Social Anxiety Disorder
Social anxiety disorder is characterised by marked fear of social situations where the individual may be scrutinised or judged. It is the third most common mental health disorder.
Key Facts
Lifetime prevalence ~7-12%; typical onset in early-mid teens (mean age 13) Core fear: Negative evaluation by others — embarrassment, humiliation, rejection First-line treatment: Individual CBT based on Clark and Wells model (NICE CG159) SSRI (escitalopram 10-20mg or sertraline 50-200mg) is first-line pharmacological if CBT alone insufficient Performance-only subtype: Fear limited to performance situations (public speaking) — may respond to propranolol PRN Highly comorbid with depression (~50%), other anxiety disorders, alcohol misuse (self-medication), and avoidant personality disorder Often underdiagnosed — patients may not present due to the nature of the disorder (fear of being judged) Liebowitz Social Anxiety Scale (LSAS) is the most widely used clinician-rated measure
Overview
Key Facts
Social anxiety disorder (SAD) is characterised by excessive fear and avoidance of social situations due to concerns about being negatively evaluated. It typically begins in adolescence and has a chronic course if untreated.
Epidemiology
Lifetime prevalence is 7-12%, making it one of the most common mental health conditions. Median age of onset is 13 years. Without treatment, the mean duration is approximately 20 years. Slightly more common in women. Only ~5% of sufferers seek treatment within the first year of onset.
Aetiology
- Genetic: Heritability ~30%; behavioural inhibition in childhood is a key temperamental risk factor
- Neurobiological: Amygdala hyperactivation to social stimuli; reduced serotonergic transmission
- Psychological: Clark and Wells (1995) cognitive model — self-focused attention, safety behaviours, post-event rumination
- Environmental: Bullying, social rejection, overprotective/controlling parenting, modelling of social anxiety by parents
Pathophysiology
Clark and Wells cognitive model:
- Social situation triggers negative automatic thoughts ("They'll think I'm stupid")
- Self-focused attention — internal monitoring of anxiety symptoms
- Safety behaviours — avoid eye contact, rehearse what to say, grip glass tightly (maintain beliefs)
- Post-event rumination — dwelling on perceived failures after the event
- Distorted self-image — exaggerated view of how anxious they appeared to others
This creates a vicious cycle that maintains the disorder and prevents natural disconfirmation of feared outcomes.
Clinical Presentation
Core Features
- Marked fear or anxiety in social situations where scrutinised by others
- Situations include: Conversations, meeting unfamiliar people, eating/drinking in public, performing/speaking in front of others
- Fear of showing anxiety symptoms that will be negatively evaluated (blushing, trembling, sweating, stumbling over words)
- Avoidance of social situations or endured with intense anxiety
- Persistent — ≥6 months
- Functionally impairing: Significant impact on work, education, relationships
Associated Features
- Blushing, trembling, sweating, dry mouth, tachycardia
- Difficulty making eye contact
- Low self-esteem, self-criticism
- Alcohol/substance misuse as self-medication
Red Flags
- Severe avoidance leading to inability to work or attend education
- Comorbid depression with suicidal ideation
- Heavy alcohol use to cope — dependence risk
- Childhood onset without improvement — chronic functional impairment
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| Avoidant personality disorder | Pervasive social inhibition, feelings of inadequacy, hypersensitivity — overlaps significantly | Personality assessment |
| GAD | Worry about multiple domains, not specifically social evaluation | GAD-7 |
| Agoraphobia | Fear of situations where escape is difficult, not fear of judgment | Clinical history |
| Autism spectrum disorder | Social difficulties from pragmatic communication deficits, not fear of judgment | Developmental history |
| Selective mutism | Failure to speak in specific social situations despite ability | Clinical observation |
| Body dysmorphic disorder | Social avoidance due to perceived physical defect | Clinical assessment |
Diagnosis / Investigation
Bedside
- LSAS (Liebowitz Social Anxiety Scale): 24 items — fear and avoidance ratings
- SPIN (Social Phobia Inventory): 17-item self-report
- PHQ-9, GAD-7: Comorbid depression and anxiety
- AUDIT-C: Alcohol screening
- Functional assessment: Impact on work, education, relationships
Bloods
- TFTs: If anxiety symptoms prominent — exclude thyroid dysfunction
- FBC: Baseline if starting medication
Special Tests
- Generally not required — diagnosis is clinical
- Structured clinical interview (SCID) for research/diagnostic certainty
Management
Non-pharmacological (NICE CG159)
- First-line: Individual CBT based on Clark and Wells or Heimberg model (14-16 sessions)
- Identify and test negative predictions through behavioural experiments
- Shift from self-focused to externally-focused attention
- Drop safety behaviours
- Address post-event rumination
- Video feedback to correct distorted self-image
- NOT recommended: Group CBT as first-line (individual CBT is superior for SAD)
- Psychoeducation groups, guided self-help as lower-intensity options
Pharmacological
- First-line: Escitalopram 10-20mg OD or sertraline 50-200mg OD
- Second-line: Venlafaxine 75-225mg OD (SNRI)
- Performance anxiety only: Propranolol 10-40mg PRN 30-60 minutes before event
- Not recommended: Benzodiazepines (dependence risk), MAOIs (dietary restrictions)
- Duration: Continue for ≥12 months after remission
Referral Criteria
- Social anxiety causing significant functional impairment — IAPT referral
- Treatment-resistant (failed CBT + SSRI) — specialist anxiety service
- Severe comorbidity — secondary care psychiatry
- Suspected ASD — neurodevelopmental assessment
Prognosis
- Without treatment: Chronic course — mean duration ~20 years; spontaneous remission rate low (~20-30%)
- Individual CBT (Clark model): ~75% response rate; very well-maintained at follow-up
- SSRIs: ~50-60% response rate; significant relapse on discontinuation
- Combined CBT + SSRI: May be beneficial for severe cases
- Performance-only subtype: Better prognosis; may respond to brief intervention + beta-blocker
- Comorbidity: Depression (~50%), alcohol misuse (~25%), other anxiety disorders — worsen prognosis
- Early onset and long duration before treatment predict poorer response
Other Relevant Information
Clark and Wells Model of Social Anxiety
| Component | Description |
|---|---|
| Activating situation | Social encounter triggering anxiety |
| Negative automatic thoughts | "They'll think I'm boring/stupid" |
| Self-focused attention | Internal monitoring of anxiety symptoms |
| Safety behaviours | Avoid eye contact, rehearse speech, drink alcohol |
| Anxious feelings/symptoms | Blushing, sweating, trembling |
| Post-event processing | Rumination over perceived failures |
Social Anxiety vs Avoidant Personality Disorder
| Feature | Social Anxiety Disorder | Avoidant PD |
|---|---|---|
| Onset | Teens | Early adulthood |
| Self-concept | Fear of specific situations | Pervasive inadequacy |
| Avoidance scope | Social situations | All novel situations/people |
| Treatment response | Good (CBT) | More treatment-resistant |
| Overlap | ~50% meet criteria for both | ~50% meet criteria for both |