Social Anxiety Disorder

Risk factors

• Behavioral inhibition in childhood (temperamental risk)
• Family history of anxiety disorders
• Parental overprotection or criticism
• Adverse childhood experiences, bullying
• Female sex
• Stuttering, visible difference, or other condition drawing attention

Pathophysiology

Hyperactive amygdala and insular response to social-evaluative cues with reduced prefrontal regulation. Heritable component (~30-40%). Serotonergic and GABAergic dysregulation implicated.

Clinical presentation

Differential diagnosis

• Panic disorder — Unexpected panic attacks NOT cued specifically by social/performance situations; concern is about the attacks themselves
• Agoraphobia — Fear of escape difficulty in ≥2 of 5 situations (transit, open/enclosed spaces, crowds, outside home alone); the fear is of incapacitation, not evaluation
• Generalized anxiety disorder — Excessive worry across multiple domains (work, health, finances) — not focused on social evaluation
• Avoidant personality disorder — Pervasive lifelong pattern of social inhibition + feelings of inadequacy + hypersensitivity to negative evaluation; high overlap with SAD
• Body dysmorphic disorder — Fear of being judged is specifically because of perceived appearance flaw
• Autism spectrum disorder — Social difficulty stems from communication and reciprocity deficits, not fear of evaluation
• Substance/medication-induced anxiety — Caffeine, stimulants, withdrawal states; temporal link

Diagnostic workup

Diagnostic algorithm

flowchart TD
  A[Fear of social situations] --> B{Fear of negative<br/>evaluation by others?}
  B -->|No| C[Consider panic d/o,<br/>agoraphobia, OCD]
  B -->|Yes| D{Situations<br/>almost always<br/>provoke anxiety?}
  D -->|No| E[Subthreshold —<br/>monitor]
  D -->|Yes| F{Duration ≥6 mo<br/>+ impairment?}
  F -->|No| G[Re-evaluate]
  F -->|Yes| H{Restricted to<br/>performance only?}
  H -->|Yes| I[SAD, performance-only<br/>→ CBT ± propranolol PRN]
  H -->|No| J[SAD, generalized<br/>→ CBT + SSRI/SNRI]

Treatment

Complications

• Major depressive disorder (lifetime comorbidity >50%)
• Alcohol and other substance use disorders
• Educational underachievement, job loss, social isolation
• Suicidal ideation, particularly with comorbid depression

PANCE pearls

• Paroxetine, sertraline, venlafaxine XR, and fluvoxamine carry FDA indications for SAD; clinical effect typically requires 8-12 weeks.
• Beta-blockers are appropriate for performance-only SAD; they do NOT treat generalized SAD.
• Onset in childhood/adolescence is the rule — late-onset SAD should prompt search for medical or substance contributors.
• Screen all SAD patients for alcohol use disorder; the two are tightly linked.
• CBT with graded exposure produces longer-lasting benefit than medication and should be offered to all patients.

References

• DSM-5-TR — American Psychiatric Association. DSM-5-TR. 2022.
• NICE CG159 — National Institute for Health and Care Excellence. Social Anxiety Disorder: Recognition, Assessment and Treatment. 2013 (reviewed).
• APA 2009 — American Psychiatric Association Practice Guideline for the Treatment of Patients with Panic Disorder, 2nd ed (covers anxiety-spectrum principles).