Diagnostic Criteria of Social Anxiety Disorder (Social Phobia)

DSM-5 Diagnostic Criteria for Social Anxiety Disorder

Official Name: Social Anxiety Disorder (Social Phobia)

  • Formerly called “Social Phobia”
  • DSM-5 uses both names
  • “Social Anxiety Disorder” now preferred term

Criterion A: Marked Fear or Anxiety About Social Situations

Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others

“Marked” means:

  • Intense, pronounced, strong
  • Goes beyond normal social nervousness or shyness
  • Disproportionate to the situation
  • Excessive compared to what most people would experience

“Social Situations”: Situations involving interaction with or observation by other people

Key Component: “Possible Scrutiny by Others”:

  • Fear is specifically of being observed, watched, or evaluated by others
  • Concern about what others think or how one appears to others
  • Fear of social evaluation, judgment, or criticism
  • Not just about the social situation itself, but about being in situation where others can see and judge you

Types of Social Situations That May Be Feared

Performance/Public Speaking Situations:

  • Giving presentations or speeches
  • Speaking up in class or meetings
  • Performing in front of others (music, sports, theater)
  • Reading aloud in front of others
  • Being called on in class
  • Making announcements
  • Being in spotlight or center of attention

Social Interaction Situations:

  • Having conversations, especially with unfamiliar people
  • Meeting new people or being introduced
  • Talking to authority figures (boss, teacher, doctor)
  • Asserting oneself (expressing opinions, disagreeing, making requests)
  • Dating or romantic interactions
  • Attending parties or social gatherings
  • Making phone calls (especially to unfamiliar people or for business)
  • Returning items to store, complaining about service
  • Interviewing for jobs

Being Observed Situations:

  • Eating or drinking in front of others
  • Writing while being watched (signing documents, writing on board)
  • Using public restrooms (especially when others present)
  • Entering room where others already seated
  • Walking across room or through crowded place where others can see
  • Working while being observed
  • Exercising or participating in activities where others watch

Common Specific Fears:

Most Common:

  1. Public speaking (most common and often most severe)
  2. Speaking to authority figures
  3. Meeting new people
  4. Eating or drinking in public
  5. Attending parties or social gatherings

Also Frequently Feared:

  • Being center of attention
  • Making small talk
  • Group discussions or meetings
  • Dating
  • Expressing disagreement
  • Making eye contact
  • Answering questions in group
  • Using telephone in public

Number of Situations:

  • Can fear one situation (e.g., only public speaking)
  • More commonly fear multiple social situations
  • Can fear nearly all social situations (generalized type)

Criterion B: Fear of Acting in Certain Ways or Showing Anxiety Symptoms

The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others)

Core Fear: Negative Evaluation

Specific Fears Include:

Fear of Showing Anxiety Symptoms:

  • Blushing: “Everyone will see me turn red and think I’m weird”
  • Sweating: “People will notice I’m sweating and think something’s wrong with me”
  • Trembling/shaking: “My hands will shake and people will think I’m nervous or incompetent”
  • Voice quavering: “My voice will shake and I’ll sound scared”
  • Stuttering or blocking: “I’ll stumble over my words and sound stupid”
  • Mind going blank: “I’ll forget what to say and look foolish”

Fear of Acting Inappropriately:

  • Saying something stupid, embarrassing, or offensive
  • Not knowing what to say (awkward silences)
  • Appearing boring or uninteresting
  • Seeming incompetent or unintelligent
  • Looking awkward or clumsy
  • Making fool of oneself
  • Acting in socially unacceptable way

Fear of Negative Social Consequences:

  • Humiliation: Being deeply embarrassed in front of others
  • Embarrassment: Others seeing one’s discomfort or mistakes
  • Rejection: Others not liking or accepting them; being excluded
  • Criticism: Others thinking badly of them or judging them negatively
  • Offending others: Saying or doing something that upsets or offends

Underlying Belief Structure:

Common Cognitions (Thoughts):

  • “Everyone is watching and judging me”
  • “I’ll do something embarrassing and everyone will laugh at me”
  • “People will think I’m stupid/weird/incompetent”
  • “If I show anxiety, people will reject me”
  • “I have to perform perfectly or people will think badly of me”
  • “Others can tell I’m anxious and will judge me for it”
  • “If I make a mistake, it will be catastrophic”

Cognitive Biases Present:

  • Spotlight effect: Overestimating how much others notice and pay attention to them
  • Mind reading: Assuming they know what others are thinking (and that it’s negative)
  • Catastrophizing: Expecting worst possible outcome
  • Overgeneralization: “If I mess up once, everyone will always think badly of me”
  • All-or-nothing thinking: “If I’m not perfect, I’m a complete failure”

Self as Social Object:

  • See themselves from observer perspective (as if watching themselves from outside)
  • Acutely aware of how they appear to others
  • Constant self-monitoring during social situations
  • Focus on perceived flaws or deficiencies

Criterion C: Social Situations Almost Always Provoke Fear or Anxiety

The social situations almost always provoke fear or anxiety

“Almost Always”:

  • Response is consistent and predictable
  • Occurs every time or nearly every time person is in (or anticipates being in) social situation
  • Not variable or unpredictable
  • Person knows in advance they will experience anxiety

Two Types of Anxiety:

Anticipatory Anxiety:

  • Anxiety that occurs before social situation
  • Worrying about upcoming social event
  • May begin days or weeks before event
  • Intensity increases as event approaches
  • Can be as distressing as anxiety during actual situation

Examples:

  • Worrying for weeks before presentation
  • Anxious for days before party
  • Losing sleep night before job interview
  • Ruminating about upcoming meeting

In-Situation Anxiety:

  • Anxiety experienced during actual social situation
  • Peak anxiety typically early in situation (first few minutes)
  • May remain high throughout situation
  • Rarely habituates (doesn’t decrease with continued exposure) without treatment

Intensity Can Vary Based On:

Situation Factors:

  • Number of people: More people = more anxiety (typically)
  • Familiarity of people: Strangers > acquaintances > close friends/family
  • Status of people: Authority figures > peers
  • Formality: Formal situations > informal
  • Degree of scrutiny: Being focus of attention > being in crowd

Personal Factors:

  • Recent experiences (bad social experience increases anxiety)
  • Stress level
  • Fatigue
  • Physical health
  • Use of alcohol or medications

Range of Responses:

  • Mild discomfort to full panic attack
  • In severe cases, may experience panic attacks in social situations
  • Physical symptoms always present to some degree

Criterion D: Avoidance or Endurance with Intense Fear or Anxiety

The social situations are avoided or endured with intense fear or anxiety

Two Patterns:

1. Avoidance (Very Common)

Active Avoidance: Deliberately staying away from feared social situations

Examples of Avoidance:

Performance Situations:

  • Not taking classes that require presentations
  • Choosing jobs that don’t require public speaking or meetings
  • Declining promotions that involve more social demands
  • Missing important events (graduations, weddings) if must be in spotlight

Social Interactions:

  • Turning down social invitations
  • Avoiding parties, gatherings, social events
  • Not initiating conversations
  • Eating alone rather than in cafeteria or restaurant
  • Taking online classes to avoid in-person interaction
  • Working from home to avoid office social situations

Being Observed:

  • Eating in car or bathroom rather than with others
  • Only using restroom when empty
  • Arriving late or leaving early to avoid walking in front of group
  • Always sitting in back of room where less visible

Partial Avoidance/Safety Behaviors:

  • Attending party but staying on periphery, not talking much
  • Going to restaurant but only ordering food that’s easy to eat
  • Agreeing to present but reading from script, not making eye contact
  • Participating in group but remaining silent or minimally engaged

Safety Behaviors (Subtle Avoidance):

  • Avoiding eye contact
  • Speaking very softly or briefly
  • Holding drink to hide trembling hands
  • Wearing makeup to hide blushing
  • Rehearsing excessively what to say
  • Using alcohol before social situations
  • Always going with companion (not alone)
  • Staying near exit
  • Keeping conversations superficial

Impact of Avoidance:

  • Maintains the anxiety: Never learns that feared outcomes won’t occur or aren’t as bad as expected
  • Restricts life significantly: Limits career, education, relationships, activities
  • Increases isolation: Becomes increasingly socially withdrawn
  • Reduces quality of life: Misses opportunities and experiences
  • May worsen over time: Avoidance can expand to include more situations

2. Endurance with Intense Distress

When This Occurs:

  • Situation unavoidable (required for work, school)
  • Important obligation (family event, medical appointment)
  • Forcing self because situation too important to avoid
  • Unexpected social encounter

Characteristics:

  • Extreme anxiety throughout situation
  • Severe physical symptoms
  • Intense self-consciousness
  • Constant monitoring of own behavior and others’ reactions
  • Exhaustion afterward
  • May use alcohol or medication to cope

Examples:

  • Attending required work meeting but heart racing, sweating, barely able to speak
  • Giving mandatory presentation but shaking, voice trembling, intense panic
  • Going to job interview but extremely anxious, difficulty concentrating, sure they performed terribly
  • Attending wedding but miserable, counting minutes until can leave

Post-Event Rumination (Very Common):

  • After social situation, repeatedly replaying what happened
  • Analyzing everything said and done
  • Focusing on perceived mistakes or awkward moments
  • Convinced others noticed anxiety and judged negatively
  • “Post-mortem” analysis that increases anxiety about future situations
  • Can last hours, days, or even weeks after event

Criterion E: Out of Proportion to Actual Threat

The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context

Out of Proportion to Actual Threat:

Objective Assessment:

  • Fear is excessive compared to realistic likelihood of negative outcome
  • Anticipated consequences are unlikely or unrealistic
  • Response is much stronger than situation warrants

Reality Testing:

Feared Outcome vs. Reality:

  • Fear: “If I blush during presentation, everyone will think I’m incompetent and I’ll be humiliated”

  • Reality: Most people barely notice blushing; if they do, they’re sympathetic; doesn’t indicate incompetence

  • Fear: “If I stumble over words, people will think I’m stupid”

  • Reality: Everyone occasionally stumbles over words; others quickly forget; doesn’t indicate intelligence

  • Fear: “If I say something awkward, people will reject me forever”

  • Reality: Everyone occasionally says awkward things; people are forgiving; relationships don’t end over minor social missteps

Actual Consequences Usually:

  • Much less severe than feared
  • Often don’t occur at all
  • Not noticed by others as much as feared
  • Not remembered by others
  • Don’t lead to rejection or lasting negative evaluation

Overestimation of:

  • Likelihood that negative event will occur
  • Severity of consequences if negative event occurs
  • How much others notice and care
  • How long others will remember

Underestimation of:

  • Own ability to cope
  • Others’ understanding and forgiveness
  • How common social anxiety and awkwardness are

Sociocultural Context:

Must Consider Cultural Norms:

  • What constitutes appropriate social behavior varies by culture
  • Social expectations differ across cultures
  • Degree of typical anxiety in social situations varies

Examples:

  • In some cultures, avoiding eye contact with elders is respectful (not anxious)
  • Some cultures emphasize group harmony; speaking up may be less expected
  • Cultures vary in expectations for public speaking, self-promotion, assertiveness
  • In some contexts, more social anxiety is normative (e.g., meeting very important person)

Diagnosis Requires: Fear is excessive even within person’s cultural context

Criterion F: Duration

The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

Why 6 Months?:

  • Distinguishes social anxiety disorder from temporary social discomfort
  • Brief periods of increased social anxiety common (new school, new job)
  • Persistent fear suggests true disorder

“Typically”:

  • Most cases should persist 6+ months for diagnosis
  • In severe cases causing significant impairment, may diagnose sooner
  • In children and adolescents: Must be 6 months (developmental shyness common and often transient)

Without Treatment:

  • Social anxiety disorder tends to be chronic
  • Often begins in adolescence and persists into adulthood
  • Rarely remits spontaneously
  • May worsen over time without treatment (avoidance increases)
  • Average duration without treatment: Years to decades

Course:

  • Often begins in early to mid-adolescence (average age 13)
  • Sometimes starts in childhood (very shy children)
  • Rarely begins in adulthood (after age 25)
  • If begins in childhood, may persist entire life without treatment

Criterion G: Clinically Significant Distress or Impairment

The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

Clinically Significant: Meaningful negative impact on life, not just mild discomfort

Two Ways Criterion Can Be Met:

1. Marked Distress About Having Social Anxiety

Person significantly distressed by:

  • Having the condition
  • Limitations it creates
  • Missing out on experiences
  • Impact on self-esteem and identity
  • Feeling different from others
  • Embarrassment about having anxiety

Example: College student rarely has to give presentations, but is deeply distressed about having social anxiety, feels defective, has low self-esteem because of it

2. Significant Functional Impairment

Social/Interpersonal Impairment:

  • Difficulty forming friendships: Avoids social situations where could meet people
  • Difficulty maintaining relationships: Anxiety in social interactions strains friendships
  • Romantic relationships: Difficulty dating, initiating relationships; affects relationship quality
  • Family relationships: May avoid family gatherings, strain with family members
  • Social isolation: Becomes increasingly isolated; loneliness
  • Limited social network: Has few friends or social connections
  • Social skills: May not develop due to lack of practice (social avoidance prevents skill development)

Academic Impairment:

  • Lower grades: Not participating in class; not asking questions; poor performance on presentations
  • Course selection: Avoiding classes that require presentations or participation
  • Not completing degree: Dropping out due to anxiety about social demands
  • Missed opportunities: Not joining clubs, groups, activities; not networking
  • Test anxiety: If has performance component (oral exams)

Occupational/Career Impairment:

  • Career choice limitations: Choosing careers below ability level to avoid social demands
  • Job performance: Difficulty with meetings, presentations, networking, team projects
  • Avoiding promotions: Turning down advancement opportunities that involve more social interaction or leadership
  • Job interviews: Difficulty interviewing; may not get jobs due to anxiety in interview
  • Unemployment: May be unemployed due to difficulty with job search and interviews
  • Underemployment: Working below potential to avoid social demands

Other Functional Areas:

  • Healthcare: Difficulty with medical appointments; avoiding necessary care
  • Daily errands: Difficulty with routine tasks (banking, shopping, dealing with customer service)
  • Community involvement: Not participating in community, civic, or religious activities
  • Personal growth: Not pursuing interests or goals due to social anxiety

Quality of Life:

  • Severely diminished
  • Chronic stress and distress
  • Low self-esteem
  • Depression (very common comorbidity)
  • Sense of missing out on life

Criterion H: Not Attributable to Substance or Medical Condition

The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., drug of abuse, medication) or another medical condition

Must Rule Out Medical Causes:

Medical Conditions That Can Cause Social Anxiety-Like Symptoms:

  • Parkinson’s disease: Tremor may increase self-consciousness in social situations
  • Hyperthyroidism: Can cause trembling, sweating, anxiety
  • Stuttering or other speech disorders: May lead to avoidance of speaking situations
  • Obesity: May lead to fear of negative evaluation related to appearance
  • Disfigurement or deformity: May fear others’ reactions
  • Essential tremor: Trembling may lead to social anxiety

Key Distinction:

  • If anxiety is reasonable response to actual medical condition (e.g., stuttering), may not be social anxiety disorder
  • If anxiety is excessive even considering the medical condition, may diagnose social anxiety disorder

Substance-Induced Anxiety:

  • Stimulants (caffeine, amphetamines, cocaine): Can cause anxiety symptoms
  • Withdrawal from depressants (alcohol, benzodiazepines): Can cause anxiety
  • Some medications: Steroids, bronchodilators, some antidepressants (initially)

If Due to Substance: Diagnose “Substance/Medication-Induced Anxiety Disorder” instead

Criterion I: Not Better Explained by Another Mental Disorder

The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder

Differential Diagnosis (Must Distinguish From):

Panic Disorder with Agoraphobia:

  • If fear is of having panic attack in social situation (not of social evaluation), consider panic disorder
  • Can have both disorders if fears are distinct

Agoraphobia:

  • If fear is of being trapped or unable to escape (not social evaluation)
  • If fear is about panic symptoms (not social evaluation)

Separation Anxiety Disorder:

  • If social avoidance is due to worry about being separated from attachment figure

Autism Spectrum Disorder:

  • Social difficulties in ASD due to social communication deficits, not fear of negative evaluation
  • However, individuals with ASD can also have social anxiety disorder (comorbid)

Body Dysmorphic Disorder:

  • If social avoidance is solely due to preoccupation with perceived appearance flaws
  • Can be comorbid with social anxiety

Major Depressive Disorder:

  • Social withdrawal in depression due to low mood and anhedonia, not fear of negative evaluation
  • Very commonly comorbid; can diagnose both

Psychotic Disorders:

  • If social withdrawal due to paranoid delusions or hallucinations

Avoidant Personality Disorder:

  • Very similar to social anxiety disorder (especially generalized type)
  • Personality disorder diagnosis suggests more pervasive pattern
  • Significant overlap; may diagnose both
  • Some consider avoidant personality disorder severe form of social anxiety disorder

Selective Mutism (in children):

  • Child speaks in some situations but not others (e.g., speaks at home but not at school)
  • Often considered expression of social anxiety in children
  • If criteria for both met, diagnose both

However: Can diagnose social anxiety disorder along with other disorders if criteria for both are met and social fears are distinct

Specifiers

Specify if: Performance Only

Performance-Only Type:

  • Fear is restricted to speaking or performing in public
  • Does NOT fear other social interactions (conversations, eating in front of others, etc.)

Characteristics:

  • Comfortable in conversational social situations
  • Only anxious when performing or speaking in front of audience
  • Most common performance situation: Public speaking

Examples:

  • Comfortable at parties, meeting people, eating in public
  • But terrified of giving presentations or speeches
  • May have no problems with job interviews or conversations

Prevalence: About 1/3 of people with social anxiety disorder have performance-only type

Note: If fears performance situations AND other social interactions, do NOT specify “performance only” (it’s the generalized type)

Additional Diagnostic Considerations

Children and Adolescents:

  • Must occur in peer settings, not just with adults
  • May express anxiety through crying, tantrums, freezing, clinging, shrinking
  • May not recognize fear is excessive (lack insight)
  • May express as refusal to speak in social situations (selective mutism)
  • Avoidance may manifest as school refusal

Adolescence (Typical Age of Onset):

  • Average age of onset: 13 years
  • Critical period: Increased social evaluation, peer pressure, identity formation
  • May be mistaken for normal adolescent shyness
  • Developmentally inappropriate intensity and impairment

Adults:

  • Usually have had symptoms since adolescence
  • May have developed coping strategies or lifestyle that minimizes social demands
  • Often good insight that fear is excessive

Gender Differences

Prevalence:

  • Slightly more common in females in community samples
  • Equal or more males in clinical samples (males may have more impairment or more likely to seek treatment)

Presentation May Differ:

  • Males: May self-medicate with alcohol/substances more
  • Females: May have more avoidance; more comorbid depression

Prevalence and Course

Prevalence:

  • Lifetime prevalence: 7-13% (varies by study)
  • 12-month prevalence: 7-8%
  • Third most common mental disorder (after depression and alcohol use disorder)
  • Many people never seek treatment

Age of Onset:

  • Median age: 13 years
  • Range: Can begin childhood to early twenties
  • Rarely begins after age 25
  • Childhood onset: Very shy, behaviorally inhibited children at higher risk

Course:

  • Chronic and persistent without treatment
  • Often lifelong if untreated
  • Rarely remits spontaneously
  • May wax and wane in severity
  • Avoidance tends to increase over time
  • Treatment can be very effective

Comorbidity

Very High Comorbidity:

Most Common Comorbidities:

  • Other anxiety disorders (50-60%): GAD, specific phobia, panic disorder
  • Major depressive disorder (40-50%): Often secondary to social anxiety (develops after)
  • Substance use disorders (20-30%): Often self-medication (especially alcohol)
  • Avoidant personality disorder: Very high overlap (may be severe form of social anxiety)

Also Associated With:

  • Body dysmorphic disorder
  • Eating disorders
  • Low self-esteem

Impact of Comorbidity:

  • More severe impairment
  • Worse prognosis
  • More difficult to treat
  • Higher suicide risk

Suicide Risk

  • Increased risk compared to general population
  • Especially high if comorbid depression
  • Social isolation and hopelessness increase risk
  • Important to assess

Key Points for Exams

Nine Criteria (A-I):

  1. Criterion A: Marked fear/anxiety about social situations involving possible scrutiny
  2. Criterion B: Fear of acting in way or showing anxiety that will be negatively evaluated
  3. Criterion C: Social situations almost always provoke fear/anxiety
  4. Criterion D: Active avoidance or endurance with intense distress
  5. Criterion E: Fear out of proportion to actual threat and sociocultural context
  6. Criterion F: Persistent, typically 6+ months (must be 6+ months in children/adolescents)
  7. Criterion G: Clinically significant distress or impairment
  8. Criterion H: Not attributable to substance or medical condition
  9. Criterion I: Not better explained by another mental disorder

Key Features:

  • Core fear: Negative evaluation by others
  • Fear of showing anxiety symptoms or acting inappropriately
  • Leads to avoidance or intense distress
  • Chronic and persistent
  • High comorbidity (especially depression, substance use)
  • Often begins in adolescence
  • Very common (7-13% lifetime prevalence)

Specifier:

  • Performance-only type: Fear limited to public speaking/performing
  • If fears multiple types of social situations: Generalized type (though not official specifier, commonly used term)

Differential Diagnosis: Must distinguish from agoraphobia, panic disorder, autism spectrum disorder, avoidant personality disorder, depression, normal shyness