Review of tablets used to treat social phobia. Causes and treatment of social phobia

26.11.2019 -

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Drug treatment of social phobia

Medications can be very helpful for people suffering from social phobia as they reduce symptoms. However, it is important to understand that medications cannot “cure” social phobia. Some people refuse to take any medications, others prefer to combine medications with cognitive behavioral psychotherapy and other means, and some use medications alone. The data provided here is for informational purposes only. You should not try to take the medications described here on your own. They can only be used as directed and under the supervision of a physician.

Benefits of the drugs
- The drugs reduce unpleasant symptoms of anxiety: palpitations, sweating, trembling, and so on.
- Medication can reduce the negative thoughts that almost all people with social anxiety experience.
- People with social phobia also often experience depression, and antidepressants can help improve their mood as well as reduce anxiety.

Selective serotonin reuptake inhibitors (SSRIs)

These drugs are classified as antidepressants and are currently the most popular drugs for treating anxiety and depression. This group has much less side effects than that of antidepressants from other groups. The main disadvantage of these drugs is their high price. This group includes fluoxetine (Prozac), paroxetine (Paxil), fluvoxamine (Luvox) and sertraline (Zoloft). They must be taken daily, following the treatment regimen. It may take up to several weeks for improvement to occur. Restrictions SSRIs may not be compatible with other medications, and you should talk to your doctor about this beforehand. Side effects The most common side effects from taking them are nervousness, anxiety, insomnia, headaches, nausea, and diarrhea. One of the most serious side effects is decreased sex drive. As the body adjusts to the drug, side effects go away on their own in most people. If this does not happen, the doctor will reduce the dose, change the drug, or prescribe medications to relieve side effects. Monoamine oxidase inhibitors (MAO inhibitors)

These drugs are also antidepressants that interfere with the breakdown of serotonin and norepinephrine. Increased level These substances in the brain help reduce anxiety. Restrictions
People taking a drug from this group must comply with strict diet. They should not eat foods containing tyramine (cheeses, alcoholic drinks, soybeans, some sausages). These products interact with medications, leading to increased blood pressure, and can cause symptoms such as headache and vomiting. Also, many medications are incompatible with MAO inhibitors. A severe increase in blood pressure in response to the combined use of the drug and certain foods in the absence of medical care can lead to stroke and even death.

Side effects
The most common side effects of MAO inhibitors are insomnia, fatigue, sexual dysfunction and weight gain.

Benzodiazepines

Benzodiazepines include drugs such as Valium, Xanax, and others. Benzodiazepines are very quick to calm and relieve anxiety, but their effect does not last long.

Side effects
Single doses can cause fatigue and dizziness, and reduce thinking abilities. Long-term use may cause sexual dysfunction.

Restrictions
Benzodiazepines, although effective against anxiety, have significant disadvantages. First, people who take benzodiazepines every day for more than a few weeks can become dependent on them. Moreover, these drugs should not be stopped immediately, as this can lead to withdrawal symptoms and worsening anxiety. Remember: benzodiazepines should never be taken without consulting your doctor. These drugs can be abused, so benzodiazepines are not recommended for people with drug addiction problems. In addition, alcohol should not be taken with benzodiazepines, as it increases their effect, which can lead to an overdose. Finally, people taking benzodiazepines should exercise caution when driving and operating complex devices, as their ability to do so may be impaired by the drugs.

Beta blockers

Beta blockers such as Inderal can also be used to treat anxiety. Beta blockers reduce heart palpitations, shaking, and other physical symptoms of anxiety by relaxing the muscles of the heart and skeleton. They also help with sweating and redness. Typically, such drugs are taken before an event that a person is afraid of. Their effect lasts for a couple of hours.

Restrictions
Beta blockers - the best means for the treatment of “stage fright”: fear of public speaking, exams, musical performances, and so on. Beta blockers may be less effective against the negative thoughts that are characteristic of social anxiety disorder, which lead to physical symptoms. One of the limitations of beta blockers is unexpected and unplanned social situations that cause severe anxiety.

Side effects
Beta blockers generally cannot be used by people with asthma, diabetes, and certain heart conditions.

Burns, D. D (1999). The Feeling Good Handbook. New York, New York. Plume.

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 probably 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. To relieve 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.

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, panic disorder, classified in both ICD-10 and B5M-4 as anxiety disorders, should also be included in the phobic circle disorders 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. lists treatment methods with limited or controversial effectiveness (laser therapy, acupuncture, use of thymostabilizers) used as additional ones in complex therapy, as well as treatment methods with relatively high efficiency, but rarely used nowadays (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 in the 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).

Tab. 4. Advantages and disadvantages various groups antidepressants in the treatment of phobias
Preparation		Advantages	Flaws
TCA	Amitriptyline Imipramine (melipramine)	1. Availability 2. Availability injection forms 3. Possibility of use in children	2. Less efficient 3. Lack of certainty about the mechanisms of action 4. Significant frequency and severity of side effects, including those that can increase anxiety-phobic disorders
TCA	Clomipramine (anafranil)	1. Availability 2. Relatively high efficiency 3. Pathogenetic validity of use 4. Availability of injection form 5. Possibility of use in children	1. The need for high doses 2. Frequency and severity of side effects, including those that can increase anxiety-phobic disorders
CVD	Tianeptine (Coaxil)	3. Well tolerated	1. Lack of injection form 2. Impossibility of use in children
SSRIs	Paroxetine (Paxil) Sertraline (Zoloft) Fluoxetine (Prozac) Citalopram (cipramil) Fluvoxamine (fevarin)	1. Relatively high efficiency 2. Pathogenetic validity of use 3. Possibility of using medium doses 4. Less frequency and severity of side effects	1. Less availability 2. Lack of injectable forms (except citalopram) 3. Impossibility of use in children (except for sertraline)
OIMAO-A	Moclobemide (Aurorix)	1. Relatively high efficiency 2. Less frequency and severity of side effects	1. Less availability 2. Lack of certainty about the mechanisms of action 3. Impossibility of use in children

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.

Tab. 5. Daily doses of antidepressants used in the treatment of phobias and depression
Preparation		Treatment of phobias	Treatment of depression
		most commonly used or optimal daily doses of antidepressants, mg	daily doses of antidepressants, mg
			average	maximum
TCA	Amitriptyline	100-250	150	300
	Imipramine	150-250	200	400
	Clomipramine	100-250	75	300
SSHR	Tianeptine	37,5	37,5	50
SSRIs	Paroxetine	40-60	20	60
	Sertraline	100-200	50	200
	Fluoxetine	20-40	20	80
	Citalopram	20-40	20	60
	Fluvoxamine	100-200	100	400
OIMAO-A	Moclobemide	600	300	600

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.

Tab. 6. Relative inhibitory ability of some antidepressants (according to M.H. Leider, 1994)
Preparation	Rat brain, in vivo conditions			Human platelets
Preparation	Norepinephrine	Serotonin	Dopamine	Serotonin
Amitriptyline	-	++	-	+
Clomipramine	++	++	-	+++
Fluoxetine	-	++	-	++
Imipramine	+++	+	-	++
Paroxetine	-	++	+	++
Note. "+++" - very high inhibitory activity; "++" - high inhibitory activity; "+" - weak inhibitory activity; "-" - insignificant effect or its complete absence.

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.

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 high risk formation of dependence. Psychotherapy as the only way correction of phobias is used relatively often.

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

Tab. 8. Indications for the use of antidepressants as part of monotherapy and complex therapy of phobias
Treatment Options	Indications for use
monotherapy
Antidepressants	Specific phobias (for current and frequent phobic situations) Monosymptomatic forms of agoraphobia, social phobia, nosophobia Generalized phobias during periods of remission (maintenance therapy)
complex therapy
I. Antidepressants + psychotherapy	Moderate degree of generalization of phobias, rare and abortive panic attacks, incomplete avoidance of phobic situations, lack of a pronounced tendency to progress
II. Tranquilizers at the beginning of treatment (with replacement with antipsychotics after a month) + long-term antidepressants + long-term psychotherapy + beta blockers	A high degree of generalization of phobias (up to panphobia), frequent and severe panic attacks, complete avoidance of frightening situations, a tendency to progress, social maladjustment

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.

Phobias are quite widely represented among patients; they have their own boundaries and clinical variations. Along with such recognized variants of phobias as social phobias, nosophobia, specific or isolated phobias, panic disorder, classified both in ICD-10 and DSM-4 as anxiety disorders, should also be included in the phobic circle 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. Nevertheless, fear in the structure is not obsessive in nature. It is, rather, fear taking over. But other phobias, traditionally classified as obsessions, are largely, if not for the most part, fears that are not obsessive, but overvalued.

Secondly, they become a source of social anxiety 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.

Modern treatment of phobias

Currently, the methods of treating phobias are quite diverse. Psychopharmacotherapy actually takes the leading place in the treatment of phobias. From classes psychotropic drugs in the first position are, according to the results of most studies and established therapeutic practice. This is followed by and. Application, psychotherapy are first-order methods of treating phobias, which in some cases can be used independently, in the form of monotherapy. Next come beta blockers, which usually play a supporting role in complex treatment, excluding some cases of social and isolated phobias. General vegetative stabilizing measures are practically significant, especially in the earlier stages of phobic disorders.

There are also treatment methods with limited or controversial effectiveness (laser therapy, acupuncture, the use of thymostabilizers), used as additional ones in complex therapy, as well as treatment methods with relatively high efficiency, but rarely used at present, for example, sub-shock methods.

It is also worth noting that with their advent, their intensive use in the treatment of phobias began, including parenteral administration of high doses of relanium. However, a certain disappointment set in relatively quickly, after which such treatment practically ceased. 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 the course of treatment should not exceed four and sometimes two weeks, according to some studies. The withdrawal of tranquilizers in most cases is accompanied by an exacerbation or resumption of phobias. As a result, tranquilizers, while maintaining a noticeable place in the treatment of phobias, have lost their dominant position. Currently, in the treatment of phobias, especially panic disorder, alprazolam, clonazepam, Relanium, phenazepam are mainly used. The latter is very promising due to the lower risk of addiction, according to a number of narcologists, and the emergence of injection addiction. forms.

The beginning of the use of drugs for anxiety-phobic disorders dates back to the 60s of the last century, when they were obtained positive results treatment of panic attacks. 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, however, are currently almost never used to correct phobias. The main TCAs ( , 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.

The most significant advantages of imipramine include accessibility, 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. It is known that anticholinergic effects occur in every fifth patient with phobias receiving amitriptyline or imipramine.

Clomipramine compares favorably with amitriptyline and imipramine in its higher effectiveness, associated with its pronounced serotonergic activity. The disadvantages associated with classic TCAs do not apply to tianeptine, a representative of the CVD group, which is used in a standard daily dose, is well tolerated and appears to be a very promising long-term treatment for phobic disorders.

Significant advantages of SSRIs compared to classic TCAs:

higher efficiency;
the presence of pathogenetic grounds for their use;
lower frequency and severity of side effects;
Great possibilities for long-term use.

However, SSRIs are inferior to TCAs in some respects. First of all, this is a non-medical disadvantage:

currently less affordable;
problems of long-term outpatient therapy;
lack of injection forms for most drugs;
impossibility of use in children and adolescents under 15 years of age (with the exception of).

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 a and OIMAO (moclobemide), especially often and most successfully used in disorders of the phobic circle, are close to or correspond to the maximum.

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 are used. However, various TCAs began to be used for phobias long before the advent of SSRIs. Amitriptyline and imipramine have a fairly high serotonin reuptake inhibitory ability, 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. The concept of the essential unity of phobias and depression should also be taken into account. Nevertheless, 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.

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. The lower efficacy rates of moclobemide are noteworthy. 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, the proportion of patients with improvement in condition is most often determined. Significant improvement is rarely specifically identified. Long-term results of treatment of non-psychotic disorders, including phobias, are generally 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 of drugs are needed. The effectiveness of various methods of treating phobias has been repeatedly compared: monotherapy, tranquilizers, psychotherapy alone and their combinations, with mixed results. However, complex therapy for phobias has the largest number of supporters. Monotherapy for phobias with antidepressants is becoming increasingly popular; 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.

When there is a combination of different phobias, the presence of several frightening 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 towards 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 neuroleptic behavior correctors or small or moderate doses of neuroleptic antipsychotics.

Social phobia (from English - “fear of society”) is one of the most common psychological disorders, lies in the torment of society. It is recognized as a disease of youth: most often it affects people from 15 to 30 years old.

The discomfort experienced by social phobics may be varying degrees severity - from minor timidity to large-scale phobia.

This mental illness safe for physical health, but greatly reduces the quality of life of an individual. Man experiences gamma discomfort when in crowded places, when public speaking, with increased attention to his person.

The first step to a harmonious and fulfilling life is overcoming social phobia. It is quite possible to achieve this; the most important thing is the desire and willingness to cope with difficulties. At first it will be difficult, since any personal growth is a change from established life attitudes to new ones. But when the first results are achieved, a person’s self-esteem awakens. This quality contributes to that inherent only in a strong personality.

We will look at the causes, manifestations and treatment of social phobia using various methods.

History of social anxiety

In the 60s of the twentieth century, the first patients appeared with vague complaints of fear of society. Symptoms varied significantly among people (from fear of public embarrassment to the inability to be in public). But in general they had one thing in common: they began with a large crowd of people. That's when psychotherapists first became interested in social phobia. The treatment was carried out using the method of psychoanalysis of Sigmund Freud.

Psychologists relied on his theory, according to which childhood plays a decisive role in the formation of personality, and most phobias are rooted in early age. In the case of social phobia, the emotional closeness of the parent and the small child is of great importance.

The mother is obliged to pay enough attention to the child, talk to him, smile. Thanks to the manifestation of care and affection, the child begins to subconsciously feel needed. With a lack of care, the baby feels useless: he grows up capricious and irritable. A child experiences a lot of stress when visiting a nursery or kindergarten early. He begins to emotionally miss his parents, and there is a fear of the unknown, which causes social phobia in the future.

Social phobia: causes

Treatment of social phobia directly depends on the reasons that caused it in a particular individual. For example, if a person has a pronounced imbalance of neurotransmitters, then he is prescribed treatment with pills. If difficulties in communication arise due to childhood complexes, then cognitive behavioral psychotherapy is indicated for social phobia.

What are the causes of social phobia?

Hereditary factors (if one of the parents experiences social anxiety, the child will also grow up anxious).
Imbalance of neurotransmitters. Our endocrine system produces certain hormones responsible for fear, happiness, euphoria, sadness, etc. When its work is disrupted, the correct ratio hormones. This leads to mood disorders and increased anxiety).
Introversion (most social phobes are introverts with a weak type of nervous system).
Children's grievances.

Most often, social phobia is caused by a combination of factors. A person’s anxious character is influenced by either stress, resentment, or an existential crisis. The psyche cannot stand it, and another person joins the ranks of social phobes.

Distinctive signs of a social phobia

Classic social phobes can be seen from afar: these are slender young people wearing headphones, looking younger than their years. They are characterized by a vacant look and a strange appearance.

The first social phobes to openly declare themselves were young Japanese. At the end of the twentieth century, they formed the hikikomori movement - young people who chose the path of voluntary hermitage. Their distinguishing feature- this is minimizing communication with society. The hikikomori lifestyle appealed to a certain segment of Western youth. Soon this movement gained popularity in the West and in Russia.

However, reluctance to be in society and fear of society are fundamentally different things. The first is a manifestation of nihilism, and the second is a serious phobia that causes real discomfort to a person. A real social phobe suffers from the fact that he cannot be among people: it is difficult for him to find an office job, he does not go to nightclubs and parties. At the same time, the person realizes that something is wrong with him. He wants to change the situation, but he can't.

Symptoms of social phobia

A person with severe social phobia is seriously limited. Three areas are affected:

behavioral;
physiological;
emotional.

The behavioral sphere suffers the most seriously: a person refuses to attend interesting events, avoids crowded places, and does not know how to speak in public.

The physiological component is manifested by vegetative symptoms:

tachycardia;
tremor;
redness of the skin;
lump in throat;
increased sweating.

Emotionally, social phobia manifests itself as an irrational and panicky fear of people. A person understands the absurdity of the situation with his head, but is unable to influence the situation.

Diagnosis of social phobia

Social phobia is treated by psychoanalysts, clinical psychologists and psychotherapists. You should not go to a psychiatrist, since this doctor treats the mentally ill, not neurotics. An illiterate psychiatrist will prescribe a social phobia person serious medications that will reduce anxiety, but will not eliminate the cause of the problem. The ideal option is to find a competent psychotherapist who will help a person get to the bottom of the problem.

An appointment with a psychotherapist begins with the patient telling him about his problems. Next, the doctor will suggest you undergo special tests:

Luscher test (for general psychological state person).
Spielberger-Hanin test (to determine the level of anxiety).
Social phobia test.

Based on the test results and the person’s complaints, a diagnosis is made and treatment is prescribed.

Treatment of social phobia

Robert Kiyosaki's wonderful work "Rich Dad Poor Dad" describes situations where smart and educated people were left with literally nothing because of their indecision and shyness. While less educated, but more determined and arrogant individuals achieved success. The author shows that situations where fear suppresses the will should not be allowed. Because of it, your inner abilities and aspirations begin to fade, and you stop achieving your goals.

The reason why a person feels unwell in public is social phobia. The treatment will be effective if you have found a suitable treatment method. A psychotherapist is called upon to help find it: it’s not for nothing that he studied the books of famous predecessors and applied the knowledge at seminars.

Social phobia can be treated in different ways. One of the most effective is cognitive behavioral psychotherapy. There are other methods that correct social phobia and provide treatment:

Tablets and other medications.
Healing through meditation.
Treatment of social phobia with hypnosis.

Cognitive behavioral psychotherapy

Treatment of social phobia with cognitive behavioral psychotherapy occurs in the form of meetings between a person and a psychologist (sessions).

A specialist teaches a social phobic to recognize thoughts that cause increased anxiety. Surprisingly, it turns out that “bad thoughts” revolve around the same thing. Next, a person needs to analyze his thoughts and try to replace them with more rational ones. At the end of psychotherapy sessions, a person becomes his own psychologist, he learns to reason logically and replace categorical attitudes with more flexible ones.

Signs that psychotherapy is having a positive effect:

reducing anxiety levels;
new skills of behavior in social situations (when being in the center of attention, when speaking in front of a large number of people);
a less categorical view of many things.

Social phobia: treatment, pills

And, of course, it cannot be ruled out drug therapy. Medical treatment of social phobia involves prescribing medications to a person to reduce anxiety levels. A person is prescribed:

antidepressants;
beta blockers.

The former are effective both for social phobia and for high anxiety. The latter relieve physical manifestations of anxiety - tremor, tachycardia, sweating. Many politicians and activists take beta blockers before long public appearances.

But it’s worth remembering: pills treat the effect, not the cause. They are addictive and have many unpleasant side effects. Real relief from a problem is serious personal growth, and not the short-term effect of medical drugs that depress nervous system. Therefore, resorting to pharmacotherapy should be the last resort.

Treatment of social phobia with hypnosis

Hypnosis is the second most effective treatment for social phobia. It consists of changing a person’s destructive beliefs by immersing consciousness in a state of trance. The hypnotist concentrates the person on the necessary information and suggests it. After several sessions of hypnosis, a person’s panic fear of society disappears, he is calm when society pays attention to his person.

But hypnosis has one caveat: not all people are susceptible to it. Also, this method is not acceptable to everyone: a person may simply not want someone else to delve into his mind.

Meditation

A great way to relax the body and remove internal blocks. Meditation has been known since time immemorial: it underlies many spiritual practices (yoga). IN Old Testament mentioned Latin word meditatio - to reflect, to concentrate, to inhale.

Meditation is a spiritual exercise of reflection or self-talk. There are different ways meditation. To relieve anxiety and calm the mind, there is a breathing meditation technique. She teaches you to breathe correctly and calmly. During practice, a person calms down, reflects, and learns to focus on positive emotions.

A meditating person is calm and does not tend to be anxious. helps improve communication skills.

Bottom line

A complex of various social fears is combined into the concept of social phobia. The strategy of competent treatment is to replace destructive categorical attitudes with more flexible and adaptive ones. An excellent addition to working on your thoughts is breathing meditation: relaxing, removing internal blocks and giving a positive attitude.

All social phobes should remember: water does not flow under a lying stone. You need to look for a treatment method that will help you. At first you will make mistakes and move slowly. But gradually, step by step, you will gain invaluable experience and find something that will help you return to a happy life.