Learning Objectives

1.    Identify the core features and impact of social anxiety disorder (SAD) the occupational and social functioning of individuals.

2.    Differentiate SAD from other disorders that may present with similar symptoms, such as avoidant personality disorder and autism spectrum disorder. 

3.    Evaluate pharmacological and psychotherapeutic treatment options for SAD, including their effectiveness and potential side effects.

---

The American writer and philosopher Henry David Thoreau once said, “Public opinion is a weak tyrant when compared with our own private opinion.”
Worrying about how others will evaluate us is an almost universal human experience. While most of us can overcome these worries, for people with social anxiety disorder (SAD), the fear of being scrutinized does indeed become a tyrannical force.

The core feature of SAD is an intense fear of humiliation, embarrassment, rejection, or offending or boring others in situations such as social interactions, when being observed by other people, and when performing (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association (APA); 2013).

For patients with SAD, going on a date or attending a party with unfamiliar people, giving a speech at a wedding or at a work meeting, eating or drinking in front of others, and even urinating in a public bathroom can cause extreme worry before and during the activity. Their anxiety is further compounded by excessive worry about others being able to see the anxiety (eg, due to sweating, a shaking voice, trembling hands, or blushing).

People with SAD often go to great lengths to avoid detection of their internal state. For example, patients who are worried about others noticing them sweating may carry a napkin or towel around to wipe sweat away. Patients with SAD either endure these situations despite significant discomfort or avoid them altogether.
Understandably, this leads to significant occupational and social dysfunction. For instance, people may opt out of pursuing promotions at work that would entail public speaking or meeting new clients, and they often have trouble meeting new friends or developing romantic relationships.

Defining SAD
Since its introduction in the DSM-III in 1980 as "social phobia," the diagnosis of SAD has evolved from being considered a circumscribed, highly specific phobia (eg, a person only experiences anxiety when being interviewed but not in other circumstances) to our current understanding of a broader, more generalized anxiety affecting most social relationships and interactions.

In fact, most patients with SAD struggle with anxiety in numerous settings. One study showed that 93% of people with SAD felt fearful in three or more social situations, and only 2.7% identified just one social situation as causing extreme anxiety (Grant BF et al, J Clin Psychiatry 2005;66(11):1351–1361). There does seem to be a small subgroup of people with SAD whose fear is limited to performance settings, and there is a “performance only” specifier in DSM-5. This is most relevant for people who are musicians, athletes, or performers, where performance anxiety is likely to have a large negative impact on their livelihood.

SAD has a lifetime prevalence of 5%–8% (Ruscio AM, et al, Br J Psychiatry 2017;210(2):119-124). It is slightly more common in women than in men, in contrast to most other anxiety disorders, which are much more prevalent in women than in men (McLean CP et al, J Psychiatr Res 2011;45(8):1027–1035).

For those of us working with children and adolescents, it is particularly important to remember that the onset is typically in childhood and adolescence (the average age is 15 years old, but many people report very early onset before five years old). Onset after early adulthood is rare (Grant et al, op.cit). To be diagnosed with SAD, children must experience anxiety around both their peers and adults, beyond the standard social discomfort that is common in adolescents.

Additionally, since children’s capacity to report feelings like fear and anxiety is developmentally limited, their worry may be evident by behaviors such as crying, tantrums, clinging, or failing to speak in social situations. (It’s important to consider selective mutism as an alternative diagnosis for a child who refuses to speak.)
Notably, there is often a significant delay between onset of symptoms and treatment, with one sample reporting an average delay of 12 years (Grant et al, op.cit). While the DSM-5 includes a suggested (but not required) duration of at least six months, most people will have suffered for much longer before seeking treatment.

Comorbidities and Other Possible Diagnoses 
People with SAD have a significantly higher rate of several other disorders. Nearly 65% meet criteria for another anxiety disorder and approximately 50% have a comorbid mood disorder. Substance use disorders are also significantly more common in those with SAD: with a 27% comorbidity rate (Stein DJ et al, BMC Med 2017;15(1):143).

Social anxiety may present as a symptom in the context of (and be better explained by) several other disorders. For example, people with Asperger’s disorder often experience discomfort in social settings. They have impairment in nonverbal behaviors that negatively impact their social interactions, and they are often aware that they interact in a way that is different from most people.

However, they do not necessarily experience the classic physiologic symptoms (and worry about them) that characterize SAD. While they may be aware of some impairment, social anxiety itself is not a symptom.

Therapists should also consider the possibility of avoidant personality disorder for a patient presenting with social phobia symptoms. These patients experience extreme self-consciousness and fear of rejection and tend to be extremely critical of themselves in social interactions. They avoid close relationships unless they feel certain they will not be ridiculed.

It can be very difficult to distinguish those with severe, chronic, generalized social phobia from those with avoidant personality disorder. Both are understandably socially and occupationally impaired, and both experience social anxiety as highly ego dystonic. One clue may be that those with SAD are usually primarily focused on their own internal state. In addition to this trait, people with avoidant personality disorder also tend to pay very close attention to others' behavior and reactions, to monitor for signs of rejection.

Finally, it’s important to consider whether social anxiety is better explained by another anxiety or a mood disorder. For instance, hypersensitivity to rejection is often present during episodes of major depression.

Another example is someone with post-traumatic stress disorder who feels hypervigilant in public or crowded places. This person may describe hyperarousal (eg, tremulous hands, shaking hands or voice) that is quite similar in nature, but different in origin, to that seen in SAD. These things should be kept in mind when evaluating patients for SAD.

Treatment Overview
The treatment of SAD can be broadly categorized into two primary approaches: pharmacological treatments and psychotherapy. These treatments can be used individually, but in many cases, a combination of both approaches can be particularly effective.

Pharmacological Treatment
1. Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs): These antidepressants have been demonstrated to be effective in reducing the symptoms of SAD. Examples include fluoxetine (Prozac), sertraline (Zoloft), venlafaxine (Effexor), and escitalopram (Lexapro). (Bandelow B et al, International Clin Psychopharmacology 2015,32(4),183-192).
2.    Benzodiazepines: These drugs, such as alprazolam (Xanax) and clonazepam (Klonopin), provide rapid relief from acute symptoms of anxiety but are usually not the first line of treatment due to the risk of dependency and withdrawal symptoms.
3.    Beta Blockers: These drugs, including propranolol (Inderal), can help manage some of the physical symptoms of SAD, such as trembling and rapid heartbeat.
4.    Monoamine Oxidase Inhibitors (MAOIs): Antidepressants such as phenelzine (Nardil) have been found effective in treating SAD, but they are typically considered only when other treatments have been unsuccessful due to their risk of severe side effects.
Each of these treatments has potential side effects and risks, and it is important to have an ongoing discussion with a healthcare provider about the most suitable option.

Psychotherapy Approaches
1. Cognitive-Behavioral Therapy (CBT): This is currently the most effective therapeutic approach for treating SAD. CBT focuses on identifying, understanding, and changing thought and behavior patterns related to anxiety. Techniques such as cognitive restructuring, exposure exercises, and social skills training are commonly used. (Mayo-Wilson E et al, Lancet Psychiatry 2014;1(5):368-376).
2.    Mindfulness-Based Stress Reduction (MBSR): This is a form of meditation therapy that helps patients focus on the present moment, which can reduce symptoms of social anxiety.
3.    Group Therapy: Many people with SAD benefit significantly from group therapy, as it offers a safe and supportive environment in which they can practice social interactions and receive feedback.
4.    Acceptance and Commitment Therapy (ACT): This is a type of cognitive-behavioral therapy that uses acceptance and mindfulness strategies to help people live with their anxiety rather than fighting or avoiding it.
5. Psychodynamic Psychotherapy: Despite some controversy, psychodynamic psychotherapy has been shown to be efficacious though perhaps not as effective as CBT for this problem. However, certain patients may do better in a dynamic vs. CBT treatment (Leichsenring F et al, Am J Psychiatry 2013;170(7):759-767).

Tips for Psychotherapy
Regardless of which type of therapy you choose to use with you SAD clients, here are some strategies that are likely to be helpful for most clients.
1.    Slow the pace: In cognitive-behavioral therapy, for instance, allow patients to move at their own pace, gradually introducing cognitive restructuring or exposure exercises when they're ready.
2.    Continuous reinforcement: Continually reinforce the concept that their value as a person isn't determined by others' opinions. This might require persistent work on boosting self-esteem and self-worth.
3.    Encourage self-care: Encourage your patients to engage in self-care practices that can reduce their anxiety, such as regular physical exercise, a balanced diet, adequate sleep, and mindfulness exercises.
4.    Homework assignments: Provide homework assignments like journaling or role-play exercises to help them practice and internalize strategies discussed during the therapy session.

CARLAT TAKE: 
SAD represents a significant challenge for those who experience it, affecting their daily life, relationships, and performance in various spheres. As therapists, our role is not only to diagnose accurately but also to offer comprehensive, empathetic treatment that respects the client's pace and provides them with useful, realistic strategies to manage their symptoms. By doing so, we can guide our patients towards a greater understanding and mastery of their social anxiety, ultimately leading them to a higher quality of life and the freedom to engage more fully in the world around them.

Citations in order of appearance in this article
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Association.

Grant, B. F., et al. (2005). Prevalence, correlates, and comorbidity of DSM-IV generalized anxiety disorder in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Journal of Clinical Psychiatry, 66(11), 1351–1361

Ruscio, A. M., et al. (2017). Social fears and social phobia in the USA: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. British Journal of Psychiatry, 210(2), 119-124

McLean, C. P., et al. (2011). Gender differences in anxiety disorders: Prevalence, course of illness, comorbidity, and burden of illness. Journal of Psychiatric Research, 45(8), 1027–1035.

Stein, D. J., et al. (2017). Social anxiety disorder: evidence-based treatment, research, and new directions for psychological interventions. BMC Medicine, 15(1), 143.

Bandelow, B., et al. (2017). Efficacy of treatments for anxiety disorders: a meta-analysis. International Clinical Psychopharmacology, 32(4), 183-192.

Mayo-Wilson, E., et al. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), 368-376.

Leichsenring, F., et al. (2013). Psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: A multicenter randomized controlled trial. American Journal of Psychiatry, 170(7), 759-767.