Shyness may be a more serious disability than we have
thought
In the 7 September issue of the New England Journal of Medicine, a New York psychiatrist offers useful information for people who are anxious and self-conscious in the presence of others. Social anxiety disorder can affect people at school, at work and in other social situations. It is common, showing a lifetime prevalence
of 12 per cent of the population. About half the sufferers have a generalised
type of the disorder, and in some social situations experience fear and avoid
other people. The remainder become frightened when required to speak or perform
in public.
The disorder typically begins in the early teenage years and takes a chronic
form. It is commoner among women than among men. Those seeking treatment have
often suffered symptoms for 10 years or more and show co-existent psychiatric
disorders. Phobias may appear in more than 50 per cent over a lifetime, while
major depression and alcohol abuse occur in 15 to 20 per cent.
Social anxiety disorders showed greater severity, pervasiveness, distress and
impaired lifestyle than mere shyness and performance anxiety, and may cause sufferers
to avoid important activities such as attending school and meetings.
Development of the anxiety has factors of both heredity and environment. It may
arise from overprotective and hypercritical parenting, but abnormal serotonin
and dopamine systems may be present. In major depressive disorder the coexistence
of social anxiety disorder may increase suicidal risk.
Established treatments for the disorder include cognitive-behavioural therapy
and pharmacotherapy. With the first of these, clinical improvement is typically
apparent after six to 12 weeks and progresses over several months. Selective
serotonin-reuptake inhibitors (SSRIs) and venlafaxine have been effective, with
response rates of 50 to 80 per cent after eight to 12 weeks’ treatment.
Treatment begins with half the usual effective dose, increased after a week.
An initial trial should last 12 weeks, with maintenance treatment to minimise
the risk of relapse.
Benzodiazepines are commonly used for patients who cannot tolerate or respond
poorly to SSRIs or venlafaxine. Clonazepam is usually effective in generalised
social anxiety disorder, in divided doses daily.
Beta-blockers such as propranolol, taken an hour before a performance, may help
in performance-type social anxiety disorder, as may benzodiazepines taken at
least 30 minutes before the performance. Their effect may last up to several
hours. Tolerance and physical dependence are unlikely.
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Pharmaceutical Journal
In the 5 August issue of the BMJ, Edzard Ernst, director of complementary medicine at the Peninsula Medical School (of the Universities of Exeter and Plymouth), puts forward some helpful remarks on the need for better communication between patients and those treating them. He points out
that, although more and more people are attracted to complementary
and alternative medicine (CAM), some of the information offered to
them tends to be unreliable. So that patients can co-operate with their
doctors and other health advisers as much as
possible, the information available to them must be accurate, objective,
sufficiently detailed and comprehensive and understandable.