Social Anxiety Disorder

Persistent fear of social or performance situations where the person feels subject to critical scrutiny by others (e.g. canteens, restaurants, staff meetings, speaking engagements) — fear of negative evaluation, humiliation, or embarrassment. The sufferer is often a shy, self-conscious, “premorbid” personality, and symptoms are often related to sympathetic overactivity.

There are two subtypes with different treatment approaches:

• Generalised — fear of numerous social situations, both performance-based and interactional.
• Non-generalised — fear of one or a few specific situations, usually performance-type (e.g. public speaking).

Management

The basis of treatment for all phobia-spectrum conditions is psychotherapy — behaviour therapy (e.g. graded exposure) and cognitive therapy.

Generalised social anxiety disorder

Psychological: CBT with exposure-based therapy and social skills training — often not sufficient alone to fully resolve symptoms.

Pharmacotherapy: SSRIs are first-line if medication is needed — citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, or sertraline. Venlafaxine and other SNRIs (desvenlafaxine, duloxetine) are alternatives with less evidence than SSRIs. MAOIs have also been used but are reserved for treatment resistance given their side-effect burden.

Non-generalised (performance-only) social anxiety disorder

Psychological strategies — control of hyperventilation, relaxation techniques.

Pharmacological strategies target the physical symptoms of anticipatory anxiety rather than treating an ongoing daily condition:

• Propranolol 10–20 mg, 30–60 minutes before the event; the dose may be increased to a maximum of 60 mg if needed. Avoid in patients with asthma or severe peripheral vascular disease.
• A short-acting benzodiazepine is an alternative, but carries adverse effects including disinhibition and impaired coordination.