Practice recommendations
- Cognitive Behavioral Therapy (CBT) is an effective treatment for social anxiety disorder. (B)
- Medication also helps patients with social anxiety disorder lead more functional lives. (B)
Strength of recommendation (SOR)
- Good quality patient-oriented evidence
- Inconsistent or limited-quality patient-oriented evidence
- Consensus, usual practice, opinion, disease-oriented evidence, case series
Janice L, 41, comes into her physician’s office complaining that she’s “feeling anxious all the time” at her job at a local bank. She tells him that she’s been treated for depression in the past, though she’s not currently taking any antidepressants. As her physician takes a more thorough history, he notices that her alcohol consumption seems a bit excessive. Her demeanor, which he had previously chalked up to as “shyness,” comes into focus. He begins to suspect that his patient is more than just “quiet and unassuming” and may, in fact, be suffering from social anxiety disorder.
To confirm his suspicions, he excuses himself to retrieve an article he’d saved on the topic—one that identifies a quick screening tool for social anxiety disorder.1 He then asks his patient to rate the following statements on a scale of 0 to 4, with 0 being “not at all” and 4 being “extremely present”:
- Fear of embarrassment causes me to avoid doing things or speaking to people.
- I avoid activities in which I am the center of attention.
- Being embarrassed or looking stupid are among my worst fears.
His suspicions are confirmed when she scores a 10—well above the 6 that is highly suggestive of social anxiety disorder.
A debilitating disorder that’s all too common
Social anxiety, also known as social phobia, is the most common anxiety disorder, and is the third most common psychiatric disorder after depression and alcohol dependence.2 The Epidemiological Catchment Area Study revealed that 2% to 4% of the sample suffered from social anxiety with a lifetime prevalence of 2.8%. Other studies have found that as many at 10% of the sample suffer from social anxiety when a more appropriate diagnostic interview is used.3-5 Similarly, Kessler et al conducted a study investigating the prevalence of DSM-IV disorders and concluded that 6.8% of the entire sample suffered from social anxiety disorder.6
Distinguishing shyness from social anxiety in kids
The difference between social anxiety disorder and shyness in children is that social anxiety debilitates the child’s ability to grow and develop socially in an appropriate manner. While children with—and without—social anxiety disorder may be uncomfortable around unfamiliar adults, children with this disorder will also be uncomfortable in a peer setting with unfamiliar kids their own age. Children with social anxiety may express their discomfort through crying, tantrums, or freezing from the social situation. In order for the child to meet full criteria for social anxiety, the duration of the symptoms must span at least 6 months.17
Social anxiety disorder is characterized as a persistent and debilitating fear of social interaction where patients fear negative evaluations by others. As a result, these patients may have trouble building and maintaining social relationships, which can result in a particularly isolated and depressed lifestyle.7
There are 2 subtypes of social anxiety disorder:
- Generalized social anxiety is generally more severe and more generalized and therefore, more disabling to patients. The majority of patients seen by the medical community tend to exhibit this sub-type of the disorder.
- Nongeneralized anxiety (also known as specific or discrete social phobia) is the less common and usually includes a fear associated with 1 or a few specific situations.
Although nongeneralized anxiety may be less likely to cause severe impairment in the patient’s life, it still may lead to significant underachievement in school or work.8 Still, patients with public speaking–only social anxiety are more likely to recover spontaneously, while patients with generalized social anxiety rarely recover spontaneously from the disorder.
The 2 subtypes also differ in their origin. Generalized social anxiety—the focus of this article—is significantly more prevalent among relatives who also suffer from the disorder, while patients with nongeneralized social anxiety disorder do not necessarily have relatives with the condition.9
“Shyness” in childhood that’s often overlooked
Social anxiety is a lifelong disorder that may begin as early as childhood, but is often described as beginning at age 13. At this age, though, the social anxiety is often mistaken for extreme shyness and therefore goes untreated.10 (See “Distinguishing shyness from social anxiety in kids,”.)
Overlooking shyness in such a young patient is particularly problematic as the avoidance that characterizes the social anxiety disorder can result in a lost opportunity to acquire social skills that are needed to ease the transition from adolescence to adulthood. This relative loss of social skills often facilitates the development of social dysfunction that is characteristic of this illness.11 As time goes by, sufferers eventually become accustomed to their fears and create a way of life that accommodates them.