Social Anxiety Disorder

Overview

Definition

• A phobia can be defined as an irrational fear that results in avoidance of the feared subject, activity, or situation. 
• Patients with phobic disorders may have good insight and know that their fear is excessive, or may have poor insight.
• Social phobias involve the fear of embarrassing oneself in public or receiving negative evaluations from others.

Epidemiology

• Usually starts during late childhood and early adolescent years
• Prevalence:
  • Common disorder
  • Annual prevalence in the United States: approximately 7%
  • Women > men
• Risk factors:
  • Female gender
  • Family history 
  • Excessive shyness in childhood
• Comorbid conditions:
  • Other psychiatric conditions
  • Substance abuse
  • Anxiety disorders
  • Avoidant personality disorders

Pathophysiology

Biological basis:

• Pathological neurotransmitter distribution: 
  • Dopamine
  • Serotonin
  • Glutamate
  • Oxytocin 
• Hyperactive sympathetic system: 
  • Exaggerated sympathetic response to stress
  • Can cause tremors, tachycardia, and diaphoresis
• Hypothalamic-pituitary-axis dysfunction:
  • Involved in stress response in healthy individuals
  • Overreactivity in patients with social anxiety disorder
  • Seen in patients with history of trauma/abuse
• Structural brain changes:
  • Increased activation of limbic and paralimbic areas (especially amygdala and insula), medial prefrontal cortex, medial parietal, and occipital cortical regions
  • These brain regions are known to be related to executive functioning, behavior, and emotion processing.

Psychological theories:

• Phobic disorders may be defensive mechanisms of intrapsychic conflict.
• Phobias may be a learned behavior, where one associates certain responses with certain stimuli.

Diagnosis

The diagnosis of social anxiety disorder is entirely clinical, based on meeting specific criteria.

• Excessive anxiety or fear in ≥ 1 social situations lasting > 6 months (e.g., having a conversation, meeting new people, being watched (while, e.g., eating or drinking), and performing in front of a group (e.g., giving a speech))
• Fear stems from a belief that the individual will be judged, evaluated, humiliated, embarrassed, or rejected by others.
• Symptoms provoked almost always by the same stimuli
• Patient shows avoidance behavior or intense fear and anxiety that is out of proportion to the situation. 
• Symptoms cause a significant decline in function.
• Symptoms cannot be caused by:
  • Substance use
  • Medical conditions
  • Other mental disorders (e.g., panic disorder, body dysmorphic disorder, autism spectrum disorder)

Management

Both pharmacologic and psychological treatments are shown to be effective. Patients who also have avoidant personality disorder have a worse prognosis and require a longer period of treatment.

Psychotherapy

Cognitive behavioral therapy is considered to be the best initial treatment for treatment of social anxiety disorder (includes psychoeducation, cognitive reframing, and exposure therapy).

Pharmacology

• Antidepressants (specifically selective serotonin reuptake inhibitor (SSRIs)) are the 1st-line treatment.
• Beta-blockers (propranolol)
  • Used in performance-only subtype
  • Inhibits the hyperactive sympathetic symptoms (tremors, tachycardia, diaphoresis)
• Benzodiazepines (alprazolam, lorazepam): usually avoided due to side effects (sedation, cognitive decline) and high risk of dependence and misuse
• D-cycloserine (DCS): 
  • Partial N-methyl-d-aspartate (NMDA) receptor agonist 
  • Shows some evidence in augmenting CBT during exposure therapy

Differential Diagnosis

• Panic disorder: a chronic mental disorder marked by recurrent and episodic panic attacks that occur abruptly without a trigger. The disorder is associated with anxiety or the fear of having another attack or its complications. Patients with social anxiety can also suffer from panic attacks; however, these patients are more concerned with social situations rather than the onset of future panic attacks. 
• Avoidant personality disorders: lifelong pattern of thoughts and behaviors marked by social isolation, feelings of inadequacy, and hypersensitivity to negative evaluation. There are considerable similarities with social anxiety disorder as both frequently co-occur. The main difference with social anxiety disorder is the feeling of inferiority and hypersensitivity to criticism.
• Agoraphobia: the fear of being in public or open spaces. Agoraphobia is best treated with medications (SSRIs) and CBT. Patients with agoraphobia may be comforted by other people but those with social anxiety will feel more anxious. Social anxiety disorder can be complicated by or associated with agoraphobia, but the 2 are not always seen together.