Approach

As with other anxiety disorders, individuals with social anxiety often delay seeking medical and psychiatric care for long periods.[40][41] Diagnosis is based on self-reported patient history, clinical interview, and behavioural observation. Objective findings based on physical examination or laboratory testing are generally not required.

History

All patients must meet the following diagnostic criteria for social anxiety disorder:[3]

  • Marked fear or anxiety in one or more social or performance situations in which the person is exposed to possible scrutiny by others. In children, anxiety must occur in peer settings and not just during interactions with adults.

  • Fear that they will act in a way (or show anxiety symptoms) that will be humiliating, embarrassing, will lead to rejection or will offend others.

  • Exposure to the feared social situation almost invariably provokes anxiety or a panic attack. In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

  • The fear or anxiety is out of proportion to the actual threat of the situation and to the sociocultural context.

  • Feared social or performance situations are either avoided or endured with intense anxiety or distress.

  • The fear or avoidance interferes significantly with the person's normal routine, occupational functioning, relationships, or social activities.

  • The duration of symptoms must be at least 6 months (in both children and adults).

  • The fear or avoidance is not due to the direct physiological effects of a substance or a general medical condition, and is not better accounted for by another mental disorder.

  • If a general medical condition or another mental disorder is present, the social anxiety disorder is unrelated to it.

Although social anxiety disorder tends to have its onset during later childhood and adolescence, a childhood history of behavioural inhibition, shyness, introversion, and separation anxiety is common.[32] Anxious individuals will typically report coping with their anxiety through behavioural avoidance, safety seeking from trusted companions, or the use of substances, which likely contribute to maintaining the impairments across time. Functional impairments in personal, social, and occupational domains are common. Depression and social anxiety are strongly correlated.[1] Therefore, the authors of this topic recommend screening patients who present with depression as the primary concern for a history of social anxiety. A history of phobias and/or separation anxiety is common prior to the onset of social anxiety.[32] 

Brief screening questions during the clinical interview can be helpful in assessing the potential presence of social anxiety disorder. If the individual responds affirmatively to many of the questions below, consider administering a standardised self-report measure of social anxiety disorder to further establish a diagnosis.

  • Do you feel anxious or uncomfortable being around other people?

  • Do social situations often make you feel anxious or nervous?

  • Are you worried about being rejected, embarrassed, or criticised by others?

  • In what ways has this anxiety interfered with your life? Are you avoiding situations because of your anxiety?

  • Do you often use alcohol or other substances in order to feel comfortable in social situations?

Typically, patients report post-event processing in which they have a tendency to replay social encounters in a negative, self-critical manner.[24]​ They may also have attentional biases, whereby they give heightened attention to negative evaluative threat cues and have a lack of attention to positive or benign cues.[23]​[24]​

In children, social anxiety may be expressed by crying, tantrums, 'freezing', or clinging when certain social situations cannot be avoided. Parents may reveal any childhood history of shyness, introversion, inhibition, or insecure attachment.[32] Children may not necessarily recognise their fear as unreasonable. Assessment can be further augmented by key informant interviews with family members regarding developmental and temperamental factors.[42]

Physical examination

Physical examination typically does not reveal objective findings in a patient with a social anxiety disorder. However, individuals may become noticeably anxious, nervous, or embarrassed when discussing their anxiety. In addition, eye contact may be poor, and they may display other signs of social skill difficulties (e.g., closed stance, quiet tone of speech, difficulties initiating conversations). Individuals may present with symptoms suggestive of heightened sympathetic nervous system activity (e.g., tachycardia, hyperventilation, sweating, flushing).

Laboratory tests

Typically, these are not indicated. However, for intense, persistent levels of anxiety, physicians may consider taking a routine blood panel and thyroid function tests to rule out biological factors that may contribute to the clinical presentation (e.g., hyperthyroidism, hypoglycaemia). Toxicology screening may also be indicated according to the individual clinical picture, as alcohol, marijuana, and nicotine use may be disproportionately high among individuals with social anxiety.

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