Social Anxiety Disorder

1. Epidemiology
   1. Prevalence: very common
      1. Lifetime Prevalence: 13.3%
      2. Annual Prevalence rate: 7.9%
   2. Onset
      1. Peaks between ages 11 and 19 years old
      2. Rarely has onset after age 25 years
2. Symptoms: Common Social Phobia Fears
   1. Attending social gatherings
      1. Public speaking or performance
      2. "Small Talk"
      3. Small group discussion
      4. Asking questions in groups
      5. Being introduced
      6. Meeting or talking with strangers
      7. Interacting with "important" people
      8. Being assertive
   2. Performing activities in public
      1. Being observed performing an activity
      2. Indirect evaluation (Test anxiety)
      3. Using the telephone
      4. Using public restrooms
3. Diagnostic Criteria (DSM IV)
   1. Marked and persistent fear of social situations
      1. Exposure to unfamiliar people
      2. Exposure to scrutiny by others
      3. Performance before others
   2. Person fears humiliation or embarrassment
   3. Fear unrelated to underlying medical condition
      1. Trembling in Parkinson's Disease
      2. Abnormal eating in eating disorder
   4. No other psychiatric condition explains symptoms
      1. See Differential Diagnosis below
   5. Exposure to feared social situation results in anxiety
      1. Panic Attack may occur
   6. Person has insight into fear as unreasonable, excessive
   7. Person avoids feared social or performance situations
   8. Impaired function or distress related to Social Phobia
      1. Interferes with normal daily routine
      2. Interferes with occupational or academic functioning
      3. Interferes with social activities or relationships
   9. Special criteria modifications in children
      1. Anxiety related to peer setting
      2. Anxiety expressed by crying, tantrums, or withdrawal
      3. Child may not have insight into unreasonable fear
      4. Duration persists >6 months in age under 18 years
4. Differential Diagnosis
   1. Avoidant Personality Disorder
   2. Schizoid Personality Disorder
   3. Panic Disorder
   4. Separation Anxiety Disorder
   5. Body Dysmorphic Disorder
   6. Developmental disorder
   7. Substance Abuse
5. Management: Cognitive-Behavioral Therapy
   1. Background
      1. Offered as 16 to 24 weekly sessions
      2. Group therapy preferred over individual counseling
      3. Total Cost: $750 to $2000 (Insurance covers 50-80%)
   2. Anxiety Management skills
      1. Relaxation and calming techniques
   3. Social skills training
      1. Initiating and maintaining conversation
      2. Making appropriate eye contact
      3. Appropriate self-assertion
   4. Cognitive restructuring
      1. Change fearful thinking about social situations
   5. Gradual exposure to feared situations
      1. Gradual challenges into feared social situations
6. Management: Medications
   1. SSRI (50-75% efficacy)
      1. Paroxetine (Paxil)
      2. Fluvoxamine (Luvox)
   2. MAO inhibitors (66% efficacy)
      1. Phenelzine (Nardil)
   3. Benzodiazepine (40-80% efficacy)
      1. Clonazepam (Klonopin) 0.25 to 0.5 mg PO bid
   4. Beta Blocker (for Performance Anxiety, 45 min before)
      1. Propranolol (Inderal) 20-40 mg PO prn performance
      2. Atenolol (Tenormin) 50 to 100 mg PO prn performance
7. References
   1. APA (1994) DSM IV, APA, p. 416-7
   2. Bruce (1999) Am Fam Physician 60(8): 2311-2320
   3. Weiller (1996) Br J Psychiatry 168: 169-74