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Beyond shy: when to suspect social anxiety disorder: a 3-point screening tool can help you identify whether that "shy" patient is really suffering from this common psychiatric disorder.

Practice recommendations

* Cognitive Behavioral Therapy (CBT) is an effective treatment for social anxiety disorder. (B)

* Medication also helps patients with social anxiety disorder lead more functional lives. (B)

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence

B Inconsistent or limited-quality patient-oriented evidence

C Consensus, usual practice, opinion, disease-oriented evidence, case series

Janice L, 41, comes into her physician's office complaining that she's "feeling anxious all the time" at her job at a local bank. She tells him that she's been treated for depression in the past, though she's not currently taking any antidepressants. As her physician takes a more thorough history, he notices that her alcohol consumption seems a bit excessive. Her demeanor, which he had previously chalked up to as "shyness," comes into focus. He begins to suspect that his patient is more than just "quiet and unassuming" and may, in fact, be suffering from social anxiety disorder.

To confirm his suspicions, he excuses himself to retrieve an article he'd saved on the topic--one that identifies a quick screening tool for social anxiety disorder. (1) He then asks his patient to rate the following statements on a scale of 0 to 4, with 0 being "not at all" and 4 being "extremely present":

* Fear of embarrassment causes me to avoid doing things or speaking to people.

* I avoid activities in which I am the center of attention.

* Being embarrassed or looking stupid are among my worst fears.

His suspicions are confirmed when she scores a 10--well above the 6 that is highly suggestive of social anxiety disorder.

* A debilitating disorder that's all too common

Social anxiety, also known as social phobia, is the most common anxiety disorder, and is the third most common psychiatric disorder after depression and alcohol dependence. (2) The Epidemiological Catchment Area Study revealed that 2% to 4% of the sample suffered from social anxiety with a lifetime prevalence of 2.8%. Other studies have found that as many at 10% of the sample suffer from social anxiety when a more appropriate diagnostic interview is used. (3-5) Similarly, Kessler et al conducted a study investigating the prevalence of DSM-IV disorders and concluded that 6.8% of the entire sample suffered from social anxiety disorder. (6)

Social anxiety disorder is characterized as a persistent and debilitating fear of social interaction where patients fear negative evaluations by others. As a result, these patients may have trouble building and maintaining social relationships, which can result in a particularly isolated and depressed lifestyle. (7)

There are 2 subtypes of social anxiety disorder:

* Generalized social anxiety is generally more severe and more generalized and therefore, more disabling to patients. The majority of patients seen by the medical community tend to exhibit this subtype of the disorder.

* Nongeneralized anxiety (also known as specific or discrete social phobia) is the less common and usually includes a fear associated with I or a few specific situations.

Although nongeneralized anxiety may be less likely to cause severe impairment in the patient's life, it still may lead to significant underachievement in school or work. (8) Still, patients with public speaking--only social anxiety are more likely to recover spontaneously, while patients with generalized social anxiety rarely recover spontaneously from the disorder.

The 2 subtypes also differ in their origin. Generalized social anxiety--the focus of this article--is significantly more prevalent among relatives who also suffer from the disorder, while patients with nongeneralized social anxiety disorder do not necessarily have relatives with the condition. (9)

* "Shyness" in childhood that's often overlooked

Social anxiety is a lifelong disorder that may begin as early as childhood, but is often described as beginning at age 13. At this age, though, the social anxiety is often mistaken for extreme shyness and therefore goes untreated. (10) (See "Distinguishing shyness from social anxiety in kids," above.)

Overlooking shyness in such a young patient is particularly problematic as the avoidance that characterizes the social anxiety disorder can result in a lost opportunity to acquire social skills that are needed to ease the transition from adolescence to adulthood. This relative loss of social skills often facilitates the development of social dysfunction that is characteristic of this illness. (11) As time goes by, sufferers eventually become accustomed to their fears and create a way of life that accommodates them.

Social anxiety can interrupt education or job success, cause financial dependence, and impair relationships. (10) (See "Fear of embarrassment hinders relationships and careers" on page 371.) Sufferers tend to miss out on important social events and activities in their lives, (12) and they begin to accumulate comorbidities such as depression and substance abuse. (13) In fact, while many cases of social anxiety are overlooked as shyness, others are misdiagnosed as depression.

Complicating matters further is the issue of substance abuse. The Epidemiological Catchment Area Study found that alcohol abuse was reported in 17% of social anxiety cases and drug abuse was reported in 13%. (5) In the study conducted by Kessler et al, results indicated that 8.8% of individuals suffering from a substance abuse problem also suffered from comorbid social anxiety. (6)

The substance abuse evolves slowly, (14) and tends to arise as an inappropriate coping mechanism because so many cases of social anxiety go untreated. (15)

* Symptoms to watch for, questions to ask

The primary indicator of social anxiety is intense fear of social situations. A patient suffering from social anxiety fears that he or she will act in a way that will be humiliating when confronted with unfamiliar situations or people or by the possibility of being scrutinized by others. (16) While many people with social anxiety realize that their fears are excessive or unreasonable, they are unable to overcome them. (17)

There are also a number of physical, cognitive, and behavioral symptoms that are associated with social anxiety. The physical symptoms may include rapid heart rate, trembling, shortness of breath, sweating, and abdominal pain. The cognitive symptoms include maladaptive thoughts and beliefs about social situations (ie, irrational thought processes), that increase the anxiety when in the situation. Finally, behavioral symptoms include phobic avoidance of the feared situation. (18)

There are many screening devices that you can use to identify patients with social anxiety disorder or to assess the severity of symptoms. Some examples include the Liebowitz Social Phobia Scale, (19) the Social Phobia Inventory (SPIN), (20) Fear of Negative Evaluation Scale, (21) and the Social Avoidance and Distress Scale. (22) These tools, however, can be a bit time consuming.

A more handy--though admittedly less comprehensive--screening device is the "mini SPIN" that was used by the physician in our opener. In a study of 7165 managed care patients, 89% of the cases meeting criteria for social anxiety disorder were detected (with a score of 6 or better) using this screening method. (1)

To review, you'll need to ask patients to rate the following statements on a scale of 0 "not at all" to 4 "extremely present":

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.

A score of 6 or higher should prompt you to further evaluate the patient using one of the screening devices listed earlier.

* Treatments of choice: CBT and drug therapy

Although social anxiety most commonly spans a lifetime, studies indicate that treatment--typically cognitive behavioral therapy (CBT) with drug therapy--can help sufferers deal with their fears and function more efficiently in their everyday lives. The best effects in treating social anxiety, therefore, are in combining the different treatment strategies. (14)

Cognitive behavioral therapy

Heimberg and colleagues found that 75% of social anxiety patients who participated in a cognitive behavioral therapy group experienced improved function and saw a reduction in symptoms of social anxiety. (23) Successful CBT seems to not only alleviate symptomatic distress, but improve the patients' perceptions of their general quality of life. (24) Including behavioral components such as reinforcement or conditioning in CBT appears to be effective in helping sufferers minimize their symptoms. In addition, cognitive restructuring (ie, changing a patient's thought process) has also been shown to be a helpful treatment. (23)

Some of the basic elements of CBT include anxiety management skills (ie, breathing and relaxation techniques), social skills training (ie, maintaining conversation with the patient while monitoring the patient's eye contact), and gradual exposure to the feared situation (ie, exposure to social situations).

Drug therapy

Studies have also demonstrated the effectiveness of a variety of medications (including Venlafaxine XR [Effexor XR], Paroxetine [Paxil], Paroxetine CR [Paxil CR], Sertraline [Zoloft], and Fluvoxamine [Luvox]) in managing social anxiety disorder. (25-28) If you are caring for a patient with social anxiety disorder, you'll want to start him on a selective serotonin reuptake inhibitor (SSRI) or serotonin-norepinephrine reuptake inhibitor (SNRI).

If this doesn't achieve the desired results, the next step is a monoamine oxidase inhibitor, such as phenelzine (Nardil), or a reverse inhibitor of monoamine oxidase A, such as moclobemide. Additionally, some benzodiazepines and anticonvulsants (clonazepam and pregabalin [Lyrica]) may also be effective if the other options do not achieve the desired results. The TABLE outlines common medications used to treat social anxiety, as well as recommended dosages. (29)

When putting your patient on any of these medications, patient teaching will be important. You'll need to advise the patient that common antidepressant side effects include, but are not limited to, nausea, diarrhea, sexual dysfunction (ie, delayed orgasm), and headaches. These effects, however, typically disappear by the second week of intake. (15) If the patient is taking a benzodiazepine, you'll need to warn him about the risk of psychomotor or cognitive impairment.

If the patient has a comorbid substance abuse problem, you and the patient will also need to adjust your expectations somewhat. That's because patients with a substance abuse problem are likely to have a poorer response to some of these medications than patients without a substance abuse problem. (30)

Though the time it takes to manage the condition is variable, patients with social anxiety disorder can improve their situation and go on to live more fulfilling and happy lives. The trick, really, is spotting the disorder early, rather than assuming your patient is simply the "quiet type."


Martin A. Katzman, MD, FRCPC, START Clinic for Mood and Anxiety Disorders, 790 Bay St, Toronto, Ontario, Canada M5G 1N8


No potential conflict of interest relevant to this article was reported.


(1.) Connor KM, Kobak KA, Churchill LE, Katzelnick D, Davidson JR. Mini-Spin: A brief screening assessment for generalized social anxiety disorder. Depress Anxiety 2001; 14:137-140.

(2.) Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12 month prevalence of DSM III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51:8-19.

(3.) Robins LN, Regier DA. Psychiatric Disorders in America: The Epidemiological Catchment Area Study. New York: Free Press; 1990.

(4.) Eaton WW, Weissman M. Panic and phobias. In: Robins E, DA Regier, eds. Psychiatric Disorders in America: The Epidemiological Catchment Area Study. New York: Free Press; 1991:155-179.

(5.) Scheier FR, Johnson J, Hornig, CD, Liebowitz, MR, Weissman MM. Social phobia: Comorbidity and morbidity in an epidemiological sample. Arch Gen Psychiatry 1992; 49:282-288.

(6.) Kessler RC, Chiu WT, Demier O, Waiters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Arch Gen Psychiatry 2005; 62:617-627.

(7.) Lepine JP, Pelissolo A. Why take social anxiety disorder seriously? Depress Anxiety 2000; 11:87-92.

(8.) Wittchen HU, Fuetsch M, Sonntag H, Muller N, Liebowitz M. Disability and quality of life in pure and comorbid social phobia- findings from a controlled study. Eur Psychiatry 1999; 14:118-131.

(9.) Stein MB, Chavira DA. Subtypes of social phobia and comorbidity with depression and other anxiety disorders. J Affect Disord 1998; 50:S11-S16.

(10.) Valente S. Social phobia. J Am Psychiatric Nurses Assoc 2002; 8:67-75.

(11.) Beidel DC. Social phobia: etiology and evolution. J Clin Psychiatry 1998; 59(Suppl 17):27-31.

(12.) Greist JH. The diagnosis of social phobia. Clin Psychiatry 1995; 56(5):5-12.

(13.) Den Boer JA, Baldwin D, Bobes J, Katschnig H, Westenberg H, Wittchen HU. Social anxiety disorder--our current understanding. Intl J Psychiatry Clin Pract 1999; 3:S3-S12.

(14.) Montgomery SA. Social phobia: Diagnosis, severity and implications for treatment. Eur Arch Psychiatry Clin Neurosci 1999; 249:S1-S6.

(15.) Davidson JR, Potts NL, Richichi E, et al. Treatment of social phobia with Clonazepan and placebo. J Clin Pharmacol 1993; 13:423-428.

(16.) Kasper S. Social phobia: The nature of the disorder. J Affect Disord 1998; 50:S3-S9.

(17.) American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text rev. Washington, DC: APA; 2000.

(18.) Ross J. Social phobia: The consumer's perspective. J Clin Psychiatry 1993; 54:S5-S9.

(19.) Bruce TJ, Saeed SA. Social anxiety disorder: A common under recognized mental disorder. Am Fam Physician 1999; 60:2311-2322.

(20.) Connor K T, Davidson JRT, Churchill E, Sherwood A, Foa E, Weisler RH. Psychometric properties of the Social Phobia Inventory (SPIN). Br J Psychiatry 2000; 176:379-386.

(21.) Watson D, Friend R. Measurement of social-evaluative anxiety. J Consulting Clin Psychol 1969; 33:448-457.

(22.) Heimberg RG, Hope DA, Rapee RM, Bruch MA. The validity of the Social Avoidance and Distress Scale and the Fear of Negative Evaluation Scale with social phobic patients. Behav Res Ther 1988; 26:407-410.

(23.) Antony M, Swinson R. The Shyness and Social Anxiety Workbook: Proven Techniques for Overcoming Your Fears. Oakland, Calif: New Harbinger; 2000.

(24.) Safren SA, Heimberg R, Brown E, Holle C. Quality of life in social phobia. Depress Anxiety 1996/1997; 4:126-133.

(25.) Heimberg RG, Liebowitz, MR, Hope DA, et al. Cognitive behavioral group therapy vs phenelzine therapy for social phobia. Arch Gen Psychiatry 1998; 55:1133-1141.

(26.) Van V, Den Boer JA, Westenberg HG. Psychopharmacological treatment of social phobia: A double blind placebo controlled study with Fluvoxamine. Psychopharmacol 1994; 115:128-134.

(27.) Kelsey JE. Venlafaxine in social phobia. Psychopharmacol Bull 1995; 31:767-771.

(28.) Allgulander C. Paroxetine in social anxiety disorder: A randomized placebo controlled study. Acta Psychiatr Scand 1999; 100:193-198.

(29.) Muller JE, Koen L, Seedat S, Stein DJ. Social anxiety disorder: current treatment recommendations. CNS Drugs 2005; 19:377-391.

(30.) Sareen L, Stein M. A review of the epidemiology and approaches to the treatment of social anxiety disorder. Drugs 2000; 3:497-509.

(31.) Lader M. The clinical relevance of treating social phobia. J Affect Disord 1998; 50:S29-S34.

(32.) Dupont RL, Rice DP, Miller LS, Shiraki SS, Rowland CR, Harwood HJ. Economic costs of anxiety disorders. Anxiety 1996; 2:167-172.

(33.) Wittchen HU, Fuetsch M, Sonntag H, Muller N, Liebowitz M. Disability and quality of life in pure and comorbid social phobia: findings from a controlled study. Eur Psychiatry 1999; 14:118-131.

Distinguishing shyness from social anxiety in kids

The difference between social anxiety disorder and shyness in children is that social anxiety debilitates the child's ability to grow and develop socially in an appropriate manner. While children with--and without--social anxiety disorder may be uncomfortable around unfamiliar adults, children with this disorder will also be uncomfortable in a peer setting with unfamiliar kids their own age. Children with social anxiety may express their discomfort through crying, tantrums, or freezing from the social situation. In order for the child to meet full criteria for social anxiety, the duration of the symptoms must span at least 6 months. (17)

Fear of embarrassment hinders relationships and careers

Patients suffering from social anxiety tend to have more difficulty in dating situations because of their constant fear of participating in social interactions. (31) In fact, a large study in France found a connection between social anxiety and marriage rates. Forty-three percent of individuals who reported symptoms of social anxiety were married, compared with 65% of those who reported no symptoms. (7)

Careers also suffer because of the patient's constant fear of embarrassment. Patients who have social anxiety record more sick days than those without the disorder. (32) In addition, socially anxious patients have reduced work productivity compared with healthy controls. (33) As a result of their inability to perform adequately in their career, many patients may have to rely on social assistance. In fact, one study indicates that 22% of patients with social anxiety were on social assistance compared with 10% of a matched controlled group. (32)

Patient resources


* The Anxiety Disorders Association of Canada/Association Canadienne des Troubles des Anxieux

* The Social Anxiety Network

* The Social Phobia and Social Anxiety Association


* Dying of Embarrassment: Help for Social Anxiety & Phobia (Barbara Markway, C. Alec Pollard, and Teresa Flynn), 1992

* Painfully Shy: How to Overcome Social Anxiety and Reclaim your Life (Barbara Markway and Gregory Markway), 2003

* The Shyness and Social Anxiety Workbook: Proven Techniques for Overcoming your Fears (Martin M. Anthony and Richard P. Swinson), 2000


While many cases of social anxiety are overlooked as shyness, others are misdiagnosed as depression

Substance abuse evolves as an inappropriate coping mechanism since so many cases of social anxiety go untreated

Benzodiazepines and anticonvulsants may work when other options fail

Patients may want to check out the Social Anxiety Network, at

Jessica Rosenthal, BA, Leslie Jacobs, and Madalyn Marcus, BA START Clinic for Mood and Anxiety Disorders, Toronto, Ontario, Canada

Martin A. Katzman, MD, FRCPC START Clinic for Mood and Anxiety Disorders; University of Toronto; Northern Ontario School of Medicine
Pharmacologic options for treating social anxiety disorder

                               INITIAL DAILY   MAXIMUM DAILY
                               DOSE (MG)       DOSE (MG)


Citalopram (Celexa)            20              40-60
Escitalopram (Cipralex)        5-10            20
Fluoxetine (Prozac)            20              80
Fluvoxamine (Luvox)            50              300
Paroxetine (Paxil)             20              60
Paroxetine CR (Paxil CR)       25              62.5
Sertraline (Zoloft)            50              200


Moclobemide                    300             600
Phenelzine (Nardil)            15              90


Clomipramine                   25              200
Imipramine                     25              150

Other antidepressants

Bupropion SR (Wellbutrin SR)   100-150         300
Bupropion XL (Wellbutrin XL)   150             300
Mirtazapine (Remeron)          15              45
Mirtazapine RD (Remeron RD)    15              45
Venlafaxine XR (Effexor XR)    37.5-75         225


Alprazolam                     0.25            1.5-3.0
Bromazepam                     6               30
Clonazepam                     .25             4
Diazepam                       2.5             10
Lorazepam                      0.5             3-4


Gabapentin (Neurontin)         900             3600
Lamotrigine (Lamictal)         25              200
Pregabalin (Lyrica)            150             600
Topiramate (Topamax)           25              800

Atypical antipsychotics

Olanzapine (Zyprexa)           2.5             20
Risperidone (Risperdal)        0.5             6
Quetiapine (Seroquel)          50              800

SSRI, selective serotonin reuptake inhibitor; MAOI, monoamine oxidase
inhibitor; RIMA, reverse inhibitor of monoamine oxidase A.
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Author:Rosenthal, Jessica; Jacobs, Leslie; Marcus, Madalyn; Katzman, Martin A.
Publication:Journal of Family Practice
Geographic Code:1CONT
Date:May 1, 2007
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