A 27-year-old man comes to the office due to anxiety and poor sleep that has been worsening over the last year. He worries that he will say something stupid or embarrassing at his weekly staff meeting, and so he has particular difficulty falling asleep for 2 or 3 nights leading up to it. He says, "It's just so difficult for me to relax at those meetings even though I am always well prepared." Although the patient's work performance is good, he recently turned down a promotion because he worried that he would be required to interact more regularly with clients. He is experiencing no depression, difficulty concentrating, or appetite disturbance. The patient previously used alcohol daily to calm his nerves when meeting new people but now limits alcohol to 2 drinks twice a week. Medical history is insignificant. Blood pressure is 130/80 mm Hg, pulse is 82/min, and respirations are 16/min. On mental status examination, the patient sighs frequently and has a tense appearance and poor eye contact. He is reluctant to consider psychotherapy and requests medication to help him relax. Which of the following is the most appropriate pharmacotherapy?
Social anxiety disorder (social phobia) | |
Diagnosis |
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Treatment |
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SNRI = serotonin-norepinephrine reuptake inhibitor; SSRI = selective serotonin reuptake inhibitor. | |
This patient's extreme anxiety in social situations and fears of scrutiny and negative evaluation are consistent with social anxiety disorder. The patient's fear of saying something embarrassing and his anticipatory anxiety about interacting with coworkers and meeting new people (both work-related and social) are characteristic of the disorder. His refusal of a job promotion that requires more social interaction is an example of the resulting functional impairment. Self-medication of social anxiety with alcohol is a common complication of the disorder.
Selective serotonin reuptake inhibitors (SSRIs) (eg, sertraline) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are used as first-line medication for social anxiety disorder. Cognitive-behavioral therapy is considered a first-line nonpharmacological treatment.
(Choice A) Bupropion, a norepinephrine and dopamine reuptake inhibitor, has limited evidence for the treatment of social anxiety disorder and is not considered first-line pharmacotherapy. It is used in major depressive disorder or tobacco dependence.
(Choice B) Buspirone, an antianxiety medication that targets serotonin receptors, is indicated for the treatment of generalized anxiety disorder (GAD), not social anxiety disorder. Patients with GAD have chronic anxiety surrounding multiple issues (eg, work, finances, safety) rather than anxiety exclusively focused on social interactions, as seen in this patient.
(Choice C) Benzodiazepines, such as lorazepam, have a role in the treatment of the performance-only type of social anxiety disorder (eg, public speaking). They are less preferred in patients who have anxiety in more generalized nonperformance social situations, such as meeting new people and regular interactions with coworkers and clients. In addition, benzodiazepines are generally avoided in patients with a history of self-medication with alcohol, as in this case.
(Choice D) Beta blockers (eg, propranolol) can be used for the performance-only subtype of social anxiety disorder. They are used on an as-needed basis and are most useful for patients with prominent physiological symptoms such as tachycardia or tremor.
Educational objective:
Social anxiety disorder is characterized by anxiety and fear of scrutiny in social situations, resulting in avoidance, distress, and social-occupational dysfunction. The preferred pharmacological treatment is a selective serotonin reuptake inhibitor or serotonin-norepinephrine reuptake inhibitor.