Social Phobia – Do you have it?
Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are considered by many to be the first choice medication for generalised social phobia.
These drugs elevate the level of the neurotransmitter serotonin, among other effects. The first drug formally approved by the Food and Drug Administration was paroxetine, sold as Paxil in the U.S. or Seroxat in the UK. Compared to older forms of medication, there is less risk of tolerability and drug dependency.
However, their efficacy and increased suicide risk has been subject to controversy.
In a 1995 double-blind, placebo-controlled trial, the SSRI paroxetine was shown to result in clinically meaningful improvement in 55 percent of patients with generalized social anxiety disorder, compared with 23.9 percent of those taking placebo.
An October 2004 study yielded similar results.
Patients were treated with either fluoxetine, psychotherapy, fluoxetine and psychotherapy, placebo and psychotherapy, or a placebo.
The first four sets saw improvement in 50.8 to 54.2 percent of the patients.
Of those assigned to receive only a placebo, 31.7 percent achieved a rating of 1 or 2 on the Clinical Global Impression-Improvement scale.
Those who sought both therapy and medication did not see a boost in improvement.
General side-effects are common during the first weeks while the body adjusts to the drug.
Symptoms may include headaches, nausea, insomnia and changes in sexual behavior.
Treatment safety during pregnancy has not been established.
In late 2004 much media attention was given to a proposed link between SSRI use and juvenile suicide.
For this reason, the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor.
Recent studies have shown no increase in rates of suicide.
These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder.
However, it should be noted that due to the nature of the conditions, those taking SSRIs for social phobias are far less likely to have suicidal ideation than those with depression.
Although SSRIs are often the first choice for treatment, other prescription and illegal drugs are commonly used, sometimes only if SSRIs fail to produce any clinically significant improvement.
In 1985, before the introduction of SSRIs, anti-depressants such as monoamine oxidase inhibitors (MAOIs) were frequently used in the treatment of social anxiety.
Their efficacy appears to be comparable or sometimes superior to SSRIs or benzodiazepines.
However, because of the dietary restrictions required, high toxicity in overdose, and incompatibilities with other drugs, its usefulness as a treatment for social phobics is now limited.
Some argue for their continued use, however, or that a special diet does not need to be strictly adhered to.
A newer type of this medication, Reversible inhibitors of monoamine oxidase subtype A (RIMAs) inhibit the MAO enzyme only temporarily, improving the adverse-effect profile but possibly reducing their efficacy.
Benzodiazepines are a short-acting and more potent alternative to SSRIs.
These drugs are often used for short-term relief of severe, disabling anxiety. Alprazolam and clonazepam are usual benzodiazepines for social fear.
Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is much concern over the development of drug tolerance, dependency and recreational abuse.
Benzodiazepines augment the action of GABA, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours.
In recent years, the novel antidepressant mirtazapine has been proven effective in treatment of social anxiety disorder.
This is especially significant due to mirtazapine’s fast onset and lack of many unpleasant side-effects associated with SSRIs (particularly, sexual dysfunction).
Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure.
Taken in low doses, they control the physical manifestation of anxiety and can be taken before a public performance.
A novel treatment approach has recently been developed as a result of translational research.
It has been shown that a combination of acute dosing of d-cycloserine (DCS) with exposure therapy facilitates the effects of exposure therapy of social phobia (Hofmann, Meuret, Smits, et al., 2006).
DCS is an old antibiotic medication used for treating tuberculosis and does not have any anxiolytic properties per se.
However, it acts as an agonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor site, which is important for learning and memory (Hofmann, Pollack, & Otto, 2006).
It has been shown that administering a small dose acutely 1 hour before exposure therapy can facilitate extinction learning that occurs during therapy.
Many people choose to self-medicate using legally available nutritional supplements.
One such supplement believed to benefit sufferers of social anxiety is L-tryptophan,an amino acid that serves as a building block in natural production of serotonin. L-tryptophan also should be taken with vitamin B6 to aid conversion to serotonin and to avoid B6 depletion.