Social Anxiety Disorder
Overview and Presentation
Social anxiety disorder is a type of fear that is confined to settings of social interactions. These would include speaking in public, eating in restaurants, and social interactions such as parties.
Social anxiety disorder (previously referred to as social phobia) is defined as excessive fear of situations in which they may act in an anxious manner (e.g., have trembling hands) or otherwise show the anxiety and in which others might negatively evaluate.
Individuals with social anxiety disorder typically fear that they will do something humiliating or embarrassing, which may lead to rejection or offense to others. This anxiety may be coupled together with a fear of being unable to avoid or escape certain situations (e.g., agoraphobiaOpens in new window).
Many people experience fear or anxiety in almost all social situations. In children, the fearOpens in new window or anxietyOpens in new window may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
In social situations, people may experience anxiety that approaches the severity experienced in a panic attack. Consequently, the situations are either avoided or endured with intense discomfort.
The presence of fear or anxiety is often not circumscribed to a single type of situation, and may extend to multiple social situations, even generalizing to all social interactions. This latter state is referred to as generalized social anxiety disorderOpens in new window, which may produce significant impairment.
A patient may experience fear when required to peform socially, such as speaking or performing publicly, participating in groups, or engaging in conversation.
These kinds of fear are common, and may not meet full diagnostic criteria for social anxiety disorderOpens in new window.
Other fears may involve more unusual situations. These can involve fears of eating in public, using public restrooms, or even writing while others are watching (for example, signing a check).
Social anxiety disorder usually has a circumscribed fear of embarrassmentOpens in new window. For example, although fear of writing may seem strange, the anxiety derives from a fear of appearing anxious, such as having shaking of the hands.
Similarly, people often fear speaking in public because of a worry that they may exhibit the fear itself. People fear others’ seeing their hands shake while speaking. Therefore, social anxiety disorder has a self-perpetuating characteristic.
The symptoms associated with fear, such as shortness of breath, tachycardia, and tremor, actually aggravate the anxiety. This, subsequently, augments the anticipatory anxietyOpens in new window of other similar circumstances. The person often has had growing anxiety over time, which culminates in the actual experience. Showing anxietyOpens in new window, then, is inevitable.
In social anxiety disorder, a person must show significant fear related to being exposed to scrutiny by others. People with this condition fear showing their anxiety and experiencing embarrassment.
In other situations, people may fear saying something foolish, unintelligent, or embarrassing, and, therefore, avoid social interactions.
There often is a history of avoiding social or performance situations, or enduring such situations with great distress. The fear often involves multiple areas of social interactions, and may result in significant impairment.
The fear is distressing and often causes significant problems in the person’s life, interfering with multiple areas requiring social interactions.
Although people may learn to “live around” the phobiaOpens in new window, it often is at the price of educational or occupational attainment, or relationships. The symptoms are persistent, usually lasting at least 6 months. As in all anxiety disordersOpens in new window, social anxiety disorder must be distinguished from general medical conditions, the effects of substances, or other mental disorders.
The 12-month prevalence of social anxiety disorder is 7.1%, while the lifetime prevalence rate is 12.1%. However, this may represent an underestimate, since mild symptoms are common.
In the same epidemiological survey cited above, 24.1% of respondents reported at least one social fear during their lifetimes. Many people have significant fears of public speaking or being in public while engaging in various activities such as eating or writing, but only a small percentage of them meet full criteria for social anxiety disorder.
This may be the result of having engaged in effective avoidance of the kinds of interaction that stimulate the fears. Females have a greater prevalence rate than males in the population, but an equal portion appear to present for treatment. The age of onset is usually during adolescence.
Genetics and biology may play a significant role in the development of this disorder. One study, using neuroimaging, demonstrated increased reactivity in the amygdala in response to social cues.
Abnormalities in the serotonergic and dopaminergic systems, as well as hyperreactivity of the autonomic nervous system in afflicted individuals have been noted.
Family and twin studies suggest that genetics contributes a moderate level of risk, and that the remainder of the risk is largely due to environmentally specific factors.
As noted for other anxiety disorders, the emotionally reactive temperament appears to contribute significantly to the predisposition to phobias in general. Best-fit models support the notion that genetics, familial (i.e., “shared”) environment, and individual-specific environmental factors contribute independent, but interacting, risk.
There is also evidence to support that temperament and other factors such as cognitive distortions play a role in the development of social anxiety disorder, along with interaction with the environment.
Children who have a first-degree relative with social anxiety disorder appear to be at a two- to threefold greater risk for developing social anxiety disorder than children who do not have a first-degree relative with this disorder.
In addition, a mounting body of evidence implicates various neurobiological pathways in the development of this disorder, similar to those found in other anxiety disordersOpens in new window.
Social learning theorists have asserted that social anxiety can be “learned” through vicarious observation of others being humiliated in a social situation. Additionally, it has been found that patients diagnosed with social anxiety disorder are more likely to report that their parents avoided social interactions, suggesting that the modeling of social anxiety plays a role.
However, these theorists are quick to note that a temperament known as behavioral inhibitionOpens in new window is thought to be the diathesis that separates persons who develop social anxiety disorder from those who do not, as certainly every person who has observed social adversity does not develop social anxiety disorder.
Classic behavioral theory posits that persisting fears may be associated with certain environmental stimuli (for example, a threatening animal), or that fears may develop in the context of pairing of a benign cue and another feared stimulus.
The latter is a traditional view of “irrational phobias,” that is, phobias of relatively neutral, non-threatening objects or situations. Although phobias may occur in the context of an adverse situation, traditional behavioral views have certain significant limitations.
The fear of either an unconditioned (i.e., threatening) or conditioned stimulus (one that generates fear as a result of being paired with a conditioned cue) may certainly occur; however, the repeated presentation of the situation without threat typically results in extinction of the fear.
This phenomenon, almost by definition, does not occur with phobic disorders. Therefore, although phobias may, on the surface, appear to correspond to a classical conditioning model, certain features are not consistent with this view. Therefore, sustained phobias are likely to arise from a mixed model, which may or may not depend on the presentation of an environmental threat.
Differential Diagnosis and Comorbidity
The diagnosis of social anxiety disorder requires differentiation from other similar appearing clinical pictures. The most significant differential is with other anxiety disorders.
As already noted, interviewing to elicit specific features is most helpful. Although people with obsessive-compulsive disorderOpens in new window may avoid social situations, the reasons typically are clear. For example, they may have social avoidance because of a fear of contamination by exposure to others.
Similarly, panic disorderOpens in new window often results in social avoidance, but in the context of a history of spontaneous panic attacks. Moreover, whereas both social anxiety disorder and panic disorder may share a fear of public embarrassment, the episodes of panic disorder are not context-specific—that is, they do not always occur on social exposure.
People with post-traumatic stress disorderOpens in new window may have social anxiety and aversionOpens in new window, but this is specific to earlier trauma. For example, a woman who has been raped may carefully avoid situations in which she is exposed to men. However, the causal thread to the earlier trauma is usually clear.
Various personality disorders also may have a significant component of social avoidance. Patients with schizoidOpens in new window or schizotypal personality disordersOpens in new window may have little social interaction. However, their minimal social interaction is not the result of social anxiety per se, but rather is preferred by the individual.
People with avoidant personality disorderOpens in new window also have social fears, including fears of embarrassmentOpens in new window; however, this is a life-long and pervasive pattern. Of note, however, generalized social anxiety disorder is difficult to distinguish from avoidant personality and, in fact, may be the same condition, as both tend to be chronic and pervasive.
Psychotic disorders such as schizophreniaOpens in new window must also be considered. For example, psychotic patients may avoid social interaction, but because of specific, paranoid fears.
They may, for example, fear that people are plotting harm against them, not simply that they might do something embarrassing. Moreover, the so-called negative symptoms of schizophrenia, which include apathy and social withdrawal, can result in similar avoidance. However, this occurs in the broader context of schizophrenia.
Social avoidance is seldom the result of the direct effects of substances (or withdrawal) or other general medical conditions. People with serious substance abuse may have relatively little social interaction. However, this is usually not the result of fear of embarrassment (although the physical consequences of substance abuse may make people want to avoid others).
Both pharmacological and psychotherapeutic methods are useful in the treatment of social anxiety disorder. A number of drugs carry specific indications for its treatment. In particular, these nclude the SSRIs paroxetine and sertraline, as well as the SNRIs duloxetine and venlafaxine extended release. A summary of these medications along with their common dosages are found in Table X-1.
The doses used are similar to those used for major depression. The problem of increased anxiety early in treatment with SSRIs and SNRIs seen in panic disorder is not as prominent with social anxiety disorder. However, the principle is the same: start at a low dose and titrate upward until the desired result is achieved—that is, suppression of the social anxiety.
|Table X-1 Medications with indications for social anxiety disorder|
|Medication||Starting dosage||Recommended dosage|
|10 mg daily||20-50 mg daily|
|12.5 mg||12.5 – 37.5 mg daily|
|25 mg daily||50 – 200 mg daily|
|37.5 – 75 mg daily||75 – 225 mg daily|
|Note that table applies to regular adult dosing. Pediatric and elderly dosing will be different, and may not be indicated.|
Other medications are also sometimes used in the treatment of the disorder. BenzodiazepinesOpens in new window may be helpful when used on an as-needed basis; for example, people may take a relatively low dose of benzodiazepines such as lorazepamOpens in new window, clonazepamOpens in new window, or alprazolamOpens in new window in situations in which the feared social interactions cannot be avoided.
This is often done prior to public speaking, for example. However, adverse reactions such as drowsiness or interference with recall may pose a problem. Therefore, the drug should be tested in a “non-demand” situation prior to being implemented. Note that many people have anxiety in multiple social situations, or may have unpredictable social interactions, making the use of benzodiazepines problematic.
Due to the issue of dependence, benzodiazepines should generally be avoided for continuous use, particularly given the evidence of the effectiveness of SSRIs and SNRIs. Buspirone may also be effective in social anxiety disorder but the data are conflicting. Older drugs such as the monoamine oxidase inhibitors may also be effective, but are seldom used because of the risk of adverse events.
Finally, drugs that block the autonomic arousal associated with social situations can also be used. Most particularly, this includes beta-blockers such as propranololOpens in new window or atenololOpens in new window, which can be used in anticipation of social exposure such as public speaking. As with benzodiazepines, beta-blockers should be tried prior to the social interaction because of the potential for side effects.
Traditional behavioral and cognitive behavioral therapyOpens in new window are effective. Both involve common elements, most particularly graded exposure to the feared stimulus.
For example, a person with a severe fear of public speaking may begin by giving a speech alone to a mirror, followed by giving the speech to the therapist, then a small number of family and friends, a larger number of familiar people, and, eventually, working up to large groups of unfamiliar people.
Cognitive methods include elements such as reappraisal and hypothesis testing.
- Reappraisal involves actually addressing the negative thoughts associated with the fear, for example, that the person is likely to say something foolish or otherwise be noticed by others.
- Hypothesis testing may involve having the patient ask the other people whether they noticed the symptoms of fear (such as shaking hands), or if the patient had said something foolish.
These treatments are often effective in producing long-term improvement. In addition, the use of medications in the absence of behavioral methods is often only partially effective.
Course and Prognosis
The course of social anxiety disorder is typically chronic in the absence of specific treatment. Moreover, the chronicity may contribute significantly to social and occupational impairment. In addition, other comorbid mental disorders such as depression may contribute independent risk, worsening the overall course. It should be noted, however, that many people have mild symptoms without significant impairment.
- Ruscio AM, Brown TA, Chiu WT, Sareen J, Stein MB, Kessler RC. Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychol Med 2008; 38: 15 – 28.
- Stein MB, Goldin PR, Sareen, J, Zorrilla LT, Brown GG. Increased amygdale activation to angry and contemptuous faces in generalized social phobia. Arch Gen Psychiatry 2002;59: 1027 – 1034.
- Hofman SG, Heinrichs N, Moscovitch DA. The nature and expressions of social phobia: toward a new classification. Clin Psychol Rev 2004;24: 769 – 797.
- Argyropoulos SV, Bell CJ, Nutt DJ. Brain function in social anxiety disorder. Psychiatr Clin North Am 2001;24: 707 – 722.