Social Anxiety Disorder - Anatomy of Psych

What is social anxiety disorder?

Social anxiety disorder (social phobia) is an anxiety disorder characterized by excessive fear that one might do something embarrassing or be negatively evaluated by others. It often begins in late childhood or early adolescence and is more common in women than in men. The lifetime prevalence rate for social anxiety disorder is 8-12%.

What does social anxiety disorder look like?

Signs & Symptoms

Fear of situations in which you may be judged negatively
Worry about embarrassing or humiliating yourself
Intense fear of interacting or talking with strangers
Fear that others will notice that you look anxious
Fear of physical symptoms that may cause you embarrassment, such as blushing, sweating, trembling or having a shaky voice
Avoidance of doing things or speaking to people out of fear of embarrassment
Avoidance of situations where you might be the center of attention
Anxiety in anticipation of a feared activity or event
Intense fear or anxiety during social situations
Analysis of your performance and identification of flaws in your interactions after a social situation
Expectation of the worst possible consequences from a negative experience during a social situation

DSM-5 Criteria

Criterion 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 ob- served (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.

Criterion B. 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 others).

Criterion C. 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.

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

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

Criterion F. The fear, anxiety, or avoidance is persistent, typically lasting 6 months or more.

Criterion G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupation, or other important areas of functioning.

Criterion 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.

Criterion 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.

Criterion 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.

Subtypes & Specifiers

Specifiers:

Performance only
- If the fear is restricted to speaking or performing in public
Panic attacks
- Recurrent unexpected panic attacks. An abrupt surge of intense fear or intense discomfort that reaches a peak within minutes, and during which time at least 4 of the following symptoms occur (Note: The abrupt surge can occur from a calm state or an anxious state):
  - Sweating
  - Trembling or shaking
  - Unsteady, dizziness, light-headed, or feeling faint
  - Derealization (feelings of unreality) or depersonalization (being detached from one self)
  - Excessive/accelerated heart rate, palpitations, or pounding heart
  - Nausea or abdominal distress
  - Tingling, numbness, parathesesias
  - Shortness of breath
  - Fear of losing control or “going crazy”
  - Fear of dying
  - Choking feelings
  - Chest pain or discomfort
  - Chills or heat sensations

Risk Factors

High behavioral inhibition
Fear of negative evaluation
First degree relatives of individuals with social anxiety disorder have a two to six times higher chance of having social anxiety disorder

Comorbidity

Seen in roughly 72% of individuals with social anxiety disorder
Other anxiety disorders, major depressive disorder, and substance use disorders

Normal shyness
Agoraphobia
Panic disorder
Generalized anxiety disorder
Separation anxiety disorder
Specific phobias
Selective mutism
Major depressive disorder
Body dysmorphic disorder
Delusional disorder
Oppositional defiant disorder
Autism spectrum disorder
Avoidant personality disorder

How is social anxiety disorder investigated?

Screening/Scale	Rater	Description
Liebowitz Social Anxiety Scale (LSAS)	Clinician	24-item scale to assess for social anxiety disorder

How is social anxiety disorder treated?

Selective serotonin reuptake inhibitors (SSRIs)
Benzodiazepines

Note: medications are not first line treatment for social anxiety disorder

Nursing Management

Social isolation

Causes & Behaviors:

Panic levels of anxiety
Past experiences of difficulty in interaction with others
Repressed fears
Stays at home alone, afraid to venture out alone
Uncommunicative
Withdrawn
No eye contact
Insecurity in public
Expression of feelings of rejection
Preoccupation with own thoughts; repetitive meaningless actions

Interventions:

Convey an accepting and positive attitude by making brief, frequent contacts to increase feelings of self-worth and to build rapport
Be with the client to offer support during group activities that may be frightening or difficult for him or her to provide emotional security
Ensure the client has adequate space and an avenue for exit
Give recognition and positive reinforcement for client’s voluntary interaction with others

Fear

Causes & Behaviors:

Phobic stimulus
Physiological symptoms - mental or cognitive behaviors indicative of panic
Behavior directed toward avoidance of a feared object or situation

Interventions:

Provide reassurance that the client is safe
Explore client’s perception of threat to physical integrity or threat to self-concept to help build an understanding of the the client's own condition so that they can work toward desensitization
Encourage the client to explore underlying feelings that may be contributing to irrational fears. Help client to understand that facing these feelings, rather than suppressing them, can result in more adaptive coping abilities
Discuss the process of thinking about the feared object/situation before it occurs, as anticipation of a future phobic reaction allows client to be prepared to deal with the physical manifestations of fear
Encourage the client to use relaxation techniques

References

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.