Social Anxiety Disorder

See Also

Epidemiology

Prevalence: very common
1. Lifetime Prevalence: 13.3%
2. Annual Prevalence rate: 7.9%
Onset
1. Peaks between ages 11 and 19 years old
2. Rarely has onset after age 25 years

Symptoms
Common Social Phobia Fears

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
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)

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)
The same social situations almost always provoke fear, panic or anxiety and persists >6 months
Person fears humiliation or embarrassment, leading to rejection or the offense of others
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
Person avoids feared social or performance situations (or indures with severe fear or anxiety)
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
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)
No other psychiatric condition explains symptoms
1. See Differential Diagnosis below
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
Specifiers: Performance
1. Fear limited to public speaking or public performance
References
1. (2013) DSM-5, APA

Differential Diagnosis

Avoidant Personality Disorder
Schizoid Personality Disorder
Autism Spectrum Disorder
Panic Disorder
Separation Anxiety Disorder
Body Dysmorphic Disorder
Developmental Disorder
Substance Abuse (e.g. stimulants such as Cocaine, Methamphetamine)
Substance Withdrawal (Alcohol Withdrawal, Benzodiazepine Withdrawal, Opioid Withdrawal)

Management
Cognitive-Behavioral Therapy

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%)
Anxiety Management skills
1. See Relaxation Training (e.g. Progressive Relaxation)
2. Relaxation and calming techniques
Social skills training
1. Initiating and maintaining conversation
2. Making appropriate eye contact
3. Appropriate self-assertion
Cognitive restructuring
1. Change fearful thinking about social situations
Gradual exposure to feared situations
1. Gradual challenges into feared social situations

Management
Medications

SSRI (50-75% efficacy)
1. Paroxetine (Paxil)
2. Fluvoxamine (Luvox)
MAO Inhibitors (66% efficacy)
1. Phenelzine (Nardil)
Benzodiazepine (40-80% efficacy)
1. Clonazepam (Klonopin) 0.25 to 0.5 mg PO bid
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

References