Social Anxiety Disorder

SAD: Definition & Diagnosis - Spotlight Fears

• Social Anxiety Disorder (SAD): Also known as Social Phobia. Characterized by marked and persistent fear or anxiety concerning one or more social situations where the individual is exposed to possible scrutiny by others.
• Core Fear: Negative evaluation by others (e.g., being judged as anxious, weak, stupid, boring, unlikeable, or that one will show anxiety symptoms that will be negatively evaluated).
• Diagnostic Highlights (DSM-5):
  • Social situations almost invariably provoke fear/anxiety.
  • Situations are actively avoided or endured with intense distress.
  • Fear/anxiety is out of proportion to the actual threat.
  • Causes clinically significant distress or functional impairment.

⭐ DSM-5: Marked fear/anxiety about ≥1 social situations where exposed to possible scrutiny by others, lasting ≥6 months.

• Common "Spotlight" Situations Feared:
  • Public speaking or performing
  • Meeting new people / Interacting with unfamiliar individuals
  • Eating, drinking, or writing in public
  • Using public restrooms
  • Being the center of attention
• Typical Onset: Adolescence, often mid-teens (median age 13 years).

SAD: Etiology - Roots of Anxiety

• Neurobiological Factors:
  • Brain Circuitry: ↑ Amygdala (fear response); ↓ Prefrontal cortex (regulation).
  • Neurotransmitters: Serotonin (5-HT), Dopamine (DA) dysregulation; GABA deficits.

  ⭐ Amygdala hyperactivity and altered serotonin/dopamine pathways are key neurobiological findings in SAD.

• Genetic Predisposition:
  • Heritability: ~30-40%.
  • Polygenic influence; gene-environment interaction (e.g., SLC6A4 variants and stress).
• Environmental & Psychological Factors:
  • Early Experiences: Parental overprotection, criticism, anxious modeling; childhood bullying or public humiliation.
  • Temperament: Behavioral inhibition (innate shyness, fear of novelty).
  • Cognitive Biases: Fear of negative evaluation; negative self-focus; attentional bias to social threats.

SAD: Clinical Picture & DDx - More Than Shyness

Clinical Picture:

• Core: Intense fear/anxiety in social situations (potential scrutiny).
  • Fears negative evaluation (humiliation, rejection).
  • Situations provoke fear/anxiety; avoided or endured with distress.
• Duration: ≥6 months.
• Impact: Significant distress or functional impairment.
• Specifier: "Performance only" - fear restricted to public speaking/performing.

⭐ The 'performance only' specifier for SAD applies if fear is restricted to speaking or performing in public.

Key Differential Diagnoses (DDx):

• Normal Shyness: No significant impairment.
• Agoraphobia: Fear of no escape/help, not scrutiny.
• Panic Disorder: Unexpected attacks vs. SAD's cued attacks.
• Avoidant Personality Disorder (AvPD): Pervasive avoidance, negative self-concept.
• Generalized Anxiety Disorder (GAD): Broad worry, not social evaluation focus.

SAD: Management - Calming Strategies

• Goal: ↓ anxiety, ↑ social functioning.

• Multimodal Approach: Psychotherapy + Pharmacotherapy often most effective.

• Psychotherapy (First-line)

  • Cognitive Behavioral Therapy (CBT): Core component.
    • Techniques: Cognitive restructuring, exposure therapy (gradual).
    • Group CBT can be beneficial.
  • Social Skills Training (SST).
  • Relaxation Techniques: Deep breathing, progressive muscle relaxation.

• Pharmacotherapy

  • SSRIs (First-line): Sertraline, Paroxetine, Escitalopram.
    • Start low, go slow; therapeutic effect in 4-12 weeks.
  • SNRIs: Venlafaxine (extended-release).
  • Beta-blockers: Propranolol, Atenolol.
    • For performance anxiety (e.g., public speaking).
    • Dose: Propranolol 10-40 mg, 1 hr before event.
  • Benzodiazepines (Short-term/PRN): Clonazepam, Lorazepam.
    • ⚠️ Risk of dependence; use cautiously.
  • MAOIs (e.g., Phenelzine): Reserved for treatment-resistant cases due to side effects & dietary restrictions.

⭐ First-line treatment for SAD typically involves SSRIs (e.g., sertraline, paroxetine, escitalopram) or CBT (especially exposure therapy).

High‑Yield Points - ⚡ Biggest Takeaways

• Marked fear/anxiety about social situations with potential scrutiny.
• Fears acting or showing anxiety symptoms leading to negative evaluation.
• Social situations almost always provoke fear/anxiety; often avoided or intensely endured.
• Fear/anxiety is out of proportion to the actual social threat.
• Symptoms persist for ≥6 months, causing significant distress/impairment.
• "Performance only" specifier: fear restricted to public speaking/performing.
• First-line treatment: SSRIs (e.g., sertraline, paroxetine) and CBT (especially exposure therapy).