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Web audio at CurrentPsychiatry.com Dr. Dalrymple: Treating social disorder

When does benign become , a treatable disorder?

The authors pinpoint the fine line between overdiagnosis and underdiagnosis of SAD

ince the appearance of social (SAD) in the DSM-III in 1980, research on its prevalence, charac- Steristics, and treatment have grown (Box 1, page 221,2). In addition to the name, the definition of SAD has changed over the years; as a result, its prevalence has increased in recent cohort studies. This has led to debate over whether the experience of shyness is being over-pathologized, or whether SAD has been underdiagnosed in earlier decades. Those who argue that shyness is being over-pathologized note that it is a normal experience that has evolution- ary functions (eg, preventing engagement in harmful social relationships3). Others argue that a high degree of shyness is not beneficial in terms of evolution because it causes the © IMAGES.COM/CORBIS individual to be shunned, so to speak, by .4 Kristy L. Dalrymple, PhD Staff Department of Why about ‘over-pathologizing’? Rhode Island Hospital The of shyness might be a reflection of Assistant Professor (Research) of Psychiatry and Human Behavior Western societal values of assertiveness and gregarious- Alpert Medical School of Brown University Providence, Rhode Island ness; other that modesty and reticence do not over-pathologize shyness.5 It is important not to assume that Mark Zimmerman, MD Director of Outpatient Psychiatry someone who is shy necessarily has a “pathologic” level of Rhode Island Hospital social anxiety, especially because some people who are shy Associate Professor, Psychiatry and Human Behavior view that condition as a positive quality, much like sensitiv- Alpert Medical School of Brown University Providence, Rhode Island ity and conscientiousness.5 The broader issue of what constitutes a Disclosure The authors report no financial relationships with any company whose products arises in this debate. A “disorder” is a socially constructed are mentioned in this article or with manufacturers of competing products. label that describes a set of symptoms occurring together and its associated behaviors, not a real entity with etiological homogeneity.6 Labeling emotional problems “disordered” Current Psychiatry assumes that is the natural homeostatic state, and Vol. 12, No. 11 21 Box 1 pertains to management, and provide sug- gestions for treatment approaches. What’s in a name?

he name of (SAD) Thas changed over the years in the DSM. SAD: Definition, prevalence First referred to as social in the SAD is defined as a significant of em- DSM-III, it later was given the alternative name of social anxiety disorder in DSM-IV. Most barrassment or in social or Social anxiety recently, it has been fully changed to social performance-based situations, to a point disorder anxiety disorder (social phobia) in DSM-5, at which the affected person often avoids based on the that “social phobia” does not reflect the impairing and pervasive nature these situations or endures them only with of the disorder.1 a high level of distress9 (Table 1, and Box 2, The generalized specifier was removed in page 35). SAD can be distinguished from DSM-5, perhaps because the name change other anxiety disorders based on the source is more reflective of this more severe subtype, and the specifier “performance only” was and content of the fear (ie, the source being added, based on recent research suggesting social interaction or performance situations, that persons with performance-only and the content being a fear that one will significantly differ from those with multiple Clinical Point fears (see Bögels and colleagues’ review of show a behavior that will cause embarrass- Determining when this topic2). The performance-only form of ment). SAD also should be distinguished SAD is significantly less prevalent than the from spectrum disorders, in which shyness becomes a generalized form, and tends to be treated with as-needed (eg, a beta persons have limited social clinically significant blocker) that can be taken before entering a capabilities and inadequate age-appropri- problem demands a performance situation. ate social relationships. delicate distinction SAD is most highly comorbid with and anxiety disorders, with rates of that has treatment at least 30% in clinical samples.10 The disor- implications distressing emotional states are abnormal der also is highly comorbid with avoidant and need to be changed.7 A diagnostic la- —to a point at which bel can help improve communication and it is argued that they are one and the same understand maladaptive behaviors; if that disorder.11 label is reified, however, it can lead to as- As with other psychiatric disorders, sumptions that the etiology, course, and anxiety must cause significant impairment treatment response are known. Proponents or distress. What constitutes significant im- of the diagnostic psychiatric nomenclature pairment or distress is subjective, and the have acknowledged the dangers of over- arbitrary nature of this criterion can influ- pathologizing normal experiences of living ence estimates of the prevalence of SAD. (such as fear) by way of diagnostic labeling.8 For example, prevalence ranges as widely Determining when shyness becomes a as 1.9% to 20.4% when different cut-offs are clinically significant problem—what we used for distress ratings and the number of call SAD here—demands a delicate distinc- impaired domains.12 tion that has important implications for The prevalence of SAD varies from treatment. On one hand, if shyness is over- 1 epidemiological study to another (ie, the pathologized, persons who neither Epidemiological Catchment Area [ECA] nor need treatment might be subjected to Study and the National unnecessary and costly intervention. On Survey [NCS])—in part, a consequence the other hand, if SAD is underdiagnosed, of the differing definitions of significant Discuss this article at some persons will not receive treatment impairment or distress. The ECA study www.facebook.com/ that might be beneficial to them. assessed the clinical significance of each CurrentPsychiatry In this article, we review the similari- symptom in anxiety disorders; the NCS ties and differences between shyness and assessed overall clinical significance of the SAD, and provide recommendations for disorder. When the clinical significance cri- determining when shyness becomes a more terion was applied at the symptom level to clinically significant problem. We also high- the NCS dataset (as was done in the ECA Current Psychiatry 22 November 2013 light the importance of this distinction as it study), 1-year prevalence decreased by 50% (from 7.4% to 3.7%).13 The manner in Table 1 which significant impairment or distress is defined (ie, conservatively or liberally) im- Summarizing DSM-5 diagnostic pacts whether social anxiety symptoms are criteria for SAD classified as disordered or non-disordered. 1. Significant anxiety occurs in interaction or performance-based situations when one fears being judged negatively by others because of their behavior (eg, saying something “foolish”), Shyness: Definition, prevalence or because they may appear nervous or Shyness often refers to 1) anxiety, inhibi- anxious tion, reticence, or a combination of these 2. These types of situations often cause the person to feel anxious, and this anxiety should findings, in social and interpersonal situa- persist for >6 months tions, and 2) a fear of negative evaluation by 3. The anxiety is excessive compared with 14 others. It is a normal facet of personality what would be expected given the situation or that combines the experience of social anxi- cultural context ety and inhibited behavior,15 and also has 4. The feared social situations often are been described as a stable .16 avoided or, if unavoidable, are endured with a high degree of distress Shyness is common; in the NCS study,17 Clinical Point 5. The person experiences several negative 26% of women and 19% of men character- consequences because of anxiety or Temperament and ized themselves as “very shy”; in the NCS avoidance (eg, inability to perform in important Adolescent study,18 nearly 50% of adoles- social, educational, or occupational roles), or is behavioral inhibition cents self-identified as shy. highly distressed because of his (her) anxiety are risk factors for Persons who are shy tend to self-report 6. The anxiety is not due to substances, mood and anxiety medical conditions, or symptoms of other greater social anxiety and mental disorders. disorders, and appear in social situations than non-shy persons 7. When a person has a medical condition to have a strong do; they also might experience greater (such as ), SAD can be diagnosed autonomic reactivity—especially blush- 1) as long as the presence of the disorder is relationship with SAD ing—in social or performance situations.15 unrelated to the medical condition, or 2) if the anxiety is greater than what would be expected Furthermore, shy persons are more likely given the medical condition to have axis I comorbidity and traits of SAD: social anxiety disorder introversion and , compared with non-shy persons.14 Research suggests that temperament and behavioral inhibition are risk fac- Continuum hypothesis. Support for the tors for mood and anxiety disorders, and continuum hypothesis includes evidence appear to have a particularly strong re- that SAD and shyness share several fea- lationship with SAD.19 A recent prospec- tures, including autonomic , defi- tive study showed that shyness tends cits in (eg, aversion of gaze, to increase steeply in toddlerhood, then difficulty initiating and maintaining con- stabilizes in childhood. Shyness in - versation), avoidance of social situations, hood—but not toddlerhood—is predictive and fear of negative evaluation.21,22 In ad- of anxiety, , and poorer social dition, both shyness and SAD are highly skills in .20 heritable,23 and mothers of shy children have a significantly higher rate of SAD than non-shy children do.24 No familial A qualitative, or just quantitative, or genetic studies have compared herita- difference? bility and familial aggregation in shyness It is clear that SAD and shyness share and SAD. several features—including anxiety and According to the continuum hypothesis, embarrassment—in social interactions. This if SAD is an extreme form of shyness, all raises a question: Are SAD and shyness distinct (or nearly all) persons who have a diag- qualitatively, or do they represent points along a nosis of SAD also would be characterized continuum, with SAD being an extreme form as shy. However, only approximately one- Current Psychiatry of shyness? half of such persons report having been Vol. 12, No. 11 23 continued on page 35 continued from page 23

Box 2 Presentations of normal shyness and SAD Shyness: SAD: She “hangs back” at social occasions He never raised his hand in school Margaret, age 35, is a married woman who works John, age 50, is a single man who reports full-time as an accountant. She describes herself significant anxiety when interacting with as always having been a “quiet and reserved” others socially and during public speaking— person. She reports having a few friends as an fearing that he will say something “stupid” adolescent and “sometimes” participating in and therefore embarrass himself. He describes group activities, although she considered herself experiencing this anxiety since childhood, to be more of a follower than a leader. during which time he never raised his hand Margaret has 2 or 3 close friends with whom in class, often skipped classes when he was she socializes a few times a month, but spends required to give a speech, and had only most of her leisure time with her husband 1 friend. and 2 children. When meeting new people or Because of his anxiety about speaking in speaking with smaller groups of people at a social class, John never attended college after he gathering, she tends to “hang back” and say little, received his high school degree. He has held especially at the beginning of the conversation. various jobs at fast-food restaurants, but is She sometimes worries that other people may not unemployed now. Clinical Point like her, but she nonetheless makes an effort to Although John considers himself a hard join in on the conversation. worker, he experienced difficulty in previous To determine whether Margaret has received good performance jobs when having to interact with customers shyness crosses into reviews. She tends to keep to herself at work, or his supervisor. He wants to re-enter the but occasionally strikes up a conversation with workforce, but is highly nervous about having to a clinically significant a coworker while waiting for a meeting to begin. apply and interview for jobs. problem, assess Although she prefers to not speak up at meetings, John has never been married, and dated on she will do so when necessary. Margaret only a few occasions. He would like to have a anxiety severity and describes herself as satisfied with the quality and romantic relationship at some point, but fears quantity of her social relationships, and indicates rejection. He continues to have only 1 friend, degree of impairment that she that work is going well. with whom he socializes once a month. and distress

shy in childhood.17 Less than one-quarter Given the evidence, experts have con- of shy persons meet criteria for SAD.14,18 cluded that shyness and a SAD diagnosis Because many persons who are shy do are overlapping yet different constructs not meet criteria for SAD, and many who that encapsulate qualitative and quantita- have SAD were not considered shy earlier tive differences.25 There is a spectrum of in life, it has been suggested that this sup- shyness that ranges from a normative level ports a qualitative distinction. to a higher level that overlaps the experi- ence of SAD, but the 2 states represent dif- Qualitative distinctiveness. Despite hav- ferent constructs.25 ing similarities, several features distin- guish the experience of SAD from that of Guidance for making an assessment. shyness. Compared with shyness, a SAD Because of similarities in anxiety, embar- diagnosis is associated with: rassment, and other symptoms in social • greater comorbidity situations, the best way to determine • greater severity of avoidance and whether shyness crosses the line into a impairment clinically significant problem is to assess • poorer quality of life.18,21,25 the severity of the anxiety and associated Studies that compared SAD, shyness degree of impairment and distress. More without SAD, and non-shyness have shown severe anxiety paired with distress about that the shyness without SAD group more having anxiety and significant impairment closely resembles the non-shy group than in multiple areas of functioning might in- the SAD group—particularly with regard dicate more problematic social anxiety— to impairment, presence of substance use, a diagnosis of SAD—not just “normal” Current Psychiatry and other behavioral problems.18,25 shyness. Vol. 12, No. 11 35 continued Table 2 be present during a major life change (eg, beginning to date again after the loss of a Sample questions for lengthy marriage or romantic relationship). determining clinical significance of symptoms Has this anxiety interfered with your ability to Assessment tools initiate or maintain ? If so, how? Assessment tools can help you differentiate Social anxiety In what ways has this anxiety interfered with normal shyness from SAD. Several empiri- disorder your ability to work or go to school? cally-validated rating scales exist, including Has this anxiety prevented you from having clinician-rated and self-report scales. romantic relationships? How satisfied are you with your social life? Liebowitz Social Anxiety Scale26 rates the Are you unable to hold a job or apply for jobs severity of fear and avoidance in a variety because of this anxiety? of social interaction and performance-based How distressed or upset are you about having situations. However, it was developed pri- this anxiety? marily as a clinician-rated scale and might Clinical Point How would your life be different if you were not be more burdensome to complete in prac- bothered by this anxiety? One disadvantage to tice. In addition, it does not provide cut-offs Did this anxiety your grades when you to indicate when more clinically significant were in school? relying on a rating anxiety might be likely. scale alone is Does this anxiety prevent you from being the type of employee you would like to be? the narrow focus Clinically Useful Social Anxiety Disorder Has this anxiety affected the quality of Outcome Scale (CUSADOS)27 and Mini- on symptoms relationships you would like to have with 28 family? Social Phobia Inventory (Mini-SPIN) are brief self-report scales that provide cut-offs In what ways has this anxiety affected your role as a parent?a to suggest further assessment is warrant-

aOr as a sibling, friend, partner, coworker, etc. ed. A cut-off score of 16 on the CUSADOS suggests the presence of SAD with 73% di- agnostic efficiency. One disadvantage to relying on a rating It is important to take into account the scale alone is the narrow focus on symptoms. environmental and cultural context of a Given that shyness and SAD share similar patient’s distress and impairment because symptoms, it is necessary to assess the de- these features might fall within a normal gree of impairment related to these symp- range, given immediate circumstances toms to determine whether the problem is (such as speaking in front of a large audi- clinically significant. The overly narrow fo- ence when one is not normally called on to cus on symptoms utilized by the biomedical do so, to a degree that does not interfere approach has been criticized for contributing with general social functioning6). to the medicalization of normal shyness.5 What is considered a normative range Diagnostic interviews, such as the depends on the developmental stage: Structured Clinical Interview for DSM-IV • Among children, a greater level of shy- Axis I Disorders29 include sections on SAD ness might be considered more normative that assess avoidance and impairment/dis- when it manifests during developmental tress associated with anxiety. Because these stages in which separation anxiety appears. interviews may increase the time burden • Among adolescents, a greater level during an office visit, there are several gen- of shyness might be considered normative eral questions outside of a structured inter- especially during early adolescence (when view that you can ask, such as: “Has this social relationships become more impor- anxiety interfered with your ability to initi- tant), and during times of transition (ie, ate or maintain friendships? If so, how?” entering high school). (Table 2). Persons with clinically significant • In adulthood, a greater level of nor- social anxiety, rather than shyness, tend to Current Psychiatry 36 November 2013 mative shyness or social anxiety might report greater effects on their relationships and on work or school performance, as well Table 3 as greater distress about having that anxiety. Options for treating SADa Pharmacotherapy Treatment approaches based on Cognitive- Selective distinctions behavior therapy reuptake inhibitors (individual or • Exercise care in making the distinction be- group) • tween normal shyness and dysfunctional • and impairing levels of anxiety character- • istic of SAD, because persons who display and Serotonin-norepinephrine commitment reuptake inhibitor: normal shyness but who are overdiag- therapy nosed might feel stigmatized by a diagnos- Interpersonal label.5 Also, overpathologizing shyness psychotherapy • takes what is a social problem out of con- • text, and could promote treatment strate- Short-term Monoamine oxidase psychodynamic inhibitor: gies that might not be helpful or effective.30 therapy Clinical Point Unnecessary diagnosis might lead to un- aBased on empirical studies necessary treatment, such as prescribing an Note: with an FDA indication for SAD are in Persons who exhibit or . Avoiding bold type such a situation is important, because of the SAD: social anxiety disorder normal shyness do side effects associated with medication and not require medical the potential for dependence and withdraw- treatment; however, al effects with benzodiazepines. CBT is recommended as an appropriate some may want to Persons who exhibit normal shyness do first-line option, especially for mild and improve their social not require medical treatment and, often, moderate SAD; it is the preferred initial do not want it. However, some people may treatment option of the United Kingdom’s functioning be interested in improving their ability to National Institute for and Care function in social interactions. Self-help ap- Excellence (NICE). For more severe presen- proaches or brief psychotherapy (eg, cogni- tations (such as the presence of comorbid- tive-behavioral therapy [CBT]) should be the ity) or when a patient did not respond to first step—and might be all that is necessary. an adequate course of CBT, combined treat- ment might be an option—the goal being to The opposite side of the problem. taper the medication and continue CBT as a Under-recognition of clinically significant longer-term treatment. Research has shown social anxiety can lead to under-treatment, that continuing CBT while discontinuing which is common even in patients with medication helps prevent .32,33 a SAD diagnosis.31 Treatment options in- Appropriate pharmacotherapy options clude CBT, medication, and CBT combined include selective serotonin reuptake inhibi- with medication (Table 3): tors and serotonin-norepinephrine reuptake • several studies have demonstrated inhibitors.34 Increasingly, benzodiazepines the short- and long-term efficacy of are considered less desirable; they are not CBT alone for SAD recommended for routine use in SAD in the • medication alone has been efficacious NICE guidelines. Those guidelines call for in the short-term, but less efficacious continuing pharmacotherapy for 6 months than CBT in the long-term when a patient responds to treatment with- • combined treatment also has been in 3 months, then discontinuing medication shown to be more efficacious than CBT with the aid of CBT. or medication alone in the short-term • there is evidence to suggest that CBT References 1. Bruce LC, Coles ME, Heimberg RG. Social phobia and social alone is more efficacious in the long-term anxiety disorder: effect of disorder name on recommendation compared with combined treatment.a for treatment. Am J Psychiatry. 2012;169(5):538. 2. Bögels SM, Alden L, Beidel DC, et al. Social anxiety disorder: aFor more information about treatment strategies, Dalrymple has questions and answers for the DSM-V. Depress Anxiety. Current Psychiatry published a review elsewhere.11 2010;27:168-189. Vol. 12, No. 11 37 continued 15. Hofmann SG, Moscovitch DA, Hyo-Jin K. 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Burstein M, Ameli-Grillon L, Merikangas KR. Shyness Alprazolam • Xanax Paroxetine • Paxil versus social phobia in US youth. . 2011;128: 917-925. Clonazepam • Klonopin Phenelzine • Nardil Fluoxetine • Prozac Sertraline • Zoloft 19. Hirshfeld-Becker DR, Micco J, Henin A, et al. Behavioral inhibition. Depress Anxiety. 2008;25:357-367. Fluvoxamine • Luvox Venlafaxine • Effexor 20. Karevold E, Ystrom E, Coplan RJ, et al. A prospective longitudinal study of shyness from infancy to adolescence: stability, age-related changes, and prediction of socio- emotional functioning. J Abnorm Child Psychol. 2012; 40:1167-1177. 3. Wakefield JC, Horwitz AV, Schmitz MF. Are we 21. Chavira DA, Stein MB, Malcarne VL. Scrutinizing the overpathologizing the socially anxious? Social phobia relationship between shyness and social phobia. J Anxiety from a harmful dysfunction perspective. Can J Psychiatry. Disord. 2002;16:585-598. Clinical Point 2005;50(6):317-319. 22. Schneier FR, Blanco C, Antia SX, et al. 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Bottom Line The severity of anxiety and associated impairment and distress are the main variables that differentiate normal shyness and clinically significant social anxiety. Taking care not to over-pathologize normal shyness and common social anxiety concerns or underdiagnose severe, impairing social anxiety disorder has important Current Psychiatry 38 November 2013 implications for treatment—and for whether a patient needs treatment at all.