social anxiety disorders

**Definition (DSM-5-TR):** Marked fear or anxiety about one or more social situations involving possible scrutiny by others (conversations, being observed eating, public speaking/performance). The person fears acting in a way that will be negatively evaluated (humiliation, embarrassment, rejection). Criteria: social situations almost always provoke fear; they are avoided or endured with intense distress; the fear is out of proportion to the actual threat; duration ≥6 months (in all ages); clinically significant distress or impairment; not better explained by substances, another medical condition, or another mental disorder (e.g., panic disorder, body dysmorphic disorder, autism spectrum disorder).

**Specifiers:** - *Performance only*: fear limited to speaking or performing in public (e.g., stage fright). - *Generalized* (older terminology): fear spans most social situations; more severe and more disabling.

**Epidemiology/Risk factors:** Typical onset in mid-teens (often by age 13–20); lifetime prevalence ~10%; slightly more common in women. Risk factors include behavioral inhibition in childhood, a family history (first-degree relatives have ~2–6x risk), parental overprotection or criticism, bullying, and childhood maltreatment. Common comorbidities: major depression, other anxiety disorders, and alcohol/substance use disorders (self-medication). Also associated with an increased risk of suicidality.

**Pathophysiology:** Hyperreactivity of the amygdala to social threat cues (e.g., angry or critical faces), with impaired prefrontal regulation. Serotonergic, noradrenergic, and GABAergic dysregulation are implicated. Cognitive models describe negative self-focused attention, anticipatory anxiety, and post-event rumination, which maintain avoidance.

**Clinical presentation:** Anticipatory anxiety, blushing, tremor, sweating, tachycardia, nausea, a shaky voice, and avoidance of school, work, or dating. Physical symptoms are sympathetic (autonomic) and can progress to situationally bound panic attacks.

**Differential diagnosis (high-yield):** - *Avoidant personality disorder*: pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to criticism since early adulthood; it overlaps heavily with generalized SAD, and the distinction is that avoidant PD is more pervasive and trait-like. - *Panic disorder*: unexpected panic attacks with fear of further attacks, not fear of social evaluation. - *Agoraphobia*: fear of situations where escape is difficult, not fear of scrutiny. - *Selective mutism*: childhood failure to speak in specific social settings. - *Normal shyness*: no significant impairment. - *Autism spectrum disorder*: deficits in social communication, with restricted/repetitive behaviors. - *Generalized anxiety disorder*: excessive worry about multiple domains, not focused on social evaluation. - *Specific phobia*: fear of a specific object or situation (e.g., heights), not social judgment.

**Management:** - *Psychotherapy*: CBT, with cognitive restructuring and graded exposure, is first-line and has durable benefit. - *Pharmacotherapy*: SSRIs (sertraline, paroxetine, fluvoxamine, escitalopram) and SNRIs (venlafaxine XR) are first-line for generalized SAD. Second-line options include benzodiazepines (e.g., clonazepam; limited by dependence and tolerance, and avoided in substance use) and MAOIs (phenelzine; effective, but dietary tyramine restrictions and the risk of serotonin syndrome limit use). Gabapentin and pregabalin are alternatives. - *Performance-only type*: propranolol (or atenolol) 30–60 minutes before the event blunts adrenergic symptoms (tremor, palpitations). It does not treat the cognitive anxiety, and it is used as needed rather than daily. - *Avoid*: alcohol as self-medication; buspirone is not effective.

**Boards pearls:** - Onset in adolescence + fear of embarrassment/scrutiny + avoidance → SAD. - "Fear of public speaking only" → propranolol PRN. - Generalized/chronic → SSRI + CBT. - Duration of ≥6 months is required (a requirement for all ages in DSM-5). - Differentiate from avoidant PD (pervasive, lifelong trait with a feeling of inadequacy).