Social Phobia
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process
A Presentation for the Students of Ohio University
Heritage College of Osteopathic Medicine
Kendall L. Stewart, MD, MBA, DFAPA
November 29, 2011
Why is this important?1
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The 12-month prevalence rate of Social
Anxiety Disorder (SAD) is
– 6.6% for males and
– 9.1% for females.
People with this disorder have a
persistent and admittedly irrational
fear of performing in social situations.
They are convinced that they will
perform poorly and be humiliated as a
result.
Their fears may be specific2 or
generalized.
These patients experience anticipatory
anxiety and/or panic attacks.
Avoidance is a common complication.
Impairment results.3
1Goldman,
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After mastering the information in
this presentation, you will be able
to
– Describe how patients with Social
Anxiety Disorder often present,
– Detail the diagnostic criteria,
– Describe some of the associated
features,
– List some differential diagnoses,
– Write a preliminary treatment
plan, and
– Identify some of the frequent
treatment challenges.
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This disorder is also called Social
Phobia.
2008
most common fear is the fear of public speaking.
3The wages of a person with SAD are 14% lower than those without the disorder.
2The
How might a patient with Social Anxiety
Disorder present?1
• This is a 22-year-old medical
student.
• “I’m thinking of dropping out of
medical school.”
• “I simply cannot give an oral
presentation.”
• “I was always able to get out of
giving speeches in high school
and college.”
• “I would have no problem with
writing a paper, but the idea of
speaking in front of a group is
unbearable.”
• “When I’ve tried to do it before,
I’ve experienced panic and had
to leave the room.”
1Goldman,
2008
2People—particularly
3Even
• “Just thinking about having to
do it makes gives me
palpitations and triggers
diaphoresis.”
• “I can’t sleep and I can’t
concentrate on my studies.”
• “If you can’t make an exception,
I will have to drop out of
school.”
• “My father dropped out of law
school for the same reason.”
• “I hate being this way.”2,3
men—are often deeply ashamed of symptoms of depression and anxiety.
accepting treatment may be too much to bear. A patient refused to take antidepressants and died.
What are the diagnostic criteria for Social
Phobia?
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The person experiences excessive and
persistent fear of one or more social
performance situations.
He or she experiences feelings of
anxiety, fear or panic immediately upon
encountering the feared social
situation.
The person recognizes that the fear is
excessive, unreasonable or out of
proportion to the actual risk in the
situation.
The patient tends to avoid the feared
social situation, or if he or she does not
avoid it, the situation is endured with
intense anxiety or discomfort.
The patient’s symptoms of anxiety and
avoidance behavior cause significant
distress or impairment.
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The problem must be present for at
least six months in children under 18.
The symptoms of anxiety are not
caused by
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A medical condition or
Substance abuse.
If the patient has another medical
condition with visible symptoms such
as stuttering, the fear must not be only
of others noticing these medical
symptoms.
If the individual fears most social
situations, the SP is viewed as
generalized.
SP can occur in very specific social
situations too.
You can watch a sufferer’s description
here.
What do people with Social Anxiety
Disorder fear and avoid?1
• Performance Situations
• Social Interaction Situations
– Public speaking
– Talking in meetings or classes
– Participating in sports or
working out in front of others
– Performing music or acting on
stage
– Writing in front of others
– Eating or drinking in front of
others
– Using public restrooms while
others are nearby
– Making mistakes in front of
others1
– Being in public areas such as a
shopping mall or in a bus
1Suffering
public humiliation is no fun. I once teed off first in Augusta.
– Going to parties
– Having a conversation with
others
– Talking to strangers
– Inviting friends over for dinner
– Talking on the phone
– Expressing personal opinions
– Asserting oneself
– Being in intimate situations
– Talking to authority figures
– Returning items to a store
– Sending food back in a
restaurant
What associated features might you
see?1
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Excessive sensitivity to criticism
Problems with appropriate
assertiveness
Low self-esteem
Feelings of worthlessness
Test anxiety
Inept social interactions
Poor work history
Social introversion
Suicidal thought
Epidemiological studies suggest
the disorder is more common in
women, but males are more
common in most clinical samples
Typical onset in teens
Course is typically fluctuating but
lifelong
1DSM-IV-TR,
2Be
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Physical manifestations of anxiety
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Academic underachievement
Inadequate social support
Comorbid psychiatric disorders
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Tremulousness
Shaky voice
Cold, clammy hands
Sweating
Dilated pupils
Other anxiety disorders2
Mood disorders
Substance-related disorders
Eating disorders
Personality disorders
More frequent among first-degree
biologic relatives
2000
sure to look for Generalized Anxiety Disorder. What is the most frequently-missed lesion on a medical image?
What other diagnoses might you include in
the differential diagnosis?1
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Panic Disorder with Agoraphobia usually
begins with an unexpected panic attack
and continues with subsequent avoidant
behavior not limited to social situations.
People with Agoraphobia typically prefer
to be with a trusted companion.
Children with Separation Anxiety Disorder
resist being separated from their
caretaker, but they are usually
comfortable in social situations when the
caretaker is present.2
While fear of embarrassment or
humiliation may accompany Generalized
Anxiety Disorder or Specific Phobia, these
are not the principal foci of the patient’s
dread.
1DSM-IV-TR,
2Martha
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In Pervasive Developmental Disorder and
Schizoid Personality Disorder social
situations are avoided because of a
profound lack of interest in social
interaction.
Avoidant Personality Disorder probably
overlaps with SAD, Generalized Type.
Social anxiety in a symptom is many other
mental disorders, but it is not the principal
symptom in these cases.
Of course, anxiety frequently accompanies
a variety of general medical disorders.
Substance-Use Disorders also cause
anxiety.
Performance anxiety, stage fright, and
shyness should not be diagnosed as SAD
unless clinically significant impairment or
marked distress results.
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McCranie told of taking a child to get a cola and losing money in the machine.
What might a typical treatment plan look
like?1
• Anticipatory Anxiety
– Predict it
– Consider medication options
that follow
• Panic Attacks
– Consider short-term
clonazepam 1mg twice per day
initially and taper slowly as
antidepressant kicks in.
– Begin paroxetine 10-20mg
twice per day
• Avoidance Behavior
– Real exposure therapy
– Imagined exposure therapy
– Gradual and repetitive
confrontation of feared
situations2
1DSM-IV-TR,
• Generalized Anxiety
– Buspirone 15mg twice per day
– Most SSRIs are helpful
• Maladaptive attitudes and
behaviors
– Cognitive behavioral
psychotherapy
• Education and Support
– Refer to appropriate Internet
sites
– Provide citations
– With consent, refer to other
sufferers3
– Consider referral to self-help
groups
2000
continuous exposure, mastery is quickly lost.
3Referrals to other patients doesn’t always work out well. “That woman is crazy, Doc!”
2Without
What are some of the treatment
challenges you can expect?
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1A
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Noncompliance is always the principal challenge.
Lack of motivation is often an issue.
Acceptance of disability limits further progress.
Excessive sensitivity to medication side effects frequently
complicates treatment.
These patients often have a variety of comorbid medical and
psychiatric conditions
Unrealistic expectations for a quick and permanent cure limit the
patient’s ability to adopt a chronic disease management philosophy
and practice.
People with anxiety sometimes remain convinced that something
“physical” is wrong and remains undiscovered.
These patients can be very sensitive to your perceived rejection.1
These miserable people demand a lot of attention and easily morph
into dependent, clinging emotional black holes. It is critical not to
promise more than you can deliver.2
patient misinterpreted my sigh. Another patient suspected the Lysol© was intended for her.
colleague of mine agreed to call a patient at 10 PM every day. I had to manage the case when he left.
Where can you learn more?
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American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third
Edition, 2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical
Psychiatry, 2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April
2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship,
Second Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review,
Twelfth Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,
January 2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home,
Work and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous
Patients,” 2000
Where can you find evidence-based
information about mental disorders?
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Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties of your
choice here.
Subscribe to Evidence-Based Mental Health and search a database at the
National Registry of Evidence-Based Programs and Practices maintained by
the Substance Abuse and Mental Health Services Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
StewartK@somc.org
KendallLStewartMD@yahoo.com
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
John Gilbert, DO
OUCOM 1989
Kevin Kammler, DO
OUCOM 1993
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