Social Anxiety Disorder (Social Phobia)

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. Individuals often fear of acting in a way (or showing anxiety symptoms) that will be embarrassing or humiliating. This can lead to avoidance or fear of social or performance situations.

Social anxiety disorder has a lifetime prevalence of 13%, making it the third most common psychiatric diagnosis. It affects females and males equally. There is frequent comorbidity with other anxiety disorders, depression, and alcohol use disorder.

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, GI symptoms, dry mouth, palpitations, trembling, urgency of micturition, and panic attacks.
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.[1]

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.[2]:

  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?

Consider social anxiety disorder in patients who appear reticent or shy and in all depressed or alcohol-dependent patients.

The following treatment recommendations are based on the 2014 Canadian Clinical Practice Guidelines for anxiety, posttraumatic stress and obsessive-compulsive disorders:[3]

Pharmacotherapy for social anxiety disorder

1st line Escitalopram, fluvoxamine, paroxetine, venlafaxine, sertraline
2nd line clonazepam, alprazolam, bromazepam, gabapentin, citalopram, phenelzine
3rd line Fluoxetine, bupropion, mirtazapine, moclobemide, divalproex, topiramate, levetiracetam, olanzapine, quetiapine, selegiline, clomipramine

Adjunctive: risperidone, aripiprazole, tiagabine
Not recommended Atenolol, propranolol, buspirone, imipramine, pergolide, St John’s wort

Adjunctive: pindolol, clonazepam

Pharmacotherapy for non-generalized social anxiety disorder (performance-type)

1st line SSRI or SNRI, plus a beta-blocker (propranolol)
2nd line moclobemide
Medication Tips
  • In performance-type social anxiety disorder, beta-blockers have been used for performance anxiety. In two clinical trials, no better than placebo, but clinically is used off-label in practice
  • 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
  • Switch to second line 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).

Cognitive behavioural therapy is a first-line treatment for social anxiety disorder 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