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 Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with phobic disorders may have good insight Insight Psychiatric Assessment and know that their fear is excessive, or may have poor insight Insight Psychiatric Assessment.
• Social phobias Phobias Neurological Examination 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 Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency:
  • Common disorder
  • Annual prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in the United States: approximately 7%
  • Women > men
• Risk factors:
  • Female gender Gender Gender Dysphoria
  • Family history Family History Adult Health Maintenance 
  • Excessive shyness in childhood
• Comorbid conditions:
  • Other psychiatric conditions
  • Substance abuse
  • Anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorders
  • Avoidant personality disorders Personality Disorders A major deviation from normal patterns of behavior. Cluster A Personality Disorders

Pathophysiology

Biological basis:

• Pathological neurotransmitter distribution: 
  • Dopamine Dopamine One of the catecholamine neurotransmitters in the brain. It is derived from tyrosine and is the precursor to norepinephrine and epinephrine. Dopamine is a major transmitter in the extrapyramidal system of the brain, and important in regulating movement. Receptors and Neurotransmitters of the CNS
  • Serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS
  • Glutamate Glutamate Derivatives of glutamic acid. Included under this heading are a broad variety of acid forms, salts, esters, and amides that contain the 2-aminopentanedioic acid structure. Synthesis of Nonessential Amino Acids
  • Oxytocin 
• Hyperactive sympathetic system Sympathetic system The thoracolumbar division of the autonomic nervous system. Sympathetic preganglionic fibers originate in neurons of the intermediolateral column of the spinal cord and project to the paravertebral and prevertebral ganglia, which in turn project to target organs. The sympathetic nervous system mediates the body’s response to stressful situations, i.e., the fight or flight reactions. It often acts reciprocally to the parasympathetic system. Autonomic Nervous System: Anatomy: 
  • Exaggerated sympathetic response to stress
  • Can cause tremors, tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children, and diaphoresis
• Hypothalamic-pituitary-axis dysfunction:
  • Involved in stress response in healthy individuals
  • Overreactivity noted in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder
  • Seen in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with history of trauma/abuse
• Structural brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification changes:
  • Increased activation of limbic and paralimbic areas (especially amygdala Amygdala Almond-shaped group of basal nuclei anterior to the inferior horn of the lateral ventricle of the temporal lobe. The amygdala is part of the limbic system. Limbic System: Anatomy and insula), medial prefrontal cortex, medial parietal Parietal One of a pair of irregularly shaped quadrilateral bones situated between the frontal bone and occipital bone, which together form the sides of the cranium. Skull: Anatomy, and occipital Occipital Part of the back and base of the cranium that encloses the foramen magnum. Skull: Anatomy cortical regions
  • These brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification 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 Phobias Neurological Examination may be a learned behavior, where one associates certain responses with certain stimuli.

Diagnosis

The diagnosis of social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder is entirely clinical, based on meeting specific criteria.

• Excessive anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder or fear in ≥ 1 social situations lasting > 6 months (e.g., having a conversation, meeting new people, being watched while 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 Avoidance behavior Specific Phobias or intense fear and anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder 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 Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder, body dysmorphic disorder Body dysmorphic disorder Body dysmorphic disorder (BDD) is a psychiatric disorder characterized by a patient’s preoccupation with minor or imagined flaws in their physical appearance. The obsession over the perceived defect leads to compulsive behaviors to cover it up, either with cosmetic therapy or social avoidance. Body Dysmorphic Disorder, autism spectrum disorder Autism spectrum disorder Autism spectrum disorder (ASD) is a neurodevelopmental disorder marked by poor social skills, restricted interests/social interactions, and repetitive/stereotyped behaviors. The condition is termed a “spectrum” because of the wide variability in the severity of symptoms exhibited. Autism Spectrum Disorder)

Management

Both pharmacologic and psychological treatments are shown to be effective. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who also have avoidant personality disorder Avoidant Personality Disorder Cluster C Personality Disorders have a worse prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas and require a longer period of treatment.

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy

Cognitive behavioral therapy Cognitive behavioral therapy A directive form of psychotherapy based on the interpretation of situations (cognitive structure of experiences) that determine how an individual feels and behaves. It is based on the premise that cognition, the process of acquiring knowledge and forming beliefs, is a primary determinant of mood and behavior. The therapy uses behavioral and verbal techniques to identify and correct negative thinking that is at the root of the aberrant behavior. Psychotherapy is considered to be the best initial treatment for treatment of social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder (includes psychoeducation Psychoeducation Psychotherapy, cognitive reframing, and exposure Exposure ABCDE Assessment therapy).

Pharmacology

• Antidepressants (specifically selective serotonin Serotonin A biochemical messenger and regulator, synthesized from the essential amino acid l-tryptophan. In humans it is found primarily in the central nervous system, gastrointestinal tract, and blood platelets. Serotonin mediates several important physiological functions including neurotransmission, gastrointestinal motility, hemostasis, and cardiovascular integrity. Receptors and Neurotransmitters of the CNS reuptake inhibitor ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants)) are the 1st-line treatment.
• Beta-blockers Beta-blockers Drugs that bind to but do not activate beta-adrenergic receptors thereby blocking the actions of beta-adrenergic agonists. Adrenergic beta-antagonists are used for treatment of hypertension, cardiac arrhythmias, angina pectoris, glaucoma, migraine headaches, and anxiety. Class 2 Antiarrhythmic Drugs (Beta Blockers) ( propranolol Propranolol A widely used non-cardioselective beta-adrenergic antagonist. Propranolol has been used for myocardial infarction; arrhythmia; angina pectoris; hypertension; hyperthyroidism; migraine; pheochromocytoma; and anxiety but adverse effects instigate replacement by newer drugs. Antiadrenergic Drugs)
  • Used in performance-only subtype
  • Inhibits the hyperactive sympathetic symptoms (tremors, tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children, diaphoresis)
• Benzodiazepines Benzodiazepines Benzodiazepines work on the gamma-aminobutyric acid type A (GABAA) receptor to produce inhibitory effects on the CNS. Benzodiazepines do not mimic GABA, the main inhibitory neurotransmitter in humans, but instead potentiate GABA activity. Benzodiazepines ( alprazolam Alprazolam A triazolobenzodiazepine compound with antianxiety and sedative-hypnotic actions, that is efficacious in the treatment of panic disorders, with or without agoraphobia, and in generalized anxiety disorders. Benzodiazepines, lorazepam Lorazepam A benzodiazepine used as an anti-anxiety agent with few side effects. It also has hypnotic, anticonvulsant, and considerable sedative properties and has been proposed as a preanesthetic agent. Benzodiazepines): 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 Receptor Receptors are proteins located either on the surface of or within a cell that can bind to signaling molecules known as ligands (e.g., hormones) and cause some type of response within the cell. Receptors agonist 
  • Shows some evidence in augmenting CBT during exposure Exposure ABCDE Assessment therapy

Differential Diagnosis

• Panic disorder Panic disorder Panic disorder is a condition marked by recurrent and episodic panic attacks that occur abruptly and without a trigger. These episodes are time-limited and present with cardiorespiratory (palpitations, shortness of breath, choking), GI (nausea, abdominal distress), and neurologic (paresthesias, lightheadedness) symptoms. Panic Disorder: a chronic mental disorder marked by recurrent and episodic panic attacks that occur abruptly without a trigger Trigger The type of signal that initiates the inspiratory phase by the ventilator Invasive Mechanical Ventilation. The disorder is associated with anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder or the fear of having another attack or its complications. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder can also suffer from panic attacks; however, these patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship are more concerned with social situations rather than the onset of future panic attacks. 
• Avoidant personality disorders Personality Disorders A major deviation from normal patterns of behavior. Cluster A 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 Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder as both frequently co-occur. The main difference with social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder is the feeling of inferiority and hypersensitivity to criticism.
• Agoraphobia Agoraphobia Agoraphobia is fear or anxiety in a situation that would be difficult to leave or to obtain help in the event that one develops panic-like symptoms. Situations include being in public or open spaces, lines, crowds, or public transport. Agoraphobia: the fear of being in public or open spaces. Agoraphobia Agoraphobia Agoraphobia is fear or anxiety in a situation that would be difficult to leave or to obtain help in the event that one develops panic-like symptoms. Situations include being in public or open spaces, lines, crowds, or public transport. Agoraphobia is best treated with medications ( SSRIs SSRIs Serotonin Reuptake Inhibitors and Similar Antidepressants) and CBT. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with agoraphobia Agoraphobia Agoraphobia is fear or anxiety in a situation that would be difficult to leave or to obtain help in the event that one develops panic-like symptoms. Situations include being in public or open spaces, lines, crowds, or public transport. Agoraphobia may be comforted by other people but those with social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder will feel more anxious. Social anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder disorder can be complicated by or associated with agoraphobia Agoraphobia Agoraphobia is fear or anxiety in a situation that would be difficult to leave or to obtain help in the event that one develops panic-like symptoms. Situations include being in public or open spaces, lines, crowds, or public transport. Agoraphobia, but the 2 are not always seen together.