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Social anxiety disorder in adults: Epidemiology, clinical manifestations, and diagnosis

Franklin R Schneier, MD
Section Editor
Murray B Stein, MD, MPH
Deputy Editor
Richard Hermann, MD


Social anxiety disorder (SAD), also known as social phobia, is a common disorder characterized by excessive fears of scrutiny, embarrassment, and humiliation in social or performance situations, leading to significant distress or impairment in functioning.

SAD is a prevalent condition, estimated to affect between 3 and 7 percent of the adult United States population over a 12-month period. SAD typically begins in childhood or adolescence and, untreated, can be associated with the subsequent development of major depression, substance abuse, and other mental health problems. The disorder can be associated with extensive functional impairment and reduced quality of life [1].

This topic addresses the epidemiology, pathogenesis, clinical manifestations, and diagnosis for SAD. Psychotherapy and pharmacotherapy for the disorder are discussed separately. (See "Psychotherapy for social anxiety disorder in adults" and "Pharmacotherapy for social anxiety disorder in adults".)


Behavioral inhibition — A childhood temperament that has been operationally defined by researchers to refer to young children who manifest fear and withdrawal behavior when introduced to novel situations or unfamiliar persons.

Avoidant personality disorder — An avoidant personality disorder is described in DSM-5 as a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction [2].

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Literature review current through: Nov 2017. | This topic last updated: May 03, 2017.
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  1. Ruscio AM, Brown TA, Chiu WT, et al. Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychol Med 2008; 38:15.
  2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington 2013.
  3. Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005; 62:593.
  4. Grant BF, Hasin DS, Blanco C, et al. The epidemiology of social anxiety disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2005; 66:1351.
  5. Stein DJ, Ruscio AM, Lee S, et al. Subtyping social anxiety disorder in developed and developing countries. Depress Anxiety 2010; 27:390.
  6. Low, NC, Cui, L, Merikangas, KR. Specificity of familial transmission of anxiety and comorbid disorders. J Psychiatric Res 2008; 42: 596.
  7. Hirshfeld-Becker DR, Micco J, Henin A, et al. Behavioral inhibition. Depress Anxiety 2008; 25:357.
  8. Cougle JR, Keough ME, Riccardi CJ, Sachs-Ericsson N. Anxiety disorders and suicidality in the National Comorbidity Survey-Replication. J Psychiatr Res 2009; 43:825.
  9. Katzelnick DJ, Kobak KA, DeLeire T, et al. Impact of generalized social anxiety disorder in managed care. Am J Psychiatry 2001; 158:1999.
  10. Kendler KS, Neale MC, Kessler RC, et al. The genetic epidemiology of phobias in women. The interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia. Arch Gen Psychiatry 1992; 49:273.
  11. Hofmann SG, Newman MG, Ehlers A, Roth WT. Psychophysiological differences between subgroups of social phobia. J Abnorm Psychol 1995; 104:224.
  12. Schneier FR, Abi-Dargham A, Martinez D, et al. Dopamine transporters, D2 receptors, and dopamine release in generalized social anxiety disorder. Depress Anxiety 2009; 26:411.
  13. Sareen J, Campbell DW, Leslie WD, et al. Striatal function in generalized social phobia: a functional magnetic resonance imaging study. Biol Psychiatry 2007; 61:396.
  14. Phan KL, Fitzgerald DA, Cortese BM, et al. Anterior cingulate neurochemistry in social anxiety disorder: 1H-MRS at 4 Tesla. Neuroreport 2005; 16:183.
  15. Hoge EA, Pollack MH, Kaufman RE, et al. Oxytocin levels in social anxiety disorder. CNS Neurosci Ther 2008; 14:165.
  16. Ziegler C, Dannlowski U, Bräuer D, et al. Oxytocin receptor gene methylation: converging multilevel evidence for a role in social anxiety. Neuropsychopharmacology 2015; 40:1528.
  17. Roelofs K, van Peer J, Berretty E, et al. Hypothalamus-pituitary-adrenal axis hyperresponsiveness is associated with increased social avoidance behavior in social phobia. Biol Psychiatry 2009; 65:336.
  18. Elzinga BM, Spinhoven P, Berretty E, et al. The role of childhood abuse in HPA-axis reactivity in Social Anxiety Disorder: a pilot study. Biol Psychol 2010; 83:1.
  19. Furmark T, Tillfors M, Marteinsdottir I, et al. Common changes in cerebral blood flow in patients with social phobia treated with citalopram or cognitive-behavioral therapy. Arch Gen Psychiatry 2002; 59:425.
  20. Goldin PR, Manber T, Hakimi S, et al. Neural bases of social anxiety disorder: emotional reactivity and cognitive regulation during social and physical threat. Arch Gen Psychiatry 2009; 66:170.
  21. Sripada CS, Angstadt M, Banks S, et al. Functional neuroimaging of mentalizing during the trust game in social anxiety disorder. Neuroreport 2009; 20:984.
  22. Brühl AB, Delsignore A, Komossa K, Weidt S. Neuroimaging in social anxiety disorder—a meta-analytic review resulting in a new neurofunctional model. Neurosci Biobehav Rev 2014; 47:260.
  23. Essex MJ, Klein MH, Slattery MJ, et al. Early risk factors and developmental pathways to chronic high inhibition and social anxiety disorder in adolescence. Am J Psychiatry 2010; 167:40.
  24. Rodebaugh TL, Levinson CA, Langer JK, et al. The structure of vulnerabilities for social anxiety disorder. Psychiatry Res 2017; 250:297.
  25. Simon NM, Herlands NN, Marks EH, et al. Childhood maltreatment linked to greater symptom severity and poorer quality of life and function in social anxiety disorder. Depress Anxiety 2009; 26:1027.
  26. Rapee RM, Spence SH. The etiology of social phobia: empirical evidence and an initial model. Clin Psychol Rev 2004; 24:737.
  27. McCabe RE, Miller JL, Laugesen N, et al. The relationship between anxiety disorders in adults and recalled childhood teasing. J Anxiety Disord 2010; 24:238.
  28. Chartier MJ, Walker JR, Stein MB. Social phobia and potential childhood risk factors in a community sample. Psychol Med 2001; 31:307.
  29. Rapee RM, Heimberg RG. A cognitive-behavioral model of anxiety in social phobia. Behav Res Ther 1997; 35:741.
  30. Lazarov A, Abend R, Bar-Haim Y. Social anxiety is related to increased dwell time on socially threatening faces. J Affect Disord 2016; 193:282.
  31. Lissek S, Levenson J, Biggs AL, et al. Elevated fear conditioning to socially relevant unconditioned stimuli in social anxiety disorder. Am J Psychiatry 2008; 165:124.
  32. Cox BJ, Fleet C, Stein MB. Self-criticism and social phobia in the US national comorbidity survey. J Affect Disord 2004; 82:227.
  33. Taylor CT, Pearlstein SL, Stein MB. The affective tie that binds: Examining the contribution of positive emotions and anxiety to relationship formation in social anxiety disorder. J Anxiety Disord 2017; 49:21.
  34. Kessler RC, Stein MB, Berglund P. Social phobia subtypes in the National Comorbidity Survey. Am J Psychiatry 1998; 155:613.
  35. Ruscio, AM, Brown, TA, Chiu, WT, et al. Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychol Med 2008;35:15.
  36. Beesdo K, Bittner A, Pine DS, et al. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry 2007; 64:903.
  37. Schneier FR, Foose TE, Hasin DS, et al. Social anxiety disorder and alcohol use disorder co-morbidity in the National Epidemiologic Survey on Alcohol and Related Conditions. Psychol Med 2010; 40:977.
  38. Chambless DL, Fydrich T, Rodebaugh TL. Generalized social phobia and avoidant personality disorder: meaningful distinction or useless duplication? Depress Anxiety 2008; 25:8.
  39. Black, B, Uhde, T. Psychiatric characteristics of children with selective mutism: a pilot study. J Am Acad Child Adol Psychiatry 1995; 34:847.
  40. Dummit ES, Klein RG, Tancer NK, et al. Systematic assessment of 50 children with selective mutism. J Am Acad Child Adol Psychiatry 1997; 36:653.
  41. Simonoff E, Pickles A, Charman T, et al. Psychiatric disorders in children with autism spectrum disorders: prevalence, comorbidity, and associated factors in a population-derived sample. J Am Acad Child Adol Psychiatry 2008 2008; 47:921.
  42. Cath DC, Ran N, Smit JH, et al. Symptom overlap between autism spectrum disorder, generalized social anxiety disorder and obsessive-compulsive disorder in adults: a preliminary case-controlled study. Psychopathology 2008; 41:101.
  43. Gijsman HJ, Geddes JR, Rendell JM, et al. Antidepressants for bipolar depression: a systematic review of randomized, controlled trials. Am J Psychiatry 2004; 161:1537.
  44. Achim, A. How Prevalent Are Anxiety Disorders in Schizophrenia? A Meta-Analysis and Critical Review on a Significant Association. Schizophrenia Bulletin, doi:10.1093 Advance Access published online on December 3, 2009.
  45. Choy Y, Schneier FR, Heimberg RG, et al. Features of the offensive subtype of Taijin-Kyofu-Sho in US and Korean patients with DSM-IV social anxiety disorder. Depress Anxiety 2008; 25:230.
  46. Schneier, FR, Socha, J. Is there a spectrum of social anxiety disorder?. In: Anxiety Disorders, Theory, Research, and Clinical Perspectives, Simpson, HB, Neria, Y, Lewis-Fernandez, R, Schneier, F (Eds), Cambridge University Press, Cambridge, UK 2010. p.80.
  47. Schneier FR, Barnes LF, Albert SM, Louis ED. Characteristics of social phobia among persons with essential tremor. J Clin Psychiatry 2001; 62:367.
  48. Schneier FR. Clinical practice. Social anxiety disorder. N Engl J Med 2006; 355:1029.
  49. Ipser JC, Kariuki CM, Stein DJ. Pharmacotherapy for social anxiety disorder: a systematic review. Expert Rev Neurother 2008; 8:235.
  50. Juster HR, Heimberg RG. Social phobia. Longitudinal course and long-term outcome of cognitive-behavioral treatment. Psychiatr Clin North Am 1995; 18:821.
  51. Keller, MB. Social anxiety disorder clinical course and outcome: review of Harvard/Brown Anxiety Research Project (HARP) findings. J Clin Psychiatry 2006; 12:14.
  52. Nelson EC, Grant JD, Bucholz KK, et al. Social phobia in a population-based female adolescent twin sample: co-morbidity and associated suicide-related symptoms. Psychol Med 2000; 30:797.
  53. Connor KM, Kobak KA, Churchill LE, et al. Mini-SPIN: A brief screening assessment for generalized social anxiety disorder. Depress Anxiety 2001; 14:137.
  54. Seeley-Wait E, Abbott MJ, Rapee RM. Psychometric properties of the mini-social phobia inventory. Prim Care Companion J Clin Psychiatry 2009; 11:231.
  55. Mennin DS, Fresco DM, Heimberg RG, et al. Screening for social anxiety disorder in the clinical setting: using the Liebowitz Social Anxiety Scale. J Anxiety Disord 2002; 16:661.
  56. Heimberg RG, Horner KJ, Juster HR, et al. Psychometric properties of the Liebowitz Social Anxiety Scale. Psychol Med 1999; 29:199.
  57. Stein MB, Stein DJ. Social anxiety disorder. Lancet 2008; 371:1115.
  58. Belzer K, Schneier FR. Comorbidity of anxiety and depressive disorders: issues in conceptualization, assessment, and treatment. J Psychiatr Pract 2004; 10:296.
  59. Coles ME, Phillips KA, Menard W, et al. Body dysmorphic disorder and social phobia: cross-sectional and prospective data. Depress Anxiety 2006; 32:26.