Social anxiety disorder: an underappreciated and misunderstood condition.
TALES FROM THE CLINIC
-Series Editor Nidal Moukaddam, MD, PhD
In this installment of Tales From the Clinic: The Art of Psychiatry, we examine a case of social anxiety disorder (SAD), an underappreciated entity that is often confused with shyness and with temperamental disposition. In contrast to shyness, introversion, and temperamental disposition, SAD can cause significant lifelong social impairment. SAD is common and thought to rank third after depressive and addictive disorders worldwide; however, it is often challenging to diagnose because social interactions are heavily modulated by cultural and gender considerations as well as setting-specific considerations including work and school expectations.
“Damien” is a 27-year-old medical trainee who presents to the clinic with a complaint of anxiety exacerbated by social situations. He outlines anxiety that he noted as early as the age of 10: “We have a big family, lots of uncles, aunts, cousins. Going into those gatherings was always so hard even though everyone there cared—and I have known them all since birth!” In high school, he had excellent grades but struggled when he tried taking a communications elective and recalls panic symptoms before a group presentation: “I had sweaty palms and my heart was skipping. I could not collect my thoughts, I must have looked like an idiot.”
The solution Damien devised was to be the note-taker for the group, in which he prepared PowerPoints and did background work. That way, he felt he was still actively participating and his work was appreciated without being in the spotlight. Throughout his adult life, he experienced further challenges; when he tried to ask someone out on a date, and when he had trouble placing his food order in front of others in a restaurant. He jokingly adds being a medical student helps as he can always pretend he is busy, instead of saying he feels uncomfortable in social gatherings. He answers by text rather than calling when he has the chance. Other specific situations included difficulty calling to schedule his own medical appointments and going through mock exams. He finds introducing himself to patients to be challenging and feels his voice is shaky when he presents in rounds.
Damien is presenting to care because he feels his symptoms have brought about significant impairment in his social life and career. His social anxiety has prevented him from meeting new friends and affected his scholarly activities as he feels he cannot present his research findings for fear of getting panicky.
What Is Social Anxiety?
Social anxiety refers to the anxiety occurring directly in conjunction with social situations and the fear of being scrutinized in those situations. The gamut of situations that could trigger social anxiety ranges from meeting or talking to unfamiliar individuals, to presenting or performing in front of others, to acts that are seemingly mundane such as eating with others present (Figure 1). Some anxiety in social situations may be situation-congruent (eg, major presentation that could determine a promotion), but the core of SAD is the underlying layer of negative cognition suggesting to the beholder that they will be judged, ridiculed, or otherwise negatively perceived. A traumatic experience in social settings is not needed as an antecedent of SAD, and the disorder is far-reaching, causing impairment in multiple life functional areas. A duration of 6 months is needed for an SAD diagnosis as per the DSM-5.
As with other anxiety disorders, clinical manifestations must be considered within developmental stage parameters. For instance, in a child, SAD may manifest as refusal to go to school thereby raising the possibility of a separation anxiety disorder. In a teenager or young adult, SAD may interfere with asking others out or engaging with new friends (eg, when starting a new sport or moving to middle/high school or college). In individuals with medical conditions with noticeable movement abnormalities or post-accident/post-surgery disfigurement, some anxiety about interacting with others is common, and the diagnosis of SAD can only be applied in those situations where the anxiety is excessive or unrelated. SAD also includes paruresis, the fear of urinating in a public bathroom.
The prevalence of SAD in the United States is about 7%, with higher prevalence in women than men.1 SAD has a global prevalence ranging from 5% to 10% and a lifetime prevalence of 8.4% to 15%. The prevalence rose slowly from the 1960s to the early 2000s with a preponderance in married, more educated populations.2 The relationship between SAD and problematic internet use is not well understood but a small study in medical students has shown an association between anxiety and excessive internet usage.3 Using alcohol or other substances before or during events to mitigate distress is common in SAD, as is blushing, which is a hallmark physiological response of SAD.4
According to the DSM-5, SAD can have a subtype of performance-only anxiety, which is given when the fear is restricted to speaking or performing in public. This fear could be particularly impairing if/when school or work requires performance in front of others, such as in public speaking class or a musical performance.
Avoidance of the feared situation is a common feature of SAD. In history taking for patients, it is essential to ask about what situations were missed because of fear, and what the costs of those avoidant behaviors has been professionally and personally on the individual. Less severe manifestations include a high level of anticipatory anxiety, over-preparation, or only joining the event with a companion or some assistance.
Screening for comorbid conditions is essential, and clinicians should inquire about other anxiety disorders, alcohol or other substance use, and mood disorders, especially depression. Diagnosis of SAD is facilitated by the Social Phobia Inventory and the Liebowitz Social Anxiety Scale.
Management strategies for SAD involve a combination of 2 primary treatment approaches, namely psychotherapy and focused pharmacologic intervention. Treatment also varies between adults and children/adolescents. Details outlining each treatment strategy are delineated here and in Figure 2.
Cognitive-behavioral therapy (CBT) remains the recommended first line psychotherapeutic intervention for SAD in both adults and younger patients. There are also mindfulness and acceptance-based therapies, which include acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), and in vivo exposure—all of which aim to provide disconfirming evidence for cognitive distortions related to social expectations. While the focus in adults lies on guided interactive sessions between the psychiatrist and the patient, in younger patients, the parents are also included in the physician-patient interaction.5,6
Typically, 15 to 20 CBT sessions are administered ranging from 1 to 1.5 hours in length focusing on a multitude of practices: gradual exposure to social situations that incite fear after preparation of a rank ordered list of such scenarios, with the least terror inducing situation being the point of initiation in order to achieve habituation and extinction which lead to reductions in fear7; exercises emphasizing cognitive restructuring before and after said exposures, which have been demonstrated to reduce social phobia and promote positive cognition8; alteration of strongly held core beliefs which have been shown to improve quality of life in patients with social phobias9 and the prevention of relapse to following avoidant behaviors. In young individuals, additional focus on parental education on the disorder is applied and parents are taught how to reinforce acceptable ways of addressing anxiety inducing situations. Variations of CBT with social skill training are also included in the management plan.10
First line pharmacotherapies that have clearly demonstrated efficacy in reducing social anxiety and improving quality of life include selective serotonin reuptake inhibitors (SSRI) and serotonin–norepinephrine reuptake inhibitors (SNRI) such as paroxetine, sertraline, fluvoxamine, and venlafaxine. Citalopram, escitalopram, and vilazodone have also shown promise, and tend to be more effective than fluoxetine. Minimum treatment durations of 4 to 6 weeks are needed for a notable benefit. Paroxetine and sertraline are the 2 most impactful drugs in the treatment of SAD, owing to their exceptional relapse prevention rates11 and a 10 to 50 mg/day dose of paroxetine is considered the gold standard for the best response rates (>50%) if overall adverse effects are taken into account.12 While some clinical studies have shown monoamine oxidase inhibitors like phenelzine to possess astounding response rates (> 80%), the diverse host of adverse effects attributed to them prevents them from being recommended as a first line option.13
Finally, while psychotherapy and pharmacologic intervention are rarely combined for the treatment of SAD, evidence demonstrating the benefit of combination CBT and paroxetine is beginning to accumulate and it would not be surprising to see future guidelines reflecting these changes.14 A major change in the treatment of SAD could be brought about by the recent positive results of nasal anti-anxiolytics such as PH94B/fasenediol: antidepressant and anti-anxiolytic effects of pherine molecules can provide a short-acting, as needed administration, treatment tool to be used before anxiety-provoking situations. Pherine molecules [neuroactive steroids], when sprayed intranasally, interface with the olfactory bulb which then feedback into gamma-aminobutyric acid and corticotropin-releasing hormone neurons in the limbic amygdala.14
SAD is a common and significant disorder that carries silent suffering, and contributes to depression, underemployment, and overall lack of ability of achieving one’s socio-educational potential. Increased screening and recognition are essential for proper diagnosis, and psychotropic and psychotherapeutic options can be effective.
Dr Altai is a resident at the University of California, San Francisco. Dr Chaudry is a graduate of and research associate at the Aga Khan University. Dr Moukaddam is an associate professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, as well as the Harris Health Outpatient Psychiatry Adult Outpatient Services director and the medical director of the Stabilization, Treatment & Rehabilitation (STAR) Program for Psychosis, also at Baylor College of Medicine. She also serves on the Psychiatric Times Advisory Board.
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