Guest Editorial
Social Anxiety Disorder
Richard P Swinson MD, FRCPC, FRCPsych 1
As defined in the DSM-IV-TR (1), social anxiety disorder (SAD), or social phobia, is now well recognized as a prevalent and significantly impairing disorder with an onset early in life. Since Liebowitz and colleagues’ commentary regarding the neglect of SAD in the contemporary literature (2), there has been considerable research into the nature of SAD, its natural history, its biological and environmental underpinnings, and its treatment. There has also been concern about the pathologizing of normal temperamental variations. This concern is most commonly linked to the use of pharmacologic treatments, particularly in younger patients, and has been exacerbated by the debate about the safety of antidepressant treatment of children and adolescents (3).
Epidemiologic studies show that SAD is among the most prevalent of all mental disorders. It is frequently comorbid with other anxiety disorders, mood disorders, and substance use disorders (4). It also remains undiagnosed and untreated for many years after onset. Few psychiatric disorders involve a debate about whether the condition in question should be regarded as a disorder and, if so, whether people with the condition should receive treatment for their distress. In the case of SAD, the debate extends to the question of whether the therapeutic approach with the largest data base regarding efficacy—namely, psychopharmacology—should be employed.
Longitudinal investigations of children with behavioural inhibition show that many retain these temperamental and behavioural features as they develop (5) and that they have characteristics of social anxiety and avoidance. Untreated SAD does not usually remit. The educational, interpersonal and vocational pathways of subjects with social anxiety are frequently adversely affected. Early recognition and early intervention are being increasingly advocated in other disorders and deserve consideration for the child and adolescent suffering from anxiety. It has been found that few children identified as meeting criteria for SAD receive any treatment (6). In a sample of 190 parents, only 31% of the children who suffered from current anxiety disorder had received any treatment, compared with 40% of those with depression and 79% of those with attention-deficit hyperactivity disorder. With the exception of specific phobia, the commonest anxiety disorder was social phobia, which had a 1-year prevalence rate of 3.2% (standard error 1.3%) (6).
The approach of intervening early begs the question of where the threshold is set for defining a “case.” Wakefield and colleagues (7) offer a provocative reexamination of social anxiety and its disorders, founded in a critique of the current DSM criteria. In their view, the number of true cases of SAD is markedly lower than epidemiologic studies based on DSM or ICD criteria recognize in community samples. These authors raise the concept of nondisordered social fears that cause suffering as a condition separate from what psychiatrists view as SAD.
Should we reexamine the criteria for caseness? Will DSM-V take on that task? It has always appeared unlikely that marked increases in case recognition over brief periods of time reflect significant shifts in the actual prevalence of similarly defined cases. Thus SAD’s current high prevalence (often quoted as 13.5%), compared with the fact that it was virtually unrecognized 20 years ago, reflects changes in awareness, in the criteria used for diagnosis, in the methods of screening for cases, and in the thresholds used to define caseness.
If we cannot be reasonably sure of how to define cases, do we have sufficient evidence to recommend treatment? Our understanding of the efficacy of interventions in SAD is based on 2 streams of investigation: the common dichotomy of psychosocial and pharmacologic treatments, together with the combination of these treatments in willing subjects diagnosed with SAD according to DSM-III or DSM-IV criteria. Rowa and Antony provide a useful review of psychosocial interventions, including several recent developments in cognitive-behavioural approaches, and they also briefly discuss the evidence in regard to combination therapies (8).
Several investigators have reviewed the efficacy of antidepressant treatment for SAD. Stein and colleagues reported through the Cochrane Collaboration the available information to that point (9). They reviewed 36 randomized controlled trials (RCTs) using selective serotonin reuptake inhibitors (SSRIs) or monoamine oxidase inhibitors. Twenty-six trials demonstrated that all medication groups showed short-term superiority in treatment response, compared with placebo. The SSRIs were significantly more effective than both moclobemide and, to a lesser extent, brofaramine. Long-term medication treatment was supported by the findings of 4 maintenance and 4 relapse-prevention studies. The results for performance anxiety RCTs were less clear. In addition to proving superior to no active treatment, the medications also reduced comorbid depression and disability associated with SAD.
Since Stein and others’ review, evidence has accumulated about the efficacy of other SSRIs and serotonin norepinephrine reuptake inhibitors (SNRIs), including escitalopram (10,11), paroxetine (12,13), and venlafaxine (14). In addition to its results in short-term efficacy studies, paroxetine has been shown to prevent relapse of SAD in a 24-week study.
Paroxetine was more effective than placebo in a major 16-week study of 322 children and adolescents treated with medication or placebo (12). The response rate in the paroxetine group was 77.6%, compared with 38.3% in the placebo group. Although 47.8% of the subjects treated with active medication improved “very much,” as is usual in adult investigations, 50% did not. One of the important findings was that the rate of adverse effects in both groups was low. However, the rate of suicidal ideation or threat was higher in the paroxetine group than among the control subjects (4 vs 0, P = 0.12). None of the events were considered to be serious, and none were attributed to the medication used.
Venlafaxine extended release had efficacy comparable with that of paroxetine in a 12-week investigation, in contrast to placebo (15). Venlafaxine was significantly more effective than placebo by week 1, whereas paroxetine took until week 3 to show differential efficacy from placebo. Response rates for both active agents were approximately 60%. Fluvoxamine controlled release has also been shown to be a well-tolerated, effective method of reducing social anxiety symptoms (16).
In addition, agents beyond the antidepressant group have been investigated as primary treatments. In an 11-week trial of adults with social phobia, pregabalin 600 mg daily was superior to placebo, whereas pregabalin 150 mg daily was not (17). St John’s wort was not found to be more effective than placebo in a study of 40 subjects over 12 weeks (18). An open study of topiramate pointed to some suggestion of improvement over 16 weeks, but 50% of subjects dropped out before study completion; further, although 11 of 23 in the intent-to-treat sample were responders, only 6 were considered to be in remission at study end (19).
Social anxiety can no longer claim to be a neglected area of study. However, determining who should be regarded as needing treatment; how they are to be recognized in the community; which treatment they should receive, depending on their condition’s severity and their age; how treatments (particularly evidence-based psychosocial interventions) can be made accessible; and how we get beyond a 50% response rate remain significant areas for study and improvement. The issue of the safety of the most commonly available treatments—SSRIs or SNRIs—continues to be the subject of study and debate (20). Despite all the caveats, many available and effective treatments exist that can and should be offered to people who meet the criteria for the diagnosis of SAD.
References
References
1. American Psychiatric Association: Diagnostic and statistical manual of mental disorders. 4th ed. Text revision. Washington (DC): American Psychiatric Association; 2000.
2. Liebowitz MR, Gorman JM, Fyer AJ, Klein DF. Social phobia. Review of a neglected anxiety disorder. Arch Gen Psychiatry 1985;42:729–36.
3. Healy D. Lines of evidence on the risks of suicide with selective serotonin reuptake inhibitors. Psychother Psychosom 2003;72(2):71–9.
4. Wittchen HU, Fehm L. Epidemiology, patterns of comorbidity and associated disabilities of social phobia. Psychiatr Clin North Am 2001;24:617–41.
5. Kagan J, Snidman N, Zentner M, Peterson E. Infant temperament and anxious symptoms in school age children. Dev Psychopathol 1999;11:209–24.
6. Chavira DA, Stein MB, Bailey K, Stein MT. Child anxiety in primary care: prevalent but untreated. Depress Anxiety 2004;20:155–64.
7. Wakefield JC, Horwitz AV, Schmitz MF. Are we overpathologizing the socially anxious? Social phobia from a harmful dysfunction perspective. Can J Psychiatry 2005;50:317–9.
8. Rowa K, Antony MM. Psychological treatments for social phobia. Can J Psychiatry 2005 2005;50:308–16.
9. Stein DJ, Ipser JC, van Balkom AJ. Pharmacotherapy for social anxiety disorder. The Cochrane database of systematic reviews 2000, Issue 4. CD001206. DOI:10.1002/14651858.CD001206.pub2.
10. Stein DJ, Kasper S, Andersen EW, Nil R, Lader M. Escitalopram in the treatment of social anxiety disorder: analysis of efficacy for different clinical subgroups and symptom dimensions. Depress Anxiety 2004;20:175–81.
11. Kasper S, Stein DJ, Loft H, Nil R. Escitalopram in the treatment of social anxiety disorder: randomized, placebo-controlled, flexible dosage study. Br J Psychiatry 2005;186:222–6.
12. Wagner KD, Berard R, Stein MB, Wetherold E, Carpenter DJ, Perera P, and others. A multicenter, randomized, double-blind, placebo-controlled trial of paroxetine in children and adolescents with social anxiety disorder. Arch Gen Psychiatry 2004;61:1153–62.
13. Stein DJ, Versiani M, Hair T, Kumar R. Efficacy of paroxetine for relapse prevention in social anxiety disorder. Arch Gen Psychiatry 2002;59:1111–8.
14. Leibowitz MR, Mangano RM, Bradwejn J, Asnis G, SAD Study Group. A randomized controlled trial of venlafaxine extended release in generalized social anxiety disorder. J Clin Psychiatry 2005;66:238–47.
15. Leibowitz MR, Gelenberg AJ, Munjack D. Venlafaxine extended release vs placebo and paroxetine in social anxiety disorder. Arch Gen Psychiatry 2005;62:190–8.
16. Westenberg HG, Stein DJ, Yang H, Li D, Barbato LM. A double-blind placebo-controlled study of controlled release fluvoxamine for the treatment of generalized social anxiety disorder. J Clin Psychopharmacol 2004;24:49–55.
17. Pande AC, Feltner DE, Jefferson JW, Davidson JR, Pollack M, Stein MB, and others. Efficacy of the novel anxiolytic pregabalin in social anxiety disorder: a placebo-controlled, multicenter study. J Clin Psychopharmacol 2004;24:141–9.
18. Kobak KA, Taylor LV, Warner G, Futterer R. St John’s wort vs placebo in social phobia: results from a placebo-controlled pilot study. J Clin Psychopharmacol 2005;25:51–8.
19. Van Ameringen M, Mancini C, Pipe B, Oakman J, Bennett M. An open trial of topiramate in the treatment of generalized social phobia. J Clin Psychiatry 2004;65:1674–8.
20. Fergusson D, Doucette S, Glass KC, Shapiro S, Healy D, Hebert P, and others. Association between suicide attempts and selective serotonin reuptake inhibitors: systematic review of randomised controlled trials. BMJ. 2005;330:396.
Author
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1. Professor and Morgan Firestone Chair, Department of Psychiatry and Behavioural Neurosciences, Michael G de Groote School of Medicine, McMaster University, Hamilton, Ontario.
Books Received
The following books have been received; the courtesy of the sender is acknowledged
by this listing. Books of particular interest to readers of the Journal
will be reviewed by selected individuals. Not all books are available for
review.
Treating Generalized Anxiety Disorder: Evidence-Based Strategies, Tools,
and Techniques. Jayne L Rygh, William C Sanderson. New York: The Guilford
Press; 2004. 210 p. US$30.00.
Sexualized Violence against Women and Children: A Psychology and Law Perspective.
BJ Cling, editor. New York: The Guilford Press; 2004. 305 p. US$38.00.
Essential Psychopharmacology: The Prescriber’s Guide. Stephen M Stahl.
Cambridge: Cambridge University Press; 2005. 571 p. US$50.00.
Medical Management of Eating Disorders. C Laird Birmingham, Pierre Beumont.
Cambridge: Cambridge University Press; 2004. 289 p. US$55.00.
Boys Who Have Abused: Psychoanalytic Psychotherapy with Victim/Perpetrators
of Sexual Abuse. John Wood. London: Jessica Kingsley Publishers; 2003.
240 p. US$29.95.
Assessment in Psychiatric and Mental Health Nursing. Philip J Barker. Cheltenham:
Nelson Thornes Ltd; 2004. 384 p. US$32.00.
Understanding Sleeplessness: Perspectives on Insomnia. David N Neubauer.
Baltimore: Johns Hopkins University Press; 2003. 192 p. US$45.00.
Sharing the Journey: A Psychotherapist Reflects on Her Work. Judith A Goren.
Lincoln: iUniverse Inc; 2004. 125 p. US$14.95.
Basic Child Psychiatry. Philip Barker. Oxford: Blackwell Science Ltd; 2004.
248 p. CAN$52.95.
The Neurobiology of Autism. Margaret L Bauman, Thomas L Kemper, editors.
Baltimore: Johns Hopkins University Press; 2005. 404 p. US$95.00.
Aggression, Antisocial Behavior, and Violence Among Girls. Martha Putallaz,
Karen L Bierman. New York: The Guilford Press; 2004. 322 p. US$38.00.
Manual of Psychiatric Care for the Medically Ill. Antoinette Ambrosino
Wyszynski, Bernard Wyszynski, editors. Washington: American Psychiatric
Publishing Inc.; 2005. 385 p. US$64.00.
Mind Magic. John Laurence Miller. New York: McGraw-Hill; 2005. 282 p. CAN$39.95.
Understanding the Addicted Brain: From Science to Service. Karienne Stovell,
executive editor. Providence: Manisses Communications Group, Inc.; 2004.
89 p. US$19.95.
Treating ADHD in Children: Understanding the Role of Medication. Karienne
Stovell, executive editor. Providence: Manisses Communications Group, Inc;
2004. 89 p. US$19.95.
Textbook of Psychosomatic Medicine. James L Levenson. Arlington: American
Psychiatric Publishing Inc; 2005. 1092 p. US$169.00.
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