Social anxiety disorder

Social anxiety disorder (SAD) is a widespread and serious malady causing significant distress and debilitation throughout several sections of the society. It begins characteristically in the mid-teenage years, a time when it is likely to cause the greatest damage to the psychological development of relationships and the establishment of goals in life. Untreated, SAD may continue to hinder the social functioning of the sufferer throughout his/her life. People with this disorder are more likely to be partly educated and often prefer to live in isolation.
Over the past 5 years we have learned a great deal about the underlying causes of social anxiety disorder. We have now in our hands a number of highly effective interventions, which can relieve years of chronic distress and impairment. Of greater priority, however, is the need to teach both healthcare professionals and the general public that social anxiety disorder is a soaring medical disorder and that there is no need to stigmatize it.
Social anxiety disorder, also known as social phobia, was believed to be a rare condition, but now it is estimated that it strikes at least one in ten people sometimes in their lives. The sufferers of this disorder are at considerable risk of co-morbidity with conditions such as major depressive illness, panic disorder and agoraphobia. These patients tend to have a high rate of alcohol and substance abuse and are twice as likely as the general population to attempt suicide.
Most of the distress and impairment in SAD can be alleviated if this condition is diagnosed earlier and treated effectively. Sadly, this disorder remains under-diagnosed and under-treated in Pakistan: only between 3 to 25 per cent of social anxiety suffers receive treatment.
In recent years, dramatic increase in research conducted in this field has made the diagnostic criteria increasingly practical and precise.

The essential features of social anxiety disorder are:

1) Fear of scrutiny by other people in social situations.

2) Marked persistent fear of performing situations in which embarrassment or humiliation may occur.

3) Avoidance of fear situations.

People suffering from this disorder have disproportionate fear of being negatively evaluated in a wide range of situations.
This condition may be specific to certain activities or performance situations or it may be generalized in which fear involves almost all social conducts.

The most common precipitating situations are:

1) Meeting people in authority.

2) Receiving visitors.

3) Being introduced.

4) Using telephone.

5) Being watched doing something.

6) Eating at home with acquaintances or in public.

7) Writing, speaking in public or in front of others.

When exposed to feared situations, the sufferer frequently experiences symptoms of anxiety such as palpitations, trembling, sweating, terse muscles, a sinking feeling in the stomach, dry throat, hot or cold feelings, tension or headaches.
Some people do not complain of somatic symptoms, but experience intense fear and apprehension and become extremely self-conscious. The sufferer with somatic complaints may be convinced that these symptoms are his/her primary problem and seeks medical treatment for these complaints, instead of proper medical intervention.
Avoidance of the feared situation is marked and in extreme cases it may lead to complete social isolation. Consequently, attempted suicide and suicidal ideations are common. A sufferer with combined depressive or phobic disorder is more than five times more likely than general population to attempt suicide.
Clinical experience of social anxiety disorder indicates that co-morbidity (that is pressure of other disorders like depressive illness, phobia disorders etc) is the rule. Though it can be uncomplicated by other disorders, it is important not to allow one condition to take precedence over the other while treating the patient.

Treatment

Social anxiety disorder must be treated when it causes personal distress and when adequate or optimal function is not being achieved due to symptoms or when avoidance of a certain common situation is marked.
It has been observed that patients response well to appropriate treatment. Phobic avoidance is driven by anxiety. Medication can directly alleviate this anxiety. In generalized social anxiety disorders excessive vulnerability or rejection or criterion can be specifically modified by certain pharmacotherapeutic regimens.
Drug treatment is not addictive or habit forming and does not cause withdrawal symptoms. It is important to know that this disorder is a chronic condition and it is likely to require long-term management. Even when the treatment is maintained for 6 months the relapse rate is 20 to 50 per cent when medication is withdrawn. The pharmacologic agents found to be most effective in social anxiety disorder are SSRIs and MAOIs. Other agents used are Benzodiazepnes and beta-blockers.
Psychotherapy is useful, particularly cognitive behaviour therapy has been found to be useful in encouraging suffers to confront their negative beliefs. Group therapy sessions are also helpful. Psychological techniques may be used as an alternative to psychotherapeutic drug therapy.

Case history

Arif, a married man, was referred by his physician for treatment of chronic anxiety. He complained of panic attacks, which worsened over the last one year, when he was promoted as field manager in the company he worked. In the last one year he had at least one major panic attack per week, characterized by symptoms of feeling apprehension, and that the world was going to end. He had dizziness, chest pain, trembling and hot and cold flushes during this attack.
The attacks occurred only in specific situations when he had to make a presentation at work. He became increasingly sad, had feelings of hopelessness and helplessness about his panic attacks and these secondary depressive symptoms also lead to his worries about his physical health. He gradually became so phobic that he refused to attend any social event, because of fear of embarrassing himself when he spoke.
His past history revealed that he was a shy child, and was always afraid in school and college to get up and answer a question in class. For a short period he developed school phobia for which he was treated by a child psychotherapist. His shyness and fear of social situations continued for many years before finally leading to panic attacks.
He had a positive history, that is, his sister and brother had also suffered panic attacks and his mother was diagnosed to have major depressive illness. Medically, he was fit. There was no history of drug abuse, he did not smoke and avoided caffeine.
Psychiatric evaluation showed anxiety and mild symptoms of depression. He was treated with paroxetine and SSRI (the first FDA approved drug for social phobia), along with cognitive behaviour therapy and social skills training. The key goal in the treatment was to curtail anxiety, improve ability to function socially at work, improve well being and quality of life and alleviate coexisting depression. In 6-8 weeks he made a fair recovery and the treatment was continued for 12 months. There is evidence of relapse if treatment is stopped before time.

Ref. Dawn