Social Anxiety Disorder
Definition
Social anxiety disorder is under-recognised in primary care.
Social anxiety disorder is persistent fear of or anxiety about one or more social or performance situations that is out of proportion to the actual threat posed by the situation.
Typical situations:
meeting people, including strangers
talking in meetings or in groups
going to school
public performances such as public speaking.
Fear of humiliation or embarrassment (such as blushing, sweating, appearing boring or stupid, shaking, appearing incompetent, looking anxious).
Social anxiety disorder can have a great impact on a person's functioning.
People with the disorder may misuse alcohol or drugs to try to reduce their anxiety (and alleviate depression).
Children may show their anxiety by social withdrawal (particularly classroom activities), cry, freeze or have tantrums.
They may also be less likely to acknowledge that their fears are irrational when they are away from a social situation.
Prevalence
Lifetime prevalence
12% social anxiety disorder at some point in their lives,
6% for generalised anxiety disorder (GAD)
5% for panic disorder
7% for post-traumatic stress disorder (PTSD)
2% for obsessive–compulsive disorder.
There is co-morbidity with other mental health problems: depression (19%), substance-use disorder (17%), GAD (5%), panic disorder (6%), and PTSD (3%).
Social anxiety disorder has an early median age of onset (13 years)
Diagnosis
Use the 3-item Mini-Social Phobia Inventory (Mini-SPIN) or
Screening questions:
Do you find yourself avoiding social situations or activities?
Are you fearful or embarrassed in social situations?
If the person scores 6 or more on the Mini-SPIN, or answers yes to either of the 2 questions above, refer for, or conduct, assessment for social anxiety disorder.
When assessing an adult with possible social anxiety disorder:
conduct an assessment that considers fear, avoidance, distress and functional impairment
be aware of comorbid disorders, including avoidant personality disorder, alcohol and substance misuse, mood disorders, other anxiety disorders, psychosis and autism.
Management
Effective psychological and pharmacological interventions for social anxiety disorder exist but may not be accessed due to poor recognition.
When it coexists with depression and presents as a depressive episode, the underlying and more persistent social anxiety disorder may go unrecognised.
Patients may be offered two treatment options:
Psychological therapy
Individual cognitive behavioural therapy (CBT) that has been specifically developed to treat social anxiety disorder (preferred option)
CBT-based supported self-help
Drug therapy
Offer SSRI (escitalopram or sertraline).
Arrange to see people aged 30 years and older who are not assessed to be at risk of suicide within 1 to 2 weeks of first prescribing SSRIs or SNRIs
For people aged under 30 years who are offered an SSRI or SNRI:
warn them that these drugs are associated with an increased risk of suicidal thinking and self-harm in a minority of people under 30 and
see them within 1 week of first prescribing and
monitor the risk of suicidal thinking and self-harm weekly for the first month.