A 17 year old girl comes to see her GP complaining of an intermittent shaking of her hands which has made her very worried about the possibility of dropping things when out socially. On looking at her past notes she has presented a couple of times in the past 18 months with minor physical problems, but does not have any significant past medical history.
On further questioning it becomes clear that this symptom only occurs in social situations – most recently it led to her not going out for a meal with her family for fear of embarrassing herself, and her mother was cross with her. She has been avoiding situations where she may be expected to eat or drink in public and it is affecting her social relationships and school attendance. She feels very self-conscious in social situations and says that she often feels embarrassed and inadequate around her peers. She attends a local sixth form college and tends to keep very quiet in class to avoid drawing attention to herself. She has never had a boyfriend and admits to having a couple of alcoholic drinks at home beforehand to help with her anxiety when she does go out socially, but denies any illicit drug use. She hasn’t told her parents or teachers about her concerns. Neurological examination is normal.
Social anxiety disorder (previously known as ‘social phobia’) is one of the most common anxiety disorders. It manifests as excessive or persistent fear provoked by exposure to social or performance situations1,2 and is different from shyness. It has an early median age of onset at 13 years and is one of the most persistent anxiety disorders, although some of those who develop social anxiety in adolescence may recover spontaneously. Epidemiological studies have shown high community prevalence rates, but people are often reluctant to present to their GPs 2,3 and those who do have usually had the disorder for many years.1 Characteristic features include:
- Fear of scrutiny by other people leading to avoidance of social situations.
- Awareness (in adults) that this fear or anxiety is excessive.
- Low self-esteem and fear of criticism.
- Complaints of blushing, tremor, nausea or urgency of micturition in social situations.
- Safety-seeking and avoidant behaviours.
- Use of medication, alcohol or recreational drugs in an attempt to combat the anxiety.
- Symptoms can progress to panic attacks in social situations.
Social anxiety disorder can, and frequently does, co-occur with major depression or other anxiety disorders. At clinical assessment the disorder causing the most distress to the patient should be established and be the focus of any initial treatment.1,2 Alcohol and substance misuse are common.
Social anxiety disorder causes significant distress and avoidance of situations, which impacts on the patient’s level of functioning. The degree to which people can be affected may vary. Some people have quite circumscribed social anxiety which leads to them avoiding speaking in meetings or groups or avoiding eating or drinking in public, while others will be anxious in any situation where they may feel observed by others, for example walking down the street. More severe forms are associated with lower educational attainment and higher levels of unemployment. People may also have difficulty forming and maintaining friendships, poor social support and an increased likelihood of living alone. There is a risk of significant alcohol abuse in an attempt to manage social situations. The course can be chronic and lead to severe functional impairment, but patients can respond well if diagnosed and treated.
If a diagnosis of social anxiety disorder is suspected you can ask the following two screening questions:1
- Do you find yourself avoiding social situations or activities?
- Are you fearful or embarrassed in social situations?
Or use the 3-item Mini-Social Phobia Inventory (Mini-SPIN)4
|Not at all||A little bit||Somewhat||Very much||Extremely|
Does fear of embarrassment cause you to avoid doing things or speaking to people?
Do you avoid activities in which you are the centre of attention?
Is being embarrassed or looking stupid among your worst fears?
If the person scores six or more on the Mini-SPIN or answers ‘yes’ to either of the two screening questions then a diagnosis of social anxiety disorder should be considered and an assessment for this by a suitably qualified health professional offered. This should include assessing the person for other comorbid mental health difficulties and alcohol or substance misuse, as well as assessing the level of social and functional impairment.1
If a diagnosis of social anxiety disorder has been made, the treatment of choice for adults (16 and above) is individual CBT using a model specifically developed to treat social anxiety disorder. Individual CBT should also be available for the treatment of children and younger people following assessment via CAMHS. If the person does not want CBT and would prefer a pharmacological intervention they should be offered an SSRI– escitalopram or sertraline are suggested by the NICE clinical guidelines. In those showing a partial response to either CBT or medication a combination of the two may be suggested. Pharmacological interventions should not be routinely offered to children or young people.1
Dr Marta Buszewicz is a GP in North London and reader in primary care at University College London Medical School.
With many thanks to Dr John Cape, director of psychological therapies programme, University College London, who commented on an earlier draft of this article.