Social Phobia-Social Anxiety Disorder

Anxiety, fear and avoidance behaviors are the symptoms of social anxiety disorder in certain social situations usually when there is some form of human interaction, even if the presence of another person. They tend to avoid eye contact. Unlike panic disorder, people with social anxiety usually know it not require physical help..ie can't breathe. They are usually comfortable when home. Over seven percent of population suffer from some form of it.
Zoloft was just approved for social anxiety disorder in Feb 2003. Paxil has already been approved. They are selective serotonin reuptake inhibitors, or SSRIs The U.S. Food and Drug Administration has approved GlaxoSmithKline's Paxil CR Controlled-Release Tablets for the treatment of social anxiety disorder in October 2003..

Behav Res Ther. 2003 Nov;41(11):1355-71. : Social anxiety and interpersonal perception: a social relations model analysis.
Niels Christensen P, Stein MB, Means-Christensen A.
Department of Psychology, San Diego State University, San Diego, CA, USA

Cognitive models of social phobia posit that an individual's negative beliefs about the way he or she is perceived by others (metaperceptions) are a core feature of the disorder. The social relations model () was used to analyze interpersonal perception data collected following unstructured social interactions in 62 socially anxious (SA) and 62 not socially anxious (NSA) individuals. Using this model, the interpersonal perceptions were analyzed to evaluate whether pathological levels of social anxiety are associated with self-perceptions, metaperceptions, and perceptions from others. SA participants saw themselves negatively and believed others saw them negatively. Although seen as more nervous by others, SA participants were not seen as less likeable. A mediational model demonstrated that the negative metaperceptions of SA individuals were more a function of their own self-perceptions than the negative perceptions of others. These findings were not attributable to depressive symptoms. Implications for theory and treatment of social phobia are discussed. .

Int Clin Psychopharmacol 2003 May;18(3):169-72 : Valproic acid for the treatment of social anxiety disorder.
Kinrys G, Pollack MH, Simon NM, Worthington JJ, Nardi AE, Versiani M.
The aim of the study was to examine the efficacy of valproic acid in participants with social anxiety disorder. Following a 2-week single-blind, placebo run-in period, 17 participants were enrolled in a 12-week open flexible-dose trial of valproic acid (500-2500 mg). The primary outcome measures were the mean change from baseline in the Liebowitz Social Anxiety Scale (LSAS) total score and responder status [defined as a Clinical Global Impression of Improvement score (CGI-I)

CNS Drugs 2002;16(6):425-34 : Spotlight on paroxetine in psychiatric disorders in adults.
Wagstaff AJ, Cheer SM, Matheson AJ, Ormrod D, Goa KL
. Adis International Limited, Auckland, New Zealand.
demail@adis.co.nz
Paroxetine is a selective serotonin reuptake inhibitor (SSRI), with antidepressant and anxiolytic activity. In 6- to 24-week well designed trials, oral paroxetine 10 to 50 mg/day was significantly more effective than placebo, at least as effective as tricyclic antidepressants (TCAs) and as effective as other SSRIs and other antidepressants in the treatment of major depressive disorder. Relapse or recurrence over 1 year after the initial response was significantly lower with paroxetine 10 to 50 mg/day than with placebo and similar to that with imipramine 50 to 275 mg/day. The efficacy of paroxetine 10 to 40 mg/day was similar to that of TCAs and fluoxetine 20 to 60 mg/day in 6- to 12-week trials in patients aged > or = 60 years with major depression. Paroxetine 10 to 40 mg/day improved depressive symptoms to an extent similar to that of TCAs in patients with comorbid illness, and was more effective than placebo in the treatment of dysthymia and minor depression. Paroxetine 20 to 60 mg/day was more effective than placebo after 8 to 12 weeks' treatment of obsessive-compulsive disorder (OCD), panic disorder, social anxiety disorder (social phobia), generalised anxiety disorder (GAD) and post-traumatic stress disorder (PTSD). Improvement was maintained or relapse was prevented for 24 weeks to 1 year in patients with OCD, panic disorder, social anxiety disorder or GAD. The efficacy of paroxetine was similar to that of other SSRIs in patients with OCD and panic disorder and similar to that of imipramine but greater than that of 2'chlordesmethyldiazepam in patients with GAD. Paroxetine is generally well tolerated in adults, elderly individuals and patients with comorbid illness, with a tolerability profile similar to that of other SSRIs. The most common adverse events with paroxetine were nausea, sexual dysfunction, somnolence, asthenia, headache, constipation, dizziness, sweating, tremor and decreased appetite. In conclusion, paroxetine, in common with other SSRIs, is generally better tolerated than TCAs and is a first-line treatment option for major depressive disorder, dysthymia or minor depression. Like other SSRIs, paroxetine is also an appropriate first-line therapy for OCD, panic disorder, social anxiety disorder, GAD and PTSD. Notably, paroxetine is the only SSRI currently approved for the treatment of social anxiety disorder and GAD, which makes it the only drug of its class indicated for all five anxiety disorders in addition to major depressive disorder. Thus, given the high degree of psychiatric comorbidity of depression and anxiety, paroxetine is an important first-line option for the treatment of major depressive disorder, OCD, panic disorder, social anxiety disorder, GAD and PTSD.

J Anxiety Disord 2003;17(1):33-44 : Social phobics do not see eye to eye: A visual scanpath study of emotional expression processing.
Horley K, Williams LM, Gonsalvez C, Gordon E.
The Brain Dynamics Centre, Westmead Hospital, NSW 2145, Westmead, Australia
Clinical observation suggests that social phobia is characterised by eye avoidance in social interaction, reflecting an exaggerated social sensitivity. These reports are consistent with cognitive models of social phobia that emphasize the role of interpersonal processing biases. Yet, these observations have not been verified empirically, nor has the psychophysiological basis of eye avoidance been examined. This is the first study to use an objective psychophysiological marker of visual attention (the visual scanpath) to examine directly how social phobia subjects process interpersonal (facial expression) stimuli. An infra-red corneal reflection technique was used to record visual scanpaths in response to neutral, happy and sad face stimuli in 15 subjects with social phobia, and 15 age and sex-matched normal controls. The social phobia subjects showed an avoidance of facial features, particularly the eyes, but extensive scanning of non-features, compared with the controls. These findings suggest that attentional strategies for the active avoidance of salient facial features are an important marker of interpersonal cues in social phobia. Visual scanpath evidence may, therefore, have important implications for clinical intervention.

Arch Gen Psychiatry 2002 Dec;59(12):1111-8 : Efficacy of paroxetine for relapse prevention in social anxiety disorder: a 24-week study.
Stein DJ, Versiani M, Hair T, Kumar R. University of Stellenbosch, Fransie van Zyl Dr, Tygerberg 7505, Cape Town, South Africa. djs2@sun.ac.za
BACKGROUND: The efficacy of selective serotonin reuptake inhibitors in the acute treatment of social anxiety disorder (social phobia) is well established. OBJECTIVE: To evaluate whether the efficacy of paroxetine hydrochloride in this disorder is maintained in the long term. METHODS: This was a placebo-controlled multicenter study comprising a single-blind acute treatment phase (12 weeks) and a randomized, double-blind maintenance treatment phase (24 weeks) for patients who had responded to paroxetine during the acute phase. Four hundred thirty-seven adult patients with social anxiety disorder (according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria, code 300.23) entered the acute phase, and 323 continued into the maintenance phase (162 paroxetine and 161 placebo). The principal outcome measure was the proportion of patients relapsing during the maintenance phase. RESULTS: Two hundred fifty-seven patients completed the study (136 paroxetine-treated and 121 placebo-treated patients). Significantly fewer patients relapsed in the paroxetine group than in the placebo group (14% vs 39%; odds ratio, 0.24; 95% confidence interval, 0.14-0.43; P<.001). At the end of the study, a significantly greater proportion of patients in the paroxetine group showed improvement as shown on the Clinical Global Impression global improvement rating compared with the placebo group (78% vs 51%; odds ratio, 3.66; 95% confidence interval, 2.22-6.04; P<.001). Compared with placebo, paroxetine treatment significantly (P<.001) improved the symptoms of social anxiety as shown on the Liebowitz Social Anxiety Scale, Social Phobia Inventory, Sheehan Disability Scale, Symptom Checklist-90 score, and EuroQol visual analogue scale, indicating decreased disability and increased well-being. Paroxetine was well tolerated. CONCLUSION: Paroxetine is an effective long-term treatment for social anxiety disorder.

citalopram-Celexa

Prog Neuropsychopharmacol Biol Psychiatry 2002 Jan;26(1):205-8 : Treatment of social anxiety disorder with citalopram. Varia IM, Cloutier CA, Doraiswamy PM.
Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC 27710, USA.
varia001@mc.duke.edu
Selective serotonin reuptake inhibitors (SSRIs) are used as treatment for generalized and specific social phobias (social anxiety disorders). The efficacy of citalopram, an SSRI, for the treatment of social anxiety disorders has not yet been fully evaluated. These cases suggest that citalopram may be an effective treatment for social anxiety disorder (social phobia). These cases are consistent with two other published reports with citalopram from outside the US. Randomized controlled studies are warranted.

Hum Psychopharmacol 2002 Dec;17(8):401-5 : Efficacy of citalopram and moclobemide in patients with social phobia: some preliminary findings.
Atmaca M, Kuloglu M, Tezcan E, Unal A. Firat University, School of Medicine, Department of Psychiatry, Elazig, Turkey.
The efficacy of irreversible and reversible monoamine oxidase inhibitors (MAOIs) in the treatment of social phobia (SP) is well established. Recently, selective serotonin reuptake inhibitors (SSRIs) have been used more frequently. In the present study, the efficacy and side-effect profile of citalopram, an SSRI, and moclobemide, the only MAOI used in Turkey, were compared. The 71 patients diagnosed with SP according to DSM-III-R were randomly assigned to two subgroups; citalopram (n = 36) or moclobemide (n = 35). The study was an 8-week, randomized, open-label, rater-blinded, parallel-group trial. All patients were assessed by Hamilton anxiety rating (HAM-A), Liebowitz social anxiety (LSAS), clinical global impression-severity of illness (CGI-SI) and clinical global impression-improvement (CGI-I) scales. There was a similar percentage of responders (citalopram 75%, n = 27 and moclobemide 74.3%, n = 26), with a >50% or greater reduction in LSAS total score and ratings of 'very much' or 'much improved' on the CGI-I. None of the patients withdrew from the study. The results of the present study suggest that citalopram has shown promising results in patients with SP.

Arch Gen Psychiatry 2002 Nov;59(11):1027-34 : Increased amygdala activation to angry and contemptuous faces in generalized social phobia.
Stein MB, Goldin PR, Sareen J, Zorrilla LT, Brown GG.
Department of Psychiatry, University of California-San Diego, CA 92093-0985, USA.
mstein@ucsd.edu
BACKGROUND: Generalized social phobia (GSP) is characterized by fear of social interactions and sensitivity to disapproval by others. Given the established role of the amygdala as part of a distributed neural system for the processing of emotional cues, we hypothesized that subjects with GSP would exhibit greater amygdala activation in response to harsh (angry, fearful, and contemptous) vs accepting (happy) facial emotional expressions compared with healthy control subjects (HCs). METHODS: Fifteen subjects with DSM-IV GSP and 15 age-, sex-, handedness-, and education-matched HCs, free of psychotropic medication for at least 12 weeks, viewed 60 color photographs from a standardized set of human facial stimuli, during which the task was to identify the sex of the person in the photograph. Data were collected across 3 functional (echo-planar) runs using a Siemens 1.5-T magnet, and analyzed using Analysis of Functional Neuroimaging software (Medical College of Wisconsin, Milwaukee). RESULTS: In the left allocortex (including the amygdala, uncus, and parahippocampal gyrus), subjects with GSP produced a significantly greater percent blood oxygen level-dependent signal change than did HCs for contemptous compared with happy faces (GSP: 0.72% vs HC: -0.01%; F(1,29) = 9.56, P =.004, Cohen d = 1.15) and for angry compared with happy faces (GSP: 0.45% vs HC: -0.09%; F(1,29) = 6.78, P =.02, Cohen d = 1.00). Subjects with GSP and HCs did not produce a statistically different percent signal change for fearful or nonexpressive faces compared with the happy faces in this region. CONCLUSIONS: These findings are consistent with a role for differential amygdala (and associated limbic) functioning in GSP. The pronounced response to contemptuous and angry facial expressions suggests that the amygdala in GSP may be particularly active in the processing of disorder-salient stimuli.

Br J Clin Psychol 2002 Nov;41(Pt 4):361-74 : Behavioural inhibition and symptoms of anxiety and depression: Is there a specific relationship with social phobia?
Neal JA, Edelmann RJ, Glachan M.
School of Psychology & Counselling, University of Surrey Roehampton, London, UK.
OBJECTIVES: The aim of the study was to examine the relationships between tendencies towards different mental health problems assessed via questionnaires (social phobia, agoraphobia, general anxiety/panic, depression), the two latent dimensions of behavioural inhibition (childhood social/school fears, non-social fears/ illness), and sensory-processing sensitivity. DESIGN: A cross-sectional design was employed. METHOD: Volunteer participants (N = 234) from anxiety and depression self-help organizations completed five mailed questionnaires. These were the Social Phobia and Anxiety Inventory, Beck Depression Inventory II and Beck Anxiety Inventory; the Highly Sensitive Person Scale, a measure of trait sensitivity to environmental stimuli; and the Retrospective Self-Report of Inhibition. RESULTS: Higher levels of anxiety, but not depression, were associated with increased self-reported sensitivity to environmental stimuli. Recalled childhood social/school fears were related to elevated scores on measures of social phobia and depression, while recalled non-social fears/illness were not associated with any index of psychopathology. CONCLUSION: These results extend those of previous research by suggesting specific patterns of relationships of both sensitivity to environmental stimuli and behavioural inhibition with symptoms of anxiety and depression. It is suggested that in investigating long-term outcome, prospective behavioural inhibition studies would benefit from examining the temporal corollaries of the underlying social and non-social dimensions. Sample and design limitations are discussed.

J Clin Psychiatry 2002 Oct;63(10):874-9 : Sexual function and behavior in social phobia.
Bodinger L, Hermesh H, Aizenberg D, Valevski A, Marom S, Shiloh R, Gothelf D, Zemishlany Z, Weizman A.
Geha Psychiatric Hospital, Petah Tiqva, Israel.
BACKGROUND: Social phobia is a type of performance and interpersonal anxiety disorder and as such may be associated with sexual dysfunction and avoidance. The aim of the present study was to evaluate sexual function and behavior in patients with social phobia compared with mentally healthy subjects. METHOD: Eighty subjects participated in the study: 40 consecutive, drug-free outpatients with social phobia (DSM-IV) attending an anxiety disorders clinic between November 1997 and April 1999 and 40 mentally normal controls. The Structured Clinical Interview for DSM-IV Axis I Disorders and the Liebowitz Social Anxiety Scale were used to quantitatively and qualitatively assess sexual function and behavior. RESULTS: Men with social phobia reported mainly moderate impairment in arousal, orgasm, sexual enjoyment, and subjective satisfaction domains. Women with social phobia reported severe impairment in desire, arousal, sexual activity, and subjective satisfaction. In addition, compared with controls, men with social phobia reported significantly more frequent paid sex (p < .05), and women with social phobia reported a significant paucity of sexual partners (p < .05). CONCLUSION: Patients with social phobia exhibit a wide range of sexual dysfunctions. Men have mainly performance problems, and women have a more pervasive disorder. Patients of both genders show difficulties in sexual interaction. It is important that clinicians be aware of this aspect of social phobia and initiate open discussions of sexual problems with patients.

Neurosci Lett 2002 Aug 16;328(3):233-6 : Brain circuits involved in emotional learning in antisocial behavior and social phobia in humans.
Veit R, Flor H, Erb M, Hermann C, Lotze M, Grodd W, Birbaumer N.
Institute of Medical Psychology and Behavioral Neurobiology, University of Tubingen, Gartenstrasse 29, 72074, Tubingen, Germany
While psychopaths (PP) lack anticipatory fear, social phobics (SP) are characterized by excessive fear. Criminal PP, SP and healthy controls (HC) participated in differential aversive delay conditioning with neutral faces as conditioned (CS) and painful pressure as unconditioned stimuli. Functional magnetic resonance imaging revealed differential activation in the limbic-prefrontal circuit (orbitofrontal cortex, insula, anterior cingulate, amygdala) in the HC. By contrast, the PP displayed brief amygdala, but no further brain activation. The SP showed increased activity to the faces in the amygdala and orbitofrontal cortex already during habituation. Thus, a hypoactive frontolimbic circuit may represent the neural correlate of psychopathic behavior, whereas an overactive frontolimbic system may underly social fear.

Biol Psychiatry 2002 Dec 1;52(11):1113-9 : Cerebral blood flow during anticipation of public speaking in social phobia: a PET study.
Tillfors M, Furmark T, Marteinsdottir I, Fredrikson M. Department of Social Sciences (MT), Orebro University, Orebro, Sweden
The aim was to examine the neural correlates of anxiety elicited by the anticipation of public speaking in individuals with social phobia.Positron emission tomography and (15)O-water was used to measure regional cerebral blood flow in subjects with DSM-IV defined social phobia during anxiety anticipation. Heart rate and subjective anxiety were also recorded. While being scanned, subjects were speaking alone either before or after speaking in public. To evaluate anticipatory anxiety we compared individuals speaking alone before they were speaking in front of an audience with those who did the reverse.Heart rate and subjective anxiety measures confirmed anticipatory anxiety in social phobics who performed their private speech before their public. This was accompanied by enhanced cerebral blood flow in the right dorsolateral prefrontal cortex, left inferior temporal cortex, and in the left amygdaloid-hippocampal region. Brain blood flow was lower in the left temporal pole and bilaterally in the cerebellum in the anticipation group.Brain regions with altered perfusion presumably reflect changes in neural activity associated with worry about anticipated public performance. We speculate that anticipatory anxiety in social phobics originates in an affect sensitive fear network encompassing the amygdaloid-hippocampal region, prefrontal, and temporal areas.

: J Psychopharmacol 2002 Dec;16(4):365-8 : Efficacy of olanzapine in social anxiety disorder: a pilot study.
Barnett SD, Kramer ML, Casat CD, Connor KM, Davidson JR.
Department of Psychiatry and Behavioural Sciences, Duke University Medical Center, DUMC, Durham, NC 27710, USA.
stewartbarnett@bellsouth.net
Based on evidence suggesting anxiolytic properties of the atypical antipsychotic olanzapine, this study was conducted to evaluate whether olanzapine may be efficacious in treating social anxiety disorder (SAD). This study was an 8-week, double-blind, placebo-controlled evaluation of olanzapine as monotherapy in which 12 patients with the DSM-IV diagnosis of SAD were randomized to either olanzapine (n = 7) or placebo (n = 5). An initial dose of 5 mg/day was titrated to a maximum of 20 mg/day. Baseline to endpoint scores from the Brief Social Phobia Scale (BSPS), Social Phobia Inventory (SPIN), Liebowitz Social Anxiety Scale and Sheehan Disability Scale, as well as Clinical Global Impression-Improvement ratings, were compared for olanzapine versus placebo. Seven subjects completed all 8 weeks of the study, four in the olanzapine group and three in the placebo group. In the intent-to-treat analysis, olanzapine yielded greater improvement than placebo on the primary measures: BSPS (p = 0.02) and SPIN (p = 0.01). Both treatments were well tolerated, although the olanzapine group had more drowsiness and dry mouth. Olanzapine and placebo were both associated with negligible weight gain. Olanzapine was superior to placebo on the primary outcome measures in this preliminary study of SAD. Additional studies of olanzapine as a treatment for SAD are warranted.

Prog Neuropsychopharmacol Biol Psychiatry 2002 Dec;26(7-8):1327-31 : Hyperhidrosis in social anxiety disorder.
Davidson JR, Foa EB, Connor KM, Churchill LE. Duke University Medical Center, Trent Drive, 4th Floor, Yellow Zone, Room 4082B, Box 3812, Durham, NC 27710, USA.
jonathan.davidson@duke.edu
PURPOSE: Excessive sweating (hyperhidrosis) is an overlooked and potentially disabling symptom, which is often seen in social anxiety disorder (SAD). We conducted a retrospective review of data acquired in patients with SAD who had participated in placebo-controlled clinical trials of fluoxetine, cognitive behavior therapy, clonazepam and gabapentin. Four specific topics were addressed: (1) overall levels of sweating; (2) characteristics of those with hyperhidrosis; (3) a comparison of active treatments relative to placebo on hyperhidrosis; and (4) an examination of baseline sweating severity as a predictor of treatment outcome. METHODS: Using the Brief Social Phobia Scale (BSPS) and Social Phobia Inventory (SPIN), we examined the above questions. RESULTS: Hyperhidrosis was found in 24.8-32.3% of 375 subjects assessed, depending upon the scale used. Hyperhidrosis was associated with higher levels of disability, fear, avoidance, and other physiologic symptoms. While treatment in general was associated with a reduction in the rate of hyperhidrosis from 23.7% to 9.7% (BSPS), and 34.0% to 15.5% (SPIN), only fluoxetine differed significantly from placebo in respect of change in sweating score from baseline to endpoint. In an ANCOVA, gabapentin differed from placebo on the SPIN. CONCLUSION: We conclude that hyperhidrosis is frequently seen in patients with SAD, and that its response to treatment is variable. Further attention should be paid to the possible importance of this symptom in social anxiety.

Arch Gen Psychiatry 2002 Nov;59(11):1027-34 : Increased amygdala activation to angry and contemptuous faces in generalized social phobia.
Stein MB, Goldin PR, Sareen J, Zorrilla LT, Brown GG. Department of Psychiatry, University of California-San Diego, CA 92093-0985, USA.
mstein@ucsd.edu
BACKGROUND: Generalized social phobia (GSP) is characterized by fear of social interactions and sensitivity to disapproval by others. Given the established role of the amygdala as part of a distributed neural system for the processing of emotional cues, we hypothesized that subjects with GSP would exhibit greater amygdala activation in response to harsh (angry, fearful, and contemptous) vs accepting (happy) facial emotional expressions compared with healthy control subjects (HCs). METHODS: Fifteen subjects with DSM-IV GSP and 15 age-, sex-, handedness-, and education-matched HCs, free of psychotropic medication for at least 12 weeks, viewed 60 color photographs from a standardized set of human facial stimuli, during which the task was to identify the sex of the person in the photograph. Data were collected across 3 functional (echo-planar) runs using a Siemens 1.5-T magnet, and analyzed using Analysis of Functional Neuroimaging software (Medical College of Wisconsin, Milwaukee). RESULTS: In the left allocortex (including the amygdala, uncus, and parahippocampal gyrus), subjects with GSP produced a significantly greater percent blood oxygen level-dependent signal change than did HCs for contemptous compared with happy faces (GSP: 0.72% vs HC: -0.01%; F(1,29) = 9.56, P =.004, Cohen d = 1.15) and for angry compared with happy faces (GSP: 0.45% vs HC: -0.09%; F(1,29) = 6.78, P =.02, Cohen d = 1.00). Subjects with GSP and HCs did not produce a statistically different percent signal change for fearful or nonexpressive faces compared with the happy faces in this region. CONCLUSIONS: These findings are consistent with a role for differential amygdala (and associated limbic) functioning in GSP. The pronounced response to contemptuous and angry facial expressions suggests that the amygdala in GSP may be particularly active in the processing of disorder-salient stimuli.

Br J Clin Psychol 2002 Nov;41(Pt 4):361-74 : Behavioural inhibition and symptoms of anxiety and depression: Is there a specific relationship with social phobia?
Neal JA, Edelmann RJ, Glachan M. School of Psychology & Counselling, University of Surrey Roehampton, London, UK.
OBJECTIVES: The aim of the study was to examine the relationships between tendencies towards different mental health problems assessed via questionnaires (social phobia, agoraphobia, general anxiety/panic, depression), the two latent dimensions of behavioural inhibition (childhood social/school fears, non-social fears/ illness), and sensory-processing sensitivity. DESIGN: A cross-sectional design was employed. METHOD: Volunteer participants (N = 234) from anxiety and depression self-help organizations completed five mailed questionnaires. These were the Social Phobia and Anxiety Inventory, Beck Depression Inventory II and Beck Anxiety Inventory; the Highly Sensitive Person Scale, a measure of trait sensitivity to environmental stimuli; and the Retrospective Self-Report of Inhibition. RESULTS: Higher levels of anxiety, but not depression, were associated with increased self-reported sensitivity to environmental stimuli. Recalled childhood social/school fears were related to elevated scores on measures of social phobia and depression, while recalled non-social fears/illness were not associated with any index of psychopathology. CONCLUSION: These results extend those of previous research by suggesting specific patterns of relationships of both sensitivity to environmental stimuli and behavioural inhibition with symptoms of anxiety and depression. It is suggested that in investigating long-term outcome, prospective behavioural inhibition studies would benefit from examining the temporal corollaries of the underlying social and non-social dimensions. Sample and design limitations are discussed.

J Clin Psychiatry 2002 Oct;63(10):874-9 : Sexual function and behavior in social phobia.
Bodinger L, Hermesh H, Aizenberg D, Valevski A, Marom S, Shiloh R, Gothelf D, Zemishlany Z, Weizman A. Geha Psychiatric Hospital, Petah Tiqva, Israel.
BACKGROUND: Social phobia is a type of performance and interpersonal anxiety disorder and as such may be associated with sexual dysfunction and avoidance. The aim of the present study was to evaluate sexual function and behavior in patients with social phobia compared with mentally healthy subjects. METHOD: Eighty subjects participated in the study: 40 consecutive, drug-free outpatients with social phobia (DSM-IV) attending an anxiety disorders clinic between November 1997 and April 1999 and 40 mentally normal controls. The Structured Clinical Interview for DSM-IV Axis I Disorders and the Liebowitz Social Anxiety Scale were used to quantitatively and qualitatively assess sexual function and behavior. RESULTS: Men with social phobia reported mainly moderate impairment in arousal, orgasm, sexual enjoyment, and subjective satisfaction domains. Women with social phobia reported severe impairment in desire, arousal, sexual activity, and subjective satisfaction. In addition, compared with controls, men with social phobia reported significantly more frequent paid sex (p < .05), and women with social phobia reported a significant paucity of sexual partners (p < .05). CONCLUSION: Patients with social phobia exhibit a wide range of sexual dysfunctions. Men have mainly performance problems, and women have a more pervasive disorder. Patients of both genders show difficulties in sexual interaction. It is important that clinicians be aware of this aspect of social phobia and initiate open discussions of sexual problems with patients.

Clin Psychol Rev 2002 Sep;22(7):947-75 : Self-focused attention in social phobia and social anxiety.
Spurr JM, Stopa L.
Department of Psychology, University of Southampton, Southampton S017 1BJ, UK.
Self-focused attention is an awareness of self-referent information and is present in many emotional disorders. This review concentrates on the role of self-focused attention in social anxiety with particular reference to the Clark and Wells [Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. R. G. Heimberg, M. Liebowitz, D. A. Hope, & S. Scheier (Eds.), Social phobia: diagnosis, assessment and treatment. New York: Guilford.] model of social phobia. According to Clark and Wells, self-focused attention is an important maintaining factor in the disorder because it increases access to negative thoughts and feelings, can interfere with performance, and prevents the individual from observing external information that might disconfirm his or her fears. Clark and Wells also propose that socially phobic individuals construct a distorted impression of themselves, based on internally generated information, that takes the form of a visual image (often seen from the perspective of an observer) or felt sense. This paper describes the model and then reviews other theories of self-focused attention, and empirical evidence on self-focused attention. Two types of evidence are reviewed: one, studies that have been conducted from a variety of theoretical perspectives that have relevance either to social anxiety in general or to the Clark and Wells model in particular; two, studies that were designed as a direct test of Clark and Wells' predictions. The final section of the review summarizes the conclusions and suggests areas for future examination.

Veit R, Flor H, Erb M, Hermann C, Lotze M, Grodd W, Birbaumer N.
Institute of Medical Psychology and Behavioral Neurobiology, University of Tubingen, Gartenstrasse 29, 72074, Tubingen, Germany.TARGET="_blank">
While psychopaths (PP) lack anticipatory fear, social phobics (SP) are characterized by excessive fear. Criminal PP, SP and healthy controls (HC) participated in differential aversive delay conditioning with neutral faces as conditioned (CS) and painful pressure as unconditioned stimuli. Functional magnetic resonance imaging revealed differential activation in the limbic-prefrontal circuit (orbitofrontal cortex, insula, anterior cingulate, amygdala) in the HC. By contrast, the PP displayed brief amygdala, but no further brain activation. The SP showed increased activity to the faces in the amygdala and orbitofrontal cortex already during habituation. Thus, a hypoactive frontolimbic circuit may represent the neural correlate of psychopathic behavior, whereas an overactive frontolimbic system may underly social fear.

Eur Neuropsychopharmacol 2002 Aug;12(4):349-54 : A preliminary study of buspirone stimulated prolactin release in generalised social phobia: evidence for enhanced serotonergic responsivity?
Condren RM, Dinan TG, Thakore JH.
Neuroscience Department, St. Vincent's Hospital, Richmond Rd, Fairview, Dublin 3, Ireland.
Serotonergic dysfunction has been postulated to play a role in the aetiology of social phobia. Buspirone, which is a partial agonist at 5HT1A receptors, increases prolactin release and may be used as a probe to examine serotonergic responses, dysfunction of which may be relevant to the pathophysiology of social phobia. We compared buspirone stimulated prolactin release in 14 patients with generalised social phobia and 14 healthy controls. Buspirone 30 mg was administered orally and prolactin release over 180 min was monitored. Overall, patients with generalised social phobia had greater prolactin release in response to buspirone challenge than healthy comparison subjects. There was no correlation between prolactin response and measures of severity of social phobia. Patients with generalised social phobia had enhanced central serotonergic responses, an abnormality shared with some other anxiety disorders and which may be of aetiological significance.

Int Clin Psychopharmacol 2002 Jul;17(4):161-70 : Moclobemide is effective and well tolerated in the long-term pharmacotherapy of social anxiety disorder with or without comorbid anxiety disorder.
Stein DJ, Cameron A, Amrein R, Montgomery SA;
Moclobemide Social Phobia Clinical Study Group. Department of Psychiatry, University of Stellenbosch, Cape Town, South Africa.
djs2@sun.ac.za
Social phobia (social anxiety disorder) is a highly prevalent and chronic disorder that is associated with significant comorbidity and disability. Despite recent advances in the pharmacotherapy of the disorder, there is a paucity of randomized controlled trials on patients with comorbid disorders and on maintenance treatment. A randomized placebo-controlled, double-blind multi-site trial of moclobemide, a reversible inhibitor of monoamine oxidase A, was undertaken with 390 subjects. After an initial 12 weeks, there was the option of continuing for an additional 6 months of treatment. The primary efficacy parameter chosen was responder status as defined by the Clinical Global Impression scale change item. From week 4 onwards, there was a significantly higher response rate on moclobemide than on placebo. Superiority of medication over placebo was similar in patients with comorbid anxiety disorders (33% of subjects) and without, as well as in patients with different subtypes of social anxiety disorder; indeed, treatment with moclobemide rather than placebo was the strongest predictor of response. Adverse events were similar across treatment groups, and were typically mild and transient. In the extension phase, response rates remained higher in the moclobemide group, and ratings of tolerability were equally high in both groups. Thus, in a large sample of social anxiety disorder patients with and without comorbid anxiety disorders, moclobemide was both effective and well-tolerated in the short as well as long-term. These data confirm and extend previous findings on the value of moclobemide in the treatment of social anxiety disorder, and strengthen the range of therapeutic options for managing this important disorder.

J Clin Psychopharmacol 2002 Jun;22(3):257-62 : Fluoxetine in social phobia: a double-blind, placebo-controlled pilot study.
Kobak KA, Greist JH, Jefferson JW, Katzelnick DJ.
Dean Foundation for Health, Research and Education, Middleton, Wisconsin, USA. Kobak@healthtechsys.com
The objective of the study was to examine the efficacy of fluoxetine in social phobia. Sixty subjects were randomly assigned to 14 weeks of double-blind therapy with either fluoxetine or placebo. Dose was fixed at 20 mg for fluoxetine during the first 8 weeks of double-blind treatment; during the final 6 weeks, the dose could be increased every two weeks by 20 mg to a maximum of 60 mg/day. An intentto-treat analysis was used. A significant change from baseline to endpoint was found for both fluoxetine and placebo on the Liebowitz Social Anxiety Scale. However, no significant difference was found between fluoxetine and placebo. The change for fluoxetine was somewhat lower than that found with other selective serotonin reuptake inhibitors, whereas the placebo response was greater. Fluoxetine failed to separate from placebo in this trial. It is unknown whether a larger dose for longer duration would have yielded separation from placebo. A higher than usual placebo response rate was found.