ICD-11 Criteria for Social Anxiety Disorder (Social Phobia)

Foundation URI : http://id.who.int/icd/entity/2062286624

ICD-11 Criteria for Social Anxiety Disorder (Social Phobia): 6B04

Description

Social anxiety disorder is characterised by marked and excessive fear or anxiety that consistently occurs in one or more social situations such as social interactions (e.g. having a conversation), doing something while feeling observed (e.g. eating or drinking in the presence of others), or performing in front of others (e.g. giving a speech). The individual is concerned that he or she will act in a way, or show anxiety symptoms, that will be negatively evaluated by others. Relevant social situations are consistently avoided or else endured with intense fear or anxiety. The symptoms persist for at least several months and are sufficiently severe to result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning.

Diagnostic Requirements

Essential (Required) Features:

• Marked and excessive fear or anxiety that occurs consistently in one or more social situations such as social interactions (e.g., having a conversation), doing something while feeling observed (e.g., eating or drinking in the presence of others), or performing in front of others (e.g., giving a speech).
• The individual is concerned that he or she will act in a way, or show anxiety symptoms, that will be negatively evaluated by others (i.e., be humiliating, embarrassing, lead to rejection, or be offensive).
• Relevant social situations are consistently avoided or endured with intense fear or anxiety.
• The symptoms are not transient; that is, they persist for an extended period of time (e.g., at least several months).
• The symptoms are not better accounted for by another mental disorder (e.g., Agoraphobia, Body Dysmorphic Disorder, Olfactory Reference Disorder).
• The symptoms result in significant distress about experiencing persistent anxiety symptoms or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.

Additional Clinical Features:

• Individuals with Social Anxiety Disorder may report concerns about physical symptoms, such as blushing, sweating, or trembling rather than initially endorsing fears of negative evaluation.
• Social Anxiety Disorder frequently co-occurs with other Anxiety or Fear-Related Disorders as well as Depressive Disorders.
• Individuals with Social Anxiety Disorder are at higher risk for developing Disorders due to Substance Use, which may arise subsequent to use for the purposes of attenuating anxiety symptoms in social situations.
• Individuals with Social Anxiety Disorder may not view their fear or anxiety in response to social situations as excessive. As such, clinical judgment should be applied to determine whether the reported fear, anxiety, or avoidance behaviour is disproportionate to what the social situation warrants, taking into consideration both accepted cultural norms and the specific environmental circumstances to which that the individual is subjected (e.g., fear of interacting with peers may be appropriate if the individual is being bullied).

Boundary with Normality (Threshold):

• Social Anxiety Disorder can be differentiated from normal developmental fears (e.g., a child’s reluctance to interact with unfamiliar people in novel situations) by fear and anxiety reactions that are typically excessive, interfere with functioning, and persist over time (e.g., lasting more than several months).
• Many individuals experience fear in social situations (e.g., it is common for individuals to experience anxiety about speaking in public) or manifest the normal personality trait of shyness. Social Anxiety Disorder should only be considered in cases in which the individual reports social fear, anxiety, and avoidance that are clearly in excess of what is normative for the specific cultural context and result in significant distress or impairment.

Course Features:

• Although onset of Social Anxiety Disorder can occur during early childhood, onset typically occurs during childhood and adolescence, with a large majority of cases emerging between 8 and 15 years of age.
• Onset of Social Anxiety Disorder can be gradual or occur precipitously subsequent to a stressful or humiliating social experience.
• Social Anxiety Disorder is generally considered to be a chronic condition; however, later age of onset, less severe level of impairment, and absence of co-occurring disorders have been associated with spontaneous remission among individuals in the community.
• High rates of co-occurring mental disorders make it difficult to distinguish long-term prognosis attributable specifically to Social Anxiety Disorder. Poorer long-term prognosis has been associated with greater symptom severity, and co-occurring Disorders due to Use of Alcohol, Personality Disorder, Generalized Anxiety Disorder, Panic Disorder, and Agoraphobia.
• Remission rates for Social Anxiety Disorder vary widely with some individuals experiencing spontaneous remission of symptoms.

Developmental Presentations:

• Social Anxiety Disorder is less common in young children under the age of 10, with occurrence of the disorder increasing significantly during adolescence.
• In children, the diagnosis of Social Anxiety Disorder should not be used to describe developmentally normative stranger anxiety or shyness.
• Social Anxiety Disorder is associated with the temperamental trait of behavioural inhibition, that is, the tendency for some individuals to experience novel situations as distressing and to withdraw from or avoid unfamiliar contexts or people. Behaviourally inhibited children are ‘slow to warm up’ to new people and new situations. Behavioural inhibition is considered to be a normal variation in temperament, but is also a risk factor for the development of Social Anxiety Disorder.
• Similar to adults, children and adolescents may employ subtle avoidance strategies during social situations to manage their anxiety, including limiting speech or making poor eye contact with others. Children and adolescents with Social Anxiety Disorder may also evidence social skills deficits, such as difficulty with starting or maintaining conversations or asserting their wishes or opinions.
• Social Anxiety Disorder symptoms may only become evident with the start of school, with the onset of demands to interact socially with unfamiliar peers and teachers. The manifestations of Social Anxiety Disorder may also vary across age groups, with younger children more likely to exhibit social anxiety primarily with adults, and adolescents more likely to experience increased social anxiety with peers. There are also individual differences with respect to the degree of social anxiety experienced when interacting with members of the same or opposite sex. Soliciting information from collateral informants who know the child well about how they react in various situations and contexts can assist in making the diagnosis.
• Social Anxiety Disorder symptoms may become more evident with age as social demands exceed individuals’ capabilities to cope with and manage their anxiety. Adolescents may exhibit various associated difficulties, including social withdrawal, school refusal, and reluctance to assert their needs. Some adolescents may participate in social situations for fear of the consequences to their social status if they do not, but do so with significant distress.

Culture-Related Features:

• Identification of Social Anxiety Disorder may depend on assessment of social situations relevant for the cultural group (e.g., being expected to dance in public among some Latin American cultures) that may be associated with excessive anxiety and whether the degree of anxiety is outside the cultural norms for the individual. To avoid stereotyping, individuals should be asked openly about social situations associated with excessive anxiety.
• Anxiety and avoidance of certain social situations may be considered normative in some cultural groups (e.g., public speaking or voicing dissent in some Asian cultures) and therefore may not indicate a disorder unless this fear or anxiety is out of proportion to the actual danger posed by the social situation when considering the sociocultural context.
• There are cultural concepts of distress that are related to Social Anxiety Disorder. For example, among Japanese taijin kyofusho, and related conditions among Koreans, may represent a form of Social Anxiety Disorder associated with the fear that others will be offended by one’s own inappropriate social behaviour (e.g., inappropriate gaze or facial expression, blushing, body odour, loud bowel sounds). Other presentations of taijin kyofusho may be better captured by a diagnosis of Delusional Disorder, Body Dysmorphic Disorder, or Olfactory Reference Disorder.
• Prevalence rates of Social Anxiety Disorder may not follow self-reported social anxiety levels in the same culture; that is, societies with strong collectivistic orientations may report high levels of social anxiety but lower prevalence of Social Anxiety Disorder. This may be due to higher tolerance for socially reticent and withdrawn behaviours, resulting in better psychosocial functioning, or to lower recognition of Social Anxiety Disorder.

Sex- and/or Gender-Related Features:

• Whereas prevalence rates for Social Anxiety Disorder are higher for women in community samples, gender differences are not observed in clinical samples. The disparity in prevalence across settings has been attributed to gender role expectations such that men experiencing greater severity of symptoms are more willing to seek professional services.
• Women report greater symptom severity and a greater variety of social fears, whereas men are more likely to fear dating and urinating in public.
• Co-occurring Depressive, Bipolar, and Anxiety or Fear-Related Disorders are more common among women; whereas, men are more likely to experience co-occurring Oppositional Defiant Disorder, Conduct-Dissocial Disorder, and Disorders Due to Substance Use.
• The use of alcohol and illicit drugs to relieve symptoms of Social Anxiety Disorder is common among men.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Generalized Anxiety Disorder: Generalized Anxiety Disorder can be differentiated from Social Anxiety Disorder because the main focus of worry is negative consequences that can occur in multiple everyday situations (e.g., work, relationships, finances) rather than being restricted to concerns about one’s behaviour or appearance being negatively evaluated in social situations.
• Boundary with Panic Disorder: If an individual with Social Anxiety Disorder experiences panic attacks exclusively in the context of actual or anticipated social or performance situations, an additional diagnosis of Panic Disorder is not warranted and the presence of panic attacks may be indicated using the ‘with panic attacks’ specifier. However, if unexpected panic attacks also occur, an additional diagnosis of Panic Disorder may be assigned.
• Boundary with Agoraphobia: Fear or anxiety in Agoraphobia centres on imminent perceived dangerous outcomes (e.g., panic attacks, symptoms of panic, incapacitation, or embarrassing physical symptoms) that are anticipated to occur in multiple situations where obtaining help or escaping might be difficult rather than on concerns that others are negatively evaluating them. Unlike Social Anxiety Disorder, embarrassment in Agoraphobia is secondary to the concerns that escape or obtaining assistance may not be possible should symptoms (e.g., diarrhoea in a public place) occur.
• Boundary with Specific Phobia: Specific Phobia can be differentiated from Social Anxiety Disorder because, in general, fears are of specific situations or stimuli (e.g., heights, animals, blood-injury) and not of social situations.
• Boundary with Selective Mutism: Selective Mutism is characterized by a failure to speak in specific situations whereas in Social Anxiety Disorder fear and anxiety result in avoidance of multiple social contexts.
• Boundary with Autism Spectrum Disorder: Individuals with Autism Spectrum Disorder and Social Anxiety Disorder may both appear to be socially withdrawn. However, those with Autism Spectrum Disorder can be differentiated because of the presence of social communication deficits and typically a lack of interest in social interactions.
• Boundary with Depressive Disorders: Beliefs of social inadequacy, rejection, and failure are common in Depressive Disorders and may be associated with avoidance of social situations. However, unlike in Social Anxiety Disorder, these symptoms occur almost exclusively during a Depressive Episode.
• Boundary with Body Dysmorphic Disorder: In Body Dysmorphic Disorder, individuals worry about a perceived physical defect that is often undetectable or very minor from the point of view of others. These individuals may be concerned about others’ negative judgment of the perceived defect. However, unlike in Social Anxiety Disorder, their concerns are restricted to how others will evaluate the perceived defect rather than other aspects of their behaviour or appearance across social contexts.
• Boundary with Olfactory Reference Disorder: In Social Anxiety Disorder, social situations are avoided because the individual is concerned that he or she will act in a way, or show anxiety symptoms, that will be negatively evaluated by others (i.e., be humiliating, embarrassing, lead to rejection, or be offensive). In contrast, individuals with Olfactory Reference Disorder may avoid social situations specifically because they believe they are emitting a foul odour.
• Boundary with Oppositional Defiant Disorder: Irritability, anger, and noncompliance are sometimes associated with anxiety in children and adolescents. For example, children may exhibit angry outbursts when asked to enter situations that make them feel anxious (e.g., being asked to attend a social gathering). If the defiant behaviours only occur when triggered by a situation or stimulus that elicits anxiety, fear, or panic, a diagnosis of Oppositional Defiant Disorder is generally not appropriate.
• Boundary with other Mental and Behavioural Syndromes due to another medical condition: Individuals with certain medical conditions (e.g., Parkinson Disease) as well as those with other Mental, Behavioural or Neurodevelopmental Disorders (e.g., Schizophrenia) may demonstrate avoidance of social situations because of concerns that others will negatively evaluate their symptoms (e.g., tremor, unusual behaviours). An additional diagnosis of Social Anxiety Disorder should only be assigned if all diagnostic requirements are met taking into consideration that it is normal for individuals with visible symptoms of a medical condition to experience some concerns about how others perceive their symptoms. Typically, individuals with medical conditions adapt to concerns related to their manifest symptoms and do not display persistent excessive fear or anxiety in social situations.

REFERENCE:

International Classification of Diseases Eleventh Revision (ICD-11). Geneva: World Health Organization; 2022. License: CC BY-ND 3.0 IGO.

https://creativecommons.org/licenses/by-nc-nd/3.0/igo/