Basics
Description
- Social anxiety disorder, also known as social phobia, is a psychological condition with developmental underpinnings.
- The disorder is characterized by marked and persistent fear of social situations in which the person is exposed to unfamiliar people or possible scrutiny by others.
- DSM-5 criteria:
- Marked fear or anxiety of one or more social situations in which the individual is exposed to possible scrutiny by others (In children: anxiety must occur in peer situations, not just in interactions with adults)
- The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated.
- The social situations almost always provoke fear or anxiety and are avoided or endured with intense fear or anxiety.
- The fear/anxiety is out of proportion to the actual threat posed by the situation/context and is persistent, typically lasting 6 months or more.
- The fear/anxiety or avoidance causes significant distress or impairment in social, occupational, or other areas of functioning.
- The fear/anxiety is not attributable to psychological effects of substances, a medical condition, or by another psychiatric diagnosis.
- Specify if performance only (fear/anxiety restricted to speaking/performing in public)
Epidemiology
- Approximately 7% of youths suffer from social anxiety disorder.
- The prevalence is somewhat higher in girls than in boys.
Risk Factors
- Preexisting shyness or social inhibition
- Avoidant temperament
- Behavioral inhibition
- Family history: 1st-degree relatives have 2 " 6 times greater chance of having the disorder.
- Moderate genetic component based on twin studies
Commonly Associated Conditions
- Anxiety disorders
- Generalized anxiety disorder
- Specific phobia
- Selective mutism
- Obsessive-compulsive disorder
- Panic disorder
- ADHD
- Depression
Diagnosis
History
- The diagnostic evaluation should entail gathering of data through separate interviews with the child/adolescent and the parents.
- Current symptoms should be elicited with attention to severity, duration, and level of functional impairment.
- Core symptoms of marked anxiety in social situations, fear of negative scrutiny by others, and avoidance of these situations should be present.
- Distress can be manifested by physical symptoms such as
- Blushing
- Palpitations
- Trembling
- Gastrointestinal (GI) upset
- Younger children may exhibit periods of selective mutism in social situations while having the ability to talk freely while at home.
- Older children may appear oppositional and exhibit school refusal.
- Symptoms may be exacerbated by environmental transitions such as a new school or the family moving.
Physical Exam
There are no pertinent findings on physical exam.
Diagnostic Tests & Interpretation
Lab
Consider additional screening if symptoms are more pervasive than just social situations.
Diagnostic Procedures/Other
- Diagnostic scales:
- Multidimensional Anxiety Scale for Children (MASC): broad anxiety scale (ages 8 " 18 years), self-report
- Social Phobia and Anxiety Inventory for Children (SPAI-C) (ages 8 " 17 years), self-report
- Social Anxiety Scale for Children-Revised (SASC-R) (ages 8 " 14 years) and Adolescents (SAS-A) (ages 13 " 18 years), self-administered
- Liebowitz Social Anxiety Scale for Children and Adolescents (LSAS-CA) (ages 13 " 17 years), clinician-administered
Differential Diagnosis
- Normative shyness (personality trait without significant adverse impact on functioning)
- Anxiety disorders
- Depression
- Autistic spectrum disorders
Treatment
General Measures
- Potential pitfalls
- Incomplete assessment of the comorbid psychiatric illnesses
- Parental accommodation of the child 's avoidant patterns
- Both psychotherapy and medications have roles in core treatment and symptom alleviation.
- Additional therapies such as group therapy, individual and family psychoeducation, and/or self-regulation strategies can be considered first line in mild cases or adjuncts for more clinically impairing cases.
- Combination treatment with SSRIs and CBT may be superior to either treatment alone.
Additional Therapies
- The most studied and most supported by structured clinical trials is cognitive behavioral therapy (CBT).
- Exposure to a hierarchy of avoided situations with concomitant cognitive reframing is core to CBT.
- Other psychotherapeutic approaches such as play therapy, interpersonal, or psychodynamic therapy may be better suited in some cases.
- Supportive psychosocial treatments can include mind " body strategies to support self-regulation skills. These may include the following:
- Biofeedback
- Progressive muscle relaxation
- Self-hypnosis
- Mindfulness techniques
- Group therapy may also be helpful.
- Family therapy or collaborative work with parents may be important to decrease parental accommodation or help with other dysfunctional dynamics.
Medication
- Selective serotonin reuptake inhibitors (SSRIs)
- First line for symptom control and adjunctive psychopharmacologic support.
- Begin half the recommended starting dose for children with anxiety disorders.
- Side effects include GI upset, headaches, dizziness, and agitation.
- There is a black box warning by the FDA indicating that all antidepressants may increase suicidal thinking and behavior in children and adolescents. It is not clear how this warning may apply to treatment of social anxiety disorder that presents without depression.
- Close monitoring is important following initiation of treatment.
- Fluoxetine (Prozac) (10 " 60 mg)
- Sertraline (Zoloft) (25 " 200 mg)
- Paroxetine (Paxil) (10 " 40 mg)
- Citalopram (Celexa) (10 " 40 mg)
- Escitalopram (Lexapro) (10 " 20 mg)
- Fluvoxamine (Luvox) (25 " 200 mg)
- Serotonin-norepinephine reuptake inhibitor (SNRI)
- Second-line
- Side effects include somnolence, insomnia, dizziness, anxiety, headache, sweating, and tremor.
- There is a black box warning by the FDA indicating that all antidepressants may increase suicidal thinking and behavior in children and adolescents.
- Venlafaxine extended release (Effexor XR) (25 " 225 mg)
- Benzodiazepines
- May be considered for short-term symptomatic relief in rare circumstances
- Not appropriate for long-term therapy
- Side effects include sedation, dizziness, and weakness.
Ongoing Care
Follow-up Recommendations
Patient Monitoring
- Psychotherapy on a weekly or twice-weekly regimen
- If medication is initiated, close monitoring on a weekly basis is recommended for the first 4 weeks followed by monthly monitoring.
- The primary care provider should monitor the response to the chosen treatment plan at least every 2 " 3 months.
- Monitoring of any emerging comorbidities is suggested.
Prognosis
- Among patients who come to the attention of clinicians, social anxiety disorder is generally considered a chronic condition that does not significantly improve without intervention.
- Significant comorbidities may develop in adulthood, such as depression and alcohol dependence.
Additional Reading
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder. 5th ed. Arlington, VA: American Psychiatric Association; 2013.
- Beesdo K, Knappe S, Pine D. Anxiety and anxiety disorder in children and adolescents: developmental issues and implications for DSM-V. Psychiatr Clin North Am. 2009;32(3):483 " 524. [View Abstract]
- Beesdo-Baum K, Knappe S, Fehm L, et al. The natural course of social anxiety disorder among adolescents and young adults. Acta Psychiatr Scand. 2012;126(6):411 " 425. [View Abstract]
- Beidel DC, Ferrell C, Alfano CA, et al. The treatment of childhood social anxiety disorder. Psychiatr Clin North Am. 2001;24(4):831 " 846. [View Abstract]
- Khalid-Khan S, Santibanez MP, McMicken C, et al. Social anxiety disorder in children and adolescents: epidemiology, diagnosis, and treatment. Paediatr Drugs. 2007;9(4):227 " 237. [View Abstract]
- Masi G, Pfanner C, Mucci M, et al. Pediatric social anxiety disorder: predictors of response to pharmacological treatment. J Child Adolesc Psychopharmacol. 2012;22(6):410 " 414. [View Abstract]
- Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavior therapy, sertraline, or a combination in childhood anxiety. N Engl J Med. 2008;359:1 " 14.
Codes
ICD09
- 300.23 Social phobia
- 300.09 Other anxiety states
- 313.21 Shyness disorder of childhood
- 313.23 Selective mutism
- 313.22 Introverted disorder of childhood
ICD10
- F40.10 Social phobia, unspecified
- F41.8 Other specified anxiety disorders
- F40.11 Social phobia, generalized
- F94.8 Other childhood disorders of social functioning
- F94.0 Selective mutism
SNOMED
- 25501002 Social phobia (disorder)
- 247825008 Anxiety about behavior or performance (finding)
- 62351001 Generalized social phobia (disorder)
- 64165008 avoidant disorder of childhood (disorder)
- 268669006 Childhood and adolescent disturbance with elective mutism (disorder)