Social phobia has recently been recognized as a chronic and often debilitating disorder. It is estimated to affect up to 10% of the population, with onset occurring early in life.l According to the DSM-IV, in order to be diagnosed with social phobia individuals must meet several criteria. They must have a persistent fear of one or more social or performance situations where they are exposed to unfamiliar people or to possible scrutiny by others. The essential fear of the patient is that he or she may act in a way that will be humiliating or embarrassing. Individuals may be fearful of specific situations such as speaking, eating or writing in front of others, or they may have generalized anxiety involving all social situations. In an attempt to abate their fear, patients will make an effort to avoid social situations. When unavoidable, these social situations provoke anxiety that causes the individual to experience panic-like symptoms (e.g., tachycardia, sweating, trembling, blushing and muscle tension) which continue to escalate throughout the situation. These individuals recognize that their fears are excessive and unreasonable but are unable to prevent their anxieties from interfering with their occupational, academic and social functioning.

While behavior therapy is considered an essential component of treatment, several classes of drugs have been found to be effective. Beta-blockers (atenolol, propranolol) have been used to control bodily symptoms (e.g., tachycardia, trembling and sweating), but their tendency to cause depression is a potential complication. Monoamine oxidase inhibitors (phenelzine, tranylcypromine) also have shown efficacy, but extensive potential for drug-drug and drug-food interactions that may predispose individuals to a hypertensive crisis have decreased their use in many disorders. Benzodiazepines (clonazepam, alprazolam) have also been shown to be effective. Recently, several selective serotonin reuptake inhibitors (SSRIs) have been used successfully to treat patients who suffer from social phobia.

Fluoxetine (Prozac)

A study by Van Ameringen et al. is the most recent open trial evaluating fluoxetine’s efficacy in social phobia. Sixteen patients suffering from social phobia as a primary diagnosis were administered fluoxetine (Prozac) for 12 weeks. Fourteen of the subjects suffered from other psychiatric disorders such as major depression, generalized anxiety, dysthymia and obsessive compulsive disorder. Doses of fluoxetine were initially 20 mg/day and were increased every four weeks according to clinical response and adverse effects. Patients completed various self-reported measures of anxiety, depression and social avoidance at baseline and at weeks 4, 8 and 12. The measures used were the Beck Depression Inventory, Social Avoidance and Distress Scale, Fear of Negative Evaluation Scale, Social Phobia Subscale and Social Anxiety Thoughts Questionnaire. A Clinical Global Improvement Score was also completed by physicians. Thirteen of the 16 patients completed the trial. Those who withdrew did so due to adverse effects. Ten of the 13 patients were considered responders to fluoxetine (Prozac) and three were considered nonresponders. The previously mentioned measures of social anxiety and phobia avoidance showed significant improvement from baseline (p < 0.005). Although the investigators concluded that fluoxetine was successful in treating social phobia, the results were difficult to interpret because 11 of the 13 subjects had comorbid psychiatric disorders known to respond to SSRI therapy. Therefore, the improvement seen may have been due to improvement of symptoms in the concurrent disorders rather than the social phobia.

Fluvoxamine (Luvox)

Fluvoxamine was compared to placebo in a 12-week, double-blind, placebo-controlled trial by Van Vliet et al. Thirty subjects who met the DSM-IV criteria for social phobia were included in the study. Unlike in the previous trial, subjects were excluded from participating if they had concurrent anxiety, depression or personality disorders. Doses of fluvoxamine (Luvox) were gradually increased from 50 mg/day to 150 mg/day over the course of the study. Seven of 15 patients treated with fluvoxamine (Luvox) experienced a statistically significant (p < 0.001) improvement by week 12, as defined by a reduction of 50% or more in the anxiety subscale of the Liebowitz Social Anxiety Scale. When social avoidance tendencies were examined, a nonsignificant improvement was seen in the fluvoxamine (Luvox) group. The investigators concluded that fluvoxamine appears effective in the treatment of social phobia. They suggest that the characteristic of avoidance indicates more resistance to treatment and patients with this characteristic may require longer treatment periods.

Sertraline (Zoloft)

A small, 22-week, double-blind, placebo-controlled crossover study (n = 12) involving sertraline was performed by Katzelnick et al. Subjects had no comorbid mood disorders and were relatively free from depressive symptoms. Sertraline (Zoloft) dosing was initiated at 50 mg/day and was increased by 50 mg every two weeks if there was no treatment response. A statistically significant improvement as measured by the Liebowitz Social Anxiety Scale, the primary outcome measure, was found with sertraline (p = 0.001) but not with placebo. While taking sertraline, 50% of subjects were rated moderately or markedly improved versus 9% of subjects with placebo. The mean daily dose for the sertraline (Zoloft) responders was 100 mg/day. Based on these results, the investigators concluded that sertraline appears to be effective in the treatment of social phobia.

Conclusion

SSRIs have a more favorable side effect profile and lower toxicity risk in overdose situations than other agents used for social phobia (e.g., MAO inhibitors, beta-blockers). In addition, they carry less risk of abuse and dependence than the benzodiazepines. For these reasons, it is hoped that SSRIs will prove effective for this disorder. The above studies show that fluoxetine, fluvoxamine and sertraline appear to be promising treatments. However, the current literature discussing these agents is limited to anecdotal reports, open studies and double-blind trials, each involving a small number of patients. Larger controlled trials comparing the SSRIs to current therapies must be performed before a definitive conclusion can be made on the role of SSRIs in the treatment of social phobia.

Currently, it is recognized that a comprehensive, personalized treatment plan is the best approach in dealing with social phobia. A combination of psychotherapy and pharmacotherapy is ideal. When choosing pharmacotherapy, a valid choice can be made from among selected benzodiazepines, MAO inhibitors or SSRIs. From these options, SSRIs may be a preferred choice when the patient has a comorbid diagnosis such as major depression or obsessive-compulsive disorder. By choosing an SSRI, the clinician is potentially treating several disorders with one agent. However, for a social phobia patient who does not have additional psychiatric disorders, no one agent is considered to be the treatment of choice, due to the lack of comparative trials. Therefore, the choice of an agent should be guided by carefully assessing the individual needs of the patient.

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