BMJ  2003;327:515-516 (6 September), doi:10.1136/bmj.327.7414.515

Editorial

Social anxiety disorder

Is common, underdiagnosed, impairing, and treatable

The hallmark of social anxiety disorder is extreme and persistent fear of embarrassment and humiliation.¹ People with this condition (which is also known as social phobia) often avoid participating in social and public activities, such as public speaking, social gatherings, or meetings. Whereas normative social anxiety may serve to focus attention and prevent inappropriate behaviour, the intense symptoms of social anxiety disorder, by definition, interfere with functioning or cause marked distress.

Differentiation of social anxiety disorder from other phobic disorders was first validated by its characteristic age of onset in the mid-teens and greater ratio of men to women.² Although once believed to be uncommon, social anxiety disorder was found to be the third most prevalent psychiatric disorder in the US national comorbidity survey,³ and most studies in Europe and North America have found a 7-12% lifetime prevalence in the community and higher rates in primary care samples.⁴

Despite increasing recognition of social anxiety disorder as common, impairing, yet treatable, it often remains undiagnosed.⁴ The reticence and shame that are intrinsic to social anxiety disorder inhibit help seeking. Persons usually come for treatment only after years of suffering and may present initially with a complication, such as major depression or alcohol abuse. Clinicians can encourage patients to discuss their symptoms by including a brief query into social anxiety or avoidance in a review of systems assessment.

In feared situations, patients with social anxiety disorder typically experience self consciousness, embarrassment, and difficulty speaking. Autonomic arousal symptoms, such as blushing, sweating, trembling, and palpitations, are sometimes prominent. Thoughts often dwell on inferiority to others, desire to flee, and anticipated negative evaluation by others. Weeks of anticipatory anxiety may precede a social event, with self deprecating thoughts and demoralisation in its aftermath.

Persons with the generalised subtype of social anxiety disorder, defined by fear of most social situations,¹ are most impaired, most likely to seek treatment, and have been studied most in clinical trials.⁵ Patients with the non-generalised form are typically comfortable in informal social settings but experience distressing or impairing anxiety attacks during public speaking or performance.¹ The anxiety related symptoms of social anxiety disorder may take the form of a panic attack, but they can be differentiated from symptoms of panic disorder by their consistent relation to social cues. With its trait-like early onset, pervasiveness, and high chronicity, social anxiety disorder may be alternatively conceptualised as the pathologically extreme form of the continuum of social anxiety present in the community.

The best established treatments for social anxiety disorder are cognitive behaviour therapy and serotonin reuptake inhibitors. Cognitive behaviour therapy addresses a dysfunctional cycle in which avoidance of feared situations diminishes opportunities for social growth and reinforces fears, which in turn lead to further avoidance. The therapist works in the here and now to help the patient identify fears and avoidance, develop more productive coping thoughts and behaviours, and systematically confront feared situations while using new coping techniques. Controlled studies show clinical improvement over 12-16 weekly sessions,⁶ with gains usually persisting after discontinuation of therapy.⁷

Selective serotonin reuptake inhibitors are the best established drug treatment for social anxiety disorder, with controlled trials showing efficacy for paroxetine, sertraline, and fluvoxamine.⁸ Doses typically used for depression seem adequate, but many patients will require a longer 12 week trial to establish clear outcome. Drug treatment should continue for 6-12 months after response, and some patients may require longer treatment to maintain gains.⁷ Alternative drugs include the monoamine oxidase inhibitor phenelzine, which has been shown to be effective in several controlled trials but is usually reserved for patients who do not respond to other treatment. This is due to the need for dietary restrictions and risk of hypertensive reaction.⁶ The newer reversible monoamine oxidase inhibitor moclobemide has seemed effective for social anxiety disorder in some but not all controlled trials.⁹ The benzodiazapines clonazepam and bromazepam and novel anticonvulsant gabapentin have been shown to be efficacious in single controlled trials. adrenergic blockers have not differed from placebo in efficacy for treatment of generalised social anxiety disorder, but they seem to be useful taken on an as-needed basis in treatment of the non-generalised subtype. No Cochrane reviews of social anxiety disorder have been undertaken.

Twin and family studies show substantial genetic and environmental contributions to social anxiety disorder.¹⁰ Studies of toddlers exposed to novel stimuli have suggested that behavioural inhibition coupled with autonomic reactivity characterise a relatively stable temperament that predicts development of social anxiety in adolescence.¹¹ Parenting that is overprotective yet critical may contribute to the development of social anxiety disorder in vulnerable children. Several neurotransmitter systems, including dopamine and serotonin, manifest differences in social anxiety disorder, and subcortical fear circuitry involving activation of the amygdala may be hypersensitive and easily conditioned to social stimuli.¹²

As social anxiety disorder has gained recognition as a common, impairing, and treatable condition, more attention has focused on improving detection of serious cases in the community. Earlier identification of symptomatic individuals holds promise for prevention of long term dysfunction and complications.

Department of Psychiatry, Columbia University, New York State Psychiatric Institute, Unit 69, 1051 Riverside Drive, New York NY 10032, USA (frs1{at}columbia.edu)

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Competing interests: FRS has received support from Glaxo-SmithKline and Pfizer for speaking and attending meetings and from Solvay, Somerset, and Forest for research.

References

1. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: American Psychiatric Association, 1994.
2. Marks IM, Gelder MG. Different ages of onset in varieties of phobia. Am J Psychiatry 1966; 123: 218-21.[Abstract/Free Full Text]
3. Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshleman S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the national comorbidity survey. Arch Gen Psychiatry 1994; 51: 8-19.[Abstract]
4. Wittchen H-U, Fehm L. Epidemiology, patterns of comorbidity, and associated disabilities of social phobia. Psychiatric Clin North Am 2001; 24: 617-641[CrossRef][ISI][Medline]
5. Mannuzza S, Schneier FR, Chapman TF, Liebowitz MR, Klein DF, Fyer AJ. Generalized social phobia. Reliability and validity. Arch Gen Psychiatry 1995; 52: 230-237.[Abstract]
6. Heimberg RG, Liebowitz MR, Hope DA, Schneier FR, Holt CS, Welkowitz LA, et al. Cognitive behavioral group therapy vs phenelzine therapy for social phobia. Arch Gen Psychiatry 1998; 55; 1133-41.[Abstract/Free Full Text]
7. Liebowitz MR, Heimberg RG, Schneier FR, Hope DA, Davies S, Holt CS, et al. Cognitive-behavioral group therapy versus phenelzine in social phobia: Long term outcome. Depression and Anxiety 1999; 10: 89-98.[CrossRef][ISI][Medline]
8. Stein, MB, Liebowitz, MR, Lydiard, RB, Pitts, CD, Bushnell, W, Gergel, I. Paroxetine treatment of generalized social phobia (social anxiety disorder): A randomized controlled trial. JAMA 1998; 280: 708-13.[Abstract/Free Full Text]
9. Schneier FR, Goetz D, Campeas R, Fallon B, Marshall R, Liebowitz MR. Placebo controlled trial of moclobemide for social phobia. Br J Psychiatry 1998; 172: 70-7.[Abstract/Free Full Text]
10. Kendler KS, Karkowski LM, Prescott CA. Fears and phobias: Reliability and heritability. Psychol Med 1999; 29: 539-53.[CrossRef][ISI][Medline]
11. Schwartz CE, Snidman N, Kagan J. Adolescent social anxiety as an outcome of inhibited temperament in childhood. J Am Acad Child Adolesc Psychiatry 1999; 38: 1008-15.[CrossRef][ISI][Medline]
12. Stein MB, Goldin PR, Sareen J, Zorrilla LTE, Brown GG. Increased amygdala activation to angry and contemptuous faces in generalized social phobia. Arch Gen Psychiatry 2002; 59: 1027-34.[Abstract/Free Full Text]

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