Drug treatment of social phobia. Can antidepressants, beta blockers and other drugs cure social anxiety? The strongest antidepressants for social anxiety, top of the best

Panic attacks, VSD, phobias, OCD belong to the group anxiety disorders(neuroses), and the official treatment regimen for such disorders is psychotherapy plus pharmacological support. If the problem is not severe, then you can do without pharmacology and solve it only through psychotherapy - working with a psychologist. In severe cases, pharmacology cannot be avoided.

The main drug of pharmacological support for panic attacks and VSD is an antidepressant. Many people think that an antidepressant is only needed for depression, but in fact this is not the case. Antidepressants have both antidepressant and anti-anxiety effects. Depending on the class of antidepressant, the anti-anxiety effect may be weaker or stronger. At the moment, the strongest anti-anxiety effect is found in antidepressants of the SSRI group, which is why they are most often prescribed for anxiety disorders and anxiety-depressive disorders.

Antidepressants SSRIs and SSRIs for panic attacks, VSD, OCD and social phobia

SSRIs are selective serotonin reuptake inhibitors. To put it simply, antidepressants increase the amount of serotonin in the brain, which gives anti-anxiety and antidepressant effects.

The most modern and popular second generation SSRIs are ESCTALOPRAM, SERTRALINE and PAROXETINE. It is these antidepressants that are most often prescribed for panic attacks, VSD, OCD and social phobia. These are the names of the active ingredients, they may differ from the trade names of the drugs themselves. Manufacturers come up with their own trade name to promote a product, so you need to rely not on the trade name, but on active substance.

Taking antidepressants is often associated with unpleasant side effects in the first days of use. In order to smooth out side effects, a very gradual increase in dosage is recommended.. It is better to start with 1/4 of the tablet, monitor your condition and if everything is fine, then increase the dosage by another 1/4. Approximate diagram taking it may look like this: two days 1/4 tablet, five days 1/2 tablet and if everything is fine then switch to a whole tablet. As soon as the active substance accumulates in the body, the unpleasant side effects will disappear and your condition will improve. As a rule, this takes no more than two weeks.

Also, to combat side effects, a “cover” drug is prescribed in the first 2-3 weeks of taking antidepressants. This is usually a tranquilizer or antipsychotic. The purpose of this drug is to stabilize the condition and compensate for side effects until the antidepressant begins to act.

You can take antidepressants for quite a long time without serious health consequences. Usually the course is prescribed for six months. A long course is necessary to form the habit of living without anxiety. However, if you do not decide psychological reasons increased anxiety, then after canceling the course, after some time the anxiety disorder will resume. According to some statistics, after stopping an antidepressant for panic attacks, in about half of the cases, panic attacks return within three months. To prevent this from happening, it is very important during the course to solve the psychological causes of the problem through.

After stopping a course of antidepressant, the so-called “withdrawal syndrome” appears, which is accompanied by unpleasant sensations. To reduce withdrawal symptoms, you need to very gradually reduce the dose of the antidepressant. It is recommended to gradually reduce the dosage by a quarter of a tablet and monitor your condition.

Probably the main disadvantage of SSRI antidepressants is a decrease in libido. About half of patients experience this side effect. This is expressed in a decrease in sexual desire and difficulty in achieving orgasm in both men and women. An erection in men most often remains. Sometimes this side effect goes away after some time, sometimes it doesn’t go away, and sometimes it doesn’t appear at all, everything is individual. Therefore, if the sexual sphere is very important to you, then it is better to choose an antidepressant from another group.

Also, for the treatment of panic attacks, VSD and other anxiety disorders, antidepressants of the SSRI group are used - selective serotonin and norepinephrine reuptake inhibitors. At low doses, these antidepressants behave like regular SSRIs, but at medium doses they increase the amount of norepinephrine, which gives a stronger antidepressant effect. Thus, this group is preferable for anxiety-depressive disorder. In addition, antidepressants in this group reduce libido less. The most popular representative of this group VENLAFAXINE.

Choosing an antidepressant for panic attacks, VSD and other anxiety disorders

Antidepressants are sold by prescription, and the prescription is written by a doctor. Accordingly, the antidepressant is selected by the doctor. But the choice of a doctor is often determined by the promotion of “their” brand or habit or some kind of personal preference. Therefore, the choice of a doctor is not always good; old antidepressants with a large number of side effects are often prescribed. Therefore, it is better to prepare in advance, choose the option that suits you and discuss this option with your doctor at your appointment.

Escitalopram

Trade names: cipralex, selectra, elycea, esipy, esopram, esoprex, essobel, lenuxin, lexapro, miracitol, cytoles, escitam, depresan.

Today it is the most prescribed antidepressant in the West. With good effectiveness, it has the least side effects among the entire group of SSRIs and the most comfortable withdrawal syndrome.

The dosage is selected individually and varies from 5 mg to 20 mg per day. For panic attacks, they usually gradually switch to 10 mg of an antidepressant, and if after a couple of weeks on this dose the condition is not stable enough, then increase it to 15 mg. If after a couple of weeks and at this dose the condition is not stable enough, then increase to 20 mg.

Considering all of the above, escitalopram is perhaps the best antidepressant from the SSRI group for the treatment of panic attacks, VSD, social phobia and other anxiety disorders.

Sertraline

Trade names: Zoloft, Stimuloton, Asentra, Serenata, Sirlift, Torin, Deprefolt, Zalox, Sertraloft, Depraline, Aleval, Lustral.

The dosage is selected individually and varies from 25 mg to 200 mg per day. The dosage is increased gradually until the condition stabilizes.

Sertraline is slightly stronger than escitalopram, but the side effects are also slightly higher. These two antidepressants can be taken during pregnancy, provided that the benefits exceed possible risks for the fetus. It is difficult to assess possible risks to the fetus; large studies have not been conducted on this topic. Presumably the risk of complications for the fetus is not high and does not exceed 5%.

Paroxetine

Trade names: Paxil, Rexetine, Plisil, Adepress, Actaparoxetine, Paroxin, Luxotil, Xet, Sirestill, Seroxat.

The most powerful antidepressant from the SSRI group. Accordingly, it has the strongest side effects and the most severe withdrawal syndrome. It is recommended to opt for it if the strength of escitalopram or sertraline is not enough to stabilize the condition.

The dosage is selected individually and varies from 10 mg to 50 mg per day. The dosage is increased gradually until the condition stabilizes. You can increase the dosage by 10 mg every week.

Venlafaxine (SSRI)

Trade names: velaxin, velafax, efevelon, effexor, venlaxor, trevilor, newelong, deprexor.

The drug, unlike SSRIs, suppresses libido less, so if the sexual sphere is important to you, then this is worth paying attention to. The anti-anxiety effect is comparable to paroxetine, and the antidepressant effect exceeds it. The side effects and withdrawal symptoms are quite strong and comparable to paroxetine.

The dosage is selected individually and varies from 75 mg to 375 mg per day. Somewhere starting from 150 mg, the effect of increasing norepinephrine appears. Given the strong side effects, for venlafaxine and paroxetine it is important to very gradually increase the dosage and use a cover drug.

Summary table of the most common side effects

As mentioned above, in most cases, side effects disappear after the first two weeks of taking the drug. If the side effects are noticeable and last more than a month, then it is better to change the antidepressant. For cupping side effects in the first month of use, and to reduce anxiety for the first time, until the antidepressant begins to act, a tranquilizer or antipsychotic is prescribed.

Let me make a reservation right away that this article is for informational purposes only. There is no specific information here about which pills you should take and which you shouldn't. Perhaps it will appear in the future. If you don’t want to miss it, you can subscribe to updates in any convenient way (by mail, by joining VKontakte group, as well as via RSS or using Twitter). Now let's move on to the article itself.

There are several various types pills for social anxiety. The main ones include:

• benzodiazepines
• monoamine oxidase inhibitors (MAOIs)
• beta blockers
• selective serotonin reuptake inhibitors (SSRIs)
• selective serotonin and norepinephrine reuptake inhibitors (SSRIs)

Each type of social anxiety pill has its own advantages and disadvantages, depending on your specific situation.

Benzodiazepines

Description

Benzodiazepines relieve symptoms of anxiety, which is achieved by influencing the central nervous system. Benzodiazepines can cause sedation and addiction, so they are preferred not to be used as the main drug for treatment.

List of drugs

• Ativan (lorazepam)
• Valium (diazepam)
• Xanax (alprazolam)
• Klonopin (clonazepam)

Beta blockers

Description

Beta blockers for social phobia are usually taken some time before events that may cause anxiety. Beta blockers are useful in situations requiring mental alertness because they do not have the adverse effects on cognitive abilities that are true of benzodiazepines.

List of drugs

• Anaprilin (propranolol)
• Tenormin (atenolol)

Monoamine oxidase inhibitors (MAOIs)

Description

MAOIs were once considered the most effective tablets for social anxiety, however, they carry the risk of serious side effects. Currently, MAOIs are not generally used unless there is reason to believe they will be more effective than other drugs.

List of drugs

• Nardil (phenelzine)
• Transamine (tranylcypromine)
• Marplan (isocarboxazid)

Selective serotonin reuptake inhibitors (SSRIs)

Description

SSRIs are currently the main weapon in the fight against social phobia (due to minor side effects and high effectiveness)

List of drugs

• Citalopram (cipramil)
• Escitalopram (Cipralex)
• Fluoxetine (Prozac)
• Fluvoxamine (fevarin)
• Paroxetine (Paxil)
• Sertraline (Zoloft)

Selective serotonin and norepinephrine reuptake inhibitors (SSRIs)

SSRIs are antidepressants used to treat anxiety.

List of drugs

• Velafax MV (venlafaxine)
• Duloxetine

Other anti-anxiety pills

List of drugs

• Atarax (hydroxyzine)
• Buspirone (buspirone hydrochloride)

The article was prepared using the book "Clinical Handbook of Psychotropic Drugs"

ATTENTION! This article is slightly outdated, perhaps someday I will update it. If you don’t want to miss this event, then subscribe to updates in any convenient way.

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This article will help you understand whether medications can help get rid of social phobia and in what cases they should be taken. You will learn about the benefits and harms of pharmacological drugs in the treatment of social phobia. In addition, I will describe effective technique working on social fears.

What is necessary for taking medications to be truly justified?

Social phobia manifests itself in some typical physiological and psychological reactions: trembling in the body, increased sweating, facial redness, anxiety, depression, apathy, etc. It is precisely to quickly eliminate such undesirable consequences of social phobia that medications are used.

However, there is one important clarification: in order for the medication to be truly effective, it must be accompanied by non-drug methods treatments (cognitive behavioral therapy, NLP, gestalt therapy...). This is true in all 100% cases when we're talking about about the treatment of social phobia.

Without successful psychological treatment of fears, taking medications is absolutely unjustified. In this case, a person taking, for example, antidepressants, will be like a person who is trying to drown his grief in alcohol: while the alcohol is working, the person “feels good” - he forgets about his problems and “has fun.”

When the effect of alcohol wears off, the person returns to reality, and often finds himself even more unhappy than initially.

Of course, alcohol cannot be equated with drugs, but, nevertheless, they have one common feature: If a person taking antidepressants does not work on learning to stop running away from situations that frighten him along with taking them, after finishing the course of taking antidepressants, he, as in the case of alcohol intoxication, will return to where he started.

The biggest disadvantage of medications in the treatment of social phobia?

Imagine that you are a gardener, and your trees are sick with some kind of nasty thing, because of which all their leaves have turned yellow. You call a specialist and ask him to cure the trees. And he, instead of understanding the causes of the disease and eliminating them, simply takes and paints the yellowed leaves in green... “Voila!”, he tells you... But time passes, the paint fades from the leaves, and appearance trees again begin to correspond to their internal state...

This analogy well illustrates what happens in most cases known to me when psychotherapists prescribed drugs to patients... doctors, just like our would-be tree specialist, followed the path of least resistance.

Their logic is this: if there are no symptoms, there is no disease. They prescribe medications to a person that remove the physiological and psychological manifestations of social phobia, and do not really deal with the problem. Naturally, we are not talking about 100% of psychotherapists now. I’m just sharing the experience of the guys I’ve worked with personally.

What is needed to really work through social phobia?

To really work through social phobia, it is necessary first of all to work through the “root” – a person’s negative beliefs. This study should be accompanied by exercises aimed at developing calm and confident behavior in situations that cause fear (panic). In conclusion, to build warm relationships with people, you need to learn the main principles of attraction between them and the rules of communication, which, unfortunately, most people do not realize (which is why there are so many scandals, quarrels and misunderstandings between people).

Unfortunately, for some reason, not every psychotherapist is willing (or able) to offer such in-depth work. Therefore, before you start working with any specialist, if he wants to prescribe you to take medications, you should ask what direction your future work will take.

If a specialist does not offer a comprehensive treatment of fears and recommends limiting yourself only to medications (or does not give a clear description of further work), it is better to think three times before dealing with him.

Don't forget that drug therapy can only be an addition and not the basis for the treatment of social phobia.

The basis of effective treatment has been and remains therapy aimed at working through fears, flawed beliefs, and acquiring the necessary social skills.

By the way, in most cases drug therapy not necessary at all (and may even be harmful, given the presence of side effects)...

My newsletter is dedicated to working through flawed beliefs and acquiring the necessary skills, which you can subscribe to at the top of this page.

I.I.Sergeev
Department of Psychiatry and Medical Psychology
Russian State Medical University,
Moscow

Before discussing the role of antidepressants in the treatment of phobias, it is advisable to dwell on the boundaries of phobic disorders and their clinical variants (Table).

From our point of view, along with such recognized variants of phobias as agoraphobia, social phobias, nosophobia, specific (isolated) phobias, phobic circle disorders should also include panic disorder, classified both in ICD-10 and B5M-4 as anxiety disorders.

Firstly, both the psychopathological and substantive features of the patients’ experiences during a panic attack are more typical for phobias than for anxiety: paroxysmal thanatophobia, cardiophobia, lyssophobia arise, and not anxiety, tension, devoid of a certain content. True, fear in the structure of panic attacks is not obsessive in nature. It is, rather, fear taking over. But other phobias, traditionally classified as obsessions, in large part, if not for the most part, according to our team (L.G. Borodina, 1996; A. Shmilovich, 1999), are not obsessive fears, but overvalued ones.

Secondly, panic attacks become the source of agoraphobia, social phobia and other phobias much more often than the basis of generalized and other protracted anxiety disorders. In this case, panic attacks lose their independence and act as one of the components of the phobic syndrome.

The means and methods for treating phobias are varied. In table they are, if possible, arranged in descending order of their current importance.

Psychopharmacotherapy actually takes the leading place in the treatment of phobias. Among the classes of psychotropic drugs, antidepressants occupy the first position (if we take into account the results of most studies and established therapeutic practice). Next come tranquilizers and antipsychotics.

Psychotherapy could claim a leading position if there were a sufficient number of qualified psychotherapists, as evidenced by comparative studies (for example, A.B. Smulevich et al., 1998).

The use of antidepressants and psychotherapy are first-order methods of treating phobias, which in some cases can be used independently, as monotherapy.

General vegetative stabilizing measures are practically significant, especially at more early stages phobic disorders.

At the end of the table. Treatment methods with limited or controversial effectiveness are listed (laser therapy, acupuncture, the use of thymostabilizers), used as additional ones in complex therapy, as well as treatment methods with relatively high effectiveness, but rarely used at present (sub-shock methods).

Without delving too deeply into the history of the issue, it should be noted that with the advent of tranquilizers, their intensive use in the treatment of phobias began, including the parenteral administration of high doses of relanium. However, a certain disappointment set in relatively quickly (table).

The effectiveness of tranquilizers was not as high as expected. In addition, the use of tranquilizers has time limits due to the risk of addiction (the duration of a course of treatment with tranquilizers should not exceed 4 or even 2 weeks, according to foreign data). The withdrawal of tranquilizers in most cases is accompanied by an exacerbation or resumption of phobias. As a result, tranquilizers, while maintaining a prominent place in the treatment of phobias, lost their dominant position. Currently, alprazolam, clonazepam, Relanium, and phenazepam are mainly used in the treatment of phobias, especially panic disorder. The latter is very promising due to the lower risk of addiction, according to a number of narcologists, and the emergence of an injectable form.

The beginning of the use of antidepressants for anxiety-phobic disorders dates back to 1962, when D.E. Klein reported positive results treatment of panic attacks with imipramine.

In fact, all or almost all antidepressants, both known for a long time and those that appeared relatively recently, have been used or are currently used for phobias.

Tricyclic antidepressants (TCAs) and irreversible monoamine oxidase inhibitors (MAOIs) were the first to be introduced into the treatment of phobias. The latter, like four-cyclic antidepressants, are in Table. are not presented, since at present they are almost never used to correct phobias. The main TCAs (amitriptyline, imipramine and especially clomipramine) are still widely used.

With the advent of new groups of antidepressants - selective serotonin reuptake inhibitors (SSRIs), reversible monoamine oxidase inhibitors (MAOIs) - the intensive introduction of these drugs into the treatment of phobic disorders began. A kind of competition has emerged between TCAs and newer antidepressants. Each group of antidepressants has its own advantages and disadvantages in terms of treating phobias (table).

The most significant advantages of amitriptyline and imipramine include availability, reasonable cost of outpatient therapy, availability of injectable forms, and the possibility of use in children. Disadvantages: the need to use high doses, lower effectiveness compared to SSRIs (although the comparison results are not entirely clear), insufficient clarity of ideas about the mechanisms of their action in phobias, frequency and severity of side effects, including anticholinergic ones (tachycardia, extrasystole, arterial hypertension, tremor), which correspond to somatovegetative manifestations of panic attacks and other phobias and, in some cases, contribute to the strengthening of phobic disorders. According to our data, anticholinergic effects occur in every fifth patient with phobias receiving amitriptyline or imipramine (L.G. Borodina, 1996).

Clomipramine compares favorably with amitriptyline and imipramine in its higher effectiveness, associated with its pronounced serotonergic activity.

The disadvantages inherent in classical TCAs do not apply to tianeptine, a representative of the SSRI group, which is used in standard daily dose, is well tolerated and appears to be a very promising long-term treatment for phobic disorders. We have a number of observations in which tianeptine was used for a long time and successfully for agoraphobia.

Significant advantages of SSRIs in comparison with classical TCAs: higher efficiency, presence of pathogenetic grounds for their prescription, lower frequency and severity side effects and, accordingly, great opportunities long-term use. However, SSRIs are inferior to TCAs in some respects. First of all, this is a non-medical disadvantage - the current lower economic accessibility and the associated problems of long-term outpatient therapy, the lack of injection forms for most drugs and the impossibility of use in children and adolescents under 15 years of age (with the exception of sertraline).

The advantages and disadvantages of MAOIs (moclobemide) are generally consistent with those noted for SSRIs.

In table the most used or optimal ones are presented, according to those who compared the effectiveness different dosages, daily doses of antidepressants used in monotherapy of phobias, compared with average and maximum doses, used for depression (from the literature and partly our own data).

Daily doses of TCAs used for phobias are quite high and approach the doses used in the treatment of severe depressive episodes.

At the same time, analysis of the relevant data on SSRIs only partially confirms the well-known position about the advisability of using low doses of SSRIs for phobias, which are significantly lower than the doses used for severe depression. This is true for fluoxetine, citalopram, fluvoxamine and, to some extent, paroxetine. The daily doses of sertraline and OIMAO (moclobemide), especially often and most successfully used in phobic disorders, are close to or correspond to the maximum.

To date, the insufficiency of central serotonergic structures in phobias can be considered established, which is usually considered as their main pathogenetic mechanism. This explains the significant effectiveness found in many studies for phobias of clomipramine and SSRIs, which increase the concentration of serotonin in the intersynaptic spaces.

It is more difficult to explain the effectiveness of amitriptyline and imipramine in relation to phobic symptoms. There is a point of view that while many TCAs can be successfully used for panic disorders, for obsessions only clomipramine and SSRIs can be used. However, various TCAs began to be used for phobias long before the advent of SSRIs. The results of their use, according to most publications and our own data, are generally positive, which becomes, at least partly, understandable taking into account the data of M.Kh. Leider (1994) about the inhibitory ability of some antidepressants at the experimental level (table).

From these data it follows that amitriptyline and imipramine have a fairly high inhibitory ability for serotonin reuptake, not inferior or slightly inferior in this regard to fluvoxamine and paroxetine.

In addition, the effectiveness of TCAs may be partly due to their positive effect on depressive symptoms associated with phobias. One should also take into account the concept of the essential unity of phobias and depression, which is actively developed in Russian psychiatry by O.P. Vertrogradova (1998), who considers phobias as “a special equivalent of depression.”

In our opinion, today it is premature to reduce the pathogenetic mechanisms of phobias to the insufficiency of the functions of serotonergic structures. Most likely, the pathogenesis of phobias is more complex, and not all of its links have been established.

In table Literature data and partially data from our team are presented in a generalized form on the results of short-term and long-term monotherapy for phobias with various groups of antidepressants. The lowest and most high performance efficiencies are excluded.

The effectiveness of monotherapy for phobias in all groups of antidepressants is relatively high. Compared with amitriptyline and imipramine, the effectiveness rates of clomipramine and SSRIs are slightly higher. Pay more attention low performance effectiveness of moclobemide. However, when assessing them, it must be taken into account that moclobemide was tested mainly for social phobias, which are particularly resistant to treatment.

As a result, taking into account the better tolerability of SSRIs and the possibility of using relatively low doses, they show noticeable advantages compared to TCAs. It should be noted that when assessing the immediate effectiveness of antidepressants, most often, as follows from table. , the proportion of patients with improvement is determined. Significant improvement is rarely specifically identified. According to our own observations, long-term results of treatment of non-psychotic disorders, including phobias, are mostly successful in cases where the immediate results of therapy reach the level of significant improvement. Otherwise, there is a high risk of exacerbations and relapses. According to various sources, for phobias it is 30-70%.

The antiphobic activity of specific antidepressants from the SSRI group is usually considered the same, which raises some doubts. To clarify this issue, comparative clinical trials drugs.

The effectiveness has been compared repeatedly in various ways therapy of phobias: monotherapy with antidepressants, tranquilizers, psychotherapy alone and their combinations, with mixed results. However, complex therapy for phobias has the largest number of supporters.

Monotherapy of phobias with antidepressants is becoming increasingly popular, but in practice in our country it is carried out not so often and mainly on an outpatient basis. Long-term monotherapy with tranquilizers should not be carried out at all due to the high risk of addiction. Psychotherapy is used relatively often as the only way to correct phobias.

Indications for the use of antidepressants as part of monotherapy and complex therapy of phobias (according to our own data) are presented in Table. .

Indications for monotherapy with antidepressants are very limited. These are isolated phobias, monosymptomatic variants of agoraphobia, nosophobia, social phobia and those cases of agoraphobia, social phobia when the degree of generalization of pathological fears and the degree of avoidant behavior are low and phobias do not show a tendency to progress. In addition, monotherapy with antidepressants can be used as long-term maintenance treatment after a successful course of active complex therapy. For social phobias and isolated phobias that arise in one, relatively rare and predictable situation, one-time doses of beta blockers or alprazolam before the occurrence of such a situation are sufficient.

When there is a combination of different phobias, the presence of several confusing situations with incomplete avoidance, a combination of antidepressants and psychotherapeutic measures is indicated.

For generalized phobias with complete avoidance, maladaptive personality, frequent and severe panic attacks, chronic or recurrent course of phobic disorders, the presence of a tendency to their progression, the endogenous nature of phobic symptoms, the most active complex therapy is indicated, which is advisable to begin with the prescription of tranquilizers, including parenterally . Further treatment includes antidepressants, psychotherapy, and vegetative-stabilizing measures. After a month, tranquilizers are replaced with neuroleptics-behavior correctors or small or moderate doses of neuroleptics-antipsychotics.

Panic attacks often have a specific biological basis, being essentially vegetative crises with a phobic component (caused by cerebral-organic, endocrine, infectious-allergic or other visceral pathology). In such cases special meaning is acquired by correction of the somatic basis of vegetative paroxysms.

Phobic disorders in most cases require long-term (at least 6-12 months) treatment with very slow drug withdrawal.

As a result, antidepressants today occupy a leading position in the treatment of phobias, either in the form of monotherapy or as the main component of complex treatment.

Medical care for social phobia

Klevtsov Dmitry Alexandrovich

Criteria for diagnosing “Social phobia”.

Social phobia is a disabling disorder that occurs, as a rule, without remission (recovery of the condition), chronic disease. If left untreated, it may be accompanied by a high risk of morbidity, alcoholism, drug addiction and suicide. Persons suffering from SF have high risk development of comorbid conditions such as severe depression, agoraphobia and panic disorder. They have a high incidence of alcohol and drug abuse and are almost twice as likely as the general population to be suicidal. Most of these adverse effects could have been avoided with more early diagnosis and more effective treatment of this disease. Otherwise, left unattended, SF can lead to loneliness, more low level education than in the population, and financial dependence, thus disrupting social life patient at all ages.

Important signs of social phobia are:
- fear of evaluation (criticism, condemnation) by other people in social situations
- expressed and constant fear public performance situations in which feelings of embarrassment or humiliation may arise
- avoidance of situations that inspire fear.

Individuals with social phobia have an inappropriate fear that they will be judged negatively in a variety of social situations.

This condition may be:
- generalized when fear covers almost everything social contacts or
- non-generalized, when fears relate to certain types social activities or performance situations in public.

The most common fear-provoking situations are those in which patients have to:
- get acquainted (be introduced to other people)
- communicate with superiors (bosses)
- talk on the phone
- receive visitors
- do something in the presence (under the supervision) of others
- feel like they are being teased
- have guests at home
- eat at home with family members
- write something in the presence of others
- speak publicly.

In a situation that instills a feeling of fear, they often experience somatic symptoms Anxieties such as heart palpitations, trembling, sweating, muscle tension, a feeling of "sucking" in the pit of the stomach, dry mouth, feelings of heat, cold and headache.
A person suffering from social phobia may be convinced that their main problem is one of the secondary manifestations of anxiety. Some patients, however, do not present somatic complaints, but experience severe shyness, fears and apprehensions.
There is often a tendency to avoid fearful situations, which in its extreme expression can lead to almost complete social isolation. Suicidal thoughts and suicide attempts are typical for social phobia: patients with a comorbid condition are five times more likely to make such attempts throughout their lives than in the general population. The risk of suicidal ideation is higher with comorbid social phobia than with comorbid panic disorder.

Diagnostic criteria ICD-10 ( International Classification Diseases) for social phobia are:
- Social phobia is a condition expressed mainly in the fear of evaluation (criticism, judgment) from other people in relatively small groups (but not in a crowd).
- These fears can be specific: eating in the presence of other people public speaking communication with people of the opposite sex
- Or generalized (diffuse): almost all non-family social situations
- An important sign there may be a fear of vomiting in the presence of other people.
- Social phobia is usually associated with low self-esteem and fear of criticism.
- Psychological, behavioral or autonomic symptoms must be the primary manifestations of anxiety and not secondary to other symptoms, such as delusions or intrusive thoughts.
- Anxiety should predominate in certain social situations or be limited to them.
- If possible, patients avoid the phobic situation. Avoidance is often very severe and, in extreme forms, can lead to almost complete social isolation.
- There are often pronounced phenomena of agoraphobia and depression, both of which can aggravate the condition of patients, chaining them to the house.

If you carry out differential diagnosis Between social phobia and agoraphobia is very difficult, preference should be given to agoraphobia. Diagnosis depressive disorder should not be placed until a full-blown depressive syndrome is clearly identified.

How can a doctor help with social phobia?

Severe disorders, the formation of inadequate, harmful methods of adaptation and the occurrence of comorbid (combined with the underlying disease) conditions associated with social phobia can be prevented or reduced with the early administration of pharmacological and/or psychotherapeutic treatment. Therefore, it is extremely important that effective therapeutic measures are promptly implemented as soon as a diagnosis of social phobia is made. Unfortunately, only about 25% of those suffering from social phobia currently receive any treatment, and even fewer patients receive therapy with proven effectiveness.

When to treat?

In general, the decision to treat social phobia should be reserved for those cases in which symptoms or avoidance behavior are associated with significant psychosocial impairment.
Treatment should be offered to any patient whose avoidance behavior is affecting their work or social life, who has severe fears, or whose ability to form social connections is severely impaired.

How to organize treatment?

Many people suffering from social phobia have never heard of the condition. They may view their symptoms as extreme timidity or bad character traits and should be reassured that long-term treatment can help.
Spending sufficient time explaining the need drug therapy can significantly improve the degree to which patients comply with medical recommendations and satisfy the patient with the results of treatment.
There are five complementary approaches that make it possible to present to the patient the need for treatment:
- emphasize that social phobia is a well-studied disease, and that, according to many studies, it responds well to appropriate treatment;
- explain that phobic avoidance of situations is caused by anxiety. Medications can directly reduce this anxiety;
- for generalized social phobia - explain that excessive sensitivity to criticism or refusal can be specifically influenced by certain medications,
- explain what drug treatment does not form dependence, there will be no addiction to it, and after stopping it will not cause withdrawal symptoms; - establish a therapeutic “contract” with the patient.

Medical "contract".

Establishing a formal treatment contract can greatly help a person comply medical recommendations. The contract must:
- explain the symptoms of the disorder as social phobia
- emphasize that social phobia is a generally recognized disease that is highly treatable
- describe the treatment plan
- list problems and priorities
- set a realistic time frame for improvement - discuss regular review of the treatment regimen.

How long to treat?

It is important to specifically point out to the person that social phobia is a chronic condition that will likely require long-term treatment.
Even if treatment is carried out for 6 months, the relapse rate after drug withdrawal is about 50%. Therefore, medications should be discontinued gradually, with periodic attempts to reduce the dose.
Pharmacotherapy should begin with the most effective and safe drug available. After the initial treatment period (1-2 months), it is necessary to evaluate clinical effectiveness. If the patient’s symptoms persist to a significant extent, the doctor may increase the dose to the most effective one or prescribe a drug from a different group. It should also be remembered possible application psychotherapy in addition to medication.

Evaluation of clinical response.

The outcome of a pharmacotherapeutic intervention can be assessed by the presence of significant improvement in the following areas:
- the anxiety that a person feels during social communication or the need for any activity, as well as, possibly, the quality of performance of this activity and social interactions
- anxiety experienced in anticipation of a “frightening” situation (anticipatory anxiety)
- avoidance of social interactions or obligations, opportunities to form bonds or perform any activity - comorbidity associated with social phobia, such as secondary depression, demoralization or alcoholism.

Choice of drug.

Medications commonly effective for social phobia include inhibitors of the enzyme monoamine oxidase in the central nervous system. nervous system- reversible monoamine oxidase inhibitors (ROIMA) and monoamine oxidase inhibitors (MAOIs). Other medications used to treat social phobia include benzodiazepines, beta blockers, and selective serotonin reuptake inhibitors (SSRIs).

Inverse monoamine oxidase inhibitors (IMAs).
OIMAs are a new class of drugs that selectively act on the isoenzyme of monoamine oxidase A. OIMAs reversibly bind to the isoenzyme, so that MAO activity is restored after a decrease in the concentration of the drug in the serum.
OIMAs are safer and better tolerated than MAOIs. The TMA drug moclobemide was studied in four placebo-controlled studies, one of which was a long-term study. The studies included more than 1,000 patients with social phobia and showed significant benefits and a strong dose-dependence of the drug's effectiveness.
In a comparative study good effect was observed in 80-90% of patients treated with moclobemide or phenelzine, in whom symptoms of social phobia almost disappeared after 16 weeks.
OIMA was much better tolerated than more old drug: adverse reactions were observed in approximately 11.8% of patients taking moclobemide, compared with 95.2% of patients on phenelzine. In the phenelzine group, adverse reactions also persisted longer, were more pronounced, occurred in greater numbers per patient, and required more measures to control and eliminate them.
Moclobemide is the only drug that has been studied in long-term studies for the treatment of social phobia. However, it is too early to assess the frequency of relapses after its discontinuation. It is possible that in order to maintain the effect achieved with the help of pharmacotherapy, a method of selective “immersion” in frightening situations and behavioral correction is necessary.

Reversible monoamine oxidase inhibitors for social phobia (MAOIs).
Phenelzine, a monoamine oxidase inhibitor, has been shown to have rapid beneficial effects in approximately 60-75% of patients; Moreover, significant clinical improvement is observed after 8-12 weeks of treatment. At long-term use phenelzine remains effective: although after discontinuation of treatment, a fairly high relapse rate is observed.
One of the problems associated with phenelzine therapy is how to convince patients to comply with doctor's orders.
A number of unpleasant adverse reactions can lead to the fact that a large number of patients “drop out” from the treatment program even before it has its full effect. These adverse reactions include hypertensive crisis due to non-compliance with dietary restrictions (refusal of tyramine-containing foods), insomnia, sexual dysfunction, orthostatic hypotension and weight gain. In addition to phenelzine, other irreversible monoamine oxidase inhibitors have been studied, although data from controlled studies are lacking. The results of two open studies of tranylcypromine indicate the therapeutic effectiveness of the drug.

Benzodiazepines.
Benzodiazepines have not gained a reputation as suitable drugs for the treatment of social phobia.
A possible exception is clonazelam, which also has serotonergic effects. One placebo-controlled study of 75 patients receiving either clonazepam or placebo for 10 weeks found that positive reaction on treatment was observed in 78% of patients on benzodiazepine and only in 20% on placebo. However, treating social phobia with benzodiazepines has disadvantages, not the least of which is the risk of developing physical dependence in patients receiving this therapy for a long time. The association between social phobia and alcoholism also suggests that benzodiazepines should not be the drug of choice for many patients.

Beta blockers.
There is very little evidence that beta blockers have any beneficial effect on the underlying condition of social phobia.
However, they can be taken periodically to relieve tremors, palpitations and tachycardia, which are often experienced by patients with social phobia in certain situations forcing them to be active. For this reason, many people with social phobia take medications such as propranolol when necessary.

Other medicines.
Open-label studies have suggested that a number of other treatments may be useful for social phobia. medicines. The most promising of these are buspirone, a non-benzodiazepine anxiolytic, and fluoxetine and fluvoxamine, selective serotonin reuptake inhibitors. A number of studies evaluating the use of cognitive therapy in the treatment of social phobia have found interesting results, although some adjustments need to be made to these findings. Most of the studies were very small in size and did not have sufficient statistical power to adequately assess the effectiveness of treatment. Additionally, a difficulty in behavioral therapy research is the selection of a truly neutral control group. Since one of the main goals of cognitive therapy is to help patients cope with their anxiety, group forms of treatment are especially useful for social phobia. Psychotherapeutic techniques can be used as a complement or alternative to pharmacotherapy.

RESUME.
Social phobia is highly treatable. Early initiation of therapy can prevent severe maladaptation, the development of inadequate adaptation mechanisms and the occurrence of comorbid conditions such as severe depression and alcoholism.
Treatment should be initiated when symptoms or avoidance behavior are accompanied by significant psychosocial impairment.
Patients will be more likely to comply with their doctor's recommendations if they are informed that they will likely need to take medications for some time and the reasons for such treatment are explained.
It has been found that the most effective pharmacological drugs For the treatment of social phobia are inhibitors of the enzyme monoamine oxidase in the central nervous system - OIMA and MAOI. Other drugs used to treat social phobia are benzodiazepines, beta blockers and SSRIs. Psychotherapy can also be helpful and is used either as monotherapy or in combination with medications.