II. Epidemiology
-
Prevalence: very common
- Lifetime Prevalence: 13.3%
- Annual Prevalence rate: 7.9%
- Onset
- Peaks between ages 11 and 19 years old
- Rarely has onset after age 25 years
III. Symptoms: Common Social Phobia Fears
- Attending social gatherings
- Public speaking or performance
- "Small Talk"
- Small group discussion
- Asking questions in groups
- Being introduced
- Meeting or talking with strangers
- Interacting with "important" people
- Being assertive
- Performing activities in public
- Being observed performing an activity
- Indirect evaluation (Test anxiety)
- Using the telephone
- Using public restrooms
IV. Diagnostic Criteria (DSM V)
- Marked and persistent fear of one or more social situations (with exposure to possible scrutiny of others)
- Social Interactions (conversations, unfamiliar people)
- Being observed (e.g. eating, drinking)
- Performance before others (e.g. public speaking)
- The same social situations almost always provoke fear, panic or anxiety and persists >6 months
- Person fears humiliation or embarrassment, leading to rejection or the offense of others
- Fear or anxiety is out of proportion to actual threat of the situation
- Adults typically have insight into the fear as unreasonable and excessive
- Person avoids feared social or performance situations (or indures with severe fear or anxiety)
- Impaired function or distress related to Social Phobia
- Interferes with normal daily routine
- Interferes with occupational or academic functioning
- Interferes with social activities or relationships
- Fear unrelated to underlying medical condition (or excessive, unreasonable response)
- Trembling in Parkinson's Disease
- Abnormal eating in Eating Disorder
- Substance (e.g. medication, substance used disorder)
- No other psychiatric condition explains symptoms
- See Differential Diagnosis below
- Special criteria modifications in children
- Anxiety related to peer setting (not simply exposure to adults)
- Anxiety may be expressed by crying, tantrums, clinging, freezing, shrinking or withdrawal
- Child may not have insight into unreasonable fear
- Specifiers: Performance
- Fear limited to public speaking or public performance
- References
- (2013) DSM-5, APA
V. Differential Diagnosis
- Avoidant Personality Disorder
- Schizoid Personality Disorder
- Autism Spectrum Disorder
- Panic Disorder
- Separation Anxiety Disorder
- Body Dysmorphic Disorder
- Developmental Disorder
- Substance Abuse (e.g. stimulants such as Cocaine, Methamphetamine)
- Substance Withdrawal (Alcohol Withdrawal, Benzodiazepine Withdrawal, Opioid Withdrawal)
VI. Management: Cognitive-Behavioral Therapy
- Background
- Offered as 16 to 24 weekly sessions
- Group therapy preferred over individual counseling
- Total Cost: $750 to $2000 (Insurance covers 50-80%)
-
Anxiety Management skills
- See Relaxation Training (e.g. Progressive Relaxation)
- Relaxation and calming techniques
- Social skills training
- Initiating and maintaining conversation
- Making appropriate eye contact
- Appropriate self-assertion
- Cognitive restructuring
- Change fearful thinking about social situations
- Gradual exposure to feared situations
- Gradual challenges into feared social situations
VII. Management: Medications
- SSRI (50-75% efficacy)
- MAO Inhibitors (66% efficacy)
-
Benzodiazepine (40-80% efficacy)
- Clonazepam (Klonopin) 0.25 to 0.5 mg PO bid
-
Beta Blocker (for Performance Anxiety, 45 min before)
- Propranolol (Inderal) 20-40 mg PO prn performance
- Atenolol (Tenormin) 50 to 100 mg PO prn performance