Anxiety

Social Anxiety Disorder

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Social Anxiety Disorder, Social Phobia, Performance Anxiety, Social Fear

  • Epidemiology
  1. Prevalence: very common
    1. Lifetime Prevalence: 13.3%
    2. Annual Prevalence rate: 7.9%
  2. Onset
    1. Peaks between ages 11 and 19 years old
    2. Rarely has onset after age 25 years
  • Symptoms
  • Common Social Phobia Fears
  1. Attending social gatherings
    1. Public speaking or performance
    2. "Small Talk"
    3. Small group discussion
    4. Asking questions in groups
    5. Being introduced
    6. Meeting or talking with strangers
    7. Interacting with "important" people
    8. Being assertive
  2. Performing activities in public
    1. Being observed performing an activity
    2. Indirect evaluation (Test anxiety)
    3. Using the telephone
    4. Using public restrooms
  • Diagnostic Criteria (DSM V)
  1. Marked and persistent fear of one or more social situations (with exposure to possible scrutiny of others)
    1. Social Interactions (conversations, unfamiliar people)
    2. Being observed (e.g. eating, drinking)
    3. Performance before others (e.g. public speaking)
  2. The same social situations almost always provoke fear, panic or anxiety and persists >6 months
  3. Person fears humiliation or embarrassment, leading to rejection or the offense of others
  4. Fear or anxiety is out of proportion to actual threat of the situation
    1. Adults typically have insight into the fear as unreasonable and excessive
  5. Person avoids feared social or performance situations (or indures with severe fear or anxiety)
  6. Impaired function or distress related to Social Phobia
    1. Interferes with normal daily routine
    2. Interferes with occupational or academic functioning
    3. Interferes with social activities or relationships
  7. Fear unrelated to underlying medical condition (or excessive, unreasonable response)
    1. Trembling in Parkinson's Disease
    2. Abnormal eating in Eating Disorder
    3. Substance (e.g. medication, substance used disorder)
  8. No other psychiatric condition explains symptoms
    1. See Differential Diagnosis below
  9. Special criteria modifications in children
    1. Anxiety related to peer setting (not simply exposure to adults)
    2. Anxiety may be expressed by crying, tantrums, clinging, freezing, shrinking or withdrawal
    3. Child may not have insight into unreasonable fear
  10. Specifiers: Performance
    1. Fear limited to public speaking or public performance
  11. References
    1. (2013) DSM-5, APA
  • Management
  • Cognitive-Behavioral Therapy
  1. Background
    1. Offered as 16 to 24 weekly sessions
    2. Group therapy preferred over individual counseling
    3. Total Cost: $750 to $2000 (Insurance covers 50-80%)
  2. Anxiety Management skills
    1. See Relaxation Training (e.g. Progressive Relaxation)
    2. Relaxation and calming techniques
  3. Social skills training
    1. Initiating and maintaining conversation
    2. Making appropriate eye contact
    3. Appropriate self-assertion
  4. Cognitive restructuring
    1. Change fearful thinking about social situations
  5. Gradual exposure to feared situations
    1. Gradual challenges into feared social situations
  • Management
  • Medications
  1. SSRI (50-75% efficacy)
    1. Paroxetine (Paxil)
    2. Fluvoxamine (Luvox)
  2. MAO Inhibitors (66% efficacy)
    1. Phenelzine (Nardil)
  3. Benzodiazepine (40-80% efficacy)
    1. Clonazepam (Klonopin) 0.25 to 0.5 mg PO bid
  4. Beta Blocker (for Performance Anxiety, 45 min before)
    1. Propranolol (Inderal) 20-40 mg PO prn performance
    2. Atenolol (Tenormin) 50 to 100 mg PO prn performance