Social anxiety disorder is characterized by fear of and anxiety about being exposed to certain social or performance situations. These situations are avoided or endured with substantial anxiety. Diagnosis is based on clinical criteria. Treatment involves cognitive-behavioral therapy, exposure therapy, and sometimes pharmacotherapy.
Social anxiety disorder affects about 2.8% of people in a given year, with a lifetime prevalence of about 5% (1). These rates appear to be higher in the United States. Men are more likely than women to also have avoidant personality disorder, which can be seen as an anxiety disorder that is severe and persistent enough to affect the person's personality.
Fear and anxiety in patients with social anxiety disorder often center on being embarrassed or humiliated if they fail to meet people's expectations or are scrutinized by other people in social interactions. Often, the concern is that their anxiety will be apparent through sweating, blushing, vomiting, or trembling (sometimes as a quavering voice) or that the ability to keep a train of thought or find words to express themselves will be lost. Usually, the same activity done alone causes no anxiety.
Situations in which social anxiety is common include public speaking, acting in a theatrical performance, and playing a musical instrument. Other potential situations include eating with others, meeting new people, having a conversation, signing a document before witnesses, or using public bathrooms. A more generalized type of social anxiety causes anxiety in a broad array of social situations.
Most patients with social anxiety disorder recognize that their fears are unreasonable and excessive.
General reference
1. Grant BF, Hasin DS, Blanco C, et al: The epidemiology of social anxiety disorder in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry66(11):1351-1361, 2005 . doi: 10.4088/jcp.v66n1102
Diagnosis of Social Anxiety Disorder
Diagnostic and Statistical Manual of Mental Disorders, 5th edition, Text Revision (DSM-5-TR) criteria
To meet the DSM-5-TR criteria for diagnosis (1), patients must have
Marked, persistent (≥ 6 months) fear of or anxiety about one or more social situations in which they may be scrutinized by others
Fear must involve a negative evaluation by others (eg, that patients will be humiliated, embarrassed, or rejected or will offend others). In addition, all of the following should be present:
The same social situations nearly always trigger fear or anxiety.
Patients actively avoid the situation.
The fear or anxiety is out of proportion to the actual threat (taking into account sociocultural norms).
The fear, anxiety, and/or avoidance cause significant distress or significantly impair social or occupational functioning.
Also, the fear and anxiety cannot be more correctly characterized as a different mental disorder (eg, agoraphobia, panic disorder, body dysmorphic disorder, avoidant personality disorder).
As is true for other anxiety disorders, it is useful to identify a catastrophic spiral of cognition when diagnosing social anxiety disorder; for example, patients with social anxiety disorder might worry that if they go to a party, they will embarrass themselves, be mocked by strangers, and then will have to flee the party. Often, this anxiety begins reasonably but spirals into fears of a highly unlikely catastrophe.
Patients with social anxiety disorder tend to develop avoidance strategies, such as declining party invitations or meeting new people. These strategies may become second nature, such that the avoidance behavior may not be seen as having anything to do with the anxiety. For example, they may initially report that they avoid parties because they are "boring." However, such avoidance reinforces the anxiety by allowing the threat of exaggeration to go unchallenged and deprives them of any positive experiences in the feared setting.
Diagnosis reference
1. Diagnostic and Statistical Manual of Mental Disorders, 5th edition,Text Revision (DSM-5-TR), American Psychiatric Association Publishing, Washington, DC, pp 229-235.
Treatment of Social Anxiety Disorder
Cognitive-behavioral therapy
Exposure therapy
Sometimes a selective serotonin reuptake inhibitor (SSRI)
As with other anxiety disorders, social anxiety disorder varies in severity and waxes and wanes over time. Many people with social anxiety never seek treatment but instead develop their own set of strategies. For example, they might minimize or avoid social situations, "self-medicate" with drugs such as alcohol or marijuana, or just uncomfortably grit their way through social obligations. However, there are multiple therapeutic options available for patients (1).
Cognitive-behavioral therapy (CBT) involves teaching patients to recognize and control their distorted thinking and false beliefs as well as instructing them on how to use exposure therapy (controlled exposure to the anxiety-provoking situation).
SSRIs and benzodiazepines are also effective for social anxiety, although benzodiazepines may be physically addictive and may also impair thinking and memory (1).
For patients who experience distress when they need to perform in public, beta-blockers may be prescribed to reduce the increased heart rate, trembling, and sweating.
Treatment reference
1. Williams T, McCaul M, Schwarzer G, et al: Pharmacological treatments for social anxiety disorder in adults: A systematic review and network meta-analysis. Acta Neuropsychiatr 32(4):169-176, 2020. doi: 10.1017/neu.2020.6
