Synonym: social anxiety disorder

Social anxiety disorder was recognised as a psychiatric entity in 1980. It is said to be the third most common condition, after depression and alcoholism. The abbreviation 'SAD' may lead it to be confused with seasonal affective disorder, which can occur when people in high latitudes get depressed during the long nights and short hours of daylight in winter.

We all have some degree of social anxiety. It may be an interview or a public performance such as public speaking, acting, singing or playing a musical instrument. A certain amount of adrenaline can enhance the performance but we are all aware of how too much can also ruin it. A fairly normal trait may become a disease when the severity interferes with normal everyday life.

Epidemiology

Like most other phobias, social phobias are more common in women.¹ They are more common in young people but there is a shortage of surveys in children and the elderly.²

Features of the disorder

• Social anxiety is a fear of being around people and having to interact with them. Sufferers fear being watched and criticised. Normal activities such as working, shopping, or speaking on the telephone are marked by persistent feelings of anxiety and self-consciousness. They feel dread as a situation approaches and afterwards they analyse or ruminate on how they could have done better. Hence, it may be seen as a fundamentally normal response but exaggerated to the point of being pathological.
• Physical symptoms include trembling, blushing, sweating and palpitations.
• They often experience chronic insecurity about their relationships with others, excessive sensitivity to criticism, and profound fears of being judged negatively, mocked, or rejected by others.
• There are two forms of the condition:
  • Performance social anxiety is where these feelings only occur in a few specific situations such as public speaking, eating in public or dealing with authority figures.
  • Generalised social anxiety which affects most, if not all areas of life. This is the more common type and affects around 70% of sufferers.
• Social phobias often start in adolescence and are centred around a fear of scrutiny by other people in comparatively small groups, often peer groups, rather than crowds, leading to avoidance of social situations. It can start in childhood and any assessment must take account of what is appropriate for age.
• There may be specific problems such as eating in public, public speaking, or encounters with the opposite sex; or, they may be diffuse, involving almost all social situations outside the family circle. A fear of vomiting in public is not uncommon. This is called emetophobia. Direct eye-to-eye contact is avoided but in some cultures it is inappropriate to look one's superiors in the eye. Ethnicity matters and culture are very important in differentiating the normal and the abnormal.
• There is usually low self-esteem and fear of criticism. They may present to the doctor complaining of flushing, tremor, nausea, or urgency of micturition. They may be convinced that these physical manifestations of anxiety are the primary problem. It may progress to panic attacks. Avoidance may be marked or extreme, resulting in almost complete social isolation.

Diagnostic criteria

The condition is included in the diagnostic and statistical manual of the American Psychiatrists Association, known as DSM-IV, the 4th issue being 1994, and also in the World Health Organization's International Classification of Diseases (ICD-10) that was published in 1992. The American definition is slightly different from the European definition that will be used here.

For diagnosis, all of the following criteria should be fulfilled:

1. The psychological, behavioural, or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
2. The anxiety must be restricted to or predominate in particular social situations
3. Avoidance of the phobic situations must be a prominent feature

Differential diagnosis

Anthropophobia or social neurosis is part of the condition. A degree of depression or another diagnosis may be present but the final diagnosis needs to be made on the basis of the most important features.

• Panic disorder with agoraphobia or agoraphobia without panic disorder
• Separation anxiety disorder (another 'SAD'). This is really a behavioural pattern of small children that presents at an inappropriate age, as in adolescence. The ICD classification for children is F90.3³
• General anxiety disorder, also known as anxiety neurosis
• Specific phobias
• Schizoid personality disorder is not the same as schizophrenia. They tend to be emotionally rather cold and isolated. It excludes Asperger's syndrome and autism and is listed in the ICD classification as F60.1⁴
• Avoidant personality disorder is a continuum, even perhaps a more severe form of social anxiety disorder. The European definition requires at least three of the following:
  • Persistent and pervasive feelings of tension and apprehension
  • Belief that one is socially inept, personally unappealing, or inferior to others
  • Excessive preoccupation with being criticised or rejected in social situations
  • Unwillingness to become involved with people unless certain of being liked
  • Restrictions in lifestyle because of the need to have physical security
  • Avoidance of social or occupational activities that involve significant interpersonal contact because of fear of criticism, disapproval, or rejection
• It may be part of other mental disorders
• There is considerable association between social avoidance and alcohol-related problems. A level of suspicion is required as the diagnosis and management of alcoholism is often unclear. The question arises as to which came first, the social avoidance or the alcoholism?⁵
• Performance anxiety, stage fright, and shyness are more personality traits than diseases

Management

Treatment may be psychological, pharmacological or both.

• Cognitive and behavioural therapy is effective in adults as shown by meta-analysis and there is growing evidence of similar benefit in children and adolescents.^2,6,7,8 The disorder may be seen as more a disorder of behaviour than an illness and so more suitable for behavioural than pharmacological intervention, although this would not rule out potential advantage of medication. Newer behavioural therapies include acceptance and commitment with exposure strategies - these appear to have some efficacy.^8,9 The basis of treatment is essentially:
  1. Recognise the automatic or irrational thought processes
  2. Identify the underlying beliefs
  3. Challenge those irrational beliefs
  4. Replace those beliefs with suitable alternatives

Prognosis

There is remarkably little known about the long-term outcome of this disorder and response to treatment. Behavioural modification in the form of exposure does seem to have long-term benefits. About 1 patient in 3 had either no benefit or was unable to complete the course; however, of the rest, 85% were free at 10 years.¹⁶ Long-term follow-ups of large numbers of patients are few. One from Australia examined both panic disorder and social phobia and found that of 124 patients, 93 could be assessed 2 years later and a quarter no longer needed treatment and did not meet the diagnostic criteria for the condition.¹⁷ There is also some data that suggest social anxiety disorder may increase the risk of depression in later life.¹⁸ This requires further research.

Document references

1. Fehm L, Pelissolo A, Furmark T, et al; Size and burden of social phobia in Europe. Eur Neuropsychopharmacol. 2005 Aug;15(4):453-62. [abstract]
2. Fink M, Akimova E, Spindelegger C, et al; Social anxiety disorder: epidemiology, biology and treatment. Psychiatr Danub. 2009 Dec;21(4):533-42. [abstract]
3. Separation Anxiety Disorder; The ICD-10 Classification of Mental and Behavioural Disorders World Health Organization, Geneva, 1992
4. Schizoid Personality Disorder; The ICD-10 Classification of Mental and Behavioural Disorders World Health Organization, Geneva, 1992
5. Morris EP, Stewart SH, Ham LS; The relationship between social anxiety disorder and alcohol use disorders: a critical review. Clin Psychol Rev. 2005 Sep;25(6):734-60. [abstract]
6. Rodebaugh TL, Holaway RM, Heimberg RG; The treatment of social anxiety disorder. Clin Psychol Rev. 2004 Nov;24(7):883-908. [abstract]
7. Mancini C, Van Ameringen M, Bennett M, et al; Emerging treatments for child and adolescent social phobia: a review. J Child Adolesc Psychopharmacol. 2005 Aug;15(4):589-607. [abstract]
8. Singh JS, Hope DA; Cognitive-behavioral approaches to the treatment of social anxiety disorder. Isr J Psychiatry Relat Sci. 2009;46(1):62-9. [abstract]
9. Dalrymple KL, Herbert JD; Acceptance and commitment therapy for generalized social anxiety disorder: a pilot study. Behav Modif. 2007 Sep;31(5):543-68. [abstract]
10. Stein DJ, Ipser JC, Balkom AJ; Pharmacotherapy for social phobia. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD001206. [abstract]
11. Muller JE, Koen L, Seedat S, et al; Social anxiety disorder : current treatment recommendations. CNS Drugs. 2005;19(5):377-91. [abstract]
12. Scott RW, Mughelli K, Deas D; An overview of controlled studies of anxiety disorders treatment in children and adolescents. J Natl Med Assoc. 2005 Jan;97(1):13-24. [abstract]
13. Denys D, de Geus F; Predictors of pharmacotherapy response in anxiety disorders. Curr Psychiatry Rep. 2005 Aug;7(4):252-7. [abstract]
14. Depression in children and young people; NICE guidance; CG28; Sept 2005.
15. Stein MB, Ravindran LN, Simon NM, et al; Levetiracetam in generalized social anxiety disorder: a double-blind, randomized J Clin Psychiatry. 2009 Dec 15. [abstract]
16. Fava GA, Grandi S, Rafanelli C, et al; Long-term outcome of social phobia treated by exposure. Psychol Med. 2001 Jul;31(5):899-905. [abstract]
17. Hunt C, Andrews G; Long-term outcome of panic disorder and social phobia. J Anxiety Disord. 1998 Jul-Aug;12(4):395-406. [abstract]
18. Beesdo K, Bittner A, Pine DS, et al; Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry. 2007 Aug;64(8):903-12. [abstract]

Internet and further reading

• Anxiety (partial update), NICE Clinical Guideline (January 2011); Generalised anxiety disorder and panic disorder (with or without agoraphobia) in adults

Acknowledgements