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usmle step 2 ck

Social Anxiety Disorder

Marked fear of social scrutiny or negative evaluation leading to avoidance or endurance with intense anxiety for at least 6 months

Review date
reviewed 2026-05-04
Reading time
6 min read
Author
Dr Kola Tytler MBBS CertHE MBA MSt MRCGP
Psychiatry & Behavioral Sciencecommonlong-term-condition
On this page
Condition details
Psychiatry & Behavioral Science
common
6 min read
reviewed 2026-05-04
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About This Page

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.

Key points

  • 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

Management

DSM-5-TR criteria and APA psychiatric evaluation guidance
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

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Verified Sources & References

APA DSM-5-TR Educational Resources
APA Psychiatric Evaluation of Adults Guideline
APA Clinical Practice Guidelines
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