History

Fact Explanation
Marked and persistent fear of social or performance situations in which people are exposed to unfamiliar people or possible scrutiny by others. The person thinks he or she will act in a way which will be humiliating or will show anxiety symptoms. [1]
Exposure to social situations almost invariably provoke anxiety. It may take form of a situationally provoked panic attack. [1]
The person recognizes that the fear is excessive and unreasonable . The children having social phobia may not show this. [2]
The feared social performance situations are avoided. Sometimes these situations are endured with dread. [1]
The avoidance, anxious anticipation interferes significantly with person's normal routine. It interferes with occupational functioning and social activities and relationships and the person is markedly distressed about having the phobia. [3]
In individuals under 18 years duration is at least 6 months. The course of social phobia tends to be chronic, with a long duration of illness and low rates of recovery. [1]
The fear or avoidance is not due to a direct physiological effects of a substance or a general medical condition and is not better accounted by another mental disorder. Panic disorder, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, schizoid personality disorder. Anxiety symptoms are brought about by substance use/abuse (eg, caffeine, amphetamines, marijuana, cocaine) and withdrawal (eg, from alcohol) . And medications with anxiogenic effects (β-adrenergic agonists,theophylline, corticosteroids, thyroid hormone, sympathomimetics,psychostimulants). Hyperthyroidism, Congestive heart failure, Cardiac arrhythmia, Chronic obstructive pulmonary disease, hyperventilation, Pulmonary embolism, Pheochromocytoma, Hyperadrenalism can cause anxiety symptoms. [1]
If a general medical condition or another mental disorder is present, the fear is unrelated to it. Anxiety symptoms are not exclusively present during the time period of the other mental disorder or the medical condition. [1]
References
  1. CANTON J, SCOTT KM, GLUE P. Optimal treatment of social phobia: systematic review and meta-analysis Neuropsychiatr Dis Treat [online] 2012:203-215 [viewed 14 June 2014] Available from: doi:10.2147/NDT.S23317
  2. BURSTEIN M, HE JP, KATTAN G, ALBANO AM, AVENEVOLI S, MERIKANGAS KR. Social Phobia and Subtypes in the National Comorbidity Survey-Adolescent Supplement: Prevalence, Correlates, and Comorbidity J Am Acad Child Adolesc Psychiatry [online] 2011 Sep, 50(9):870-880 [viewed 14 June 2014] Available from: doi:10.1016/j.jaac.2011.06.005
  3. WONG N, SARVER DE, BEIDEL DC. Quality of Life Impairments among Adults with Social Phobia: The Impact of Subtype J Anxiety Disord [online] 2012 Jan, 26(1):50-57 [viewed 14 June 2014] Available from: doi:10.1016/j.janxdis.2011.08.012

Examination

Fact Explanation
Cardiovascular examination Symptoms of anxiety are seen in patients with ischemic heart disease and arrhythmia. Therefore a detailed examination of the cardiovascular system should be performed. Possible findings include: tachycardia, irregular pulse, tachypnoea. [1]
Respiratory examination Hyperventilation is a sign that can be seen in patients with bronchial asthma. Respiratory system examination findings should be normal in anxiety disorders. [2]
Mental State Examination: Appearance Patient looks shy, looking downwards, poor eye contact. When talking with strangers,the face looks strained,with furrowed brow. Posture is tensed tremors and sweating may be seen in the hands and the patient is restless. Also exclude co-morbid conditions like depression, where vertical furrows in the brow can be seen. [3]
Mental State Examination: Speech Normal. May speak in a soft voice.May speak slowly if the patient has co morbid depression. [3]
Mental State Examination: Mood. Associated symptoms like palpitations, dry mouth, tremor. [3]
Mental State Examination: Thoughts Preoccupation with anxious thoughts and possibility of being publicly embarrassed or scrutinized. [3]
Mental State Examination: Perception. They do not have any illusions or hallucinations. [3]
Mental State Examination: Depersonalization/ Derealization Depersonalization can occur during an anxiety attack. The patient will feel detached from their own body, and will experience a sense of 'unreality' about themselves. [3]
Mental State Examination: Cognitive function. Normal. [3]
Mental State Examination: Insight Insight is preserved. [3]
References
  1. HAMANG A, EIDE GE, ROKNE B, NORDIN K, ØYEN N. General anxiety, depression, and physical health in relation to symptoms of heart-focused anxiety- a cross sectional study among patients living with the risk of serious arrhythmias and sudden cardiac death Health Qual Life Outcomes [online] :100 [viewed 15 June 2014] Available from: doi:10.1186/1477-7525-9-100
  2. COOPER CL, PARRY GD, SAUL C, MORICE AH, HUTCHCROFT BJ, MOORE J, ESMONDE L. Anxiety and panic fear in adults with asthma: prevalence in primary care BMC Fam Pract [online] :62 [viewed 15 June 2014] Available from: doi:10.1186/1471-2296-8-62
  3. BYSTRITSKY A, KHALSA SS, CAMERON ME, SCHIFFMAN J. Current Diagnosis and Treatment of Anxiety Disorders P T [online] 2013 Jan, 38(1):30-57 [viewed 15 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173

Differential Diagnoses

Fact Explanation
Panic disorder with agoraphobia. Characterized by initial onset of unexpected panic attacks and the patient's subsequent avoidance of situations thought to be likely triggers of the panic attacks. And recurrent panic attacks are present which are not restricted to social situations. [1]
Agoraphobia without history of panic disorder. Fear of facing cluster of situations alone, which may or may not involve scrutiny by others(being alone outside the home or being home alone, traveling in a bus). [1]
Separation anxiety disorder. May avoid social situations due to concerns about being separated from their caretaker.Children with separation anxiety disorder are usually comfortable in social gatherings in their own home, but persons with social phobia display signs of discomfort and anxiety even when feared social situations occur at home. [1]
Generalized anxiety disorder (GAD) or specific phobia. Embarrassment may be present (about the fainting attacks and anxiety symptoms) , but it is not the main concern or the focus of the patient. In GAD the main focus is the excessive worry of the quality of the performance whether or not they are evaluated by the others. In social phobia, the main worry is about being evaluated by others.[3]
Pervasive development disorder or schizoid personality development. Social situations are avoided because of lack of interest in relating to other individuals. [2]
Other mental disorders. Major depressive disorder, dysthymic disorder, schizophrenia, body dysmorphic disorder. If the symptoms of social phobia appear exclusively during another mental disorder and if the symptoms are better accounted for that disorder, an additional diagnosis of social phobia is not given. [1]
Performance anxiety, stage fright, shyness. Shyness in social situations which involve unfamiliar people.This should not be diagnosed as social phobia unless the anxiety leads to clinically significant impairment or marked distress. [4]
References
  1. BYSTRITSKY A, KHALSA SS, CAMERON ME, SCHIFFMAN J. Current Diagnosis and Treatment of Anxiety Disorders P T [online] 2013 Jan, 38(1):30-57 [viewed 15 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173
  2. ESTERBERG ML, GOULDING SM, WALKER EF. A Personality Disorders: Schizotypal, Schizoid and Paranoid Personality Disorders in Childhood and Adolescence J Psychopathol Behav Assess [online] 2010 Dec 1, 32(4):515-528 [viewed 15 June 2014] Available from: doi:10.1007/s10862-010-9183-8
  3. LENZE EJ, WETHERELL JL. A lifespan view of anxiety disorders Dialogues Clin Neurosci [online] 2011 Dec, 13(4):381-399 [viewed 15 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3263387
  4. BURSTEIN M, AMELI-GRILLON L, MERIKANGAS KR. Shyness Versus Social Phobia in US Youth Pediatrics [online] 2011 Nov, 128(5):917-925 [viewed 15 June 2014] Available from: doi:10.1542/peds.2011-1434

Investigations - for Diagnosis

Fact Explanation
ECG and echocardiogram To exclude any underlying cardiac disease. Conditions like arrhythmia and supra ventricular tachycardia. [1]
Thyroid Function Tests. TSH and free T4 levels. To exclude thyroid disease giving rise to anxiety episodes. [2]
References
  1. HAMANG A, EIDE GE, ROKNE B, NORDIN K, ØYEN N. General anxiety, depression, and physical health in relation to symptoms of heart-focused anxiety- a cross sectional study among patients living with the risk of serious arrhythmias and sudden cardiac death Health Qual Life Outcomes [online] :100 [viewed 15 June 2014] Available from: doi:10.1186/1477-7525-9-100
  2. BYSTRITSKY A, KHALSA SS, CAMERON ME, SCHIFFMAN J. Current Diagnosis and Treatment of Anxiety Disorders P T [online] 2013 Jan, 38(1):30-57 [viewed 15 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3628173

Management - General Measures

Fact Explanation
Assess the severity of the phobia and the interference in person's life due to the phobia. Amount of interference of daily life, work , in the relationships and person's occupational, social and academic impairment due to the condition. [1]
Identify unhealthy coping mechanisms and advice against them. Use of alcohol to cope with the situation is maladaptive. [2]
Educate the patient and the family members about the disorder and reassure them. Education of the family members and the patient ensures the support of both parties which is necessary for the continuation of the treatment. [3]
Exclude a co existant depressive disorder Anxiety symptoms can be present in depressive disorder or patients with social phobia can be depressed due to their condition. If depressive symptoms are present, treatment for depression should be started. [4]
Improving social skills and public speaking skills. Practicing social skills and public speaking skills. (first without an audience- in front of a mirror-, then with a familiar audience and so on). This improves the confidence of the patient regarding his ability to face the social situations, and reduce the anxiety attached to them. [1]
References
  1. WONG N, SARVER DE, BEIDEL DC. Quality of Life Impairments among Adults with Social Phobia: The Impact of Subtype J Anxiety Disord [online] 2012 Jan, 26(1):50-57 [viewed 15 June 2014] Available from: doi:10.1016/j.janxdis.2011.08.012
  2. SMITH JP, RANDALL CL. Anxiety and Alcohol Use Disorders: Comorbidity and Treatment Considerations Alcohol Res [online] 2012, 34(4):414-431 [viewed 15 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3860396
  3. BURSTEIN M, AMELI-GRILLON L, MERIKANGAS KR. Shyness Versus Social Phobia in US Youth Pediatrics [online] 2011 Nov, 128(5):917-925 [viewed 15 June 2014] Available from: doi:10.1542/peds.2011-1434
  4. MARTIN P. The epidemiology of anxiety disorders: a review Dialogues Clin Neurosci [online] 2003 Sep, 5(3):281-298 [viewed 15 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181629

Management - Specific Treatments

Fact Explanation
Self- help methods Encourage the patients to face or get exposed to social situations while using distraction techniques. [1]
Pharmacological treatment- Antidepressant medication- Selective serotonin re uptake inhibitor- SSRIs(paroxetine, fluvoxamine, sertraline) and Serotonin and norepinephrine re uptake inhibitors -SNRIs -(venlafaxine) First choice in pharmacological treatment. While taking antidepressants patients should practice exposure to situations that they previously avoided. Gastrointestinal effects - nausea, vomiting, dyspepsia, constipation, diarrhea. Serious side effects - seizures, hyponatremia, increase suicidal risk in children and adolescents. [2]
Pharmacological treatment- Antidepressant medication -Monoamine oxidase inhibitors- MAOIs Moclobemide is effective, but drug and dietary interactions limit the use. MAOIs inhibit monoamine oxidase causing accumulation of amine neurotransmitters. Metabolism of indirect acting sympathomimetics inhibited and their action potentiated. Effect of tyramine (mature cheese, pickled herring, fermented soya bean extract) may also be potentiated. And can cause a dangerous rise in the blood pressure. Moclobemide, a reversible MAOI has lesser side effects when compared to irreversible inhibitors (phenelzine, isocarboxazid, tranylcypromine). Moclobemide should not be given with another antidepressant. No treatment free period is required after it is stopped (due to its short duration of action, but moclobemide should not be started until at least a week after stopping another antidepressants. Side effects - postural hypotension and dizziness, drowsiness, insomnia, headache, dry mouth, constipation, elevated liver enzymes, agitation and tremors. [2]
Anxiolytic medication - Benzodiazepine (alprazolam) For immediate short term relief (for important social situations) before the long term treatment has taken effect. If taken regularly dependence may occur. Adverse effects of benzodiazepines-physiological and psychological dependence, potential fatalities upon withdrawal, impaired cognition and coordination, a potentially lethal overdose when they are mixed with alcohol or opioids, inhibition of memory encoding, which can interfere with the efficacy of concomitant psychotherapy. [3]
Beta adrenergic antagonist - propranolol Used for short term control of tremor, palpitations which are unresponsive to anxiolytic treatment. Contra-indications- Second- or third-degree heart block, history of asthma or bronchospasm, Side effects- gastro-intestinal disturbances, bradycardia, heart failure, hypotension, peripheral vasoconstriction (exacerbation of intermittent claudication), bronchospasm. [3]
Cognitive behavioral therapy (CBT) - Relaxation techniques. Consists of exposure to feared situations and introduction of methods to reduce patient's anxiety provoking thoughts. The goal of treatment is for the patient to develop the ability to recognize, eliminate, and correct his or her dysfunctional assumptions and thoughts in order to to cope more appropriately with various situations. Relaxation - Relaxation of muscle groups one by one, breathing slowly, clearing mind of anxious thoughts by concentrating on a calming image. Techniques for changing anxiety provoking conditions - Teach the nature of the normal anxiety response and explain that the symptoms are harmless. and explain hoe the fearfulness and the concerns of the symptoms give rise to a vicious cycle of anxiety. Teach about using distraction techniques to reduce the anxiety. [2]
Cognitive behavioral therapy (CBT) -Exposure. Determine the situations that are avoided. arrange the situations in order of the amount of anxiety generated. Persuade patient to face the situation which brings out the least amount of anxiety, and to stay there until the anxiety is declined. And to repeat the exercise until the situation is faced without the anxiety at all. And advice to move up in the list of situations and face the more difficult situations one by one. Problem-solving techniques- Practicing problem-solving strategies to lessen inappropriate approaches to problems and constant worrying. [2]
References
  1. CHEN JP, REICH L, CHUNG H. Anxiety disorders West J Med [online] 2002 Sep, 176(4):249-253 [viewed 13 June 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1071743
  2. CANTON J, SCOTT KM, GLUE P. Optimal treatment of social phobia: systematic review and meta-analysis Neuropsychiatr Dis Treat [online] 2012:203-215 [viewed 15 June 2014] Available from: doi:10.2147/NDT.S23317
  3. RUSCIO AM, BROWN TA, CHIU WT, SAREEN J, STEIN MB, KESSLER RC. Social Fears and Social Phobia in the United States: Results from the National Comorbidity Survey Replication Psychol Med [online] 2008 Jan, 38(1):15-28 [viewed 15 June 2014] Available from: doi:10.1017/S0033291707001699