22nd February 2024

Social Anxiety Disorder

Background

Social anxiety disorder, also known as social phobia, is associated with a constant fear of being humiliated, judged, or embarrassed. It often occurs in a social setting or where some sort of performance is required. It can include meeting or talking to new people, social gatherings, eating in public, giving a presentation or anything involving being in public. Whilst these situations can induce anxiety in the average person, in individuals with social anxiety disorder this fear is often out of proportion and they will worry excessively before, during and after these situations. This can be due to a previous experience or fear of potential outcomes from a scenario. They can worry about saying or doing the wrong thing, coming across negatively, or humiliating themselves. It is also common in children and young adults and may present with crying, freezing, or having tantrums when in social situations.  It is associated with distress and anxiety, which leads to avoidance of social settings, which can impact the individual’s ability to go to work, school and socialise. It is also associated with somatic symptoms such as tachycardia, palpitations, sweating, shaking, nausea, and panic attacks. Due to the debilitating nature of social anxiety disorder, there is substantial comorbidity between this and depression, substance misuse, panic disorder, GAD and PTSD.  The average age of onset is believed to be 13 years. Most sufferers don’t seek treatment, and if they do, they may wait decades after onset to do so. Social anxiety disorder is often undiagnosed in primary care settings due to poor recognition or awareness. Often, individuals will be diagnosed with depression, anxiety or panic disorders without the underlying social anxiety disorder being identified or addressed. 

 Risk factors include female gender, a family history, shyness in childhood and being behaviourally inhibited. 

Presentation

• Fear of other people noticing that they are overly anxious.
• Avoidance of social situations
• Avoidance behaviours such as not making eye contact or not starting conversations.
• Individuals may concentrate on things they feel they have done incorrectly, berate themselves, and feel depressed as a result. 
• Show symptoms of panic or have a panic attack in a social setting e.g., eating in public
• Negative emotions

Investigations

If a social anxiety disorder is suspected, the 3-item Mini-Social Phobia Inventory (Mini-Spin) or the following two questions can be asked as screening tools:

2 questions used for screening:

• Do you avoid social settings or activities?
• Do you become scared or embarrassed in social situations?

If the patient answers yes to one of the above questions or scores >6 on the Mini-Spin tool, they should be referred for further testing. 

Social anxiety disorder assessment tools: 

• The Social Phobia Inventory (SPIN) is sensitive and specific for social anxiety disorder – It is a 17-item questionnaire, with each question rated out of 5. Scores range from 0-68. A SPIN score of 21-30 = mild social phobia, 31-40 = moderate phobia, 41-50= severe phobia and >50= very severe phobia
• The Liebowitz Social Anxiety Scale (LSAS) assesses how much of an impact social anxiety disorder has on different activities of daily living. It is commonly used to measure response to treatment. It is a 24-item questionnaire, scores range from 0-144.  A score of 0-29 indicates no social anxiety disorder, 30-49 indicates mild social anxiety, 50-64 moderate social anxiety, 65-79 marked social anxiety, 80-94 severe social anxiety and >95 very severe social anxiety.

Diagnosis

Diagnosis is made by considering both the patient’s symptoms and diagnostic tools such as SPIN and LSAS.

Individuals with suspected social anxiety disorder may find it difficult to attend appointments in person. Therefore, alternative ways of initial assessment should be used, for example, online or telephone consultations. 

A thorough history should be taken including what the patient fears, their levels of avoidance, and the level of impairment to day-to-day activities. Many patients have comorbid mood, anxiety, personality and alcohol and substance misuse disorders. These should also be considered on assessment. 

Social anxiety disorder can be subtyped into generalised or performance social anxiety disorder. In the former, symptoms occur in a social/public setting, whereas in the latter, symptoms are only present when an individual needs to perform e.g. speaking in front of people or performing for an audience.

Management 

CBT

First line management is CBT which has been developed specifically for social anxiety disorder. It is based on the Clark and Wells model or Heimberg model. 

• The Clarks and Wells model: 14 sessions lasting over 90 mins each for approx. 4 months. It focuses on the following concepts:
  • Providing education about social anxiety
  • Exercises to show patients the downsides of SAD related safety seeking / avoidance behaviours and self-focus.
  • Video feedback so patients can see how they come across, which challenges a negative self-image
  • Dealing with any memories of social trauma 
  • Identifying and modifying negative core beliefs
  • Prevention of relapse
  • Training in externally focused attention 
• The Heimberg model. It focuses on the following concepts:
  • Providing education about social anxiety 
  • Cognitive restricting 
  • Gradual / graded exposure to situations the individual fears
  • Identifying and modifying negative core beliefs

Supported CBT

If CBT is declined or another option is sought, supported (self-help) CBT should be offered. Supported self-help consists of 9 sessions over approx. 4 months where patients are guided through a CBT based self-help book. 

Pharmacological management 

Pharmacological management should be started if CBT has been ineffective.

• 1st line – Selective Serotonin Reuptake Inhibitors (SSRIs) e.g., Sertraline or Escitalopram. If these aren’t tolerated, alternative SSRIs can be given, e.g., Paroxetine. 
• 2nd line – Serotonin Noradrenaline Reuptake Inhibitor (SNRIs) e.g., Venlafaxine. If symptoms don’t improve after 10-12 weeks, consider individual CBT.
• 3rd line – Monoamine oxidase inhibitor e.g., Moclobemide

Psychodynamic psychotherapy 

Patients who decline CBT or pharmacological treatment can be offered psychodynamic psychotherapy aimed at SAD. However, this has limited effectiveness and is not cost effective, so is used as the last line of management. 

It involves up to 30 sessions, each lasting up to 50 minutes for 6-8 months, and focuses on the following concepts:

• Providing education about social anxiety 
• Focusing on shame
• Encouraging patients to face social scenarios that they fear outside of sessions.
• Promoting self-affirmation
• Improving social skills. 

References

• Overview: Social anxiety disorder: Recognition, assessment and treatment: Guidance [Internet]. NICE. 2013 [cited 2023Apr25]. Available from: https://www.nice.org.uk/guidance/cg159 
• Bittner A, Goodwin RD, Wittchen H-U, Beesdo K, Höfler M, Lieb R. What characteristics of primary anxiety disorders predict subsequent major depressive disorder? The Journal of Clinical Psychiatry. 2004;65(5):618–26. 
• Mennin DS, Fresco DM, Heimberg RG, Schneier FR, Davies SO, Liebowitz MR. Screening for social anxiety disorder in the clinical setting: Using the Liebowitz Social Anxiety Scale. Journal of Anxiety Disorders. 2002;16(6):661–73.