Medication therapy for social phobia.

Social phobia, though the third most common psychiatric disorder in the United States, has received little systematic attention until recently. Chronic and disabling symptoms usually precede other disorders in individuals with comorbidity, including alcohol abuse. Though about 80% of individuals do not seek treatment, controlled trials have demonstrated efficacy for several medications, of which phenelzine (an irreversible monoamine oxidase inhibitor [MAOI]) is the best studied. The benzodiazepines, clonazepam and alprazolam, also hold promise. New reversible MAOIs such as moclobemide and brofaromine are under investigation; fluoxetine and other serotonin selective reuptake inhibitors need further controlled study. The benefits of group cognitive-behavioral therapy also appear substantial. Issues for future investigation include long-term outcome, differential therapeutics, diagnostic subtyping, and combination treatments.

Alpidem in the treatment of panic disorder.

Alpidem, an imidazopyridine that acts at the gamma-aminobutyric acid/benzodiazepine receptor complex, has been reported to be an effective anxiolytic with a more favorable side effect profile than benzodiazepines. The effect of alpidem was investigated in an 8-week, open, clinical trial in 13 patients with panic disorder, with or without agoraphobia. Three patients were responders (much improved or very much improved), five patients were nonresponders, and five patients dropped out after less than 6 weeks of treatment. Significant improvement was seen in the sample as a whole for spontaneous panic attacks, phobic avoidance, and anticipatory anxiety. Most improvement occurred during the first 4 weeks of treatment, and responders had milder panic disorder at baseline. Adverse effects were generally mild. After 8 weeks of treatment, taper of medication over 2 weeks occurred without significant worsening of panic disorder symptoms. The efficacy of alpidem in the treatment of panic disorder remains uncertain and requires assessment in a controlled trial.

Reversible monoamine oxidase-A inhibitors in social phobia.

Placebo-controlled studies of standard and reversible monoamine oxidase-A (MAO-A) inhibitors in social phobia are reviewed. Four studies utilized several common measures, including the Liebowitz Social Anxiety Scale and the Hamilton Anxiety Scale. Efficacy for phenelzine, moclobemide, and brofaromine appeared comparable across studies on both categorical and dimensional measures, as did placebo results. In terms of patient characteristics, baseline social phobia ratings were similar across studies, but initial Hamilton Anxiety Scale scores differed. Although the reason for this is uncertain, it is more likely due to rater differences than to patient differences.

Open trial of intravenous clomipramine in five treatment-refractory patients with obsessive-compulsive disorder.

In a preliminary trial, five oral-clomipramine-refractory patients with obsessive-compulsive disorder (OCD) were treated openly with 14 intravenous clomipramine infusions each. Using standardized assessments, three patients were rated as much improved, one as unchanged, and one as minimally improved. Statistically significant improvements were noted on both the Yale-Brown Obsessive Compulsive Scale and the NIMH Global OCD scores. No patient discontinued treatment because of side effects. Although the results are provocative in that three of five patients were much improved at the end of the protocol, conclusions about preferential efficacy for the intravenous route must await a placebo-controlled trial.

Treatment of social phobia with drugs other than benzodiazepines.

Social phobia is emerging as an important cause of psychiatric morbidity. Reasons for this are described, as are clinical issues of importance to social phobia, including the extensive associated distress and disability. The use of phenelzine, atenolol, buspirone, fluoxetine, and moclobemide are described. Diagnostic and transcultural aspects of social phobia are described.