Selective Serotonin Reuptake Inhibitors and Venlafaxine

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The efficacy of paroxetine, sertraline, and escitalopram was established in large controlled trials.60-63 SSRIs improve social anxiety and phobic avoidance and reduce overall disability. Approximately 50% of patients achieve response during acute treatment. Limited data suggest that both fluvoxamine and citalopram are effective in SAD. Fluoxetine is not effective.60,61

The initial dose of SSRI is similar to that used in depression. Patients should be titrated as tolerated to response. Many patients will require maximum recommended daily doses. Patients with comorbid PD should be started on lower doses (Table 40-6). When discontinuing SSRIs, the dose should be tapered slowly to avoid withdrawal symptoms. Relapse rates may be as high as 50%, and patients should be monitored closely for several weeks.60, 1 Side effects of SSRIs in SAD patients are similar to those seen in depression and most commonly include nausea, sexual dysfunction, somnolence, and sweating.

Gerveraliiert social arnoiely disorder r

Gerveraliiert social arnoiely disorder

Na response: Parlial response

SwiicH to anoliier SSRI.:"—. Consider augmeniali&n or vanfalaxine XR wüh Buspirone

Na response: Parlial response

SwiicH to anoliier SSRI.:"—. Consider augmeniali&n or vanfalaxine XR wüh Buspirone

i-nadequale response: Response:

5£Ri ± BZ Continue for 12 morHTis inadequate response:

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Consider gabapentin

- * ICfjntinue lor months

FIGURE 40-4. Algorithm for the pharmacotherapy of SAD. BZ, benzodiazepines; SSRI, selective serotonin reuptake inhibitor (Adapted from Kirkwood CK, Melton ST. Anxiety disorders: I. Generalized anxiety, panic and social anxiety disorders. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, et al., eds. Pharmacotherapy: A Pathophysiologic Approach, 7th ed. New York: McGraw-Hill, 2008:1163-1178.)

Venlafaxine extended release, in doses of 75 to 225 mg/day, improves social anxiety, performance, and avoidance behavior with a reduction in disability.64 Treatment with venlafaxine results in response rates similar to those seen with paroxetine.64 Venlafaxine may be effective in SSRI nonresponders.65 As with SSRIs, doses should be tapered slowly when discontinuing therapy. Tolerability is similar to that observed in depression trials with venlafaxine extended release. Common side effects are anorexia, dry mouth, nausea, insomnia, and sexual dysfunction.

MAOIs/Reversible Inhibitors of MAO-A

Phenelzine is effective in 64% to 69% of SAD patients.61 It is generally reserved for treatment-refractory patients owing to dietary restrictions,66 drug interactions, and side effects. The RIMAs brofaromine and meclobemide are effective in SAD. Neither is currently available in the United States, but they are available in Canada.

inadequate response:

Swilcii 1o phenelzine

Alternative Agents


Benzodiazepines are used commonly in SAD; however, there are limited data supporting their use. Clonazepam has been effective for social anxiety, fear, and phobic avoidance, and it reduced social and work disability during acute treatment.61 Long-term treatment is not desirable for many SAD patients owing to the risk of withdrawal and difficulty with discontinuation, cognitive side effects, and lack of effect on depressive symptoms. Benzodiazepines may be useful for acute relief of physiologic symptoms of anxiety when used concomitantly with antidepressants or psychotherapy. Benzodiazepines are contraindicated in SAD patients with alcohol or substance abuse or history of such.

Anticonvulsants (Gabapentin, Pregabalin)

Gabapentin, a nonbenzodiazapine GABA analog, was modestly effective in a 14-week controlled trial in SAD. Most patients were titrated to a maximal dose of 3,600 mg/ day.61 Pregabalin 600 mg/day was effective for social anxiety, fear, and avoidance behavior in a 10-week controlled trial.67 Pregabalin was well tolerated, and the most common side effects were somnolence and dizziness.


ß-Blockers decrease physiologic symptoms of anxiety and are useful for reducing performance anxiety. Propranolol or atenolol should be administered 1 hour before a performance situation. ^-Blockers are not useful in generalized SAD.61

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Free Yourself from Panic Attacks

Free Yourself from Panic Attacks

With all the stresses and strains of modern living, panic attacks are become a common problem for many people. Panic attacks occur when the pressure we are living under starts to creep up and overwhelm us. Often it's a result of running on the treadmill of life and forgetting to watch the signs and symptoms of the effects of excessive stress on our bodies. Thankfully panic attacks are very treatable. Often it is just a matter of learning to recognize the symptoms and learn simple but effective techniques that help you release yourself from the crippling effects a panic attack can bring.

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