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This is a clinician-written, evidence-based summary aligned to the USMLE Step 2 CK Content Outline. It is intended for medical students preparing for USMLE Step 2 CK. Management reflects current ACC/AHA, USPSTF, and APA guidelines. Always cross-reference with UpToDate, institutional protocols, and clinical judgment.
The Bottom Line
- Fear of scrutiny, humiliation, embarrassment, or rejection in social/performance situations for >=6 months
- Avoidance causes impairment; panic attacks may be situationally bound
- First-line: CBT with exposure and/or SSRI/SNRI
- Performance-only anxiety can use situational propranolol if no contraindications
- Differentiate from ASD, which has early social communication deficits plus restricted/repetitive behaviors
Overview
Social anxiety disorder is marked fear or anxiety about social situations in which the patient may be scrutinized. The core fear is negative evaluation. Symptoms persist for at least 6 months, are out of proportion, and impair functioning.
Epidemiology
Social anxiety commonly begins in adolescence and can be mistaken for shyness. It is associated with school refusal, occupational underachievement, depression, alcohol misuse, loneliness, and avoidant personality traits.
Clinical Features
Symptoms
Fear of public speaking, meeting new people, dating, eating or writing in public
Avoidance of classes, meetings, interviews, calls, or social events
Blushing, sweating, trembling, nausea, shaky voice, mind going blank
Anticipatory anxiety days to weeks before events
Severe depression, substance misuse, suicidality, or inability to attend school/work
Signs
Anxious affect, poor eye contact, soft speech, tremor, blushing
Normal exam between exposures
Early communication deficits/restricted interests suggest ASD rather than primary social anxiety
Investigations
First-line
DSM-5-TR assessmentFear of scrutiny, avoidance/endurance, duration >=6 months, impairment, exclusion of substances/medical causes
Comorbidity screenDepression, alcohol use, panic disorder, selective mutism, ASD, avoidant traits
Functional assessmentSchool, employment, relationships, presentations, eating/writing in public, calls/video
Second-line
Liebowitz Social Anxiety ScaleQuantifies severity and monitors exposure treatment
Substance reviewAlcohol before social events is common
Specialist
CBT referralExposure-based CBT is first-line and can be individual or group
1
Psychotherapy
- CBT with graduated exposure, cognitive restructuring, attention training, and reducing safety behaviors
- Group CBT can provide live social exposure
- Behavioral experiments are preferred over reassurance seeking
2
Pharmacotherapy
- SSRIs such as sertraline, paroxetine, fluoxetine, escitalopram; venlafaxine is also effective
- Start low, titrate, continue 6-12 months after response
- Avoid chronic benzodiazepines
3
Performance-only subtype
- Propranolol 10-40 mg before performance can reduce tremor/palpitations
- Avoid propranolol in asthma, bradycardia, heart block, and some depression contexts
- Exposure practice remains central
Complications
- Major depression:
- Alcohol use disorder:
- Educational/occupational impairment:
- Avoidant personality traits:
- Social isolation:
USMLE Step 2 CK Exam Tips
- 1Core fear is negative evaluation
- 2Performance-only anxiety + tremor before presentations = propranolol
- 3Generalized social anxiety = CBT and SSRI/SNRI, not PRN propranolol alone
- 4ASD requires early social communication deficits and restricted/repetitive behaviors
- 5Drinking before parties to calm nerves: screen for AUD
practicetest your knowledge on social anxiety disorderApply what you've learnt with USMLE Step 2 CK-style questions from the iatroX Q-Bank — psychiatry and beyond.
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