See ASDI Groups.

Social anxiety disorder can present as generalized (across many situations--see below) or specific. The specific form involves only a particular performance situation (e.g., public speaking, music/dance/athletic performance).

Typical Features of Generalized Social Anxiety Disorder (SAD)

Common Fear of:

• being looked at
  
• someone noticing anxiety
  
• bungling social performance
  
• feeling forever humiliated
  
• freezing--being unable to perform
  
• voice/hands shaking; blushing
  
• seeming foolish or awkward
  
• being disapproved of
  
• being bland, boring or dumb
  
• being seen as weak or weird
  
• having to escape--being forever disrespected or humiliated
  
  
  
  Common Avoidance of:
  
• being the center of attention
  
• public speaking; reading aloud
  
• writing while watched by others
  
• telephone use
  
• using public restrooms
  
• entering crowded rooms
  
• introductions/social events
  
• speaking to authority
  
• initiating social conversations
  
• dating
  
• assertiveness
  
• eating or drinking in public
  
• any potential embarrassments
  
  
  
  Prevalence: 1 year = 2.8%; lifetime =5.0%
  
  Average age of onset = 15; Average age of first treatment =27.2
  
  But, 80% received no treatment (Grant, et al., 2005)
  
  
  
  Screening: 3 questions identify SAD with 89% sensitivity & 90% specificity (Kobak, 1998)
  
• Is being embarrassed or looking stupid among your worst fears?
  
• Does fear of embarrassment cause you to avoid doing things or speaking to people?
  
• Do you avoid activities in which you are the center of attention?

Are embarrassing/humiliating experiences contributory?

Except in extreme cases, probably only if one is "wired" for anxious apprehension or behavioral inhibition. However, a history of severe teasing experiences has been noted: social phobia (92%) vs. OCD (50%) and panic disorder (35%).(McCabe, et al., 2003)

Both SAD and shyness are moderately heritable. But most "shy" people do not truly have social anxiety disorder.
"Behavioral inhibition" = temperament risk factor for social anxiety disorder?
Then panic attacks and conditioning may contribute to initial onset.

Avoidance only perpetuates social anxiety disorder:

• diminished opportunities to disprove irrational predictions and beliefs
  
• catastrophic assumptions can never be proven wrong
  
• the momentary relief that follows avoidance reinforces avoidance and makes it more likely
  
• with every avoidance, self-confidence is further eroded
  
• ruminative repetition of worries escalates avoidance in a vicious cycle

Evaluating performance while performing:

• self-absorption and self-observation raise anxiety and lower performance
  
• can make mistakes; can look nervous; can receive disapproval
  

Alcohol may lead to alcohol dependence and more isolation, especially in young men with social anxiety.

• Teach relaxation training and breathing skills for general coping.
  
• Focus on perfectionism, inevitable mistakes & accepting disapproval.
  
• Focus on distortions of both probability and severity of consequences.
  
• Assess and remediate actual skill deficits.

• Exposure treatment, including self-conducted practice, is more important than cognitive intervention.
  
  
  Start slow with collaboration/humor/role-playing/modeling.
  Shows that actions don't predictably lead to disapproval.
  When disapproval or embarrassment occasionally occur, it's not a catastrophe.
  Allows habituation of bodily responses and gradual self-confidence.
  Minimize use of distraction; stay until anxiety lessens.
  Later, focus on making intentional mistakes, seeking actual disapproval and willingly seeking embarrassed feelings.

Drug Treatment: SSRI's + venlafaxine (Effexor)

• Paroxetine (Paxil) is best established; venlafaxine (Effexor) & sertraline (Zoloft) have also gotten FDA indications; more will follow.
• For example, in recent randomized controlled trials, mirtazapine (Remeron) (Muehlbacher, et al, 2005) and escitalopram (Lexapro) (Montgomery, et al., 2005) were also effective for SAD.
• "Significantly improved" rates are usually twice the rate of improvement with placebo.
• Be patient. In one paroxetine trial, among nonresponders at week 8, 28% were responders by week 12. (Stein, et al., 2002)
• Higher dosing may be necessary than is common in primary care (e.g., sertraline 150 mg; venlafaxine 225 mg) (Leibowitz, et al., 2003)
• Given the overlap with depression and the effectiveness of "antidepressants," are we just treating primary depression? No. Mediational analyses of CBT reveal that improvements in social anxiety mediated 91% of the improvements in depression over time. Conversely, decreases in depression only accounted for 6% of the decreases in social anxiety over time. (Moskovitch, et al., 2005)
• Beta-blockers (e.g., propranolol) are sometimes useful for circumscribed performance situations but have not demonstrated efficacy for generalized social anxiety disorder.

Drug Treatment vs. Cognitive-Behavioral Treatment with Exposure:

• Drug treatment yields greater acute efficacy for social anxiety disorder.
  
• But, cognitive-behavioral treatment yields more durable efficacy for social anxiety disorder.
  
• Exposure therapy (ET) alone continued to yield improvement at 1-year follow-up, but ET + sertraline (Zoloft) and sertraline alone showed a tendency toward deterioration after 24 weeks of treatment. (Haug, et al., 2003)
• Medication may be important early on, but the continuing commitment to regular, willing exposure seems imperative for true recovery from SAD.

SS

Anxiety and Stress Disorders Institute of Maryland:
Treating anxiety disorders and stress-related disorders in Towson, Maryland, since 1978.