Approach to treating social anxiety disorder in adults
- Murray B Stein, MD, MPH
Murray B Stein, MD, MPH
- Editor-in-Chief — Psychiatry
- Section Editor — Anxiety Disorders
- Professor of Psychiatry and Family Medicine & Public Health
- University of California San Diego
- Charles T Taylor, PhD
Charles T Taylor, PhD
- Assistant Professor of Psychiatry
- University of California San Diego
Social anxiety disorder (SAD), also known as social phobia, is a condition marked by extreme fear of situations that involve possible scrutiny by others. The individual is concerned that embarrassment or humiliation will result, and so he or she avoids such situations, or endures them with intense anxiety.
SAD is a prevalent condition, estimated to affect between 4 and 10 percent of the adult United States population over a 12-month period. SAD typically begins in childhood or adolescence and, untreated, can be associated with the subsequent development of major depression, substance abuse, and other mental health problems. The disorder can be associated with extensive functional impairment and reduced quality of life .
This topic describes our approach to selecting treatments for SAD (algorithm 1) and performance-only SAD (algorithm 2). The epidemiology, pathogenesis, clinical manifestations, assessment, and diagnosis of SAD are discussed separately, as are the efficacy, side effects, and administration of individual psychotherapies and medications for SAD. (See "Social anxiety disorder in adults: Epidemiology, clinical manifestations, and diagnosis" and "Psychotherapy for social anxiety disorder in adults" and "Pharmacotherapy for social anxiety disorder in adults".)
NEWLY DIAGNOSED PATIENTS
Decision to treat — Not all patients with social anxiety disorder (SAD) require immediate treatment. Young adults, in particular, may benefit from education about their disorder and may need time to reflect on the extent to which social anxiety and avoidance have negatively impacted their lives. It is not unusual for a newly diagnosed patient with SAD to be surprised that these symptoms can diminish or resolve with treatment as opposed to being an inalterable aspect of their self. The need for treatment of SAD is rarely an emergency. Most patients have had SAD for many years, and the decision to seek a diagnosis may have taken a long time.
After the diagnosis of SAD is established, if the patient prefers to meet further before deciding about treatment, the clinician and patient can further discuss the need for treatment in the context of a longitudinal evaluation of the extent to which social anxiety has impacted the individual’s quality of life, as well as consideration of future life goals and how those may be affected by social anxiety and avoidance. Once a mutual decision is reached that treatment is indicated, the next step involves discussion of treatment options.
- Ruscio AM, Brown TA, Chiu WT, et al. Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychol Med 2008; 38:15.
- American Psychiatric Association. DSM-5 Task Force. In: Diagnostic and Statistical Manual of Mental Disorders: DSM-5, 5th ed, American Psychiatric Association, Arlington 2013.
- Stein MB, Stein DJ. Social anxiety disorder. Lancet 2008; 371:1115.
- Blanco C, Heimberg RG, Schneier FR, et al. A placebo-controlled trial of phenelzine, cognitive behavioral group therapy, and their combination for social anxiety disorder. Arch Gen Psychiatry 2010; 67:286.
- Davidson JR, Foa EB, Huppert JD, et al. Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. Arch Gen Psychiatry 2004; 61:1005.
- Blomhoff S, Haug TT, Hellström K, et al. Randomised controlled general practice trial of sertraline, exposure therapy and combined treatment in generalised social phobia. Br J Psychiatry 2001; 179:23.
- Hofmann SG, Smits JA, Rosenfield D, et al. D-Cycloserine as an augmentation strategy with cognitive-behavioral therapy for social anxiety disorder. Am J Psychiatry 2013; 170:751.
- Guastella AJ, Richardson R, Lovibond PF, et al. A randomized controlled trial of D-cycloserine enhancement of exposure therapy for social anxiety disorder. Biol Psychiatry 2008; 63:544.
- Hofmann SG, Meuret AE, Smits JA, et al. Augmentation of exposure therapy with D-cycloserine for social anxiety disorder. Arch Gen Psychiatry 2006; 63:298.
- Cohen JN, Potter CM, Drabick DA, et al. Clinical presentation and pharmacotherapy response in social anxiety disorder: The effect of etiological beliefs. Psychiatry Res 2015; 228:65.
- Stangier U, Schramm E, Heidenreich T, et al. Cognitive therapy vs interpersonal psychotherapy in social anxiety disorder: a randomized controlled trial. Arch Gen Psychiatry 2011; 68:692.
- Clark DM, Ehlers A, McManus F, et al. Cognitive therapy versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. J Consult Clin Psychol 2003; 71:1058.
- Leichsenring F, Salzer S, Beutel ME, et al. Long-term outcome of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder. Am J Psychiatry 2014; 171:1074.
- Leichsenring F, Salzer S, Beutel ME, et al. Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: a multicenter randomized controlled trial. Am J Psychiatry 2013; 170:759.
- Bögels SM, Wijts P, Oort FJ, Sallaerts SJ. Psychodynamic psychotherapy versus cognitive behavior therapy for social anxiety disorder: an efficacy and partial effectiveness trial. Depress Anxiety 2014; 31:363.
- Mayo-Wilson E, Dias S, Mavranezouli I, et al. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. Lancet Psychiatry 2014; 1:368.
- Hofmann SG, Smits JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry 2008; 69:621.
- Barkowski S, Schwartze D, Strauss B, et al. Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized-controlled trials. J Anxiety Disord 2016; 39:44.
- Amir N, Beard C, Taylor CT, et al. Attention training in individuals with generalized social phobia: A randomized controlled trial. J Consult Clin Psychol 2009; 77:961.
- Schmidt NB, Richey JA, Buckner JD, Timpano KR. Attention training for generalized social anxiety disorder. J Abnorm Psychol 2009; 118:5.
- Beard C, Sawyer AT, Hofmann SG. Efficacy of attention bias modification using threat and appetitive stimuli: a meta-analytic review. Behav Ther 2012; 43:724.
- Lipsitz JD, Gur M, Vermes D, et al. A randomized trial of interpersonal therapy versus supportive therapy for social anxiety disorder. Depress Anxiety 2008; 25:542.
- Hofmann, SG, Otto, MW. Cognitive-behavior therapy of social phobia: Evidence-based and disorder specific treatment techniques, Routledge, New York 2008.
- Stein DJ, Ipser JC, Balkom AJ. Pharmacotherapy for social phobia. Cochrane Database Syst Rev 2004; :CD001206.
- Liebowitz MR, Gelenberg AJ, Munjack D. Venlafaxine extended release vs placebo and paroxetine in social anxiety disorder. Arch Gen Psychiatry 2005; 62:190.
- Liebowitz MR, Mangano RM, Bradwejn J, et al. A randomized controlled trial of venlafaxine extended release in generalized social anxiety disorder. J Clin Psychiatry 2005; 66:238.
- Stein MB, Pollack MH, Bystritsky A, et al. Efficacy of low and higher dose extended-release venlafaxine in generalized social anxiety disorder: a 6-month randomized controlled trial. Psychopharmacology (Berl) 2005; 177:280.
- Gelernter CS, Uhde TW, Cimbolic P, et al. Cognitive-behavioral and pharmacological treatments of social phobia. A controlled study. Arch Gen Psychiatry 1991; 48:938.
- Davidson JR, Potts N, Richichi E, et al. Treatment of social phobia with clonazepam and placebo. J Clin Psychopharmacol 1993; 13:423.
- Pande AC, Davidson JR, Jefferson JW, et al. Treatment of social phobia with gabapentin: a placebo-controlled study. J Clin Psychopharmacol 1999; 19:341.
- Pande AC, Feltner DE, Jefferson JW, et al. Efficacy of the novel anxiolytic pregabalin in social anxiety disorder: a placebo-controlled, multicenter study. J Clin Psychopharmacol 2004; 24:141.
- Lydiard RB, Rickels K, Herman B, Feltner DE. Comparative efficacy of pregabalin and benzodiazepines in treating the psychic and somatic symptoms of generalized anxiety disorder. Int J Neuropsychopharmacol 2010; 13:229.
- Mula M, Pini S, Cassano GB. The role of anticonvulsant drugs in anxiety disorders: a critical review of the evidence. J Clin Psychopharmacol 2007; 27:263.
- Pollack MH, Van Ameringen M, Simon NM, et al. A double-blind randomized controlled trial of augmentation and switch strategies for refractory social anxiety disorder. Am J Psychiatry 2014; 171:44.
- Ravindran LN, Stein MB. The pharmacologic treatment of anxiety disorders: a review of progress. J Clin Psychiatry 2010; 71:839.
- Van Ameringen M, Mancini C, Wilson C. Buspirone augmentation of selective serotonin reuptake inhibitors (SSRIs) in social phobia. J Affect Disord 1996; 39:115.
- Steenen SA, van Wijk AJ, van der Heijden GJ, et al. Propranolol for the treatment of anxiety disorders: Systematic review and meta-analysis. J Psychopharmacol 2016; 30:128.
- Liebowitz MR, Schneier F, Campeas R, et al. Phenelzine vs atenolol in social phobia. A placebo-controlled comparison. Arch Gen Psychiatry 1992; 49:290.
- NEWLY DIAGNOSED PATIENTS
- Decision to treat
- SAD versus SAD, performance only
- Choosing between psychotherapy and medication
- - Patient preference for psychotherapy
- Comparative efficacy
- - Patient preference for medication
- TREATMENT RESPONSE
- Response to CBT
- - Robust response
- - Poor or partial response
- Response to SSRI/SNRI
- - No SUD history
- - SUD history
- MEDICATION RESISTANT
- SAD, PERFORMANCE ONLY
- SUMMARY AND RECOMMENDATIONS