Social phobia

Pavo Filakovi 1, Veljko or evi 2, Elvira Koi 3 and Lana Mu ini 4.
1Psychiatric Clinic, University Hospital Osijek; 3Psychiatric Department, General Hospital Virovitica; ABSTRACT
Social anxiety disorder (Social phobia) is an irrational fear of being observed and judged by other people in various social settings. It is often a chronic, disabling condition that is characterized by a phobic avoidance of most social situations. Social anxiety disorder occurs in two subtypes – generalized and specific. Patient with social anxiety disorder develops a strong anticipating anxiety of being confronted with phobic situations, and tries to avoid them if possible. Social anxiety disorder is often unrecognized as the cause of failure in school and career, divorce, inexplicable rejections of good business offers, asocial life, alcohol and drug abuse or dependence, and more other forms of life failures that resulted The aim of this study was to establish: prevalence, recognition, socio- psychological and neurobiological explanations, comorbidity, measurements and the treatment of social anxiety disorder. Authors reviewed recent data on this topic Social anxiety disorder occurs between 13.3% in USA and 14.4% in Europe (Magee et al. 1996., Weiller et al. 1996.), but the recognition of the disorder in practice is very low. Only about 5% of persons with this disorder ask for help, and when they do, only a quarter of them are diagnosed this disorder. As social anxiety disorder usually occurs in adolescence, a period that is important for education and future career, the impairment of the quality of their life is more serious. The generalized subtype appeared earlier, with patient having a mean age et onset of 11 years, in contrast to a mean age at onset of 17 years for patients with the specific subtype. The onset of social anxiety disorder prior to 11 years of age predicts nonrecovery in adulthood. Behavioral theories point to three key factors in the development of the disorder: direct fear conditioning, secondary fear conditioning (learning through observation), and verbal and nonverbal transfer of information about phobic social situations. Family can influence the onset of social anxiety disorder in many ways: through direct conditioning, learning by observation, transferring information, and through biological hereditary factors. Neurobiology of anxiety is complex and probably consists of interaction between several neuron pathways, which use several neurotransmitting systems. Concept of "innate anxiety circuit" (Nutt DJ, et al. 1998), is very useful to show the model of main components of social anxiety disorder and possible spots the available therapy methods could affect. According to this model, persons with social anxiety disorder perceive social situations as threatening, what activates the innate anxiety circuit. The circuit provokes the inception of and reflexively feeds on negative cognitive judgments. The circuit also activates the reaction of hypothalamic-pituitary-adrenal axis with characteristic cortisol response to stress and stimulates the autonomic system with consequential characteristic blushing, sweating and trembling. These body symptoms reflexively intensify the anxiety circuit by setting a positive reflexive loop, which worsens the condition further. When the unbearable level of anxiety and excitation of the autonomic nervous system is reached, the person is forced to look for the way out by learning how to avoid similar situations in future. According to studies that use exogenous compounds to provoke anxiety, the sensitivity of chemoreceptors in social anxiety disorder runs between the normal and the sensitivity in panic attack. There is also plenty of evidence about the role of GABA-dysfunction in the inception and intensification of anxiety. Alcohol and benzodiazepines, stimulators of GABA neurotransmission, reduce social anxiety. Efficiency of selective serotonin reuptake inhibitors in treatment of the disorder is supported by studies that point to supersensitivity of 5HT2A- receptors and anxiolytic-like effect of paroxetine in rats. It is not quite clear how the mechanism of selective serotonin reuptake inhibitors, which reduces anxiety in persons with social anxiety disorder, function, but postponed effect of these agents suggests that it is a question either of postsynaptic desensitization or of intensification of presynaptic function. Social anxiety disorder often precedes other mental disorders, which dissemble it, and therefore clinicians have difficulties to recognize it. According to one large epidemiological study (Schneier et al. 1992.) 59% of subjects with social anxiety disorder had secondary simple phobia, 45% had agoraphobia, and 17% had major depression. Besides that, 19% were alcohol dependent, and 13 % were drug dependent. In one French study of comorbidity in social anxiety disorder (Weiller et al. 1996.) it was found that in 75% of cases it precedes depression at least a year. Standardized scales for measurement social anxiety disorder can be divided into those that evaluate a person's clinical condition, disability and quality of life (for example, Hamilton Rating Scale for Anxiety – HAM-A, Liebowitz Social Anxiety Scale – LSAS, Global Assessment of Functioning, Sheehan Disability Scale, Liebowitz Self-Rated Disability Scale, WHO Quality of Life-100, Quality of Life Inventory). Psychosocial therapists suggest behavioral therapies in the treatment of social phobia. There are two group cognitive behavioral psychotherapeutic techniques: cognitive behavioral group therapy and social effectiveness therapy (social skills training). Selective serotonin reuptake inhibitors (SSRI-s) and benzodiazepines are usually used in the treatment of social anxiety disorder. SSRIs are efficient in reducing somatic symptoms (blushing, trembling, sweating), and therefore there is no need to combine them with N-blockers. The most comprehensive database of treatment with selective serotonin reuptake inhibitors (SSRIs) refers to paroxetine. The authors conclude that drugs of choice for social anxiety disorder are first of all selective serotonin reuptake inhibitors and highly-potent anxiolytics. The first should be given an advantage, and the second should be applied occasionally in order to intensify anxiolytic effect in acute phase of the disorder. Treatment of social anxiety disorder should last at least 3 months up to one year. Key words: social phobia, social anxiety disorder, neurobiology, treatment, SSRIs


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