An Abstract on Social Phobia by Dr. Mark Pollack:Journal of Clinical Psychiatry 2001;62 Suppl 12:24-9
Comorbidity, Neurobiology, and Pharmacotherapy of Social Anxiety disorder.
Pollack MH, Department of Psychiatry, Harvard Medical School, Massachusetts General Hospital, Boston 02114
Social anxiety disorder is a common psychiatric illness that imposes persistent functional impairment and disability on persons who have the disorder. The disorder is characterized by a marked and persistent fear of social or performance situations in which embarrassment may occur. It is the most prevalent of any anxiety disorders and is the third most common psychiatric disorder after depression and alcohol abuse. Social anxiety disorder typically begins during childhood with a mean age at onset between 14 and 16 years and is sometimes preceded by a history of social inhibition or shyness. Persons who have social anxiety disorder either endure or avoid social situations altogether because the fear of embarrassment causes such intense anxiety; such avoidance may ultimately interfere with occupational and/or social functioning and lead to significant disability. The duration of social anxiety disorder is frequently lifelong, and there is a high degree of comorbidity with other psychiatric disorders. Social anxiety disorder is a serious illness that frequently runs a chronic course and is associated with significant morbidity. Patients should be treated aggressively using pharmacotherapeutic agents that can be tolerated over the long term. Cognitive-behavioral therapy should also be considered in treatment planning. Efforts to increase the recognition of social anxiety disorder as a common, distressing, and disabling condition are critical. This article discusses the comorbidity, neurobiology, and pharmacotherapy of social anxiety disorder.
Two SSRI's (Paxil and Zoloft) and one SNRI (Effexor) are the only drugs officially approved for the treatment of Social Anxiety Disorder as of 2022.
Unfortunately SRI's are at best usually only MILDLY to MODERATELY helpful for the treatment of SP. They are considered the "first line" treatment for Social Phobia primarily because doctors usually perceive them as the "safest" of available drug treatments. Also, SRI's are often very good at treating some other anxiety and depressive disorders which are often "comorbid with" (accompany) SP, such as Dysthymia, Depression, Panic Disorder, Generalized Anxiety Disorder (GAD), and Obsessive Compulsive Disorder (OCD).
SSRI's work best when one of these other disorders is the "primary" problem - but usually not so well when Social Phobia is the primary problem. Poor response or tolerance problems are addressed by changing the dose, switching to another medication, or various augmentation strategies.
Prozac (fluoxetine): An "activating" SSRI with the least side effects.
These include Effexor, Cymbalta, Pristiq, Remeron, Wellbutrin, and others. They all boost norepinephrine, and to different degrees also serotonin.
The MAOI "Nardil" is definitely the most powerful and effective antidepressant for Social Phobia.
Nardil (phenelzine): Nardil usually works great for SP! It the "Gold Standard" antidepressant for SP. Nardil is excellent for many other anxiety and depressive disorders also. Reports of Nardil side effects are frequently exaggerated, particularly since Nardil's side effects typically take 2-4 months to diminish or disappear. After several months Nardil tends to cause less side effects than SSRI's across comparable dose ranges, with the exception of Prozac. Effective dose range for SP is usually 60-105 mg/day. MAOI related "Hypertensive crisis" is rare in responsible patients, and the risk is certainly overestimated in most literature on the topic. Many experts consider the MAOI's to be underutilized. Updated, friendlier MAOI diet.
Parnate (tranylcypromine): Parnate is not as effective as Nardil for SP, but occasionally may work well. It is a very activating, dopaminergic antidepressant.
Emsam / Eldepryl (selegiline): Emsam is relatively unstudied for the treatment of Social Anxiety Disorder. There is no reason to think it would be any more effective than Parnate.
Aurorix (moclobemide): Moclobemide is a 'reversible' MAOI. It has not proven to be an effective treatment of SP.
Long term use of benzodiazepines remains controversial. About 10 are available but Klonopin is by far the most effective for SP. Xanax is sometimes helpful also.
Klonopin (clonazepam): Klonopin is very effective for SP and usually works great. Klonopin can be taken either "as needed" or everday. "As needed" (prn) use can be done up to twice per week, and will usually provide excellent effect within 30 minutes, lasting several hours to 1/2 day. Long term (everyday) use is more controversial.
Xanax (alprazolam): May be helpful. Xanax has a short half life which may limit its utility in long term use.