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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;
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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