Social anxiety disorder

Social anxiety cases often look like shyness, depression or a personality issue; the exam tests whether you identify the core fear, negative evaluation by others, and separate it from look-alikes with different engines.

Criteria at exam depth. Marked fear or anxiety about one or more social situations in which the client may be scrutinized by others: conversations, meeting unfamiliar people, being observed eating or drinking, or performing in front of others. The client fears acting in a way, or showing anxiety symptoms, that will be negatively evaluated (humiliating, embarrassing, leading to rejection or offending others). Social situations almost always provoke fear and are avoided or endured with intense fear. The fear is out of proportion to the actual threat and sociocultural context, lasts six months or more, causes impairment, and is not due to a substance, medical condition or another disorder. In children, the anxiety must occur in peer settings, not only with adults, and may show as crying, tantrums, freezing, clinging, shrinking or failing to speak. If another medical condition is present (e.g., stuttering, obesity, disfigurement), the fear is unrelated or excessive. Specifier: performance only when the fear is restricted to speaking or performing in public.

Hinge differentials.

• Avoidant personality disorder: a broader, pervasive pattern of inhibition and inadequacy across nearly all contexts from early adulthood; the two often co-occur.
• Autism spectrum disorder: social difficulty comes from deficits in social communication and reciprocity, often with limited social interest, rather than fear of judgment.
• Selective mutism: consistent failure to speak in specific settings despite speaking elsewhere; may co-occur with social anxiety.
• Agoraphobia: fear of being trapped without help, not of scrutiny.
• Panic disorder: fear of the attacks themselves; in social anxiety, attacks are cued by social situations.
• Major depressive disorder: withdrawal from anhedonia and low energy, not fear of evaluation.
• Normative shyness: no significant impairment.

On the NCMHCE. The counselor clarifies what the client fears will happen in social situations; that answer separates the diagnosis from its look-alikes. Screen for alcohol or cannabis used to cope in social settings, co-occurring depression, and suicide risk. First-line treatment is CBT with graded exposure to feared social situations, cognitive restructuring of predictions about judgment, reduction of safety behaviors, and social skills work when needed; group CBT is a natural fit. Refer for medication evaluation if impairment is severe. Consider cultural norms around eye contact, deference and self-presentation before labeling behavior as anxiety; some cultures emphasize fear of offending others.

Clinical Pearl: The engine is fear of negative evaluation for six months; in children it must show with peers. Performance-only is the specifier, and avoidant personality disorder is the broader, more pervasive look-alike.