Researchers Seeking Better Social Phobia Treatment

Not long ago, a young woman, “Susan,” took skydiving lessons. She and her fellow students boarded a plane to practice. When it came time to bail out of the plane, Susan volunteered to be the first to jump. The reason wasn't because she was courageous, but because she dreaded having to talk with other people on the plane.

Susan, in short, suffered from social anxiety (social phobia) disorder, a condition that can be profoundly distressing and disabling, triggering blushing, sweating, stuttering, shaking, and nausea.

“Social anxiety really strikes at the heart of what it is to be human—to interact with other people,” Mark Pollack, M.D., an associate professor of psychiatry at Harvard University and director of the Massachusetts General Hospital anxiety treatment program, told Psychiatric News.

Fortunately, Susan is being treated for her disorder. “More and more Americans are seeking help for social anxiety, thanks to awareness campaigns and media coverage of the past decade or so,” Pollack said.

The scientific evidence of the effectiveness of a growing number of treatments is robust. Notably, there are the SSRIs, SNRIs, monoamine oxidase inhibitors, benzodiazepines, and cognitive-behavioral therapy, which in turn includes cognitive restructuring and exposure therapy. Moreover, the SSRIs and cognitive-behavioral therapy appear to be equally effective at combating social anxiety, a recent study suggests (Psychiatric News, November 5).

Nonetheless, the treatments do have some downsides. For instance, the benzodiazepines can lead to abuse and do not relieve any depression that may exist along with social anxiety, Pratap Chokka, M.D., an associate clinical professor of psychiatry at the University of Alberta, reported at the annual meeting of the Canadian Psychiatric Association in October.

Further, some questions about the deployment of these treatments for social anxiety disorder beg for answers. For example, should clinicians combine treatments or not? What is the optimal time for treatment? Can early intervention change the course of the disorder? Unfortunately, the scientific evidence needed to answer these questions is not yet available, John Walker, Ph.D., a professor of clinical health psychology at the University of Manitoba, pointed out at the meeting.

“If you rate available treatments on a 10-point scale, I would give them about a 6,” Jonathan Davidson, M.D., a professor of psychiatry at Duke University and director of the anxiety treatment program there, said in an interview. “That is to say, they can make a difference, but they leave people with a huge amount of continuing morbidity. If you treat somebody for three to six months, they have still relatively significant scores on anxiety measures. So there is need for improvement.”

A cure for the disorder does not appear to be imminent. Nonetheless, some new treatments being explored for social anxiety may expand the treatment repertoire.

For example, Davidson and colleagues recently completed a small, placebo-controlled study to determine whether the anticonvulsant levetiractam (Keppra) might counter social anxiety disorder. The results, which have been submitted for publication to a scientific journal, look promising. Davidson and coworkers have found that when the botulism toxin (Botox) is given with an SSRI, it can help with the sweating associated with social anxiety disorder, as well as with the social anxiety itself. They were scheduled to present the results of this double-blind trial at a meeting of the American College of Neuropsychopharmaoclogy in San Juan at press time.

Davidson and his group are now conducting a double-blind, placebo-controlled study to determine whether St. John's wort can ease social anxiety disorder. There is also a possibility that chromium, which affects the neurotransmitter serotonin, might help counter the condition. Chromium appears to mitigate atypical depression, Davidson and his team have found.

Drugs that thwart the actions of corticotropin-releasing factor or substance P may also turn out to dampen social anxiety disorder, Pollack said. Corticotropin-releasing factor is produced by the hypothalamus in response to stress and deployed by the amygdala to communicate with other structures in the brain. Substance P is a neuromodulator that may play an important role in the regulation of emotions.

“Though cognitive-behavioral therapy is clearly effective for the treatment of social phobia and other anxiety disorders, it has not been widely disseminated and is often available only at specialized treatment centers to help affected individuals,” Pollack added. “Efforts are starting here and elsewhere to develop a more easily administered and time-efficient form of CBT in order to make this treatment modality more widely available.” ▪