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Recent Advances in Understanding and Treating Social Anxiety Disorder

Published online by Cambridge University Press:  07 November 2014

Herman G. M. Westenberg
Herman G. M. Westenberg*
Affiliation:
Dr. Westenberg is professor in the Section Psychiatric Phenotypes of Biological Psychiatry at the Rudolf Magnus Institute of Neuroscience and the Department of Psychiatry at the, University Medical Center Utrecht, in, The Netherlands.
*
Herman G. M. Westenberg, PhD, Department of Psychiatry, University Medical Center Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands; Tel: 31-88-755-9019; Fax: 31-30-212-9205; E-mail: h.g.m.westenberg@umcutrecht.nl.
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Abstract

The common occurrence and high level of morbidity and burden associated with social anxiety disorder (SAD) are gaining widespread recognition. Interest in understanding and treating the disorder has also grown in response to large-scale investigations that have demonstrated high levels of efficacy with both pharmacologic and nonpharmacologic treatments. Such trials indicate that many patients with generalized SAD (roughly 40% to 60%) respond (eg, Clinical Global Impressions–Improvement rating 1 or 2) after an adequate treatment trial, despite having suffered with disabling symptoms for most of their adult lives. First-line therapy options include the selective serotonin reuptake inhibitors and the dual-acting serotonin-norepinephrine reuptake inhibitor venlafaxine. Second-line options consist of anticonvulsants (gabapentin, pregabalin, valproic acid) and benzodiazepines (clonazepam). Reversible and irreversible monoamine oxidase inhibitors (moclobemide and phenelzine, respectively), while effective, are not widely used. Nonpharmacologic approaches, such as cognitive-behavioral therapy (CBT), are also effective for SAD. Newer treatment strategies such as levetiracetam, atypical antipsychotics, or D-cycloserine in combination with CBT appear promising but require further investigation. Finding a well-tolerated, safe, and effective treatment for each individual patient is crucial as most will require ongoing treatment in order to maintain benefits, prevent SAD relapse, and to experience optimal outcomes in the long term.

Type
Research Article
Information
CNS Spectrums , Volume 14 , Issue S3 , 2009 , pp. 24 - 33
Copyright
Copyright © Cambridge University Press 2009

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References

1.Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev. Washington, DC: American Psychiatric Association; 2000.Google Scholar
2.Ruscio, AM, Brown, TA, Chiu, WT, Sareen, J, Stein, MB, Kessler, RC. Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychol Med. 2008;38(1):15–28.CrossRefGoogle ScholarPubMed
3.Magee, WJ, Eaton, WW, Wittchen, HU, McGonagle, KA, Kessler, RC. Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey. Arch Gen Psychiatry. 1996;53(2):159–168.Google Scholar
4.Kessler, RC, Berglund, P, Demler, O, Jin, R, Walters, EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602.Google Scholar
5.Vorcaro, CM, Rocha, FL, Uchoa, E, Lima-Costa, MF. The burden of social phobia in a Brazilian community and its relationship with socioeconomic circumstances, health status and use of health services: the Bambui study. Int J Soc Psychiatry. 2004;50(3):216–226.CrossRefGoogle Scholar
6.Alonso, J, Lepine, JP. Overview of key data from the European Study of the Epidemiology of Mental Disorders (ESEMeD). J Clin Psychiatry. 2007;68(suppl 2):3–9.Google Scholar
7.Fehm, L, Pelissolo, A, Furmark, T, Wittchen, HU. Size and burden of social phobia in Europe. Eur Neuropsychopharmacol. 2005;15(4):453–462.CrossRefGoogle ScholarPubMed
8.Beesdo, K, Bittner, A, Pine, DS, et al.Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry. 2007;64(8):903–912.Google Scholar
9.Wells, JE, Browne, MA, Scott, KM, McGee, MA, Baxter, J, Kokaua, J, and the New Zealand Mental Health Survey Research Team. Prevalence, interference with life and severity of 12 month DSM-IV disorders in Te Rau Hinengaro: the New Zealand Mental Health Survey. Aust N Z J Psychiatry. 2006;40(10):845–854.CrossRefGoogle ScholarPubMed
10.Kessler, RC, Stein, MB, Berglund, P. Social phobia subtypes in the National Comorbidity Survey. Am J Psychiatry. 1998;155(5):613–619.Google Scholar
11.Yonkers, KA, Dyck, IR, Keller, MB. An eight-year longitudinal comparison of clinical course and characteristics of social phobia among men and women. Psychiatr Serv. 2001;52(5):637–643.CrossRefGoogle ScholarPubMed
12.Stein, MB, Fuetsch, M, Muller, N, Hofler, M, Lieb, R, Wittchen, HU. Social anxiety disorder and the risk of depression: a prospective community study of adolescents and young adults. Arch Gen Psychiatry. 2001;58(3):251–256.Google Scholar
13.Goodwin, RD, Stayner, DA, Chinman, MJ, Wu, P, Tebes, JK, Davidson, L. The relationship between anxiety and substance use disorders among individuals with severe affective disorders. Compr Psychiatry. 2002;43(4):245–252.Google Scholar
14.Goodwin, RD, Fergusson, DM, Horwood, LJ. Association between anxiety disorders and substance use disorders among young persons: results of a 21-year longitudinal study. J Psychiatr Res. 2004;38(3):295–304.CrossRefGoogle ScholarPubMed
15.Wang, PS, Lane, M, Olfson, M, Pincus, HA, Wells, KB, Kessler, RC. Twelve-month use of mental health services in the United States: results from the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):629–640.Google Scholar
16.Kessler, RC, Stang, P, Wittchen, HU, Stein, M, Walters, EE. Lifetime co-morbidities between social phobia and mood disorders in the US National Comorbidity Survey. Psychol Med. 1999;29(3):555–567.Google Scholar
17.Harmer, CJ, Bhagwagar, Z, Perrett, DI, Vollm, BA, Cowen, PJ, Goodwin, GM. Acute SSRI administration affects the processing of social cues in healthy volunteers. Neuropsychopharmacology. 2003;28(1):148–152.Google Scholar
18.Tse, WS, Bond, AJ. Serotonergic intervention affects both social dominance and affiliative behaviour. Psychopharmacology (Berl). 2002;161(3):324–330.CrossRefGoogle ScholarPubMed
19.Argyropoulos, SV, Hood, SD, Adrover, M, et al.Tryptophan depletion reverses the therapeutic effect of selective serotonin reuptake inhibitors in social anxiety disorder. Biol Psychiatry. 2004;56(7):503–509.Google Scholar
20.Lanzenberger, RR, Mitterhauser, M, Spindelegger, C, et al.Reduced serotonin-1A receptor binding in social anxiety disorder. Biol Psychiatry. 2007;61(9):1081–1089.Google Scholar
21.van der Wee, NJ, Van Veen, JF, Stevens, H, van Vliet, IM, van Rijk, PP, Westenberg, HG. Increased serotonin and dopamine transporter binding in psychotropic medication-naive patients with generalized social anxiety disorder shown by 123I-beta-(4-iodophenyl)-tropane SPECT. J Nucl Med. 2008;49(5):757–763.Google Scholar
22.Stein, MB, Heuser, IJ, Juncos, JL, Uhde, TW. Anxiety disorders in patients with Parkinson’s disease. Am J Psychiatry. 1990;147(2):217–220.Google Scholar
23.Pallanti, S, Quercioli, L, Rossi, A, Pazzagli, A. The emergence of social phobia during clozapine treatment and its response to fluoxetine augmentation. J Clin Psychiatry. 1999;60(12):819–823.Google Scholar
24.Schneier, FR, Liebowitz, MR, Abi-Dargham, A, Zea-Ponce, Y, Lin, SH, Laruelle, M. Low dopamine D(2) receptor binding potential in social phobia. Am J Psychiatry. 2000;157(3):457–459.Google Scholar
25.Schneier, FR, Martinez, D, Abi-Dargham, A, et al.Striatal dopamine D(2) receptor availability in OCD with and without comorbid social anxiety disorder: preliminary findings. Depress Anxiety. 2008;25(1):1–7.Google Scholar
26.Tiihonen, J, Kuikka, J, Bergstrom, K, Lepola, U, Koponen, H, Leinonen, E. Dopamine reuptake site densities in patients with social phobia. Am J Psychiatry. 1997;154(2):239–242.Google Scholar
27.Phan, KL, Fitzgerald, DA, Nathan, PJ, Tancer, ME. Association between amygdala hyperactivity to harsh faces and severity of social anxiety in generalized social phobia. Biol Psychiatry. 2006;59(5):424–429.CrossRefGoogle ScholarPubMed
28.Stein, MB, Goldin, PR, Sareen, J, Zorrilla, LT, Brown, GG. Increased amygdala activation to angry and contemptuous faces in generalized social phobia. Arch Gen Psychiatry. 2002;59(11):1027–1034.CrossRefGoogle ScholarPubMed
29.Stein, MB, Simmons, AN, Feinstein, JS, Paulus, MP. Increased amygdala and insula activation during emotion processing in anxiety-prone subjects. Am J Psychiatry. 2007;164(2):318–327.Google Scholar
30.Amir, N, Klumpp, H, Elias, J, Bedwell, JS, Yanasak, N, Miller, LS. Increased activation of the anterior cingulate cortex during processing of disgust faces in individuals with social phobia. Biol Psychiatry. 2005;57(9):975–981.CrossRefGoogle ScholarPubMed
31.Phan, KL, Fitzgerald, DA, Cortese, BM, Seraji-Bozorgzad, N, Tancer, ME, Moore, GJ. Anterior cingulate neurochemistry in social anxiety disorder: 1H-MRS at 4 Tesla. Neuroreport. 2005;16(2):183–186.CrossRefGoogle Scholar
32.Furmark, T, Appel, L, Michelgard, A, et al.Cerebral blood flow changes after treatment of social phobia with the neurokinin-1 antagonist GR205171, citalopram, or placebo. Biol Psychiatry. 2005;58(2):132–142.Google Scholar
33.Sareen, J, Campbell, DW, Leslie, WD, et al.Striatal function in generalized social phobia: a functional magnetic resonance imaging study. Biol Psychiatry. 2007;61(3):396–404.Google Scholar
34.Carey, PD, Warwick, J, Niehaus, DJ, et al.Single photon emission computed tomography (SPECT) of anxiety disorders before and after treatment with citalopram. BMC Psychiatry. 2004;4:30.Google Scholar
35.Arbelle, S, Benjamin, J, Golin, M, Kremer, I, Belmaker, RH, Ebstein, RP. Relation of shyness in grade school children to the genotype for the long form of the serotonin transporter promoter region polymorphism. Am J Psychiatry. 2003;160(4):671–676.Google Scholar
36.Battaglia, M, Ogliari, A, Zanoni, A, et al.Influence of the serotonin transporter promoter gene and shyness on children’s cerebral responses to facial expressions. Arch Gen Psychiatry. 2005;62(1):85–94.Google Scholar
37.Furmark, T, Tillfors, M, Garpenstrand, H, et al.Serotonin transporter polymorphism related to amygdala excitability and symptom severity in patients with social phobia. Neurosci Lett. 2004;362(3):189–192.Google Scholar
38.Stein, MB, Seedat, S, Gelernter, J. Serotonin transporter gene promoter polymorphism predicts SSRI response in generalized social anxiety disorder. Psychopharmacology (Berl). 2006;187(1):68–72.CrossRefGoogle ScholarPubMed
39.Gelernter, J, Page, GP, Stein, MB, Woods, SW. Genome-wide linkage scan for loci predisposing to social phobia: evidence for a chromosome 16 risk locus. Am J Psychiatry. 2004;161(1):59–66.Google Scholar
40.Ballenger, JC, Davidson, JR, Lecrubier, Y, et al.Consensus statement on social anxiety disorder from the International Consensus Group on Depression and Anxiety. J Clin Psychiatry. 1998;59(suppl 17):54–60.Google Scholar
41.Stein, MB, Liebowitz, MR, Lydiard, RB, Pitts, CD, Bushnell, W, Gergel, I. Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial. JAMA. 1998;280(8):708–713.Google Scholar
42.Liebowitz, MR. Social phobia. Mod Probl Pharmacopsychiatry. 1987;22:141–173.CrossRefGoogle ScholarPubMed
43.Guy, W. Clinical Global Impressions. ECDEU Assessment Manual for Psychopharmacology. Rockville, Md: US Department of Health, Education, and Welfare; 1976:217–22. Publication ADM 76-338.Google Scholar
44.Baldwin, D, Bobes, J, Stein, DJ, Scharwachter, I, Faure, M. Paroxetine in social phobia/social anxiety disorder. Randomised, double-blind, placebo-controlled study. Paroxetine Study Group. Br J Psychiatry. 1999;175:120–126.Google Scholar
45.Sheehan, DV. Sheehan disability scale. In: Rush, AJ, Pincus, HA, First, MB, et al. eds. Handbook of Psychiatric Measures. 1st ed. Washington, DC: American Psychiatric Association; 2000:113–115.Google Scholar
46.Lepola, U, Bergtholdt, B, St Lambert, J, Davy, KL, Ruggiero, L. Controlled-release paroxetine in the treatment of patients with social anxiety disorder. J Clin Psychiatry. 2004;65(2):222–229.Google Scholar
47.Blomhoff, S, Haug, TT, Hellstrom, K, et al.Randomised controlled general practice trial of sertraline, exposure therapy and combined treatment in generalised social phobia. Br J Psychiatry. 2001;179:23–30.CrossRefGoogle ScholarPubMed
48.Van Ameringen, MA, Lane, RM, Walker, JR, et al.Sertraline treatment of generalized social phobia: a 20-week, double-blind, placebo-controlled study. Am J Psychiatry. 2001;158(2):275–281.Google Scholar
49.Liebowitz, MR, DeMartinis, NA, Weihs, K, et al.Efficacy of sertraline in severe generalized social anxiety disorder: results of a double-blind, placebo-controlled study. J Clin Psychiatry. 2003;64(7):785–792.CrossRefGoogle ScholarPubMed
50.Katzelnick, DJ, Kobak, KA, Greist, JH, Jefferson, JW, Mantle, JM, Serlin, RC. Sertraline for social phobia: a double-blind, placebo-controlled crossover study. Am J Psychiatry. 1995;152(9):1368–1371.Google Scholar
51.Westenberg, HG, Stein, DJ, Yang, H, Li, D, Barbato, LM. A double-blind placebo-controlled study of controlled release fluvoxamine for the treatment of generalized social anxiety disorder. J Clin Psychopharmacol. 2004;24(1):49–55.Google Scholar
52.Davidson, J, Yaryura-Tobias, J, DuPont, R, et al.Fluvoxamine-controlled release formulation for the treatment of generalized social anxiety disorder. J Clin Psychopharmacol. 2004;24(2):118–125.Google Scholar
53.Lader, M, Stender, K, Burger, V, Nil, R. Efficacy and tolerability of escitalopram in 12- and 24-week treatment of social anxiety disorder: randomised, double-blind, placebo-controlled, fixed-dose study. Depress Anxiety. 2004;19(4):241–248.Google Scholar
54.Kasper, S, Stein, DJ, Loft, H, Nil, R. Escitalopram in the treatment of social anxiety disorder: randomised, placebo-controlled, flexible-dosage study. Br J Psychiatry. 2005;186:222–226.Google Scholar
55.Hedges, DW, Brown, BL, Shwalb, DA, Godfrey, K, Larcher, AM. The efficacy of selective serotonin reuptake inhibitors in adult social anxiety disorder: a meta-analysis of double-blind, placebo-controlled trials. J Psychopharmacol. 2007;21(1):102–111.Google Scholar
56.Kobak, KA, Greist, JH, Jefferson, JW, Katzelnick, DJ. Fluoxetine in social phobia: a double-blind, placebo-controlled pilot study. J Clin Psychopharmacol. 2002;22(3):257–262.Google Scholar
57.van Vliet, IM, den Boer, JA, Westenberg, HG. Psychopharmacological treatment of social phobia; a double blind placebo controlled study with fluvoxamine. Psychopharmacology (Berl). 1994;115(1-2):128–134.Google Scholar
58.Stein, MB, Fyer, AJ, Davidson, JR, Pollack, MH, Wiita, B. Fluvoxamine treatment of social phobia (social anxiety disorder): a double-blind, placebo-controlled study. Am J Psychiatry. 1999;156(5):756–760.Google Scholar
59.Allgulander, C. Paroxetine in social anxiety disorder: a randomized placebo-controlled study. Acta Psychiatr Scand. 1999;100(3):193–198.Google Scholar
60.Liebowitz, MR, Stein, MB, Tancer, M, Carpenter, D, Oakes, R, Pitts, CD. A randomized, double-blind, fixed-dose comparison of paroxetine and placebo in the treatment of generalized social anxiety disorder. J Clin Psychiatry. 2002;63(1):66–74.Google Scholar
61.Blanco, C, Schneier, FR, Schmidt, A, et al.Pharmacological treatment of social anxiety disorder: a meta-analysis. Depress Anxiety. 2003;18(1):29–40.Google Scholar
62.Stein, DJ, Ipser, JC, Balkom, AJ. Pharmacotherapy for social phobia. Cochrane Database Syst Rev. 2004;(4):CD001206.Google Scholar
63.Rickels, K, Mangano, R, Khan, A. A double-blind, placebo-controlled study of a flexible dose of venlafaxine ER in adult outpatients with generalized social anxiety disorder. J Clin Psychopharmacol. 2004;24(5):488–496.Google Scholar
64.Liebowitz, MR, Gelenberg, AJ, Munjack, D. Venlafaxine extended release vs placebo and paroxetine in social anxiety disorder. Arch Gen Psychiatry. 2005;62(2):190–198.Google Scholar
65.Allgulander, C, Mangano, R, Zhang, J, et al.and the SAD 388 Study Group. Efficacy of venlafaxine ER in patients with social anxiety disorder: a double-blind, placebo-controlled, parallel-group comparison with paroxetine. Hum Psychopharmacol. 2004;19(6):387–396.Google Scholar
66.Stein, MB, Pollack, MH, Bystritsky, A, Kelsey, JE, Mangano, RM. Efficacy of low and higher dose extended-release venlafaxine in generalized social anxiety disorder: a 6-month randomized controlled trial. Psychopharmacology (Berl). 2005;177(3):280–288.Google Scholar
67.Connor, KM, Davidson, JR, Churchill, LE, Sherwood, A, Foa, E, Weisler, RH. Psychometric properties of the Social Phobia Inventory (SPIN). New self-rating scale. Br J Psychiatry. 2000;176:379–386.CrossRefGoogle ScholarPubMed
68. Paxil [package insert]. Research Triangle Park, NC: GlaxoSmithKline; 2002.Google Scholar
69. Zoloft [package insert]. New York, NY: Pfizer Pharmaceuticals; 2006.Google Scholar
70.Liebowitz, MR, Schneier, F, Campeas, R, et al.Phenelzine vs atenolol in social phobia. A placebo-controlled comparison. Arch Gen Psychiatry. 1992;49(4):290–300.Google Scholar
71.Heimberg, RG, Liebowitz, MR, Hope, DA, et al.Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome. Arch Gen Psychiatry. 1998;55(12):1133–1141.Google Scholar
72.Versiani, M, Nardi, AE, Mundim, FD, Alves, AB, Liebowitz, MR, Amrein, R. Pharmacotherapy of social phobia. A controlled study with moclobemide and phenelzine. Br J Psychiatry. 1992;161:353–360.Google Scholar
73.The International Multicenter Clinical Trial Group on Moclobemide in Social Phobia. Moclobemide in social phobia. A double-blind, placebo-controlled clinical study. Eur Arch Psychiatry Clin Neurosci. 1997;247(2):71–80.Google Scholar
74.Schneier, FR, Goetz, D, Campeas, R, Fallon, B, Marshall, R, Liebowitz, MR. Placebo-controlled trial of moclobemide in social phobia. Br J Psychiatry. 1998;172:70–77.Google Scholar
75.Stein, DJ, Cameron, A, Amrein, R, Montgomery, SA. Moclobemide is effective and well tolerated in the long-term pharmacotherapy of social anxiety disorder with or without comorbid anxiety disorder. Int Clin Psychopharmacol. 2002;17(4):161–170.Google Scholar
76.van Vliet, IM, den Boer, JA, Westenberg, HG. Psychopharmacological treatment of social phobia: clinical and biochemical effects of brofaromine, a selective MAO-A inhibitor. Eur Neuropsychopharmacol. 1992;2(1):21–29.Google Scholar
77.Lott, M, Greist, JH, Jefferson, JW, et al.Brofaromine for social phobia: a multicenter, placebo-controlled, double-blind study. J Clin Psychopharmacol. 1997;17(4):255–260.Google Scholar
78.Crippa, JA, Filho, AS, Freitas, MC, Zuardi, AW. Duloxetine in the treatment of social anxiety disorder. J Clin Psychopharmacol. 2007;27(3):310.Google Scholar
79.Muehlbacher, M, Nickel, MK, Nickel, C, et al.Mirtazapine treatment of social phobia in women: a randomized, double-blind, placebo-controlled study. J Clin Psychopharmacol. 2005;25(6):580–583.Google Scholar
80.Van Ameringen, M, Mancini, C, Oakman, J, et al.Nefazodone in the treatment of generalized social phobia: a randomized, placebo-controlled trial. J Clin Psychiatry. 2007;68(2):288–295.Google Scholar
81.Van Veen, JF, van Vliet, IM, Westenberg, HG. Mirtazapine in social anxiety disorder: a pilot study. Int Clin Psychopharmacol. 2002;17(6):315–317.Google Scholar
82. Remeron [package insert]. West Orange, NJ: Organon, Inc; 2005.Google Scholar
83. Serzone [package insert]. Princeton, NJ: Bristol-Myers Squibb, Co; 1998.Google Scholar
84.Pande, AC, Davidson, JR, Jefferson, JWet al.Treatment of social phobia with gabapentin: a placebo-controlled study. J Clin Psychopharmacol. 1999;19(4):341–348.Google Scholar
85.Pande, AC, Feltner, DE, Jefferson, JW, et al.Efficacy of the novel anxiolytic pregabalin in social anxiety disorder: a placebo-controlled, multicenter study. J Clin Psychopharmacol. 2004;24(2):141–149.Google Scholar
86.Dunlop, BW, Papp, L, Garlow, SJ, Weiss, PS, Knight, BT, Ninan, PT. Tiagabine for social anxiety disorder. Hum Psychopharmacol. 2007;22(4):241–244.Google Scholar
87.Simon, NM, Worthington, JJ, Doyle, AC, et al.An open-label study of levetiracetam for the treatment of social anxiety disorder. J Clin Psychiatry. 2004;65(9):1219–1222.Google Scholar
88.Van Ameringen, M, Mancini, C, Pipe, B, Oakman, J, Bennett, M. An open trial of topiramate in the treatment of generalized social phobia. J Clin Psychiatry. 2004;65(12):1674–1678.Google Scholar
89.Kinrys, G, Pollack, MH, Simon, NM, Worthington, JJ, Nardi, AE, Versiani, M. Valproic acid for the treatment of social anxiety disorder. Int Clin Psychopharmacol. 2003;18(3):169–172.Google Scholar
90.Davidson, JR, Potts, N, Richichi, E, et al.Treatment of social phobia with clonazepam and placebo. J Clin Psychopharmacol. 1993;13(6):423–428.Google Scholar
91.Gelernter, CS, Uhde, TW, Cimbolic, P, et al.Cognitive-behavioral and pharmacological treatments of social phobia. A controlled study. Arch Gen Psychiatry. 1991;48(10):938–945.Google Scholar
92.Otto, MW, Pollack, MH, Gould, RA, Worthington, JJ 3rd, McArdle, ET, Rosenbaum, JF. A comparison of the efficacy of clonazepam and cognitive-behavioral group therapy for the treatment of social phobia. J Anxiety Disord. 2000;14(4):345–358.Google Scholar
93.van Vliet, IM, den Boer, JA, Westenberg, HG, Pian, KL. Clinical effects of buspirone in social phobia: a double-blind placebo-controlled study. J Clin Psychiatry. 1997;58(4):164–8.Google Scholar
94.Ponniah, K, Hollon, SD. Empirically supported psychological interventions for social phobia in adults: a qualitative review of randomized controlled trials. Psychol Med. 2008;38(1):3–14.Google Scholar
95.Furmark, T, Tillfors, M, Marteinsdottir, I, et al.Common changes in cerebral blood flow in patients with social phobia treated with citalopram or cognitive-behavioral therapy. Arch Gen Psychiatry. 2002;59(5):425–433.Google Scholar
96.Hofmann, SG. Cognitive mediation of treatment change in social phobia. J Consult Clin Psychol. 2004;72(3):392–399.Google Scholar
97.Davidson, JR, Foa, EB, Huppert, JD, et al.Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. Arch Gen Psychiatry. 2004;61(10):1005–1013.Google Scholar
98.Hofmann, SG, Smits, JA. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69(4):621–632.Google Scholar
99.Seedat, S, Stein, MB. Double-blind, placebo-controlled assessment of combined clonazepam with paroxetine compared with paroxetine monotherapy for generalized social anxiety disorder. J Clin Psychiatry. 2004;65(2):244–248.Google Scholar
100.Van Ameringen, M, Mancini, C, Wilson, C. Buspirone augmentation of selective serotonin reuptake inhibitors (SSRIs) in social phobia. J Affect Disord. 1996;39(2):115–121.Google Scholar
101.Schneier, FR, Blanco, C, Campeas, R, et al.Citalopram treatment of social anxiety disorder with comorbid major depression. Depress Anxiety. 2003;17(4):191–196.Google Scholar
102.Randall, CL, Johnson, MR, Thevos, AK, et al.Paroxetine for social anxiety and alcohol use in dual-diagnosed patients. Depress Anxiety. 2001;14(4):255–262.Google Scholar
103.Thomas, SE, Randall, PK, Book, SW, Randall, CL. A complex relationship between co-occurring social anxiety and alcohol use disorders: what effect does treating social anxiety have on drinking? Alcohol Clin Exp Res. 2008;32(1):77–84.Google Scholar
104.March, JS, Entusah, AR, Rynn, M, Albano, AM, Tourian, KA. A Randomized controlled trial of venlafaxine ER versus placebo in pediatric social anxiety disorder. Biol Psychiatry. 2007;62(10):1149–1154.CrossRefGoogle ScholarPubMed
105.Wagner, KD, Berard, R, Stein, MB, et al.A multicenter, randomized, double-blind, placebo-controlled trial of paroxetine in children and adolescents with social anxiety disorder. Arch Gen Psychiatry. 2004;61(11):1153–1162.Google Scholar
106.Isolan, L, Pheula, G, Salum, GA Jr, Oswald, S, Rohde, LA, Manfro, GG. An open-label trial of escitalopram in children and adolescents with social anxiety disorder. J Child Adolesc Psychopharmacol. 2007;17(6):751–760.Google Scholar
107.Stein, DJ, Versiani, M, Hair, T, Kumar, R. Efficacy of paroxetine for relapse prevention in social anxiety disorder: a 24-week study. Arch Gen Psychiatry. 2002;59(12):1111–1118.Google Scholar
108.Montgomery, SA, Nil, R, Dürr-Pal, N, Loft, H, Boulenger, JP. A 24-week randomized, double-blind, placebo-controlled study of escitalopram for the prevention of generalized social anxiety disorder. J Clin Psychiatry. 2005;66(10):1270–1278.Google Scholar
109.Connor, KM, Davidson, JR, Potts, NL, et al.Discontinuation of clonazepam in the treatment of social phobia. J Clin Psychopharmacol. 1998;18(5):373–378.Google Scholar
110.Walker, JR, Van Ameringen, MA, Swinson, R, et al.Prevention of relapse in generalized social phobia: results of a 24-week study in responders to 20 weeks of sertraline treatment. J Clin Psychopharmacol. 2000;20(6):636–644.Google Scholar
111.Barnett, SD, Kramer, ML, Casat, CD, Connor, KM, Davidson, JR. Efficacy of olanzapine in social anxiety disorder: a pilot study. J Psychopharmacol. 2002;16(4):365–368.Google Scholar
112.Schutters, SI, van Megen, HJ, Westenberg, HG. Efficacy of quetiapine in generalized social anxiety disorder: results from an open-label study. J Clin Psychiatry. 2005;66(4):540–542.Google Scholar
113.Vaishnavi, S, Alamy, S, Zhang, W, Connor, KM, Davidson, JR. Quetiapine as monotherapy for social anxiety disorder: a placebo-controlled study. Prog Neuropsychopharmacol Biol Psychiatry. 2007;31(7):1464–1469.Google Scholar
114.Davidson, JR, Potts, NL, Richichi, EA, et al.The Brief Social Phobia Scale. J Clin Psychiatry. 1991;52(suppl):48–51.Google Scholar
115.Hofmann, SG, Meuret, AE, Smits, JA, et al.Augmentation of exposure therapy with D-cycloserine for social anxiety disorder. Arch Gen Psychiatry. 2006;63(3):298–304.Google Scholar
116.Guastella, AJ, Richardson, R, Lovibond, PF, et al.A randomized controlled trial of D-cycloserine enhancement of exposure therapy for social anxiety disorder. Biol Psychiatry. 2008;63(6):544–549.Google Scholar
117.Richardson, R, Ledgerwood, L, Cranney, J. Facilitation of fear extinction by D-cycloserine: theoretical and clinical implications. Learn Mem. 2004;11(5):510–516.Google Scholar
118.Beidel, DC, Borden, JW, Turner, SM, Jacob, RG. The Social Phobia and Anxiety Inventory: concurrent validity with a clinic sample. Behav Res Ther. 1989;27(5):573–576.Google Scholar
119.Muller, JE, Koen, L, Seedat, S, Stein, DJ. Social anxiety disorder: current treatment recommendations. CNS Drugs. 2005;19(5):377–391.Google Scholar