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social phobia; social anxiety disorder

A disabling fear of events in which the person is exposed to scrutiny by others: 1) public speaking 2) eating 3) using the lavoratory 4) events with friends or family Epidemiology: 1) 3-13% lifetime prevalence 2) more common in women than men 3) less common in the elderly 4) 13% of population [4] Clinical manifestations: - severe & persistent fear of social or performance situations, especially but not limited to, when encountering unfamiliar people - public speaking - examinations - somatic symptoms or panic attacks in anticipation of social events - avoidance of occupational & social situations because of fears of interacting with other people [1] - physical symptoms (blushing, dyspnea, palpitations, chest pain, dyspnea, nausea, diarrhea) emotional distress, or panic attacks may occur in anticipation of feared situations [5] - patients generally present for medical help for coexisting condition [4] Diagnostic criteria: - disabling fear of events in which the person is exposed to scrutiny by others - in children, the anxiety must occur in peer settings, not just during interactions with adults - fear of disapproval - recognition that the fear is excessive or unreasonable (may be absent in children) - in children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. - social situations are avoided or endured with intense fear or anxiety - fear or anxiety is out of proportion to the social situation - fear, anxiety, or avoidance >= 6 months - fear, anxiety, or avoidance is disabling - clinically significant distress - impairment in social, occupational, or other important areas of functioning - fear, anxiety, or avoidance is not attributable to the physiologic effects of a substance or another medical condition or better explained by another mental disorder - if another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive [3] Complications: - increased risk of other mental disorders - depression - substance abuse Differential diagnosis: - distinct from shyness [2] - agoraphobia - patients may dislike social situations, but are not afraid of social interactions [5] Management: - psychotherapy [2] - cognitive behavioral therapy 1st line [1,4] - durability of effects > 12 months small to medium [5] - desensitization - group therapy - selective serotonin reuptake inhibitors (SSRI) - generally pharmaceutical treatment of choice [1] - sertraline or other SSRI - venlafaxine (SNRI) is alternative [1] - anxiolytic agent if SSRI is ineffective - benzodiazepine - remission rates with pharmacotherapy low [2] - beta-blockers for specific & episodic performance anxiety such as 'stage fright'

General

phobia anxiety disorder social disorder

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 17, 18. American College of Physicians, Philadelphia 1998, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Burstein M et al. Shyness versus social phobia in US youth. Pediatrics 2011 Nov; 128:917. PMID: 22007009
  3. Soreff S Fast Five Quiz: Anxiety Medscape. August 9, 2021 https://reference.medscape.com/viewarticle/955963 - Bernstein BE, Pataki C Social Phobia Medscape. Nov 20, 2018 https://emedicine.medscape.com/article/290854-overview
  4. Leichsenring F, Leweke F Social Anxiety Disorder. N Engl J Med 2017; 376:2255-2264. June 8, 2017. PMID: 28591542 http://www.nejm.org/doi/full/10.1056/NEJMcp1614701
  5. NEJM Knowledge+ Psychiatry
  6. Pollack MH et al. A double-blind randomized controlled trial of augmentation and switch strategies for refractory social anxiety disorder. Am J Psychiatry 2014 Jan 1; 171:44 PMID: 24399428 http://ajp.psychiatryonline.org/article.aspx?articleID=1809641
  7. Social Phobia http://www.nimh.nih.gov/healthinformation/socialphobiamenu.cfm