The video below is the section for Social Anxiety Disorder from Part 8 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 8, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.
Transcript of DSM-5 EPPP Lecture Video: Social Anxiety Disorder
An individual with Social Anxiety Disorder (also called Social Phobia) experiences significant fear (response to real or perceived imminent threat) or anxiety (anticipation of future threat) related to one or more social situations in which the individual is exposed to possible evaluation by others. These situations may involve a public performance, meeting new people, having a conversation, or being observed. The individual fears he/she will act in a way or show signs of anxiety, leading others to evaluate him/her negatively, or in a rejecting manner. The fear or anxiety is out of proportion to the actual threat posed by the social situation, and the individual may or may not recognize this disproportion. The DSM-5 allows for the diagnosis of Social Phobia with a “performance only” specifier. The fear, anxiety or avoidance typically lasts more than six months, causing clinically significant distress and/or impairment in important areas of functioning. In children the fear or anxiety should not be limited to interactions with adults: the symptoms must occur in peer settings to warrant this diagnosis.
The median age at onset of social anxiety disorder is 13 years. The 12-month prevalence rates in children and adolescents are comparable to adult rates, and decreases with age. Women appear to suffer from social anxiety disorder at higher rates than men, in the general population. Gender rates in clinical samples are equivalent, or a little higher for males, perhaps because of gender roles and social expectations. In the United States, when compared to non-Hispanic Whites, American Indians are more frequently diagnosed with social phobia, while Asian, Latino, African American, and Afro-Caribbean descendants are less frequently diagnosed.
The diagnosis of social anxiety disorder is associated with high rates of school dropout, and consequently with decreased employment, productivity at work, socioeconomic status, and quality of life. It is also associated with being unmarried or divorced, and with not having children (especially among men). Despite the distress and impairment experienced with social anxiety disorder, only about half of the individuals with these symptoms seek treatment, and often only after more than a decade of suffering.
The anxiety in Social Anxiety Disorder is related to scrutiny by others, while in Panic Disorder the anxiety is about the panic attacks themselves. In agoraphobia the fear in social settings is focused on the difficulty of escaping the situation, in contrast with the anxiety in separation anxiety disorder which is out of concern about being separated from attachment figures. The long-term pattern of symptoms may suggest a personality disorder, and comorbidity with avoidant personality disorder is the more common than with any other personality disorder.
Social Phobia may be associated with other anxiety disorders, major depressive disorder, and substance use disorders. The onset of social anxiety disorder usually precedes that of other disorders, with exception of specific phobia and separation anxiety disorder. In children, autism and selective mutism are often comorbid with social anxiety disorder.
The most common social and performance situation feared by those with Social Phobia is public speaking. Less than half of those diagnosed fear interacting with strangers or meeting new people. Fear of eating or drinking in public, writing in public, and public urination are less common.
Treatment for Social Phobia generally involves cognitive-behavioral group therapy (CBGT). During group therapy sessions, members role play or rehearse anxiety-producing social situations. The therapist challenges the clients’ automatic and unrealistic perception of danger in social situations. Clients may also be taught relaxation techniques to cope with their social anxiety. CBGT is considered more effective than simple psychoeducation about anxiety and Social Phobia, demonstrating maintenance of therapeutic gains for years after treatment has ended. Antidepressant medications (monoamine oxidase inhibitors (MAOIs) or SSRIs) have proven effective, although their benefits may not maintain after discontinuing the medication.
Social Phobia (also termed Social Anxiety Disorder)
1. Marked by unreasonable fear of social or performance situations (e.g., speaking in front of a group, asking someone out, performing certain behaviors in public)
2. With exposure to such social evaluation, individuals with Social Phobia experience marked anxiety that is sometimes tantamount to situationally bound/predisposed panic attacks. Insight usually present about the anxiety and avoidance of the feared situations
3. Distinguished from Panic Disorder because symptoms limited to the anxiety-provoking social situation
4. Hypersensitivity to rejection common; poor self-esteem, feelings of inferiority, and depression can result
5. Public speaking is the most commonly feared performance situation; fear of interacting with strangers/meeting new people/eating or drinking in public/etc. also possible
6. Children demonstrate anxiety through crying, tantrums, freezing, clinging to familiar adults, refusal to engage in group play, school refusal, and excessive timidity in unfamiliar environments
7. Lifetime prevalence rates between 3 percent and 13 percent
8. Age of onset typically during the mid-teens. Although women with the disorder slightly outnumber men in community samples, clinical samples contain roughly equal numbers of men and women
1. Cognitive-behavioral group therapy (CBGT), considered more effective than psychoeducation
2. Antidepressant medications (MAOIs or SSRIs) also effective, shorter-term
Danny, a 7-year-old boy, clings to his mother whenever she drops him off at school. When he arrives in the classroom, he tends to stay close to his teacher. Danny rarely raises his hand in class and never volunteers to read out loud. He generally refuses to participate in group play, often blushing or even crying if the issue is forced. Danny would most likely be diagnosed with:
A. Separation Anxiety Disorder.
B. Reactive Attachment Disorder.
C. Social Anxiety Disorder.
D. Generalized Anxiety Disorder.
C is correct, as these are the common features of Social Anxiety Disorder in children. A is incorrect, because the primary fear does not relate to safety of his parent figures or himself (note that clinging to parents and school refusal can manifest in Social Anxiety Disorder, not just Separation Anxiety Disorder). B and D are incorrect, because Danny’s fear centers on social interactions at school.