Discussion: Social Anxiety Disorder (SAD)

Discussion: Social Anxiety Disorder (SAD)

Discussion: Social Anxiety Disorder (SAD)

Social anxiety disorder (SAD) is a fear of appearing clumsy, silly, or shameful. Patients dread social gaffes such as choking when eating in public, trembling when writing, or being unable to perform when speaking or playing a musical instrument. Using a public urinal will cause anxiety for some men. Fear of blushing affects especially women, who may not be able to put into words what’s so terrible about turning red. Fear of further choking is often acquired after an episode of choking on food; it can occur any time from childhood to old age. Some patients fear (and avoid) multiple such public situations.

Many people, men and women, have noticeable physical symptoms with SAD: blushing, hoarseness, tremor, and perspiration. Such patients may have actual panic attacks. Children may express their anxiety by clinging, crying, freezing, shrinking back, throwing tantrums, or refusing to speak.

ORDER COMPREHENSIVE SOLUTION PAPERS ON Discussion: Social Anxiety Disorder (SAD)

Studies of general populations report a lifetime occurrence of SAD ranging from 4% to as high as 13%. However, if we consider only those patients who are truly inconvenienced by their symptoms, prevalence figures are probably lower. Whatever the actual figure, these findings contradict previous impressions that SAD is rare. Perhaps interviewers tend to overlook a common condition that patients silently endure. Though males outnumber females in treatment settings, women predominate in general population samples.

Onset is typically in the middle teens. The symptoms of SAD overlap with those of avoidant personality disorder; the latter is more severe, but both begin early, tend to last for years, and have some commonalities in family history. Indeed, SAD is reported to have a genetic basis.

Essential Features of Social Anxiety Disorder

Inordinate anxiety is attached to circumstances where others could closely observe the patient—public speaking or performing, eating or having a drink, writing, perhaps just speaking with another person. Because these activities almost always provoke disproportionate fear of embarrassment or social rejection, the patient avoids these situations or endures them with much anxiety.

The Fine Print

For children, these “others” must include peers, not just adults.

The D’s: • Duration (6+ months) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood and psychotic disorders, anorexia nervosa, OCD, avoidant personality disorder, normal shyness, and other anxiety disorders—especially agoraphobia)

Coding Notes

Specify if:

Performance only. The patient fears public speaking or performing, but not other situations.

Valerie Tubbs

“It starts right here, and then it spreads like wildfire. I mean, like real fire!” Valerie Tubbs pointed to the right side of her neck, which she kept carefully concealed with a blue silk scarf. “It” had been happening for almost 10 years, any time she was with people; it was worse if she was with a lot of people. Then she felt that everybody noticed.

Although she had never tried, Valerie didn’t think that her reaction was something she could control. She just blushed whenever she thought people were watching her. It had started during a high school speech class, when she had to give a talk. She had become confused about the difference between a polyp and a medusa, and one of the boys had commented on the red spot that had appeared on her neck. She had quickly flushed all over and had to sit down, to the general amusement of the class.

“He said it looked like a bull’s-eye,” she said. Since then, Valerie had tried to avoid the potential embarrassment of saying anything to more than a handful of people. She had given up her dream of becoming a fashion buyer for a department store, because she couldn’t tolerate the scrutiny the job would entail. Instead, for the last 5 years she had worked dressing mannequins for the same store.

Valerie said that it seemed “stupid” to be so afraid. It wasn’t just that she turned red; she turned beet-red. “I can feel prickly little fingers of heat crawling out across my neck and up my cheek. My face feels like it’s on fire, and my skin is being scraped with a rusty razor.” Whenever she blushed, she didn’t feel exactly panicky. It was a sense of anxiety and restlessness that made her wish her body belonged to someone else. Even the thought of meeting new people caused her to feel irritable and keyed up.

Evaluation of Valerie Tubbs

For years, Valerie had feared being embarrassed by the blushing that occurred whenever she spoke with other people (criteria A, B, C, and F in one sentence). Her fear was excessive (E), and she knew it—though insight isn’t required for the diagnosis. With her reluctance to speak publicly (and her scarf), she avoided exposure to scrutiny (D). Her anxiety also prevented her from working at the job she would have preferred (G).

With no actual panic attacks, and in the absence of anxiety disorder due to another medical condition and substance-induced anxiety disorder (H), determining her disorder would come down to the differential diagnosis of phobias (I). In the absence of a typical history, we can quickly dismiss specific phobia. People who have agoraphobia may avoid dining out because they fear the embarrassment of having a panic attack in a public restaurant. Then you would only diagnose SAD if it had been present prior to the onset of the agoraphobia and was unrelated to it. (Sometimes even clinicians who specialize in diagnosing and treating the anxiety disorders can have trouble deciding between these two diagnoses.) Patients with anorexia nervosa avoid eating, but the focus is on their weight, not on the embarrassment that might result from gagging or leaving food on their lips.

It is important to differentiate SAD from the ordinary shyness that is so common among children and other young people; this shows the value of the criterion that symptoms must be present for at least half a year, required by DSM-5 for adults as well as for children. Also keep in mind that many people worry about or feel uncomfortable with social activities such as speaking in public (stage fright or microphone fright). They should not receive this diagnosis unless it in some important way affects their working, social, or personal functioning.

Social phobia (as SAD used to be called) is often associated with suicide attempts and mood disorders. Anyone with SAD may be at risk for self-treatment with drugs or alcohol; Valerie’s clinician should ask carefully about these conditions. SAD has elements in common with avoidant personality disorder, which, often comorbid in these patients, may be a warranted diagnosis in a patient who is generally inhibited socially, is overly sensitive to criticism, and feels inadequate. Other mental disorders you might sometimes need to rule out—no problem for Valerie—would include panic disorder, separation anxiety disorder, body dysmorphic disorder, and autism spectrum disorder.

Valerie’s fears involved far more than performances, so the specifier wouldn’t apply. With a GAF score of 61, her diagnosis would be as follows: