10 March 2004

Treatment for social phobia

Because of misdiagnosis and inappropriate treatment, fewer than 25% of social phobia sufferers receive treatment for their conditions, despite the fact that social phobia responds extremely well to treatment.

Because of misdiagnosis and inappropriate treatment, fewer than 25% of social phobia sufferers receive treatment for their conditions, despite the fact that social phobia responds extremely well to treatment. Several factors confound the successful treatment of social phobia:
  • The perception of social phobia as an exaggerated form of shyness or social unease. As a result of this, many sufferers do not consider their condition to be a disorder for which consultation with a doctor is appropriate.
  • The nature of social phobia means that sufferers are often reluctant to seek treatment. This is due in part to a fear of public scrutiny and the belief that nothing can be done to help.
  • There is a low level of awareness among many doctors of the diagnosis and treatment of social phobia.

However, severe impairment and the onset of comorbid conditions can be prevented or minimised by the early administration of pharmacological and psychological therapies. Once social phobia is diagnosed, it is imperative that treatment is introduced without delay. Research suggests that in anxiety disorders, a combination of drug and psychological therapy yields the best treatment results as well as the most rapid recovery with the fewest relapses.

Social Phobia responds well to drug therapy, but it is important to realise that social phobia is a chronic condition that requires long-term management. Drug therapy should preferably be maintained for at least one year. Upon completion of the drug treatment program, medication should be withdrawn gradually, with periodic attempts to lower the dose.

Drugs found to be the most effective in treating social phobia are the Anti-depressants: Monoamine Oxidase Inhibitors (MA01s), Reversible Inhibitors of Monoamine Oxidase (RIMAS) and Selective Serotonin Reuptake Inhibitors (SSR1s), being the most commonly used.

Different Types of Antidepressants
Monoamine Oxidase Inhibitors (MA01s)
These are antidepressants which work by activating an enzyme called Monoamine Oxidase. The only MAOI available in South Africa is Parnate (tranylcypromine). The MAOls have been in existence for about 30 years and are effective for the treatment of Depression and social phobia. They are not widely used because they may have a dangerous reaction with certain foods, and tend to be reserved for patients who have not responded to other medications. Patients on Pamate need to adhere to a strict diet. If switching between an MAOI and another antidepresant, there will need to be an interval of between one and two weeks for the drug to wash-out.

Reversible Inhibitors of Monoamine Oxidase (RIMAS)
RIMAs are a new class of drug which are safer and better tolerated than MA01s. The drug functions by selectively binding to a specific isoenzyme of Monoamine Oxidase. At present, Aurorix (Moclobemide) is the only drug in South Afrita to have undergone long-term trials in the treatment of social phobia and is currently the only drug registered in South Africa for the treatment of social phobia.

Selective Scrotonin Reuptake Inhibitors
The SSRls are among the newer antidepressants and have been available since 1988. SSRls include Aropax (Paroxetine), Cipramil (Citalopram), Luvox (Fluvoxamine), Prozac/Lorien (Fluoxetine) and Zoloft (Sertraline). They are now the most widely used antidepressants because they tend to have fewer side effects than the older drugs. Although called antidepressants, the SSRIs are also used to treat other anxiety disorders such as social phobia, panic disorder and obsessive-compulsive disorder.

Are Antidepressants Safe to Take?
Antidepressants are safe to take in prescribed doses, but are not suited to everyone. There are some conditions where extra care will need to he taken. If any of the following apply to you, you should discuss medication with your doctor:

  • If you are taking other prescribed or over-the-counter medication, including antihistamines, stomach acid neutralisers, cough and cold treatments and the like.
  • If you have any pre-existing illnesses, including diabetes, epilepsy, heart problems, kidney or liver problems, hyperthyroidism etc.
  • If you are pregnant, breast feeding or hoping to fall pregnant.

Mild side effects of the antidepressants are likely to be experienced during the first few weeks of treatment, but usually dissapear with time. It is important to overcome this period of having to endure side-effects in order to allow for a full recovery to take place. The most common side-effects include nervousness, sleep problems and impaired sexual functioning.

Other typical side-effects of SSRIs include:

  • Headaches
  • Nausea

Other typical side-effects of MAOls include:

  • Dizziness and restlessness
  • The need for a special diet

Particular care must be taken when MAOls are usd as the drug interacts with several food types, including cheese and wine. These foods must be avoided during the course of treatment with MA01s.

Other Medications
Certain benzodiazepines are useful in the treatment of social phobia. In addition, Beta-blockers are useful in treating performance anxiety.

Continuation of treatment is important as there is a substantial rate of relapse once therapy has been prematurely withdrawn.

"I first noticed the treatment was working when I had to cash a cheque at the bank. For the first time that remember, my hand did not shake as I signed it"

Psychological Treatment
Psychological intervention is an important component in the treatment of social phobia since it encourages the sufferer to confront negative beliefs and feelings which are proposed by some to be causes of their social phobia. The most important negative belief which needs to be challenged is that of failure being inevitable in social situations.

There are three basic forms of psychological treatment available for social phobia sufferers:

Social Skills Training
This form.of therapy helps people feel more relaxed and confident in the company of others by teaching many of the social skills taken for granted in society, such as initiating a conversation with a stranger. The emphasis is on practice and feedback, a process that allows the sufferer to monitor his or her social interactions.

Exposure Therapy
Exposure therapy essentially involves exposure to feared situations, helping the social phobia sufferer to relax when in a situation they perceive to be frightening. It is usually conducted in stages according to a hierarchy, bringing about gradual desensitisation to the feared situation or location.

Cognitive Behavioural Therapy
CBT helps social phobia sufferers change the way they think about themselves, their surroundings and other people. Therapy brings about a more realistic and less worrying way of thinking about fearful situations, while challenging anxiety-provoking thoughts and feelings. Since one of the main goals of cognitive therapy is to encourage patients to confront their anxieties, group therapy sessions are particularly appropriate to the treatment of certain forms of social phobia.

Almost 80 percent of people suffering from social phobia find relief from their symptoms when treated with a combination of medication and psychotherapy it may be advantageous to make use of both forms of treatment, since they complement each other and bring about more rapid, long-term recovery. A combination of the two treatments results in a reduced risk of relapse upon discontinuing medication.

Real-Life Desensitisation
Real-life desensitisation is the single most effective treatment available for social phobia. Also called exposure or in-vivo desensitisation, real-life desensitisation involves overcoming fears and phobias through direct exposure. Improvement resulting from real-life exposure usually does not disappear shortly after treatment - once people have fully desensitised themselves, they can remain free of fear. Real-life desensitisation does however involve the uncomfortable prospect of having to tolerate the unpleasantness of facing phobic situations, and of having to persist with the practising of real-life desensitisation on a regular basis.

The procedure of real-life desensitisation involves the use of a basic hierarchy of phobic scenes that have been constructed to bring about desensitisation (see examples). Goals must be clearly defined, with careful consideration given to what constitutes full recovery. A timeframe should be decided on by which goals should be realised. Broad goals, such as shopping in a mall for example, are fragmented into smaller, more manageable goals, such as travelling to the mall, walking around outside the mall and then eventually shopping in the mall.

The hierarchies presented below can be used as guidelines for attaining desensitisation to three of the most common social phobias:

Fear Of Speaking In Public

  • In any group situation, while sitting down, make a one-sentence comment.
  • Make a 3 to 5 minute comment while sitting with a group.
  • Standing up in a small group, make a 30 second comment.
  • Announce to a small group that you will be giving a short comment at every break.
  • Join Toastmasters.
  • In a familiar group, stand up and make a comment.
  • In a familiar group, stand up and make a short statement.
  • Present a short talk on any subject.
  • Make a comment at any meeting you may attend.
  • Return to the group some time later and comment on your progress.

"It took a lot of hard work and patience to get through my social phobia. At times I thought I'd never make it. It's not that I never feel any anxiety anymore... l just feel it less and less. I know how to control the anxiety when it does emerge... and how to stop it preventing me from doing the things I want to do."

If you suspect you may be suffering from social phobia, learning about the disease is the first step to recovery. You should seek help from a doctor if you have not yet been examined or diagnosed - if you are already on treatment, continue with the prescribed treatment, taking one day at a time.

Remember not to let others discourage you. Don't feel ashamed about social phobia, it is a very real disease just like any other illness. Learn more about the disorder - ask your doctor, pharmacist or the Depression and Anxiety Support Group should you have any queries or concerns. Seek support from others, and take an active role in your recovery.

Most importantly, keep in mind that you can overcome social phobia - recovery will take work, but it will be well worth the effort.

Information supplied by the Depression and Anxiety Support Group

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