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:

• The psychological, behavioural, or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts
• The anxiety must be restricted to or predominate in particular social situations
• 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 F90.3^[3]
• 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 F60.1^[4]
• 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:
  • Recognise the automatic or irrational thought processes
  • Identify the underlying beliefs
  • Challenge those irrational beliefs
  • Replace those beliefs with suitable alternatives
• Pharmacological therapy seems to predominate in the literature on social anxiety disorder. There are often associated features of anxiety and depression. A Cochrane review noted that there is growing evidence that the condition is mediated by specific neurobiological factors and so drugs may be more logical than formerly supposed.^[10] This review found that the strongest evidence for efficacy was amongst the selective serotonin reuptake inhibitors (SSRIs). A review from 2005 entitled 'Social anxiety disorder: current treatment recommendations' suggested that venlafaxine XR (modified release) should be the first line.^[11] The second line should be monoamine oxidase inhibitors (MAOIs) such as phenelzine and reversible inhibitors of monoamine oxidase, such as moclobemide. Some benzodiazepines and antiepileptics like clonazepam and pregabalin may also be useful. It continued that, over the past two decades, cognitive behavioural therapies have gained increasing empirical support, suggesting a lack of good support from trials. It concluded that the optimal approach to the management of patients who are refractory to treatment requires additional study.
• There is a shortage of good trials with adequate power to examine the management of children and adolescents in both modalities.^[12]
• Drugs that have been demonstrated to work include tricyclic antidepressants, SSRIs, high-potency benzodiazepines and MAOIs; however, 20 to 40% still fail to respond.^[2][13] The literature seems remarkably uncritical of the use of these drugs in this condition. Benzodiazepines may be effective at reducing the level of anxiety but this is a chronic condition and these drugs should be used with considerable care because of the risk of addiction. It is also a condition that affects young people, including children and adolescents, and the literature seems remarkably uncritical of the use of SSRIs in children and adolescents. The question is raised in who benefits from antidepressants? A review of the treatment of depression in children, from the National Institute for Health and Clinical Excellence (NICE), recommended great caution and circumspection in prescribing antidepressants, especially SSRIs for children and adolescents.^[14] A particular problem appears to be an increased risk of suicidal ideation, especially with paroxetine. Similar warnings were given by the Committee on the Safety of Medicines (CSM) in December 2004. Although this is not depression that is being treated, it is often associated with an element of depression and it would be most unwise to assume that, in the absence of evidence, SSRIs are safe to use in this condition in a young age group.
• Drugs that do not work include levetiracetam.^[15]

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.