FOBIA SOCIAL

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FOBIA SOCIAL

Mensagem  WANDERLEY SOUZA em Sex Jun 26, 2015 4:19 pm

Making the diagnosis:
clinical diagnosis based on history of persistent and disabling anxiety or emotional distress in relation to social situations, including(1)
marked and persistent fear of situations in which patient is exposed to unfamiliar people or possible scrutiny, fear of doing something humiliating or embarrassing, or showing anxiety symptoms
anxiety almost always provoked by exposure to feared social situation
patient recognizes fear as excessive or unreasonable
phobic situation avoided or endured with intense anxiety or distress
avoidant behavior interferes with occupational functioning, social activities, or presence of marked distress about having fear
symptoms persist > 6 months if < 18 years old
fear not due to physiological effect of substance or another psychiatric disorder and is unrelated to comorbid medical conditions
Differential diagnosis:
nonpathological shyness and performance anxiety(1, 2)
several conditions may need to be ruled out as either principal diagnosis or comorbidity(1, 2)
generalized anxiety disorder
panic disorder
agoraphobia (fear of being in places or situations where escape might be difficult or embarrassing rather than fear of social situations)
specific phobia
major depression
autism spectrum disorders
bipolar disorder
body dysmorphic disorder
schizophrenia
schizoid personality disorder
avoidant personality disorder
school refusal and separation anxiety disorder
selective mutism
organic causes of medical conditions that might create discomfort in social situations(1, 2)
Parkinson disease
disfigurement
essential tremor
obesity
stuttering
Testing overview:
no specific testing necessary

Treatment overview:
for generalized social anxiety disorder, consider either psychosocial or pharmacological treatment
cognitive-behavioral therapies appear to be most effective psychosocial treatment for social anxiety disorder
both group and individual cognitive-behavioral therapy reported effective in treatment of generalized social anxiety disorder (level 3 [lacking direct] evidence)
individual cognitive-behavioral therapy may be more effective than group cognitive-behavioral therapy initially, but therapies yield similar results at 1-year follow-up (level 2 [mid-level] evidence)
cognitive-behavioral therapy (CBT) appears effective for inducing remission of mild-to-moderate childhood and adolescent anxiety disorders (level 2 [mid-level] evidence)
consider selective serotonin reuptake inhibitors (SSRIs) as first-line pharmacologic treatment
selective serotonin reuptake inhibitors appear to reduce symptoms of social anxiety disorder (level 2 [mid-level] evidence)
options include
sertraline (Zoloft) 50 mg/day, titrating to 50-200 mg/day
paroxetine (Paxil) 10 mg/day, titrating to 10-60 mg/day
paroxetine CR (Paxil CR) 12.5 mg/day, titrating to 12.5-75 mg/day
escitalopram (Lexapro) 5 mg/day, titrating to 5-20 mg/day
fluvoxamine (Luvox) 50 mg/day, titrating to 50-300 mg/day
inconsistent data for efficacy of fluoxetine in social anxiety disorder
other medications with evidence of efficacy
venlafaxine extended-release 75 mg/day, titrating to 75-375 mg/day appears effective in short term and comparable to paroxetine for generalized social anxiety disorder (level 2 [mid-level] evidence)
monoamine oxidase inhibitors (such as phenelzine [Nardil] 15 mg/day, titrating to 30-60 mg/day) appear to reduce symptoms of social anxiety disorder (level 2 [mid-level] evidence)
clonazepam 0.25 mg/day, titrating to 0.5-5 mg/day appears to reduce symptoms of generalized social anxiety disorder (level 2 [mid-level] evidence)
consider treatment with combination of CBT and medication
for performance-type social anxiety disorder, consider prescribing benzodiazepines for use as needed
alprazolam (Xanax) 0.25 mg as needed titrating to 0.25-1 mg as needed
lorazepam (Ativan) 0.5 mg as needed titrating to 0.5-2 mg as needed
Counseling:
Cognitive-behavioral therapy:
both group and individual cognitive-behavioral therapy reported effective in treatment of social anxiety disorder (level 3 [lacking direct] evidence)
based on systematic review without reporting of direct comparisons of treatment
systematic review of 108 treatment arms of psychological or pharmacological treatments for social anxiety disorder
meta-analysis combined and analyzed effect of group cognitive-behavioral therapy (CBT) in 17 arms, individual cognitive-behavioral therapy in 4 treatment arms, and exposure therapy in 7 treatment arms with 432 total patients completing treatment
significant improvement difference in pretest vs. posttest measures measured by both patient-reported or observer-rated outcomes for individual or group cognitive-behavioral therapy
no significant improvement difference from baseline with exposure therapy in either patient-reported or observer-rated outcomes
Reference - J Clin Psychopharmacol 2001 Jun;21(3):311
individual cognitive-behavioral therapy may be initially more effective than intensive group cognitive-behavioral therapy, but therapies appear to yield similar results at 1-year follow-up (level 2 [mid-level] evidence)
based on randomized trial with high dropout rate
100 patients with social anxiety disorder randomized to individual cognitive-behavioral therapy vs. intensive group cognitive-behavioral therapy vs. treatment as usual for 16 weeks
individual cognitive-behavioral therapy was delivered over 16 weekly sessions, intensive group cognitive-behavioral therapy was delivered in 16 group sessions over 3 weeks, and treatment as usual consisted of antidepressant prescription in 89% of patients and benzodiazepine in 11%
72 patients completed treatment and were included in intention-to-treat analysis at posttreatment, 4 months, 8 months, and 1 year
primary outcome was composite score derived from averaging scores from 5 standardized self-report social phobia scales: Liebowitz Social Anxiety Scale, Social Phobia Scale (SPS), Social Interaction Anxiety Scale, Fear Questionnaire Social Phobia subscale, and Fear of Negative Evaluation scale
clinically significant improvement defined as change in Social Phobia Composite scores ≥ 2 standard deviations below pretreatment mean score
comparing individual vs. intensive group cognitive-behavioral therapy vs. treatment as usual
patients achieving clinically significant improvement in composite score by 4 months
56% with individual cognitive-behavioral therapy (p < 0.025 vs. group therapy, NNT 4, and p < 0.01 vs. treatment as usual, NNT 4)
26% with intensive group cognitive-behavioral therapy
24% with treatment as usual
patients no longer meeting diagnosis of social anxiety disorder at 12 months
75% with individual cognitive-behavioral therapy (not significant compared to group therapy, but p < 0.05 compared to treatment as usual, NNT 4)
66% with intensive group cognitive-behavioral therapy
48% in treatment as usual group
Reference - Acta Psychiatr Scand 2007 Feb;115(2):142 Translation:TranslateMessage('fulltext', $languageID)Texto completo do EBSCOhost
similar results at 5-year follow-up
based on follow-up study

WANDERLEY SOUZA

Mensagens : 4
Data de inscrição : 14/03/2015

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