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anxiety:social-anxiety [on January 20, 2020]
anxiety:social-anxiety [on January 11, 2024] (current)
psychdb [Psychotherapy]
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 ====== Social Anxiety Disorder (Social Phobia) ====== ====== Social Anxiety Disorder (Social Phobia) ======
- {{INLINETOC}} ​+{{INLINETOC}} ​
  
 ===== Primer ===== ===== Primer =====
-**Social Anxiety Disorder** (also known as social phobia), is an anxiety disorder characterized by a significant amount of fear in one or more social situations, causing significant distress and impaired ability to function in some aspects of daily life. These fears can be triggered by perceived or actual scrutiny, or negative evaluation from others. Individuals often fear of acting in a way (or showing anxiety symptoms) that will be embarrassing or humiliating. This can lead to avoidance or fear of social or performance situations.+**Social Anxiety Disorder** (also known as social phobia), is an [[anxiety:​home|anxiety disorder]] characterized by a significant amount of fear in one or more social situations, causing significant distress and impaired ability to function in some aspects of daily life. These fears can be triggered by perceived or actual scrutiny, or negative evaluation from others.
  
-==== Epidemiology ​==== +== Epidemiology == 
-Social anxiety disorder has a lifetime prevalence ​of 13%, making it the third most common psychiatric diagnosis. ​It affects females ​and males equallyThere is frequent comorbidity ​with other anxiety disorders, ​depression, and alcohol ​use disorder. +  * The lifetime prevalence ​rates for social anxiety disorder ranges from 8 to 12%, making it one of the more common ​anxiety disorders. 
-===== Diagnostic Criteria =====+  * It is more common in women than men (about twice as many women).[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])][(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +  * The average age of onset is between 8 to 15 years, and most have a childhood history of social inhibition or shyness.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 + 
 +== Prognosis == 
 +  * About 30% of individuals experience remission within 1 year, and about 50% experience remission within several years.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] For those not receiving treatment, about 60% of individuals take several more years to achieve remission. 
 +  * Individuals are more likely to be unemployed, single, unmarried, or divorced and childless, particularly among men. 
 +  * Only about half of individuals seek treatment, and typically after 15 to 20 years of experiencing symptoms.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 + 
 +== Comorbidity == 
 +  * Up to 72% of individuals have another ​psychiatric ​disorder ​diagnosis.[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress ​and obsessive-compulsive disordersBMC psychiatry, 14(1), 1-83.]])] 
 +  * Social anxiety disorder ​is comorbid ​with other anxiety disorders, ​major depressive disorder, and substance ​use disorder ​(to self-medicate in anticipation of social events). 
 +  * Other comorbidities include bipolar disorder, ADHD, and body dysmorphic disorder.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +  * Individuals with the generalized subtype of social anxiety disorder may also be more likely to have [[personality:​avoidant|avoidant personality disorder]].[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 + 
 +== Risk Factors == 
 +  * Temperamental traits such as high behavioural inhibition and fear of negative evaluation is a risk factor. 
 +  * First degree relatives of individuals with social anxiety disorder have a two to six times higher chance of having social anxiety disorder.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 + 
 +== Cultural == 
 +  * Fear of offending others by a gaze or by showing anxiety symptoms may be the predominant fear in individuals from cultures with strong collectivistic orientations.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +    * In Japan and Korea, this is known as //taijin kyofusho//, where the individual believes their gaze is upsetting others, and so others look away from them. Sometimes, this fear can attain a delusional intensity.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +    * The North American equivalent of this syndrome is termed "​olfactory-reference syndrome." 
 +===== DSM-5 Diagnostic Criteria =====
 <WRAP group> <WRAP group>
 <WRAP half column> <WRAP half column>
 == Criterion A == == Criterion A ==
-Marked fear or anxiety about ''​1''​ or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g.having a conversation,​ meeting unfamiliar people), being observed (e.g.eating or drinking), and performing in front of others (e.g.giving a speech).+Marked fear or anxiety about ''​1''​ or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g. having a conversation,​ meeting unfamiliar people), being observed (e.g. eating or drinking), and performing in front of others (e.g. giving a speech).
  
-<callout type="​info"​ icon="​fa fa-child">​In children, the anxiety must occur in peer settings and not just during interactions with adults.+<callout type="​info"​ icon="​fa fa-child">​ 
 +In children, the anxiety must occur in peer settings and not just during interactions with adults.
 </​callout>​ </​callout>​
- 
  
 == Criterion B == == Criterion B ==
-The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e.will be humiliating or embarrassing:​ will lead to rejection or offend others).+The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. will be humiliating or embarrassing:​ will lead to rejection or offend others).
  
 == Criterion C == == Criterion C ==
 The social situations almost always provoke fear or anxiety. The social situations almost always provoke fear or anxiety.
  
-<callout type="​info"​ icon="​fa fa-child">​In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.+<callout type="​info"​ icon="​fa fa-child">​ 
 +In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
 </​callout>​ </​callout>​
  
Line 38: Line 61:
  
 == Criterion G == == Criterion G ==
-The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g.a drug of abuse, a medication) or another medical condition.+The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g. a drug of abuse, a medication) or another medical condition.
  
 == Criterion H == == Criterion H ==
Line 44: Line 67:
  
 == Criterion J == == Criterion J ==
-If another medical condition (e.g.Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.+If another medical condition (e.g. - [[geri:​parkinsons|Parkinson’s disease]], obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
  
-<callout type="​info"​ title="​Physical ​symptoms ​of social anxiety" icon="​true">​Though not specifically part of the diagnostic criteria, common physical symptoms of social anxiety disorder include: blushing, stammering, sweating, ​GI symptoms, dry mouth, palpitations,​ trembling, urgency of micturition,​ and panic attacks.</​callout>​+<callout type="​info"​ title="​Physical ​Symptoms ​of Social Anxiety" icon="​true">​ 
 +Though not specifically part of the diagnostic criteria, common physical symptoms of social anxiety disorder include: blushing, stammering, sweating, ​gastrointestinal ​symptoms, dry mouth, palpitations,​ trembling, urgency of micturition,​ and panic attacks. 
 +</​callout>​
 </​WRAP>​ </​WRAP>​
 </​WRAP>​ </​WRAP>​
-===== Scales =====+ 
 +==== Specifiers ​==== 
 +<panel icon="​fa fa-search-plus fa-fw" size="​xs"​ title="​Performance Specifier">​ 
 +**Specify if**: 
 +  * **Performance only**: If the fear is restricted to speaking or performing in public. 
 +</​panel>​ 
 + 
 +{{page>​anxiety:​gad#​specifiers&​nouser&​noheader&​nodate&​nofooter}} 
 + 
 +==== Signs and Symptoms ==== 
 +  * The anticipatory anxiety in social anxiety can sometimes occur far in advance of upcoming situations (e.g. - worrying every day for weeks before the social event). 
 +    * Individuals often overestimate the negative consequences of the social situations, but the sociocultural context always needs to be taken into account by the clinician. 
 +  * Individuals (e.g. - public speakers, musicians, dancers, performers, athletes) with the performance only type of social anxiety disorder will have performance fears that are typically most impairing during their careers or professional lives. Importantly,​ in performance only type, individuals do not fear or avoid //​non-performance//​ social situations. 
 +  * Some individuals may have a fear of public restrooms and avoid urinating when other individuals are present (this is also called paruresis, or "shy bladder syndrome"​).[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +    * This is more common in males.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 +  * Blushing is considered a hallmark response for social anxiety disorder.[(American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.)] 
 + 
 +===== Screening and Rating ​Scales ===== 
 +<panel title="​Scales"​ no-body="​true">​ 
 +<​mobiletable 1> 
 +^ Name                                   ^ Rater      ^ Description ​                                                            ^ Download ​                                                             ^ 
 +^ Liebowitz Social Anxiety Scale (LSAS) ​ | Clinician ​ | The LSAS is a 24-item scale that assesses for social anxiety symptoms. ​ | [[https://​nationalsocialanxietycenter.com/​liebowitz-sa-scale/​|Link]] ​ | 
 +</​mobiletable>​ 
 +</​panel>​ 
 + 
 == Social Phobia Inventory (SPIN) == == Social Phobia Inventory (SPIN) ==
 The Social Phobia Inventory (SPIN) demonstrates solid psychometric properties and shows promise as a measurement for the screening of, and treatment response to, social phobia.[([[http://​bjp.rcpsych.org/​content/​bjprcpsych/​176/​4/​379.full.pdf|Connor,​ MK. Psychometric properties of the Social Phobia Inventory (SPIN). Br J Psychiatry. 2000 Apr;​176:​379-86.]])] The Social Phobia Inventory (SPIN) demonstrates solid psychometric properties and shows promise as a measurement for the screening of, and treatment response to, social phobia.[([[http://​bjp.rcpsych.org/​content/​bjprcpsych/​176/​4/​379.full.pdf|Connor,​ MK. Psychometric properties of the Social Phobia Inventory (SPIN). Br J Psychiatry. 2000 Apr;​176:​379-86.]])]
  
 == Mini-Social Phobia Inventory (mini-SPIN) == == Mini-Social Phobia Inventory (mini-SPIN) ==
-The [[https://​www.google.ca/​url?​sa=t&​rct=j&​q=&​esrc=s&​source=web&​cd=1&​cad=rja&​uact=8&​ved=0ahUKEwjNtanq2M7VAhWCwVQKHcBPA_cQFggoMAA&​url=http%3A%2F%2Fprimarycare.ementalhealth.ca%2Fdownload.php%3FencodedName%3Dy4PmRf6fa5zuueT7shOCtabViQve-slash-Ths8VWd50Ja6TI-equals-%26folder%3DdiagnosticTools%26fileName%3DSocial%2520anxiety%2520-%2520Mini%2520SPIN%2520dcg_o15.pdf&​usg=AFQjCNGQ6xyZ6HGs_5q-RixiJQM7hOPbzQ|Mini-Social Phobia Inventory (Mini-SPIN)]] is a 3-question screening tool that has a 90% screening accuracy for diagnosing ​ generalized social anxiety.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2781035/​|Seeley-Wait E, Abbott MJ, Rapee RM. Psychometric Properties of the Mini-Social Phobia Inventory. Primary Care Companion to The Journal of Clinical Psychiatry. 2009;​11(5):​231-236.]])]:​+The Mini-Social Phobia Inventory (Mini-SPIN) is a 3-question screening tool that has a 90% screening accuracy for diagnosing ​ generalized social anxiety.[([[https://​www.ncbi.nlm.nih.gov/​pmc/​articles/​PMC2781035/​|Seeley-Wait E, Abbott MJ, Rapee RM. Psychometric Properties of the Mini-Social Phobia Inventory. Primary Care Companion to The Journal of Clinical Psychiatry. 2009;​11(5):​231-236.]])]:​
   - Does fear of embarrassment cause you to avoid doing things or speaking to people?   - Does fear of embarrassment cause you to avoid doing things or speaking to people?
   - Do you avoid activities in which you are the centre of attention?   - Do you avoid activities in which you are the centre of attention?
   - Is being embarrassed or looking stupid among your worst fears?   - Is being embarrassed or looking stupid among your worst fears?
- 
-Consider social anxiety disorder in patients who appear reticent or shy and in all depressed or alcohol-dependent patients. ​ 
  
 ===== Pathophysiology ===== ===== Pathophysiology =====
 +  * The neural mechanisms behind social anxiety disorder is thought to be an interplay between non-specific genetic (neurotic temperament) factors and the environment ​ (e.g. - fear of negative evaluation) interactions.
 ===== Differential Diagnosis ===== ===== Differential Diagnosis =====
 +<alert type="​info"​ icon="​fa fa-book fa-lg fa-fw">​
 +See also: **[[http://​www.psychiatrictimes.com/​special-reports/​managing-anxiety-medically-ill|Dong,​ Yu, et al. Managing anxiety in the medically ill. Psychiatric Times 32.1 (2015): 33-33.]]**
 +</​alert>​
  
-===== Investigations =====+<WRAP group> 
 +<WRAP half column>​ 
 +  * **Normal shyness** 
 +    * Shyness is a very common personality trait and is not pathological. However, when there is a significant adverse impact on social, occupational,​ and other important areas of functioning,​ a diagnosis of social anxiety disorder should be considered. 
 +  * **[[anxiety:​agoraphobia|Agoraphobia]]** 
 +    * Individuals with agoraphobia may fear and avoid social situations (e.g. - going to a concert) because escape might be difficult or help might not be available in the event of incapacitation or panic-like symptoms. The differentiating factor is that individuals with social anxiety disorder are most fearful of //​scrutiny//​ by others. They are also very likely to be calm when left entirely alone in these "​agoraphobic"​ environments,​ which is typically not the case in agoraphobia. 
 +  * **[[anxiety:​panic|Panic disorder]]** 
 +    * Individuals with social anxiety disorder can have panic attacks, but the concern is about fear of //negative evaluation//​ (i.e. - social judgment), whereas in panic disorder the concern is about the panic attacks themselves. 
 +  * **[[anxiety:​gad|Generalized anxiety disorder (GAD)]]** 
 +    * Social worries are common in GAD, but the focus is more about interpersonal relationships rather than fear of //negative evaluation//​. Children may have excessive worries about the quality of their social performance,​ but these worries also extend to nonsocial performance. The key difference again is the //social// aspect of the worries. 
 +  * **[[anxiety:​separation|Separation anxiety disorder]]** 
 +    * Individuals with separation anxiety disorder may avoid social settings (including school refusal) because of concerns about being separated from attachment figures. Individuals with separation anxiety disorder are usually comfortable in social settings when their attachment figure is present or when they are at home. Compare with social anxiety disorder may be uncomfortable even when social situations occur at home or in the presence of attachment figures. 
 +  * **[[anxiety:​phobia|Specific phobias]]** 
 +    * Individuals with specific phobias may fear embarrassment or humiliation (e.g. - embarrassment about fainting when they have their blood drawn), but they do not generally fear negative evaluation in other social situations. 
 +  * **[[anxiety:​selective-mutism|Selective mutism]]** 
 +    * Individuals with selective mutism may fail to speak because of fear of negative evaluation, but they do not fear negative evaluation in social situations where no speaking is required (e.g. - nonverbal play). 
 +  * **[[mood:​1-depression:​home|Major depressive disorder (MDD)]]** 
 +    * Individuals with MDD may be worried about being negatively evaluated by others because they feel guilty, hopeless, or worthless. Individuals with social anxiety disorder on the other hand, are worried about being negatively evaluated because of certain social behaviors or physical symptoms. 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +  * **[[ocd:​body-dysmorphic|Body dysmorphic disorder (BDD)]]** 
 +    * Individuals with BDD are preoccupied with one or more perceived defects or flaws in their physical appearance that are not observable or appear slight to others. It is this specific preoccupation that causes the social anxiety and avoidance. If the social fears and avoidance are caused //only// by concerns regarding one's appearance, the additional diagnosis of social anxiety disorder is not warranted. 
 +  * **[[psychosis:​delusional-disorder|Delusional disorder]]** 
 +    * In delusional disorder, there can be very fixed non-bizarre delusions and/or hallucinations related to the delusional theme that focus on being rejected by or offending others. Compare this with social anxiety disorder, where there is generally good insight that their beliefs are out of proportion to the actual threat posed. 
 +  * **[[child:​disruptive-impulsive:​odd|Oppositional defiant disorder]]** 
 +    * Not speaking as a way to oppose authority figures should be differentiated from failure to speak due to a fear of negative evaluation. 
 +  * **[[child:​asd|Autism spectrum disorder]]** 
 +    * Social anxiety and social communication deficits are key features of autism spectrum disorder. However, those with social anxiety disorder typically have adequate age-appropriate social relationships and social communication capacity. It only //appears// that they have impairment in these areas when first interacting with unfamiliar peers or adults in stressful social settings. 
 +  * **[[personality:​avoidant|Avoidant personality disorder]]** 
 +    * Since onset is common childhood, social anxiety disorder may resemble avoidant personality disorder. The key difference is that with avoidant personality disorder, individuals have a broader and more pervasive avoidance pattern. Of note, avoidant personality disorder is also more comorbid with social anxiety disorder than with other anxiety disorders. 
 +  * **Other mental disorders (e.g. - schizophrenia,​ eating disorders, obsessive-compulsive disorder) ** 
 +    * In schizophrenia,​ social fears and discomfort can occur, but psychotic symptoms are usually evident. 
 +    * In eating disorders, it is important to determine if the fear of negative evaluation is about eating disorder symptoms or behaviors (e.g. - purging and vomiting) before diagnosing social anxiety disorder. 
 +    * In obsessive-compulsive disorder, social anxiety may be present, but the additional diagnosis is used only when social fears and avoidance are separate from the original obsessions and compulsions. 
 +  * **Other medical conditions** 
 +    * Medical conditions may produce symptoms that may be embarrassing (e.g. - trembling in Parkinson'​s disease). When the fear of negative evaluation due to other medical conditions becomes excessive, a diagnosis of social anxiety disorder should be considered. 
 +</​WRAP>​ 
 +</​WRAP>​
  
 +
 +
 +===== Investigations =====
 +  * Depending on the initial presenting symptoms (e.g. - dizziness, tachycardia),​ potential investigations can include: CBC, fasting glucose, fasting lipid profiles, electrolytes,​ liver enzymes, serum bilirubin, serum creatinine, urinalysis, [[meds:​urine-drug-screen|urine toxicology]] for substance use, thyroid stimulating hormone (TSH).[([[https://​pubmed.ncbi.nlm.nih.gov/​25081580/​|Katzman,​ M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.]])]
 ===== Treatment ===== ===== Treatment =====
  
 The following treatment recommendations are based on the 2014 Canadian Clinical Practice Guidelines for anxiety, posttraumatic stress and obsessive-compulsive disorders:​[([[https://​bmcpsychiatry.biomedcentral.com/​track/​pdf/​10.1186/​1471-244X-14-S1-S1?​site=bmcpsychiatry.biomedcentral.com|Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;​14(Suppl 1):S1.]])] The following treatment recommendations are based on the 2014 Canadian Clinical Practice Guidelines for anxiety, posttraumatic stress and obsessive-compulsive disorders:​[([[https://​bmcpsychiatry.biomedcentral.com/​track/​pdf/​10.1186/​1471-244X-14-S1-S1?​site=bmcpsychiatry.biomedcentral.com|Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;​14(Suppl 1):S1.]])]
  
-==== Pharmacological ​==== +==== Psychotherapy ​==== 
- +<WRAP group> 
-<panel type="​info"​ title="​Pharmacotherapy for social anxiety disorder"​ no-body="​true"​+<WRAP half column
-^ 1st line         ​| ​[[meds:​antidepressants:​ssri:escitalopram|Escitalopram]], [[meds:​antidepressants:​ssri:​fluvoxamine|fluvoxamine]],​ [[meds:​antidepressants:​ssri:​paroxetine|paroxetine]],​ [[meds:​antidepressants:​snri:​venlafaxine|venlafaxine]],​ [[meds:​antidepressants:​ssri:​sertraline|sertraline]] ​     | +[[psychotherapy:cbt|Cognitive behavioural therapy]] with exposure is a first-line, gold-standard treatment ​for social anxiety disorder. ​Importantlythe gains from CBT are longer lasting and more enduring ​than those achieved through ​medication treatmentand includes several components:
-^ 2nd line         | [[meds:​benzos:​2-clonazepam|clonazepam]][[meds:​benzos:​3-alprazolam|alprazolam]],​ bromazepam, [[meds:​mood-stabilizers-anticonvulsants:​gabapentin|gabapentin]],​ [[meds:​antidepressants:​ssri:​citalopram|citalopram]],​ phenelzine ​       | +
-^ 3rd line         | Fluoxetine, bupropion, mirtazapine,​ moclobemide,​ divalproex, topiramate, levetiracetam,​ olanzapine, quetiapine, selegiline, clomipramine \\ \\ //​Adjunctive//:​ risperidone,​ aripiprazole,​ tiagabine ​ | +
-^ Not recommended ​ | Atenolol, propranolol,​ buspirone, imipramine, pergolide, St John’s wort \\ \\ //​Adjunctive//:​ pindolol, clonazepam ​                                                                                  | +
-</​panel>​ +
- +
-<panel type="​info"​ title="​Pharmacotherapy ​for non-generalized ​social anxiety disorder ​(performance-type)"​ no-body="​true">​ +
-^ 1st line         | SSRI or SNRI, plus a beta-blocker ([[meds:​non-benzo-anxiolytics:​propranolol|propranolol]]) ​ | +
-^ 2nd line         | moclobemide ​ | +
-</​panel>​ +
- +
-== Medication Tips == +
-  * In performance-type social anxiety disorder, beta-blockers have been used for performance anxietyIn two clinical trialsno better ​than placebo, but clinically is used off-label in practice +
-  * If response to a medication ​is inadequate, dosing should be optimized and compliance assessed before switching to another agent +
-  * In patients who have inadequate response to optimal dosages of a first line agent or in whom the agent is not tolerated, switch to another first-line agent +
-  * Switch to second line after ''​2''​ failed trials of first-line +
-  * While benzodiazepines are a second-line ​treatment, they may be used at any time if there is an acute and severe exacerbation of agitation or anxiety in individuals with SAD who do not have co-morbid alcohol or substance abuse. However they should be used as a short term solution only (1⁄4 of patients with generalized SAD have co-morbid substance use). +
- +
-==== Cognitive Behavioural Therapy ==== +
-Cognitive behavioural therapy for social anxiety disorder ​includes several components:+
   - **Education** – about disorder and treatment, recommends self-help materials   - **Education** – about disorder and treatment, recommends self-help materials
   - **Exposure** – offers imaginal exposure to situations that are difficult to practice regularly in real life, offers in-vivo exposure to situations that provoke social anxiety during treatment sessions and homework, provides exposure role-play simulations,​ reduces safety behaviours in social situations   - **Exposure** – offers imaginal exposure to situations that are difficult to practice regularly in real life, offers in-vivo exposure to situations that provoke social anxiety during treatment sessions and homework, provides exposure role-play simulations,​ reduces safety behaviours in social situations
   - **Cognitive restructuring** – aims to reduce negative beliefs about self and others, works to reduce the excessive self-focus that is characteristic of SAD, examines and changes perfectionistic attitudes   - **Cognitive restructuring** – aims to reduce negative beliefs about self and others, works to reduce the excessive self-focus that is characteristic of SAD, examines and changes perfectionistic attitudes
   - **Social skills training** – deals with any areas of weak social skills such as eye contact or conversation skills, addresses any interpersonal problems, including lack of social contacts and friendships,​ improving social life, assertiveness,​ managing conflict, and dealing with romantic or problematic relationships   - **Social skills training** – deals with any areas of weak social skills such as eye contact or conversation skills, addresses any interpersonal problems, including lack of social contacts and friendships,​ improving social life, assertiveness,​ managing conflict, and dealing with romantic or problematic relationships
-  - **Emotion-regulation approaches** – offer relaxation approaches, acceptance of symptoms and anxiety ​+  - **Emotion-regulation approaches** – offer relaxation approaches, acceptance of symptoms and anxiety 
 +</​WRAP>​ 
 +<WRAP half column>​ 
 +<​HTML>​ 
 +<div id="​amazon">​ 
 +<div class="​ribbon"><​i class="​fa fa-star"></​i>​ Recommended Reading</​div>​ 
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 +<p> 
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 +</​WRAP>​ 
 +</​WRAP>​
  
 +==== Pharmacological ====
 +  * In performance-type social anxiety disorder only, beta-blockers have been used for performance anxiety.
 +  * If response to a medication is inadequate, dosing should be optimized and compliance assessed before switching to another agent.
 +  * In patients who have inadequate response to optimal dosages of a first line agent or in whom the agent is not tolerated, switch to another first-line agent.
 +    * Titrate up to higher doses of medication, as social anxiety typically responds only partially to antidepressants and usually requires the upper end of the dose range.
 +  * Switch to a second line medication after ''​2''​ failed trials of first-line.
 +  * While benzodiazepines are a second-line treatment, they may be used at any time if there is an acute and severe exacerbation of agitation or anxiety in individuals with SAD who do not have co-morbid alcohol or substance abuse. However they should be used as a short term solution only (1⁄4 of patients with generalized SAD have co-morbid substance use).
 +
 +<panel type="​info"​ title="​Pharmacotherapy for social anxiety disorder"​ subtitle="​Katzman,​ M. A. et al. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83." footer="​* = Beta-blockers have been successfully used in clinical practice for performance situations such as public speaking."​ no-body="​true">​
 +^ 1st line            | **Monotherapy**:​ escitalopram,​ fluvoxamine,​ fluvoxamine CR, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR                                           |
 +^ 2nd line            | **Monotherapy**:​ alprazolam, bromazepam, citalopram, clonazepam, gabapentin, phenelzine ​                                                                                |
 +^ 3rd line            | **Monotherapy**:​ atomoxetine,​ bupropion SR, clomipramine,​ divalproex, duloxetine, fluoxetine, mirtazapine,​ [[meds:​antidepressants:​maoi:​moclobemide|moclobemide]],​ olanzapine, selegiline, tiagabine, topiramate. ​ |
 +^ Adjunctive therapy ​ | Aripiprazole,​ buspirone, paroxetine, risperidone ​                                                                                                                       |
 +^ Not recommended ​    | **Monotherapy**:​ atenolol*, buspirone, imipramine, levetiracetam,​ propranolol*,​ quetiapine\\ **Adjunctive therapy**: clonazepam, pindolol ​                              |
 +</​panel>​
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