Social Phobia

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What is social phobia, also called social anxiety disorder?

Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.

While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.

Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family.

Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with post-traumatic stress disorder feel as though all eyes are focused on them.

Social phobia affects about 15 million American adults. Women and men are equally likely to develop the disorder, which usually begins in childhood or early adolescence. There is some evidence that genetic factors are involved. Social phobia is often accompanied by other anxiety disorders or depression, and substance abuse may develop if people try to self-medicate their anxiety.

Social phobia can be successfully treated with certain kinds of psychotherapy or medications.

Specific Phobias

A specific phobia is an intense fear of something that poses little or no actual danger. Some of the more common specific phobias are centered around closed-in places, heights, escalators, tunnels, highway driving, water, flying, dogs, and injuries involving blood. Such phobias aren't just extreme fear; they are irrational fear of a particular thing. You may be able to ski the world's tallest mountains with ease but be unable to go above the 5th floor of an office building. While adults with phobias realize that these fears are irrational, they often find that facing, or even thinking about facing, the feared object or situation brings on a panic attack or severe anxiety.

Specific phobias affect an estimated 19.2 million adult Americans1 and are twice as common in women as men. They usually appear in childhood or adolescence and tend to persist into adulthood. The causes of specific phobias are not well understood, but there is some evidence that the tendency to develop them may run in families.

If the feared situation or feared object is easy to avoid, people with specific phobias may not seek help; but if avoidance interferes with their careers or their personal lives, it can become disabling and treatment is usually pursued.

Specific phobias respond very well to carefully targeted psychotherapy.

Will medication cure an anxiety disorder?

Medication will not cure anxiety disorders, but it can keep them under control while the person receives psychotherapy. Medication must be prescribed by physicians, usually psychiatrists, who can either offer psychotherapy themselves or work as a team with psychologists, social workers, or counselors who provide psychotherapy. The principal medications used for anxiety disorders are antidepressants, anti-anxiety drugs, and beta-blockers to control some of the physical symptoms. With proper treatment, many people with anxiety disorders can lead normal, fulfilling lives.

Antidepressants

Antidepressants were developed to treat depression but are also effective for anxiety disorders. Although these medications begin to alter brain chemistry after the very first dose, their full effect requires a series of changes to occur; it is usually about 4 to 6 weeks before symptoms start to fade. It is important to continue taking these medications long enough to let them work.

SSRIs

Some of the newest antidepressants are called selective serotonin reuptake inhibitors, or SSRIs. SSRIs alter the levels of the neurotransmitter serotonin in the brain, which, like other neurotransmitters, helps brain cells communicate with one another.

Fluoxetine (Prozac?), sertraline (Zoloft?), escitalopram (Lexapro?), paroxetine (Paxil?), and citalopram (Celexa?) are some of the SSRIs commonly prescribed for panic disorder, obsessive-compulsive disorder, post-traumatic stress disorder, and social phobia. SSRIs are also used to treat panic disorder when it occurs in combination with obsessive-compulsive disorder, social phobia, or depression. Venlafaxine (Effexor?), a drug closely related to the SSRIs, is used to treat generalized anxiety disorder. These medications are started at low doses and gradually increased until they have a beneficial effect.

SSRIs have fewer side effects than older antidepressants, but they sometimes produce slight nausea or jitters when people first start to take them. These symptoms fade with time. Some people also experience sexual dysfunction with SSRIs, which may be helped by adjusting the dosage or switching to another SSRI.

Tricyclics

Tricyclics are older than SSRIs and work as well as SSRIs for anxiety disorders other than obsessive-compulsive disorder. They are also started at low doses that are gradually increased. They sometimes cause dizziness, drowsiness, dry mouth, and weight gain, which can usually be corrected by changing the dosage or switching to another tricyclic medication.

Tricyclics include imipramine (Tofranil?), which is prescribed for panic disorder and GAD, and clomipramine (Anafranil?), which is the only tricyclic antidepressant useful for treating obsessive-compulsive disorder.

MAOIs

Monoamine oxidase inhibitors (MAOIs) are the oldest class of antidepressant medications. The MAOIs most commonly prescribed for anxiety disorders are phenelzine (Nardil?), followed by tranylcypromine (Parnate?), and isocarboxazid (Marplan?), which are useful in treating panic disorder and social phobia. People who take MAOIs cannot eat a variety of foods and beverages (including cheese and red wine) that contain tyramine or take certain medications, including some types of birth control pills, pain relievers (such as Advil?, Motrin?, or Tylenol?), cold and allergy medications, and herbal supplements; these substances can interact with MAOIs to cause dangerous increases in blood pressure. The development of a new MAOI skin patch may help lessen these risks. MAOIs can also react with SSRIs to produce a serious condition called 'serotonin syndrome,' which can cause confusion, hallucinations, increased sweating, muscle stiffness, seizures, changes in blood pressure or heart rhythm, and other potentially life-threatening conditions.

Anti-Anxiety Drugs

High-potency benzodiazepines combat anxiety and have few side effects other than drowsiness. Because people can get used to them and may need higher and higher doses to get the same effect, benzodiazepines are generally prescribed for short periods of time, especially for people who have abused drugs or alcohol and who become dependent on medication easily. One exception to this rule is people with panic disorder, who can take benzodiazepines for up to a year without harm.

Clonazepam (Klonopin?) is used for social phobia and generalized anxiety disorder, lorazepam (Ativan?) is helpful for panic disorder, and alprazolam (Xanax?) is useful for both panic disorder and generalized anxiety disorder.

Some people experience withdrawal symptoms if they stop taking benzodiazepines abruptly instead of tapering off, and anxiety can return once the medication is stopped. These potential problems have led some physicians to shy away from using these drugs or to use them in inadequate doses.

Buspirone (Buspar?), an azapirone, is a newer anti-anxiety medication used to treat generalized anxiety disorder. Possible side effects include dizziness, headaches, and nausea. Unlike benzodiazepines, buspirone must be taken consistently for at least 2 weeks to achieve an anti-anxiety effect.

Beta-Blockers

Beta-blockers, such as propranolol (Inderal?), which is used to treat heart conditions, can prevent the physical symptoms that accompany certain anxiety disorders, particularly social phobia. When a feared situation can be predicted (such as giving a speech), a doctor may prescribe a beta-blocker to keep physical symptoms of anxiety under control.

Psychotherapy

Psychotherapy involves talking with a trained mental health professional, such as a psychiatrist, psychologist, social worker, or counselor, to discover what caused an anxiety disorder and how to deal with its symptoms.

Cognitive-Behavioral Therapy

Cognitive-Behavioral Therapy Cognitive-behavioral therapy (CBT) is very useful in treating anxiety disorders. The cognitive part helps people change the thinking patterns that support their fears, and the behavioral part helps people change the way they react to anxiety-provoking situations.

For example, CBT can help people with panic disorder learn that their panic attacks are not really heart attacks and help people with social phobia learn how to overcome the belief that others are always watching and judging them. When people are ready to confront their fears, they are shown how to use exposure techniques to desensitize themselves to situations that trigger their anxieties.

People with obsessive-compulsive disorder who fear dirt and germs are encouraged to get their hands dirty and wait increasing amounts of time before washing them. The therapist helps the person cope with the anxiety that waiting produces; after the exercise has been repeated a number of times, the anxiety diminishes. People with social phobia may be encouraged to spend time in feared social situations without giving in to the temptation to flee and to make small social blunders and observe how people respond to them. Since the response is usually far less harsh than the person fears, these anxieties are lessened. People with post-traumatic stress disorder may be supported through recalling their traumatic event in a safe situation, which helps reduce the fear it produces. CBT therapists also teach deep breathing and other types of exercises to relieve anxiety and encourage relaxation.

Exposure-based behavioral therapy has been used for many years to treat specific phobias. The person gradually encounters the object or situation that is feared, perhaps at first only through pictures or tapes, then later face-to-face. Often the therapist will accompany the person to a feared situation to provide support and guidance.

CBT is undertaken when people decide they are ready for it and with their permission and cooperation. To be effective, the therapy must be directed at the person's specific anxieties and must be tailored to his or her needs. There are no side effects other than the discomfort of temporarily increased anxiety.

CBT or behavioral therapy often lasts about 12 weeks. It may be conducted individually or with a group of people who have similar problems. Group therapy is particularly effective for social phobia. Often 'homework' is assigned for participants to complete between sessions. There is some evidence that the benefits of CBT last longer than those of medication for people with panic disorder, and the same may be true for obsessive-compulsive disorder, post-traumatic stress disorder, and social phobia. If a disorder recurs at a later date, the same therapy can be used to treat it successfully a second time.

Medication can be combined with psychotherapy for specific anxiety disorders, and this is the best treatment approach for many people.

Before taking medication for an anxiety disorder:

* Ask your doctor to tell you about the effects and side effects of the drug.

* Tell your doctor about any alternative therapies or over-the-counter medications you are using.

* Ask your doctor when and how the medication should be stopped. Some drugs can't be stopped abruptly but must be tapered off slowly under a doctor's supervision.

* Work with your doctor to determine which medication is right for you and what dosage is best.

* Be aware that some medications are effective only if they are taken regularly and that symptoms may recur if the medication is stopped.

Where can I get help for an anxiety disorder?

If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.

If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed.

You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.

Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it's possible that they can be eliminated by adjusting how much medication you take and when you take it.

Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don't have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.

Source: National Institutes of Health

Generic Prescription Drug Plan to Provide Relief for Regence Members

The program encourages the use of high-quality generic medications that have proven track records. "The antidepressant market has substantially changed over the last several years," said David Clark, vice president of Medical Services and Pharmacy for Regence. "More generic antidepressants are available for the majority of patients. Evidence indicates that most antidepressants are equally effective when comparable doses are used, we're encouraging our members and physicians to consider generic drugs when prescribing antidepressants for the first time."

Because generics can meet the needs of most patients, new prescriptions for name-brand drugs Cymbalta, Lexapro, Paxil CR, and Effexor XR need prior authorization beginning in September. Prior authorization means Regence must authorize coverage for the prescription under a member's prescription drug plan. Prior authorization is not necessary for members already on these medications. For members starting on one of the brand-name antidepressants listed, Regence has asked physicians to prescribe a generic antidepressant such as citalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, mirtazapine or bupropion SR first.

"These generics are a good value for members and are available without prior authorization," said Clark, who pointed out that a 30-day prescription of a brand-name drug can cost as much as $83 while the same prescription of that drug's generic equivalent is only $30.

Clark said the continuously rising cost of prescription drugs caused Regence, a not-for-profit company, to create its own in-house Pharmacy Benefit Management (PBM) function for its four affiliate Blue Cross and/or Blue Shield Plans.

Since the formation in 2000 of RegenceRx, one of the few not-for-profit PBMs in the country, the cost of managing drug benefits has dropped. Dollars gained through the use of RegenceRx are used to help keep the cost of health coverage as low as possible, and the focus of RegenceRx on lower net costs has saved Regence and our customers more than $400 million since 2000.

Clark said RegenceRx performed an extensive analysis of the scientific data and relative costs for the antidepressant class. Besides treatment in depression, some antidepressants are also indicated for other conditions, including anxiety, obsessive-compulsive and panic disorder, social phobia, bulimia nervosa, and post-traumatic stress disorder. For the majority of patients with these conditions, a generic antidepressant provides effective treatment.

"We focus on getting the right medication to the right patient, saving money whenever appropriate," Clark said. "With the dramatic rise in health care costs, that's become increasingly important. One of the simplest things you can do to save on medical expenses is to remember to ask your doctor or pharmacist if there's a generic alternative for any prescription drug you are taking."

Clark acknowledged that some people may be skeptical of lesser-known generic drugs, but said, "The Food and Drug Administration requires that generics meet the same strict standards of safety and effectiveness as the equivalent brand name drug. The generic may be a different shape or color than the expensive brand name, but the active ingredients inside remain the same and that's what's important."

For more information about RegenceRx, visit http://www.regencerx.com/.

Keywords: Depression, Antidepressant, Therapy, Treatment, Regence BlueCross BlueShield of Oregon.

This article was prepared by Biotech Business Week editors from staff and other reports. Copyright 2007, Biotech Business Week via NewsRx.com.