA approved for long-term use)

- escitalopram (prevents relapse)

- fluvoxamine ER

- venlafaxine ER (prevents relapse)

>> similar doses as in depression

>> improve anxiety & avoidance sx

SAD Treatment Algorithm

- SAD --> SSRI or venlafaxine XR for 12 wks

- response = continue for 6-12 mo

- no response = switch to diff SSRI or venlafaxine XR

- partial response: consider augmentation w/ buspirone or clonazepam

SAD Alternatives

- clonazepam: improves fear & phobic avoidance, interpersonal sensitivity

- B-blockers: for performance-related situations, decr perception of anxiety (propranolol, atenolol)

>> take 1-2 hrs b4 performance

Key Points

- SAD = intense, irrational, persistent fear of being negatively evaluated or scrutinized

- SSRIs/SNRIs are 1st line

- B-blockers should be used for performance anxiety