Social Anxiety Disorder (Social Phobia)

Primer

Social Anxiety Disorder (also known as social phobia), is an anxiety disorder characterized by a significant amount of fear in one or more social situations, causing significant distress and impaired ability to function in some aspects of daily life. These fears can be triggered by perceived or actual scrutiny, or negative evaluation from others.

Epidemiology
  • The lifetime prevalence rates for social anxiety disorder ranges from 8 to 12%, making it one of the more common anxiety disorders.
  • It is more common in women than men (about twice as many women).[1][2]
  • The average age of onset is between 8 to 15 years, and most have a childhood history of social inhibition or shyness.[3]
Prognosis
  • About 30% of individuals experience remission within 1 year, and about 50% experience remission within several years.[4] For those not receiving treatment, about 60% of individuals take several more years to achieve remission.
  • Individuals are more likely to be unemployed, single, unmarried, or divorced and childless, particularly among men.
  • Only about half of individuals seek treatment, and typically after 15 to 20 years of experiencing symptoms.[5]
Comorbidity
  • Up to 72% of individuals have another psychiatric disorder diagnosis.[6]
  • Social anxiety disorder is comorbid with other anxiety disorders, major depressive disorder, and substance use disorder (to self-medicate in anticipation of social events).
  • Other comorbidities include bipolar disorder, ADHD, and body dysmorphic disorder.[7]
  • Individuals with the generalized subtype of social anxiety disorder may also be more likely to have avoidant personality disorder.[8]
Risk Factors
  • Temperamental traits such as high behavioural inhibition and fear of negative evaluation is a risk factor.
  • First degree relatives of individuals with social anxiety disorder have a two to six times higher chance of having social anxiety disorder.[9]
Cultural
  • Fear of offending others by a gaze or by showing anxiety symptoms may be the predominant fear in individuals from cultures with strong collectivistic orientations.[10]
    • In Japan and Korea, this is known as taijin kyofusho, where the individual believes their gaze is upsetting others, and so others look away from them. Sometimes, this fear can attain a delusional intensity.[11]
    • The North American equivalent of this syndrome is termed “olfactory-reference syndrome.”

DSM-5 Diagnostic Criteria

Criterion A

Marked fear or anxiety about 1 or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g. - having a conversation, meeting unfamiliar people), being observed (e.g. - eating or drinking), and performing in front of others (e.g. - giving a speech).

In children, the anxiety must occur in peer settings and not just during interactions with adults.
Criterion B

The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. - will be humiliating or embarrassing: will lead to rejection or offend others).

Criterion C

The social situations almost always provoke fear or anxiety.

In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
Criterion D

The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

Criterion E

The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

Criterion F

The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion G

The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g. - a drug of abuse, a medication) or another medical condition.

Criterion H

The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

Criterion J

If another medical condition (e.g. - Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Physical Symptoms of Social Anxiety

Though not specifically part of the diagnostic criteria, common physical symptoms of social anxiety disorder include: blushing, stammering, sweating, gastrointestinal symptoms, dry mouth, palpitations, trembling, urgency of micturition, and panic attacks.

Specifiers

Performance Specifier

Specify if:

  • Performance only: If the fear is restricted to speaking or performing in public.

Panic Attack Specifier

Specify if:

  • Recurrent unexpected panic attacks. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least 4 of the following symptoms occur (Note: The abrupt surge can occur from a calm state or an anxious state):
  1. Sweating
  2. Trembling or shaking
  3. Unsteady, dizziness, light-headed, or faint
  4. Derealization (feelings of unreality) or depersonalization (being detached from one self)
  5. Excessive/accelerated heart rate, palpitations, or pounding heart
  6. Nausea or abdominal distress
  7. Tingling, numbness, parathesesias
  8. Shortness of breath
  9. Fear of losing control or “going crazy”
  10. Fear of dying
  11. Choking feelings
  12. Chest pain or discomfort
  13. Chills or heat sensations
Note: The symptoms presented in this specifier are for the purpose of identifying a panic attack. However, panic attacks are not a mental disorder. Panic attacks can occur in the context of any anxiety disorder as well as other mental disorders (e.g. - depressive disorders, posttraumatic stress disorder, substance use disorders) and some medical conditions (e.g. - cardiac, respiratory, vestibular, gastrointestinal). When the presence of a panic attack is identified, it should be noted as a specifier (e.g. - “social anxiety disorder with panic attacks”). For panic disorder, the presence of panic attack is contained within the criteria for the disorder and panic attack is not used as a specifier.
Note: Culture-specific symptoms (e.g. - tinnitus, neck soreness, headache, uncontrollable screaming or crying) may be seen. Such symptoms should not count as one of the four required symptoms.

Signs and Symptoms

  • The anticipatory anxiety in social anxiety can sometimes occur far in advance of upcoming situations (e.g. - worrying every day for weeks before the social event).
    • Individuals often overestimate the negative consequences of the social situations, but the sociocultural context always needs to be taken into account by the clinician.
  • Individuals (e.g. - public speakers, musicians, dancers, performers, athletes) with the performance only type of social anxiety disorder will have performance fears that are typically most impairing during their careers or professional lives. Importantly, in performance only type, individuals do not fear or avoid non-performance social situations.
  • Some individuals may have a fear of public restrooms and avoid urinating when other individuals are present (this is also called paruresis, or “shy bladder syndrome”).[12]
    • This is more common in males.[13]
  • Blushing is considered a hallmark response for social anxiety disorder.[14]

Screening and Rating Scales

Scales

Name Rater Description Download
Liebowitz Social Anxiety Scale (LSAS) Clinician The LSAS is a 24-item scale that assesses for social anxiety symptoms. Link
Social Phobia Inventory (SPIN)

The Social Phobia Inventory (SPIN) demonstrates solid psychometric properties and shows promise as a measurement for the screening of, and treatment response to, social phobia.[15]

Mini-Social Phobia Inventory (mini-SPIN)

The Mini-Social Phobia Inventory (Mini-SPIN) is a 3-question screening tool that has a 90% screening accuracy for diagnosing generalized social anxiety.[16]:

  1. Does fear of embarrassment cause you to avoid doing things or speaking to people?
  2. Do you avoid activities in which you are the centre of attention?
  3. Is being embarrassed or looking stupid among your worst fears?

Pathophysiology

  • The neural mechanisms behind social anxiety disorder is thought to be an interplay between non-specific genetic (neurotic temperament) factors and the environment (e.g. - fear of negative evaluation) interactions.

Differential Diagnosis

  • Normal shyness
    • Shyness is a very common personality trait and is not pathological. However, when there is a significant adverse impact on social, occupational, and other important areas of functioning, a diagnosis of social anxiety disorder should be considered.
  • Agoraphobia
    • Individuals with agoraphobia may fear and avoid social situations (e.g. - going to a concert) because escape might be difficult or help might not be available in the event of incapacitation or panic-like symptoms. The differentiating factor is that individuals with social anxiety disorder are most fearful of scrutiny by others. They are also very likely to be calm when left entirely alone in these “agoraphobic” environments, which is typically not the case in agoraphobia.
  • Panic disorder
    • Individuals with social anxiety disorder can have panic attacks, but the concern is about fear of negative evaluation (i.e. - social judgment), whereas in panic disorder the concern is about the panic attacks themselves.
  • Generalized anxiety disorder (GAD)
    • Social worries are common in GAD, but the focus is more about interpersonal relationships rather than fear of negative evaluation. Children may have excessive worries about the quality of their social performance, but these worries also extend to nonsocial performance. The key difference again is the social aspect of the worries.
  • Separation anxiety disorder
    • Individuals with separation anxiety disorder may avoid social settings (including school refusal) because of concerns about being separated from attachment figures. Individuals with separation anxiety disorder are usually comfortable in social settings when their attachment figure is present or when they are at home. Compare with social anxiety disorder may be uncomfortable even when social situations occur at home or in the presence of attachment figures.
  • Specific phobias
    • Individuals with specific phobias may fear embarrassment or humiliation (e.g. - embarrassment about fainting when they have their blood drawn), but they do not generally fear negative evaluation in other social situations.
  • Selective mutism
    • Individuals with selective mutism may fail to speak because of fear of negative evaluation, but they do not fear negative evaluation in social situations where no speaking is required (e.g. - nonverbal play).
  • Major depressive disorder (MDD)
    • Individuals with MDD may be worried about being negatively evaluated by others because they feel guilty, hopeless, or worthless. Individuals with social anxiety disorder on the other hand, are worried about being negatively evaluated because of certain social behaviors or physical symptoms.
  • Body dysmorphic disorder (BDD)
    • Individuals with BDD are preoccupied with one or more perceived defects or flaws in their physical appearance that are not observable or appear slight to others. It is this specific preoccupation that causes the social anxiety and avoidance. If the social fears and avoidance are caused only by concerns regarding one's appearance, the additional diagnosis of social anxiety disorder is not warranted.
  • Delusional disorder
    • In delusional disorder, there can be very fixed non-bizarre delusions and/or hallucinations related to the delusional theme that focus on being rejected by or offending others. Compare this with social anxiety disorder, where there is generally good insight that their beliefs are out of proportion to the actual threat posed.
  • Oppositional defiant disorder
    • Not speaking as a way to oppose authority figures should be differentiated from failure to speak due to a fear of negative evaluation.
  • Autism spectrum disorder
    • Social anxiety and social communication deficits are key features of autism spectrum disorder. However, those with social anxiety disorder typically have adequate age-appropriate social relationships and social communication capacity. It only appears that they have impairment in these areas when first interacting with unfamiliar peers or adults in stressful social settings.
  • Avoidant personality disorder
    • Since onset is common childhood, social anxiety disorder may resemble avoidant personality disorder. The key difference is that with avoidant personality disorder, individuals have a broader and more pervasive avoidance pattern. Of note, avoidant personality disorder is also more comorbid with social anxiety disorder than with other anxiety disorders.
  • Other mental disorders (e.g. - schizophrenia, eating disorders, obsessive-compulsive disorder)
    • In schizophrenia, social fears and discomfort can occur, but psychotic symptoms are usually evident.
    • In eating disorders, it is important to determine if the fear of negative evaluation is about eating disorder symptoms or behaviors (e.g. - purging and vomiting) before diagnosing social anxiety disorder.
    • In obsessive-compulsive disorder, social anxiety may be present, but the additional diagnosis is used only when social fears and avoidance are separate from the original obsessions and compulsions.
  • Other medical conditions
    • Medical conditions may produce symptoms that may be embarrassing (e.g. - trembling in Parkinson's disease). When the fear of negative evaluation due to other medical conditions becomes excessive, a diagnosis of social anxiety disorder should be considered.

Investigations

  • Depending on the initial presenting symptoms (e.g. - dizziness, tachycardia), potential investigations can include: CBC, fasting glucose, fasting lipid profiles, electrolytes, liver enzymes, serum bilirubin, serum creatinine, urinalysis, urine toxicology for substance use, thyroid stimulating hormone (TSH).[17]

Treatment

The following treatment recommendations are based on the 2014 Canadian Clinical Practice Guidelines for anxiety, posttraumatic stress and obsessive-compulsive disorders:[18]

Psychotherapy

Cognitive behavioural therapy with exposure is a first-line, gold-standard treatment for social anxiety disorder. Importantly, the gains from CBT are longer lasting and more enduring than those achieved through medication treatment. and includes several components:

  1. Education – about disorder and treatment, recommends self-help materials
  2. Exposure – offers imaginal exposure to situations that are difficult to practice regularly in real life, offers in-vivo exposure to situations that provoke social anxiety during treatment sessions and homework, provides exposure role-play simulations, reduces safety behaviours in social situations
  3. Cognitive restructuring – aims to reduce negative beliefs about self and others, works to reduce the excessive self-focus that is characteristic of SAD, examines and changes perfectionistic attitudes
  4. Social skills training – deals with any areas of weak social skills such as eye contact or conversation skills, addresses any interpersonal problems, including lack of social contacts and friendships, improving social life, assertiveness, managing conflict, and dealing with romantic or problematic relationships
  5. Emotion-regulation approaches – offer relaxation approaches, acceptance of symptoms and anxiety
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Pharmacological

  • In performance-type social anxiety disorder only, beta-blockers have been used for performance anxiety.
  • If response to a medication is inadequate, dosing should be optimized and compliance assessed before switching to another agent.
  • In patients who have inadequate response to optimal dosages of a first line agent or in whom the agent is not tolerated, switch to another first-line agent.
    • Titrate up to higher doses of medication, as social anxiety typically responds only partially to antidepressants and usually requires the upper end of the dose range.
  • Switch to a second line medication after 2 failed trials of first-line.
  • While benzodiazepines are a second-line treatment, they may be used at any time if there is an acute and severe exacerbation of agitation or anxiety in individuals with SAD who do not have co-morbid alcohol or substance abuse. However they should be used as a short term solution only (1⁄4 of patients with generalized SAD have co-morbid substance use).

Pharmacotherapy for social anxiety disorder

Katzman, M. A. et al. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.
1st line Monotherapy: escitalopram, fluvoxamine, fluvoxamine CR, paroxetine, paroxetine CR, pregabalin, sertraline, venlafaxine XR
2nd line Monotherapy: alprazolam, bromazepam, citalopram, clonazepam, gabapentin, phenelzine
3rd line Monotherapy: atomoxetine, bupropion SR, clomipramine, divalproex, duloxetine, fluoxetine, mirtazapine, moclobemide, olanzapine, selegiline, tiagabine, topiramate.
Adjunctive therapy Aripiprazole, buspirone, paroxetine, risperidone
Not recommended Monotherapy: atenolol*, buspirone, imipramine, levetiracetam, propranolol*, quetiapine
Adjunctive therapy: clonazepam, pindolol
* = Beta-blockers have been successfully used in clinical practice for performance situations such as public speaking.

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References

1) Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.
7) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
8) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
9) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
10) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
11) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
12) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
13) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
14) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
15) Connor, MK. Psychometric properties of the Social Phobia Inventory (SPIN). Br J Psychiatry. 2000 Apr;176:379-86.
16) Seeley-Wait E, Abbott MJ, Rapee RM. Psychometric Properties of the Mini-Social Phobia Inventory. Primary Care Companion to The Journal of Clinical Psychiatry. 2009;11(5):231-236.
17) Katzman, M. A., Bleau, P., Blier, P., Chokka, P., Kjernisted, K., & Van Ameringen, M. (2014). Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC psychiatry, 14(1), 1-83.
18) Katzman MA, Bleau P, Blier P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14(Suppl 1):S1.