Clinical Pearls & Morning Reports
Social anxiety disorder is characterized by an intense fear of social situations in which the person may be scrutinized by others. More than 90% of persons with the disorder report psychosocial impairments (e.g., increased risk of dropping out of school, reduced workplace productivity, and reduced socioeconomic status and quality of life), and more than one third report severe impairments. Read the latest Clinical Practice review on this topic.
Q. How common is social anxiety disorder?
A. Social anxiety disorder is one of the most prevalent mental disorders, with a lifetime prevalence of 13% and a 12-month prevalence of 8% among adults and similar prevalences among adolescents in the United States. The disorder has an early onset (mean age, 13 years) and is often chronic. Common coexisting conditions include other anxiety disorders, major depressive disorder, substance-use disorder, and avoidant personality disorder.
Q. Is social anxiety disorder mistaken for shyness?
A. Social anxiety disorder is often mistaken for shyness and remains both underrecognized and undertreated. Persons with social anxiety disorder visit their primary care physician less frequently than do patients with other mental disorders. They also avoid consulting a physician for psychological problems. Among persons who do seek care, most avoid talking about their social anxiety. Often it is a coexisting condition that leads persons with social anxiety disorder to seek medical help. To screen for the disorder, two questions can be asked: First, “Do you find yourself avoiding social situations or activities?” Second, “Are you fearful or embarrassed in social situations?” Clinical experience suggests that these questions are very useful in screening, although their sensitivity and specificity for social anxiety disorder are not known.
Table 2. Differential Diagnosis.
A: Social anxiety disorder can be treated with psychotherapy, pharmacotherapy, or both. The choice of treatment depends on the patient’s preferences and on clinical judgment. Several methods of psychotherapy are available for the treatment of social anxiety disorder. Cognitive behavioral therapy (CBT) is currently regarded as the first-line treatment. In high-quality studies of CBT for the treatment of social anxiety disorder, response rates were between 50% and 65%, an outcome that was superior to placebo (32%) and wait-list control groups, for which response rates were between 7% and 15%. Remission rates with CBT were between 8.8% and 36%. For adults who do not have access to face-to-face CBT, guided Web-based CBT may be an alternative. The efficacy of Web-based CBT has been reported to be similar to that of face-to-face CBT and is applicable in primary care settings. Other types of psychotherapy are also used to treat social anxiety disorder, but there have been fewer studies of these treatments.
A: Pharmacotherapy and CBT appear to have a similar efficacy for the short-term treatment of social anxiety disorder. The available head-to-head comparisons suggest that more immediate improvements are achieved with pharmacotherapy but that the effects of CBT are more enduring. Several medications have been used for the treatment of social anxiety disorder. Selective serotonin-reuptake inhibitors (SSRIs) are considered to be the first-line pharmacologic treatment. Response rates reported for the serotonin–norepinephrine reuptake inhibitor (SNRI) venlafaxine have been similar to those reported for SSRIs. Randomized trials have also supported the efficacy of benzodiazepines for social anxiety disorder (specifically, clonazepam and bromazepam, although the latter is not available in the United States). However, benzodiazepines carry a risk of physiological dependency and withdrawal symptoms and are not recommended for patients with coexisting depression or a history of substance abuse. Tricyclic antidepressants are not considered to be useful in the treatment of social anxiety disorder.
Table 4. Pharmacotherapies for Social Anxiety Disorder and Performance Anxiety.