Social Anxiety Disorder

Background

• Social anxiety disorder is characterized by marked, excessive fear or anxiety that one may be scrutinized, humiliated, or embarrassed in social situations or during professional performance often resulting in avoidance of these situations.
• Selective mutism is considered a separate disorder from social anxiety disorder, but children with selective mutism are generally acknowledged to meet diagnostic criteria for social anxiety disorder.
• Patients with social anxiety disorder may have other concurrent anxiety disorders as well as other comorbid psychiatric conditions.

Evaluation

• Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria for social anxiety disorder:
  • marked fear or anxiety causing significant distress or impairment, typically present for ≥ 6 months, about social situations in which the patient may be exposed to scrutiny by others
  • fear that actions or showing anxiety will cause negative evaluation or offend others
  • social situation in question
    • almost always provokes fear or anxiety
    • is actively avoided or endured with marked fear or anxiety
  • the fear, anxiety, or avoidance is out of proportion to the actual threat posed by the social situation
  • if another medical condition present such as stuttering or obesity, the disturbance is unrelated or out of proportion to it
  • specify "performance only" if fear is restricted to speaking or performing in public
• Consider using an inventory or questionnaire to aid in the diagnosis or to monitor response to treatment.
• Consider testing to rule out other diagnoses or suspected comorbidities such as alcohol and other substance use disorders, thyroid disease, cardiac disease, and asthma.

Management

• Consider management by symptom severity:
  • In patients with mild anxiety, consider either cognitive behavioral therapy (CBT) or Internet-based CBT.
  • CBT or pharmacotherapy or both may be offered for moderate anxiety.
  • Consider combination therapy with CBT plus pharmacotherapy for severe or treatment-resistant anxiety.
• For pharmacologic management, consider a selective serotonin reuptake inhibitor or a serotonin-norepinephrine reuptake inhibitor. Selection may be guided by previous response to medication, patient preference, and prescriber familiarity with a given drug.
  • Start with a dose that is half of what is recommended for depression, continuing that dose for 1-2 weeks, and then doubled if tolerated; titrate at 1- to 2-week intervals over 4-6 week until effective.
  • Counsel patients that symptom relief onset may take 2-8 weeks, and full response may take ≥ 12 weeks.
  • Consider continuing treatment for 9-12 months, though relapse following discontinuation is common (40%) and patients may need ongoing treatment.