E. The avoidance, anxious anticipation, or distress in the feared social or performance situation interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
F. In children <18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiologic effects of a drug of abuse, a medication, or a general medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, pervasive developmental disorder, or schizoid personality disorder).
H. If a general medical condition or another mental disorder is present, the fear in criterion A is unrelated to it (e.g., the fear is not of stuttering or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa).
Specify the following:
Generalized: if the fears include most social situations (e.g., initiating or maintaining conversations, participating in small groups, dating, speaking to authority figures, attending parties). Note: Also consider the additional diagnosis of avoidant personality disorder.
Family and individual psychotherapy and care coordination with a patient’s school is helpful. Reassurance that the patient does not have a life-threatening illness is important. Other psychosocial treatments include stress management, supportive therapies, and biofeedback. Emphasis is placed on decreasing morbidity through proper treatment. Panic disorder tends to be chronic but usually is responsive to treatment. In PTSD trauma-focused cognitive behavioral therapy has shown efficacy. Critical-incident stress debriefing and “psychological first aid,” soon after the event, greatly reduce distress and involve discussing the nature and impact of the trauma event in a group format.
Selective serotonin reuptake inhibitors (SSRIs) are the medication of choice. The SSRIs approved for children by the U.S. Food and Drug Administration (FDA) are fluoxetine, sertraline, and fluvoxamine. They can initially exacerbate anxiety or even panic symptoms. Clomipramine requires electrocardiographic and blood level monitoring but may be effective and is approved by the FDA for obsessive-compulsive disorder. Tricyclic antidepressants have also shown efficacy. Benzodiazepines (alprazolam and clonazepam) include a risk of causing disinhibition in children. Alpha-2a-agonists (guanfacine and clonidine) may be useful if autonomic symptoms are present. Anticonvulsant agents (gabapentin, topiramate, and oxcarbazepine) are used when other agents are ineffective. β-Blockers help with performance anxiety.
Co-occurrence of the inattentive type of attention-deficit/hyperactivity disorder (ADHD) and an anxiety disorder is common. When using a stimulant, it is advisable to start at a low dose, increasing slowly to minimize the risk of increasing anxiety.
For PTSD, antidepressants may be augmented by clonidine (also useful in hyperarousal and impulsivity) in the presence of severe affective dyscontrol. Atypical antipsychotics are used if self-injurious behavior, dissociation, psychosis, and aggression are present. Atomoxetine is useful in PTSD with concurrent ADHD.