Elsevier

The Lancet

Volume 371, Issue 9618, 29 March–4 April 2008, Pages 1115-1125
The Lancet

Seminar
Social anxiety disorder

https://doi.org/10.1016/S0140-6736(08)60488-2Get rights and content

Summary

Our understanding of social anxiety disorder (also known as social phobia) has moved from rudimentary awareness that it is not merely shyness to a much more sophisticated appreciation of its prevalence, its chronic and pernicious nature, and its neurobiological underpinnings. Social anxiety disorder is the most common anxiety disorder; it has an early age of onset—by age 11 years in about 50% and by age 20 years in about 80% of individuals—and it is a risk factor for subsequent depressive illness and substance abuse. Functional neuroimaging studies point to increased activity in amygdala and insula in patients with social anxiety disorder, and genetic studies are increasingly focusing on this and other (eg, personality trait neuroticism) core phenotypes to identify risk loci. A range of effective cognitive behavioural and pharmacological treatments for children and adults now exists; the challenges lie in optimum integration and dissemination of these treatments, and learning how to help the 30–40% of patients for whom treatment does not work.

Introduction

Anxiety disorders are the most pervasive class of mental disorders, with a 12-month prevalence in the community of about 18%.1 Social anxiety disorder (also known as social phobia) is classified in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV; panel 1)2 and in the International Classification of Diseases 10 (ICD-10; panel 2)3 as a phobic (anxiety) disorder, alongside agoraphobia and specific phobias (from which it was first distinguished only 40 years ago4). People with social anxiety disorder fear and avoid the scrutiny of others. The concern in such situations is that the individual will say or do something that will result in embarrassment or humiliation. These concerns can be so pronounced that the individual shuns most interpersonal encounters, or endures such situations only with intense discomfort. Once largely neglected by the medical community, social anxiety disorder came to the attention of the general medical community a decade ago,5 and is now garnering increased attention and recognition as a widespread, impairing, but treatable condition.6

Individuals with social anxiety disorder are typically shy when meeting new people, quiet in groups, and withdrawn in unfamiliar social settings. When they interact with others, they might or might not show overt evidence of discomfort (eg, blushing, not making eye contact), but invariably experience intense emotional or physical symptoms, or both (eg, fear, heart racing, sweating, trembling, trouble concentrating). They crave the company of others, but shun social situations for fear of being found out as unlikable, stupid, or boring. Accordingly, they avoid speaking in public, expressing opinions, or even fraternising with peers; in some situations, this can lead to such individuals being mistakenly labelled as snobs. People with social anxiety disorder are typified by low self-esteem and high self-criticism,7 and as detailed below, often have depressive symptoms. The specific fear of urinating in public restrooms (paruresis, or so-called shy bladder syndrome) can be regarded as a discrete, relatively rare subtype of social anxiety disorder.8

DSM-IV recognises a common subtype of social anxiety disorder that it refers to as generalied. Recent studies find little evidence for distinct subtypes based on the content or number of fears.9 But retention of the term generalised in the diagnostic nomenclature might be useful for denoting a pervasive form of the illness characterised by fear and avoidance of a wide range of situations (eg, speaking to others in small groups; socialising at parties; speaking to authority figures).10 Believed to account for about half of cases in the community, and most individuals seeking treatment for social anxiety disorder,11 generalised social anxiety disorder is also the most disabling form of the disorder.10, 11 Although people with generalised social anxiety disorder can fear and avoid specific performance situations such as public speaking,12 their social fears and avoidance extend far beyond that relatively common sphere of concern.

Section snippets

Epidemiology

The National Comorbidity Survey-Replication provides prevalence estimates of 12-month and lifetime DSM-IV social anxiety disorder as 7·1% (SE 0·3%) and 12·1%, respectively, with higher prevalence in females.1, 9 The contemporaneous National Epidemiologic Survey on Alcohol and Related Conditions prevalence estimates of 12-month and lifetime DSM-IV social anxiety disorder were 2·8% (95% CI 2·5–3·1) and 5·0% (95% CI 4·6–5·4), respectively.13 The lower rates in this study are probably attributable

Diagnosis and evaluation

In medical settings, people with social anxiety disorder might speak quietly or offer only cursory answers to questions. Eye contact is often kept to a minimum. But, more often, they will reveal their problems with social anxiety only upon direct questioning, rarely offering their symptoms up to their caregiver without solicitation. This reticence might be due to embarrassment about their symptoms, their belief that the practitioner would not take their problem seriously, or it could simply

Differential diagnosis

Social anxiety disorder is not especially difficult to diagnose in a clinical context—once an index of suspicion is high enough and appropriate queries are made. However, the differential diagnosis can be somewhat more challenging (figure 1) for several other disorders.

Normal shyness: as discussed earlier, shyness (ie, social reticence) is a common personality trait, and is not by itself regarded as pathological. But when combined with concern on the part of the individual about their shyness

Causes and pathogenesis

The causes and pathogenesis of social anxiety disorder are not well elucidated, but progress is being made. In the only reported genome-wide linkage analysis for social phobia, chromosome 16 seemed to be implicated, in a region proximate to a candidate gene, the norepinephrine transporter.59 Nature is not compelled to adhere to our psychiatric diagnostic nomenclature (ie, DSM or ICD). In this regard, some underlying behavioural trait (eg, behavioural inhibition or neuroticism)25, 29 is thought

Treatment

A large database of randomised controlled trials shows efficacy of medications and cognitive behavioural therapy in social anxiety disorder,91, 92 with relatively high effect sizes. In a meta-analysis, selective serotonin reuptake inhibitors had an effect size of 1·5, and exposure therapy and cognitive restructuring had an effect size of 1·8 on clinician-rated scales.91 Comparison of effect sizes in pharmacotherapy and psychotherapy trials is difficult, because of differences in the design of

Conclusion

In the past two decades, significant advances have been made in the nosology, epidemiology, psychobiology, pharmacotherapy, and psychotherapy of social anxiety disorder. At the same time, many challenges remain. Despite validation of the diagnostic construct, the opinion that social anxiety disorder is merely shyness or an entity designed by the pharmaceutical industry to expand the market is still common. We argue that a view that accepts the validity of expanding markets for general medical

Search strategy and selection criteria

We searched Medline, PsychInfo, and the Cochrane Library from 1980, to April, 2007 for the terms “social anxiety disorder” and “social phobia” in combination with “behaviour therapy”, “childhood”, “cognitive therapy”, “developmental”, “diagnosis”, “epidemiology”, “genetics”, “neuroimaging”, “personality”, “pharmacotherapy”, “psychotherapy”, and “treatment”. We focused on studies reported in the past 10 years but also included commonly referenced and highly regarded older publications.

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