Continuing Education Activity

Social anxiety disorder (SAD) includes the essential feature of marked fear or anxiety of one or more social situations during which the individual may or may not be under scrutiny by others. Exposure to such a social situation almost always provokes fear or anxiety in the affected individual, and the individual experiences concern that they will be judged negatively. These individuals often avoid the social situations that they fear or endure with intense anxiety, which results in impairment in social, occupational, or other realms important to function in society. This activity describes the evaluation and treatment of social anxiety disorder and reviews the role of the interprofessional team in managing patients with this condition.

Objectives:

• Describe the etiology of social anxiety disorder.
• Explain how to evaluate for social anxiety disorder.
• Outline the management options available for social anxiety disorder.
• Review some interprofessional team strategies for improving care coordination and communication to educate patients and professionals about social anxiety disorder and improve outcomes.

Introduction

Social anxiety disorder (SAD) is characterized by excessive fear of embarrassment, humiliation, or rejection when exposed to possible negative evaluation by others when engaged in a public performance or social interaction. It is also known as social phobia. Over fifty years ago, in 1966, social phobia was first differentiated from agoraphobia and specific phobias. Since that time, the concept has transformed from being a relatively rare and neglected condition to one that is recognized as prevalent throughout the world.[1] The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 described social phobia in a way that limited the diagnosis due to exclusionary criteria, including those with an avoidant personality disorder, a new category at the time. In 1985 that view was challenged, and by 1987 the  DSM-III-R removed the exclusion. In 1994, DSM-IV added the alternative name of SAD due to a recognition that social phobia could be differentiated from specific phobias due to important pathophysiological and clinical factors. With the publication of DSM-5 in 2013, SAD became the primary name.[2] With the publication of DSM-5, the diagnostic criteria for SAD have been broadened from previous editions to include fear of acting in a way or showing anxiety symptoms that offend others or lead to rejection in addition to fear of humiliation or embarrassment.[3] Additionally, the latest edition of DSM removed the generalized subtype and added the "performance only" specifier.[4]

Etiology

Family and twin studies suggest that genetic factors' role as an etiological factor in social anxiety disorder is believed to be largely dependent on environmental factors.[5] Genetic markers have been difficult to identify. Parenting that is overly controlling, or intrusive may result in inhibited temperament in children, increasing the risk for SAD. Adverse and stressful life events may also increase risk. A search for neurobiological factors associated with SAD has been largely non-specific. Advances in neuroimaging technology may increase insight into the disorder in the future. Recent evidence suggests the 'extended amygdala' to be an essential region in anxiety disorders.[1]

Epidemiology

Epidemiological studies have shown that social anxiety disorder has a worldwide prevalence of 5 to 10% and a lifetime prevalence of 8.4 to 15%.[6] Prevalence rates are comparable within the United States. The prevalence rates in children and adolescents are similar to those of adults. Social anxiety disorder more commonly affects women than men. Social anxiety disorder is the third most common mental disorder behind substance use disorder and depression and is the most common anxiety disorder.[7]

Pathophysiology

Studies in the past have found that persons with performance-type social anxiety disorder may have a greater response of the autonomic nervous system, including elevated heart rate.[8] Additionally, multiple neurotransmitter systems, including serotonin, dopamine, and glutamate, may be implicated in the pathogenesis of social anxiety disorder.[9][10] Brain imaging of those with social anxiety disorder reveals the increased activity of paralimbic and limbic circuitry.[11] Certain temperaments of toddlers and maternal stress have also been shown to be associated with persons that develop a social anxiety disorder.[12]

History and Physical

The majority of individuals with social anxiety disorder will report the onset of symptoms before 20 years old when obtaining a history. Many will report symptoms beginning in early childhood. Social anxiety is a chronic disorder, typically lasting for 6 months or more. Individuals with SAD are more likely to be less educated, unmarried, and have lower socioeconomic status. Additionally, many patients with SAD may not seek treatment because they believe the social anxiety to be part of their personality structure and therefore does not require treatment.[7] Patients with SAD frequently present to physicians because of other disorders, including major depression or substance use and related disorders.[5]

Evaluation

Evaluation of social anxiety disorder must include its diagnostic criteria as classified in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). Criteria include pronounced fear or anxiety around one or multiple social situations where a person is possibly exposed to the possible scrutiny of others. The person fears they will act a certain way that may be evaluated negatively. The social situation, for the most part, provokes anxiety or fear. The situations are either endured with anxiety or fear or avoided entirely. This fear or anxiety is disproportionate to the threat actually posed by the situation. The avoidance, fear, or anxiety lasts typically for at least 6 months and causes significant impairment or distress in an important area of functioning. The fear must not be attributable to the effects of a substance or medical condition or the symptoms of a different mental disorder.  Additionally, the anxiety, avoidance, or fear is excessive or unrelated if a separate medical condition is present. There is a performance only specifier if fear is restricted exclusively to performing or speaking in public.

A core feature of SAD is the fear of negative evaluation. Instruments that assess for SAD include but are not limited to Social Phobia Inventory (SPIN), Mini-SPIN, Liebowitz Social Anxiety Scale (LSAS), Liebowitz Self-Rated Disability Scale, Disability Profile, Brief Social Phobia Scale (BSPS), and Social Phobia Safety Behaviors Scale and Self Statements During Public Speaking Scale.[13] There is evidence that the items on SPIN capture multiple symptoms of SAD, including fear of negative evaluation, distress as a result of physical symptoms of anxiety, and the fear of uncertainty when in social situations.[14] Patients with SAD may speak quietly or offer cursory answers to questions. In addition, eye contact is often less than normal. Often, individuals with SAD will reveal their symptoms with direct questioning.[15]

Treatment / Management

There is a large amount of evidence supporting the efficacy of medications and cognitive behavioral therapy (CBT) in social anxiety disorder.[15] According to meta-analysis, SAD responds well to treatment with individual CBT and selective serotonin reuptake inhibitors (SSRIs). Additionally, serotonin-norepinephrine reuptake inhibitors (SNRIs) have a greater effect on outcomes than placebo. The SSRIs sertraline and paroxetine, as well as the SNRI venlafaxine, have FDA approval. Comparing different psychotherapies, SAD responded better to CBT than psychodynamic therapy and other psychological therapies. The beta-blocker propranolol, as well as benzodiazepines, are also used in the treatment of social anxiety disorder. Propranolol has the advantage of being used on an as-needed basis without the risk of developing dependence and tolerance, as exists with benzodiazepines. Currently, there is a lack of evidence that a combination of pharmacological and psychological interventions is more efficacious than monotherapy either.[16] A comparison of pharmacotherapy and psychotherapy trials suggests medication has faster effects, but CBT has longer-lasting effects.[15]

Differential Diagnosis

Social anxiety disorder must be differentiated from other disorders, including neurodevelopment disorders such as autism spectrum disorder, panic disorder and agoraphobia, depressive disorders, substance-related and addictive disorders, body dysmorphic disorder, and personality disorders such as schizoid personality disorder and avoidant personality disorder. As indicated in the DSM-5 criteria, to make a diagnosis of social anxiety disorder, the individual's symptoms must not be better explained by symptoms of another mental disorder.  Other diagnoses to rule out include hikikomori, an extreme form of social withdrawal lasting more than 6 months, occurring among 1.2% of adults in Japan, and schizophrenia.[5]

Prognosis

Left untreated, social anxiety disorder is recognized as a debilitating and highly prevalent disorder that may result in lower educational attainment, worse occupational performance, hampered social interaction, lower-quality relationships, and decreased quality of life. SAD is associated with suicidal ideation, low self-esteem, lower socioeconomic status, unemployment, financial issues, and being unmarried. Many individuals with SAD are not aware of their mental health problems and, therefore, do not seek treatment.[17][18]

Complications

Comorbid psychiatric disorders occur in up to 90% of patients with SAD. SAD's presence is a predictor for the development of major depression and alcohol use disorder. Patients who have comorbid psychiatric disorders have an increased likelihood of greater severity of symptoms, treatment resistance, decreased functioning, and increased rates of suicide.[6] 

Deterrence and Patient Education

Many patients with social anxiety disorder do not realize they have a treatable illness and, therefore, do not seek treatment. Patient education, including educating the public, is an essential part of treating and preventing this disorder.[7]

Enhancing Healthcare Team Outcomes

As discussed previously, the education of patients and the public is a vital part of the management and prevention of social anxiety disorder. Recognition of SAD is poor and requires more effort from healthcare professionals to recognize it, as individuals with the disorder are unlikely to self-report it due to their symptoms. SAD is the third most common mental illness affecting a significant proportion of the general population in their lifetimes. An important role of a primary care physician is to recognize the illness and either treat the disorder themselves or refer to a mental health specialist who has experience with the condition.[19] Evidence shows that social anxiety disorder is highly treatable with either cognitive behavioral therapy (CBT) or pharmacotherapy in the form of SSRIs and SNRIs or beta-blocker.[16] [Level 1]