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Table 1. Unanswered Questions and Suggestions for Future Research About the Diagnosis and Treatment of Social Anxiety Disorder.  



Issues and Controversies Surrounding the Diagnosis and Treatment of Social Anxiety Disorder

  • Authors: Kristy L. Dalrymple, PhD
  • CME Released: 9/24/2012
  • Valid for credit through: 9/24/2013
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Target Audience and Goal Statement

This activity is intended for psychiatrists, psychologists, pediatricians, and other clinicians caring for patients with SAD.

The goal of this activity is to describe controversies in the management of SAD.

Upon completion of this activity, participants will be able to:

  1. Describe the clinical characteristics and epidemiology of SAD, based on a review
  2. Describe challenges in the diagnosis of SAD, based on a review
  3. Describe challenges in the management of SAD, based on a review


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  • Kristy L. Dalrymple, PhD

    Rhode Island Hospital and the Alpert Medical School of Brown University, Providence, Rhode Island


    Disclosure: Kristy L. Dalrymple, PhD, has disclosed no relevant financial relationships.


  • Elisa Manzotti

    Publisher, Future Science Group, London, United Kingdom


    Disclosure: Elisa Manzotti has disclosed no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer, Medscape, LLC


    Disclosure: Laurie Barclay, MD, has disclosed no relevant financial relationships.

CME Reviewer

  • Nafeez Zawahir, MD

    CME Clinical Director, Medscape, LLC


    Disclosure: Nafeez Zawahir, MD, has disclosed no relevant financial relationships.

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Issues and Controversies Surrounding the Diagnosis and Treatment of Social Anxiety Disorder

Authors: Kristy L. Dalrymple, PhDFaculty and Disclosures

CME Released: 9/24/2012

Valid for credit through: 9/24/2013


Abstract and Introduction


Although much has been learned about social anxiety disorder (SAD) in recent decades, many questions and controversies surrounding its diagnosis and treatment have remained. Similar to the state of affairs with other psychiatric disorders, no clear pathophysiology has been identified for SAD, and the question of where to draw the line between shyness, SAD and even avoidant personality disorder continues to be debated. Much of the evidence to date suggests that among persons with SAD, it is under-recognized and undertreated; however, other researchers contend that it may be overdiagnosed in some individuals. Questions also remain as to how best treat these individuals, such as with pharmacotherapy, psychotherapy or a combination of the two. The aim of this review is to provide an overview of the controversies related to the diagnosis and treatment of SAD. In addition, suggestions for future research are provided that could perhaps clarify these remaining questions, such as maximizing treatment efficacy by targeting broader outcomes such as quality of life and addressing common comorbidities that occur with SAD.


Social anxiety disorder (SAD) currently is defined as a significant fear of embarrassment or humiliation in social situations to the point that these situations often are avoided or endured with a significant amount of distress.[1] Typical situations feared or avoided by individuals with SAD include performance situations (e.g., giving a speech to an audience) or interpersonal situations (e.g., initiating conversations with individuals at a party). Currently, two subtypes are distinguished: generalized and specific. Definitions of the subtypes vary, but the DSM-IV defines the generalized subtype as fear in ‘most’ social situations, while the specific subtype is fear in only a few situations.[1] Epidemiological studies have indicated a lifetime prevalence rate of SAD of approximately 7–13% in Western countries, and it is the fourth most common mental disorder in the USA.[2,3] Studies within clinical samples have found a prevalence rate as high as 30%.[4] In addition, SAD has a cumulative incidence rate of 11% in the first three decades of life, with peak incidence generally occurring between 10 and 19 years of age.[5] SAD largely follows a chronic course, with patient populations reporting an average duration of SAD between 10 and 24 years[6] and recovery rates of approximately one-third after 8 years.[7] A more recent prospective community study of German females also found a full recovery rate of 36% after 1.5 years.[6]

It has been well documented that SAD is highly comorbid with other psychiatric disorders, including mood, other anxiety and substance use disorders.[8] For example, Acarturk et al . found that 66% of individuals with SAD in a population-based sample met criteria for at least one other psychiatric disorder.[9] Among Axis II disorders, avoidant personality disorder (AVPD) is most commonly associated with SAD, occurring in up to 89% of individuals with the generalized subtype of SAD.[10] SAD is associated with lower levels of educational attainment, single marital status and unemployment,[11] as well as fewer days worked and reduced work productivity.[12] Individuals with SAD also report poor quality of life[12,13] and high levels of service utilization,[12,14] although not always for SAD specifically (see below). As a result, SAD is associated with substantial economic costs.[15] Despite all that has been discovered about SAD in the past three decades, controversies and questions remain about its etiology, diagnosis and treatment.