Social Phobia Clinical Presentation

Updated: Nov 20, 2018
  • Author: Bettina E Bernstein, DO; Chief Editor: Caroly Pataki, MD  more...
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The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for social phobia are as follows: [29]

  • Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. In children, the anxiety must occur in peer settings and not just during interactions with adults.

  • The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated.

  • The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent.

  • The social situations almost always provoke fear or anxiety. In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

  • The social situations are avoided or endured with intense fear or anxiety.

  • The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

  • The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

  • The fear, anxiety, or avoidance cause clinically significant distress or impairment in social, occupationals, or other important areas of functioning.

  • The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance or another medical condition.

  • The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder.

  • If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

A Hypothetical Case Presentation

The chief complaint of a 9-year-old boy is, "No one likes me or wants to play with me, and I hate it when the teacher asks me to read aloud." He has difficulties with functioning at school, his teacher reports that he rarely raises his hand to be called on, and his mother reports that he has frequent stomachaches, especially the night before he is supposed to take standardized tests. At home, he seems content to play his clarinet by himself, and he tells the clinician that he dreads concerts because he is expected to play in front of others.



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). [30]

  • 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. [31]

  • 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 fixed delusions are not consistent with social phobia and are more suggestive of schizophrenia. [31]

    • A 2015 study of adolescents found that individuals with social anxiety disorder (SAD) displayed more frequent and intense paranoid thoughts than a control group and that the level of paranoid thoughts was significantly predicted by the degree of social phobia, even after adjusting for sex and other anxiety disorders, although adjusting for depression slightly reduced the extent and significance of the prediction. [32]

  • 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. [33, 34]



Very low weight (600–1250g) premature babies may be at higher risk for later development of social anxiety disorder, possibly owing to abnormalities in the uncinate fasciculus, the major white matter tract connecting the frontal cortex to the amygdala, and other limbic temporal regions. [10]

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. [33, 34]

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. [35]

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. [36]

A severe form of social phobia and avoidant personality disorder, Hikikomori has been associated with adverse cardiovascular consequences including hypertension. [18]

The importance of culturally sensitive measures in diagnosis of social phobia and social anxiety is critical, although social phobia and social anxiety has been found in many cultures, not exclusively in Japan but also in Hong Kong, China, India, South Korea, Spain, and the United States. One study found differences in sensitivity of detection of the disorder finding that the Social Interaction Anxiety Scale and Social Phobia Scale were not as sensitive in detecting the disorder in test subjects from Japan compared with those from Australia. [37]

Preliminary findings of one study show possible blood biomarkers that may reflect increased risk for Hikikomori—lower serum HDL-C in females and lower serum uric acid in males—which may reflect an underlying mechanism of oxidative stress and inflammation increasing risk of social phobia. [38]


Physical Examination

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) via taking blood pressure, pulse, and observing for abnormal facies like "mood facies." [39]



Social phobia has a wide range of severity. It may be mild and associated with minimal distress or may be severe to the point of causing marked disability. Extreme avoidance behavior (i.e., avoiding contact with others and being unable to maintain employment) sometimes complicates this condition.

Substance abuse, particularly the abuse of alcohol, sedatives, or narcotics, can also make treatment more difficult because benzodiazepines may not be appropriate or may need to be used with extreme caution in patients with substance dependency.

School refusal is a common complication of social anxiety disorder. A classic article highlights the importance of using cognitive behavioral therapy techniques for youth who are on an inpatient psychiatric unit to prevent school refusal. [40]