Overview

Social anxiety disorder is also known as social phobia, and it is defined as an intense fear of judgment, rejection and negative evaluation. Most people in the society who experiences social anxiety disorder often get frustrated on acting, or they feel anxious visibly, for example, stumbling over words and blushing. Some people can also have the same feeling when they are considered or viewed as boring, awkward and stupid. The impact such feelings produces in an individual comprises of avoiding social or performance issues, but when such situations are beyond avoidance, they will feel distressed and anxious. Several individuals, who have social anxiety experiences numerous physical symptoms like nausea, sweating, fast heart rate, and full-blown attacks while dealing with feared situations. Despite acknowledging excessive and unreasonable fear, people with social anxiety will always feel less powerful to handle their anxiety. Social anxiety disorder is common among the modern society population; for example, 15 million American adults are affected by the disorder. The teenagers are more prevalent to social anxiety disorder where shyness is reported in childhood but essentially not only shyness indicates the presence of the disease. Social anxiety disorder can completely distort the ordinary interaction qualities of the affected individuals.  Such individuals can decline a job opportunity that will require frequent interactions with new people. Severe symptoms of the condition can disrupt the daily life of people, the daily routines, social life, and professional performance. The adverse effects of the signs are that teenagers may find it challenging to complete school, acquire normal and romantic relationships and to go through an interview to get a job successfully. People with social anxiety are also highly prevalent to major depressive disorders and alcohol abuse disorders. There are a variety of effective treatments that can be assigned to the social anxiety disorder patients but, it is reported that less than 5% of the affected people seek treatment in the year after initial onset. Unfortunately, more than a third of the population report symptoms for ten or more years before seeking treatment.

Psychopharmacological treatment approaches

The social anxiety disorder was found to be so much common among children and adolescents. In children and adolescents, a multimodal treatment approach is necessary, and it is considered to be the most effective approach. The multimodal approach encompasses exposure-based cognitive behavior therapy, patient and family education, use of medications and family therapy. Selective Serotonin reuptake inhibitors (SSRIs) are the best treatment that is required among children and adolescents. The efficacy of other drugs in the treatment of anxiety disorders in this group is not well established so far.  The cure for Social anxiety disorder is shown to be dependent on the severity of the physical and emotional symptoms and the ability to function daily.  The length of treatment also plays a significant role since some people can respond positively to the initial treatment while others may need moral support in their entire life. Psychopharmacology as a form of treatment involves the combination of both therapy and medication, and this is the best treatment for social anxiety disorders in all the groups.

Pharmacological treatment

Several forms of treatment are proposed for Social anxiety disorder, and every treatment has its advantages and disadvantages depending on the situation. The Selective serotonin reuptake inhibitors (SSRIs) are considered as the best medication for social anxiety disorder. SSRIs, when combined with cognitive behavioral therapy, an effective treatment outcome, is likely to be achieved.  SSRIs action takes place through the blocking of the serotonin reuptake and the pre-synaptic neurons hence enhancing serotonergic neurotransmissions.

Side effects

Gastrointestinal side effects

Gastrointestinal side effects are familiar with the SSRIs to use among the patients with SAD. The common symptoms involve nausea, decreased appetite, vomiting, heartburn, and dry mouth. Most of these side effects can only resolve after some few weeks. In children and adolescents, it is observed that gaining weight becomes much more problematic than losing weight.

Behavioral activation

The condition is common among children and adolescents as compared to adults. Activation is common in the initial days of SSRI treatment and after an escalation in the dose.  Behavioral activation is composed of dysphonia, altered cognition, mood, agitation, and severe akathisia.

Bipolar Switching

In bipolar switching, the mood of the patient changes from an anxious mood to a hypomanic state.  The change in mood is a distinguishing factor between behavioral activation and bipolar switching since in behavioral activation the mood is not affected.  The family and the patient will often acknowledge these as new symptoms which were not reported in the initial stages of treatment with SSRI. There is always a difference between bipolar switching and behavioral activation. The symptoms of bipolar switching always occur in later stages in the course of treatment a may not stop even after discontinuing the treatment with SSRI.  When symptoms developed in the patient are suspected to be of a bipolar switching, it is advisable that the discontinuous patient treatment with SSRI and begin a relevant therapy for the bipolar disorder after an intense examination.

Serotonin Syndrome (SS)

The SS is not that common, but it is a serious adverse event which is associated with the use of the SSRIs. SS is caused by the excessive activation of the serotonergic neural activation. There are high chances of SS to occur with a high dose of SSRI and when the patient is taking several medications with serotonergic activity.  The clinical characteristics of the SS encompass confusion, hypertension, muscular rigidity, myoclonus, renal failure, excessive sweating, and diarrhea.  The moment any clinical sign of SS is recognized, it is advisable that all the serotonergic drugs are discontinued immediately and an appropriate treatment be initiated.

Withdrawal or discontinuation syndrome

The discontinuation syndrome is majorly common in patients when the use of SSRI is abruptly stopped following a period of consistent and regular application.  The primary cause is associated with the use of short lifespan SSRI, abrupt discontinuation and more prolonged duration use of the medication. The symptoms for withdrawal include gastrointestinal disturbances, headache, sweating, dizziness, confusion, chills, fatigue, and sensory disorders and sleep disturbances. The signs are experienced within the 2-5 days of discontinuing or reducing the dose of the medication. The symptoms mostly resolve within 1-2 weeks. It does not mean that all the symptoms experienced may result to discontinuation with the treatment, but there are others which when experienced can be controlled through a reduction in the medication or restarting the patient on an SSRI but at a lower dose. The symptoms of discontinuation syndrome should be differentiated from the ones of anxiety disorder relapse or recurrence.

Benzodiazepines

Benzodiazepines can join to a particular site of the receptor organ and initiates GABA inhibitory effects by acting on the channel of chloride ion. These were considered as the first treatment of the anxiety disorder, but due to their reduced tolerability and reduced efficacy, they were deemed to be second in the line. The SSRI was commonly preferred since they have improved efficiency in treatment and are more tolerable. Currently, the Benzodiazepines are used among those individuals who have experienced suboptimal responses to antidepressants. The Benzodiazepines are used to decrease levels of anxiety during the initial weeks when the anxiolytic effects are yet to occur. The uses might not be so much appealing to the patient since they reinforce pill taking and this undermines self-efficacy. Upon discontinuation of the treatment, the associated effects may involve short-term cognitive, physiological dependence, rebound anxiety, and psychomotor impairment. The patients may be at risk of abusing Benzodiazepine if they have a history with drug abuse.

Beta Blockers and azapirones

Beta Blockers and azapirones do not have many uses. Beta blockers are prescribed as single dose agents for the anxiety disorder which is related to performance. Their principal function is attributed to their ability to reduce peripheral physical symptoms of anxiety. The Beta Blockers, however, do not affect the emotional and cognitive symptoms of anxiety. The medication often takes between 2-4 weeks to take effect and are comprehensively well tolerated and lack dependence issues such as the ones observed with Benzodiazepines. Propranolol reduces the outflow of neuronal sympathetic by blocking the beta-adrenergic receptors. The Beta Blockers differ in their level of selectivity for the beta 1 and beta two receptors. Beta Blockers have different degrees of lipophilicity. The extra-mechanism function of the Beta Blockers on the CNS was not yet coherently elucidated. Propranolol is a non-selective beta-adrenergic receptor blocker and decreases peripheral autonomic tone which is believed to result in amelioration of somatic symptoms of anxiety.  It can reduce emotional symptoms of anxiety.

Side effects

The common side effects associated with the treatment encompasses hypotension, fatigue, Dizziness, gastrointestinal upset, and bradycardia. The more severe but less frequent side effects consist of Bronchospasm and heart failure, but they are often less frequent.

Precautions

The Beta blockers should not be used among the children and adolescents with sinus bradycardia and more than a severe first-degree heart blockage, asthma, uncompensated heart failure, and sick sinus syndrome. The Beta-Blockers should be applied with caution in patients with significant peripheral disease of the artery, diabetes mellitus, and myasthenia. Propranolol can accelerate depression in children and adolescents.

Psychological therapies

Psychotherapy can be used alone or comprehensively with other forms of treatment. The available techniques are psychological which are intended at assisting the patient change their behavior into a desirable thing. There is nothing to be embarrassed about going to psychotherapist since most people who have gone to a psychiatrist have always benefited.

Cognitive Behavioral Therapy (CBT)

CBT is a form of psychotherapy which is specifically designed to alter individual thoughts and behaviors so that their emotions are influenced positively. There three commonly used types of treatment which involve exposure, social skills training, and cognitive restructuring.

Exposure

Exposure can take place through either experiencing a particular performance or social situation in life or through imaginations.  If an individual has experienced a more severe Social anxiety disorder, the therapist is likely to start with an imagined exposure and ultimately progressing to real-life exposures. The principle of exposure therapy is that through practice and experience, a person will begin becoming comfortable in the situations that they are likely to avoid. The recognized exposures that an individual can try on their own comprises of Exposure for phone fears and shy bladder syndrome.

Cognitive restructuring

Cognitive restructuring mainly focuses on the cognitive symptoms of Social Anxiety Disorder, fear of adversely being evaluated by others, negative attribution bias and poor self-concept. Cognitive restructuring encompasses a series of exercises which are concerned with acknowledging negative thoughts, examining the truth beyond them and developing alternative ideas to challenge original views. Cognitive restructuring is always thought to be the most important for the treatment of social anxiety disorder since it has an improved cognitive concept of the SAD and can challenge original thoughts.

Social training skills

Social training skills comprise of numerous exercises like rehearsal, modeling, and role-playing which are specifically meant to help individuals learn adequate behaviors and decrease the levels of anxiety in social situations. The social skills training exercise is only designed to benefit those who have actual deficits in social interaction above and beyond fear. The areas of target encompass eye contact, telephone calls, conversation, and assertiveness.

Acceptance and Commitment Therapy

Acceptance and Commitment Therapy (ACT) for the social disorder was developed after CBT, and it is defined by Buddhist philosophy. Through the elements of ACT, an individual learns to accept negative thoughts and anxiety rather than trying to annihilate them. Through the process of detachment from social anxiety, it is expected that the symptoms of an individual will reduce naturally. An ACT therapist uses the experiential exercise, mindfulness skills training and value-guided interventions.

Psychoanalysis

Psychoanalysis involves a therapist who tries to help a person to comprehend underlying issues from childhood that might have resulted in social anxiety. The treatment is diligent to those who have unresolved conflicts which contribute to their anxiety.

Pharmacology in combination with Psychotherapy

Parents with anxiety disorders often prefer psychotherapy over the psychotropic medication, but often the medicine comes first. There has been an increased need to reinforce existing treatment with the antidepressants and benzodiazepines with cognitive behavioral interventions. The combination of such treatments has often contributed to a lot of critics on their efficacy.

Conclusion

In conclusion, children and adults with symptoms of Social Anxiety Disorders are present in the primary care setting. The signs and symptoms of anxiety include physiological, cognitive and behavioral manifestations. There are always other associated mental health disorders that can be related to anxiety disorders and they should also be recognized as well. Behavioral treatment has shown a lot of success in the treatment of Social Anxiety Disorder among children and adolescents. Most patients may need pharmacotherapy; at the same time, behavioral treatment is being initiated to permit more active participation in the therapy. Generally, a multimodal treatment approach which involves pharmacotherapy and behavioral is shown to be the most effective among those people with severe Social Anxiety Disorder. SSRIs are the medication of choice in treating anxiety in children and adolescents.  Most people respond diligently with extended lasting treatment with resolution symptoms. Recurrence of the same disorder or development of a different form of an anxiety disorder is also an expectation in most individuals. Anxiety disorders often persist and extend into adulthood hence requiring a long and extended treatment plan.

 
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