Muzina

DAVID J. MUZINA, MD
SAMAR EL-SAYEGH, MD
Director, Adult Psychiatry Inpatient Unit, Recognizing and treating
social anxiety disorder
A B S T R AC T
M about social anxiety disorder, their
Social anxiety disorder is the third most common psychiatric interest piqued by popular reports of treatment disorder in the United States. Patients strive to avoid stress- inducing situations, or they may endure them with marked advertising about medications. However, thenature of social anxiety disorder often prevents psychological distress and physical reactions, including sweating and tachycardia. Social anxiety disorder can be diagnosed by a careful history and can be treated important because pharmacologic, psychoso- successfully with medications or psychosocial interventions.
cial, and even surgical treatments are success-ful in reducing the personal and social burden ■ K E Y P O I N T S
of this common condition. Unfortunately, likemany other psychiatric disorders, social anxi- Basic screening questions for this condition can be asked in ety disorder remains under-recognized by clin- a few minutes and can identify patients who need further ed the lifetime prevalence of social anxiety dis- Patients with social anxiety disorder frequently have order to be 13.3%, making it the most com-mon anxiety disorder and the third most com- psychological comorbidities, including major depressive mon psychiatric disorder in the United States, after major depression and alcohol depen-
dence (FIGURE 1).4–6
Genetic, familial, and neurobiological factors are thought toplay interrelated causative roles.
■ SYMPTOMS AND SUBTYPES
OF SOCIAL ANXIETY DISORDER
Comprehensive treatment includes pharmacologic andpsychotherapeutic interventions, which can greatly alleviate It is normal to experience occasional mild the symptoms and negative consequences.
discomfort and anxiety in a new social situa-tion or public engagement. However, whenthis emotion becomes a marked and persis-tent fear causing distress or leading to avoid-ance of certain situations, the physicianshould consider a diagnosis of social anxietydisorder, a condition previously termed socialphobia.7 scrutinized by others or doing somethingembarrassing in front of strangers is the hall-mark of social anxiety disorder.7 Patients withthe disorder may go to great lengths to avoid a C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E V O L U M E 6 8 • N U M B E R 7 J U LY 2 0 0 1 SOCIAL ANXIETY DISORDER
their performance. They may fear that a socialsituation will induce “thought blocking,”causing them to become speechless or inco-herent. Patients may also have an overwhelm-ing fear that they will appear unwell by trem-bling, blushing, or sweating, or they may worrythat they will do or say something stupid or“crazy.”7,13 Activities feared by many patientswith social anxiety disorder include being inpublic while eating, ordering food, or writing; Not available for online publication.
asking questions or introducing themselves in See print version of the
a group; meeting strangers or people in author- Cleveland Clinic Jour nal of Medicine
ity; or using public facilities such as restrooms
or telephones (TABLE 2).11,14,15
In addition, patients with social anxiety disorder experience many physical symptoms
(TABLE 3).5 These include sweating, trembling,
palpitations, shortness of breath, nausea, diar-
rhea, and blushing.11,16 The last is very com-
mon, reported in approximately 50% of
patients. As Charles Darwin noted, blushing
occurs in response to “thinking of what others
think of us,”17 a problem central to social anx-
iety disorder. FIGURE 2 schematically demon-
situation that requires them to interact or per- strates the feedback loop between the physical form in a social setting, or they may endure such situations with anxiety and dismay.8,9 Social anxiety
TABLE 1 lists the diagnostic criteria from the
■ USE OF SCREENING QUESTIONS
fourth edition of the American Psychiatric FOR SOCIAL ANXIETY DISORDER
disorder usually Association’s Diagnostic and Statistical Manual
develops
for Mental Disorders (DSM-IV).
Often, the topic of social anxiety disorder aris- Two subtypes of social anxiety disorder are es during an appointment with a physician before age 20
recognized. When the fear is confined to a when a patient refers to having problems from particular type of social or performance situa- tion—the most common is speaking in front of an audience—the disorder is called specific questions to identify patients requiring further (or discrete) social anxiety disorder or perfor- investigation (TABLE 4). Patients who respond
affirmatively to several of these questions and abling type is generalized social anxiety disor- who are experiencing distress, negative conse- der, in which the patient experiences perva- quences, or both may have significant social sive fears in most social interactions and situ- anxieties and may benefit from treatment or Typically, social anxiety disorder develops the Liebowitz Social Anxiety Scale19 are also individuals report an onset in early childhood.
available and may allow patients the comfort The onset may be insidious or may follow a of rating their own symptoms privately with- out feeling intimidated by direct questioning Patients with social anxiety disorder expe- rience cognitive distortions, including unreal- istic false beliefs about social situations and patient’s history meets the DSM-IV criteria negative perceptions of others’ reactions to (TABLE 1).
650 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 68 • NUMBER 7 JULY 2001 ■ DIFFERENTIAL DIAGNOSIS
The differential diagnosis of social anxiety dis-
order includes a wide array of psychiatric and
medical disorders that can cause the patient to
develop a pattern of avoiding social situations.
The most common conditions to be excluded
are major depressive disorder, panic disorder
with agoraphobia, avoidant personality disor-
der, medical conditions with physical manifes-
tations that cause social withdrawal, and gen-
eral shyness (TABLE 5).
Not available for online publication.
See print version of the
Depression
Cleveland Clinic Jour nal of Medicine
In some patients, major depressive disordermay be characterized by severe anxiety andsocial isolation. However, depression is alsoassociated with neurovegetative signs andsymptoms that are not typical of social anxi-ety disorder: sleep and appetite changes,anhedonia or lack of ability to feel pleasure,and suicidal thinking. Fortunately, antide-pressant medications are helpful for bothdepression and social anxiety disorder,whether they occur independently or ascomorbidities.
Panic disorder
Medical disorders
Common fears
The panic attacks associated with panic disor- Medical conditions such as Parkinson disease include eating
der may be triggered by social situations.
that produce obvious physical symptoms such However, in contrast to patients with social as stuttering can lead to socially avoidant in public or
anxiety, those with panic disorder do not fear behavior. For example, stutterers may avoid the social exposure but rather are concerned speaking in new social settings for fear that by the panic attack itself. In fact, patients strangers
with severe panic disorder complicated by these individuals have fears that are rational- agoraphobia often dread being alone and pre- ly grounded in their symptoms. In contrast, fer being around people in case they need help patients with social anxiety disorder have Avoidant personality
should be diagnosed with social anxiety only if Personality can confound the diagnosis of the social fear is unrelated to the physical social anxiety. Avoidant personality disorder symptoms. For example, social anxiety may be may cause significant social anxiety and inhi- identified in a Parkinson patient who avoids bition. Patients with this condition experi- social interactions, not for fear of being seen trembling, but rather because of a fear of act- marked hypersensitivity to negative evalua- tion. Like patients with social anxiety, theyavoid activities that involve significant social or interpersonal contact. However, unlike General, nonpathologic shyness may be simi- most social anxiety disorder patients, they lar to social anxiety, and the two can be diffi- often view themselves as inferior to others or cult to distinguish in some cases. A guiding principle should be that shyness does not usu- C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E V O L U M E 6 8 • N U M B E R 7 J U LY 2 0 0 1 SOCIAL ANXIETY DISORDER
Some common fears
Physical signs and symptoms
in social anxiety disorder
of social anxiety disorder
Asking questions or giving reports in groups Meeting or talking to people in authority Being assertive or expressing disagreement tions.20 In addition, persons with social anxi- ety disorder are less likely to marry, more like- ly to divorce, and more likely to be unem- Consequently, at least one third of these Experience
patients have reduced productivity, leading to dependence on the family and the state. In attenuates
one sample of patients with social anxiety dis- shyness but not ally invoke considerable socially disabling dis- appear to have a higher rate of concomitant
social anxiety
tress. Also, shyness can be attenuated by expe- physical illnesses and to use medical outpa- rience. In contrast, social anxiety causes pro- tient services more often than subjects with- disorder
found distress and functional limitations, and social experiences may actually reinforce thefears. Psychiatric consultation can help clarify ■ PSYCHIATRIC COMORBIDITIES
Social anxiety disorder is complicated by the ■ PERSONAL AND SOCIAL EFFECTS
presence of coexisting psychiatric conditions OF SOCIAL ANXIETY DISORDER
in 70% to 80% of cases.20 In the primary caresetting, patients with social anxiety disorder Because social anxiety disorder usually starts at an early age, it can interfere meaningfully with comorbid major depressive disorder, which normal development and create harmful cop- usually develops after the onset of the social ing mechanisms.1,20 Having the disorder is anxiety. Comorbidity increases the probability associated with lower educational achieve- of disability and suicide. The suicide attempt rate in uncomplicated social anxiety disorder higher frequency of being absent or late for is 1%, rising to 16% when the disorder is com- work. It is also sometimes associated with plicated by a comorbid psychiatric condi- avoiding work duties such as making presenta- C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E V O L U M E 6 8 • N U M B E R 7 J U LY 2 0 0 1 though inappropriate, coping mechanisms.
Social anxiety disorder:
Alcohol may be used by many patients in an A positive feedback loop
attempt to “self-medicate” or reduce anxietyin social situations. Alcohol abuse is report- Social situation
ed in 17% of social anxiety disorder patients,and other drug abuse in 13%.21 Alcoholabuse usually evolves over many years after Perception of social situation
the onset of social anxiety disorder. In theo- as threatening
ry, detecting social anxiety disorder earlymay assist in the prevention of alcohol ordrug dependence in these susceptible Autonomic stimulation
Avoidance
■ CAUSES OF SOCIAL ANXIETY DISORDER
Although the pathophysiology of social anxi- ety disorder is not fully understood, it likelyinvolves interplay between genetics, family Negative cognitions
modeling, neurobiology, and cognitive behav- Genetic and familial factors
FIGURE 2. A model illustrating the basic concept of
Evidence for a genetic contribution comes social anxiety disorder. In this model, the patient from twin studies, which report concordance perceives interactions with strangers as threatening rates of 24% in monozygotic twins and 15% in as a result of negative cognitions. This leads to dizygotic twins. First-degree relatives of activation of the autonomic system and avoidance of patients are more than three times as likely to the situation, which in turn reinforces the negative develop social anxiety disorder than are unre- perception and sense of failure, again leading toavoidance.
lated individuals.22 Children of parents withsocial anxiety disorder are more likely todevelop the condition than children of par-ents without it.23 Also, parental overprotection or rejection must experience the situation, they feel high is associated with increased rates of the disor- levels of anxiety. A vicious cycle develops, in der.23 Children may learn fears from observing which the heightened anxiety reinforces their fear reactions from their parents, consequent- belief that the world is a bad place or that oth- ly modeling or developing avoidance behav- ior. Overprotection may prevent childrenfrom being exposed to challenging or stressful Neurobiological factors
situations, which are normal factors in human Serotonergic function. A role for sero-
tonin is suggested by the clinical efficacy of psychotropic medications such as monoamineoxidase inhibitors (MAOIs), reversible The cognitive behavioral model
monoamine oxidase inhibitors (RIMAs), and Patients with social anxiety disorder tend to view the world as a negative, defeating place, (SSRIs). Increased serum cortisol levels and a mindset that is known as having negative anxiety in response to fenfluramine challenge cognitions. They frequently judge themselves provide limited evidence to support postsy- harshly and perceive others’ reactions to their naptic hypersensitivity in at least a subgroup performance to be negative. They learn to avoid the stress-inducing situations; if they study that measured peripheral serotonergic C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E V O L U M E 6 8 • N U M B E R 7 J U LY 2 0 0 1 SOCIAL ANXIETY DISORDER
function did not show any difference betweenpatients and controls.5,16,24 Screening questions
Dopaminergic function.
for social anxiety disorder*
involvement has been suggested by two lines ofevidence. First, social anxiety disorder develops Are you uncomfortable or embarrassed when you are the center in some patients treated with antidopaminergic of attention, or when you are asked to do things in public likespeaking, eating, or signing a check? agents such as haloperidol (Haldol) and insome patients with Parkinson disease, which is Do you find it hard to interact with people? associated with dopaminergic changes. Second, Is being embarrassed or looking “stupid” among your worst fears? social anxiety symptoms respond to MAOIsand bupropion (Wellbutrin), both of which Does fear of doing something embarrassing or humiliating cause you to avoid doing things or speaking to people? The clinical studies are, however, contra- Do you avoid activities that put you at the center of attention? dictory. One study showed no differencebetween social anxiety patients and controls *An affirmative answer to two or more of these questions should cause in levodopa levels, prolactin levels, and eye one to suspect the diagnosis and warrants further investigation blink response.24 However, another smallstudy found that patients had markedly lowerstriatal dopamine reuptake site densities thandid controls.25,26 Adrenergic function. Patients with spe-
cific performance social anxiety disorder expe- Differential diagnosis
rience larger increases in heart rate than do of social anxiety disorder
patients with the generalized disorder. The dif- All of the following lead to avoidance of social situations:
ference may explain why beta-blockers areeffective in specific social anxiety but not in Social anxiety disorder
generalized social anxiety disorder. No consis- tent abnormalities have been found in plasma Medical condition with physical manifestation
Central chemoreceptor sensitivity can be
assessed by having patients inhale 35% carbon dioxide, an anxiogenic or panic-inducer.
When subjected to this test, patients withsocial anxiety disorder have central chemore- Panic with agoraphobia
ceptor sensitivity levels somewhere between those of normal controls and those of panic Fear that escape or help is not available Dread being alone and prefer being around people Growth hormone deficiency may be asso-
Depression
ciated with increased risk of developing an anx- Differentiated by clear anhedonia (lack of all pleasure) iety disorder, but further studies are needed.24 Abnormal patterns of brain activation.
Neuroimaging studies in social anxiety disor-der patients have shown that the right dorso- lateral prefrontal cortex and the left parietal cortex are uniquely activated while the patient experiences anxiety. Interestingly, these areas Avoidant personality disorder
may be related to planning effective behavioral responses and awareness of body position, May be a more severe form of social anxiety disorder chopathology of social anxiety disorder.24 (Asmentioned previously, patients with socialanxiety disorder are concerned by potential C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E V O L U M E 6 8 • N U M B E R 7 J U LY 2 0 0 1 Medication dosing strategies
for generalized social anxiety disorder
STARTING DOSE
TARGET DOSE
SSRIs (first-line therapies for generalized social anxiety disorder)
Citalopram (Celexa)
Alternative therapies
Gabapentin (Neurontin)
Therapies for specific performance anxieties
Propranolol (Inderal, others)
10–80 mg 1 hour before a stress-inducing performance 25–100 mg 1 hour before a stress-inducing performance scrutiny. Their topographical relationship to tine (Paxil) was effective and well-tolerated in others and their own responses behaviorally are key factors in understanding this illness.) are characteristic of social anxiety disorder.
SSRIs are
In one study, functional magnetic resonance The trial lasted 12 weeks; the dosage of parox- the preferred
imaging showed that the amygdala and hip- pocampus were activated more intensely in Other small studies demonstrated the effi- treatment
patients with social anxiety disorder than in cacy of fluvoxamine (Luvox) at 100 to 300 mg for social
controls presented with similar stimuli.27 daily and of sertraline (Zoloft) at 50 to 200 mgdaily. Citalopram (Celexa) and fluoxetine ■ PHARMACOLOGIC TREATMENT
(Prozac) have also been shown to be effective disorder
Several pharmacologic therapies have proven Generally well tolerated, SSRIs have pro- effective for reducing the symptoms and func- tional limitations experienced by patients with social anxiety disorder (TABLE 6). The pre-
Starting dosages for social anxiety disor- ferred medication class is the selective sero- tonin reuptake inhibitors, but several other depressive disorders to reduce chances of an drugs also have a role in the treatment of this acute activating or energizing effect (TABLE 6).
Starting the dose too high or increasing thedosage too quickly may actually worsen anxi- Selective serotonin
ety in these already anxious patients.
reuptake inhibitors (SSRIs)
This group of medications is considered the
Monoamine oxidase inhibitors (MAOIs)
first line of pharmacologic treatment for social Before the advent of SSRIs, MAOIs were con- sidered the first-line drug treatment for social anxiety disorder. However, problems with tol- ble-blind study of an SSRI found that paroxe- erability, including drug interactions, limit C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E V O L U M E 6 8 • N U M B E R 7 J U LY 2 0 0 1 SOCIAL ANXIETY DISORDER
their use. A tyramine-restricted diet is required TABLE 6 lists starting and target doses for med-
to reduce the chances of hypertensive crises.4 ications for the treatment of generalized social anxiety disorder. However, SSRIs remain the treating social anxiety disorder is phenelzine first-line agents, and MAOIs or newer agents (Nardil), which is effective in doses between should generally be reserved for treatment- 30 to 90 mg per day. However, psychiatric and refractory patients or used in consultation before initiating therapy with MAOIs.
■ PSYCHOLOGICAL TREATMENT
Benzodiazepines
Limited data support the efficacy of high-
The cornerstone of psychosocial treatment for potency benzodiazepines, specifically clon- anxiety is exposure to the feared situation, azepam (Klonopin) and alprazolam (Xanax).
either in real life or in role-play. Of the psy- The rapid anxiolytic effect of these medica- chosocial interventions for social anxiety dis- tions may be advantageous for some patients order, cognitive-behavioral therapy is support- with a specific performance anxiety, such as fear of giving a speech, who could take the behavioral therapy, the therapist uses exposure medication just before the performance.
to help induce cognitive restructuring, that is, to change the patient’s interpretation of the unwanted side effects such as sedation and feared situation and the belief that the out- come is a failure. The patient also undergoes social skill training, including modeling zodiazepines because long-term use may lead appropriate behavior, receiving feedback, and to physical dependence, including withdrawal symptoms when the drug is discontinued. In Cognitive-behavioral therapy appears to be addition, benzodiazepines interact strongly particularly effective for treating social anxi- with alcohol, and comorbid alcohol depen- Beta-blockers
In other psychological disorders, combin- may be useful
therapy is more effective than either modality for specific
Beta-blockers
Although beta-blockers may be used to treat therapy with nefazodone is an effective com- performance
specific performance-related anxiety, con- bination for treatment of chronic depression, trolled studies have not supported their effica- cy in generalized social anxiety disorder.5,30 imipramine is effective for panic disorder.32,35 Their efficacy in performance anxiety may be Such combinations have not been studied in attributable to their ability to decrease the social anxiety disorder, but the effectiveness of peripheral physical symptoms of anxiety, such each modality alone suggests that combina- as tachycardia and tremor, thus minimizing the perception of anxiety. Beta-blockers are Specific anxieties, such as the fear of pub- less likely to cause sedation and cognitive side lic speaking, can be addressed in a group set- effects than are benzodiazepines. Propranolol ting that educates and desensitizes the affect- (Inderal, others; 10 to 80 mg) and atenolol (Tenormin, others; 25 to 100 mg) are equally International is an organization that gives effective and may be used as needed 1 hour members the opportunity to speak to groups before the triggering event in patients with and work with others in a supportive environ- specific performance-related anxiety.5,30 ment. A typical Toastmasters club is made upof 20 to 30 people who meet once a week for Other medications
about an hour. Local meetings can be found by contacting Toastmasters at 949-858-8255 or include venlafaxine (Effexor), nefazodone by accessing the organization’s website at (Serzone), and gabapentin (Neurontin).31–33 www.toastmasters.org.
C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E V O L U M E 6 8 • N U M B E R 7 J U LY 2 0 0 1 ■ SURGICAL INTERVENTIONS
with severe, treatment-resistant social anxietydisorder.
One prospective study suggests that endoscop-ic thoracic sympathicotomy may be effective ■ FOLLOWING UP WITH PATIENTS
in patients who do not respond to medicationor psychological therapy. Ablating the upper Patients will probably benefit in the short thoracic sympathetic nerve segments relieves physical signs and symptoms of sympathetic general practitioner. In addition, most should arousal (such as sweating) that precipitate or also be considered for referral to a psychiatrist reinforce negative cognitions and avoidance.36 for a complete medical, psychiatric, and psy- chological evaluation and formulation of a in deep brain stimulation, it is also possible that this procedure may offer hope to patients ■ REFERENCES
20. Montgomery SA. Social phobia: diagnosis, severity and implications
for treatment. Eur Arch Psychiatry Clin Neurosci 1999; 249(suppl 1. Ballenger JC, Davidson JR, Lecrubier Y, et al. Consensus statement on
social anxiety disorder from the International Consensus Group on 21. Lecrubier Y. Comorbidity in social anxiety disorder: impact on disease
Depression and Anxiety. J Clin Psychiatry 1998; 59(suppl 17):54–60.
burden and management. J Clin Psychiatry 1998; 59(suppl 17):33–37.
2. Westenberg HG. The nature of social anxiety disorder. J Clin Psychiatry
22. Kaplan HI, Sadock BJ. Comprehensive textbook of psychiatry. 6th ed.
Vol. 1. Baltimore: Williams & Wilkins; 1989:1204–1217.
3. Haug TT, Hellstrom K, Blomhoff S, et al. The treatment of social pho-
23. Lieb R, Wittchen HU, Hofler M, Fuetsch M, Stein MB, Merikangas KR.
bia in general practice. Is exposure therapy feasible? Fam Pract 2000; Parental psychopathology, parenting styles, and the risk of social pho- bia in offspring: a prospective-longitudinal community study. Arch 4. Scott EL, Heimberg RG. Social phobia: an update on treatment.
24. Bell CJ, Malizia AL, Nutt DJ. The neurobiology of social phobia. Eur
5. Fones CS, Manfro GG, Pollack MH. Social phobia: an update. Harv Rev
Arch Psychiatry Clin Neurosci 1999; 249(suppl 1):S11–S18.
25. Nutt DJ, Bell CJ, Malizia AL. Brain mechanisms of social anxiety disor-
6. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month
der. J Clin Psychiatry 1998; 59(suppl 17):4–11.
prevalence of DSM-III-R psychiatric disorders in the United States.
26. Tiihonen J, Kuikka J, Bergstrom K, Lepola U, Koponen H, Leinonen E.
Results from the National Comorbidity Survey. Arch Gen Psychiatry Dopamine reuptake site densities in patients with social phobia. Am J 7. American Psychiatric Association. Diagnostic and statistical manual of
27. Schneider F, Weiss U, Kessler C, et al. Subcortical correlates of differ-
mental disorders. 4th ed. Washington, D.C.: American Psychiatric ential classical conditioning of aversive emotional reactions in social phobia. Biol Psychiatry 1999; 45:863–871.
8. Elliot WH, Reifler B. Social anxiety disorder. A guide for primary care
28. Stein MB, Liebowitz MR, Lydiard RB, Pitts CD, Bushnell W, Gergel I.
physicians. North Carolina Med J 2000; 61(3):176–178.
Paroxetine treatment of generalized social phobia (social anxiety dis- 9. Lamberg L. Social phobia: Not just another name for shyness. JAMA
order): a randomized controlled trial. JAMA 1998; 280:708–713.
29. Bouwer C, Stein DJ. Use of the selective serotonin reuptake inhibitor
10. Stein MR, Chavira DA. Subtypes of social phobia and comorbidity with
citalopram in the treatment of generalized social phobia. J Affect depression and other anxiety disorders. J Affect Disord 1998; 30. Davidson JR. Pharmacotherapy of social anxiety disorder. J Clin
11. Brunello N, den Boer JA, Judd LL, et al. Social phobia: diagnosis and
Psychiatry 1998; 59(suppl 17):47–53.
epidemiology, neurobiology and pharmacology, comorbidity and 31. Altamura AC, Pioli R, Vitto M, Mannu P. Venlafaxine in social phobia: a
treatment. J Affect Disord 2000; 60:61–74.
study in selective serotonin reuptake inhibitor non-responders. Int Clin 12. Sareen L, Stein M. A review of the epidemiology and approaches to
the treatment of social anxiety disorder. Drugs 2000; 59:497–509.
32. Keller MB, McCullough JP, Klein DN, et al. A comparison of nefa-
13. Stravynski A, Greenberg D. The treatment of social phobia: a critical
zodone, the cognitive behavioral-analysis system of psychotherapy, assessment. Acta Psychiatr Scand 1998; 98:171–181.
and their combination for the treatment of chronic depression. N Engl 14. Bruce TJ, Saeed SA. Social anxiety disorder: A common, underrecog-
nized mental disorder. Am Fam Physician 1999; 60:2311–2322.
33. Pande AC, Davidson JR, Jefferson JW, et al. Treatment of social phobia
15. Stein MB, Torgrud LJ, Walker JR. Social phobia symptoms, subtypes,
with gabapentin: a placebo-controlled study. J Clin Psychopharmacol and severity: findings from a community survey. Arch Gen Psychiatry 34. Telaranta T. Treatment of social phobia by endoscopic thoracic sympa-
16. Kasper S. Social phobia: The nature of the disorder. J Affect Disord
thicotomy. Eur J Surg Suppl 1998; 580:27–32.
35. Ballenger JC. Anxiety disorders in adults. Biol Psychiatry 1999;
17. Stein DJ, Bouwer C. Blushing and social phobia: A neuroethological
speculation. Med Hypotheses 1997; 49:101–108.
36. Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral
18. Turner SM, Beidel DC, Dancv CV, et al. An empirically derived invento-
therapy, imipramine, or their combination for panic disorder: a ran- ry to measure social fears and anxiety: The Social Phobia and Anxiety domized controlled trial. JAMA 2000; 283:2529–2536.
Inventory. Psychological Assessment: A Journal of Consulting andClinical Psychology 1989; 1:35–40.
ADDRESS: David J. Muzina, MD, Department of Psychiatry and Psychology,
19. Liebowitz MR. Social phobia. Mod Probl Pharmacopsychiatry 1987;
P57, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH C L E V E L A N D C L I N I C J O U R N A L O F M E D I C I N E V O L U M E 6 8 • N U M B E R 7 J U LY 2 0 0 1

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