Day # 69: Social Anxiety Disorder (SAD)

Today we will discuss social anxiety disorder. We will cover the clinical features, epidemiology, clinical pearls, and treatment options for social anxiety disorder.


Today's Content Level: Beginner, Intermediate



CLINICAL FEATURES


•Last post we discussed phobias, which we defined as an intense, excessive, and unreasonable fear of a specific object or situation.


•Today we will be discussing social anxiety disorder (SAD) which is also sometimes called social phobia. The diagnostic criteria of SAD and phobias are similar except the phobic stimulus is related to social scrutiny and being negatively evaluated.


•The patient fears social situations, particularly ones where they may experience embarrassment, humiliation, and rejection.


•They tend to avoid many of these situations. In extreme cases they may avoid any social situation. This avoidance may result in significant social, occupational, or academic impairment.


The diagnostic criteria for social anxiety are as follows 1:

  • Marked fear or anxiety about ≥1 social situations in which the individual is exposed to possible scrutiny by others.

  • The social situation almost always provokes fear/anxiety. The fear is that they will act in a way that will show anxiety symptoms that will be negatively evaluated (ex.. humiliating, embarrassing, lead to rejection, or offend others).

  • Situation or object is avoided when possible or tolerated with intense anxiety.

  • The fear is out of proportion to the actual risk of the social situation.

  • Duration ≥ 6 months.


•Specific examples of fear social situations include starting conversations, meeting people, dating, public speaking or other performances, parties/events, or even eating in public or using a public bathroom.


•In some individuals the fear may be limited to performance or public speaking. The "performance-only" specifier of social anxiety disorder is used in these cases.


•Patients often have good insight. They know they are irrationally anxious, and this leads to a frustrating cycle of increased anticipatory anxiety in social situations.



EPIDEMIOLOGY AND PATHOGENESIS


Epidemiology 2

  • 12-month prevalence ~ 7%

  • Lifetime prevalence ~ 13%

  • Can present at any age, but much younger age of onset on average. Can occur as early as age 5. Median age of onset is 13 yo. 95% onset by age 34.

  • Slightly more common in women than man, but less so than all other anxiety disorders.


Risk Factors 3

  • Factors that increase risk include: Early childhood adversity, family history of SAD, female gender (mild), younger age, early childhood shyness, behaviorally inhibited temperament (tendency to experience distress and withdraw), native american heritage, and low socioeconomic status.

  • Factors that decrease risk include: asian, black, or latino heritage and living in an urban setting.


Pathogenesis 4

  • May be related to exaggerated autonomic arousal that is over responsive in public situations and leads to positive feedback. Autonomic arousal = increased heart rate, tremor, GI upset.

  • The phobia may develop in the wake of negative or traumatic encounters with the stimulus.



CLINICAL PEARLS


Evaluation

  • Examples of screening questions include -> Are you preoccupied with thoughts of being humiliated, embarrassed, or rejected? Has this fear led you to avoid doing things or speaking to people or leave social situations early? Do you fear that people will notice you appear anxious? Have you felt sweaty, faint, or a racing heart in social situations? Have you had difficulty eating in front of others? Difficulty using a public bathroom?

  • Keep in mind that the patient's fear of embarrassment during the assessment itself may lead them to minimize their symptoms or be reluctant to disclose all of their symptoms.

  • The history should be focused on settings that trigger symptoms and contrast them to situations that are comfortable (such as close friends or family).

  • Screen for other anxiety disorders, especially panic and generalized anxiety disorder. Also screen for depression.

  • Optional questionnaires: Social phobia inventory (SPIN); Liebowitz Social Anxiety Scale (LSAS).

  • Other important features of the clinical interview include:

  • Screen for stressful events or trauma.

  • Substance history (including nicotine and caffeine).

  • Family history of anxiety or depressive disorders.

  • Rule out anxiety/panic due to another medical condition (see day 64). Particularly in those with atypical, late-onset or new physical symptoms.


Comorbid conditions 5

  • SAD is highly comorbid with other anxiety, depressive (especially atypical depression), and substance use disorders (especially alcohol use disorder).

  • Also remember that anxiety disorders such as SAD can present with panic attacks without meeting the criteria for panic disorder. SAD + panic attacks may resemble panic disorder or agoraphobia. The primary difference is that in panic disorder there is a fear of unanticipated and unpredictable panic attacks, whereas in SAD their predictable anxiety before or during a social event may rise to the level of a panic attack.

  • Also, highly comorbid with avoidant personality disorder.



TREATMENT


•Treatment for all anxiety disorders are similar, so we have written a detailed post titled "Treatment of Anxiety Disorders" where we discuss treatment options in detail. Please refer to that post for a more thorough discussion.


•Treatment options for SAD include psychotherapy, pharmacotherapy, and other alternative treatments. Therapy and medications are both effective separately and together in SAD and the most effective treatment is probably a combination of these approaches. About 67% respond to treatment. Discuss patient’s preference for psychotherapy and/or pharmacotherapy. 6


Psychotherapy

  • Cognitive Behavioral Therapy (CBT): Considered first-line. Best studied and most efficacious psychotherapy tested in SAD. Includes psychoeducation, cognitive restructuring, and exposure practices. Often done in courses of 12-16 weeks of weekly psychotherapy.

  • Attention Retraining: Trains patients to attend to certain types of stimuli and reduce attention to excessive and automatically deployed triggers. Clinical trials suggest efficacy in SAD, but larger studies needed before routine use can be recommended.

  • Psychodynamic Psychotherapy (PDP): Has been found to be efficacious compared with a control condition but less efficacious compared with CBT.

  • Interpersonal Therapy (IPT): Clinical trials have found mixed evidence of efficacy for IPT in SAD.

  • See this post for more details on each of these forms of therapy.


Pharmacotherapy

  • SSRIs and SNRIs: Considered first-line for SAD if medical management is initiated. No specific drug has been shown to have significantly higher efficacy than any other, however formally paroxetine, sertraline, and venlafaxine are approved for SAD. Mixed results with fluoxetine. Initiate at half the usual effective dose and increase after 1 week and then increase again in the following weeks. Effective but takes weeks to see treatment effect. Response rate is 50-80% after 8-12 weeks. If good response, continue at least 12 months before discontinuing. If poor response after full trial then switch to different SSRI. If partial response consider augmentation with benzodiazepine or buspirone.

  • Beta-blockers (propranolol): Often used as a prn to treat "non-generalized SAD" which basically means performance anxiety / public speaking.

  • Benzodiazepines: Limited evidence, but can be used in those who cannot tolerate SSRIs/SNRIs, have residual symptoms, or when urgent symptom reduction is necessary. Normally for short-term use only. Not recommended as monotherapy. Ideally maximum is 2-4 weeks while initiating SSRI/SNRI, but may be considered as augmentation in severe anxiety. Favor longer half lives (such as clonazepam) unless slow metabolizers (increased age or liver disease). May worsen the common comorbid depression. Not recommended in those with comorbid substance use disorders.

  • Buspirone: Partial agonist of serotonin receptors. Sometimes effective. Used to augment SSRI/SNRI, but takes weeks for full effectiveness.

  • Pregabalin/Gabapentin: Off-label for treatment or augmentation of anxiety disorders. Studies demonstrate mixed results. Less effective than SSRIs/SNRIs. Relatively quick onset of action.

  • Treatment-Refractory cases: In these cases other medications can be tried, but are not first line due to adverse effects and no evidence of greater efficacy. Examples include: TCAs, MAOIs, mirtazapine, antipsychotics, and hydroxyzine.

  • See this post for more details on medication options for treatment of anxiety.



CONCLUSION


Great work today. Next lesson we will discuss panic disorder. If you want more learning resources then check out our recommended resources page.


Resources for today's post include: Kaplan and Sadock's Synopsis of Psychiatry, The Maudsley Prescriber's Guide, DSMV, Pocket Psychiatry, and First Aid for the Psychiatry Clerkship.

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