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Generalized social anxiety disorder (SAD), the most common chronic anxiety disorder in the United States, is characterized by excessive fear of embarrassment and rejection, as well as by excessive sensitivity to criticism that leads to impaired functioning. SAD may also be accompanied by physiological symptoms, such as blushing, trembling, or sweating, and by the fear that others will notice these signs. The effects of SAD can be profound and include diminished educational and vocational attainment, an inability to date or maintain romantic relationships, and/or impaired relations with family, friends, and co-workers. SAD usually starts during childhood or adolescence and affects women more often than men. It’s frequently associated with comorbid conditions, especially major depression, simple phobias, agoraphobia, and alcohol abuse.

Assessing Pharmacotherapy Options

When selecting medications known to be effective in treating SAD, clinicians should consider side effect profiles, potential drug interactions, the results of prior trials, historical familial responses to the particular drug, and insurance issues. Many selective-serotonin reuptake inhibitors (SSRIs) and the serotonin/norepinephrine reuptake inhibitor, venlafaxine, are FDA-approved for treating SAD. SSRIs are among the most effective treatments and have favorable side effect profiles and excellent efficacy when compared with drugs in other classes. SSRIs also treat depressive moods and other anxiety conditions that may accompany SAD and have limited potential for abuse. A recent addition to the SSRI armamentarium for treating SAD is controlled-release fluvoxamine. It represents an attractive new option because clinical trials indicate that it may have an earlier onset of action, a lower incidence of sexual side effects, and no propensity to induce weight gain.

Some benzodiazepines are also FDA-approved for the treatment of SAD, but these agents are associated with cognitive dulling, sleepiness, and physical dependence. These drugs are also ineffective for many disorders, such as major depression, that often accompany SAD. As a result, benzodiazepines should be considered second-line agents. Gabapentin and pregabalin have been helpful in some SAD cases depending on patient characteristics, but only limited data support their use. Monoamine oxidase inhibitors have more serious side effect profiles (eg, weight gain, hypertension, insomnia, and sexual side effects) and should be considered only when other treatment options have been exhausted.

Cognitive behavioral therapy (CBT)—which often includes cognitive restructuring and social skills training—can serve as an alternative to pharmacotherapy, but therapists skilled in CBT for SAD are difficult to find. Studies indicate that combining CBT and SSRIs provides no greater efficacy than either treatment alone.

Assess Efficacy Often

To determine whether a medication is effective, physicians should monitor patients for 10 to 12 weeks after the dose has been titrated (as tolerated) to the maximum known effective dose level. If a particular agent is ineffective, clinicians should explore potential issues surrounding compliance, pharmacokinetics, and psychosocial factors, as well as comorbid substance use or personality disorders. When a medication is effective for patients with SAD, they should continue the drug for at least a year because the risk of relapse within that timeframe is substantial.

Educating SAD patients about the nature of their disorder is an important element of treatment. They should understand that they didn’t cause their disorder and they’re not alone. SAD patients should be directed to reliable educational resources, such as the Anxiety Disorders Association of America (www.adaa.org). These advocacy organizations can help patients find support groups and learn more about SAD and its treatments. Educational efforts are paramount to optimizing treatment outcome.

Lorrin M. Koran, MD, has indicated to Physician’s Weekly that he is on the speaker’s bureau for Forest and has received grants from Ortho-McNeil, Eli Lilly, Forest, Somaxon, Jazz, Sepracor.