Social Phobia Medication
- Author: Bettina E Bernstein, DO; Chief Editor: Eduardo Dunayevich, MD more...
The goal of pharmacotherapy is to reduce morbidity.
Selective Serotonin Reuptake Inhibitors
This class of agents is emerging as the DOC for social phobia because of their clinical efficacy, ease of use, and excellent safety profile with relatively few adverse effects. Benzodiazepines are effective but require caution because of their lower safety margin and addiction potential. Benzodiazepines can be administered during the 4-6 weeks before SSRIs become effective. Buspirone is clinically efficacious, and studies indicate that gabapentin is also effective.
SSRI and S -enantiomer of citalopram. Used for the treatment of depression. Mechanism of action is thought to be potentiation of serotonergic CNS activity due to inhibition of CNS neuronal reuptake of serotonin. Onset of depression relief may occur after 1-2 wk, which is sooner than conferred by other antidepressants.
FDA approved for social phobia in adults and for OCD in children >12 y. Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane.
Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Available in susp.
Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Although SSRIs have not been compared with one another, based on metabolism and adverse effects, citalopram is considered SSRI of choice in patients with head injury.
SSRIs are antidepressants of choice because of their minimal anticholinergic effects compared with older typical antidepressants, which tend to be more likely to cause mania or behavioral activation. The specific choice of subtype of SSRI or SNRI depends to a large degree on adverse effects and drug interactions.
Enhances serotonin activity because of selective reuptake inhibition at neuronal membrane.
FDA approved for social phobia. Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Shorter half-life predisposes to SSRI withdrawal syndrome if abruptly discontinued; therefore, it is recommended to dose this medication twice a day.
Serotonin/norepinephrine reuptake inhibitors
These agents inhibit neuronal serotonin and norepinephrine reuptake.
Indicated for social anxiety disorder, which is also known as social phobia. Patients have a 40-50% lifetime prevalence of coexisting major depressive disorder. Inhibits neuronal serotonin and norepinephrine reuptake. In addition, causes beta-receptor down-regulation.
By binding to specific receptor sites, benzodiazepines appear to potentiate effects of GABA and facilitate inhibitory GABA neurotransmission and other inhibitory transmitters. It is best to avoid the use of these medications in children unless no other medications can be used. Benzodiazepine therapy in children younger than 10 years increases the risk of paradoxical excitation. Children older than 10 years old seem to be at higher risk than adults of drug-induced cognitive deficits, including decreased attention/concentration, slurred speech, and newly onset suicidal ideation and attempts, especially in the presence of comorbid depression.
May have quicker onset of action than SSRIs but has greater addiction potential and narrower therapeutic window.
Extremely short half-life. Fastest onset of action and also may have most addiction potential.
Sedative hypnotic with short onset of effects and relatively long half-life.
Depresses all levels of CNS (eg, limbic and reticular formation), possibly by increasing activity of GABA.
Individualize dosage and increase cautiously to avoid adverse effects. Relatively long half-life.
These agents reduce anxiety levels.
A 5-HT1 agonist with serotonergic neurotransmission and some dopaminergic effects in CNS. Has anxiolytic effect but may take as long as 2-3 wk for full efficacy. Low adverse effect profile. Efficacy not well established.
Anticonvulsants are used if known to have anxiolytic properties.
Pregabalin (Lyrica) is not an FDA-approved treatment. It is an amino acid derivative of gamma-amino butyric acid, a GABA analogue, and is similar to gabapentin because it is an alpha-delta calcium-channel anticonvulsant that resembles benzodiazepines due to the ability to alter the balance between inhibitory and excitatory neuronal activity; however, it may have higher bioavailability and more rapid absorption, which may increase potency and thus may be more effective in decreasing social anxiety with panic disorder. A risk of dependence is possible.
Anticonvulsant with apparent anxiolytic properties.
D-cycloserine is an emerging medication in the treatment of anxiety that may be effective but may cause adverse effects such as somnolence or cognitive slowing.
A partial agonist at the glycine recognition site of the NMDA receptor in the amygdala. Inhibits cell-wall synthesis in susceptible strains of gram-positive and gram-negative bacteria and in Mycobacterium tuberculosis
These agents are usually reserved for patients who do not tolerate other types of antidepressants.
MAOI most commonly used for anxiety disorders. Usually reserved for patients who do not tolerate or whose conditions do not respond to TCA or SSRI antidepressants.
Reversible inhibitor of monoamine oxidase type A. Because of selectivity and reversibility, dietary restrictions are not required while taking this medication; hypertensive crises are rare. Not available in the United States.
Irreversible MAOI. Has greater affinity for MAO-B than for MAO-A; however, at antidepressant doses, inhibits both isoenzymes. MAO-A and MAO-B catabolize neurotransmitter amines in CNS (eg, norepinephrine, dopamine, serotonin). Indicated for treating major depressive disorder. At lowest strength (ie, 6 mg delivered over 24 h), may be used without the dietary restrictions required for oral MAOIs used to treat depression.
Beidel DC. Social anxiety disorder: etiology and early clinical presentation. J Clin Psychiatry. 1998. 59 Suppl 17:27-32. [Medline].
Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994 Jan. 51(1):8-19. [Medline].
Heimberg RG, Stein MB, Hiripi E, Kessler RC. Trends in the prevalence of social phobia in the United States: a synthetic cohort analysis of changes over four decades. Eur Psychiatry. 2000 Feb. 15(1):29-37. [Medline].
Wiltink J, Haselbacher A, Knebel A, Tschan R, Zwerenz R, Michal M, et al. Social Phobia - An Anxiety Disorder Underdiagnosed in Outpatient and Consultation-Liaison Service?. Psychother Psychosom Med Psychol. 2009 May 18. [Medline].
Ranta K, Tuomisto MT, Kaltiala-Heino R, Rantanen P, Marttunen M. Cognition, Imagery and Coping among Adolescents with Social Anxiety and Phobia: Testing the Clark and Wells Model in the Population. Clin Psychol Psychother. 2013 Jan 24. [Medline].
Phan KL, Orlichenko A, Boyd E, Angstadt M, Coccaro EF, Liberzon I, et al. Preliminary evidence of white matter abnormality in the uncinate fasciculus in generalized social anxiety disorder. Biol Psychiatry. 2009 Oct 1. 66(7):691-4. [Medline]. [Full Text].
Stein MB. Neurobiological perspectives on social phobia: from affiliation to zoology. Biol Psychiatry. 1998 Dec 15. 44(12):1277-85. [Medline].
Conner OL, Siegle GJ, McFarland AM, et al. Mom-it helps when you're right here! Attenuation of neural stress markers in anxious youths whose caregivers are present during fMRI. PLoS One. 2012. 7(12):e50680. [Medline]. [Full Text].
Constable RT, Ment LR, Vohr BR, Kesler SR, Fulbright RK, Lacadie C, et al. Prematurely born children demonstrate white matter microstructural differences at 12 years of age, relative to term control subjects: an investigation of group and gender effects. Pediatrics. 2008 Feb. 121(2):306-16. [Medline].
Roberts S, Keers R, Lester KJ, Coleman JR, Breen G,et al. HPA AXIS RELATED GENES AND RESPONSE TO PSYCHOLOGICAL THERAPIES: GENETICS AND EPIGENETICS. Depress Anxiety. 2015 Dec. 32 (12):861-70. [Medline].
Burstein M, He JP, Kattan G, Albano AM, Avenevoli S, Merikangas KR. Social phobia and subtypes in the national comorbidity survey-adolescent supplement: prevalence, correlates, and comorbidity. J Am Acad Child Adolesc Psychiatry. 2011 Sep. 50(9):870-80. [Medline]. [Full Text].
Pöhlmann K, Döbbel S, Löffler S, Israel M, Joraschky P. [Social phobia - the blind spot: infrequently diagnosed, highly complex, and a predictor for unfavourable therapy outcomes?]. Z Psychosom Med Psychother. 2009. 55(2):180-8. [Medline].
Keyes KM, McLaughlin KA, Vo T, Galbraith T, Heimberg RG. ANXIOUS AND AGGRESSIVE: THE CO-OCCURRENCE OF IED WITH ANXIETY DISORDERS. Depress Anxiety. 2015 Sep 30. [Medline].
Fichter MM, Kohlboeck G, Quadflieg N, Wyschkon A, Esser G. From childhood to adult age: 18-year longitudinal results and prediction of the course of mental disorders in the community. Soc Psychiatry Psychiatr Epidemiol. 2009 Sep. 44(9):792-803. [Medline].
Kuusikko S, Pollock-Wurman R, Jussila K, Carter AS, Mattila ML, Ebeling H, et al. Social anxiety in high-functioning children and adolescents with Autism and Asperger syndrome. J Autism Dev Disord. 2008 Oct. 38(9):1697-709. [Medline].
Weinstock LS. Gender differences in the presentation and management of social anxiety disorder. J Clin Psychiatry. 1999. 60 Suppl 9:9-13. [Medline].
Lau AS, Fung J, Wang SW, Kang SM. Explaining elevated social anxiety among Asian Americans: emotional attunement and a cultural double bind. Cultur Divers Ethnic Minor Psychol. 2009 Jan. 15(1):77-85. [Medline].
Hsu L, Alden LE. Cultural influences on willingness to seek treatment for social anxiety in Chinese- and European-heritage students. Cultur Divers Ethnic Minor Psychol. 2008 Jul. 14(3):215-23. [Medline].
Guntheroth W. Link among mitral valve prolapse, anxiety disorders, and inheritance. Am J Cardiol. 2007 May 1. 99(9):1350. [Medline].
Hamilton JL, Potter CM, Olino TM, Abramson LY, Heimberg RG, Alloy LB. The Temporal Sequence of Social Anxiety and Depressive Symptoms Following Interpersonal Stressors During Adolescence. J Abnorm Child Psychol. 2015 Jul 5. [Medline].
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision. 4th ed. Washington, DC: American Psychiatric Association; 2000.
Amir N, Beard C, Burns M, Bomyea J. Attention modification program in individuals with generalized anxiety disorder. J Abnorm Psychol. 2009 Feb. 118(1):28-33. [Medline].
Suveg C, Hudson JL, Brewer G, Flannery-Schroeder E, Gosch E, Kendall PC. Cognitive-behavioral therapy for anxiety-disordered youth: secondary outcomes from a randomized clinical trial evaluating child and family modalities. J Anxiety Disord. 2009 Apr. 23(3):341-9. [Medline].
Titov N, Andrews G, Johnston L, Schwencke G, Choi I. Shyness programme: longer term benefits, cost-effectiveness, and acceptability. Aust N Z J Psychiatry. 2009 Jan. 43(1):36-44. [Medline].
Suveg C, Sood E, Comer JS, Kendall PC. Changes in emotion regulation following cognitive-behavioral therapy for anxious youth. J Clin Child Adolesc Psychol. 2009 May. 38(3):390-401. [Medline].
Berger T, Hohl E, Caspar F. Internet-based treatment for social phobia: a randomized controlled trial. J Clin Psychol. 2009 Oct. 65(10):1021-35. [Medline].
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association; 2013.
Letamendi AM, Chavira DA, Hitchcock CA, Roesch SC, Shipon-Blum E, Stein MB. Selective Mutism Questionnaire: Measurement Structure and Validity. J Am Acad Child Adolesc Psychiatry. 2008 Aug 8. [Medline].
Mazeh D, Bodner E, Weizman R, Delayahu Y, Cholostoy A, Martin T, et al. Co-morbid social phobia in schizophrenia. Int J Soc Psychiatry. 2009 May. 55(3):198-202. [Medline].
Pisano S, Catone G, Pascotto A, Iuliano R, Tiano C, Milone A, et al. Paranoid Thoughts in Adolescents with Social Anxiety Disorder. Child Psychiatry Hum Dev. 2015 Dec 10. [Medline].
Evans KC, Wright CI, Wedig MM, Gold AL, Pollack MH, Rauch SL. A functional MRI study of amygdala responses to angry schematic faces in social anxiety disorder. Depress Anxiety. 2008. 25(6):496-505. [Medline].
Stein MB, Goldin PR, Sareen J, Zorrilla LT, Brown GG. Increased amygdala activation to angry and contemptuous faces in generalized social phobia. Arch Gen Psychiatry. 2002 Nov. 59(11):1027-34. [Medline].
Maeda F, Nathan JH. Understanding taijin kyofusho through its treatment, Morita therapy. J Psychosom Res. 1999 Jun. 46(6):525-30. [Medline].
van Peer JM, Spinhoven P, van Dijk JG, Roelofs K. Cortisol-induced enhancement of emotional face processing in social phobia depends on symptom severity and motivational context. Biol Psychol. 2009 May. 81(2):123-30. [Medline].
Walter D, Hautmann C, Rizk S, et al. Short term effects of inpatient cognitive behavioral treatment of adolescents with anxious-depressed school absenteeism: an observational study. Eur Child Adolesc Psychiatry. 2010 Nov. 19(11):835-44. [Medline].
Blair K, Shaywitz J, Smith BW, Rhodes R, Geraci M, Jones M, et al. Response to emotional expressions in generalized social phobia and generalized anxiety disorder: evidence for separate disorders. Am J Psychiatry. 2008 Sep. 165(9):1193-202. [Medline].
Duval ER, Javanbakht A, Liberzon I. Neural circuits in anxiety and stress disorders: a focused review. Ther Clin Risk Manag. 2015. 11:115-26. [Medline].
Hauser TU, Iannaccone R, Walitza S, Brandeis D, Brem S. Cognitive flexibility in adolescence: neural and behavioral mechanisms of reward prediction error processing in adaptive decision making during development. Neuroimage. 2015 Jan 1. 104:347-54. [Medline].
Miller G. Society for Neuroscience meeting. Pills and games help conquer fear. Science. 2003 Nov 21. 302(5649):1321. [Medline].
Victor AM, Bernstein GA. Anxiety disorders and posttraumatic stress disorder update. Psychiatr Clin North Am. 2009 Mar. 32(1):57-69. [Medline].
Davidson JR. Pharmacotherapy of social anxiety disorder: what does the evidence tell us?. J Clin Psychiatry. 2006. 67 Suppl 12:20-6. [Medline].
Katzelnick DJ, Kobak KA, Greist JH, et al. Sertraline for social phobia: a double-blind, placebo-controlled crossover study. Am J Psychiatry. 1995 Sep. 152(9):1368-71. [Medline].
Pande AC, Davidson JR, Jefferson JW, et al. Treatment of social phobia with gabapentin: a placebo-controlled study. J Clin Psychopharmacol. 1999 Aug. 19(4):341-8. [Medline].
Guastella AJ, Richardson R, Lovibond PF, Rapee RM, Gaston JE, Mitchell P, et al. A randomized controlled trial of D-cycloserine enhancement of exposure therapy for social anxiety disorder. Biol Psychiatry. 2008 Mar 15. 63(6):544-9. [Medline].
Rapee RM, Gaston JE, Abbott MJ. Testing the efficacy of theoretically derived improvements in the treatment of social phobia. J Consult Clin Psychol. 2009 Apr. 77(2):317-27. [Medline].
Stangier U, Schramm E, Heidenreich T, Berger M, Clark DM. Cognitive Therapy vs Interpersonal Psychotherapy in Social Anxiety Disorder: A Randomized Controlled Trial. Arch Gen Psychiatry. 2011 Jul. 68(7):692-700. [Medline].
James AC, James G, Cowdrey FA, Soler A, Choke A. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev. 2015 Feb 18. 2:CD004690. [Medline].
Maric M, Heyne DA, de Heus P, van Widenfelt BM, Westenberg PM. The Role of Cognition in School Refusal: An Investigation of Automatic Thoughts and Cognitive Errors. Behav Cogn Psychother. 2011 Jun 29. 1-15. [Medline].
Heyne D, Sauter FM, Van Widenfelt BM, Vermeiren R, Westenberg PM. School refusal and anxiety in adolescence: Non-randomized trial of a developmentally sensitive cognitive behavioral therapy. J Anxiety Disord. 2011 Apr 28. [Medline].
Knijnik DZ, Salum GA Jr, Blanco C, Moraes C, Hauck S, Mombach CK, et al. Defense style changes with the addition of psychodynamic group therapy to clonazepam in social anxiety disorder. J Nerv Ment Dis. 2009 Jul. 197(7):547-51. [Medline].
Midgley N. Re-reading "Little Hans": Freud's case study and the question of competing paradigms in psychoanalysis. J Am Psychoanal Assoc. 2006 Spring. 54(2):537-59. [Medline].
Mörtberg E, Andersson G. Predictors of response to individual and group cognitive behaviour therapy of social phobia. Psychol Psychother. 2013 Jan 18. [Medline].
Hudson JL, Keers R, Roberts S, Coleman JR, Breen G, et al. Clinical Predictors of Response to Cognitive-Behavioral Therapy in Pediatric Anxiety Disorders: The Genes for Treatment (GxT) Study. J Am Acad Child Adolesc Psychiatry. 2015 Jun. 54 (6):454-63. [Medline].
Bechor M, Pettit JW, Silverman WK, Bar-Haim Y, Abend R, Pine DS, et al. Attention Bias Modification Treatment for children with anxiety disorders who do not respond to cognitive behavioral therapy: a case series. J Anxiety Disord. 2014 Mar. 28 (2):154-9. [Medline].
Shechner T, Rimon-Chakir A, Britton JC, Lotan D, Apter A, Bliese PD, et al. Attention bias modification treatment augmenting effects on cognitive behavioral therapy in children with anxiety: randomized controlled trial. J Am Acad Child Adolesc Psychiatry. 2014 Jan. 53 (1):61-71. [Medline].
Klein AM, Rapee RM, Hudson JL, Schniering CA, Wuthrich VM, Kangas M, et al. Interpretation modification training reduces social anxiety in clinically anxious children. Behav Res Ther. 2015 Dec. 75:78-84. [Medline].
Fu X, Du Y, Au S, Lau JY. Reducing negative interpretations in adolescents with anxiety disorders: a preliminary study investigating the effects of a single session of cognitive bias modification training. Dev Cogn Neurosci. 2013 Apr. 4:29-37. [Medline].
Reuland MM, Teachman BA. Interpretation bias modification for youth and their parents: a novel treatment for early adolescent social anxiety. J Anxiety Disord. 2014 Dec. 28 (8):851-64. [Medline].
Costa VA, Haimowitz R, Cheng YI, Wang J, Silverman RA, Bauman NM. Social Impact of Facial Infantile Hemangiomas in Preteen Children. JAMA Otolaryngol Head Neck Surg. 2015 Nov 19. 1-7. [Medline].
Bögels SM, Alden L, Beidel DC, et al. Social anxiety disorder: questions and answers for the DSM-V. Depress Anxiety. 2010 Feb. 27(2):168-89. [Medline].
Altamura AC, Pioli R, Vitto M, Mannu P. Venlafaxine in social phobia: a study in selective serotonin reuptake inhibitor non-responders. Int Clin Psychopharmacol. 1999 Jul. 14(4):239-45. [Medline].
Bailey JE, Papadopoulos A, Lingford-Hughes A, Nutt DJ. D-Cycloserine and performance under different states of anxiety in healthy volunteers. Psychopharmacology (Berl). 2007 Sep. 193(4):579-85. [Medline].
Connor KM, Davidson JR, Potts NL, et al. Discontinuation of clonazepam in the treatment of social phobia. J Clin Psychopharmacol. 1998 Oct. 18(5):373-8. [Medline].
Hofmann SG, Pollack MH, Otto MW. Augmentation treatment of psychotherapy for anxiety disorders with D-cycloserine. CNS Drug Rev. 2006 Fall-Winter. 12(3-4):208-17. [Medline].
Nutt DJ, Bell CJ, Malizia AL. Brain mechanisms of social anxiety disorder. J Clin Psychiatry. 1998. 59 Suppl 17:4-11. [Medline].
Schmidt NB, Richey JA, Buckner JD, Timpano KR. Attention training for generalized social anxiety disorder. J Abnorm Psychol. 2009 Feb. 118(1):5-14. [Medline].
Stallard P, Simpson N, Anderson S, Goddard M. The FRIENDS emotional health prevention programme: 12 month follow-up of a universal UK school based trial. Eur Child Adolesc Psychiatry. 2008 Aug. 17(5):283-9. [Medline].
Stein DJ, Westenberg HG, Yang H, et al. Fluvoxamine CR in the long-term treatment of social anxiety disorder: the 12- to 24-week extension phase of a multicentre, randomized, placebo-controlled trial. Int J Neuropsychopharmacol. 2003 Dec. 6(4):317-23. [Medline].
Stein MB, Chavira DA. Subtypes of social phobia and comorbidity with depression and other anxiety disorders. J Affect Disord. 1998 Sep. 50 Suppl 1:S11-6. [Medline].
Stein MB, Liebowitz MR, Lydiard RB, et al. Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial. JAMA. 1998 Aug 26. 280(8):708-13. [Medline].
Velosa JF, Riddle MA. Pharmacologic treatment of anxiety disorders in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2000 Jan. 9(1):119-33. [Medline].
Weeks JW, Heimberg RG, Fresco DM, Hart TA, Turk CL, Schneier FR, et al. Empirical validation and psychometric evaluation of the Brief Fear of Negative Evaluation Scale in patients with social anxiety disorder. Psychol Assess. 2005 Jun. 17(2):179-90. [Medline].
Westenberg HG. The nature of social anxiety disorder. J Clin Psychiatry. 1998. 59 Suppl 17:20-6. [Medline].
White M, Dorman SM. Receiving social support online: implications for health education. Health Educ Res. 2001 Dec. 16(6):693-707. [Medline].
Zaider TI, Heimberg RG. Non-pharmacologic treatments for social anxiety disorder. Acta Psychiatr Scand Suppl. 2003. 72-84. [Medline].