Social Anxiety Disorder in Adults – Practical Clinical Guidance for Diagnosis and Management

DIAGNOSIS

Two core components characterise SAD:

• Fear of negative evaluation leading to anxiety in social situations
• Avoidance or use of safety-seeking behaviours is typical in feared situations

DSM-5 Criteria:

1. Marked Fear or Anxiety about one or more social situations in which an individual is exposed to scrutiny by others
2. The social situations almost always provoke fear or anxiety
3. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the socio-cultural context.
4. The social situations are avoided or endured with intense fear or anxiety.

Screening questions: 

Do you worry about looking anxious or being embarrassed in social situations?

Do you worry a lot about what people think of you?

SAD was initially termed social phobia and is often misdiagnosed with agoraphobia due to the similarity in symptoms related to a fear of social situations (e.g. crowded spaces). However, differentiating SAD from agoraphobia requires an understanding of the underlying cause: negative evaluations of themselves in SAD versus fear of physical or mental harm in agoraphobia. [APA 2013]

SAD is associated with a high degree of comorbidity but is often the initial diagnosis due to its early age of onset. [Andrews et al., 2002]

• Other anxiety disorders (50-60%)
• Depressive disorders (30–50%)
• Substance use disorders (20– 40%)

Therefore, distinguishing SAD from other diagnoses is difficult:

• Normal Shyness: differentiated from SAD by the lack of persistence, generalisation, impairment and significant distress.
• MDD: Symptoms of MDD include social anxiety biases, although these social concerns are unlikely to occur early in life during adolescence or young adulthood.
• Body dysmorphic disorder can also present with a high degree of social anxiety, although this is keenly associated with shame due to the patient’s beliefs about body shape and weight.
• Narcissism can also present with social anxiety due to a fear of not being recognised as superior; this is categorically different to a SAD patient’s fear of social inappropriateness.
• Avoidant personality disorder (AvPD) and SAD are often disputed as the same disorder. Still, AvPD (present in 1/3rd of individuals with SAD) can be partially differentiated by the patient’s belief that the judgement is justified. In AvPD, there is a globally negative self-view and a debilitating fear of rejection that leads to extensive avoidance.
• Many eating disorders are also associated with social anxiety, possibly due to body image and weight control. Consider eating disorders when self-concept is integrally centred on body image, and excessive activity focuses on weight and dietary control.
• Generalised anxiety disorder: Consider GAD in preference to SAD when worries cover a broader range than just social situations, centre on minor daily matters, are constant and intrusive, and are a source of distress in and of themselves.

INITIAL ASSESSMENT AND MANAGEMENT

During the initial assessment, clinicians should establish a good therapeutic relationship to determine whether the primary diagnosis is SAD.

Co-morbid disorders that may affect short- and long-term treatment goals should be identified during assessment.

Furthermore, the clinician should prepare the groundwork for an appropriate treatment strategy.

Important points of a comprehensive assessment should include the following points [Andrews et al. 2018]:

• To assess the severity and duration of symptoms and has the patient received prior treatment?
• What level of distress or functional impairment is the patient experiencing?
• Does the patient have any co-morbid depressive or anxiety disorders, substance abuse disorders, or medical health issues?
• What is the mental health history of the patient and family?
• What is the quality of the patient’s interpersonal relationships and support network, and are these affected by employment status or living conditions?
• Finally, what are the goals the patient expects from treatment?

Rating Scales: 

1. The Social Phobia Inventory (SPIN):  The scale provides a brief assessment of the fears and avoidance characteristics of SAD.

2. The mini-SPIN :

• For rapid screening
• Comprises three items that can identify and distinguish SAD from non-clinical populations with 0.88 sensitivity and 0.98 specificity.

The Mini-SPIN contains three items about avoidance and fear of embarrassment that you rate based on the past week.

1. Fear of embarrassment causes me to avoid doing things or speaking to people.
2. I avoid activities in which I am the center of attention.
3. Being embarrassed or looking stupid are among my worst fears.

3. Liebowitz Social Anxiety Scale (LSAS)   

4. The Social Phobia and Anxiety Inventory (SPAI)

• A more comprehensive measure comprising over 45 items

5. Social Interaction Anxiety Scale SIAS 

6. Social Phobia Scale: 

CLINICAL RECOMMENDATIONS

The clinician should adopt a pragmatic and collaborative approach.

Enhance lifestyle factors:

• Regular exercise
• Healthy eating habits
• Improved sleeping routines
• Reduction in caffeine, tobacco, and alcohol intake [Andrews et al. 2018]

Treatment

A watchful waiting approach to therapy is advised to monitor the efficacy of psychoeducation and the patient’s uptake of recommended lifestyle improvements. [Andrews et al. 2018]

If treatment is indicated, clinical practice guidelines emphasise that psychotherapy is the first-line choice when congruent with patient preferences:

Mild SAD :

• Administration of CBT by a clinician face to face or a program of guided digital CBT (dCBT) is advised for those patients with mild SAD.
• Individual CBT is superior to group CBT.
• Please read about the principles and steps in CBT here. 

Moderate to Severe SAD: 

• Combination of CBT and pharmacotherapy with an SSRI or SNRI.
• Research shows that paroxetine, sertraline, fluoxetine, escitalopram, fluvoxamine, and the SNRI venlafaxine, have been previously used in the treatment of SAD. [Canton et al 2012] , [Ipser et al 2008];
• Simplified Guide to 21 Common Antidepressants – Mechanisms of Action, Side effects and Indications
• Evaluate treatment response after 4-6 weeks (or 4-6 sessions of weekly CBT)
• Continue therapy if a full or partial response is obtained.

Non-response: 

• Modify or escalate treatment if there is an inadequate response.
• For non-responders, consider adding an SSRI if not already administered, changing dCBT for CBT face to face with an experienced clinician, or increasing the antidepressant dose if the current dose is tolerated.
• If an SSRI is effective but is not tolerated, consider switching to another SSRI.
• If the second SSRI is not tolerated, consider switching to an SNRI.

Monitoring progress

• A second review at weeks 8 to 10 should be carried out to consider whether there is continuing distress and whether treatment should be further modified: increase CBT frequency and/or combine CBT with an SSRI or SNRI.
• Furthermore, clinicians are encouraged to check for diagnostic accuracy, level of SAD severity, the presence of comorbidities, and to seek a second opinion. [Andrews et al. 2018]
• A delayed response to treatment is possible as it can take up to 12 weeks before an adequate response is observed. However, this assumes that there has been good adherence to the full therapeutic dose and that the patient can tolerate any ongoing side-effects if treatment continues.
• Antidepressant medication can be changed to a different SSRI or switched to an SNRI antidepressant. However, if both an SSRI and an SNRI have already been sufficiently trialled, then a MAOI such as phenelzine can be administered after a washout period. [Curtiss et al., 2017]
• Moclobemide also has modest efficacy in SAD but is less efficacious than phenelzine but has better tolerability. [Blanco et al., 2013]
• Monoamine Oxidase Inhibitors (MAOI) – Mechanism of Action | Psychopharmacology | Clinical Application
• Combined phenelzine and Cognitive-behavioural group therapy (CBGT) treatment is superior to either treatment alone on response and remission rates. [Blanco et al., 2010]
• A systematic review and meta-analysis also found that the combination of CBT plus medication for SAD was superior to medication or CBT alone.
• A further review found that the combination of CBT plus medication for SAD was superior to CBT alone in the short term but equivalent in the long term. [Bandelow et al, 2007], [Würz  & Sungur, 2009] 
• Neuropathic pain drugs, pregabalin and gabapentin, can be considered at this stage and although these have been rationalised as off-label anxiolytics for anxiety-related disorders, there is a lack of evidence for efficacy in these psychiatric indications.
• Pregabalin was also shown to have potential efficacy in SAD but only at 450 or 600 mg doses, based on three randomised, double-blind, placebo-controlled trials. [Garakani et al., 2020]
• Finally, benzodiazepines can also be trialled for the short term (not PRN); however, it is not considered a long-term option in SAD.
• Beta-blockers, buspirone, and anti-psychotics should be avoided to treat SAD.
• Topiramate and valproate showed some efficacy in open-label trials. [Garakani et al., 2020]
• The Canadian practice guidelines for anxiety recommend risperidone and aripiprazole as adjunctive drugs in the treatment of SAD [Katzman et al., 2014]
• Since ketamine has anxiolytic effects, a double-blind RCT of intravenously administered ketamine at 0.5 mg/kg compared to saline placebo showed benefit in patients with SAD measured using the Liebowitz Social Anxiety Scale (LSAS). [Taylor et al., 2017]
• There is some evidence for Cannabidiol (CBD) in SAD at a dose range of 300 -400 mg, reducing anxiety scores. [Masataka, 2019]
• Pre-treatment with CBD (single dose 600 mg) before a public speaking test was associated with significantly reduced anxiety, cognitive impairment and discomfort in their speech performance and significantly decreased alert in their anticipatory speech. [Bergamaschi et al., 2011]

A recent systematic review and network meta-analysis suggested the following options for treatment of SAD: [Williams et al., 2020]

• Paroxetine as the first-line treatment of SAD
• Consideration of future research for olanzapine due to a high rank on efficacy.
• Brofaromine, bromazepam, clonazepam, escitalopram, fluvoxamine, phenelzine, and sertraline as other options due to an observed response to treatment.

Algorithm for the management of SAD: 

SUMMARY

The persistent fear of social situations is a pervasive and distressing disorder that can be situation-specific or more generalised.

SAD is often comorbid with other psychiatric disorders, which can complicate diagnosis and treatment.

Treatments that have an educational foundation can help address the psychological basis of SAD, although psychotherapy with CBT is encouraged.

Combination therapies with pharmacological interventions may be indicated due to individual comorbid disorders.