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Social Phobia Medication

  • Author: Bettina E Bernstein, DO; Chief Editor: Eduardo Dunayevich, MD  more...
 
Updated: Jan 12, 2016
 

Medication Summary

The goal of pharmacotherapy is to reduce morbidity.

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Selective Serotonin Reuptake Inhibitors

Class Summary

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.

Escitalopram (Lexapro)

 

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.

Sertraline (Zoloft)

 

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.

Fluoxetine (Prozac)

 

Enhances serotonin activity because of selective reuptake inhibition at the neuronal membrane. Available in susp.

Citalopram (Celexa)

 

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.

Fluvoxamine (Luvox)

 

Enhances serotonin activity because of selective reuptake inhibition at neuronal membrane.

Paroxetine (Paxil)

 

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.

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Serotonin/norepinephrine reuptake inhibitors

Class Summary

These agents inhibit neuronal serotonin and norepinephrine reuptake.

Venlafaxine (Effexor, Effexor XR)

 

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.

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Benzodiazepines

Class Summary

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.

Clonazepam (Klonopin)

 

May have quicker onset of action than SSRIs but has greater addiction potential and narrower therapeutic window.

Alprazolam (Xanax)

 

Extremely short half-life. Fastest onset of action and also may have most addiction potential.

Lorazepam (Ativan)

 

Sedative hypnotic with short onset of effects and relatively long half-life.

Diazepam (Valium)

 

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.

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Antianxiety agents

Class Summary

These agents reduce anxiety levels.

Buspirone (BuSpar)

 

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.

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Anticonvulsants

Class Summary

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.

Gabapentin (Neurontin)

 

Anticonvulsant with apparent anxiolytic properties.

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Antibiotic, Miscellaneous

Class Summary

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.

D-cycloserine (Seromycin)

 

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

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Monoamine Inhibitor

Class Summary

These agents are usually reserved for patients who do not tolerate other types of antidepressants.

Phenelzine (Nardil)

 

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.

Moclobemide (Moclamine)

 

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.

Selegiline transdermal (Eldepryl, Zelapar)

 

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.

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Contributor Information and Disclosures
Author

Bettina E Bernstein, DO Distinguished Fellow, American Academy of Child and Adolescent Psychiatry; Distinguished Fellow, American Psychiatric Association; Clinical Assistant Professor of Neurosciences and Psychiatry, Philadelphia College of Osteopathic Medicine; Clinical Affiliate Medical Staff, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Consultant to theVillage, Private Practice; Consultant PMHCC/CBH at Family Court, Philadelphia

Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Eduardo Dunayevich, MD Executive Director, Clinical Development, Amgen

Eduardo Dunayevich, MD is a member of the following medical societies: Schizophrenia International Research Society

Disclosure: Received salary from Amgen for employment; Received stock from Amgen for employment.

Additional Contributors

Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor, Kiki D Chang, MD, to the development and writing of this article.

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