Evidence-Based Reviews

When does shyness become a disorder?

Current Psychiatry. 2002 March;1(3):41-50

References

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4. Schneier FR, Johnson J, et al. Social phobia: comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry. 1992;49:282-288.

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8. Greenberg PE, Sisitsky T, Kessler RC, et al. The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry. 1999;60:427-435.

9. Weiller E, Bisserbe JC, Boyer P, et al. Social phobia in general health care. Br J Psychiatry. 1996;168:169-174.

10. Katzelnick DJ, Greist JH. Social anxiety disorder: an unrecognized problem in primary care. J Clin Psychiatry. 2001;62:11.-

11. Davidson J. Social anxiety disorder under scrutiny. Depress Anxiety. 2000;11:93-98.

12. Lydiard RB. Social anxiety disorder: treatment role of the SSRIs. In Montgomery SA, den Boer JA (eds). SSRIs in Depression and Anxiety Perspectives in Psychiatry ,vol 8. NY: Wiley, Chichester, 129-150, 2001.

13. Randall CL, et al. Paroxetine improves both social anxiety and alcohol use in dually-diagnosed patients at the American College of Neuropsychopharmacology. San Juan, Puerto Rico. Dec 10-15, 2000.

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15. Boudreaux E, Kilpatrick DG, Resnick HS, et al. Criminal victimization, posttraumatic stress disorder, and comorbid psychopathology among a community sample of women. J Trauma Stress. 1998;11:665-678.

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Box 6

Pharmaceutical approaches to treatment

Nongeneralized

PRN treatment
Beta-blockers
Benzodiazepines

Generalized

Continuous treatment
Broad-spectrum antidepressants
Benzodiazepines
MAOIs
Antiepileptic agents

The tricyclic antidepressants are probably not effective, with the exception of clomipramine (also a potent inhibitor of serotonin reuptake).¹² Clomipramine, while an effective anxiolytic and antidepressant, causes prohibitive side effects in many patients (e.g., sexual dysfunction and weight gain).

Box 7

Cognitive behavioral treatment of SAD

Key elements for individual or group setting

Cognitive “restructuring”
Social skills enhancement

The newer antidepressants venlafaxine and nefazodone are less well studied than the SSRIs, but show promise as potential broad-spectrum agents. Bupropion, a novel antidepressant, and the azapirone anxiolytic buspirone do not appear to work against SAD.

The main role of the benzodiazepines in SAD treatment is adjunctive to antidepressants or in some patients intolerant of, or unresponsive to, other treatments. Clonazepam, alprazolam, and probably others are effective for SAD, but they may not effectively treat or prevent depression or other commonly associated disorders.

The anticonvulsant gabapentin has been shown in one controlled study to be effective in treating SAD.²⁰ This agent may be particularly useful for complicated patients such as those with a history of alcohol-related disorders, bipolar-spectrum disorder, or intolerance to SSRIs.

In parallel with the development of effective psychopharmacological treatments, several types of behavioral and cognitive behavioral treatments have been investigated, including imaginal flooding, graduated exposure, social skills training, cognitive-behavior approaches, and combined cognitive restructuring and graduated exposure.²¹ These treatments involve similar elements targeted at the cognitive distortions and avoidance behaviors, which represent core features of SAD (Box 7).

Many clinicians believe that combined pharmacotherapy and CBT treatment are superior to either modality alone for treating SAD. The little empirical information available indicates that acute treatment differences between drug alone and drug in combination with CBT are not impressive. However, there appears to be a lower rate of relapse following CBT than after medication discontinuation.

Despite our ability to treat this disorder, only a small fraction of sufferers get treatment. If untreated, the risk of comorbidity is extremely high. Routine screening for SAD, especially in younger individuals, could provide for early detection and treatment. Psychiatrists can play an important role in early detection and treatment by educating consumers, teachers, school nurses, psychologists, and pediatricians.

Related resources

Lydiard, R.B. Social anxiety disorder comorbidity and its implications J. Clin. Psychiatry. 2001;62(suppl):17-23.
American Psychiatric Association, http://www.psych.org
American Psychological Association, http://www.apa.org
National Institute for Mental Health: Anxiety Disorders, http://www.nimh.nih.gov/anxiety/
Anxiety Disorders Associations of America, http://www.adaa.org/

Drug brand names

Alprazolam • Xanax
Atenolol • Tenormin
Bupropion • Wellbutrin
Buspirone • Buspar
Clomipramine • Anafranil
Clonazepam • Klonopin
Fluoxetine • Prozac
Fluvoxamine • Luvox
Gabapentin • Neurontin
Lorazepam • Ativan
Nefazodone • Serzone
Paroxetine • Paxil
Phenelzine • Nardil
Propranolol • Inderal
Sertraline • Zoloft
Tranylcypromine • Parnate
Venlafaxine • Effexor

Disclosure

The author reports that he has received grant/research support and has served as a consultant to and on the speaker's bureau of Bristol-Myers Squibb Co., GlaxoSmithKline, Pfizer Inc., Eli Lilly and Co., Parke-Davis, and Solvay Pharmaceuticals. He also has received grant/research support and served as a consultant for Forest Pharmaceuticals, Wyeth-Ayerst Pharmaceuticals, and Roche; received grant/research support from Sanofi-Synthelabo; and has served as consultant for Dupont Pharmaceuticals and AstraZeneca.