Social PhobiaSocial PhobiaA Patient-Centered, Evidence-Based A Patient-Centered, Evidence-Based Diagnostic and Treatment Process Diagnostic and Treatment Process

A Presentation for the Students of Ohio University A Presentation for the Students of Ohio University Heritage College of Osteopathic MedicineHeritage College of Osteopathic Medicine

Kendall L. Stewart, MD, MBA, DFAPAKendall L. Stewart, MD, MBA, DFAPANovember 29, 2011November 29, 2011

Why is this important?1

• The 12-month prevalence rate of Social Anxiety Disorder (SAD) is

– 6.6% for males and– 9.1% for females.

• People with this disorder have a persistent and admittedly irrational fear of performing in social situations.

• They are convinced that they will perform poorly and be humiliated as a result.

• Their fears may be specific2 or generalized.

• These patients experience anticipatory anxiety and/or panic attacks.

• Avoidance is a common complication.• Impairment results.3

• After mastering the information in this presentation, you will be able to

– Describe how patients with Social Anxiety Disorder often present,

– Detail the diagnostic criteria,– Describe some of the associated

features,– List some differential diagnoses,– Write a preliminary treatment

plan, and– Identify some of the frequent

treatment challenges.• This disorder is also called Social

Phobia.

1Goldman, 20082The most common fear is the fear of public speaking.3The wages of a person with SAD are 14% lower than those without the disorder.

How might a patient with Social Anxiety Disorder present?1

• This is a 22-year-old medical student.

• “I’m thinking of dropping out of medical school.”

• “I simply cannot give an oral presentation.”

• “I was always able to get out of giving speeches in high school and college.”

• “I would have no problem with writing a paper, but the idea of speaking in front of a group is unbearable.”

• “When I’ve tried to do it before, I’ve experienced panic and had to leave the room.”

• “Just thinking about having to do it makes gives me palpitations and triggers diaphoresis.”

• “I can’t sleep and I can’t concentrate on my studies.”

• “If you can’t make an exception, I will have to drop out of school.”

• “My father dropped out of law school for the same reason.”

• “I hate being this way.”2,3

1Goldman, 20082People—particularly men—are often deeply ashamed of symptoms of depression and anxiety.3Even accepting treatment may be too much to bear. A patient refused to take antidepressants and died.

What are the diagnostic criteria for Social Phobia?

• The person experiences excessive and persistent fear of one or more social performance situations.

• He or she experiences feelings of anxiety, fear or panic immediately upon encountering the feared social situation.

• The person recognizes that the fear is excessive, unreasonable or out of proportion to the actual risk in the situation.

• The patient tends to avoid the feared social situation, or if he or she does not avoid it, the situation is endured with intense anxiety or discomfort.

• The patient’s symptoms of anxiety and avoidance behavior cause significant distress or impairment.

• The problem must be present for at least six months in children under 18.

• The symptoms of anxiety are not caused by

– A medical condition or– Substance abuse.– If the patient has another medical

condition with visible symptoms such as stuttering, the fear must not be only of others noticing these medical symptoms.

• If the individual fears most social situations, the SP is viewed as generalized.

• SP can occur in very specific social situations too.

• You can watch a sufferer’s description here.

What do people with Social Anxiety Disorder fear and avoid?1

• Performance Situations– Public speaking– Talking in meetings or classes– Participating in sports or

working out in front of others– Performing music or acting on

stage– Writing in front of others– Eating or drinking in front of

others– Using public restrooms while

others are nearby– Making mistakes in front of

others1

– Being in public areas such as a shopping mall or in a bus

• Social Interaction Situations– Going to parties– Having a conversation with

others– Talking to strangers– Inviting friends over for dinner– Talking on the phone– Expressing personal opinions– Asserting oneself– Being in intimate situations– Talking to authority figures– Returning items to a store– Sending food back in a

restaurant

1Suffering public humiliation is no fun. I once teed off first in Augusta.

What associated features might you see?1

• Excessive sensitivity to criticism• Problems with appropriate

assertiveness• Low self-esteem• Feelings of worthlessness• Test anxiety• Inept social interactions• Poor work history• Social introversion• Suicidal thought• Epidemiological studies suggest

the disorder is more common in women, but males are more common in most clinical samples

• Typical onset in teens• Course is typically fluctuating but

lifelong

• Physical manifestations of anxiety– Tremulousness– Shaky voice– Cold, clammy hands– Sweating– Dilated pupils

• Academic underachievement• Inadequate social support• Comorbid psychiatric disorders

– Other anxiety disorders2

– Mood disorders– Substance-related disorders– Eating disorders– Personality disorders

• More frequent among first-degree biologic relatives

1DSM-IV-TR, 20002Be sure to look for Generalized Anxiety Disorder. What is the most frequently-missed lesion on a medical image?

What other diagnoses might you include in the differential diagnosis?1

• Panic Disorder with Agoraphobia usually begins with an unexpected panic attack and continues with subsequent avoidant behavior not limited to social situations.

• People with Agoraphobia typically prefer to be with a trusted companion.

• Children with Separation Anxiety Disorder resist being separated from their caretaker, but they are usually comfortable in social situations when the caretaker is present.2

• While fear of embarrassment or humiliation may accompany Generalized Anxiety Disorder or Specific Phobia, these are not the principal foci of the patient’s dread.

• In Pervasive Developmental Disorder and Schizoid Personality Disorder social situations are avoided because of a profound lack of interest in social interaction.

• Avoidant Personality Disorder probably overlaps with SAD, Generalized Type.

• Social anxiety in a symptom is many other mental disorders, but it is not the principal symptom in these cases.

• Of course, anxiety frequently accompanies a variety of general medical disorders.

• Substance-Use Disorders also cause anxiety.

• Performance anxiety, stage fright, and shyness should not be diagnosed as SAD unless clinically significant impairment or marked distress results.

1DSM-IV-TR, 20002Martha McCranie told of taking a child to get a cola and losing money in the machine.

What might a typical treatment plan look like?1

• Anticipatory Anxiety– Predict it– Consider medication options

that follow• Panic Attacks

– Consider short-term clonazepam 1mg twice per day initially and taper slowly as antidepressant kicks in.

– Begin paroxetine 10-20mg twice per day

• Avoidance Behavior– Real exposure therapy– Imagined exposure therapy– Gradual and repetitive

confrontation of feared situations2

• Generalized Anxiety– Buspirone 15mg twice per day– Most SSRIs are helpful

• Maladaptive attitudes and behaviors

– Cognitive behavioral psychotherapy

• Education and Support– Refer to appropriate Internet

sites– Provide citations– With consent, refer to other

sufferers3

– Consider referral to self-help groups

1DSM-IV-TR, 20002Without continuous exposure, mastery is quickly lost.3Referrals to other patients doesn’t always work out well. “That woman is crazy, Doc!”

What are some of the treatment challenges you can expect?

• Noncompliance is always the principal challenge.• Lack of motivation is often an issue.• Acceptance of disability limits further progress.• Excessive sensitivity to medication side effects frequently

complicates treatment.• These patients often have a variety of comorbid medical and

psychiatric conditions• Unrealistic expectations for a quick and permanent cure limit the

patient’s ability to adopt a chronic disease management philosophy and practice.

• People with anxiety sometimes remain convinced that something “physical” is wrong and remains undiscovered.

• These patients can be very sensitive to your perceived rejection.1

• These miserable people demand a lot of attention and easily morph into dependent, clinging emotional black holes. It is critical not to promise more than you can deliver.2

1A patient misinterpreted my sigh. Another patient suspected the Lysol© was intended for her.2A colleague of mine agreed to call a patient at 10 PM every day. I had to manage the case when he left.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008

• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007

• Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005

• Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain,

January 2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000

Where can you find evidence-based information about mental disorders?

• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.

• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.

• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.

• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.

• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com.

• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.

• Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.

How can you contact me?1

Kendall L. Stewart, M.D.Kendall L. Stewart, M.D.VPMA and Chief Medical OfficerVPMA and Chief Medical OfficerSouthern Ohio Medical CenterSouthern Ohio Medical Center

Chairman & CEOChairman & CEOThe SOMC Medical Care Foundation, Inc.The SOMC Medical Care Foundation, Inc.

1805 27th Street1805 27th StreetWaller BuildingWaller Building

Suite B01Suite B01Portsmouth, Ohio 45662Portsmouth, Ohio 45662

740.356.8153740.356.8153

StewartK@somc.org StewartK@somc.org KendallLStewartMD@yahoo.comKendallLStewartMD@yahoo.com

www.somc.orgwww.somc.orgwww.KendallLStewartMD.comwww.KendallLStewartMD.com

1Speaking and consultation fees benefit the SOMC Endowment Fund.

SafetySafety QualityQuality ServiceService RelationshipsRelationships Performance Performance

Are there other questions?

John Gilbert, DOJohn Gilbert, DOOUCOM 1989OUCOM 1989

Kevin Kammler, DOKevin Kammler, DOOUCOM 1993OUCOM 1993