Social Anxiety Disorder

Social anxiety disorder is marked, persistent fear of scrutiny or negative evaluation in social or performance situations, leading to avoidance, for 6 months or more.

• Lifetime prevalence is 7 to 12%, with onset in the mid teens.
• Risk factors: behavioural inhibition, parental overcontrol, bullying, family history.
• Comorbidity: depression, other anxiety disorders, alcohol use disorder, avoidant personality disorder.
• Untreated it persists for decades and restricts education, employment and relationships.

• Fear of blushing, trembling, sweating, speaking, eating or writing in public, with anticipatory anxiety.
• Safety behaviours (avoiding eye contact, rehearsing), post event rumination.
• Panic attacks in social settings; self medication with alcohol.
• Performance only subtype involves public speaking or performing.

• DSM-5 criteria, with the Liebowitz Social Anxiety Scale or SPIN questionnaire for severity.
• Exclude agoraphobia, autism spectrum disorder, body dysmorphic disorder, major depression, medical causes (Parkinson disease, stuttering) and substance effects.
• Screen for alcohol misuse and suicidality.

• CBT focusing on cognitive restructuring, exposure and attention training (individual 12 to 15 sessions) is first line.
• SSRIs and SNRIs: paroxetine 20 to 60 mg daily, sertraline 50 to 200 mg, escitalopram 10 to 20 mg, fluvoxamine 100 to 300 mg, venlafaxine XR 75 to 225 mg. Allow 8 to 12 weeks, continue for at least 12 months.
• Performance only: propranolol 10 to 40 mg 30 to 60 minutes before the event, taken on a trial basis.
• Refractory: clonazepam 0.5 to 2 mg daily (short term), phenelzine 45 to 90 mg daily with dietary precautions, pregabalin 150 to 600 mg, gabapentin.
• Treat comorbid depression and alcohol misuse; encourage graded exposure and group therapy.