Social Anxiety Disorder  (Social Phobia)
Symptoms and Treatment 2024

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Welcome to my website! I have had Social Phobia (SP) since my teen years. My SP became had become pretty severe by late high school. It wasn't until the age of 26 however that I first heard the term "Social Phobia", learned what it was, and discovered that it was medically treatable. Substantial improvement in the quality of life is within the reach of most all with untreated Social Phobia. Current research is being done to promote earlier diagnosis and treatment (onset in the childhood or teenage years is common).

An Abstract on Social Phobia by Dr. Mark Pollack:

Journal of Clinical Psychiatry 2001;62 Suppl 12:24-9
Comorbidity, Neurobiology, and Pharmacotherapy of Social Anxiety disorder.
Pollack MH, Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston 02114
Social anxiety disorder is a common psychiatric illness that imposes persistent functional impairment and disability on persons who have the disorder. The disorder is characterized by a marked and persistent fear of social or performance situations in which embarrassment may occur. It is the most prevalent of any anxiety disorders and is the third most common psychiatric disorder after depression and alcohol abuse. Social anxiety disorder typically begins during childhood with a mean age at onset between 14 and 16 years and is sometimes preceded by a history of social inhibition or shyness. Persons who have social anxiety disorder either endure or avoid social situations altogether because the fear of embarrassment causes such intense anxiety; such avoidance may ultimately interfere with occupational and/or social functioning and lead to significant disability. The duration of social anxiety disorder is frequently lifelong, and there is a high degree of comorbidity with other psychiatric disorders. Social anxiety disorder is a serious illness that frequently runs a chronic course and is associated with significant morbidity. Patients should be treated aggressively using pharmacotherapeutic agents that can be tolerated over the long term. Cognitive-behavioral therapy should also be considered in treatment planning. Efforts to increase the recognition of social anxiety disorder as a common, distressing, and disabling condition are critical. This article discusses the comorbidity, neurobiology, and pharmacotherapy of social anxiety disorder.

Symptoms of Social Anxiety Disorder:

Social Anxiety Disorder is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that he or she may do something or act in a way that will be humiliating or embarrassing.   It exceeds normal "shyness" when it leads to excessive social avoidance and substantial social or occupational impairment.  Feared activities may include most any type of social interaction, especially small groups, dating, parties, talking to strangers, restaurants, etc. Physical symptoms include "mind going blank", fast heartbeat, blushing, stomach ache. Cognitive distortions are a hallmark, and learned about in CBT. Thoughts are often self-defeating and inaccurate.

Neurobiology of Social Anxiety Disorder:

Dysregulation of neurotransmitter function in the brain is thought to play a key role in Social Phobia (SP). Specifically, dopamine (DA), serotonin (SE), and / or GABA dysfunction are hypothosized in most cases of SP. in varying degrees depending on the individual. The MAOI antidepressant "phenelzine" (Nardil) uniquely boosts levels of all three - and is probably the single most effective (single drug) treatment for Social Phobia.

There is strong evidence for dopamine dysfunction in SP. Comorbidies with other DA hypofunction disorders such as atypical depression, dysthymia, attention deficit disorder (ADD), and alcoholism are common. Liebowitz observed in comparison studies between the TCA "imipramine" (Tofranil) and the MAOI "phenelzine" (Nardil) that while phenelzine was extremely effective in treating Social Anxiety, imipramine showed no efficacy - with the primary difference in the two drugs being the marked pro-DA effect of Nardil.

Since the 1990's, evidence has emerged that an area of the brain called the striatum is different in patients with generalized Social Anxiety Disorder. More recent studies have switched focus to the amygdala, where evidence of abnormality accumulates. The amygdala is a core "primitive" part of the brain where many "automatic" animal type functions are regulated or controlled, such as fear and startle response, anxiety, sex, and aggression.

Research Past and Present:

Current research trends lean towards earlier recognition and treatment of SP. As the "world's most neglected anxiety disorder" becomes more understood by the public, Social Anxiety Disorder will begin to be diagnosed far more frequently in the pre-teen or teen years, resulting in earlier treatment, more "normal" social development, and less later life complications. In my case, during my 3rd grade year I had a 2 months bout of "school phobia", which commonly predicts SP in adulthood. Although Nardil and Klonopin existed at that time, the psychiatric diagnosis of Social Phobia did not. It was not until the early 1990's that key studies began for the medication treatment of SP. Liebowitz (Nardil), and Davidson (Klonopin) were the early pioneers towards highly effective SP medication treatment. Nardil and Klonopin remain the most reliably effective medications to treat Social Anxiety Disorder.

Treatments for Social Anxiety Disorder:

Psychological Treatment:

Among possible psychological treatments for Social Anxiety Disorder, the best studied are CBT (Cognitive Behavioral Therapy) and CGBT (Cognitive Group Behavioral Therapy). CBT and CGBT have been proven effective in the treatment of SP. Although Medication Treatments have been shown to produce more robust and dramatic improvment of symptoms; CBT does seem to offer at least one advantage over medication. Namely, gains made during CBT tend to "stick" better after termination of therapy. Patients with mild symptoms may wish to pursue CBT or CGBT treatment methods as their first approach, while those with more significant symptoms may prefer to use CBT as an adjunct to Medication Treatment. Good CBT therapists for SP are not easy to find in 2024. The best places to look are probably in large cities at Health Centers or University Clinics.

Research suggests that "general" or "supportive" psychotherapy is also helpful for many patients with Social Anxiety Disorder. This is probably especially true in more moderate and severe cases where issues such as low self esteem and other psychological and/or adjustment difficulties may be more pervasive. Currently there is no evidence that CBT is more, or less, effective than other psychotherapy techniques in the treatment of Social Anxiety. There are no clear guidelines, and one is probably best off trusting their own instincts of what is best for them.

Medication Treatment:

Medication treatment is the "tried and true" method to effectively treat Social Anxiety Disorder. Research trials for the treatment of Social Anxiety are still limited primarily to "monotherapy" treatment (one drug by itself). In actual practice, it is often the case that 2 or more medications are used in combination (polypharmacy). There are likely to be many different treatments (single drug or combinations) which are helpful for a given individual. Experimentation affords one an opportunity to find out which treatments are most satisfactory for them. Patient self-education continues to play a key role for those wishing to ensure that they receive the appropriate medical intervention they deserve.

A Medication Treatment Algorithm for Social Anxiety:

One reasonable algorithm of trial is as follows: (Goal is typically effectiveness and tolerability over the long term):
  1. Antidepressant
    2.
    1. SSRI, SNRI, or moclobomide ... else try ...
    2. MAOI (Nardil)
  2. Benzodiazepine
    3.
    1. Klonopin (alone)
    2. Klonopin + Antidepressant (any above)
  3. May wish to augment (add) any of following:
    4.
    1. Wellbutrin (bupropion): Non-serotonergic antidepressant. Low doses ie; 25-100mg/day, divided
    2. Provigil (modafinil): Stimulant. Low doses ie; 25-100mg/day, divided
    3. Ritalin (methylphenidate): Stimulant. Low doses ie; 5-20mg/day, divided
    4. Neurontin (gabapentin): Anti-anxiety. 300-1800mg/day, divided
CERTAIN COMBINATIONS OR SINGLE DRUGS DANGEROUS: CHECK WITH DOCTOR FOR ALL TREATMENT RECOMMENDATION

FDA Approved Treatments

Two SSRI's (Paxil and Zoloft) and one SNRI (Effexor) are the only drugs officially approved for the treatment of Social Anxiety Disorder as of 2024.

Unfortunately SRI's are at best usually only MILDLY to MODERATELY helpful for the treatment of SP. They are considered the "first line" treatment for Social Phobia primarily because doctors usually perceive them as the "safest" of available drug treatments. Also, SRI's are often very good at treating some other anxiety and depressive disorders which are often "comorbid with" (accompany) SP, such as Dysthymia, Depression, Panic Disorder, Generalized Anxiety Disorder (GAD), and Obsessive Compulsive Disorder (OCD).

SSRI's work best when one of these other disorders is the "primary" problem - but usually not so well when Social Phobia is the primary problem. Poor response or tolerance problems are addressed by changing the dose, switching to another medication, or various augmentation strategies.

SSRI's

Prozac (fluoxetine): An "activating" SSRI with the least side effects.

Zoloft (sertraline)

Paxil (paroxetine)

Celexa (citalopram)

Lexapro (escitaloram)

SNRI's

These include Effexor, Cymbalta, Pristiq, Remeron, Wellbutrin, and others. They all boost norepinephrine, and to different degrees also serotonin.

Effexor(venlafaxine)

Cymbalta (duloxetine)

Pristiq (desvenlafaxine)

Remeron (mirtazapine)

Wellbutrin (bupropion)

MAOI's

The MAOI "Nardil" is definitely the most powerful and effective antidepressant for Social Phobia.

Nardil (phenelzine): Nardil usually works great for SP! It the "Gold Standard" antidepressant for SP. Nardil is excellent for many other anxiety and depressive disorders also. Reports of Nardil side effects are frequently exaggerated, particularly since Nardil's side effects typically take 2-4 months to diminish or disappear. After several months Nardil tends to cause less side effects (and less sexual side effects) than SSRI's across comparable dose ranges, with the exception of Prozac. Effective dose range for SP is usually 60-90 mg/day. MAOI related "Hypertensive crisis" is rare in responsible patients, and the risk is certainly overestimated in most literature on the topic. Many experts consider the MAOI's to be underutilized. Updated, friendlier MAOI diet.

Parnate (tranylcypromine): Parnate is not as effective as Nardil for SP, but occasionally may work well. It is a very activating, dopaminergic antidepressant.

Emsam / Eldepryl (selegiline): Emsam is relatively unstudied for the treatment of Social Anxiety Disorder. There is no reason to think it would be any more effective than Parnate.

Aurorix (moclobemide): Moclobemide is a 'reversible' MAOI. It has not proven to be an effective treatment of SP.

"The prescriber’s guide to classic MAO inhibitors (2022)

Benzodiazepines

Long term use of benzodiazepines remains controversial. About 10 are available but Klonopin is by far the most effective for SP. Xanax is sometimes helpful also.

Klonopin (clonazepam): Klonopin is very effective for SP and usually works great. Klonopin can be taken either "as needed" or everday. "As needed" (prn) use can be done up to twice per week, and will usually provide excellent effect within 30 minutes, lasting several hours to 1/2 day. Long term (everyday) use is more controversial.

Xanax (alprazolam): May be helpful. Xanax has a short half life which may limit its utility in long term use.

Myths About Benzodiazepines:

Possible Drawbacks of Long Term Benzodiazepine Use:

Resources

Research and Medication:
Search Pubmed

Books:
Social Phobia: From Shyness to Stagefright John Marshall, 1995
Feeling Good David Burns, 1999

email:
SocialAnxietyInfo@yahoo.com