Case: Ann Shuss

Ann Shuss is a 28-year-old woman who presents to clinic for a routine physical. As you review her history with her, you notice she is fidgeting, flushed, and sweating. She reports feeling anxious and avoids making eye contact.

Differential diagnosis?

Differential Diagnosis

• Psychiatric: GAD, Social anxiety disorder, panic disorder, phobic disorders, schizophrenia, PTSD

• Endocrine: Hyperthyroidism, hypothyroidism, pheochromocytoma, hyperparathyroidism, hypoglycemia

• Metabolic: Hypercalcemia• Neurologic: Seizures, vestibular dysfunction• Cardiac: arrhythmias, MI, CHF, cardiomyopathy,

hypoxia

(Feinstein & Brewer, 1999)

Diagnosing Anxiety

(Nakell, 1997)

Case continued…Ms. Shuss describes feeling anxious and self-conscious around people in school, work, and social situations since her early teens. She appears shy and, on questioning, describes avoidance of speaking up in work meetings, attending social gatherings, and dating. She desperately wants to be more socially active but fears she will appear nervous and embarrass herself.

(Adapted from Scheier, 2006)

What is social anxiety disorder (SAD)?

• An anxiety disorder characterized by marked fear of being embarrassed in social or performance situations, leading to significant distress or impairment in functioning

• Subtypes– Generalized: anxiety experienced in most social

situations, e.g. conversations, meetings, parties– Performance-only: anxiety is limited to public

speaking or other performance situations

Epidemiology

• Anxiety disorders are the most common class of mental disorders– 12-month prevalence in the community: 18% (Stein

& Stein, 2008)

– Lifetime prevalence of SAD: 12% (Schneier, 2006)

• Social anxiety disorder is frequently encountered in the primary care setting– 3–7% of primary care patients (Stein & Stein, 2008)

• Common across many different cultures

Clinical presentation

• Anxiety / fear of social situations or performance activities

• Poor self-esteem, fears of criticism or negative evaluation by other, perceptions of social inadequacy

• Physical symptoms: blushing, sweating, trembling, palpitations, tremor, nausea, urgency of micturition

• Panic attacks• Limited eye contact• Missed school or work

Onset & Course

• Onset in childhood or early adolescence (rare after age 30)

• Often preceded by non-impairing shyness; occasionally precipitated by a stressor

• Chronic, may fluctuate with stress

DSM-5 Diagnostic CriteriaA. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (eg, having a conversation, meeting unfamiliar people), being observed (eg, eating or drinking), and performing in front of others (eg, giving a speech).(Note: In children, the anxiety must occur in peer settings and not just during interaction with adults.)B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (ie, will be humiliating or embarrassing; will lead to rejection or offend others).C. The social situations almost always provoke fear or anxiety.(Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.)D. The social situations are avoided or endured with intense fear or anxiety.E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. F. The fear, anxiety, or avoidance is persistent, typically lasting for six months or more. G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition.I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.J. If another medical condition (eg, Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

(Schneier, 2006)

Evaluation & Work Up• Screening– Screen individuals presenting for mental health

concerns, especially comorbid conditions

(Stein & Stein, 2008)

Mini-Social Phobia Inventory (mini-SPIN)

– On a scale from 0 (not at all) to 4 (extremely), how much the following problems have bothered you during the past week:

– Scoring: 6 or higher -> concern for SAD– 89% sensitivity, 90% specificity

(Schneier, 2006)

ComorbiditiesPsychiatric / mental health conditions

• Other anxiety disorders: 49%• Avoidant personality disorder: >50% of patients with generalized SAD meet

criteria for avoidant personality disorder• Affective disorders: 38% • Alcohol dependence: 9%• Schizophrenia: ~15% of individuals with schizophrenia have SAD• Eating disorders

Pediatrics• Autism spectrum disorders: >25% of individuals with autism have SAD• Selective mutism

Other medical conditions• Essential tremor• Parkinson’s disease• Stuttering• Hyperhidrosis

Evaluation

• Psychiatric history• Physical exam• Mental status exam• Relevant labs (if concern for anxiety secondary

to another medical condition or substance use)– Glucose, Ca2+, TSH, Utox

Monitoring• Assess scope and severity of symptoms,

especially fear and avoidance of common school, work, and social situations.– Avoidance is the most impairing feature of SAD

• Predictors of poorer prognosis (Hales, Yudofsky, & Ballard, 2011)

– Onset before 11 yrs– Psychiatric comorbidity– Lower educational status– More symptoms at baseline– Comorbid health problems

SAD Treatment Toolbox

• Pharmacotherapy– SSRIs– SNRIs– Benzos

• Cognitive Behavioral Therapy (CBT)

Generalized SAD Treatment Algorithm

• 1st line: Cognitive behavioral therapy (CBT) or antidepressant therapy (SSRI or SNRI)

• 2nd line: If CBT doesn’t work, try an antidepressant (or vice versa)

• 3rd line (if insufficient response after 8-12 wks of maximally tolerated dose): SSRI/SNRI + long-acting benzo– clonazepam (Klonopin): 80% response rate – alprazolam (Xanax): inconclusive evidence

• 4th line: Gabapentin, pregabalin, mirtazapine, MAOIs (UpToDate)

Performance-only (non-generalized) SAD Treatment Algorithm

For patients w/ anxiety restricted to a discrete circumstance (e.g. performance) that is only occasionally encountered: • 1st line: benzo (if no substance use d/o)

– clonazepam (Klonopin) 0.25-1mg given 30-60 min prior to event– lorazepam 0.5-2mg given 30-60 min prior to event

• 2nd line: beta-blocker– propranolol 20-60mg given 30-60 min prior to event

For patients w/ anxiety triggered by a discrete circumstance encountered regularly: • 1st line: CBT• 2nd line: benzos or beta-blocker (as above)

(UpToDate)

*Points to remember* SSRIs

-Abrupt discontinuation after 6 wks can trigger withdrawal

Benzos-Tolerance to sedative effects develops rapidly, but not to anxiolytic effects-Physical dependence may develop after 2 weeks-Abrupt discontinuation can trigger withdrawal-Avoid in pts w/ depression or h/o substance abuse

(Schneier, 2006)

Components of Cognitive Behavior Therapy for Social Phobia

Anxiety management skills• May involve controlled breathing, relaxation and other calming

techniquesSocial skills training• Employs modeling, rehearsal, role-playing, and practice techniques to

build skills that facilitate social effectiveness (e.g. initiating and maintaining conversation, making appropriate eye contact and asserting oneself appropriately)

Cognitive restructuring• Involves learning to identify, challenge and change fearful thinking

that overestimates social threat, underestimates one's ability to manage social demands and perceives the consequences of social miscues as catastrophic

Gradual exposure to feared situations• Involves gradual reentry into feared social situations to reduce the

anxiety that they engender (Adapted from Table 8 in Bruce & Saeed, 1999)

Treatment EfficacyCBT: • Clinical improvement usually

after 6-12 weeks, may progress over months

• In trials, 50-66% of patients responded to CBT after 12 weeks

Benzos:• clonazepam (Klonopin): 80%

response rate • alprazolam (Xanax): inconclusive

evidenceAlternative medications:• gabapentin (Neurontin) &

pregabalin (Lyrica): 45% response rate

Antidepressants:• Trials comparing SSRIs against

each other or SNRIs have not shown any difference in efficacy

(Schneier, 2006; Stein & Stein, 2008)

Community Resources – Counseling & Mental HealthAccess Mental Health Appointment Line for Contra Costa County: 1-888-678-7277Contra Costa Crisis Center: 1-800-833-2900, or call 211 for info about social services and referrals. (http://www.crisis-center.org)Touchstone Counseling Services (low-fee counseling, Pleasant Hill): 925-932-0150Adolescent, Adult & Children’s Psychiatric Programs (John Muir Health Behavioral Health Center): 1-800-680-6555 John F. Kennedy University Community Counseling Center (Concord): 925-798-9240 Crockett Counseling Center (low-fee counseling, Martinez): 925-370-6544 Family Advocate Mental Health (CCHS): 925-521-5121

Community Health for Asian Americans: 925-778-1667 First Hope- CCHS: 925-681-4450 National Alliance for the Mentally Ill (NAMI): 925-942-0767 Power Program (Dual Diagnosis): 925-778-3750 (Anka Behavioral Health) The Hume Center: 925-432-4118 Familias Unidas Counseling: 510-412-5930 Native American Health Center: 510-232-7020 Concord Family Services Center / Catholic Charities (trauma-informed mental health, couseling): 925-825-3099YWCA (couseling): 925-825-9195 (Concord) / 925-226-5659 (Martinez)Rainbow Community Center (counseling, Concord): 925-692-2056

References• Bruce, T. & Saeed, S. (1999). Social Anxiety Disorder: A Common,

Under-recognized Mental Disorder. American Family Physician. 60(8):2311-2320.

• Feinstein & Brewer, Eds. (1999). Primary Care Psychiatry and Behavioral Medicine. Springer Publishing: New York, NY.

• Hales, Yudofsky, & Ballard. (2011). Essentials of Psychiatry, 3rd Ed. American Psychiatric Publishing: Washington, DC.

• Nakell, L. (1997). “Tips for Working with Anxious Patients.” (on CCRMC wiki)

• Schneier, F. (2006). Social Anxiety Disorder. NEJM. 335;10, 1029-1036. • Stein, M. & Stein, D. Social Anxiety Disorder. Lancet. 371, 1115-25.• UpToDate