Social anxiety disorder
Social anxiety disorder is marked, persistent fear of scrutiny or embarrassment in social or performance situations lasting at least 6 months with significant functional impairment. Generalized social anxiety disorder is treated with cognitive behavioral therapy (CBT) plus an SSRI such as sertraline, while the performance-only subtype is treated with a PRN beta blocker such as propranolol taken before the anticipated situation.
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What this article covers
- Overview
Fear of scrutiny defines the disorder: social anxiety disorder, previously called social phobia, is marked, persistent fear or anxiety of being criticized, humiliated, or embarrassed in social or…
- Epidemiology
Most common phobia: social anxiety disorder is the most common phobic disorder.
- Risk factors
Female sex: anxiety disorders, including social anxiety disorder, are diagnosed more often in women.
- Pathophysiology
Exaggerated, disproportionate fear response: fear and its physical manifestations (palpitations, sweating, flushing, dyspnea, chest pain) are incongruent with the actual magnitude of the social or…
- Clinical features
Diagnostic criteria (DSM-5): excessive fear or anxiety of criticism, humiliation, or embarrassment in one or more social or performance situations, present for at least 6 months, causing clinically…
- Differential diagnosis
Specific phobia: excessive fear tied to a discrete object or situation (animals, heights, flying), not social scrutiny, usually beginning in childhood.
- Diagnosis
Diagnosis is clinical: confirmed by a history establishing marked fear or anxiety of one or more social or performance situations involving possible scrutiny, present for at least 6 months, causing…
- Management
First, determine the subtype, since it dictates the entire plan: generalized social anxiety disorder is treated as a daily illness, while the performance-only subtype is treated situationally before the trigger.
- Complications
Chronic functional impairment: avoidance of social or performance situations can interfere with academic, occupational, and social functioning if the disorder goes untreated.
- Prognosis
Effective treatment, though evidence quality is low: both CBT and pharmacotherapy with SSRIs and SNRIs are effective for social anxiety disorder overall.
- Prevention
Targeted screening in women: the Women's Preventive Services Initiative recommends screening all women, including during pregnancy and postpartum, for anxiety disorders; the USPSTF gives no general recommendation, and none exists for men.
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Related articles
- Specific phobias
Specific phobia is a marked, persistent fear or anxiety about a circumscribed object or situation, lasting 6 months or more, that is out of proportion to the actual danger, provokes immediate fear on exposure, and is actively avoided or endured with distress; the diagnosis is clinical. First-line treatment is graded exposure therapy (a form of cognitive behavioral therapy), with a short-acting benzodiazepine reserved for a single known, planned exposure.
- Panic disorder
Panic disorder is an anxiety disorder defined by recurrent, unexpected panic attacks, discrete surges of fear that peak within 10 minutes with 4 or more characteristic symptoms, followed by at least 1 month of persistent worry about further attacks, worry about their consequences, or a maladaptive behavior change. Medical mimics such as acute coronary syndrome, pulmonary embolism, arrhythmia, hyperthyroidism, pheochromocytoma, and hypoglycemia must be excluded first. First-line treatment is a selective serotonin reuptake inhibitor such as sertraline, started low and titrated slowly, combined with cognitive behavioral therapy; benzodiazepines are reserved for short-term acute control.
- Agoraphobia
Agoraphobia is marked fear, anxiety, or avoidance of two or more situations, such as public transportation, open or closed spaces, lines or crowds, or being outside the home alone, driven by the concern that escape or help may be unavailable, present for 6 months or more and now diagnosed independently of panic disorder even though the two frequently coexist. First-line treatment is exposure-based cognitive behavioral therapy, with an SSRI as the pharmacologic adjunct.
- Generalized anxiety disorder
Generalized anxiety disorder is excessive, hard-to-control worry about multiple life domains occurring more days than not for at least 6 months, with at least 3 of 6 associated physical symptoms and functional impairment. Screen with the GAD-7 after excluding hyperthyroidism and substance use, then treat first-line with cognitive behavioral therapy and/or an SSRI or SNRI such as escitalopram or venlafaxine extended-release, reserving benzodiazepines for short-term severe symptom control only.
- Personality disorders
Personality disorders are enduring, pervasive, and inflexible patterns of inner experience and behavior across cognition, affect, interpersonal functioning, and impulse control that deviate markedly from cultural expectation, trace to adolescence or early adulthood, and are ego-syntonic. Diagnosis is clinical, applying a symptom-count threshold to place the patient in cluster A, B, or C. Management leads with cluster-specific psychotherapy, reserving medication for comorbid or target symptoms.
- Major depressive disorder
Major depressive disorder is a mood disorder defined by 5 or more of 9 major depressive episode symptoms, including depressed mood or anhedonia, present nearly every day for at least 2 weeks and causing significant functional impairment. Diagnosis is clinical, screened with the Patient Health Questionnaire. First-line treatment is cognitive behavioral therapy, a selective serotonin reuptake inhibitor (SSRI) such as sertraline, or both, escalating to augmentation, esketamine, or electroconvulsive therapy for refractory or acutely suicidal presentations.