Social Phobia (Social Anxiety Disorder)

Diagnostic Features
The essential feature of Social Phobia is a marked and persistent fear of social or performance situations in which embarrassment may occur (Criterion A). Exposure to the social or performance situation almost invariably provokes an immediate anxiety response (Criterion B). This response may take the form of a situationally bound or situationally predisposed Panic Attack. Although adolescents and adults with this disorder recognize that their fear is excessive or unreasonable (Criterion C), this may not be the case with children. Most often, the social or performance situation is avoided, although it is sometimes endured with dread (Criterion D).

The diagnosis is appropriate only if the avoidance, fear, or anxious anticipation of encountering the social or performance situation interferes significantly with the person’s daily routine, occupational functioning, or social life, or if the person is markedly distressed about having the phobia (Criterion E). In individuals younger than age 18 years, symptoms must have persisted for at least 6 months before Social Phobia is diagnosed (Criterion F). The fear or avoidance is not due to the direct physiological effects of a substance or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder) (Criterion G).

If another mental disorder or general medical condition is present (e.g., Stuttering, Parkinson’s disease, Anorexia Nervosa), the fear or avoidance is not limited to concern about its social impact (Criterion H).

In feared social or performance situations, individuals with Social Phobia experience concerns about embarrassment and are afraid that others will judge them to be anxious, weak, “crazy,” or stupid. They may fear public speaking because of concern that others will notice their trembling hands or voice or they may experience extreme anxiety when conversing with others because of fear that they will appear inarticulate. They may avoid eating, drinking, or writing in public because of a fear of being embarrassed by having others see their hands shake. Individuals with Social Phobia almost always experience symptoms of anxiety (e.g., palpitations, tremors, sweating, gastrointestinal discomfort, diarrhea, muscle tension, blushing, confusion) in the feared social situations, and, in severe cases, these symptoms may meet the criteria for a Panic Attack. Blushing may be more typical of Social Phobia.

Adults with Social Phobia recognize that the fear is excessive or unreasonable, although this is not always the case in children. For example, the diagnosis would be Delusional Disorder instead of Social Phobia for an individual who avoids eating in public because of a conviction that he or she will be observed by the police and who does not recognize that this fear is excessive and unreasonable. Moreover, the diagnosis should not be given if the fear is reasonable given the context of the stimuli (e.g., fear of being called on in class when unprepared).

The person with Social Phobia typically will avoid the feared situations. Less commonly, the person forces himself or herself to endure the social or performance situation, but experiences it with intense anxiety. Marked anticipatory anxiety may also occur far in advance of upcoming social or public situations (e.g., worrying every day for several weeks before attending a social event). There may be a vicious cycle of anticipatory anxiety leading to fearful cognition and anxiety symptoms in the feared situations, which leads to actual or perceived poor performance in the feared situations, which leads to embarrassment and increased anticipatory anxiety about the feared situations, and so on.

The fear or avoidance must interfere significantly with the person’s normal routine, occupational or academic functioning, or social activities or relationships, or the person must experience marked distress about having the phobia. For example, a person who is afraid of speaking in public would not receive a diagnosis of Social Phobia if this activity is not routinely encountered on the job or in the classroom and the person is not particularly distressed about it. Fears of being embarrassed in social situations are common, but usually the degree of distress or impairment is insufficient to warrant a diagnosis of Social Phobia. Transient social anxiety or avoidance is especially common in childhood and adolescence (e.g., an adolescent girl may avoid eating in front of boys for a short time, then resume usual behavior). In those younger than age 18 years, only symptoms that persist for at least 6 months qualify for the diagnosis of Social Phobia.

Specifier

Generalized. This specifier can be used when the fears are related to most social situations (e.g., initiating or maintaining conversations, participating in small groups, dating, speaking to authority figures, attending parties). Individuals with Social Phobia, Generalized, usually fear both public performance situations and social interactional situations. Because individuals with Social Phobia often do not spontaneously report the full range of their social fears, it is useful for the clinician to review a list of social and performance situations with the individual. Individuals whose clinical manifestations do not meet the definition of Generalized compose a heterogeneous group (sometimes referred to in the literature as nongeneralized, circumscribed, or specific) that includes persons who fear a single performance situation as well as those who fear several, but not most, social situations. Individuals with Social Phobia, Generalized, may be more likely to manifest deficits in social skills and to have severe social and work impairment.

Associated Features and Disorders
Associated descriptive features and mental disorders. Common associated features of Social Phobia include hypersensitivity to criticism, negative evaluation, or rejection; difficulty being assertive; and low self-esteem or feelings of inferiority. Individuals with Social Phobia also often fear indirect evaluation by others, such as taking a test. They may manifest poor social skills (e.g., poor eye contact) or observable signs of anxiety (e.g., cold clammy hands, tremors, shaky voice). Individuals with Social Phobia often underachieve in school due to test anxiety or avoidance of classroom participation. They may underachieve at work because of anxiety during, or avoidance of, speaking in groups, in public, or to authority figures and colleagues. Persons with Social Phobia often have decreased social support networks and are less likely to marry. In more severe cases, individuals may drop out of school, be unemployed and not seek work due to difficulty interviewing for jobs, have no friends or cling to unfulfilling relationships, completely refrain from dating, or remain with their family of origin. Furthermore, Social Phobia may be associated with suicidal ideation, especially when comorbid disorders are present.

Social Phobia may be associated with other Anxiety Disorders, Mood Disorders, Substance-Related Disorders, and Bulimia Nervosa and usually precedes these disorders. In clinical samples, Avoidant Personality Disorder is frequently present in individuals with Social Phobia, Generalized.

Associated laboratory findings. Thus far, no laboratory test has been found to be diagnostic of Social Phobia, nor is there sufficient evidence to support the use of any laboratory test (e.g., lactate infusion, CO2 inhalation) to distinguish Social Phobia from other Anxiety Disorders (e.g., Panic Disorder).

Specific Culture, Age, and Gender Features
Clinical presentation and resulting impairment may differ across cultures, depending on social demands. In certain cultures (e.g., Japan and Korea), individuals with Social Phobia may develop persistent and excessive fears of giving offense to others in social situations, instead of being embarrassed. These fears may take the form of extreme anxiety that blushing, eye-to-eye contact, or one’s body odor will be offensive to others (taijin kyofusho in Japan).

In children, crying, tantrums, freezing, clinging or staying close to a familiar person, and inhibited interactions to the point of mutism may be present. Young children may appear excessively timid in unfamiliar social settings, shrink from contact with others, refuse to participate in group play, typically stay on the periphery of social activities, and attempt to remain close to familiar adults. Unlike adults, children with Social Phobia usually do not have the option of avoiding feared situations altogether and may be unable to identify the nature of their anxiety. There may be a decline in classroom performance, school refusal, or avoidance of age-appropriate social activities and dating. To make the diagnosis in children, there must be evidence of capacity for social relationships with familiar people and the social anxiety must occur in peer settings, not just in interactions with adults. Because of the disorder’s early onset and chronic course, impairment in children tends to take the form of failure to achieve an expected level of functioning, rather than a decline from an optimal level of functioning. In contrast, when the onset is in adolescence, the disorder may lead to decrements in social and academic performance.

Epidemiological and community-based studies suggest that Social Phobia is more common in women than in men. In most clinical samples, however, the sexes are either equally represented or the majority are male.

Prevalence
Epidemiological and community-based studies have reported a lifetime prevalence of Social Phobia ranging from 3% to 13%. The reported prevalence may vary depending on the threshold used to determine distress or impairment and the number of types of social situations specifically surveyed. In one study, 20% reported excessive fear of public speaking and performance, but only about 2% appeared to experience enough impairment or distress to warrant a diagnosis of Social Phobia. In the general population, most individuals with Social Phobia fear public speaking, whereas somewhat less than half fear speaking to strangers or meeting new people. Other performance fears (e.g., eating, drinking, or writing in public, or using a public restroom) appear to be less common. In clinical settings, the vast majority of persons with Social Phobia fear more than one type of social situation. Social Phobia is rarely the reason for admission to inpatient settings. In outpatient clinics, rates of Social Phobia have ranged between 10% and 20% of individuals with Anxiety Disorders, but rates vary widely by site.

Course
Social Phobia typically has an onset in the mid-teens, sometimes emerging out of a childhood history of social inhibition or shyness. Some individuals report an onset in early childhood. Onset may abruptly follow a stressful or humiliating experience, or it may be insidious. The course of Social Phobia is often continuous. Duration is frequently lifelong, although the disorder may attenuate in severity or remit during adulthood. Severity of impairment may fluctuate with life stressors and demands. For example, Social Phobia may diminish after a person with fear of dating marries and reemerge after death of a spouse. A job promotion to a position requiring public speaking may result in the emergence of Social Phobia in someone who previously never needed to speak in public.

Familial Pattern
Social Phobia appears to occur more frequently among first-degree biological relatives of those with the disorder compared with the general population. Evidence for this is strongest for the Generalized subtype.

Differential Diagnosis
Individuals with both Panic Attacks and social avoidance sometimes present a potentially difficult diagnostic problem. Prototypically, Panic Disorder With Agoraphobia is characterized by the initial onset of unexpected Panic Attacks and the subsequent avoidance of multiple situations thought to be likely triggers of the Panic Attacks. Although social situations may be avoided in Panic Disorder due to the fear of being seen while having a Panic Attack, Panic Disorder is characterized by recurrent unexpected Panic Attacks that are not limited to social situations, and the diagnosis of Social Phobia is not made when the only social fear is of being seen while having a Panic Attack. Prototypically, Social Phobia is characterized by the avoidance of social situations in the absence of recurrent unexpected Panic Attacks. When Panic Attacks do occur, they take the form of situationally bound or situationally predisposed Panic Attacks (e.g., a person with fear of embarrassment when speaking in public experiences Panic Attacks cued only by public speaking or other social situations). Some presentations fall between these prototypes and require clinical judgment in the selection of the most appropriate diagnosis. For example, an individual who had not previously had a fear of public speaking has a Panic Attack while giving a talk and begins to dread giving presentations. If this individual subsequently has Panic Attacks only in social performance situations (even if the focus of fear is on the panic), then a diagnosis of Social Phobia may be appropriate. If, however, the individual continues to experience unexpected Panic Attacks, then a diagnosis of Panic Disorder With Agoraphobia would be warranted. If criteria are met for both Social Phobia and Panic Disorder, both diagnoses may be given. For example, an individual with lifelong fear and avoidance of most social situations (Social Phobia) later develops Panic Attacks in nonsocial situations and a variety of additional avoidance behaviors (Panic Disorder With Agorphobia).

Avoidance of situations because of a fear of possible humiliation is highly prominent in Social Phobia, but may also at times occur in Panic Disorder With Agoraphobia and Agoraphobia Without History of Panic Disorder. The situations avoided in Social Phobia are limited to those involving possible scrutiny by other people. Fears in Agoraphobia Without History of Panic Disorder typically involve characteristic clusters of situations that may or may not involve scrutiny by others (e.g., being alone outside the home or being home alone; being on a bridge or in an elevator; traveling in a bus, train, automobile, or airplane). The role of a companion also may be useful in distinguishing Social Phobia from Agoraphobia (With and Without Panic Disorder). Typically, individuals with agoraphobic avoidance prefer to be with a trusted companion when in the feared situation, whereas individuals with Social Phobia may have marked anticipatory anxiety, but characteristically do not have Panic Attacks when alone. A person with Social Phobia who fears crowded stores would feel scrutinized with or without a companion and might be less anxious without the added burden of perceived scrutiny by the companion.

Children with Separation Anxiety Disorder may avoid social settings due to concerns about being separated from their caretaker, concerns about being embarrassed by needing to leave prematurely to return home, or concerns about requiring the presence of a parent when it is not developmentally appropriate. A separate diagnosis of Social Phobia is generally not warranted. Children with Separation Anxiety Disorder are usually comfortable in social settings in their own home, whereas those with Social Phobia display signs of discomfort even when feared social situations occur at home.

Although fear of embarrassment or humiliation may be present in Generalized Anxiety Disorder or Specific Phobia (e.g., embarrassment about fainting when having blood drawn), this is not the main focus of the individual’s fear or anxiety. Children with Generalized Anxiety Disorder have excessive worries about the quality of their performance, but these occur even when they are not evaluated by others, whereas in Social Phobia the potential evaluation by others is the key to the anxiety.

In a Pervasive Developmental Disorder and Schizoid Personality Disorder, social situations are avoided because of lack of interest in relating to other individuals. In contrast, individuals with Social Phobia have a capacity for and interest in social relationships with familiar people. In particular, for children to qualify for a diagnosis of Social Phobia, they must have at least one age-appropriate social relationship with someone outside the immediate family (e.g., a child who feels uncomfortable in social gatherings with peers and avoids such situations, but who has an active interest in and a relationship with one familiar same-age friend).

Avoidant Personality Disorder shares a number of features with Social Phobia and appears to overlap extensively with Social Phobia, Generalized. Avoidant Personality Disorder may be a more severe variant of Social Phobia, Generalized, that is not qualitatively distinct. For individuals with Social Phobia, Generalized, the additional diagnosis of Avoidant Personality Disorder should be considered.

Social anxiety and avoidance of social situations are associated features of many other mental disorders (e.g., Major Depressive Disorder, Dysthymic Disorder, Schizophrenia, Body Dysmorphic Disorder). If the symptoms of social anxiety or avoidance occur only during the course of another mental disorder and are judged to be better accounted for by that disorder, the additional diagnosis of Social Phobia is not made.

Some individuals may experience clinically significant social anxiety and avoidance related to a general medical condition or mental disorder with potentially embarrassing symptoms (e.g., tremor in Parkinson’s disease, Stuttering, obesity, strabismus, facial scarring, or abnormal eating behavior in Anorexia Nervosa). However, if social anxiety and avoidance are limited to concerns about the general medical condition or mental disorder, by convention the diagnosis of Social Phobia is not made. If the social avoidance is clinically significant, a separate diagnosis of Anxiety Disorder Not Otherwise Specified may be given.

Performance anxiety, stage fright, and shyness in social situations that involve unfamiliar people are common and should not be diagnosed as Social Phobia unless the anxiety or avoidance leads to clinically significant impairment or marked distress. Children commonly exhibit social anxiety, particularly when interacting with unfamiliar adults. A diagnosis of Social Phobia should not be made in children unless the social anxiety is also evident in peer settings and persists for at least 6 months.

Diagnostic criteria for Social Phobia

A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Note: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
C. The person recognizes that the fear is excessive or unreasonable. Note: In children, this feature may be absent.
D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).
H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.

Specify if:

Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder)

Provided by ArmMed Media
Revision date: July 5, 2011
Last revised: by David A. Scott, M.D.