Social Anxiety Disorder
Danielle Herring
DSM-5 Changes
Previously designated Social Phobia
(Social Anxiety Disorder)
Now designated as Social Anxiety
Disorder (Social Phobia)
Individuals over 18 must recognize
their anxiety is excessive or
Anxiety must be out of proportion to
the actual danger or threat in the
situation, after taking cultural
contextual factors into account
(minimize overdiagnosis of transient
6-month duration for individuals over
6-month duration for all ages
Generalized specifier (if fears include
most social situations)
Generalized specifier deleted. Replaced
with a “performance only” specifier.
Social Anxiety Disorder (SAD)
 Found under Anxiety Disorders
 Other disorders also listed:
 Separation Anxiety Disorder
 Selective Mutism
 Specific Phobia
 Panic Disorder
 Panic Attack Specifier
 Agoraphobia
 Generalized Anxiety Disorder
 Substance/Medication-Induced Anxiety Disorder
 Anxiety Disorder Due to Another Medical Condition
 Other Specified Anxiety Disorder
 Unspecified Anxiety Disorder
Social Anxiety Disorder (SAD)
 Essential feature:
 Social anxiety
disorder is a
marked, or
intense, fear or
anxiety of social
situations in
which the
individual may be
scrutinized by
Diagnostic Criteria
A. Marked fear or anxiety about one or more social situations in
which the individual is exposed to possible scrutiny by others.
Examples include social interactions (e.g., having a conversation,
meeting unfamiliar people), being observed (e.g., eating or
drinking), and performing in front of others (e.g., giving a
speech). Note: 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 (i.e., will be
humiliating or embarrassing; will lead to rejection or offend
The social situations almost always provoke fear or anxiety.
Note: 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
The fear or anxiety is out of proportion to the actual threat posed
by the social situation and to the sociocultural context.
Diagnostic Criteria
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more.
G. The fear, anxiety, or avoidance causes clinically significant
distress or impairment in social, occupational, or other important
areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the
physiological effects of a substance (e.g., a drug of abuse, a
medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the
symptoms of another mental disorder, such as panic disorder,
body dysmorphic disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity,
disfigurement from burns or injury) is present, the fear, anxiety,
or avoidance is clearly unrelated or is excessive.
Specify if: Performance only: If the fear is restricted to speaking or
performing in public.
Diagnostic Specifier
 Performance Only:
 Performance fears that typically impair one’s
professional life
 Can manifest in work, school, or academic settings
 Those with performance only SAD do not fear or
avoid nonperformance social situations.
Associated Features
 Inadequately assertive or excessively submissive behavior
 Rigid body posture
 Inadequate eye contact
 Overly soft voice tone
 Blushing – hallmark physical response to SAD
Prevalence of SAD
 12-month prevalence estimate for the United States is approximately 7%
 12-month prevalence rates in children and adolescents are comparable to those in
Lower 12-month prevalence estimates are seen in much of the world using the
same diagnostic instrument, clustering around 0.5%–2.0%
Prevalence rates decrease with age
 12-month prevalence for older adults ranges from 2% to 5%
Generally, higher rates found in females than males in the general population odds ratios ranging from 1.5 to 2.2:1
 Gender difference in prevalence is more pronounced in adolescents and young
Median prevalence in Europe is 2.3%
Prevalence in the United States is higher in American Indians and lower in
persons of Asian, Latino, African American, and Afro-Caribbean descent
compared with non-Hispanic whites
Development & Course of SAD
 Median age at onset of social anxiety disorder in the United States is
13 years.
75% of individuals have an age at onset between 8 and 15 years
Onset can also occur in early childhood.
First onset in adulthood is relatively rare.
Onset of social anxiety disorder may follow a stressful or
humiliating experience or may develop slowly .
In the community ~30% of individuals experience remission of
symptoms within 1 year, and ~50% experience remission within a
few years.
Without a specific treatment, for ~60% of individuals course will
take several years or longer.
Risk Factors of SAD
 Environmental:
 Childhood maltreatment & adversity (not causal)
 Temperamental:
 Underlying traits that predispose for SAD include
behavioral inhibition & fear of negative evaluation
 Genetic/Physiological:
 Traits predisposing individuals, such as behavioral
inhibition, are strongly genetically influenced
 Genetic influence is subject to gene-environment
 SAD is heritable (performance-only anxiety less so)
 First-degree relatives have a two to six times greater
chance of having SAD
 Often comorbid with bipolar disorder, body dysmorphic
disorder, other anxiety disorders, major depressive
disorder, and substance use disorders
 Onset of SAD generally precedes the other disorders,
except for specific phobia and separation anxiety
SAD (but not SAD, performance only) is often comorbid
with avoidant personality disorder
In children, comorbidities with high-functioning autism
and selective mutism are common
Females - higher comorbidity with depressive, bipolar, and
anxiety disorders
Males - more likely to have ODD or CD and use alcohol or
illicit drugs to relieve symptoms of SAD
DSM-5 Model of SAD
Temperamental Factors:
• Behavioral inhibition
• Fear of negative evaluation
Environmental Factors:
• Childhood maltreatment
& adversity
Core Features:
Marked, or intense, fear
or anxiety of social
situations in which the
individual may be
scrutinized by others
Associated Features:
• Inadequately assertive or
excessively submissive
• Rigid body posture
• Inadequate eye contact
• Overly soft voice tone
• Blushing
Only Specifier:
• If the fear is
restricted to
speaking or
in public.
Literature Review
Onset & Prevalence
 Generally in late childhood/early adolescence. Not
usually diagnosed before age 10 (Weis, 2008).
Mean age of onset 15.1 years (Fink et al., 2009).
Average age of onset is considered mid-adolescence
(Schneier et al., 1992).
Lifetime prevalence of 12% and 12 month prevalence of
7.1% (Kessler et al., 2005).
Lifetime prevalence between 5% and 15% (Heimberg et
al., 2000).
Typical Course
 Most children do not have SAD long term (Weis, 2008).
 Cited:
 Pine, Cohen, Gurley, Brook & Ma (1998), most
adolescents did not continue to meet diagnostic criteria
in adulthood.
 An epidemiologically selected sample of 776, 9–18
year olds, were evaluated with structural interviews in
1983, 1985, and 1992.
 Last, Perrin, Hersen, & Kazdin (1996)
 In a study of 84 children, about half did not show the
disorder 3 years after the initial diagnosis.
Commonly Feared Situations
 Most common feared situations: formal presentations &
unstructured social interactions.
 Intense anxiety reported for:
 Reading aloud in class
 Giving a class presentation
 Performing for others on stage
 Performing at an athletic event
 (Weis, 2008).
 Giving a speech, participating in a
meeting, talking to people they do
not know (Fink et al., 2009).
Commonly Feared Situations
Associated Risk Outcomes
 Academic underachievement
 Underperformance at work
 Inability to work
 Higher rates of alcohol and drug abuse
 Higher unemployment rates in patients with SAD
 Fink et al., 2009
 Depression, social isolation, substance use problems
(Weis, 2008).
Bipolar disorder (22% BD patients had experienced SAD)
Eating disorders
Other anxiety disorders
Selective mutism
 Rates on following slide…
The National Comorbidity Survey Replication–Adolescent
Supplement is a nationally representative face-to-face survey
of 10,123 adolescents 13 to 18 years of age in the continental
United States.
Genetic Factors
 Family studies – tendency to experience anxiety runs in
families .
 Twin studies – 50% of variance in symptoms attributable
to genetics (Weis, 2008).
 First-degree relatives of adults with SAD are 3x as likely to
be affected with SAD (Ollendick & Hirshfeld-Becker, 2002).
 Family studies have consistently found significantly higher
rates of SAD in the relatives of socially phobic probands
(Fyer, Mannuzza, Chapman, martin, & Klein, 1995; Hughes,
Furr, Sood, Barmish, & Kendall, 2009; Reich & Yates, 1988).
Genetic Factors cont.
 Twin studies have consistently found evidence for the heritability of
general traits:
 Behavioral inhibition (33%)
 Shyness (22%)
 Fear of negative evaluation
 (Daniels & Plomin, 1985; Eley et al., 2003; Stein, Goldin, Sareen,
Zorrilla, & Brown, 2002; Warren, Schmitz, & Emde, 1999)
 Beatty, Heisel, Hall, Levine, & La France conducted a meta-analysis
of twin studies. Heritability estimate of .65 for SAD (2002).
 Controversy surrounding twin studies:
 Kendler, Neale, Kessler, Heath, and Eaves (1992) found a higher
concordance rate for SAD among MZ (24%) than DZ (15%) female
 Skre, Onstad, Torgersen, Lygren, & Kringlen found similar concordance
rates for SAD among MZ and DZ twins, suggesting that there is not a
specific genetic contribution (1993).
Environmental Factors
 Parent-child interactions:
 Parents of children with social phobia:
 Generally more controlling & overprotective
 High levels of critical behavior toward children
 Avoid emotional-charged discussions
 Likely to have social anxiety – anxiety responses can be taught,
modeled, or reinforced.
 Dadds, Barrett, Rapee, & Ryan (1996) - Ambiguous situations
interpreted as hostile/dangerous by children. Parents supposed
children’s decisions to overreact and withdraw from social
 Interactions bidirectional – children’s behavior can also cause
parents to be controlling, protective, or critical (Weis, 2008)
Environmental Factors cont.
 Lieb et al. (2000) – parental rejection and overprotection
more frequent when parents had psychopathology
 Parents of individuals with social anxiety are inclined to be
more socially isolated (Caster et al., 1999).
 Less likely to facilitate play dates, supervise peer
interactions, or monitor activities (Masia & Morris, 1998).
Temperamental Factors
 Behavioral inhibition (BI) marks an increased risk for
anxiety disorders in general and SAD specifically (HigaMcMillan & Ebesutani, 2011).
 Manifests differently at different stages:
 Inhibited toddlers: React to new things/situations with fear,
clinging, and avoidance
 Inhibited elementary school children: Quiet isolation with
unfamiliar peer groups, shyness with unfamiliar adults
 Kagan et al. (1994) – followed 2 independent cohorts of
inhibited toddlers -> BI moderately preserved through
early adolescence.
 Biederman et al. (2001) found that SAD more common
among children with BI than without BI.
Temperamental Factors
 Hayward et al. (1998) found that adolescents with childhood
BI were at 4 to 5 times greater risk of developing SAD than
those who did not exhibit BI (sample of 2000 ninth graders
with retrospective self-report measures).
 Hirshfeld-Becker et al. (2007): 5-year follow-up study and
found that BI specifically predicted the onset of SAD and
was not associated with any other anxiety disorders.
 Biederman et al. (1993):
 216 inhibited and non-inhibited children from a sample of
parents with panic disorder and/or MDD and non-anxious and
non-depressed controls.
 Inhibited subjects had higher rates of either SAD and avoidant
disorder (DSM-III-TR)
 Does not specify number split
Neurobiological Factors
 Dopaminergic dysregulation
 Tiihonen et al., (1997), reported that striatal dopamine reuptake
site densities were lower among SAD patients than a comparison
group matched on age and gender. (11 patients with SAD and 11
healthy controls).
 SAD patients with low dopaminergic activity also found by
Schneier et al., (2000).
 Atypical serotonergic functioning
 Respond well to drugs inhibiting serotonin reuptake (SSRIs)
(Bouwer & Stein, 1998; Katzelnick et al.,1995)
 Tancer et al. (1994–1995): Greater cortisol responses to
fenfluramine than a comparison group without anxiety—
reflecting differential levels of stimulation of central serotonin 5HT2C receptors.
 Lanzenberger et al., (20070: PET study also identified reduced
binding of a specific serotonin receptor (5-HT1A) related to SAD.
Neurobiological Factors cont.
 2004 – Gelernter et al. conducted first genome wide
linkage study in SAD patients.
 Suggested linkage of chromosome 16 markers near
norepinephrine transporter protein
 Smollen et al – strong association of corticotropin
releasing hormone (CRH) gene and BI (2005).
 Etkin & Wager, 2007 – fMRI studies that show hyperactive
areas during emotional processing of SAD patients:
 Parahippocampal and fusiform gyrus
 Interior frontal gyrus
 Amygdala*
 Insula*
 * - most consistently found to be hyperactive
Neurobiological Factors cont.
 2007 – Lanzenberger et al., PET study of serotonergic
contribution to pathophysiology of SAD.
 Compared5-HT1A receptor in male SAD (12) and control
patients (18)
 SAD patients appear to have lower receptor binding in
mesiofrontal areas, the amygdala and insula, which are
assumed to be part of the neural circuitry of SAD.
Conditioning Factors
 Direct exposure to socially traumatic events is believed to
mark the onset or dramatic increase of symptoms (HigaMcMillan & Ebesutani, 2011).
 Many individuals with SAD can recall a past traumatic
event associated with the onset of their disorder (Beidel &
Turner, 2007).
 Öst and Hugdahl - 58% of their SAD sample reported that
their SAD-related fears were the result of direct, traumatic
social experiences (1981).
Conditioning Factors
 Stemberger, Turner, Beidel, & Calhoun - 56% of
individuals with specific SAD and 40% of individuals with
generalized SAD recalled a traumatic event that
precipitated the onset and/or increase in their symptoms
 92% of adult sample diagnosed with SAD (n=26) reported
a history of severe teasing in childhood (McCabe, Antony,
Summerfeldt, Liss, & Swinson, 2003).
Developmental Model of the etiology of SAD in adolescents
Higa-McMillan &
Ebesutani, 2011.
My Model of SAD
Conditioning Factors/
Parenting Style
Environmental Factors
Genetic Factors
Neurobiological Factors
Core Feature:
Marked, or intense, fear
or anxiety of social
situations in which the
individual may be
scrutinized by others
• Depression
• Social
• Substance use
• Bipolar
• Other anxiety
Secondary Features:
• Inadequately assertive or excessively submissive
• Rigid body posture
• Inadequate eye contact and Overly soft voice tone
• Blushing
• Academic underachievement
• Underperformance at work
• Inability to work
• Alcohol and/or drug use
• Increased possibility of unemployment
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