No clear pathophysiology has been identified for social anxiety disorder (SAD), and questions remain about how to differentiate SAD from shyness or even avoidant personality disorder (AvPD).
Many patients with SAD clearly would benefit from help and support from clinicians, but population-based studies indicate that two-thirds of those with SAD have never sought medical care for this disorder. In addition, the proportion of met need for treatment is lower in those affected than in patients with any other psychiatric disorder.
Once the diagnosis of SAD is made, the central component of treatment is cognitive-behavioral therapy (CBT). In limited circumstances, medication may be used on a short-term basis.1
Issues in Differentiation
The main issue in differentiating shyness, SAD, and AvPD lies in the degree to which they are qualitatively distinct categories rather than points along the same continuum. Many persons consider themselves to be shy, but only a small percentage meet the criteria for SAD, supporting the notion that shyness is categorically distinct from SAD. However, persons who are shy share several features with those who meet criteria for SAD (albeit they are of a lesser severity). Recent studies show that shyness is at the less severe end of the SAD continuum.
Some authors argue that the criteria that currently define AvPD overlap too significantly with the criteria for SAD, and that most persons who receive a diagnosis of AvPD under the current classification system simply have a more severe form of SAD.
Under-Recognized and Undertreated?
Several studies of patients seeking treatment for SAD show that the disorder tends to be under-recognized. In one study, patients’ anxiety and depression were recognized by their primary care physicians in only 23% of cases.2
Under-recognition also occurs in specialty mental health settings. In a study in our outpatient psychiatry sample, SAD was recognized 9 times more frequently in a comprehensive diagnostic interview than in the unstructured clinical interview that is standard care in routine practice settings.3
This under-recognition may be a consequence of the nature of the disorder. That is, patients with SAD fear embarrassing themselves and are self-conscious about mentioning their social anxiety. Also, they often present with more acute problems, such as depression. Under-recognition often leads to undertreatment.
Some evidence suggests that the prevalence of SAD has increased recently, leading to the notion that SAD may be overdiagnosed now because of expansion of diagnostic criteria. Earlier population-based studies may have used diagnostic criteria that were too conservative; more recent studies may have used too liberal criteria.
Certainly, a good deal of evidence indicates that within the population of persons seeking treatment for mental health problems, SAD tends to be under-recognized relative to other mental health issues. However, debate continues as to whether SAD is being overdiagnosed within the general population.
Pharmacotherapy? Psychotherapy? A Combination?
Several studies have demonstrated the efficacy of pharmacotherapy or psychotherapy alone for treating patients with SAD. Pharmacotherapy tends to produce slightly quicker short-term improvement but more questionable long-term outcomes. Evidence-based psychotherapy tends to produce both short- and long-term benefits. A combination of pharmacotherapy and psychotherapy rapidly produces short-term benefits, but over time there is no difference between combined treatment and either treatment alone. Relapse rates tend to be higher with combination therapy once the medication is discontinued.
Although medication alone results in rapid symptom reduction in the short term, it is not clear whether these benefits outweigh the costs of adverse effects, abuse, or dependence (as in the case of benzodiazepines) and risk of relapse once the medications are discontinued. Many persons do not want to take medications for the rest of their life and discontinue therapy sooner or later.
Based on current evidence, I recommend psychotherapy—particularly CBT—as first-line treatment, given that it produces better long-term outcomes than medication and has no adverse effects. I consider adding medication in the most severe cases; for patients with comorbidities, such as depression; and in cases in which psychotherapy alone has not been beneficial. However, I view medication alone as more of a short-term strategy—medication often is continued for years in spite of a lack of evidence of long-term benefit.
Therapies are developing that shift the focus from symptom reduction to engaging in personally identified, meaningful behaviors. These newer therapies—collectively referred to as acceptance- and mindfulness-based therapies—are considered to be newer forms of CBT. These therapies also tend to more broadly address avoidance of situations and emotional experiences. They have the potential to address common comorbidities rather than just single disorders.
A recent study compared acceptance and commitment therapy (ACT) with traditional CBT for various anxiety disorders.4 Patients with comorbid depression tended to fare better with ACT than with CBT.
Our research group has developed and pilot-tested an acceptance-based psychotherapy to target both SAD and depression. The results have been promising.
How Primary Care Physicians Can Optimize Treatment
Physicians’ first step toward optimizing treatment is to increase recognition of SAD. Given the time constraints in busy office practice, brief screening measures are a viable approach, and they can prompt the physician to ask more questions. Identifying social anxiety concerns gives the physician the opportunity to discuss options, such as referrals for psychotherapy, and to conduct further assessment to determine the degree to which SAD and other comorbidities are present.
Take-Home Message
SAD often is under-recognized in primary care and mental health settings, but identification can be improved through the use of brief screening measures. However, care should be taken to avoid overdiagnosis, which may lead to prescription of medications or other therapies that may not be necessary or desired by the patient.
Although medication is helpful in the short term, CBT is more helpful long-term. The combination of medication and CBT is not necessarily more effective over the long term than CBT alone.
References
1. Dalrymple KL. Issues and controversies surrounding the diagnosis and treatment of social anxiety disorder. Expert Rev Neurother. 2012;12:993-1009.
2. Roy-Byrne PP, Wagner A. Primary care perspectives on generalized anxiety disorder. J Clin Psychiatry. 2004;65(Suppl 13):20-26.
3. Zimmerman M, Mattia JI. Psychiatric diagnosis in clinical practice: is comorbidity being missed? Compr Psychiatry. 1999;40:182-191.
4. Ruiz FJ. Acceptance and commitment therapy versus traditional cognitive behavioral therapy: a systematic review and meta-analysis of current empirical evidence. Int J Psychol Psychological Ther. 2012;12:333-357.
