History and exam
Key diagnostic factors
common
history of psychiatric comorbidity
Social anxiety disorder is highly comorbid with other anxiety, mood, and substance-use disorders.[1]
positive family history of social anxiety
Compared with data from the general population, first-degree relatives are up to 6 times more likely to be at risk of social anxiety.[15]
anticipatory anxiety and worry
Excessive concern about being negatively evaluated or criticized by others. Fears of being rejected, or worry that symptoms of anxiety are visible by others.
tachycardia
Increased sympathetic nervous system activity that is either noticeable, or perceived to be noticeable, by others.
hyperventilation
Increased sympathetic nervous system activity that is either noticeable, or perceived to be noticeable, by others.
sweating
Increased sympathetic nervous system activity that is either noticeable, or perceived to be noticeable, by others.
flushing
Increased sympathetic nervous system activity that is either noticeable, or perceived to be noticeable, by others.
muscle tension
Increased sympathetic nervous system activity that is either noticeable, or perceived to be noticeable, by others.
Other diagnostic factors
common
post-event processing
Tendency to replay social encounters in a negative, self-critical manner.[23]
attentional biases
social skills deficits
Poor eye contact, closed stance, quiet tone of speech, and difficulties initiating conversations may be common.
crying, tantrums, or "freezing"
Childhood presentations of distress associated with social anxiety.
uncommon
selective mutism
Shows some overlap with symptoms of social anxiety in children. Studies suggest selective mutism may be characterized by higher levels of social anxiety in specific situations, such as school, than those with social anxiety disorder.[4]
Risk factors
strong
psychiatric comorbidity (e.g., anxiety, mood, and substance-use disorders)
genetic
Compared with the general population, first-degree relatives are up to 6 times more likely to develop social anxiety.[15]
temperamental factors
Behavioral inhibition in early childhood is a strong risk factor for later development of social anxiety.[18] Other associated temperament factors include shyness, introversion, and anxiety sensitivity.
parenting style
A bi-directional relationship is postulated to exist between parenting styles and childhood anxiety. Parenting styles, such as criticism, over-protection, over-control, and lack of warmth, can create an insecure attachment style, which may confer greater risk for social anxiety development.[13] Likewise, temperamentally introverted and anxious children may shape and change parenting style with the result that their parents become over-protective or over-controlling.
psychological disorder
Early childhood anxiety disorders, especially separation anxiety and other phobias, are associated with elevated risk for social anxiety in adulthood.[31]
life stressors
Transitions, losses, bullying, and episodes of embarrassment may contribute to social anxiety risk.[13] Minoritized individuals may be particularly vulnerable to social anxiety given higher rates of rejection, exclusion, bullying, and violence relative to majority populations.[9] The prevalence of social anxiety among gender dysphoric youth, for example, has been reported to be as high as 31.4%.[10]
environmental factors
Major life events, including transitions, stress, losses, bullying, and episodes of embarrassment, may contribute to social anxiety risk.[13]
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