Psych · General adult psychiatry — anxiety disorders
Social anxiety disorder
Also known as Social phobia · SAD · Generalised social anxiety disorder · Performance-only social anxiety · Fear of negative evaluation
Exam-exhaustive fellowship reference on social anxiety disorder — DSM-5-TR and ICD-11 criteria; performance-only specifier; epidemiology; Clark and Wells cognitive model; differentials including AVPD and ASD; LSAS SPIN Mini-SPIN; CBT exposure and CBGT; SSRI/SNRI dosing; phenelzine and moclobemide; benzodiazepine limits; refractory pathways; NICE/Canadian/WFSBP/ANZ stepped care. FRANZCP-primary, globally tagged.
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Red flags
- New or worsening suicidal ideation — especially with comorbid depression or early after starting an SSRI/SNRI — same-day risk review, means restriction, documented safety plan
- Alcohol dependence used as the only 'anxiolytic' for social situations — assess withdrawal risk, dual diagnosis, and do not replace alcohol with unsupervised high-dose benzodiazepines
- First late-life or abrupt 'social anxiety' with weight loss, focal neurology, tremor work-up clues or substance induction — exclude organic and substance-induced causes before a pure SAD label
- Severe isolation with self-neglect, inability to attend care, or functional collapse — escalate setting and reassess comorbidity (depression, psychosis, ASD, medical illness)
- Akathisia or marked activation after antidepressant start/titration — reassess risk and regimen immediately
- MAOI prescribing errors (tyramine diet, drug interactions, inadequate washout from SSRIs) if phenelzine is used in refractory cases
Meet the patient
A 24-year-old software developer has turned down two promotions. Both involved presenting to the team. He describes the interview for his current job as "the worst hour of my life" and says he only got through it because he had two beers in the car park.[1][5]
He can talk to you fluently, one to one, because you are a doctor and doctors are "supposed to ask questions". He cannot eat in the office kitchen. He replays every meeting for hours afterwards, cataloguing everything he got wrong.[1][2]
Nobody has ever diagnosed anything. His file says "shy". The examiner's question is the one that separates a registrar from a consultant: what is the difference, and what does it cost him?[4][5]
References20ShowHide
- [1]Stein MB, Stein DJ Social anxiety disorder Lancet, 2008.PMID 18374843
- [2]Heimberg RG, Hofmann SG, Liebowitz MR, Schneier FR, et al. Social anxiety disorder in DSM-5 Depress Anxiety, 2014.PMID 24395386
- [3]Bögels SM, Alden L, Beidel DC, Clark LA, et al. Social anxiety disorder: questions and answers for the DSM-V Depress Anxiety, 2010.PMID 20143427
- [4]Stein MB An epidemiologic perspective on social anxiety disorder J Clin Psychiatry, 2006.PMID 17092189
- [5]Moutier CY, Stein MB The history, epidemiology, and differential diagnosis of social anxiety disorder J Clin Psychiatry, 1999.PMID 10335673
- [6]Mayo-Wilson E, Dias S, Mavranezouli I, Kew K, Clark DM, et al. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis Lancet Psychiatry, 2014.PMID 26361000
- [7]Katzman MA, Bleau P, Blier P, Chokka P, et al. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders BMC Psychiatry, 2014.PMID 25081580
- [8]Bandelow B, Allgulander C, Baldwin DS, Costa DLDC, et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders - Version 3. Part I: Anxiety disorders World J Biol Psychiatry, 2023.PMID 35900161
- [9]Stein MB, Liebowitz MR, Lydiard RB, Pitts CD, et al. Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial JAMA, 1998.PMID 9728642
- [10]Van Ameringen MA, Lane RM, Walker JR, Bowen RC, et al. Sertraline treatment of generalized social phobia: a 20-week, double-blind, placebo-controlled study Am J Psychiatry, 2001.PMID 11156811
- [11]Walker JR, Van Ameringen MA, Swinson R, Bowen RC, et al. Prevention of relapse in generalized social phobia: results of a 24-week study in responders to 20 weeks of sertraline treatment J Clin Psychopharmacol, 2000.PMID 11106135
- [12]Lader M, Stender K, Bürger V, Nil R Efficacy and tolerability of escitalopram in 12- and 24-week treatment of social anxiety disorder: randomised, double-blind, placebo-controlled, fixed-dose study Depress Anxiety, 2004.PMID 15274173
- [13]Liebowitz MR, Mangano RM, Bradwejn J, Asnis G, et al. A randomized controlled trial of venlafaxine extended release in generalized social anxiety disorder J Clin Psychiatry, 2005.PMID 15705011
- [14]Rickels K, Mangano R, Khan A A double-blind, placebo-controlled study of a flexible dose of venlafaxine ER in adult outpatients with generalized social anxiety disorder J Clin Psychopharmacol, 2004.PMID 15349004
- [15]Stein MB, Fyer AJ, Davidson JR, Pollack MH, et al. Fluvoxamine treatment of social phobia (social anxiety disorder): a double-blind, placebo-controlled study Am J Psychiatry, 1999.PMID 10327910
- [16]Heimberg RG, Liebowitz MR, Hope DA, Schneier FR, et al. Cognitive behavioral group therapy vs phenelzine therapy for social phobia: 12-week outcome Arch Gen Psychiatry, 1998.PMID 9862558
- [17]Liebowitz MR, Heimberg RG, Schneier FR, Hope DA, et al. Cognitive-behavioral group therapy versus phenelzine in social phobia: long-term outcome Depress Anxiety, 1999.PMID 10604081
- [18]Connor KM, Davidson JR, Churchill LE, Sherwood A, et al. Psychometric properties of the Social Phobia Inventory (SPIN). New self-rating scale Br J Psychiatry, 2000.PMID 10827888
- [19]Pollack MH, Van Ameringen M, Simon NM, Worthington JW, et al. A double-blind randomized controlled trial of augmentation and switch strategies for refractory social anxiety disorder Am J Psychiatry, 2014.PMID 24399428
- [20]Blanco C, Bragdon LB, Schneier FR, Liebowitz MR The evidence-based pharmacotherapy of social anxiety disorder Int J Neuropsychopharmacol, 2013.PMID 22436306