© 2000 WILEY-LISS, INC.

DEPRESSION AND ANXIETY 11:93–98 (2000)DA 00482

SOCIAL ANXIETY DISORDER UNDER SCRUTINY

Jonathan R.T. Davidson, M.D.*

Social anxiety disorder (social phobia) is a chronic disabling condition. As withmany psychiatric disorders, the condition is likely to have several causes, in-cluding genetic and familial factors, early experiences, and cognitive mecha-nisms. This review will briefly examine the etiology of social anxiety disorder.The approach required during diagnosis of the condition will also be addressed,in particular, the differentiation between social anxiety disorder and otheranxiety disorders with similar presentation. The main focus of this article is toreview available treatment options for social anxiety disorder, both psychosocialand pharmacotherapeutic. A number of management strategies have shownpromise for the treatment of the condition. The International ConsensusGroup on Depression and Anxiety recently recommended that a selective sero-tonin reuptake inhibitor (SSRI) should be considered as first-line pharmaco-therapy. To date, however, paroxetine is the only SSRI that is licensed for thetreatment of social anxiety disorder. Depression and Anxiety 11:93–98,2000. © 2000 Wiley-Liss, Inc.

Key words: selective serotonin reuptake inhibitor; paroxetine; monoamineoxidase inhibitor; benzodiazepine; social anxiety disorder

INTRODUCTIONSocial anxiety disorder (social phobia) is a chronic,disabling condition that has been reported to affect upto 13% of the population at some point during theirlives [Davidson et al., 1993; Lépine and Lellouch,1995; Magee et al., 1996]. This review will begin withan introduction to the etiology and diagnosis of socialanxiety disorder. The main focus of the review is a dis-cussion of treatment options. These topics were thesubject of discussions by the International ConsensusGroup on Depression and Anxiety, of which I was amember. The paper will conclude with our recom-mendations for the pharmacological management ofsocial anxiety disorder. We suggest that a selective se-rotonin reuptake inhibitor (SSRI) should be used asfirst-line therapy for this condition. To date, however,paroxetine is the only SSRI that is indicated for socialanxiety disorder, although others are effective.

ETIOLOGY OF SOCIALANXIETY DISORDER

As with many psychiatric disorders, social anxietydisorder is most likely to have several causes. Possiblecontributing factors include behavioral inhibition, cul-tural considerations, response to trauma, and underly-ing neurobiological mechanisms. This article willfocus on the role of genetic and familial factors, andearly experiences, particularly the influences of par-ents, and cognitive mechanisms.

GENETIC AND FAMILIAL FACTORSFour major studies have examined the genetic contri-

bution to social anxiety disorder: a large study con-ducted in more than 2,000 female twins from thepopulation-based Virginia State Twin Registry [Kendleret al., 1992], and three family risk studies in whichprobands with social anxiety disorder and controlgroups of healthy volunteers were interviewed, alongwith their first-degree relatives [Fyer et al., 1993;Mannuzza et al., 1995; Stein et al., 1998a].

The twin study found that the rate, or concordance,of social anxiety disorder was approximately 10%greater in genetically identical (monozygotic) than innonidentical (dizygotic) twins [Kendler et al., 1992].

The family studies demonstrated a significant eleva-

Department of Psychiatry and Behavioral Science, DukeUniversity Medical Center, Durham, North Carolina

Presented at a satellite symposium to the XXIst CINP Congress,Glasgow, United Kingdom, 13 July 1998.

Contract grant sponsor: SmithKline Beecham Pharmaceuticals.

*Correspondence to: Jonathan R.T. Davidson, M.D., Departmentof Psychiatry and Behavioral Science, Duke University MedicalCenter, Durham, NC 27710.

Received for publication 26 November 1999; Accepted 7 Decem-ber 1999

94 Davidson

tion of risk of social anxiety disorder in probands’relatives [Fyer et al., 1993; Mannuzza et al., 1995;Stein et al., 1998a]. Fyer et al. [1993] reported a 16%rate of social anxiety disorder in relatives of probandsand a 5% rate in the corresponding control group. Alater study by Mannuzza et al. [1995], which lookedonly at generalized social anxiety disorder, found asimilar increased predisposition to the disorder inrelatives of probands with this subtype of the condi-tion. Relatives of patients with the nongeneralizedsubtype of social anxiety disorder were no more likelyto have the disorder than relatives of the control sub-jects. Similarly, Stein et al. [1998] found that first-de-gree relatives of individuals with generalized socialanxiety disorder had an approximately 10-fold higherrisk of developing the condition themselves comparedwith relatives of comparison probands. In contrast, therisk of developing nongeneralized social anxiety disor-der was not significantly different between the twogroups of relatives.

EARLY EXPERIENCES AND PARENTINGAs a child is growing up, many factors may contrib-

ute to the development of social anxiety disorder. Thefamily environment can affect the likelihood of devel-oping the condition, particularly if there is already agenetic diathesis. Anxious predisposition in the par-ents and overprotective or anxiety-inducing parentalbehavior, which could restrict a child’s social engage-ment, can increase the risk of social anxiety disorder ina child [Beidel and Turner, 1998]. Furthermore, achild can acquire fear and anxiety by simply watchingand listening to their parents, a factor which shouldnot be underestimated.

COGNITIVE CHARACTERISTICSTaylor and Arnow [1991] summarized a variety of

cognitive characteristics, or particular ways in whichindividuals may think about themselves relative toother people, that can predispose them to the develop-ment of social anxiety disorder. These include overesti-mating the likelihood of scrutiny; overestimating thepossibility of being rejected, embarrassed or humili-ated; misrepresenting the way other people perceivethem, or their responses to individuals’ gestures andbehaviors; over-responsiveness to rejection, whetherreal or perceived; and the tendency to discount per-sonal achievements and overemphasize failures. Thelatter characteristic is shared by individuals prone todepression.

DIAGNOSIS OF SOCIALANXIETY DISORDER

If a clinician suspects that individuals may be suffer-ing with social anxiety disorder, a few key questionscan be asked (to give an initial confirmation of the di-

agnosis). These include: are you afraid of speaking, ei-ther to large groups or just talking socially in smallgroups?; do you avoid social events?; do you fear beingwatched closely when you are doing something?; andare you afraid of embarrassment? This procedure onlytake a few minutes to complete. If the answer to any ofthe questions is “yes,” it is important to ask individualsif they are bothered by these fears and whether theyconsider the fears to be excessive.

Social anxiety disorder is most often diagnosed us-ing the DSM-IV [Diagnostic and Statistical Manualof Mental Disorders, 1994], or ICD-10 [Tenth Inter-national Classification of Diseases, 1992] diagnosticcriteria. However, a recently developed self-ratedscale, the Social Phobia Inventory (SPIN), can alsobe used. The SPIN allows patients to be screenedrapidly for the condition. It is essentially a ratingscale that assesses the fear, avoidance, and physi-ological symptoms of social anxiety through 17 ques-tions [Connor et al., 2000]. It is easy to complete andquick to administer. Validation studies have shownthe SPIN to be a robust and reliable screening toolfor social anxiety disorder.

DIFFERENTIAL DIAGNOSIS

The diagnosis of social anxiety disorder is compli-cated. Its presentation can be mistaken for severalother psychiatric conditions, in particular, panic disor-der, agoraphobia and depression. To differentiate be-tween these conditions, careful questioning is requiredduring the psychiatric interview, specifically concern-ing the situational fears of the individual.

Panic disorder. Patients with social anxiety disor-der can experience panic attacks. These attacks areconditional upon a situation where the person feelsvulnerable to scrutiny and embarrassment. In contrast,individuals with panic disorder experience panic at-tacks, either spontaneously or in relation to situationswhere the individual is afraid of having a panic attack,or afraid of not being able to make an escape. Specificquestions about an individual’s fears will reveal thetrue diagnosis. The symptom of blushing is also a use-ful differentiating feature between individuals with so-cial anxiety disorder and panic disorder.

Agoraphobia. Individuals presenting with panic at-tacks as result of social anxiety disorder may also bemisdiagnosed as having agoraphobia with panic at-tacks. The disorders can be distinguished on the basisof the type of situational fear. Individuals with agora-phobia fear being trapped in a situation, while in so-cial anxiety disorder, the fear is of being caught in asituation where they may embarrass themselves.

Depression. Depression can also resemble socialanxiety disorder. Depressed patients will often lose theirself confidence and this can lead to avoidant behavior.However, unlike social anxiety disorder, the issue is notone of embarrassment. A psychiatric interview will re-veal that this behavior is dependent upon depression.

Theoretical Paper: Social Anxiety Disorder Under Scrutiny 95

TREATMENT OPTIONS INSOCIAL ANXIETY DISORDER

PSYCHOSOCIALThe two main methods of treatment for social anxi-

ety disorder in the psychosocial area are cognitive be-havioral therapy, an exposure-based form of treatmentwhich is often administered in a group setting (cogni-tive behavioral group therapy; CBGT), and social ef-fectiveness training, which makes more use of socialskills. The effect of combining these two treatmentapproaches is currently being investigated.

Cognitive behavioral therapy. Studies are under-way to evaluate cognitive behavioral therapy in com-parison with established pharmacotherapies for socialanxiety disorder. The findings of a study by Heimberget al. [1999] in which they compare the efficacy ofCBGT, the monoamine oxidase inhibitor (MAOI)phenelzine, placebo medication, and a psychotherapyplacebo (essentially just support and education), showthe effects of CBGT to be similar to phenelzine after12 weeks’ treatment.

Social effectiveness training. A key component ofsocial effectiveness training is social skills training. Thisis a relatively new approach developed by Dr. EdnaFoa’s group. To date, it is less well studied than CBGT.However, a similar form of treatment has been demon-strated to be more effective than placebo medication orthe beta-blocker, atenolol [Turner et al., 1994].

PHARMACOTHERAPYSeveral well-known drug classes have been investi-

gated in double-blind treatment studies during thesearch for an effective, well-tolerated treatment for so-cial anxiety disorder. These include the MAOIs, benzo-diazepines, and SSRIs. In addition to assessing theresponse rate to pharmacotherapy, it is important toconsider which aspects of the condition respond.Among the major reasons that drive sufferers of socialanxiety disorder to seek treatment are the physiologicalsymptoms of excessive blushing, trembling, and sweat-ing; during a study conducted by van Vliet et al. [1994],patients were found to be most anxious about trembling.The SPIN is a particularly useful rating scale in this re-spect because it can be used to assess physiologicalsymptoms, in addition to those of fear and avoidance.

Monoamine oxidase inhibitors. Three clinicalstudies, two conducted in the United States and one inBrazil, have shown a positive effect for phenelzine insocial anxiety disorder with response rates in the range65–75%, far in excess of the results obtained with pla-cebo (Table 1) [Gelernter et al., 1991; Liebowitz et al.,1992; Versiani et al., 1992].

Phenelzine is an irreversible MAOI which is notrecommended as first-line treatment for social anxietydisorder because of its well-characterized side effectsand necessary dietary restrictions. In contrast, the re-versible MAOIs, two of which (brofaromine and

moclobemide) have been studied (Table 1), lack thecomplications and side effects associated with phenel-zine. Brofaromine, however, is no longer available.Furthermore, despite being licensed for use in socialanxiety disorder in a small number of countries, recentstudies with moclobemide have shown disappointingresponse rates compared with placebo [Noyes et al.,1997; Schneier et al., 1998].

Benzodiazepines/anticonvulsants. There have beentwo major studies with the benzodiazepines in social anxi-ety disorder. The first, by Gelernter et al. [1991], com-pared alprazolam with phenelzine, CBGT and placebo in65 patients over a 12-week period. Only a modest re-sponse was seen for alprazolam: 38% of patients re-sponded to treatment compared with 64% of patients onphenelzine, 24% of patients on CBGT and 20% of pa-tients on placebo. The second study was conducted atDuke University Medical Center with clonazepam andplacebo. Seventy-five outpatients with social anxiety disor-der were investigated over 10 weeks. Response rates were78.3% and 20.0%, respectively [Davidson et al., 1993].Fear of negative evaluation, one of the core features of so-cial anxiety disorder, also responded well to treatmentwith clonazepam during this study; clonazepam was sig-nificantly more effective than placebo in reducing themean score on the Fear of Negative Evaluations Scale.This result is important because it indicates that thoughtpatterns can respond to pharmacotherapy as well as tocognitive and exposure methods.

In terms of pharmacology, alprazolam and clona-zepam are largely similar. However, since one treatmentstudy showed equivocal efficacy of alprazolam, there maynot be a class effect for the benzodiazepines in socialanxiety disorder. A recent study by Pande et al. [1999]found gabapentin to be effective in social phobia.

Selective serotonin reuptake inhibitors. As aclass, the SSRIs are well tolerated and are not associ-ated with the limiting side effects seen with the irre-versible MAOIs. Several SSRIs have been studied indouble-blind trials in social anxiety disorder, but thebest published evidence comes from large placebo-controlled studies with paroxetine. Paroxetine hasdemonstrated significant improvements in symptoms,overall well-being and disability in social anxiety dis-order and is now licensed for this indication.

Significantly more patients responded to treatmentwith paroxetine than placebo during two placebo-con-trolled, 12-week studies [Stein et al., 1998b; Baldwinet al., 1999] (Table 2). In all, 477 patients with socialanxiety disorder were included in the two studies, oneof which was based in the U.S.A. [Stein et al., 1998b]and the other in Europe and South Africa [Baldwin etal., 1999]. During the U.S.A. study, conducted in 187sufferers, 55% of patients on paroxetine responded totreatment, compared with 24% of patients on placebo[Stein et al., 1998b]. A similar response rate was seenin 290 patients during the European / South Africanstudy: 66% of patients on paroxetine responded totreatment compared with 32% of patients on placebo.

96 Davidson

A significant response to paroxetine was also demon-strated during a placebo-controlled dose-rangingstudy conducted in 384 patients with social anxietydisorder. Significant improvements in the anxiety andavoidance symptoms of the condition and the associ-ated disability were seen during all three studies, asmeasured by the Liebowitz Social Anxiety Scale Fear/Anxiety and Avoidance subscales and the Sheehan Dis-ability Scale, respectively.

Fluvoxamine and sertraline have also been found tobe effective in social anxiety disorder. Fluvoxamine hasdemonstrated efficacy in two placebo-controlled stud-ies [van Vliet et al., 1994; Stein et al., 1999] (Table 2).The most recent and larger of these studies was con-ducted in a population of over 90 patients with socialanxiety disorder. Fluvoxamine produced a significantlybetter effect than placebo, and 43% of patients re-sponded to treatment, compared with 22% of patientstaking placebo. Fluvoxamine was also significantlymore effective on the physiological symptoms of socialanxiety disorder and the symptoms of fear and avoid-ance, as assessed using the Brief Social Phobia Scale.

During a placebo-controlled cross-over study usingsertraline, conducted in 12 patients, approximately halfof the sufferers responded to treatment with sertraline,compared with only one patient on placebo [Katzelnicket al., 1995]. The size of this study limits the usefulnessof this result, and further controlled studies are requiredto define the role of sertraline in social anxiety disorder.

PREVENTING RELAPSE BYMAINTENANCE THERAPY

After identifying an effective treatment for socialanxiety disorder, it is important to consider how long tocontinue therapy, and the likelihood of an individual re-lapsing if treatment is discontinued. To date, there havebeen four studies addressing the issue of preventing re-lapse by maintenance therapy. These have investigatedthe use of brofaromine [Fahlen et al., 1995], clonazepam[Connor et al., 1998], moclobemide [Versiani et al.,1996], and paroxetine [Stein et al., 1996].

Thirty-two patients who responded to treatment witheither brofaromine or placebo during a 12-week, double-blind study continued on their treatments openly for

TABLE 1. Clinical studies with irreversible and reversible monoamine oxidase inhibitors in social anxiety disorder

Patients Duration Response(n) (weeks) Definition of response Treatment (%)

PhenelzineVersiani et al. [1992] 78 16 Score 2 on CGI Global Improvement item and Phenelzine 91

> 70% on the Social Phobia Scale Moclobemide 82Placebo 43

Liebowitz et al. [1992] 74 8 Score 2 on CGI Global Improvement item Phenelzine 64Atenolol 30Placebo 26

Gelernter et al. [1991] 65 12 Score >8.8 on Social Phobia Subscale of the Phenelzine 69Fear Questionnaire CBGTa 24

Alprazolam 38Placebo 20

BrofaromineLott et al. [1997] 102 10 Not measures Brofaromine Not

Placebo measuredFahlen et al. [1995] 77 Score 2 on CGI Global Improvment item Brofaromine 78

Placebo 23van Vliet et al. [1992] 30 12 Score 10 on Hamilton Anxiety Scale at week 12 Brofaromine 73

Placebo 0Moclobemide

Schneier et al. [1998] 77 8 Score 2 on CGI Global Improvement item Moclobemide 17.5Placebo 13.5

Noyes et al. [1997] 506 12 Score 2 on CGI Global Improvement item Moclobemide75 mg 33

150 mg 38300 mg 36600 mg 32900 mg 35

Placebo 33Burrows et al. [1997] 578 12 Score 2 o CGI Global Improvement item Moclobemide

300 mg 41600 mg 47

Placebo 34aCBGT, cognitive behavioral group therapy; CGI, clinical global impressions.

Theoretical Paper: Social Anxiety Disorder Under Scrutiny 97

9 months [Fahlen et al., 1995]. Of the 22 patients receiv-ing brofaromine, none relapsed, whereas 60% of the 10patients continuing on placebo treatment did so.

A high relapse rate after discontinuation from treat-ment with a reversible MAOI was also reported byVersiani et al. [1996]. When moclobemide was abruptlywithdrawn after 2 years of treatment, 88% of 101 pa-tients relapsed within 1–3 months.

A lower relapse rate was found during a recentstudy in which clonazepam treatment was graduallywithdrawn (i.e., a slow taper of medication) from 38patients with social anxiety disorder who were main-tained on the treatment [Connor et al., 1998]. Patientshad been receiving open treatment with clonazepamfor 6 months and were assigned to either continuetaking the medication for another 5 months, or to un-dergo treatment withdrawal (a taper of 0.25 mg every2 weeks with double-blind placebo substitution).Twenty-one percent of patients undergoing discon-tinuation relapsed. None of the patients continuingwith clonazepam relapsed. These results suggest that aslow taper of medication can produce good results(i.e., a lower relapse rate than obtained followingabrupt discontinuation) after short-term treatment.

After an 11-week open study with the SSRI par-oxetine, 16 patients with social anxiety disorder who hadresponded to treatment were randomized to a further12 weeks’ treatment with paroxetine or placebo [Stein etal., 1996]. The study showed further evidence of the dis-advantages of abruptly withdrawing medication for socialanxiety disorder: of the patients transferred to placebo,63% relapsed, while of those who remained on paroxe-tine, 13% relapsed during the course of the study.

Taken together, the results of these studies suggestthat social anxiety disorder is essentially a chronic, un-remitting condition. Drug therapy needs to be contin-ued for at least 12 months, particularly in individualswith generalized social anxiety disorder, and longertreatment may be necessary depending on the severityof continuing symptoms and whether or not the pa-tient makes a complete remission.

Longer periods of therapy may also be necessary forindividuals with comorbid psychiatric conditions, de-

pression in particular. Also, patients in whom socialanxiety disorder presented at an early age may requiremore than 12 months’ treatment. Patients who have amarked avoidant personality, or those who also sufferwith avoidant personality disorder may need long-termmanagement, and individuals with a history of severerelapses would also be candidates for extended therapy.

CONSENSUSRECOMMENDATIONS FOR THE

TREATMENT OF SOCIALANXIETY DISORDER

The International Consensus Group on Depressionand Anxiety issued recommendations for the pharma-cological management of social anxiety disorder [Ball-enger et al., 1998]. We recommended that an SSRIshould be considered as the first choice of pharmaco-therapy. This was a considered approach based on theavailable efficacy and safety data for managementstrategies in social anxiety disorder. Much of the posi-tive evidence for SSRIs comes from clinical data ob-tained with paroxetine, which is to date the only SSRIindicated in social anxiety disorder.

We advised that the initial dose of SSRI should becontinued for 2–4 weeks and then increased as neces-sary, and if tolerated. For example, an initial dose ofparoxetine 20 mg/day for 2–4 weeks has been proposedwith increases in dosage, as necessary, to produce a re-sponse. Most of the data published to date indicate thatan SSRI is likely to produce evidence of improvementwithin 2–3 weeks. In the event of no treatment re-sponse after approximately 8 weeks then, assuming thedose was adequate, a switch to a different type of drug,or augmentation with a second drug, was suggested.

Considering the chronic course of social anxiety dis-order, we also recommended that patients should re-main on their medication for at least 12 months. Longertreatment may be required if symptoms are unresolved,if the patient has a comorbid condition or a history ofrelapse, or if there was an early onset of the disorder.

TABLE 2. Placebo-controlled, randomized, double-blind treatment studies with the selective serotonin reuptakeinhibitor (SSRIs) in social anxiety disorder

SSRI PlaceboDaily dose Duration response response

n (mg) (weeks) (%) (%) Reference

Paroxetine 187 20–50 12 55a 24 Stein et al. [1998b]290 20–50 12 66a 32 Bladwin et al. [1999]384 20, 40, or 60 12 45a 28 SmithKlilne Beecham, (unpublished)99 20–50 12 70 8 Allgulander, [1999]

Sertraline 12 50–200 20 50b 9 Katzelnick et al. [1995]Fluvoxamine 30 150 12 46c 7 van Vliet et al. [1994]

92 50–300 12 43 22 Stein et al. [1999]aResponse defined as Clinical Global Impression global improvement rating of very much or much improved, unless otherwise indicated.bResponse defined as Liebowitz Social Phobic Disorders Rating of moderately or markedly improved.cResponse defined as reduction in LSAS fear/anxiety subscale score by ³50%

98 Davidson

CONCLUSIONSocial anxiety disorder is a chronic disorder which,

if left untreated, is unremitting. Controlled treatmentstudies have documented a beneficial effect of the irre-versible MAOI phenelzine and to a lesser extent thereversible MAOIs, brofaromine and moclobemide.The benzodiazepine clonazepam, and the SSRIs par-oxetine, fluvoxamine, and sertraline have also beenshown to have positive treatment effect, as has the an-ticonvulsant drug gabapentin [Pande et al., 1999].Based on the results of these treatment studies and clini-cal experience, the Consensus Group on Depression andAnxiety recommend that SSRIs are used as first-linetreatment for patients with social anxiety disorder.

Acknowledgments. “Face to Face with SocialAnxiety Disorder” was supported by an educationalgrant from SmithKline Beecham Pharmaceuticals.

REFERENCESAllgulander C. 1999. Paroxetine in social anxiety disorder: a random-

ized placebo-controlled study. Acta Psychiatr Scand 100:193–198.Baldwin D, Bobes J, Stein DJ, Scharwächter I, Faure M, on behalf of

the Paroxetine Study Group. 1999. A randomised, double-blind,placebo-controlled study of paroxetine in the treatment of socialphobia/social anxiety disorder. Br J Psychiatry 178:120–126.

Ballenger JC, Davidson JRT, Lecrubier Y, Nutt DJ, Bobes J, BeidelDC, Ono Y, Westenberg HG. 1998. Consensus statement on socialanxiety disorder from the International Consensus Group on De-pression and Anxiety. Int Clin Psychopharmacol 59 (suppl):54–60.

Beidel DC, Turner SM, editors. 1998. Shy children and phobicadults: the nature and treatment of social phobia. WashingtonDC: American Psychological Association. p 45–47.

Burrows G, Evans L, Baumhackl U. 1997. Moclobemide in socialphobia. A double-blind, placebo-controlled clinical study. EurArch Psychiatry Clin Neurosci 247:71–80.

Connor KM, Davidson JRT, Potts NL, Tupler LA, Miner CM,Malik ML, Book SW, Colket JT, Ferrell F. 1995. Discontinua-tion of clonazepam in the treatment of social phobia. J ClinPsychopharmacol 18:373–378.

Connor KM, Davidson JRT, Churchill LE, Sherwood A, Foa EB,Weisler RH. Psychometric properties of the social phobia inven-tory (SPIN): a new self-rating scale. Br J Psychiatry (in press).

Davidson JRT, Hughes DL, George LK, Blazer DG. 1993. The epi-demiology of social phobia. Findings from the Duke Epidemio-logic Catchment Area Study. Psychology Medicine 23: 709–718.

Diagnostic and Statistical Manual of Mental Disorders, Fourth edi-tion. 1994. Washington DC: American Psychiatric Association.

Fahlen T, Nilsson HL, Borg K, Humble M, Pauli U. 1995. Socialphobia: the clinical efficacy and tolerability of the monoamine oxi-dase-A and serotonin uptake inhibitor brofaromine. A double-blind placebo-controlled study. Acta Psychiatr Scand 92:351–358.

Fyer AJ, Mannuzza S, Chapman TF, Liebowitz MR, Klein DF. 1993.A direct interview family study of social phobia. Arch Gen Psy-chiatry 50:286–293.

Gelernter CS, Uhde TW, Cimbolic O, Arnoff DB, Vittone BJ,Tancer ME, Bartko JJ. 1991. Cognitive-behavioural and pharma-cological treatments of social phobia. A controlled study. ArchGen Psychiatry 48:938–945.

Heimberg RG, Liebowitz MR, Hope DA, Schneier FR, Holt CS,Welkowitz LA, Juster HR, Campeas R, Bruch MA, Cloitre M,Fallon B, Klein DF. 1998. Cognitive behavioral group therapy vsphenelzine therapy for social phobia: 12-week outcome. Arch GenPsychiatry 55:1133–1141.

Katzelnick DJ, Kobak KA, Greist JH, Jefferson JW, Mantle JM,Serlin RC. 1995. Sertraline for social phobia. A double-blind, pla-cebo-controlled crossover study. Am J Psychiatry 152:1368–1371.

Kendler KS, Neale MC, Kessler RC, Heath AC, Eaves LJ. 1992.The genetic epidemiology of phobias in women. The interrela-tionship of agoraphobia, social phobia, situational phobia, andsimple phobia. Arch Gen Psychiatry 49: 273–281.

Lépine J-P, Lellouch J. 1995. Classification and epidemiology of so-cial phobia. Eur Arch Psychiatry Clin Neurosci 244:290–296.

Liebowitz MR, Schneier F, Campeas R et al. 1992. Phenelzine versusatenolol in social phobia. A placebo-controlled comparison. ArchGen Psychiatry 49:290–300.

Lott M, Greist JH, Jefferson JW, Kobak KA, Katzelnick DJ, KatzRJ, Schaettle SC. 1997. Brofaromine for social phobia: a multi-center, placebo-controlled, double-blind study. J Clin Psychophar-macol 17:255–260.

Magee WJ, Eaton WW, Wittchen H-U, McGonagle KA, KesslerRC. 1996. Agoraphobia, simple phobia, and social phobia in theNational Comorbidity Survey. Arch Gen Psychiatry 53:159–168.

Mannuzza S, Schneier FR, Chapman TF, Liebowitz MR, Klein DF,Fyer AJ. 1995. Generalized social phobia. Arch Gen Psychiatry52:230–237.

Noyes R, Moroz G, Davidson JRT, Liebowitz MR, Davidson A, SiegelJ, Bell J, Cain JW, Curlik SM, Kent TA, Lydiard RB, Mallinger AG,Pollack MH, Rapaport M, Rasmussen SA, Hedges D, Schweizer E,Uhlenhuth EH. 1997. Moclobemide in social phobia: a controlleddose-response trial. J Clin Psychopharmacol 17:247–254.

Pande AC, Davidson JR, Jefferson W, Janney CA, Katzelnick DJ,Weisler RH, Greist JH, Sutherland SM. 1999. Treatment of socialphobia with gabapentin: a placebo-controlled study. J Clin Psycho-pharmacol 19:341–348.

Schneier FR, Goetz D, Campeas R, Fallon B, Marshall R, LiebowitzMR. 1998. Placebo-controlled trial of moclobemide in social pho-bia. Br J Psychiatry 172:70–77.

Stein MB, Chartier MJ, Hazen AL, Kroft CD, Chale RA, Cote D,Walker JR. 1996. Paroxetine in the treatment of generalized socialphobia: open-label treatment and double-blind placebo-controlleddiscontinuation. J Clin Psychopharmacol 16:218–222.

Stein MB, Chartier MJ, Hazen AL, Kozak MV, Tancer ME, LanderS, Furer P, Chubaty D, Walker JR. 1998a. A direct-interview fam-ily study of generalized social phobia. Am J Psychiatry 155:90–97

Stein MB, Liebowitz MR, Lydiard RB, Pitts CD, Bushnell W,Gergel I 1998b. Paroxetine treatment of generalised social phobia.A randomised, double-blind, placebo-controlled study. JAMA280:708–713.

Stein MB, Fyer AJ, Davidson JRT, Pollack MH. 1999. Fluvoxaminetreatment of social phobia: a double-blind placebo-controlledstudy. Am J Psychiatry 156:756–760.

Tenth International Classification of Diseases, Classification ofMental and Behavioural Disorders. 1992. Geneva:World HealthOrganization.

Turner SM, Beidel DC, Joerb RG. 1994. Social phobia: a compari-son of behaviour therapy and atenolol. J Consult Clin Psychol67:350–358.

van Vliet IM, den Boer JA, Westenberg HG. 1992. Psychopharma-cological treatment of social phobia: clinical and biochemicaleffects of brofaromine, a selective MAO-A inhibitor. Eur Neuro-psychopharmacol 2:21–29.

van Vliet IM, den Boer JA, Westenberg HGM. 1994. Psychopharmaco-logical treatment of social phobia; a double blind placebo controlledstudy with fluvoxamine. Psychopharmacology 115:128–134.

Versiani M, Nardi AE, Mundim FD, Alves AB, Liebowitz MR,Amrein R. 1992. Pharmacotherapy of social phobia. A controlledstudy with moclobemide and phenelzine. Br J Psychiatry 161:353–360.

Versiani M, Nardi AE, Mundim FD, Pinto S, Saboya E, Kovacs R.1996. The long-term treatment of social phobia with moclobe-mide. Int Clin Psychopharmacol 11 (suppl 3):83–88.