Social phobia

Social phobia

Journal of the American Psychiatric Nurses Association Original Articles Social Phobia Sharon M. Valente, RN, CS, PhD, FAAN Social phobia is a debil...

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Journal of the American Psychiatric Nurses Association

Original Articles

Social Phobia Sharon M. Valente, RN, CS, PhD, FAAN Social phobia is a debilitating psychiatric condition that is treatable but often remains undetected and untreated. Without treatment, clients are at risk for complications, such as reduced quality of life, social interactions, daily functioning, and treatment adherence. Social phobia leads to more sick days, poor job performance, costly medical and emergency care visits, mental health visits, and greater reliance on disability or welfare. In the worst cases, the patient may decide that life is not worth living and consider suicide. Screening and careful assessment are the keys to detection and evaluation of social phobia. This article presents a case study to illustrate evaluation and treatment of social phobia. (J Am Psychiatr Nurses Assoc [2002]. 8, 67-75.)

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ocial phobia involves a persistent and irrational fear of social interactions and evokes a compelling wish to avoid those situations. It may markedly compromise both quality of life and psychosocial function. Social phobia is classified as one of several forms of anxiety disorders. Other anxiety disorders include panic disorder and generalized anxiety disorder. Social phobia is a chronic, unremitting, lifelong disorder that typically begins between the ages of 13 and 20, although young children may also develop it. The person is paralyzed by fears that he or she will humiliate or embarrass himself or herself in front of others and has performance anxiety before a test, job interview, talk, or a first date. Although medications and psychosocial treatments can significantly improve quality of life, social phobia and its related anxiety often remain undetected and untreated (Mandelowicz & Stein, 2000). The National Institute of Mental Health (NIMH) Epidemiologic Catchment Area study showed that anxiety disorders had the highest prevalence rate among mental disorders (Regier et al., 1988). The researchers found that anxiety disorders affected 26.9

Sharon M. Valente, RN, CS, PhD, FAAN, is a fellow at the Department of Veteran Affairs and an assistant professor in the Department of Nursing, University of Southern California. This material is the result of work supported with the resources and use of the facilities at Department of Veterans Affairs Greater Los Angeles Healthcare System. Reprint requests: Sharon M. Valente, RN, CS, PhD, FAAN, 346 N. Bowling Green Way, Los Angeles, CA 90049-2818. Copyright © 2002 by the American Psychiatric Nurses Association. 1078-3903/2002/$35.00 ⫹ 0 66/1/125038 doi:10.1067/mpn.2002.125038

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million Americans during their lives. The national comorbidity study found that 13.3% of Americans had a social phobia during their lifetime. The costs of anxiety disorders were a staggering $46.6 billion, and comprised 31.5% of mental health expenditures in 1990 (DuPont et al., 1996). In the United States, only one in four people with an anxiety disorder is correctly identified, diagnosed, and treated. In inpatient and ambulatory care settings, nurses need to detect social phobia before they encourage clients to increase their social interactions. The debilitating symptoms of social phobia occur during formal and informal interactions with others, during speeches, and when one believes one is being observed by others. People with this disorder may report that, like Mickey Mantle, they often use three to four cocktails or more to reduce shyness and discomfort before appearing at social gatherings. Social phobia may interrupt education or job success, cause financial dependence and impaired relationships, and precipitate mood disorders, alcohol or substance abuse, and suicide. About half the people with this social phobia drop out of school, and 23% become unemployed and rely on welfare. People with social phobia are heavy users of sick days, health care visits, disability, and welfare. Davidson and colleagues (1993) found that people with social phobia used 6.92 sick days in the past 90 days compared with 3.13 days of control subjects. They had 3 medical visits in the past 6 months compared with 1.69 for controls; and they had 4.08 mental health visits compared with 0.23 for controls. About 22% of those with social phobia received welfare or disability compared with 10% of controls. The symptoms of social phobia complicate access to health care because social encounters are avoided. In one study, many clients (58%) diagnosed with social APNA Web site: www.apna.org 67

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phobia preferred to use a computer to report their anxiety. These clients completed a screening tool for anxiety, the Liebowitz Social Anxiety Scale (Heimberg et al., 1999), and only 17% preferred talking with the clinician rather than using the computer to complete the screening form (Katzelnick, Kobak, & Greist, 1995). Misdiagnosis of social phobia is common. When clients seek help, their symptoms may mimic cardiac conditions (e.g., palpitations, shortness of breath, and chest pain). When primary clinicians initially fail to find a medical cause for these symptoms, they refer patients to an internist or cardiac specialist. The failure to diagnose social phobia often leads to an increase in subsequent costly urgent care visits and other consequences (e.g., suicide risk, depression, and chemical dependency). However, if recognized, the disorder can be treated. Effective evaluation and management of social phobia requires sound scientific knowledge. In this article, the diagnosis, measurement, and management of social phobia are examined. DESCRIPTION AND PREVALENCE OF SOCIAL PHOBIA Although some degree of shyness is normal, persons with social phobia are often excessively anxious and cannot handle social interactions. This problem typically begins during school years when individuals will be terrified and avoid class presentations at all costs. They may drop elective courses that require a presentation and select a college major without group work and public speaking. Occasionally, a more skilled student will ask faculty for any alternative to a class presentation—and will perform well if allowed to put the presentation in writing— but this request is uncommon. People with social phobia have difficulty making friends, developing relationships, finding partners, and establishing social connections.

People with social phobia have difficulty making friends, developing relationships, finding partners, and establishing social connections.

Social phobia may be more common than previously believed (Heimberg et al., 1998). Social phobia occurs in about 7.9% of people (6.6% of men; 9.1% of women) annually, and the lifetime prevalence is 13.3%. Similar rates were reported by studies outside the United States (Goisman, Warshaw, & Keller 1999; Mandelowitz & Stein, 2000; Versiani et al., 1996). Panic disorder, another anxiety disorder, occurs in about 2.3% of people per year and 3.5% lifetime, and generalized anxiety 68 APNA Web site: www.apna.org

disorder occurs in 3.1% of people yearly and 5.1% lifetime (Goisman et al., 1999). Etiology Cognitive theorists believe that social phobias may stem from negative thinking and irrational ideas. Automatic negative thoughts and irrational ideas (e.g., I will humiliate myself in public; I have to be perfect to be loved) often precipitate anxiety in the person with social phobia. Social phobia also may be caused by genetics, biochemical sources, and unconscious conflicts. Researchers (Fones, Manfro, & Pollack, 1998) have suggested that people with close biological relatives with anxiety are more likely to develop anxiety disorders than those with a negative family history. Anxiety disorders, including social phobia, may also stem from a malfunction of the internal biochemical substances that help individuals prepare for danger. Several chemicals such as epinephrine may be implicated in anxiety disorders. Epinephrine triggers the onset of tremors, anxiety, nervousness, and increased vital signs—all common symptoms of social phobia. Neurotransmitters (norepinephrine, serotonin, and dopamine) control mood, movement, blood pressure, and neural impulse conduction. Although excess serotonin or norepinephrine stimulates anxiety, it is unclear whether a disorder of secretion or uptake of these chemicals leads to anxiety. Some individuals may also have an overly sensitive response system. Norepinephrine, serotonin, and dopamine excite transmission while other chemicals (e.g., gamma-aminobutyric acid system [GABA]) inhibit neurotransmission in the brain. Biochemical theory is important because it indicates anxiety is not caused by weak willpower or motivation. Medications to regulate anxiety are not just a crutch to reduce symptoms but a treatment for a chemical imbalance (Valente, 1996). ASSESSMENT An assessment should begin with a thorough health history and physical examination to rule out a physiological reason for symptoms. The history and physical are also critical if medications will be prescribed. Clients who recognize their social phobia could report to the clinician a history of panic during social interactions, however, clients rarely initiate the discussion unless asked about anxiety or panic. An evaluation of the onset and history of episodes of nervousness or panic in social interactions is essential. Determining when the episodes of social phobia occur and their triggers is helpful. Many people will report an insidious onset. Although in about 77% of persons, the social phobia occurs first, and it is often followed by other Vol. 8, No. 3

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Table 1. Example of a Mood Log Daily log Treatment/therapies

Atenolol (dose/#pills) CBGT

Able to

Hours

(describe situation

Irritability

Anxiety

function

Coping

Effect

slept*

that evoked anxiety)

(0-5 scale)

(0-5)

(0-5)

skill†

(0-5)

2 ⫽ slight

2

4

4

3 ⫽ jittery

3

4

Positive self talk Breathe Relax Self talk

Meeting at work—talk in group setting Evening—dinner with 3 people

Note. Scale 0 ⫽ least, 5 ⫽ most. Form also has sections for the date and for additional comments. CBGT ⫽ cognitive behavioral group therapy. * Indicate hours slept last night. † Include use of alcohol or other drugs.

disorders, such as alcohol abuse (18.8%), drug abuse (13.0%), agoraphobia (44.9%), or specific phobias (59%) (Kessler, Stang, Wittchen, Stein, & Walters, 1999). Because anxiety disorders can be familial, a family history is useful. Clients can keep a mood log (Table 1) where they document a baseline of their social anxiety and then document their anxiety after starting therapy. The baseline helps explore the situations that cause anxiety. The patient can do homework to improve the history by completing a mood diary for a couple of weeks or a daily mood chart to show anxiety, precipitants, and symptoms (e.g., “9 A.M. drank coffee; felt anxiety increase from none to severe”). Documenting use of stimulants, such as alcohol, drugs, or caffeine intake, may also suggest precipitants of anxiety that can be changed. Often, a review of the patient’s usual medications can suggest some medications that provoke anxiety as a side effect (e.g., aminophylline, amphetamines, anticholinergics, antihypertensives, or epinephrine). If alternatives exist, changing the medications that evoke anxiety is useful. Over the counter preparations, such as cold and allergy compounds, can also induce anxiety. Evaluating what reduces the anxiety is essential; some strategies are less constructive than others (e.g., alcohol, marijuana, and anxiolytic drugs may be less effective than relaxation, yoga, prayer, or other strategies).

Over the counter preparations, such as cold and allergy compounds, can also induce anxiety. Screening Instruments may help identify the occurrence of a problem and the degree of social phobia and identify the need for a psychiatric or psychological consultation or evaluation. Screening tools can identify people at June 2002

risk. However, they are not actually diagnostic tools; they simply reflect the need for a further evaluation to determine a diagnosis. Such instruments can also be used to monitor effectiveness of treatment and improve diagnosis, particularly when people hesitate to disclose their symptoms. Screening tools for social phobia are very helpful and can be completed easily (Table 2). The Mini International Neuropsychiatric Interview (MINI) (Sheehan et al., 1998) is brief and poses four questions about social phobia. Nurses can use it as a screening measure in diverse settings. The questions include: 1. In the past month were you fearful or embarrassed being watched, being the focus of attention, or fearful of being humiliated? 2. Is this excessive or unreasonable? 3. Do you fear these situations so much that you avoid them? 4. Does this fear disrupt your normal work or social functioning or cause you significant distress?

Other screening tools include the Liebowitz Social Anxiety Scale (Heimberg et al., 1999). The Liebowitz Social Anxiety Scale has 24 items and rates anxiety and avoidance. A computer version exists. The Brief Social Phobia Scale is another commonly used screening tool (Davidson et al., 1997). Broad scales, such as the Zung Anxiety Self Assessment Scale (Zung, 1986), can detect anxiety but are not specific for social phobia. Other screening tools such as the Michigan Alcoholism Screening Test (Seltzer, 1971) and the CAGE (acronym for key letter in questions; C ⫽ cut down, A ⫽ annoyed, G ⫽ guilty, and E ⫽ eyeopener) help clinicians detect alcohol abuse that may accompany social phobia (Inciardi, 1994). The CAGE is probably the most widely used screening test in clinical practice for alcohol abuse and dependency. Inciardi reported that the CAGE accurately identified 75% of alcoholics. The CAGE has four questions that can be asked in an interview or circled on a printed form. The CAGE can be given a broader focus to include drugs by adding APNA Web site: www.apna.org 69

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DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS Table 2. Highlights of Related Disorders Agoraphobia

Panic disorder

Atypical depression

Obsessive-Compulsive disorder

Substance abuse/dependence

Sudden anxiety followed by avoidance of open spaces. May occur with panic attacks. Sudden bursts of anxiety followed by anticipatory anxiety and phobic avoidance. Recurrent panic attacks and persistent concern or worry about panic attacks. Symptoms include palpitations, sweating, trembling, choking, shortness of breath, chest pain, nausea, dizziness, feelings of unreality, fear of losing control, fear of dying, paresthesias, chills. Mood disorder characterized by depression, anxiety, disruption in sleeping, eating, and interactions. Uncontrolled, irrational obsessions or repetitive thoughts (e.g., fear of dirt, leaving house unlocked) often linked with ritual behavior (e.g., washing hands 50 times or checking 5 times to make sure house is locked or counting). The person feels driven to repeat the compulsive rituals or adhere to rules rigidly (e.g., Lady MacBeth’s compulsive handwashing “out, out damned spot”). Symptoms include obsessions, repetitive thoughts, ritual, compulsive behaviors. Pattern of abuse of substances leading to significant impairment or distress at work, home, and in community. Signs: tolerance, attempts to cut down use, withdrawal, focus on obtaining substance. Denial of a substance use problem.

Social phobia involves being humiliated or embarrassed in social settings, and exposure to the feared situation provokes anxiety, avoidance, or distress. The person knows that this fear is excessive and has social or occupational problems or worries about this fear. People often use alcohol or drugs before a social situation to reduce their fear. The disorder is accompanied by preoccupation with others’ views and certainty of negative expectations (American Psychiatric Association, 1994).

People often use alcohol or drugs before a social situation to reduce their fear. Differential diagnosis includes eliminating normal and shy responses and agoraphobia, panic disorder, body dysmorphic disorder, atypical depression, avoidant personality disorder, and Axis III disorders (Table 2). To differentiate social phobia from agoraphobia, ask whether the person ever goes to a busy shopping mall without speaking to anyone. Agoraphobic clients do not avoid talking in social settings. To rule out panic disorder, ask if significant anxiety or panic attacks occur when alone. Social phobia does not usually include anxiety when alone. To evaluate body dysmorphic disorder, ask if the person is more concerned about appearance (e.g., body dysmorphic disorder) or interactions (social phobia). Atypical depression is often characterized by reversed vegetative symptoms (e.g., hypersomnia or hyperphagia) and marked anxiety. People with an avoidant personality disorder typically report a desire for social relationships but feel extremely shy and lack social skills. They also talk at others, speak too long, talk about themselves, and talk inappropriately and avoid eye contact. TREATMENT

the comment in parens at the end, and then it is called the CAGE-AID (AID ⫽ adapted to include drugs) (Brown, Edwards, & Rounds, 1995). A score of two yes answers or more to the following questions is usually considered a positive screen: 1. Have you ever felt you should cut down on your drinking (or drug use)? 2. Have people annoyed you by criticizing your drinking (or drug use)? 3. Have you ever felt bad or guilty about your drinking (or drug use)? 4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eyeopener) (or use drugs)?

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Effective treatment combines prescriptions for cognitive-behavioral therapy, education, counseling, self management techniques, and medications. Education helps the client understand the disorder and develop coping strategies for anxiety. Take home materials are useful because anxious clients have difficulty hearing and recalling information. Audio and videotapes or computer programs may help clients learn relaxation, breathing, and self-calming skills. Treatment often includes skill training and increased resources to help cope with unemployment or disability. Cognitive-Behavioral Therapy The most notable recent change in psychosocial prescriptions and empirical support is the growth of cogVol. 8, No. 3

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Table 3. Example of Negative Thoughts Log Accuracy or Mood

Identify worst

Automatic

evidence for

(rate 0-5)

fears

thoughts

thought

explanation

Other strategies

Give talk at work

Panic 5

I’ll die or have a heart attack. I should call in sick.

Scared 4

No evidence to support; I have not died yet or had a heart attack. Calling in sick won’t work. No support. She has seen me freeze, and she did not leave. I’ll have another chance with her parents.

I get anxious: I’m not perfect. Staff doesn’t laugh at mistakes. I’ll plan my talk; write it down and practice. I’ll remind her that I may freeze. I’ll plan some questions to ask her parents. We’ll pick a safe place to meet.

Confront and review the evidence for my thoughts. Attempt to construct an antidote.

Meet girlfriend’s parents

I’ll look like a fool, be a laughing stock. I’ll get fired if I’m not perfect. I’ll be a failure. They will hate me. I will be mute. She’ll leave me.

Situation

If she leaves me, no one will ever love me again.

Alternate/antidote

Distraction: use thought stopping to keep from focusing the feared result. Relax and breathe.

Note. Scale 0-5; 0, no anxiety; 5, panic/severe anxiety.

nitive and behavioral treatments (Goisman et al., 1999). Cognitive theory asserts that distorted cognitive processes of thinking, knowing, and perceiving create mood disorders. Beck and colleagues (Wright, Thase, Beck, & Ludgate, 1993) believed that the cognitive triad of negative thoughts and beliefs involved the belief that the self was worthless, the world was barren, and the future was bleak. Although social phobia may be biochemically mediated, the cognitive theorists intervene to reduce automatic negative perceptions and irrational beliefs. Negative thinking patterns trigger mood disorders. Examples such as, “I’m not worth anyone’s concern; I’m too much of a burden; I’m worthless; I’ve failed at everything; I’ll never get any better” lead the patient to reject help, ask to be left alone, and increase worthlessness. Patients rarely recognize these self-defeating and negative thinking patterns (Valente, Saunders, & Cohen, 1994). People do not know that these cognitive disortions and irrational beliefs (e.g., “Everyone must love me or I’m no good”) automatically shape emotional responses. Automatic beliefs that become a habit contribute to anxiety. However, with education, coaching, and support, people can change these automatic thought patterns. The nurse first helps the person with social phobia to be aware of these automatic thoughts. Use of a mood log and a negative thoughts log (Tables 1 and 3) may be useful. When the person reaches a negative conclusion (e.g., “I can not ever speak in front of a group, I’d just die”), the nurse encourages an examination of the thoughts and feelings that led up to this conclusion and then to think of alternative conclusions and explanations for them (e.g., “Well maybe I’d be scared to death, but I could probably say my name and June 2002

where I work”). The mood and thought logs form the basis for coaching to help the patient increase awareness of patterns and explore options. If the patient always thinks the worst will happen and becomes anxious before a performance, the nurse can help teach relaxation and talk about options to the predicted catastrophe. The nurse also can assist the patient in setting realistic goals and controlling the tendency to set unrealistic goals that are destined for failure. Cognitive behavioral strategies include gradual exposure to the anxiety provoking triggers in a real or imagined situation, cognitive restructuring, applied relaxation training, arousal reduction techniques, and social skills training. The therapist explains the nature, bodily sensations, and interpretation of anxiety and awareness of automatic thoughts linked with anxiety. Cognitive restructuring focuses on self concept and negative thinking (e.g., one imagines catastrophic conclusions to a situation or assumes negative outcomes), uses a thought log (Table 3), and corrects negative assumptions about the self, the future, and the world. The person may learn relaxation, breathing, and positive self-talk to reduce anxiety in social settings. Clients learn to reduce anticipatory anxiety and correct misperceptions (e.g., “I’m going to have a heart attack and die if I have to speak in public,” or “If I’m in a large group dressing room alone trying on clothes and others arrive, I’ll panic and run out stark naked into the mall”). A common task is to have the patient go to the supermarket and stand in line with one item and ask to go ahead of one person who only has a few items. Clients may be coached to manage common situations that trigger social anxiety including public speaking, initiating conversation with someone of the opposite sex, APNA Web site: www.apna.org 71

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eating or drinking in public, going on job interviews, or giving or receiving compliments. Cognitive behavioral therapy may include individual and group meetings. Heimberg et al. (1998) found that cognitive behavioral group participants with social phobias had a 75% response rate, that is, improved function and reduced symptoms of social phobia, compared with controls (40%) and an 81% response rate at 6 month follow-up compared with controls (47%). Relaxation Strategies Clients can also begin to reduce anxiety by using relaxation techniques, imagery, a noncompetitive exercise such as walking, and self-talk that athletes use to reduce anxiety. Often self-help videos or tape recordings are suitable for clients who may benefit from independent learning. The nurse helped Mr. Patts (see case example) practice relaxation, imagery, walking, and self talk when he felt anxious. With coaching, Mr. Patts became able to speak briefly in a group and handle social interactions by using relaxation. When he completed his mood log after practicing these skills, the scores for anxiety level decreased and his alternative thoughts increased.

Often self-help videos or tape recordings are suitable for clients who may benefit from independent learning. Behavioral Approaches Behavioral approaches and self-help groups improve recovery. Behavioral groups offer skills practice to reduce avoidance and improvement management of anxiety. In support groups, significant others learn to offer encouragement and support and recognition that the problem is not just an issue of will power. Supporters need to realize that social phobia cannot be solved by just “making up your mind,” “getting in control,” or telling someone “how to fix it”; it is not a case of “mind over matter.” Significant others need to say that “it is hard, but you can do it” and offer consistent and reliable coaching to use relaxation strategies. Pharmacotherapies Selective serotonin reuptake inhibitors (SSRIs) are popular first-line therapy because of their low side effects and benefits in older adults and those with comorbid cardiovascular disease. In a double blind, placebo controlled study, on 150 mg of fluvoxamine (Luvox), 46% of clients with social phobia improved while taking the drug compared with 7% taking placebo. People also responded better to fluoxetine (Prozac) than placebo (Davidson et al., 1993). Parox72 APNA Web site: www.apna.org

etine (Paxil) also performed better than placebo, and only 12.6% relapsed compared with 62.5% taking placebo. Caution regarding drug interactions and toxicity is important when SSRIs are used with other drugs (e.g., tricyclic antidepressants, antiarrhythmics, codeine, carbamazepine, benzodiazepines,and beta- or calcium channel blockers). One of the issues in pharmacotherapy is preventing relapse, and the rate of relapse can be high if drugs are discontinued too early. Hence treatment periods longer than 3 months are recommended (Davidson et al., 1998). Beta-blockers that are effective for one specific aspect of social phobias (e.g., performance anxiety) include oral popranolol (Inderal), 10 to 40 mg daily and atenolol (Tenormin), 50 to 150 mg daily. In single dose, placebo controlled crossover studies, beta-blockers reduced discrete performance anxiety (e.g., butterflies, palpitations, tremors) if given 1 to 2 hours before the event in about 50% of clients. During public speaking, the heart rate, blood pressure, arrhythmias, free fatty acids, and catecholamines increased and the ST segments of the electrocardiogram decreased. The betablockers decreased physical arousal symptoms but not the emotional experience of anxiety. In musicians with stage fright, beta-blockers (40 mg of oxprenolol [Transcor], which is not yet approved in the United States) decreased heart rate, nervousness, tremor, and improved performance both subjectively and objectively. Beta-blockers have also effectively reduced anxiety and improved performance on Scholastic Aptitude Tests (SAT). Students who used beta-blockers improved their scores 130 points on retest; the expected improvement on retest was 14 points. Of course, the drug does not make the student any smarter, but it does reduce anxiety. Beta-blockers effectively reduce performance anxiety but not generalized social anxiety or depression. Beta-blockers may be contraindicated in patients with a history of asthma or cardiac bundle branch block, and chronic use has been linked with depression. Monoamine oxidase inhibitors (MAOIs) are not the first line of therapy but are 75% effective and useful when other drugs do not work. Examples include phenelzine sulfate (Nardil), 45 to 90 mg daily or tranylcypromine sulfate (Parnate), 30 to 60 mg daily. MAOIs have bothersome side effects such as lightheadedness, neurological symptoms, weight gain, sexual dysfunction, and edema. They also require dietary restrictions to avoid a hypertensive crisis (e.g., no aged foods such as wine and cheese). These medications require at least 4 weeks to reach therapeutic blood levels, but the sedative and anticholinergic side effects occur immediately. If clients do not anticipate a delay in therapeutic level, they will prematurely stop the drug when adverse effects occur before benefits. Both phenelzine sulfate (Nardil) and moclobemide in a 16-week, double Vol. 8, No. 3

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CASE EXAMPLE Mr. Patts is a 39-year-old architect who is separated from his wife and child. Despite being paralyzed by anxiety before meetings and presentations since junior high school, he never sought or received treatment for this anxiety. Signs and Symptoms He nearly dropped out of high school when he had to make oral reports and group presentations, but his father insisted that the teacher offer other options. He graduated and was successful for several years in an isolated computer job. However, when his organization merged with a large corporation, he was required to make marketing and training presentations. He lost his job when he could not speak or collaborate in social settings. He moved to another city to find work. Because of anxiety, he avoided any situations in which he would meet new people or interact in a group. Because of frustration with their social isolation, his wife demanded a separation. He had extreme fears that they would not be reunited, although his wife expected a resolution. His father, a dentist, had given him increasing doses of Xanax for his nerves. Mr. Patts’ dependence and unhappiness with his need for more Xanax grew, but it was the only thing that calmed him. He was so nervous during a visit home that his parents took him to the emergency department. He had received no prior psychiatric care except for one visit to an employee assistance counselor for performance anxiety. He reported no other problems except worry about turning 40 when he feared he would become old and life would have no meaning. Mr. Patts was referred to outpatient treatment for his anxiety.

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mental status was normal with no hallucinations or thought disorders. Memory, recall, and concentration were excellent. The Liebowitz Anxiety Scale indicated social phobia; he endorsed all items on the Brief Social Phobia Scale. The Beck Depression Inventory score was within normal limits. The nurse helped Mr. Patts complete the mood and thoughts logs (see Tables 1 and 3). Differential Diagnosis Social phobia and evaluation for comorbid disorders, such as substance abuse (Xanax dependence). Treatment

A physical examination revealed a thin, welldressed, alert, and oriented White male with no abnormalities. His blood pressure was 140/80, cardiopulmonary evaluation was within normal limits (chest x-ray, complete blood count, hemoglobin, hematocrit, resting electrocardiogram, thyroxin, and cholesterol). Except for anxiety, the

In this case, treatment included detoxification from Xanax dependence and a program for substance addiction. Once he was stabilized in substance abuse treatment, he was started on cognitive behavioral therapy, skill training, relaxation, group treatment, and a selective serotonin reuptake inhibitor (SSRI) (paroxetine) with dose gradually increased from 5 to 20 mg daily and a beta-blocker, propranolol, 30 mg daily as needed for performance anxiety. The nurse educated him about social phobia, taught him relaxation and self talk strategies, and helped him examine and change his automatic thoughts. He started a new job that required some presentations. During treatment, the nurse had him complete the Liebowitz Social Phobia and Brief Social Phobia scales as measures of treatment effectiveness. He and his wife attended family counseling to discuss and resolve their difficulties, and he continued in a recovery group for his Xanax abuse. He gradually improved his ability to interact in social situations and used the Propranolol several times during the first few weeks of treatment. He demonstrated success with 4 months treatment with cognitive behavioral therapy and learned ways to reduce his anxiety. He took the paroxetene for over a year and then gradually tapered it off. Although his social anxiety increased as he stopped drug therapy, he used his cognitive behavioral therapy methods to control his anxiety and did not need to use the propranolol.

blind, placebo-controlled study for social anxiety were better than placebo, although phenelzine had more side effects (Versiani et al., 1997). High potency benzodiazepine therapy is effective, well tolerated, and fast-acting. A short-term benzodiazepine can help the anxious patient manage until the antidepressant reaches a therapeutic level. Benzodiaz-

epines are used as needed, and the dose can be rapidly adjusted. Its drawbacks include initial sedation, discontinuation difficulties, potential for abuse, and it is ineffective for depression. In a 10-week double blind, placebo controlled trial, 78% those taking 2.4 mg a day of clonazepam (Clonopin) were better than those taking placebos (20%) (Davidson et al., 1993). Some of the

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adverse effects of clonazepam include anorgasmia, unsteadiness, forgetfulness, poor concentration, and dizziness. In this study, only unsteadiness and dizziness were persistent and more severe than placebo; the other side effects were more frequent but mild (Davidson et al., 1993). IMPLICATIONS FOR NURSING The message that anxiety and social phobia are prevalent, potentially disabling, but quite treatable needs to be widely broadcast. Many people with social anxiety do not realize they need treatment. Nurses have a pivotal role to play in case finding, evaluating, and treating. Most people may recognize that anxiety is unhealthy but mistakenly believe that anxiety is not treatable or that it has positive psychological functions (e.g., “it keeps me awake and alert”). Some people may also believe that anxiety has survival value and reduces the risk of danger. In particular, people with anxiety disorders may mistakenly believe that their health care provider lacks interest in their emotional well being, can do little to improve it, or will judge them harshly for lacking willpower to overcome their feelings.

Many people with social anxiety do not realize they need treatment. Nurses are important educators who use brief counseling strategies to help clients develop the knowledge and skills they need to cope with their social phobia. Encouraging the clients and family members to share their concerns about anxiety is an important therapeutic intervention. Typically, people who are reluctant to disclose their worries and mental health problems to other caregivers will feel comfortable talking with the nurse about these problems. Identifying local resources is essential (e.g., support groups or educational materials). Evaluating social phobia in hospital, clinic, and home settings can be a challenging endeavor that requires keen assessment skills and the ability to detect emotional symptoms that are rarely spontaneously reported. Routine use of screening measures for outpatient populations improves case finding. Nurses in school and college settings need to suspect social phobia when students want to avoid public presentations at all costs or demonstrate severe anxiety when speaking in class. The nurse needs skill to recognize and knowledge to evaluate anxiety and to recommend psychosocial and cognitive behavioral interventions. Untreated anxiety disorders are painful, and the nurse’s duty is to document and report the anxiety disorder and advocate for treatment. To facilitate treatment, the nurse often requires expertise in negotiating with family members and other caregivers who may be blind to 74 APNA Web site: www.apna.org

the anxiety disorder. Clinical competence in managing anxiety stems from effective use and monitoring of educational, behavioral, cognitive, and counseling interventions to help patients manage their anxiety. People need to be informed that anxiety is treatable, will not resolve by itself, and should not be ignored. Excessive levels of anxiety can increase stress and cause disability when untreated. SUMMARY Social phobia is a chronic, unremitting, lifelong disorder that typically begins between the ages of 13 and 20. Approximately 13.3% of Americans have a social phobia during their lifetime, but only one in four is accurately diagnosed and treated. Although much of anxiety is treated in primary care, anxiety disorders cost $46.6 billion and 31.5% of mental health expenditures in 1990. Social phobia and anxiety disorders should be considered as potential diagnoses and clinicians should routinely screen patients. Diagnosis is challenging when negative attitudes toward mental health or unreported symptoms complicate the clinical picture. Often social phobia is accompanied by alcohol or drug abuse, agoraphobia, phobias, depression, and other mood disorders; clinicians need to detect or rule out these other disorders. Unfortunately, one successful treatment, cognitive-behavioral therapy, is often underprescribed despite research supporting its effectiveness. Combined treatments using education, psychosocial prescriptions, cognitive behavioral therapy, self management such as skill training, relaxation, graded exposure and medications have high success rates (Scholing & Emmelkamp, 1999; Sutherland, Tupler, Colket, & Davidson, 1996). Medications typically include SSRIs, beta-blockers, and short term benzodiazepines. Because of their side effects, MAOIs are typically considered as second line therapy when other medications do not curtail symptoms.

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Goisman, R.W., Warshaw, M.G., & Keller, M.B. (1999). Psychosocial treatment prescriptions for generalized anxiety disorder, panic disorder, and social phobia. American Journal of Psychiatry, 156,1819-1821. Heimberg, R.G., Horner, K.J., Juster, H.R., Safren, S.A., Brown, E.J., Schneier, F.R., et al. (1999). Psychometric properties of the Liebowitz Social Anxiety Scale. Psychological Medicine, 29, 199212. Heimberg, R.G, Liebowitz, M.R, Hope, D.A, Schneier F.R., Holt, C.S., Welkowitz, L.A., et al. (1998). Cognitive behavioral group therapy vs. phenelzine therapy for social phobia. Archives of General Psychiatry, 55, 1133-1141. Inciardi, J.A. (1994). Screening and assessment for alcohol and other drug abuse among adults in the criminal justice system. Rockville, MD: U.S. Department of Health and Human Services. Katzelnick, D.J., Kobak, K.A., & Greist, J.H. (1995). Sertraline for social phobia: A double blind placebo controlled crossover study. American Journal of Psychiatry, 52, 1368-1371. Kessler, R.C., Stang, P., Wittchen H.U., Stein M., & Walters E.E. (1999). Lifetime co-morbidities between social phobia and mood disorders in the U.S. National co-morbidity survey. Psychological Medicine, 29, 555-567. Mandelowicz, M.V., & Stein, M.B. (2000). Quality of life in individuals with anxiety disorder. The American Journal of Psychiatry, 157, 669-682. Regier, D.A, Boyd, J.H., Burke, J.D., Rae, D.S., Myers, J.K., Kramer M., et al. (1988). One month prevalence of mental disorders in the United States. Archives of General Psychiatry, 45, 977-986.

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