social phobia; social anxiety disorder

Introduction

A disabling fear of events in which the person is exposed to scrutiny by others:

• public speaking
• eating
• using the lavoratory
• events with friends or family

Epidemiology

• 3-13% lifetime prevalence
• more common in women than men
• less common in the elderly
• 13% of population

Clinical manifestations

• severe & persistent fear of social or performance situations, especially but not limited to, when encountering unfamiliar people
  • public speaking
  • examinations
• somatic symptoms or panic attacks in anticipation of social events
• avoidance of occupational & social situations because of fears of interacting with other people
• physical symptoms (blushing, dyspnea, palpitations, chest pain, dyspnea, nausea, diarrhea) emotional distress, or panic attacks may occur in anticipation of feared situations
• patients generally present for medical help for coexisting condition

Diagnostic criteria

• disabling fear of events in which the person is exposed to scrutiny by others
  • in children, the anxiety must occur in peer settings, not just during interactions with adults
• fear of disapproval
• recognition that the fear is excessive or unreasonable (may be absent in children)
• in children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
• social situations are avoided or endured with intense fear or anxiety
• fear or anxiety is out of proportion to the social situation
• fear, anxiety, or avoidance >= 6 months
• fear, anxiety, or avoidance is disabling
  • clinically significant distress
  • impairment in social, occupational, or other important areas of functioning
• fear, anxiety, or avoidance is not attributable to the physiologic effects of a substance or another medical condition or better explained by another mental disorder
• if another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive

Complications

• increased risk of other mental disorders
  • depression
  • substance abuse

Differential diagnosis

• distinct from shyness
• agoraphobia
  • patients may dislike social situations, but are not afraid of social interactions

Management

• psychotherapy
  • cognitive behavioral therapy 1st line
    • durability of effects > 12 months small to medium
  • desensitization
  • group therapy
• selective serotonin reuptake inhibitors (SSRI)
  • generally pharmaceutical treatment of choice
  • sertraline or other SSRI
  • venlafaxine (SNRI) is alternative
• anxiolytic agent if SSRI is ineffective
  • benzodiazepine
• remission rates with pharmacotherapy low
• beta-blockers for specific & episodic performance anxiety such as 'stage fright'

More general terms

• phobia
• anxiety disorder
• social disorder