Too quick to Medicate Social Phobias?

[Guest guest]

http://seattletimes.nwsource.com/html/health/2002042091_healthsocialphobia22.htm\

l

Are doctors too quick to medicate social phobias?

By Kyung M. Song

Seattle Times staff reporter

It's a serious affliction for those who have it, but its symptoms can also

be the bane of ordinary introverts: aversion to cocktail parties, uneasiness

with strangers and fear of public attention.

As much as any psychiatric condition, social phobia straddles a blurry line

between official disorder and normal, though uncomfortable, personality

traits.

On the surface, sufferers of social phobia, also known as social anxiety

disorder, can seem to be simply " shy persons " as Garrison Keillor would call

them.

But while shyness describes a temperament, social phobia can be a

debilitating condition.

People with social anxiety disorder experience severe distress and

impairment in ordinary social situations. They hate public scrutiny; even

eating in a restaurant causes them discomfort. In social situations, they

almost always feel physical symptoms — heart palpitations, sweating and

upset stomach — though such symptoms are not required for a diagnosis of

social phobia. People with social phobia suffer long-term consequences, too.

They are less likely to marry, they underachieve at school and at work, and

they have low self esteem.

Because of the fuzzy line between normal shyness and disabling social

phobia, mental-health professionals worry that drug manufacturers are

redefining natural human vagaries as illnesses simply to sell more pills —

what the British Medical Journal calls " disease mongering. "

" Almost everyone has felt shy at one time or another " and they don't like

it, said Dr. Marcia Angell, former editor in chief of The New England

Journal of Medicine. " If they thought there was a pill for it, they'd

probably take it. "

In June, the U.S. Food and Drug Administration (FDA) ordered GlaxoKline

to yank its ads for the antidepressant Paxil CR, which is one of several

drugs approved for treating social phobia.

Television spots for the drug featured actors in various social situations

wearing " Hello my name is " tags. One man at a party sported a tag that says

" nervous " while a female job candidate's tag read " panicky. "

The FDA accused GlaxoKline of expanding Paxil's use by " failing to

distinguish between social anxiety disorder and the lesser degrees of

performance anxiety or shyness that do not generally require

psychopharmacological treatment. "

Paxil, which in 1999 became the first drug approved by the FDA specifically

for treating social phobia, had its advertising budget nearly tripled that

year to $92 million. That helped to raise GlaxoKline's sales by $2

billion in 2000, the largest increase of any U.S. pharmaceutical company,

according to IMS, a pharmaceutical-market data company.

There is much money to be made in treating social phobia — it is one of the

most common psychiatric disorders in the United States. It ranks just behind

major depression, alcohol abuse and alcohol dependence in prevalence,

according to the National Epidemiologic Survey on Alcohol and Related

Conditions. The survey's results were published last month in the Archives

of General Psychiatry. More Americans are estimated to suffer from social

phobia than from drug abuse, bipolar disorder, anorexia or Alzheimer's

disease.

And the whole range of anxiety disorders — which include social phobia,

panic disorder, post-traumatic stress disorder, obsessive-compulsiveness and

generalized anxiety disorder — afflict 23 million American adults — more

than 11 percent of the population, according to the survey. That's more than

the number of people who have mood disorders such as chronic mild depression

(19.2 million adults) or those with alcohol- or drug-use disorders or both

(19.4 million).

Subjective diagnosis

Concerns persist, though, about where the line properly lies between a

personality trait and an illness. Mental disorders, including social phobia,

lack definitive diagnostic tests, leaving them vulnerable to subjective, and

controversial, calls.

" At what point does shyness become a disorder? " asked Dr. Wayne Katon,

director of the Division of Health Services and Psychiatric Epidemiology at

the University of Washington School of Medicine. Katon believes too few

people with social phobia get treatment. " It would be great in psychiatry if

we had a blood test that could tell us you have this disorder. "

Even among mental-health specialists, social phobia has long suffered from a

prejudice that it stretched the boundaries of normal human emotions into

clinical conditions, earning it the label a " neglected anxiety disorder " in

a 1985 edition of Archives of General Psychiatry.

, a clinical psychologist and director of the Anxiety Disorders

Program at St. Boniface General Hospital in Winnipeg, Canada, said that

diagnosing social phobia in patients who seek professional treatments isn't

too difficult. is co-author, along with Dr. Murray Stein, of a

self-help book called " Triumph Over Shyness: Conquering Shyness and Social

Anxiety. "

said people fall into a natural distribution curve between being

outgoing and bold and being shy and cautious. It's difficult to pinpoint

where on that bell curve social phobia lies, he said.

" Any cutoff point you make will automatically be arbitrary, " said ,

who also is a professor of clinical-health psychology at the University of

Manitoba.

" Clinically, people tend to ask for help when they're so shy that it's

causing distress and disability, " said.

In cases of true social phobia, the condition permeates virtually all

aspects of the patients' lives. They take night-shift jobs to minimize

contact with people, quit school early, have little contact with family

members and are more prone to suffer depression, smoking and drinking.

Children with the disorder are unable to enjoy normal activities, such as

having friends over or taking swimming lessons.

Angell, now a senior lecturer at Harvard Medical School, argues that

psychiatric diagnoses are so " vague and imprecise " that they have left the

door open for pharmaceutical companies to " make diseases for drugs. If they

can convince perfectly normal people that they have a problem, they can

expand the drug market almost indefinitely. "

Angell says physicians who accept free drug samples and who too quickly

dispense drugs that their patients see advertised are complicit in

overmedicating patients.

There's no question that pharmaceutical companies spend lavishly on

advertising. In 2003, they spent $1.71 billion to promote antidepressants

directly to doctors, including the retail cost of samples and ads in medical

journals, according to IMS.

Yet widespread consumer advertising isn't exactly turning everyone into

would-be pill poppers. A yet-unpublished Canadian study conducted by

found that given a choice, patients would choose talk therapy over

medication for anxiety problems by a 2-to-1 ratio.

The survey of 251 adults who were visiting a hospital for general medical

appointments also found that people rated psychotherapy more effective in

the long run and drugs more effective in the short run.

Causes and treatments

Researchers believe that social phobia has both biologic and environmental

causes. Experiments with infants as young as 3 months have shown that those

exhibiting timid, constrained behaviors are at higher risk of developing

anxiety disorders later in life. Social phobia also is more likely to occur

among people who have identical twins or parents with the disorder, which

could implicate both genes and family upbringing.

Two forms of treatment have proven effective for social phobia: medication

and talk therapy.

Drugs that raise the level of the mood-regulating neurotransmitter serotonin

in the brain can reduce anxiety. Paxil and Zoloft, antidepressants known as

selective serotonin reuptake inhibitors, are approved by the FDA for

treating social phobia. Effexor, which balances serotonin and another brain

chemical, norepinephrine, won FDA clearance for social phobia in 2003.

Beta-blockers, which typically are used for high blood pressure, have been

shown to work for a form of social anxiety disorder called performance

phobia among musicians, actors or others performing in public.

But drugs can cause side effects, some of them severe. In the October 2004

issue of Consumer Reports, 1,664 of the magazine's readers rate a half-dozen

antidepressants based on the one that helped them " a lot. "

The readers ranked Effexor, which is approved for both depression and social

phobia, as the most effective, but they also reported a high incidence of

side effects. For instance, more than half of the people who took Effexor

noticed a drop in sexual interest or performance and 21 percent reported

weight gain.

Among those who took Zoloft, 46 percent experienced such sexual side effects

and 17 percent reported weight gain.

Cognitive-behavior therapy is another effective treatment for muting the

effects of social phobia. This short-term talk therapy teaches patients to

alter both their actions and their thinking. Patients learn to correct

unrealistic thoughts (such as believing that others will view them as morons

if they speak in public). They also learn coping behaviors through exposure

therapy, which involves taking part in the feared activities and building

tolerance.

But some studies suggest that benefits of this sort of psychotherapy may be

limited. Patients who completed cognitive-behavior therapy for social

phobia, while significantly raising their scores on quality-of-life

questionnaires, still remained less satisfied than the general population

with their lives.

Katon, of the UW, said social phobics who do not receive proper treatment

risk social isolation that could lead to depression. In addition, some

patients may turn to a common social lubricant, alcohol, to blunt the

effects of social anxiety disorder.

Katon said alcohol can temporarily mute the symptoms of social phobia by

sedating the brain. But over time, as the drinker's nervous system gets

accustomed to the alcohol, it takes more and more of it to achieve the same

anxiety-reducing effect. What's more, the anxiety returns once the drinking

stops.

, of the University of Manitoba, said people tend to overestimate

their own shyness, with more than half the respondents in one survey rating

themselves shyer than others. But that needn't be sign of a problem.

" People often see anxiety as an abnormal thing when in fact it's normal, "

said. " Most of us are shy to some degree. "

Kyung Song: 206-464-2423 or ksong@...

[Guest guest]

http://seattletimes.nwsource.com/html/health/2002042091_healthsocialphobia22.htm\

l

Are doctors too quick to medicate social phobias?

By Kyung M. Song

Seattle Times staff reporter

It's a serious affliction for those who have it, but its symptoms can also

be the bane of ordinary introverts: aversion to cocktail parties, uneasiness

with strangers and fear of public attention.

As much as any psychiatric condition, social phobia straddles a blurry line

between official disorder and normal, though uncomfortable, personality

traits.

On the surface, sufferers of social phobia, also known as social anxiety

disorder, can seem to be simply " shy persons " as Garrison Keillor would call

them.

But while shyness describes a temperament, social phobia can be a

debilitating condition.

People with social anxiety disorder experience severe distress and

impairment in ordinary social situations. They hate public scrutiny; even

eating in a restaurant causes them discomfort. In social situations, they

almost always feel physical symptoms — heart palpitations, sweating and

upset stomach — though such symptoms are not required for a diagnosis of

social phobia. People with social phobia suffer long-term consequences, too.

They are less likely to marry, they underachieve at school and at work, and

they have low self esteem.

Because of the fuzzy line between normal shyness and disabling social

phobia, mental-health professionals worry that drug manufacturers are

redefining natural human vagaries as illnesses simply to sell more pills —

what the British Medical Journal calls " disease mongering. "

" Almost everyone has felt shy at one time or another " and they don't like

it, said Dr. Marcia Angell, former editor in chief of The New England

Journal of Medicine. " If they thought there was a pill for it, they'd

probably take it. "

In June, the U.S. Food and Drug Administration (FDA) ordered GlaxoKline

to yank its ads for the antidepressant Paxil CR, which is one of several

drugs approved for treating social phobia.

Television spots for the drug featured actors in various social situations

wearing " Hello my name is " tags. One man at a party sported a tag that says

" nervous " while a female job candidate's tag read " panicky. "

The FDA accused GlaxoKline of expanding Paxil's use by " failing to

distinguish between social anxiety disorder and the lesser degrees of

performance anxiety or shyness that do not generally require

psychopharmacological treatment. "

Paxil, which in 1999 became the first drug approved by the FDA specifically

for treating social phobia, had its advertising budget nearly tripled that

year to $92 million. That helped to raise GlaxoKline's sales by $2

billion in 2000, the largest increase of any U.S. pharmaceutical company,

according to IMS, a pharmaceutical-market data company.

There is much money to be made in treating social phobia — it is one of the

most common psychiatric disorders in the United States. It ranks just behind

major depression, alcohol abuse and alcohol dependence in prevalence,

according to the National Epidemiologic Survey on Alcohol and Related

Conditions. The survey's results were published last month in the Archives

of General Psychiatry. More Americans are estimated to suffer from social

phobia than from drug abuse, bipolar disorder, anorexia or Alzheimer's

disease.

And the whole range of anxiety disorders — which include social phobia,

panic disorder, post-traumatic stress disorder, obsessive-compulsiveness and

generalized anxiety disorder — afflict 23 million American adults — more

than 11 percent of the population, according to the survey. That's more than

the number of people who have mood disorders such as chronic mild depression

(19.2 million adults) or those with alcohol- or drug-use disorders or both

(19.4 million).

Subjective diagnosis

Concerns persist, though, about where the line properly lies between a

personality trait and an illness. Mental disorders, including social phobia,

lack definitive diagnostic tests, leaving them vulnerable to subjective, and

controversial, calls.

" At what point does shyness become a disorder? " asked Dr. Wayne Katon,

director of the Division of Health Services and Psychiatric Epidemiology at

the University of Washington School of Medicine. Katon believes too few

people with social phobia get treatment. " It would be great in psychiatry if

we had a blood test that could tell us you have this disorder. "

Even among mental-health specialists, social phobia has long suffered from a

prejudice that it stretched the boundaries of normal human emotions into

clinical conditions, earning it the label a " neglected anxiety disorder " in

a 1985 edition of Archives of General Psychiatry.

, a clinical psychologist and director of the Anxiety Disorders

Program at St. Boniface General Hospital in Winnipeg, Canada, said that

diagnosing social phobia in patients who seek professional treatments isn't

too difficult. is co-author, along with Dr. Murray Stein, of a

self-help book called " Triumph Over Shyness: Conquering Shyness and Social

Anxiety. "

said people fall into a natural distribution curve between being

outgoing and bold and being shy and cautious. It's difficult to pinpoint

where on that bell curve social phobia lies, he said.

" Any cutoff point you make will automatically be arbitrary, " said ,

who also is a professor of clinical-health psychology at the University of

Manitoba.

" Clinically, people tend to ask for help when they're so shy that it's

causing distress and disability, " said.

In cases of true social phobia, the condition permeates virtually all

aspects of the patients' lives. They take night-shift jobs to minimize

contact with people, quit school early, have little contact with family

members and are more prone to suffer depression, smoking and drinking.

Children with the disorder are unable to enjoy normal activities, such as

having friends over or taking swimming lessons.

Angell, now a senior lecturer at Harvard Medical School, argues that

psychiatric diagnoses are so " vague and imprecise " that they have left the

door open for pharmaceutical companies to " make diseases for drugs. If they

can convince perfectly normal people that they have a problem, they can

expand the drug market almost indefinitely. "

Angell says physicians who accept free drug samples and who too quickly

dispense drugs that their patients see advertised are complicit in

overmedicating patients.

There's no question that pharmaceutical companies spend lavishly on

advertising. In 2003, they spent $1.71 billion to promote antidepressants

directly to doctors, including the retail cost of samples and ads in medical

journals, according to IMS.

Yet widespread consumer advertising isn't exactly turning everyone into

would-be pill poppers. A yet-unpublished Canadian study conducted by

found that given a choice, patients would choose talk therapy over

medication for anxiety problems by a 2-to-1 ratio.

The survey of 251 adults who were visiting a hospital for general medical

appointments also found that people rated psychotherapy more effective in

the long run and drugs more effective in the short run.

Causes and treatments

Researchers believe that social phobia has both biologic and environmental

causes. Experiments with infants as young as 3 months have shown that those

exhibiting timid, constrained behaviors are at higher risk of developing

anxiety disorders later in life. Social phobia also is more likely to occur

among people who have identical twins or parents with the disorder, which

could implicate both genes and family upbringing.

Two forms of treatment have proven effective for social phobia: medication

and talk therapy.

Drugs that raise the level of the mood-regulating neurotransmitter serotonin

in the brain can reduce anxiety. Paxil and Zoloft, antidepressants known as

selective serotonin reuptake inhibitors, are approved by the FDA for

treating social phobia. Effexor, which balances serotonin and another brain

chemical, norepinephrine, won FDA clearance for social phobia in 2003.

Beta-blockers, which typically are used for high blood pressure, have been

shown to work for a form of social anxiety disorder called performance

phobia among musicians, actors or others performing in public.

But drugs can cause side effects, some of them severe. In the October 2004

issue of Consumer Reports, 1,664 of the magazine's readers rate a half-dozen

antidepressants based on the one that helped them " a lot. "

The readers ranked Effexor, which is approved for both depression and social

phobia, as the most effective, but they also reported a high incidence of

side effects. For instance, more than half of the people who took Effexor

noticed a drop in sexual interest or performance and 21 percent reported

weight gain.

Among those who took Zoloft, 46 percent experienced such sexual side effects

and 17 percent reported weight gain.

Cognitive-behavior therapy is another effective treatment for muting the

effects of social phobia. This short-term talk therapy teaches patients to

alter both their actions and their thinking. Patients learn to correct

unrealistic thoughts (such as believing that others will view them as morons

if they speak in public). They also learn coping behaviors through exposure

therapy, which involves taking part in the feared activities and building

tolerance.

But some studies suggest that benefits of this sort of psychotherapy may be

limited. Patients who completed cognitive-behavior therapy for social

phobia, while significantly raising their scores on quality-of-life

questionnaires, still remained less satisfied than the general population

with their lives.

Katon, of the UW, said social phobics who do not receive proper treatment

risk social isolation that could lead to depression. In addition, some

patients may turn to a common social lubricant, alcohol, to blunt the

effects of social anxiety disorder.

Katon said alcohol can temporarily mute the symptoms of social phobia by

sedating the brain. But over time, as the drinker's nervous system gets

accustomed to the alcohol, it takes more and more of it to achieve the same

anxiety-reducing effect. What's more, the anxiety returns once the drinking

stops.

, of the University of Manitoba, said people tend to overestimate

their own shyness, with more than half the respondents in one survey rating

themselves shyer than others. But that needn't be sign of a problem.

" People often see anxiety as an abnormal thing when in fact it's normal, "

said. " Most of us are shy to some degree. "

Kyung Song: 206-464-2423 or ksong@...

[Guest guest]

http://seattletimes.nwsource.com/html/health/2002042091_healthsocialphobia22.htm\

l

Are doctors too quick to medicate social phobias?

By Kyung M. Song

Seattle Times staff reporter

It's a serious affliction for those who have it, but its symptoms can also

be the bane of ordinary introverts: aversion to cocktail parties, uneasiness

with strangers and fear of public attention.

As much as any psychiatric condition, social phobia straddles a blurry line

between official disorder and normal, though uncomfortable, personality

traits.

On the surface, sufferers of social phobia, also known as social anxiety

disorder, can seem to be simply " shy persons " as Garrison Keillor would call

them.

But while shyness describes a temperament, social phobia can be a

debilitating condition.

People with social anxiety disorder experience severe distress and

impairment in ordinary social situations. They hate public scrutiny; even

eating in a restaurant causes them discomfort. In social situations, they

almost always feel physical symptoms — heart palpitations, sweating and

upset stomach — though such symptoms are not required for a diagnosis of

social phobia. People with social phobia suffer long-term consequences, too.

They are less likely to marry, they underachieve at school and at work, and

they have low self esteem.

Because of the fuzzy line between normal shyness and disabling social

phobia, mental-health professionals worry that drug manufacturers are

redefining natural human vagaries as illnesses simply to sell more pills —

what the British Medical Journal calls " disease mongering. "

" Almost everyone has felt shy at one time or another " and they don't like

it, said Dr. Marcia Angell, former editor in chief of The New England

Journal of Medicine. " If they thought there was a pill for it, they'd

probably take it. "

In June, the U.S. Food and Drug Administration (FDA) ordered GlaxoKline

to yank its ads for the antidepressant Paxil CR, which is one of several

drugs approved for treating social phobia.

Television spots for the drug featured actors in various social situations

wearing " Hello my name is " tags. One man at a party sported a tag that says

" nervous " while a female job candidate's tag read " panicky. "

The FDA accused GlaxoKline of expanding Paxil's use by " failing to

distinguish between social anxiety disorder and the lesser degrees of

performance anxiety or shyness that do not generally require

psychopharmacological treatment. "

Paxil, which in 1999 became the first drug approved by the FDA specifically

for treating social phobia, had its advertising budget nearly tripled that

year to $92 million. That helped to raise GlaxoKline's sales by $2

billion in 2000, the largest increase of any U.S. pharmaceutical company,

according to IMS, a pharmaceutical-market data company.

There is much money to be made in treating social phobia — it is one of the

most common psychiatric disorders in the United States. It ranks just behind

major depression, alcohol abuse and alcohol dependence in prevalence,

according to the National Epidemiologic Survey on Alcohol and Related

Conditions. The survey's results were published last month in the Archives

of General Psychiatry. More Americans are estimated to suffer from social

phobia than from drug abuse, bipolar disorder, anorexia or Alzheimer's

disease.

And the whole range of anxiety disorders — which include social phobia,

panic disorder, post-traumatic stress disorder, obsessive-compulsiveness and

generalized anxiety disorder — afflict 23 million American adults — more

than 11 percent of the population, according to the survey. That's more than

the number of people who have mood disorders such as chronic mild depression

(19.2 million adults) or those with alcohol- or drug-use disorders or both

(19.4 million).

Subjective diagnosis

Concerns persist, though, about where the line properly lies between a

personality trait and an illness. Mental disorders, including social phobia,

lack definitive diagnostic tests, leaving them vulnerable to subjective, and

controversial, calls.

" At what point does shyness become a disorder? " asked Dr. Wayne Katon,

director of the Division of Health Services and Psychiatric Epidemiology at

the University of Washington School of Medicine. Katon believes too few

people with social phobia get treatment. " It would be great in psychiatry if

we had a blood test that could tell us you have this disorder. "

Even among mental-health specialists, social phobia has long suffered from a

prejudice that it stretched the boundaries of normal human emotions into

clinical conditions, earning it the label a " neglected anxiety disorder " in

a 1985 edition of Archives of General Psychiatry.

, a clinical psychologist and director of the Anxiety Disorders

Program at St. Boniface General Hospital in Winnipeg, Canada, said that

diagnosing social phobia in patients who seek professional treatments isn't

too difficult. is co-author, along with Dr. Murray Stein, of a

self-help book called " Triumph Over Shyness: Conquering Shyness and Social

Anxiety. "

said people fall into a natural distribution curve between being

outgoing and bold and being shy and cautious. It's difficult to pinpoint

where on that bell curve social phobia lies, he said.

" Any cutoff point you make will automatically be arbitrary, " said ,

who also is a professor of clinical-health psychology at the University of

Manitoba.

" Clinically, people tend to ask for help when they're so shy that it's

causing distress and disability, " said.

In cases of true social phobia, the condition permeates virtually all

aspects of the patients' lives. They take night-shift jobs to minimize

contact with people, quit school early, have little contact with family

members and are more prone to suffer depression, smoking and drinking.

Children with the disorder are unable to enjoy normal activities, such as

having friends over or taking swimming lessons.

Angell, now a senior lecturer at Harvard Medical School, argues that

psychiatric diagnoses are so " vague and imprecise " that they have left the

door open for pharmaceutical companies to " make diseases for drugs. If they

can convince perfectly normal people that they have a problem, they can

expand the drug market almost indefinitely. "

Angell says physicians who accept free drug samples and who too quickly

dispense drugs that their patients see advertised are complicit in

overmedicating patients.

There's no question that pharmaceutical companies spend lavishly on

advertising. In 2003, they spent $1.71 billion to promote antidepressants

directly to doctors, including the retail cost of samples and ads in medical

journals, according to IMS.

Yet widespread consumer advertising isn't exactly turning everyone into

would-be pill poppers. A yet-unpublished Canadian study conducted by

found that given a choice, patients would choose talk therapy over

medication for anxiety problems by a 2-to-1 ratio.

The survey of 251 adults who were visiting a hospital for general medical

appointments also found that people rated psychotherapy more effective in

the long run and drugs more effective in the short run.

Causes and treatments

Researchers believe that social phobia has both biologic and environmental

causes. Experiments with infants as young as 3 months have shown that those

exhibiting timid, constrained behaviors are at higher risk of developing

anxiety disorders later in life. Social phobia also is more likely to occur

among people who have identical twins or parents with the disorder, which

could implicate both genes and family upbringing.

Two forms of treatment have proven effective for social phobia: medication

and talk therapy.

Drugs that raise the level of the mood-regulating neurotransmitter serotonin

in the brain can reduce anxiety. Paxil and Zoloft, antidepressants known as

selective serotonin reuptake inhibitors, are approved by the FDA for

treating social phobia. Effexor, which balances serotonin and another brain

chemical, norepinephrine, won FDA clearance for social phobia in 2003.

Beta-blockers, which typically are used for high blood pressure, have been

shown to work for a form of social anxiety disorder called performance

phobia among musicians, actors or others performing in public.

But drugs can cause side effects, some of them severe. In the October 2004

issue of Consumer Reports, 1,664 of the magazine's readers rate a half-dozen

antidepressants based on the one that helped them " a lot. "

The readers ranked Effexor, which is approved for both depression and social

phobia, as the most effective, but they also reported a high incidence of

side effects. For instance, more than half of the people who took Effexor

noticed a drop in sexual interest or performance and 21 percent reported

weight gain.

Among those who took Zoloft, 46 percent experienced such sexual side effects

and 17 percent reported weight gain.

Cognitive-behavior therapy is another effective treatment for muting the

effects of social phobia. This short-term talk therapy teaches patients to

alter both their actions and their thinking. Patients learn to correct

unrealistic thoughts (such as believing that others will view them as morons

if they speak in public). They also learn coping behaviors through exposure

therapy, which involves taking part in the feared activities and building

tolerance.

But some studies suggest that benefits of this sort of psychotherapy may be

limited. Patients who completed cognitive-behavior therapy for social

phobia, while significantly raising their scores on quality-of-life

questionnaires, still remained less satisfied than the general population

with their lives.

Katon, of the UW, said social phobics who do not receive proper treatment

risk social isolation that could lead to depression. In addition, some

patients may turn to a common social lubricant, alcohol, to blunt the

effects of social anxiety disorder.

Katon said alcohol can temporarily mute the symptoms of social phobia by

sedating the brain. But over time, as the drinker's nervous system gets

accustomed to the alcohol, it takes more and more of it to achieve the same

anxiety-reducing effect. What's more, the anxiety returns once the drinking

stops.

, of the University of Manitoba, said people tend to overestimate

their own shyness, with more than half the respondents in one survey rating

themselves shyer than others. But that needn't be sign of a problem.

" People often see anxiety as an abnormal thing when in fact it's normal, "

said. " Most of us are shy to some degree. "

Kyung Song: 206-464-2423 or ksong@...

[Guest guest]

http://seattletimes.nwsource.com/html/health/2002042091_healthsocialphobia22.htm\

l

Are doctors too quick to medicate social phobias?

By Kyung M. Song

Seattle Times staff reporter

It's a serious affliction for those who have it, but its symptoms can also

be the bane of ordinary introverts: aversion to cocktail parties, uneasiness

with strangers and fear of public attention.

As much as any psychiatric condition, social phobia straddles a blurry line

between official disorder and normal, though uncomfortable, personality

traits.

On the surface, sufferers of social phobia, also known as social anxiety

disorder, can seem to be simply " shy persons " as Garrison Keillor would call

them.

But while shyness describes a temperament, social phobia can be a

debilitating condition.

People with social anxiety disorder experience severe distress and

impairment in ordinary social situations. They hate public scrutiny; even

eating in a restaurant causes them discomfort. In social situations, they

almost always feel physical symptoms — heart palpitations, sweating and

upset stomach — though such symptoms are not required for a diagnosis of

social phobia. People with social phobia suffer long-term consequences, too.

They are less likely to marry, they underachieve at school and at work, and

they have low self esteem.

Because of the fuzzy line between normal shyness and disabling social

phobia, mental-health professionals worry that drug manufacturers are

redefining natural human vagaries as illnesses simply to sell more pills —

what the British Medical Journal calls " disease mongering. "

" Almost everyone has felt shy at one time or another " and they don't like

it, said Dr. Marcia Angell, former editor in chief of The New England

Journal of Medicine. " If they thought there was a pill for it, they'd

probably take it. "

In June, the U.S. Food and Drug Administration (FDA) ordered GlaxoKline

to yank its ads for the antidepressant Paxil CR, which is one of several

drugs approved for treating social phobia.

Television spots for the drug featured actors in various social situations

wearing " Hello my name is " tags. One man at a party sported a tag that says

" nervous " while a female job candidate's tag read " panicky. "

The FDA accused GlaxoKline of expanding Paxil's use by " failing to

distinguish between social anxiety disorder and the lesser degrees of

performance anxiety or shyness that do not generally require

psychopharmacological treatment. "

Paxil, which in 1999 became the first drug approved by the FDA specifically

for treating social phobia, had its advertising budget nearly tripled that

year to $92 million. That helped to raise GlaxoKline's sales by $2

billion in 2000, the largest increase of any U.S. pharmaceutical company,

according to IMS, a pharmaceutical-market data company.

There is much money to be made in treating social phobia — it is one of the

most common psychiatric disorders in the United States. It ranks just behind

major depression, alcohol abuse and alcohol dependence in prevalence,

according to the National Epidemiologic Survey on Alcohol and Related

Conditions. The survey's results were published last month in the Archives

of General Psychiatry. More Americans are estimated to suffer from social

phobia than from drug abuse, bipolar disorder, anorexia or Alzheimer's

disease.

And the whole range of anxiety disorders — which include social phobia,

panic disorder, post-traumatic stress disorder, obsessive-compulsiveness and

generalized anxiety disorder — afflict 23 million American adults — more

than 11 percent of the population, according to the survey. That's more than

the number of people who have mood disorders such as chronic mild depression

(19.2 million adults) or those with alcohol- or drug-use disorders or both

(19.4 million).

Subjective diagnosis

Concerns persist, though, about where the line properly lies between a

personality trait and an illness. Mental disorders, including social phobia,

lack definitive diagnostic tests, leaving them vulnerable to subjective, and

controversial, calls.

" At what point does shyness become a disorder? " asked Dr. Wayne Katon,

director of the Division of Health Services and Psychiatric Epidemiology at

the University of Washington School of Medicine. Katon believes too few

people with social phobia get treatment. " It would be great in psychiatry if

we had a blood test that could tell us you have this disorder. "

Even among mental-health specialists, social phobia has long suffered from a

prejudice that it stretched the boundaries of normal human emotions into

clinical conditions, earning it the label a " neglected anxiety disorder " in

a 1985 edition of Archives of General Psychiatry.

, a clinical psychologist and director of the Anxiety Disorders

Program at St. Boniface General Hospital in Winnipeg, Canada, said that

diagnosing social phobia in patients who seek professional treatments isn't

too difficult. is co-author, along with Dr. Murray Stein, of a

self-help book called " Triumph Over Shyness: Conquering Shyness and Social

Anxiety. "

said people fall into a natural distribution curve between being

outgoing and bold and being shy and cautious. It's difficult to pinpoint

where on that bell curve social phobia lies, he said.

" Any cutoff point you make will automatically be arbitrary, " said ,

who also is a professor of clinical-health psychology at the University of

Manitoba.

" Clinically, people tend to ask for help when they're so shy that it's

causing distress and disability, " said.

In cases of true social phobia, the condition permeates virtually all

aspects of the patients' lives. They take night-shift jobs to minimize

contact with people, quit school early, have little contact with family

members and are more prone to suffer depression, smoking and drinking.

Children with the disorder are unable to enjoy normal activities, such as

having friends over or taking swimming lessons.

Angell, now a senior lecturer at Harvard Medical School, argues that

psychiatric diagnoses are so " vague and imprecise " that they have left the

door open for pharmaceutical companies to " make diseases for drugs. If they

can convince perfectly normal people that they have a problem, they can

expand the drug market almost indefinitely. "

Angell says physicians who accept free drug samples and who too quickly

dispense drugs that their patients see advertised are complicit in

overmedicating patients.

There's no question that pharmaceutical companies spend lavishly on

advertising. In 2003, they spent $1.71 billion to promote antidepressants

directly to doctors, including the retail cost of samples and ads in medical

journals, according to IMS.

Yet widespread consumer advertising isn't exactly turning everyone into

would-be pill poppers. A yet-unpublished Canadian study conducted by

found that given a choice, patients would choose talk therapy over

medication for anxiety problems by a 2-to-1 ratio.

The survey of 251 adults who were visiting a hospital for general medical

appointments also found that people rated psychotherapy more effective in

the long run and drugs more effective in the short run.

Causes and treatments

Researchers believe that social phobia has both biologic and environmental

causes. Experiments with infants as young as 3 months have shown that those

exhibiting timid, constrained behaviors are at higher risk of developing

anxiety disorders later in life. Social phobia also is more likely to occur

among people who have identical twins or parents with the disorder, which

could implicate both genes and family upbringing.

Two forms of treatment have proven effective for social phobia: medication

and talk therapy.

Drugs that raise the level of the mood-regulating neurotransmitter serotonin

in the brain can reduce anxiety. Paxil and Zoloft, antidepressants known as

selective serotonin reuptake inhibitors, are approved by the FDA for

treating social phobia. Effexor, which balances serotonin and another brain

chemical, norepinephrine, won FDA clearance for social phobia in 2003.

Beta-blockers, which typically are used for high blood pressure, have been

shown to work for a form of social anxiety disorder called performance

phobia among musicians, actors or others performing in public.

But drugs can cause side effects, some of them severe. In the October 2004

issue of Consumer Reports, 1,664 of the magazine's readers rate a half-dozen

antidepressants based on the one that helped them " a lot. "

The readers ranked Effexor, which is approved for both depression and social

phobia, as the most effective, but they also reported a high incidence of

side effects. For instance, more than half of the people who took Effexor

noticed a drop in sexual interest or performance and 21 percent reported

weight gain.

Among those who took Zoloft, 46 percent experienced such sexual side effects

and 17 percent reported weight gain.

Cognitive-behavior therapy is another effective treatment for muting the

effects of social phobia. This short-term talk therapy teaches patients to

alter both their actions and their thinking. Patients learn to correct

unrealistic thoughts (such as believing that others will view them as morons

if they speak in public). They also learn coping behaviors through exposure

therapy, which involves taking part in the feared activities and building

tolerance.

But some studies suggest that benefits of this sort of psychotherapy may be

limited. Patients who completed cognitive-behavior therapy for social

phobia, while significantly raising their scores on quality-of-life

questionnaires, still remained less satisfied than the general population

with their lives.

Katon, of the UW, said social phobics who do not receive proper treatment

risk social isolation that could lead to depression. In addition, some

patients may turn to a common social lubricant, alcohol, to blunt the

effects of social anxiety disorder.

Katon said alcohol can temporarily mute the symptoms of social phobia by

sedating the brain. But over time, as the drinker's nervous system gets

accustomed to the alcohol, it takes more and more of it to achieve the same

anxiety-reducing effect. What's more, the anxiety returns once the drinking

stops.

, of the University of Manitoba, said people tend to overestimate

their own shyness, with more than half the respondents in one survey rating

themselves shyer than others. But that needn't be sign of a problem.

" People often see anxiety as an abnormal thing when in fact it's normal, "

said. " Most of us are shy to some degree. "

Kyung Song: 206-464-2423 or ksong@...