ICD-116B04	SOCIAL ANXIETY DISORDER Social anxiety disorder
ICD-10F40.1	Social phobias
DSM-5-TRF40.10	Social Anxiety Disorder

1. Definition and nosology

Social anxiety disorder (ICD-11: 6B04 Social Anxiety Disorder; DSM-5-TR: F40.10) — intense and persistent fear of negative evaluation or humiliation by others in social situations. The patient avoids situations such as speaking, interaction, and being observed.

2. History

• Janet P. (1903) — ‘phobie des situations sociales’.
• Marks I.M., Gelder M.G. (1966) — separation of social phobia from agoraphobia.
• DSM-III (1980) — “Social Phobia” as an official diagnosis.
• DSM-5 (2013) — “Social Anxiety Disorder” — broader and more precise term; performance-only subtype added.
• ICD-11 — parallel.

3. Epidemiology

• Lifetime prevalence: 7–13% (Kessler WMH; cultural variability).
• Sex: relatively higher in females, but males seek clinical help more often.
• Onset: adolescence (mean 13 years) — one of the earliest onset anxiety disorders.
• Comorbidity: MDD 60%, other anxiety, alcohol use (as self-medication).

4. Aetiology and pathogenesis

• Heritability ~30–40%.
• Behavioral inhibition (Kagan J.) — childhood temperament as a strong risk factor.
• Neurobiological — amygdala hyperreactivity to social stimuli; serotonergic dysregulation.
• Cognitive — self-focused attention, negative self-image, catastrophizing (Clark D.M., Wells A. model).
• Environment — childhood peer victimization, parental overprotection.

5. Clinical features

• Feared situations — public speaking, asking questions, sharing a meal, writing or eating in front of others, public toilets, talking on the phone.
• Somatic — flushing, tremor, sweating, tachycardia, dry mouth, voice tremor.
• Cognitive — negative thoughts about oneself, “post-event processing” (prolonged self-criticism after a situation).
• Avoidance and ‘safety’ behaviors (avoiding eye contact, speaking less, alcohol use).
• Functional burden — academic and occupational development, friends, romantic relationships.

6. Diagnosis

6.1 Unified diagnostic criteria

A. Marked fear in one or more social situations — being observed or evaluated by others.

B. The patient fears humiliation, rejection by others, or harming others.

C. Situations almost always provoke fear.

D. Avoidance or endurance with intense discomfort.

E. Fear is disproportionate to the social situation.

F. ≥6 months duration (DSM-5-TR).

G. Functional impairment.

H. Not fully explained by another mental disorder or medical condition.

6.2 Source-specific clarifications

• DSM-5-TR — “performance only” specifier (limited to performance situations).
• ICD-11 — the duration is “at least several months” (6 months in DSM-5-TR); in children the peer setting is assessed as well, not only contact with adults.
• NICE CG159 (Social anxiety disorder: recognition, assessment and treatment, 2013) — individual CBT first-line.

6.3 Diagnostic algorithm

1. Clinical interview.
2. SCID-5, MINI.
3. Liebowitz Social Anxiety Scale (LSAS), SPIN (Social Phobia Inventory) — scale and monitoring.
4. Comorbidity (MDD, other anxiety, alcohol use).

6.4 Differential diagnosis

7. Examination and assessment

• LSAS — gold standard scale (24 items).
• SPIN — short screening (17 items).
• BFNE (Brief Fear of Negative Evaluation).

8. Treatment

8.1 General principles (NICE CG159 · CANMAT 2014)

1. Individual CBT (Clark D.M. model) first-line — redirecting self-focused attention, video feedback, behavioral experiments, cognitive restructuring, in vivo exposure. 12–16 sessions. NICE CG159 — individual CBT superior to group CBT.
2. SSRI and SNRI first-line pharmacotherapy — escitalopram, sertraline, paroxetine (FDA approved), venlafaxine (FDA approved).
3. Second-line — moclobemide (RIMA, approved in Europe), pregabalin (evidence limited), gabapentin.
4. Benzodiazepine — only short-term for a specific situation (e.g., prior to performance); not sustained.
5. β-blocker (propranolol) — in performance subtype, 1–2 hours before performance; ineffective in social reciprocal interaction.
6. Duration of treatment — after remission ≥ 12 months.
7. Alcohol use — as a form of self-medication; requires special attention and parallel intervention.

8.2 Source-specific clarifications

• NICE CG159 (2013) — individual CBT (Clark) first-line; SSRIs alternative; group CBT or self-help may be suitable for some patients.
• CANMAT 2014 — first-line escitalopram, sertraline, paroxetine, venlafaxine.
• Mayo-Wilson E. et al. Lancet Psychiatry 2014 network meta-analysis — individual CBT has the greatest effect; SSRIs second.

Treatment methods

1. Clark CBT Model — Specifically developed for social anxiety; external redirection of self-focused attention, video feedback (seeing one's performance through others' eyes), behavioral experiments (testing fearful beliefs), in vivo exposure. Evidence: Clark D.M. et al. J Consult Clin Psychol 2003 RCT — experimental individual CBT superior to other interventions.
2. Heimberg Group CBT — 12-session group format; Heimberg R.G. model. Effective, but relatively weaker than individual CBT (NICE CG159).
3. Internet-based cognitive behavioral therapy (iCBT) — Andersson G. et al. RCTs — therapist-supported iCBT is comparable to individual CBT.
4. Liebowitz Social Anxiety Scale (LSAS — Liebowitz Social Anxiety Scale) — 24 items (11 social interaction + 13 performance); each item is rated for both fear/anxiety and avoidance (48 ratings, 0–144 points, 4 subscales); gold standard.
5. Social Phobia Inventory (SPIN) — 17 items; brief screening.

9. Prognosis

• Chronic course, high relapse rate without treatment.
• CBT and SSRIs result in significant improvement in most patients.
• Early onset and avoidant personality comorbidity as a poor prognosis marker.

10. Myths and misconceptions

Myth 1: “Social anxiety — ordinary ‘shyness about life’, does not require treatment”

Evidence: Social anxiety disorder is associated with functional impairment, academic and occupational limitations, risk of depression and alcohol use; it is evaluated as a medical condition.

Myth 2: “The patient can live a normal life by completely avoiding social situations”

Evidence: Avoidance strengthens the symptoms and leads to isolation; exposure is the main therapeutic mechanism.

Myth 3: “Alcohol ‘treats’ social anxiety”

Evidence: Alcohol provides short-term relief but long-term exacerbates distress and leads to alcohol use disorder; prevalence of this combination is 20–40%.

Myth 4: “Benzodiazepines are effective long-term for social anxiety”

Evidence: Short-term effect; addiction potential; CBT or SSRIs superior.

Myth 5: “Propranolol is effective for all forms of social anxiety”

Evidence: propranolol is effective only in the performance subtype (before a performance); it is ineffective in social interaction (parties, relationships).

Myth 6: “The patient has avoidant personality disorder, so treatment is unresponsive”

Evidence: Comorbid avoidant personality patient may also respond to standard interventions; long-term CBT or schema therapy.

Myth 7: Only hypnotherapy or NLP cures quickly

Evidence: No evidence base; CBT and SSRIs are gold standard.

Myth 8: Cannabis (CBD) is a safe alternative for social anxiety

Evidence: initial studies exist, but insufficient for clinical recommendation; THC may worsen distress.

11. Sources

1. WHO. ICD-11. 6B04 Social anxiety disorder. 2024.
2. APA. DSM-5-TR. 2022.
3. NICE CG159. Social anxiety disorder: recognition, assessment and treatment. 2013.
4. Katzman M.A. et al. CANMAT 2014. BMC Psychiatry 2014;14(Suppl 1):S1.
5. Mayo-Wilson E. et al. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. Lancet Psychiatry 2014;1(5):368–376.
6. Clark D.M., Ehlers A., McManus F. et al. Cognitive therapy versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. J Consult Clin Psychol 2003;71(6):1058–1067.
7. Liebowitz M.R. Social phobia. Mod Probl Pharmacopsychiatry 1987;22:141–173.
8. Heimberg R.G., Becker R.E. Cognitive-Behavioral Group Therapy for Social Phobia. New York: Guilford Press, 2002.
9. Kagan J., Reznick J.S., Snidman N. Biological bases of childhood shyness. Science 1988;240(4849):167–171.
10. Wells A. Metacognitive Therapy for Anxiety and Depression. New York: Guilford Press, 2009.
11. Andersson G., Cuijpers P., Carlbring P. et al. Guided internet-based vs. face-to-face cognitive behaviour therapy for psychiatric and somatic disorders: a systematic review and meta-analysis. World Psychiatry 2014;13(3):288–295.