Social anxiety disorder

Overview - The Wallflower's Worry

• Marked, persistent (≥6 months) fear or anxiety about social situations involving potential scrutiny.
• Core fear: Being negatively evaluated (e.g., humiliated, embarrassed, rejected), leading to avoidance or endurance with intense distress.
• The fear or anxiety is out of proportion to the actual threat posed by the social situation.

⭐ A "performance only" specifier applies if the fear is restricted to speaking or performing in public.

Pathophysiology & RFs - Brain's False Alarm

• Neurocircuitry Imbalance:
  • Amygdala & Insula: ↑ Hyper-reactive to social cues (the "fear center").
  • Prefrontal Cortex (PFC): ↓ Hypo-active, leading to poor emotional control.
• Neurotransmitter Dysregulation: Key roles for serotonin (5-HT), dopamine (DA), and glutamate.
• Key Risk Factors:
  • Genetic: Familial link is common; heritability ~30-40%.
  • Temperamental: Behavioral inhibition in childhood is a major predictor.
  • Environmental: Childhood adversity or public humiliation.

⭐ High-Yield: A core feature is the fear of scrutiny by others, leading to avoidance. This is NOT just shyness; it causes significant functional impairment.

Diagnosis & DDx - Telling Them Apart

• Core Feature: Marked, persistent (≥6 months) fear of social or performance situations involving potential scrutiny by others.
• Fears showing anxiety symptoms that will be negatively evaluated (humiliating, embarrassing).
• Situations are actively avoided or endured with intense distress, causing significant functional impairment.

⭐ DDx from Avoidant Personality Disorder: Social Anxiety Disorder involves fear of embarrassment in specific situations, whereas Avoidant Personality Disorder is a more pervasive, lifelong pattern of social inhibition and feelings of inadequacy.

Management - Facing the Fear

• Psychotherapy: Cognitive Behavioral Therapy (CBT) is first-line. Core components include:
  • Cognitive Restructuring: Identifying and challenging negative automatic thoughts.
  • Exposure Therapy: Gradual, repeated exposure to feared social situations.
• Pharmacotherapy:
  • First-line: SSRIs (e.g., sertraline, paroxetine) or SNRIs (venlafaxine).
  • Second-line: Benzodiazepines (short-term, risk of dependence), MAOIs.

⭐ For performance-only social anxiety (e.g., public speaking), administer a beta-blocker (Propranolol 10-40 mg) or a benzodiazepine 30-60 minutes before the event to manage autonomic hyperarousal (tachycardia, tremor).

High‑Yield Points - ⚡ Biggest Takeaways

• Social anxiety disorder involves a marked fear of scrutiny and negative evaluation in social or performance situations, leading to avoidance.
• A performance-only specifier applies if fear is restricted to public speaking or performing.
• First-line treatment consists of SSRIs/SNRIs and Cognitive Behavioral Therapy (CBT).
• For performance-only type, propranolol or benzodiazepines can be used situationally before a performance.
• Differentiate from avoidant personality disorder, which is more pervasive and chronic.
• Symptoms must persist for ≥6 months.