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Social Anxiety Disorder: A Common, Underrecognized Mental Disorder

American Family Physician, Nov 15, 1999 by Timothy J. Bruce, Sy Atezaz Saeed

Social phobia is a highly prevalent yet often overlooked psychiatric disorder that can cause severe disability but fortunately has shown responsiveness to specific pharmacotherapy and psychotherapy. Recognition of its essential clinical features and the use of brief, targeted screening questions can improve detection within family practice settings. Cognitive behavioral therapy, with or without specific antidepressant therapy, is the evidence-based treatment of choice for most patients. Adjunctive use of benzodiazepines can facilitate the treatment response of patients who need initial symptom relief. The use of beta blockers as needed has been found to be helpful in the treatment of circumscribed social and performance phobias. Treatment planning should consider the patient's preference, the severity of presenting symptoms, the degree of functional impairment, psychiatric and substance-related comorbidity, and long-term treatment goals. (Am Fam Physician 1999;60:2311-22.)

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For years, social anxiety disorder, also known as social phobia, has been underrecognized and undertreated. That situation is beginning to change, however, because recent research has shown that the disorder is highly prevalent, chronic in its untreated course, often associated with comorbid mental and substance-related problems, and capable of disabling those who have it. We now know more about recognizing social phobia and the types of interventions to which it is responsive.

Clinical Features

The Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV),(1) describes social phobia as an intense, irrational and persistent fear of being scrutinized or negatively evaluated by others (Table 1). In patients with this disorder, feared social or performance situations typically provoke an immediate anxious reaction ranging from diffuse apprehension to situational panic. The types of fears and avoidance commonly associated with social phobia (Table 2) are, to some degree, experienced by most people. However, to meet the diagnostic criteria for this disorder, the symptoms must be severe enough to cause significant distress or disability. Social phobia can be generalized, meaning that the patient fears many or most social interactions, or it can be limited to one or a few situations, such as public speaking or performing.

In social phobia, fear and avoidance typically develop into a vicious cycle that can become severely distressing, debilitating and demoralizing over time. Although patients are usually aware that their fears are unreasonable, they still find themselves experiencing significant dread before facing a feared social encounter. The encounters themselves often evoke physical sensations of anxiety (e.g., blushing, sweating) and a preoccupation with possible embarrassment or humiliation. Encounters may be endured with distress or, more typically, avoided--either subtly (e.g., by modifying one's interactions within encounters) or overtly (e.g., by nonattendance). These various forms of avoidance preclude any change in the patients's core pathologic social fears and cause significant distress or functional impairment.

It should be noted that not everyone who suffers from social phobia appears shy, withdrawn or overtly nervous. Presentation of symptoms varies widely (Table 3). In some situations, the patient may not appear anxious, thus obscuring the underlying fear, avoidance, distress and disability.

Epidemiology, Course and Disability

Recent epidemiologic studies report that social phobia has a lifetime prevalence rate of 13.3 percent and a one-year prevalence rate of 7.9 percent in community samples, making it the third most prevalent psychiatric disorder, following substance abuse and depression.(2) In community samples, circumscribed fears of public speaking or performing are most prevalent. In clinical samples, generalized fears of many social interactions predominate, perhaps because of the greater likelihood of disability, and consequent help-seeking, in generalized social phobia.

Onset of social phobia typically occurs between 11 and 19 years of age. Onset after age 25 is rare,(3,4) although it is not uncommon for an existing social phobia to remain unprovoked for years until some new social or occupational demand (e.g., meeting new people, public speaking, promotion) forces these persons into social encounters that trigger the syndrome. Slightly more females than males have social phobia.(3) In one study,(5) about one half of the patients reported that their phobia began in response to a specific embarrassing experience; the others reported that it had been with them for as long as they could remember.

Untreated, social phobia is chronic and unremitting. Selective avoidance of social situations may temporarily reduce symptoms but usually leaves underlying fears intact. Disability from social phobia can be pervasive and severe. Approximately 85 percent of patients with the disorder experience academic and occupational difficulties caused by their inability to meet the social demands of securing and maintaining employment or relationships. In one epidemiologic sample,(3) nearly one half of those with social phobia were unable to complete high school; 70 percent were in the lowest two quartiles of socioeconomic status; and approximately 22 percent were on welfare.

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Social Anxiety Disorder: A Common, Underrecognized Mental Disorder

American Family Physician, Nov 15, 1999 by Timothy J. Bruce, Sy Atezaz Saeed

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