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2001 Third Web Report
Many of us experience a pounding heartbeat or shaking when faced with a public situation, especially if we think we are going to be judged by others. When does this cross the line between normal and a mores serious disorder? Social anxiety disorder, a relatively newly recognized disorder by the psychiatric profession, involves many of the same symptoms as shyness. What makes the difference between a case of the jitters and a real disorder?
Social Anxiety Disorder was first recognized by the American Psychiatric Association as a disorder in 1980 (1). It is characterized by such physical symptoms as increased heartbeat, blushing, dry mouth, trembling and shaking, difficulty swallowing, and twitching in the muscles (2). Many people with social anxiety disorder also have depression. A study in France found that 70 percent of patients who developed social anxiety disorder before the age of 15 also suffered from major depression (3). Diagnostic criteria, according to the current definition of social anxiety disorder given by the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th ed. (DSM-IV), requires a persistent fear of at least one social situation which involves exposure to unfamiliar people or scrutiny by others. The patient must fear that he or she will act in this situation in a way that will cause embarrassment, and avoid the situation or experience extreme anxiety or a panic attack if faced with the situation. The patient must also realize that the fear is unreasonable. The avoidance or anxiety must interfere to a large extent with the normal routine, functioning, social activities, or relationships with the person (1).
This last criterion, a significant interference in the person's everyday life, is possibly the most important one in distinguishing social anxiety disorder form shyness that is a normal facet of personality. What constitutes such a significant interference in one's normal routine, however, is not necessarily easily determined; there is no specific point at which the line is drawn between shyness and social anxiety disorder. Many of the symptoms can be experienced in bouts of shyness that many people undergo from time to time. Perhaps because it is so hard to diagnose and the criteria are not absolute, estimates about how widespread social anxiety disorder is vary. The Anxiety Disorders Association of America says 10 million Americans suffer from the disorder (4), and the Social Anxiety institute says it affects 15 million Americans in a year (1). Regardless, studies show that it is the third most common mental disorder (the first two are substance abuse and depression) (3).
Social anxiety disorder is also often misdiagnosed or fails to be diagnosed at all. The Social Anxiety Institute suggests that almost 90% of people who suffer from social anxiety are misdiagnosed, often told they have schizophrenia, depression, panic disorders, or personality disorders (1). The definition used in the DSM may contribute to some of the misdiagnoses, because it refers to panic attacks, although panic disorder is an entirely separate disorder (1). Also contributing to confusion about what this disorder really is is the often synonymous use of the term social anxiety disorder with "social phobia." Thomas A. Richards, Ph.D., Director of the Social Anxiety Institute, argues that "social anxiety disorder" is the proper term for this condition, not "social phobia." Social Anxiety Disorder, he says, refers to a general fear of social situations that encompasses all of a person's life, whereas when people refer to social phobia, they get it confused with agoraphobia, which is a fear of panic attacks. The fear involved in social anxiety disorder is not attacks, but of the social situations themselves(1).
Several kinds of non-pharmacological treatment are used for social anxiety disorder, including behavior therapy, cognitive therapy, and relaxation techniques. Behavior therapy strives to help patients change behaviors that are undesirable by learning to deal with situations that cause fear for them, often by facing the situations. Cognitive therapy involves an effort to change thought patterns by examining which feelings and thoughts are realistic and which are unreasonable. Relaxation techniques include exercise and changing breathing patterns and help patients cope with and lessen stress (4).
These types of treatment are often discussed in contrast to medication, which is a relative newcomer to the treatment of social anxiety disorder, and there is some disagreement as to its effectiveness. Some organizations, like the Anxiety Network, say medication, since it cannot permanently change the brain, is not effective by itself, but only in combination with cognitive and behavioral therapy (5). Such therapy, they say, can change brain pathways and lead to permanently changing feelings (5). The social anxiety Institute also says that cognitive-behavioral methods are the only ones that work effectively and produce long-lasting improvement in symptoms (1). According to the Anxiety Disorders Association, however, medication can be effective with or without other kinds of treatment (4), and there has been clinical evidence for effectiveness, to varying degrees, of several classes of drugs to treat social anxiety disorder.
The first drug approved by the FDA for treatment of social anxiety disorder was Paxil in 1999. This approval followed clinical trials that showed it was effective in improving symptoms overall compared to a placebo at 20 mg (6). Paxil is one of the Selective Serotonin Reuptake Inhibitors, others of which include Luvox and Zoloft. Studies have shown that between 50 and 75 percent of patients taking these drugs show significant improvement in their symptoms (3). Although SSRIs tend to be tolerated fairly well by patients, side effects, often unpredictably, can occur. Among these are insomnia, agitation, sexual dysfunction, and gastrointestinal problems. If the drug is working effectively, switching to a different SSRI can sometimes alleviate the side effects and result in an effective treatment (7). Michael Zoler recommends using SSRIs for at least 18 months before taking them off because relapse rates are high when medication is stopped. He also suggests lifelong SSRI treatment because of the high comorbidity rate that social phobia has with depression (7).
Paxil has since been joined by several other classes of drugs to treat social anxiety disorder, including monoamine oxidase inhibitors (MAOIs), Beta-Adrenergic Blockers, and others, with varying frequency and degree of success and side effects. MAOIs, such as Phenelzine (brand name Nardil), have been shown in clinical trials to significantly improve the symptoms of about two thirds of patients. Some of the side effects associated with MAOIs are pustural hupotension, sedation, sexual dysfunction, and weight gain. Patients taking MAOIs must also follow a diet low in tyramine, avoiding foods such as cheese, fava beans, ovverripe fruit, certain meats, and certain types of alcoholic beverages (3). It is the side effects of MAOIs that make them often not recommended for the first consideration for drug treatment. Benzodiazepines such as Xanax have shown to act quickly and result in few side effects; however, these drugs can cause physical dependence, many patients experience a worsening of symptoms or relapse when they try to taper off the medication (3).This can also be problematic for patients with substance abuse problems, which occur frequently in those suffering from social phobia (3). Beta blockers, such as propranolol (brand name Inderal) have shown to be effective in low doses for relatively mild anxiety, but have less support from clinical trials for their effectiveness, and carry a danger of habitual overuse (3).
There are also new possibilities under investigation for drug treatment of social anxiety disorder. For example, in 2000 a study of 69 patients was published that found that gabapentin (Neurontin) produced a significant reduction in the symptoms of social phobia as compared to a placebo group (8).
The current focus on drug treatments for social anxiety disorder is encouraged by a 2000 study found that in people with social anxiety disorder, the dopamine D(sub 2) receptor binding potential was lower than that in a control group (9). If social anxiety is suggested to be associated with problems in dopamine receptors, the most tempting course of treatment is to fix dopamine binding through antidepressant drugs. Research such as this, combined with the relative ease and inexpense of drug therapy as compared to behavioral therapy, may lead to too great an emphasis on treating social anxiety with drugs alone, ignoring other types of therapy that have been shown to be effective in the long term.
Of the various drugs used to treat social anxiety disorder, Paxil, the first drug to be approved for treatment of social anxiety disorder, is the focus of much of the blame on the overuse of drugs to treat social anxiety disorder. The makers of Paxil, SmithKline Beecham, have recently sponsored advertising campaigns for organizations like which run in places such as bus shelters. These advertisements cite the large numbers of people affected by the disorder and proclaim it as treatable. SmithKline has been criticized for making these advertisements for profit rather than public service, for marketing their drug for as many purposes as possible. SmithKline addressed this concern by saying that the company is not attempting to market shyness, only to help those who are really suffering from social anxiety disorder (10).
The concern that people with normal shyness will want to take Paxil or other drugs to combat shyness may be real. Contributing to this risk is the bluriness of the line between shyness and social anxiety disorder. In fact, even if social anxiety symptoms seem to fall below the threshold for drug therapy, drugs may be recommended if the patient is also afflicted by another disorder such as depression that is also responsive to drugs (7).But determining this threshold in the first place is not an easy thing to do. Many people face extreme anxiety in social situations sometimes; should these people seek drugs for treatment? Will people start seeking "treatment" for normal shyness? Our brains are hard-wired to be nervous around strange people, dating back to the days when our ancestors feared predators (11). Will everyone who ever gets nervous in a social situation (which is almost all of us) start heading to the doctor's office for a prescription for Paxil?
To some extent, it seems appropriate and necessary to keep from drawing a sharp line between shyness and social anxiety disorder. All sufferers of social anxiety have somewhat different symptoms (2), and establishing a set of necessary criteria might keep some people from being diagnosed or even from seeking treatment in the first place if they do not feel their condition meets these standards. A commonality among patients of social phobia, however, is that they recognize to some degree that their feelings are irrational (2). Perhaps if the mass advertisements and other information available to the general public make sure to stress this acknowledgement of the anxiety as irrational, it will help prevent people from becoming convinced that their normal shyness is something more serious and thinking they need to be treated for it, yet not discourage people from seeking treatment for their condition if it seems irrational to them even if they cannot check off a list of particular symptoms. Doctors would still need to listen carefully to how patients describe their symptoms, but the problems of failure to diagnose genuine social anxiety and the overdiagnosis of shyness as social anxiety disorder might be lessened if the general public had better information available when wondering if they might have the disorder.
Much about social anxiety disorder is not agreed upon, from its definition to its prevalence to its treatment. The line between normal shyness and a true disorder is a fuzzy one which will probably never be specifically or quantitatively defined. This hazy distinction does not necessarily have to be problematic as long as doctors are trained to, and continue to, perfom careful diagnoses of each patient seeking help for distress in social situations. Although drugs such as Paxil seem to show promise in helping to treat this disorder, the attractiveness of drug treatment as a "quick fix" should not replace other methods, such as behavioral and cognitive therapy, which can change a patient's reactions and thoughts for the rest of their lives. Perhaps most troublesome aspect, however, of the increased attention given to social anxiety disorder and the increased focus on drug therapy as its solution, is the possibility that normal shyness will be seen as a disease needing a cure. Shyness is not a disease, but a facet of someone's personality, sometimes an integral one. As a somewhat shy person myself, I know that some of my behaviors, things I feel are under my control, dictated by my "I-function," are influenced by this aspect of my personality. If we are headed to the day when we regulate our personality with drugs, we might risk losing ourselves. What would happen if I took medication to change my shyness? Would it cause me to make different decisions? How would this affect my "I-function?" Would I be a different person, or just express and project myself differently? And is there even a difference between these two things? I am not sure if these questions can really be answered, but the idea that by popping a pill the way I work, even who I am, could be radically altered is a frightening one indeed.
2) Social Phobia/Social Anxiety Association
3) Social Anxiety Disorder: A Common, Underrecognized Mental Disorder , from Expanded Academic
4) Anxiety Disorders Association of America
5) Social Anxiety Disorder Questions and Answers, from the Anxiety Network
6) Paroxetine for Persons with Social Anxiety Disorder , from Expanded Academic
7) Drug Update: SSRIs in Social Phobia , from Expanded Academic
8) Gabapentin used to treat patients with social phobia , from Expanded Academic
9) Binding Potential in Social Phobia , from Expanded Academic
10) Coming to you direct , from Expanded Academic
11) Selling Shyness - How doctors and drug companies created the "social phobia" epidemic , from Expanded Academic
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