Social Phobia Clinical Presentation

  • Author: Bettina E Bernstein, DO; Chief Editor: Eduardo Dunayevich, MD   more...
 
Updated: Sep 14, 2011
 

History

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for social phobia are as follows:

  • The person has a marked and persistent fear of one or more social or performance situations in which he or she is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Children must show evidence of the capacity for age-appropriate social relationships with familiar people, and the anxiety must occur in peer settings, not just in interactions with adults.
  • Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. In children, the anxiety may be expressed as crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
  • The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent.
  • The feared social or performance situations are avoided or are endured with intense anxiety or distress.
  • The avoidance, anxious anticipation, or distress in the feared social or performance situation interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships; alternatively, the patient has marked distress about having the phobia.
  • In individuals younger than 18 years, the duration is at least 6 months.
  • The fear or avoidance is not due to the direct physiological effects of a substance (eg, drug of abuse, medication) or a general medical condition and is not better accounted for by another mental disorder (eg, panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, pervasive developmental disorder, schizoid personality disorder).
  • If a general medical condition or another mental disorder is present, the fear in one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others is unrelated to it; for example, the fear is not of stuttering, trembling in persons with Parkinson disease, or exhibiting abnormal eating behavior in persons with anorexia nervosa or bulimia nervosa.
  • The phobia is specified as generalized if the fears include most social situations; also consider the additional diagnosis of avoidant personality disorder.
  • Associated features include depressed mood; somatic/sexual dysfunction; addiction; and anxious, fearful, or dependent personality.
  • Social phobia typically manifests in middle childhood, at approximately age 10 years. Adolescents (age 11-12 y) may avoid age-appropriate social activities, such as attending parties and dating. Symptoms of social phobia in younger children include crying, temper tantrums, fidgeting, somatic complaints, and avoidance and withdrawal from social situations.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is currently reviewing research evidence to determine whether selective mutism should be a subcategory of or a separate category from social anxiety disorder. Pervasive test anxiety may be in both the social anxiety disorder category and in the generalized anxiety disorder category.[22]

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Physical

A thorough Mental Status Examination should be included, with the following areas specifically assessed:

  • General appearance: The patient may be noticeably uncomfortable or anxious in the office. The patient may be hesitant or have difficulty speaking. However, in one-on-one situations, the patient may not demonstrate significant social anxiety. Individuals observed to be silent or mute should undergo screening for selective mutism with the selective mutism questionnaire or other appropriate checklists that gather information from the child and other sources of information (eg, from parents or teachers).[23]
  • Because elevated cortisol levels may worsen symptoms of social phobia, the history and cursory observation of the patient's habitus should include ruling in or out conditions that cause elevated cortisol levels (intrinsic or extrinsic).[24]
  • Mood/affect: Because depression is commonly comorbid with social phobia, the patient may report depressed or anxious mood and may appear to have a depressed or anxious affect.
  • Speech: The patient may speak softly and with hesitancy.
  • Thought processes: Thought processes in individuals with social phobia are usually in the "normal" range. Their thought processes are usually appropriately goal-directed and syntonic without morbid preoccupation or impairment of reality.
  • Perception: Auditory or visual hallucinations are not elements of social phobia; however, schizophrenia or acute stress disorder may be comorbid with social phobia.[25]
  • Thought content: The patient may be preoccupied with what others are thinking about him or her. Delusions are not present, but preoccupation with the scrutiny of others may approach delusional levels. True paranoia or fixed delusions are not consistent with social phobia and are more suggestive of schizophrenia.[25]
  • Cognition: Cognition is normal.
  • Suicidal/homicidal ideation: This is not common with social phobia per se, but the social isolation associated with social phobia can lead to despair, depression, and suicidal ideation. Thus, it is important to screen for depression, especially in the presence of obsessive thinking accompanied by compulsive behaviors.[26, 27]
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Causes

Genetic factors may contribute to social phobia. Pedigree analyses suggest that first-degree relatives of probands with social phobia are 3 times more likely to have social phobia than controls. However, specific genes have not been isolated. An inhibited temperament in childhood has been linked with the development of social phobia in adolescence. The brain dysfunction in social phobia may result from increased activation of neural circuitry to fearful faces, specifically in the amygdala.[26, 27]

Paternal social anxiety is a specific risk factor for the development of childhood social anxiety. When fathers exhibit social anxiety, this can be interpreted by their children as a strong negative signal about the external social world and cause them to rationally adjust their beliefs and feel stressed instead of secure. This can hinder children developing feelings of security regarding individuation and autonomy.[28]

A cross-cultural perspective is essential, as individuals of some cultures (Japanese, Korean) may have a persistent and excessive fear of offending others in social situations, called taijin kyofusho. Specifically, the individual fears that his or her body odor, eye-to-eye contact, or blushing could be offensive to others.[29]

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Contributor Information and Disclosures
Author

Bettina E Bernstein, DO  Clinical Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Outpatient Consultant, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Court Appointed Evaluator, Family Court of Philadelphia; Psychiatric Consultant, Intercommunity Action, Inc, Easttown Tredyffrin School District

Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mohammed A Memon, MD  Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

Eduardo Dunayevich, MD  Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories

Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor, Kiki D Chang, MD, to the development and writing of this article.

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