Social Phobia Treatment & Management

  • Author: Bettina E Bernstein, DO; Chief Editor: Eduardo Dunayevich, MD   more...
 
Updated: Sep 14, 2011
 

Medical Care

A combination of pharmacotherapy and psychotherapy is usually indicated for persons with social phobia.

  • Pharmacotherapy
    • Antidepressants including selective serotonin reuptake inhibitors (SSRIs; citalopram [Celexa], escitalopram [Lexapro], fluvoxamine [Luvox], paroxetine [Paxil], fluoxetine [Prozac], sertraline [Zoloft]) and venlafaxine (Effexor) are commonly prescribed to treat the symptoms of social phobia and generally result in remission of symptoms after 4 weeks of treatment. However, it is important to balance benefits and the potential for adverse effects when prescribing medications.[31, 32, 4, 33]
      • SSRIs: SSRIs are quickly becoming the standard first-line medication for social phobia. Paroxetine received US Food and Drug Administration (FDA) approval for this indication in 1999, the first SSRI to gain such approval. In 2003, sertraline received FDA approval for short- and long-term (20-wk) treatment of social phobia in adults. It is also FDA-approved for the treatment of obsessive-compulsive disorder (OCD) in children older 12 years.
      • Serotonin norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine, were approved for the treatment of social phobia in 2003 for use in adults but may not be as effective or safe in children. Studies suggest that other SSRIs may also be effective. However, the FDA recommends caution when using these agents to treat social phobia in children younger than 18 years because of concerns about the potential increased risk of newly onset suicidal ideation, especially with venlafaxine and paroxetine. Nonetheless, numerous open and controlled studies support the efficacy of SSRIs/SNRIs in this population as part of a multimodal approach, with close monitoring of mental status.[34, 35, 32, 4]
      • Benzodiazepines: Benzodiazepines may be effective for social phobia but are generally undesirable in the absence of contraindications to SSRI use. Alprazolam and clonazepam have been used successfully for this indication, but all agents in this class, although very helpful in comorbid panic, should not be used for longer than 6 weeks because of the risk of increased depression and physical dependence.[32, 4]
      • Buspirone: Some studies suggest efficacy in persons with social phobia and less of a risk of physical dependence than is commonly seen with benzodiazepines. However, it has not been FDA-approved for the treatment of anxiety disorders in children.[32, 4]
      • Gabapentin: Recent studies suggest the efficacy of gabapentin for this indication; however, it is not FDA-approved for use in social phobia in adults or children.[35, 4]
      • Propranolol: Beta-blockers have been used to block the autonomic response in persons with social phobia. Preventing symptoms such as tremor and increased heart rate may lead to successful performance in social situations despite anxiety. However, propranolol should not be used in persons with asthma or in combination with other antihypertensive agents. This medication is not yet FDA-approved for use in children.[4]
      • Clonidine (alpha-adrenergic blocker) may work to block the autonomic response in persons with social phobia, similarly to the effect conferred by propranolol, and can be particularly useful in persons with comorbid posttraumatic stress disorder or acute stress reactions.[4]
      • Monoamine oxidase inhibitors (MAOIs): These agents are not approved for use in children, but they are FDA-approved for use in adults for unipolar depression. Phenelzine has been demonstrated to be effective in controlled studies. The dietary restrictions required when taking MAOIs reduces their popularity. Moclobemide, a newer reversible MAOI, has shown some efficacy in persons with social phobia. Selegiline (EmSam, a patch) may be superior to other agents in this class because of a slightly decreased risk of serotonin syndrome if used in the lowest dosage range.[4]
      • D-cycloserine: This medication has not yet been proven effective for the treatment of social phobia, but studies are ongoing.[36, 4]
  • Psychotherapy
    • Cognitive restructuring can be combined with in vivo exposure, performance feedback, and attention retraining and/or combined with nonspecific stress management or computer-based cognitive behavior therapy (CBT).[37]
    • Cognitive therapy has evidence-based efficacy.[38]
      • A recent study of adults was a randomized controlled trial of 117 persons undergoing social anxiety disorder (SAD) treatment who received 16 individual sessions of either cognitive therapy (CT) or interpersonal therapy (IPT) and 1 booster session.
      • Twenty weeks after randomization, a posttreatment assessment was conducted using the Clinical Global Impression Improvement Scale, as assessed by independent, masked evaluators, and a secondary outcome measures was conducted independent of assessor ratings using the Liebowitz Social Anxiety Scale, the Hamilton Rating Scale for Depression, and patient self-ratings of SAD symptoms.
      • At the posttreatment assessment, response rates were 65.8% for CT, 42.1% for IPT, and 7.3% for WLC (Wait List Control). Regarding response rates and Liebowitz Social Anxiety Scale scores, CT performed significantly better than IPT, and both treatments were superior to WLC. At 1-year follow-up, the differences between CT and IPT were largely maintained, with significantly higher response rates in the CT versus the IPT group (68.4% vs 31.6%) and better outcomes on the Liebowitz Social Anxiety Scale.
      • CT and IPT led to considerable improvements that were maintained 1 year after treatment; CT was more efficacious than IPT in reducing social phobia symptoms.
    • Adolescents, particularly school-refusing adolescents, improve with the use of CT, especially when developmentally sensitive, and when this therapy is performed in an inpatient setting. This may be related to the improvement of automatic thoughts and cognitive errors with the use of CBT.[39, 40]
    • Behavioral psychotherapies, such as gradual desensitization, are effective in persons with social phobia. This technique involves gradually exposing the patient to simulated situations that normally cause anxiety in the patient. By mastering the situation without anxiety, the patient is eventually able to tolerate more situations that previously induced anxiety.[12]
    • Specific CBTs that have been found to be effective include computerized CBT (several types) and clinician-assisted computerized CBT (CaCCBT). Studies have shown that cognitive restructuring needs to include a component of in vivo exposure with attention retraining and performance feedback. As CBT interventions for social phobia tend not to generalize, it is important to design interventions specific to social phobia. Computer-based interventions have the advantage of eliminating scheduling problems, as they are convenient, potentially more sensitive to cross-cultural issues, appealing to children and adults, and more easily affordable.[11, 12, 14]
    • Cognitive and insight-oriented therapies have proved useful in treating social phobia. Individuals with social phobia often have significant cognitive distortions related to what other people could be thinking about them that might respond to restructuring.[12]
    • Stress management and relaxation techniques such as biofeedback, meditation, and deep breathing can lessen anxiety but are not sufficient alone in the treatment of social phobia.[32]
    • Group psychodynamic psychotherapy and individual psychoanalytic psychotherapy (an approach used for many years in the treatment of phobias) are approaches that are especially effective if combined with pharmacotherapy such as anxiolytics.[33, 41, 42]
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Diet

No special diet is indicated in the treatment of social phobia.

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Contributor Information and Disclosures
Author

Bettina E Bernstein, DO  Clinical Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Outpatient Consultant, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Court Appointed Evaluator, Family Court of Philadelphia; Psychiatric Consultant, Intercommunity Action, Inc, Easttown Tredyffrin School District

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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, and American Psychiatric Association

Disclosure: Nothing to disclose.

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

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

Eduardo Dunayevich, MD  Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories

Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Acknowledgments

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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