Commentary

Social phobia is a situationally linked, intense, irrational, persistent fear of being scrutinised or negatively evaluated by others¹ and is associated with fear of humiliation or embarrassment.² Thus, socially demanding situations become disabling. Patients are cognitively aware of the irrationality of their fear. Prevalence rates are about 13% for lifetime³ and 7% at 1 year.^1–3. The presence of social phobia increases the risk for mental, drug, and alcohol comorbid illnesses.¹ If the condition remains untreated, it can become chronic and unremitting, leading to education and employment difficulties.^{1, 4}

Cognitive behaviour therapy with or without antidepressants is the most effective treatment.¹ However, properly administered therapy is not available, affordable, or obtainable for most people with social phobia. Current drug options are selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors, and benzodiazepines. Little evidence exists for the effectiveness of tricyclic antidepressants.¹

The study by Baldwin and colleagues and the current deluge of consumer education and marketing illuminate this hidden, underdiagnosed anxiety disorder. A crossover design would yield even more information and would perhaps address the effects after 12 weeks of treatment or after discontinuation. As is often the case, the sample was selected: patients had pure social phobia, no comorbid conditions, and no history of failed SSRI therapy for any illness. Excluding previous non-responders biases the results toward SSRI efficacy. This luxury does not exist in the office where initial treatment occurs. However, the overall results of this study support using paroxetine to treat social phobia initially; other data also support using other SSRIs and treatments.¹ The main message is the importance of recognising and diagnosing this under recognised, debilitating illness because of the tremendous implications for quality of life.