DEPRESSION AND ANXIETY 27 : 168–189 (2010)
Review
SOCIAL ANXIETY DISORDER: QUESTIONS AND ANSWERS
FOR THE DSM-V
Susan M. Bögels,1 Lynn Alden,2 Deborah C. Beidel,3 Lee Anna Clark,4 Daniel S. Pine,5 Murray B. Stein,6
and Marisol Voncken7
Background: This review evaluates the DSM-IV criteria of social anxiety disorder
(SAD), with a focus on the generalized specifier and alternative specifiers, the
considerable overlap between the DSM-IV diagnostic criteria for SAD and
avoidant personality disorder, and developmental issues. Method: A literature
review was conducted, using the validators provided by the DSM-V Spectrum
Study Group. This review presents a number of options and preliminary
recommendations to be considered for DSM-V. Results/Conclusions: Little
supporting evidence was found for the current specifier, generalized SAD. Rather,
the symptoms of individuals with SAD appear to fall along a continuum of severity
based on the number of fears. Available evidence suggested the utility of a specifier
indicating a ‘‘predominantly performance’’ variety of SAD. A specifier based on
‘‘fear of showing anxiety symptoms’’ (e.g., blushing) was considered. However, a
tendency to show anxiety symptoms is a core fear in SAD, similar to acting or
appearing in a certain way. More research is needed before considering subtyping
SAD based on core fears. SAD was found to be a valid diagnosis in children and
adolescents. Selective mutism could be considered in part as a young child’s
avoidance response to social fears. Pervasive test anxiety may belong not only to
SAD, but also to generalized anxiety disorder. The data are equivocal regarding
whether to consider avoidant personality disorder simply a severe form of SAD.
Secondary data analyses, field trials, and validity tests are needed to investigate the
recommendations and options. Depression and Anxiety 27:168–189, 2010.
r 2010 Wiley-Liss, Inc.
Key words: DSM-V; social anxiety disorder; social phobia; subtypes; classifica-
tion; interpersonal; performance; test anxiety; selective mutism; avoidant
personality disorder
1
Child Development and Education, University of Amsterdam,
Amsterdam, The Netherlands This article is being co-published by Depression and Anxiety and
2
Department of Psychology, University of British Columbia, the American Psychiatric Association.
Vancouver, Canada The authors report they have no financial relationships within the
3
Department of Psychology, University of Central Florida, past 3 years to disclose.
Orlando, Florida Correspondence to: Susan M. Bögels, Child Development and
4
Department of Psychology, University of Iowa, Iowa City, Education, University of Amsterdam, Nieuwe Prinsengracht 130,
Iowa 1018VZ, Amsterdam, The Netherlands. E-mail: s.m.bogels@uva.nl
5
National Institute of Mental Health, Bethesda, Maryland
6
Departments of Psychiatry and Family and Preventive Received for publication 5 October 2009; Revised 29 December
2009; Accepted 5 January 2010
Medicine, University of California San Diego, La Jolla,
California DOI 10.1002/da.20670
7
Department of Clinical Psychological Science, Maastricht Published online in Wiley InterScience (www.interscience.wiley.
University, Maastricht, The Netherlands com).
r 2010 Wiley-Liss, Inc.
, Review: Social Anxiety Disorder for DSM-V 169
INTRODUCTION STATEMENT OF THE ISSUES
This review evaluates several issues pertaining to the This review addresses the following questions, using
diagnostic criteria for social phobia or social anxiety the validators provided by the DSM-V Task Force: (1)
disorder (SAD) (Table 1), in light of empirical evidence What is the evidence/utility of the DSM-IV general-
gathered since DSM-IV. The review was guided by ized specifier? If there is insufficient evidence/utility
questions posed in the DSM-IV Sourcebook (Vol. 2), for a generalized specifier, what is the utility/evidence
chapters titled ‘‘Social phobia’’[1] and ‘‘Social phobia for alternative subtypes or specifiers based on the
subtypes,’’[2] a review conducted as part of the DSM-V content of feared situations: performance, interaction,
Stress Induced and Fear Circuitry Disorders Work- and observation? (2) What is the evidence/utility for a
group Conference, titled ‘‘Social Phobia: Towards specifier designating fear of showing anxiety symp-
DSM V,’’[3] by questions posed by the DSM-V Anxiety, toms? (3) What is the relation between test anxiety and
OC Spectrum, Posttraumatic, and Dissociative Dis- SAD, and should test anxiety be included in SAD? (4)
order Work Group and by issues raised by consulted What is the relation between Selective Mutism (SM)
experts and advisors. The main issues to be addressed and SAD, and should SM be considered a type of SAD?
are the generalized specifier and its alternatives, the (5) What is the evidence/utility for retaining avoidant
overlap with avoidant personality disorder, and devel- personality disorder (AVPD) and SAD as separate
opmental issues including the relationship that SAD diagnostic entities? (6) Is the diagnosis of SAD valid for
shows in childhood with selective mutism (SM) and test children and adolescents and, if so, from what age? We
anxiety. have reviewed the data based on the availability of data
and relevance of particular validators for the various
issues. Before investigating these questions, we present
a short overview of changes in the SAD diagnosis from
TABLE 1. Diagnostic criteria for Social phobia in DSM-III to DSM-IV.
DSM-IV.
Social phobia (social anxiety disorder) SIGNIFICANCE OF THE ISSUES FOR DSM-V
A. marked and persistent fear of one or more social or performance Little is known about the specific individual and
situations in which the person is exposed to unfamiliar people or
environmental factors that promote or protect against
to possible scrutiny by others. The individual fears that he or she
will act in a way (or show anxiety symptoms) that will be
SAD. The existing evidence for the causative role of life
humiliating or embarrassing. Note: In children, there must be events and shared environment is nonspecific, meaning
evidence of the capacity for age-appropriate social relationships that the environmental factors linked to SAD also show
with familiar people and the anxiety must occur in peer settings, relations to other forms of psychopathology, such as
not just in interactions with adults other anxiety disorders that frequently are comorbid
B. Exposure to the feared social situation almost invariably provokes with SAD.[4–6] One reason that etiological research has
anxiety, which may take the form of a situationally bound or not yet led to a deeper understanding of what causes
situationally predisposed panic attack. Note: In children, the SAD may be the diverse clinical presentation and
anxiety may be expressed by crying, tantrums, freezing, or associated features in individuals with this disorder.
shrinking from social situations with unfamiliar people
The DSM-IV definition for the generalized subtype of
C. The person recognizes that the fear is excessive or unreasonable.
Note: In children, this feature may be absent
SAD is based on the quantity (rather than the thematic
D. The feared social or performance situations are avoided or else are content) of social fears (‘‘fears most social situations’’).
endured with intense anxiety or distress Furthermore, diagnosticians must interpret the mean-
E. The avoidance, anxious anticipation, or distress in the feared social ing of the term ‘‘most situations’’ with little guidance,
or performance situation(s) interferes significantly with the person’s which creates opportunities for variable application of
normal routine, occupational (academic) functioning, or social this specifier. The confusion around the generalized
activities or relationships, or there is marked distress about having subtype, and perhaps the lack of content specifiers
the phobia within the broad diagnosis of SAD, may inhibit
F. In individuals under the age of 18, the duration is at least 6 months research into different pathways to this disorder and,
G. The fear or avoidance is not due to the direct physiological effects
accordingly, into its prevention and treatment. The
of a substance (e.g., drug abuse, a medication) or a general medical
condition and is not better accounted for by another mental
bulk of this review focuses on specifiers for SAD, in
disorder (e.g., panic disorder with or without agoraphobia, particular the evidence for the generalized subtype, and
separation anxiety disorder, body dysmorphic disorder, a pervasive the option of new specifiers: performance, interac-
developmental disorder, or schizoid personality disorder) tional, observational, and one based on fear of showing
H. If a general medical condition or another mental disorder is anxiety symptoms. In addition, we review the relations
present, the fear in Criterion A is unrelated to it, e.g., the fear is of SAD to test anxiety and SM, and investigate the
not of stuttering, trembling in Parkinson’s disease, or exhibiting overlap of generalized SAD and AVPD. The diagnosis
abnormal eating behavior in anorexia nervosa or bulimia nervosa of SAD in childhood has gone through substantial
Specify if: changes from DSM-III to DSM-IV. With its early
Generalized: if the fears include most social situations (also consider
mean onset, chronic course, and relatively low rate of
the additional diagnosis of avoidant personality disorder)
adult onset, SAD fits the prototype of a developmental
Depression and Anxiety
, 170 Bo¨gels et al.
disorder. However, less is known about the validity of (i.e., preoccupation with appropriateness of behavior in
the SAD diagnosis in children compared to adults. the past, excessive concern with social competence, and
Therefore, we also review the validity of SAD as a marked self-consciousness and susceptibility to embar-
diagnosis in children rassment and humiliation).
Recommendations are based on a review of the The DSM-III-R SAD criteria expanded the examples
published literature. Therefore, they are preliminary of social fears with reasons why individuals feared
and do not reflect any definitive decision-making on rejection: ‘‘Being unable to continue talking while
the part of the DSM-V Anxiety, Obsessive-Compulsive speaking in public, choking when eating in front of
Spectrum, Posttraumatic, and Dissociative Disorders others, being unable to urinate in a public lavatory,
Work Group. Decisions will be based ultimately on not hand-trembling when writing in the presence of others,
only the existing literature, but also secondary data and saying foolish things or not being able to answer
analyses, field trials, expert surveys, and group discus- questions in social situations’’ (p 243). In DSM-III-R, a
sions. Thus, these recommendations are subject to specifier indicating the presence or absence of a
change. ‘‘generalized subtype’’ was defined, and social phobia
and AVPD were no longer treated as mutually
SEARCH METHODS exclusive. Instead, in defining the generalized form of
social phobia, the diagnostic criteria stated: ‘‘Also
SAD research published since the release of DSM-IV
consider the additional diagnosis of Avoidant Person-
was searched using PSYCINFO and PUBMED
ality Disorder’’ (p 243, italics added).
searches for English language articles and books.
The DSM-IV (1994) and DSM-IV-TR text revision
Search terms included (combinations of) social anxiety
(2000) added the term Social Anxiety Disorder in
disorder, social phobia, avoidant personality disorder, selective
parentheses after Social Phobia. This reflected the
mutism, test anxiety, blushing, trembling, sweating, gen-
growing recognition that various forms of specific
eralized, interpersonal, performance, speech, children, ado-
phobias could be differentiated from social phobia
lescents, behavior inhibition. The reference lists of the
based on several important clinical and pathophysiolo-
identified key manuscripts also were reviewed. The
gical factors. Reasons for fearing rejection in SAD were
DSM-IV Sourcebook, the DSM-IV Options Book, and
further elaborated in the text: ‘‘Individuals with social
proceedings and monographs of the preparatory
phobia’’ [y] are afraid that others will judge them to
research planning conference series for DSM-V were
be anxious, weak, ‘‘crazy,’’ or stupid (p 450) or ‘‘appear
also consulted.
inarticulate’’ (p 451). Furthermore, fear of showing
anxiety symptoms was addressed specifically, by its
SOCIAL PHOBIA FROM DSM-III TO DSM-IV inclusion in criterion A as a primary source of fear:
The diagnosis of social phobia has seen substantial ‘‘The individual fears that he or she will act in a way (or
changes in the last 25 years, from its first appearance in show anxiety symptoms) that will be humiliating or
the DSM-III published in 1980 to the DSM-IV. In embarrassing’’ (p 456). Under diagnostic features in the
DSM-III, phobic disorders and anxiety states were text, the anxiety symptoms were described more
regarded as two types of anxiety disorders, and social clearly: ‘‘Individuals with social phobia almost always
phobia was considered a phobic disorder. The idea that experience symptoms of anxiety (e.g., palpitations,
social anxiety generalizes many different social situa- tremors, sweating, gastrointestinal discomfort, diar-
tions did not exist at the time, as is illustrated by the rhea, muscle tension, blushing, confusion) and in
remark in DSM-III: ‘‘Generally an individual has only severe cases these symptoms might meet the criteria
one social phobia’’ (p 227). The DSM-III examples for a Panic Attack. Blushing may be more typical of
concerned social phobias that later were considered Social Phobia’’ (p 451). Associated features included
specific social phobias: ‘‘Speaking or performing in ‘‘observable signs of anxiety (e.g., cold clammy hands,
public, using public lavatories, eating and writing in tremors, shaky voice)’’ (p 452).
public’’ (p 227). With respect to the boundaries with With respect to the overlap with AVPD, character-
AVPD, DSM-III criterion C stated that symptoms istics of AVPD (e.g., low self-esteem, feelings of
were not due to Avoidant Personality Disorder. In inferiority, and hypersensitivity to criticism) were
DSM-III, children with social anxiety were diagnosed added to the associated features of social phobia, and
with Avoidant Disorder of Childhood and Adolescence, the DSM-IV text noted that ‘‘Avoidant Personality
defined as a persistent and excessive shrinking from Disorder may be a more severe variant of Social
contact with strangers, sufficiently severe to interfere Phobia, Generalized, that is not qualitatively distinct’’
with social functioning in peer relationships. In (p 455). Also a nonsocial aspect of AVPD that is in
addition, DSM-III and DSM-III-R contained the ICD-10 and that had appeared in DSM-III-R (ex-
diagnosis of Overanxious Disorder in Childhood and aggerating the potential dangers or risks in everyday
Adolescence, which resembled both adult Generalized activities) was revised to have a social motivation in
Anxiety Disorder and social phobia. Application of this DSM-IV (‘‘because they may prove embarrassing,’’
diagnosis was also considered for children with social p 665). Test anxiety was included indirectly, as
fears, because the criteria referred to social concerns DSM-IV noted that ‘‘Individuals with social phobia also
Depression and Anxiety
