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Pharmacologic Treatment of Social Phobia

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Pediatric Social Phobia and Treatment with SSRI Antidepressants

Kourtney Koslosky

Penn State College of Medicine

October 19, 2007

I. Overview (1)

Social phobia, or social anxiety disorder, is characterized by a persistent and intense fear or anxiety of at least one social event or performance in which the person is exposed to possible criticism by others.

Exposure to these situations causes an anxiety reaction, similar to panic, and children, unlike adults, may not be fully able to understand that the reaction is out of proportion to the situation. Nonetheless, they subsequently avoid social situations that provoke fear.

Common social situations that evoke anxiety include public speaking, eating with others, using public restrooms, and general social contact and interaction with others.

The child’s level of functioning is significantly impaired, and they may experience significant emotional stress, such as increased heart rate, sweating, stomach or head aches, crying, and tantrums. This impairment leads to general social withdrawal (evidenced by anxiety, hypersensitivity, self-consciousness, and depressed mood)

II. DSM-IV Criteria:

1. A marked and persistent fear of one or more social and performance situations in which the child is exposed to unfamiliar people or to possible scrutiny by others. The person fears that he or she will display anxiety symptoms or be humiliated or embarrassed. In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not only in interactions with adults.

2. Exposure to the feared social situation almost invariably provokes anxiety or a panic attack. In children, this anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.

3. Children may or may not recognize the fear is unreasonable.

4. The feared social situation is avoided or endured with intense anxiety or distress.

5. The avoidance, anxiety, or distress in the feared situation interferes significantly with the child’s normal routine, school, social activities or relationships, or causes marked distress.

6. The duration is at least six months.

7. The fear is not due to physiological effects of a substance (drug of abuse, medication) or a general medical condition, and is not better accounted for by another mental disorder (i.e. panic disorder with or without agoraphobia, separation anxiety disorder, pervasive developmental disorder, or schizoid personality disorder).

For example, a child in elementary school may have anxiety about participating in class. He may describe that he is very worried about raising his hand in class to ask a question, because he fears that the other children in his class will make fun of him or laugh at him. His fear is so strong that he does not ask questions in class, and thus his school performance may suffer because of it. If he does try to raise his had to ask a question, he feels his heart racing, he blushes, he may have an upset stomach, or he may stutter when asking the question out of nervousness. Thus this reaction and his fear of embarrassment deter him from speaking up in class, and may lead to poorer performances in school.

III. Epidemiology (1)

Serotonin pathways are suspected to be involved in causing the anxious and obsessive qualities of social phobia.

Supporting this theory are animal models, pharmacotherapy studies, and successful responses to SSRIs or SRI medications such as fluoxetine, sertraline, fluvoxamine, paroxetine, venlafaxine.

Social phobia is the third most common mental health disorder after depression and substance abuse, and has a lifetime prevalence in the general child population between 3 and 4%. Prevalence increases with age, with the average age of onset being mid to late adolescence, however the disorder can appear much earlier.

Anxiety must be differentiated from other diseases such as hyperthyroidism or from caffeine use, both of which can mimic symptoms of anxiety.

IV. Treatment (2)

Reinforce importance of attending school, despite the child’s desire to avoid school as interventions in academic and home settings to prevent complications such as academic failure due to poor attendance.

Cognitive-behavioral therapy may be helpful to improve the level of the child's independent functioning. Cognitive approaches can be grouped into 5 major types.

Positive reinforcement: Use of positive reinforcement such as a reward system for perfect attendance at school or a favorite book or movie for attending social events or socializing in the classroom.

Systematic desensitization: The child relearns how not to be upset or anxious when in the social situation provoking fear. Instead of feeling anxious in the situation, the child connects feelings of calm with the previously anxiety-provoking social situation. This action reconditions the child’s behavioral response to autonomic nervous system deactivation instead of activation.

Modeling: The child learns from a peer or therapist how to react to the stressful situation in a calmer, less anxious way.

In vitro graded exposure: The child imagines the stressful situation starting with the least stressful aspects, learning how to deal with these, and then following up with more stress-provoking aspects in a graded fashion. This could include the use of scripted play therapy using real-life stressful situations with targeted responses for learning and incorporation. The interactions are held between the child and a peer of the same age without social phobia.

In vivo exposure: This involves repeated graded exposures as the situation becomes less new and more predictable, thus causing less and less anxiety. Real-life exposure (again, from less-threatening to more-threatening) to anxiety-provoking situations with post-exposure discussion may be helpful.

SSRIs have been well studied in the treatment of social phobia, and have proven to be effective in both adults and children (9). The theory of the involvement of serotonin in the pathophysiology of the disease has led to the successful trials and usage of SSRIs in disease management. The doses used in both children and adults are usually much higher than those used for mood disorders.

V. Evidence-Based Studies

Fluvoxamine (Luvox) (9)

Study by Research Units on Pediatric Psychopharmacology (RUPP) Anxiety Disorders

Eight week randomized, double-blind, placebo controlled trial; enrolled 128 children, ages 6-17

Maximum dose of 250 mg/day in children under 12, 300 mg/day in adolescents

Used CGI rating scale (8 points rather than 7 in CGI)

Results: 76% on fluvoxamine responded, compared with 29% on placebo

Side Effects: abdominal discomfort (49%, 28% for placebo), and increased motor activity (27%, 12% for placebo)

Fluoxetine (Prozac) (9)

Study completed by Birmaher and colleagues

Twelve week randomized, placebo controlled double blind trial; enrolled 22 children.

Results: 61% of children treated with 20 mg/day showed “much” or “very much” improvement compared with 35% of placebo

Side effects: abdominal pain, nausea, drowsiness, headache

Paroxetine (Paxil) (9)

Study by Wagner and colleagues

16 week randomized, placebo controlled double blind trial with 332 patients

Mean dose of 26.5 mg/day for children, 35 mg/day for adolescents

Results: 78% of those treated with paroxetine were responders, compared with 38% of placebo

Side effects: vomiting (6.7% versus 1.9% for placebo), decreased appetite (8% versus 3.2% for placebo), increased insomnia (14.1% versus 5.8% for placebo), 5 patients developed suicidal ideation or self-harm behavior, the latter reasons supporting the rare use of paroxetine in children.

Sertraline (Zoloft) (7, 9)

Study by Rynn and colleagues

9 week randomized, double-blind, placebo controlled trial of 22 children ages 5-17

Results: 10 of the 11 patients who received sertraline were improved (using CGI scale), compared to 1 of the 11 who received placebo. Of the 10 who improved, only 2 were markedly improved, representing a possible remission rate of only 18%

Study concluded that the daily dose of 50mg (maximum dosed used in study) of sertraline is safe and effective for treatment of social phobia in children

No statistically significant differences in adverse events between sertraline and placebo

In addition to SSRIs, some studied have looked at usage of benzodiazepines and tricyclic antidepressants.

Benzodiazepines: Due to the risk of sedation, dependence, and withdrawal, these have been effectively ruled out as a first line treatment

Tricyclic antidepressants: Studies report contrasting results. One 8 week trial of 63 children reported that imipramine plus CBT was significantly more effective than CBT alone, 54% versus 17% of CBT plus placebo. It is side effects such as heart problems (prolonged QT interval) and lethality in overdose that also make this category of antidepressants less desirable to use.

VI. Summary

In conclusion, most SSRIs have a low side effect potential, and thus are considered safe for use in children with anxiety disorder. The clinical similarity between social phobia in adults in children, and the adult response to SSRIs led to these trials in younger patients. These studies do conclude that SSRIs can be considered first line therapy when treating pediatric social phobia, have low risk for side effect potential, and are non-addictive medications.

Resources:

1. Beidel, D.C., & Turner, S.M. (2007). Shy children, phobic adults: The nature and treatment of social anxiety disorder. Washington, DC: American Psychological Association Press

2. Beidel, D.C, & Turner, S.M. (2005). Childhood anxiety disorders: A guide to research and treatment. New York: Taylor and Francis Group.

3. Beidel, D.C., Turner, S. M., & Morris, T. L. (1995). A new inventory to assess childhood social anxiety and phobia: The Social Phobia and Anxiety Inventory for Children. Psychological Assessment, 7, 73-79.

4. Beidel, D. C., Turner, S. M., & Morris, T. L. (1999). Psychopathology of childhood social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 643-650.

5. "Fluvoxamine for the treatment of anxiety disorders in children and adolescents." The New England Journal of Medicine 344.17 (2001): 1279-1285. Research Library Core. ProQuest. 17 Oct. 2007

6. Jamie A Micco, Molly L Choate-Summers, Jill T Ehrenreich, Donna B Pincus, Sara G Mattis. "Identifying Efficacious Treatment Components of Panic Control Treatment for Adolescents: A Preliminary Examination.” Child & Family Behavior Therapy 29.4 (2007): 1-23. Psychology Module. ProQuest. 17 Oct. 2007

7. Moira A Rynn, Lynne Siqueland, Karl Rickels. "Placebo-controlled trial of sertraline in the treatment of children with generalized anxiety disorder. " The American Journal of Psychiatry 158.12 (2001): 2008-14. Research Library Core. ProQuest. 17 Oct. 2007 http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=16553532&ordinalpos=3&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum

8. Pollack, Mark H, Otto, Michael W, Sabatino, Susan, Majcher, Diane, et al.

"Relationship of childhood anxiety to adult panic disorder: Correlates and influence on course. " The American Journal of Psychiatry 153.3 (1996): 376. Research Library Core. ProQuest. 17 Oct. 2007 <http://medjournal.hmc.psu.edu:2103/>

9. Scott N Compton, Christopher J Kratochvil, John S March. "Pharmacotherapy for Anxiety Disorders in Children and Adolescents: An Evidence-Based Medicine Review." Pediatric Annals 36.9 (2007): 586-590,594-598. Health Module. ProQuest. 17 Oct. 2007

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