• 40-50% of people with SAD also have depression
• SAD is the most common anxiety disorder
• 13% of the population will have SAD in their lifetime
• 50% of those with SAD do not finish high school
• 22.3% of those with SAD are on welfare
• 50% of those with SAD are single, divorced, or separated
• Onset of SAD is usually age 14-16
• 50% of those with SAD also have another psychiatric disorder, especially
alcohol abuse
• 35% of SAD occurs before age 10
• Behavior treatment with medication is the most effective treatment for SAD
• 25% of patients with SAD decline when offered behavioral treatment
• Only 5% with SAD get treatment

Cognitive behavioral therapy has proven to be very effective in treating social anxiety disorder.
Behavioral therapy focuses on specific steps to lessen anxiety and reduce the likelihood of recurrence. The patient is asked to face the thing they fear (exposure), and not avoid to cope with the situation.

Patients must be willing to endure temporary increases in anxiety and other symptoms in order to attain long term reduction of symptoms. The therapy is time consuming. Hard work is required by the patient to insure symptomatic relief.
The cognitive part of therapy involves replacing negative thoughts (self-talk) with positive. e.g., Instead of, “they will think I’m stupid”, replace it with “I know I’m smart.” Optimists see things better than they are. Pessimists see things worse than they are. Realists see things as they are.
Optimists have the highest quality of life and live longer.
Exposure therapy:
Real life (in vivo)-involves having the patient place themselves in actual anxiety provoking situations until they experience at least a 50% reduction of anxiety.
Every treatment outcome study utilizing exposure has produced significant reductions in social anxiety symptoms. The therapy requires repetitive patient exposure to all anxiety triggers for best results. This will include reduction of anticipatory anxiety and increased comfort levels in social situations.
Social Skills Training-some people benefit from learning techniques to become more assertive, make small talk more effectively, improve eye contact, etc.

• Stuttering
• Butterflies
• Sweating
• Palpitations
• Trembling/shaking

• Small group participation
• Eating, drinking, writing in public
• Talking to authority figures
• Public speaking, performing
• Attending formal family events
• Being observed working
• Meeting strangers
• Using public restrooms
• Being center of attention

Paxil was the first SSRI approved for generalized social anxiety. It may be more effective than the other SSRI’s, (Prozac, Celexa, Lexapro, Zoloft). The CR formula of Paxil is better tolerated than regular Paxil. Effexor XR and Zoloft were recently approved by the FDA for SAD also. The SSRI’s and Effexor XR probably work mostly by down regulating the brain transmitter Serotonin.
Clonazepam is the most beneficial of the benzodiazepines, probably because it has some effect on Serotonin.
Neurontin has shown beneficial effects for SAD also.
Inderal (Propranolol) is effective for heart racing and tremor in situational SAD.
Cardura has shown to be effective for excessive sweating.
The most potent medications for SAD are the MAO inhibitors (Nardil, Parnate). Unfortunately, they require diet restrictions and have significant side effects.

When a stranger walks into a nursery full of toddlers, most of them stop playing, look at the stranger for a few seconds, and then resume playing. About 10% of the toddlers are overly shy or inhibited and will not resume play until the stranger leaves. Another 10-15% are outgoing. These “bold” children will walk up to the stranger and start asking questions.
Jerome Kagan, a psychologist at Harvard University has studied social behavior for over 20 years. He has found that shy toddlers frequently grow up to be adults with significant social anxiety. Shy children are different even in utero in that they will have a much greater increase in fetal heart rate in response to a loud noise. Bold toddlers grow up to be extroverts and in some cases may even grow up to be criminals. The bold toddler’s fetal heart rate doesn’t change in response to loud noises. These as well as other studies strongly support genetics as the primary underlying cause of social anxiety disorder.

? Overestimates scrutiny by others
• Embarrassment, humiliation, and rejection over sensitivity
• Preoccupation with other’s perceptions and/or responses
• Certainty of negative evaluations
• Discounts personal achievements and over-emphasizes failures

DSM IV CRITERIA FOR SAD
A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.
B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of situationally bound or situationally predisposed panic attack.
C. The person recognizes that the fear is excessive or unreasonable.
D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the persons normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.

Social anxiety disorder is characterized by excessive fear and or avoidance of situations in which an individual believes he or she may be the subject of evaluation or scrutiny while interacting with other people or performing a specific task. The central theme of the disorder is the fear of negative evaluation by others. As a result, social situations are avoided or endured with great discomfort, leading to significant functional impairment.
Social anxiety disorder is the most common anxiety disorder, affecting 8% of the general population. The main cause is genetic. It usually starts in early life-average age 14. Social anxiety may be limited to specific situations, such as public speaking, or it may effect multiple situations and be generalized social anxiety.
There are several reasons that recognition and treatment are important: SAD has a significant impact on quality of life, both personal and occupational. Not only is there painful self-consciousness and
embarrassment, but anticipatory anxiety that sometimes lasts for weeks while awaiting a presentation or event. Social situations or events are often endured with great discomfort or avoided altogether.
Estimates are as high as 60% of alcohol problems are associated with self treatment of social anxiety.
Persons with SAD are more likely to be single and more likely to have lower levels of income and education.
Treatment involves medication, support, and desensitization. To get over social anxiety you have to confront the various situations and have them be OK. Forcing yourself to do it and suffering major embarrassment just reinforces a negative experience.
Medication can be used situationally for specific anxiety like public speaking, or on a regular basis for generalized social anxiety.

Even with the best sleep habits everyone has trouble sleeping on occasion. Almost everyone would benefit by having medication available that safely provides good quality sleep.

Our internal clock (circadian rhythm) is regulated by bright sunlight. Even on cloudy days, it is at least ten times brighter outside than indoors. Bright light suppresses melatonin, (the body’s natural sleep inducing hormone). As evening approaches and light diminishes, melatonin increases. Under these conditions, melatonin peaks around 9:00p.m. Ideally, this would make going to bed at 10:00p.m. and waking at 5:00 or 6:00a.m. a healthy sleep schedule. Going outside for the first time at noon will set your sleep clock for 16 hours later, or 4a.m. This makes it very difficult to fall asleep even at normal bedtime.

Some individuals, especially the elderly are “phase advanced.” This means melatonin peaks in the late afternoon, causing sleepiness. Even if going to bed is delayed, they often wake up in the middle of the night. They usually fall asleep in the early evening and then wake up 7 hours later at 3:00-4:00 a.m. They complain of not sleeping through the night, but are actually getting plenty of sleep.
This is helped by:
• Getting late afternoon sunlight
• Melatonin (see below) intake in the morning
• Minimizing morning bright sunlight
Others, especially teens and young adults tend to be “phase delayed.” Phase delay may be due to lack of morning bright light, lack of any exposure to outside bright light, and excessive evening artificial light. They also tend to stay up late, even when they must get up early the next morning. Their melatonin peak is delayed to midnight or later.
This is helped by:
• Getting bright morning sunlight
• Melatonin (see below) intake in the evening
• Minimizing afternoon bright sunlight
Melatonin comes in 3mg tablets.
Starting dose-1/4 tablet sublingually 3 hours before bedtime if phase delayed. If phase advanced, take in the morning.

Increase the dose to 1/2-1 if needed.

This does not help sleep associated with hyper arousal. However it can help with jet lag, shift work, or changing the internal clock.

Another option is to use an artificial full spectrum, bright light. These can be purchased by companies such as Sunbox Corp (www.sunbox.com.)

Can you sleep too much? Yes! Since after 7 1/2 hours sleep you are getting almost all REM sleep, which uses MENTAL energy, you end up more sluggish.

What’s the difference between sleep and fatigue?
Sleepiness is improved by either a nap or vigorous physical activity, fatigue is not.

People who live long, healthy lives have good sleep habits. It is like regular car maintenance. “Pay me now, or pay me later.” You can “make up” 6-10 hours of sleep loss, but each day after inadequate sleep you will have higher levels of stress hormones and potential detrimental affects to your health. Make the time to sleep 7 hours every night, or subject your body and brain to increased wear and tear.