Approximately 13% of the population experience social anxiety over the course of their lifetime (1). After alcohol abuse and depression it is the most common psychiatric illness. Yet, despite the fact that social anxiety is the most prevalent of all anxiety disorders (2), many questions and controversies surrounding its diagnosis and treatment still remain.
Currently, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) defines social anxiety disorder (SAD) as a persistent and debilitating fear of embarrassment or humiliation in social situations. People with SAD often completely avoid these social situations or endure them with significant distress (3).
Revisions to this definition have been proposed (4) since the difference between shyness and SAD is ambiguous, no clear causes for SAD have been validated, and there are contradicting views as to whether SAD is under-recognized and undertreated or over-diagnosed (5).
Perhaps one of the greatest controversies surrounding SAD is whether or not it is an extension of, or completely distinct from, shyness. How can we tell if someone simply has a shy temperament or is in need of treatment for a disorder?
The general consensus based on recent research suggests that there is a dimensional nature to social anxiety where its severity varies along a continuum. The greater the number of social fears an individual experiences, the greater the severity of the disorder (5).
One of the most common screening tools for SAD used in doctors’ offices is the “mini SPIN.” This screening device asks the patient to rate the following statements on a scale of 0 “not at all” to 4 “extremely present:”
- Fear of embarrassment causes me to avoid doing things or speaking to people.
- I avoid activities in which I am the center of attention.
- Being embarrassed or looking stupid are among my worst fears.
A score of 6 or higher suggests further evaluation is warranted. The mini SPIN has been shown to be 89% accurate in detecting cases of SAD (6). Of course, a physician must first identify the need for using the screening tool in the first place and, sadly, misdiagnosis rates for SAD are estimated at 97.8% (7), meaning that only 2.2% of those who meet criteria for SAD are correctly diagnosed with it by their primary care doctor.
One possible reason for poor detection rates of SAD may lie with the very nature of the disorder itself. Due to fears that others may judge them, people with SAD may be embarrassed to talk about their concerns and rather avoid the anxiety than face it. As a result, these individuals are less likely to seek help or state this specific type of anxiety as a concern to their doctor (5).
Typically, the disorder begins early in life and remains over a lifetime if untreated so people may mistake symptoms of SAD as part of their personality, something that cannot be changed. The term “social anxiety disorder” was not introduced until 1994 and some researchers theorize that the lack of media attention it has received in comparison to depression and other anxiety disorders has contributed to SAD being under-recognized (5).
Social anxiety can interrupt education and job success, cause financial dependence, and impair relationships (8). Sufferers of social anxiety have more difficulty dating (9), are less often married (10), record more sick days (11), experience reduced work productivity (12) and rely more on social assistance in comparison to those without the disorder (11). People with SAD are also more prone to depression and substance abuse (13).
Regardless of the reasons for it being under-recognized, it’s clear that SAD decreases the quality of life of its sufferers (14) and there is a strong need to improve screening for this disorder in the primary care setting.
Individuals who suspect they may suffer from social anxiety can complete the Web-Based Depression and Anxiety Test (http://www.wb-dat.net) and either print out the results to bring to their doctor or email the results directly to their doctor. This test is a clinically accepted screening tool (15) that may help make it easier to initiate conversation with a health professional.
SAD also seems to be undertreated. Part II of this article series will examine the efficacy of the most common conventional medical treatments for SAD, along with alternative therapies.
- Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.
- Davidson JRT, Hughes DL, George LK, Blazer DG. The epidemiology of social phobia: findings from the Duke Epidemiological Catchment Area Study. Psychol Med. 1993;23(3):709-718.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Washington: American Psychiatric Association; 1994.
- Bogels SM, Alden L, Beidel DC, Clark LA, Pine DS, Stein MB, et al. Social anxiety disorder: questions and answers for the DSM-V. Depress Anxiety. 2010;27:168-189.
- Dalrymple KL. Issues and controversies surrounding the diagnosis and treatment of social anxiety disorder. Expert Rev Neurother. 2012;12(8):993-1009.
- Connor KM, Kobak KA, Churchill LE, Katzelnick D, Davidson JR. Mini-SPIN: a brief screening assessment for generalized social anxiety disorder. Depress Anxiety. 2001;14:137-140.
- Vermani M, Marcus M, Katzman MA. Rates of detection of mood and anxiety disorders in primary care: a descriptive, cross-sectional study. Prim Care Companion CNS Disord. 2011;13(2).
- Valente S. Social phobia. J Am Psychiatric Nurses Assoc. 2002;8:67-75.
- Lader M. The clinical relevance of treating social phobia. J Affect Disord. 1998;50:S29-S34.
- Lepine JP, Pelissolo A. Why take social anxiety disorder seriously? Depress Anxiety. 2000;11:87-92.
- Dupont RL, Rice DP, Miller LS, Shiraki SS, Rowland CR, Harwood HJ. Economic costs of anxiety disorders. Anxiety. 1996;2:167-172.
- Wittchen HU, Fuetsch M, Sonntag H, Muller N, Liebowitz M. Disability and quality of life in pure and comorbid social phobia: findings from a controlled study. Eur Psychiatry. 1999;14:118-131.
- Den Boer JA, Baldwin D, Bobes J, Katschnig H, Westenberg H, Wittchen HU. Social anxiety disorder – our current understanding. Intl J Psychiatry Clin Pract. 1999;3:S3-S12.
- Wong N, Sarver DE, Beidel DC. Quality of life impairments among adults with social phobia: the impact of subtype. J Anxiety Disord. 2012;26(1):50-57.
- Farvolden P, McBride C, Bagby RM, Ravitz P. A web-based screening instrument for depression and anxiety disorders in primary care. J Med Internet Res. 2003;5(3):e23.
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