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Evidence-based assessment/Social anxiety disorder (disorder portfolio)

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EBA Implementation
Assessment phases
Steps 1-2: Preparation phase

Preparation phase

Steps 3-5: Prediction phase

Prediction phase

Steps 6-9: Prescription phase

Prescription phase

Steps 10-12: Process/progress/outcome phase

Process phase

What is a "portfolio"?

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  • For background information on what assessment portfolios are, click the link in the heading above.
  • Want even 'more' information about this topic? There's an extended version of this page here.

Preparation phase

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Diagnostic criteria for phobic anxiety disorders

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ICD-11 Diagnostic Criteria for Social Anxiety Disorder

  • Social anxiety disorder is characterized 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), being observed (e.g., eating or drinking), 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. The 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.

Changes in DSM-5

  • The diagnostic criteria for simple phobia changed slightly from DSM-IV to DSM-5. Summaries are available here and here.


Base rates of social phobia in different clinical settings

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This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of social anxiety disorder they are likely to see in their clinical practice.

  • To see prevalence rates across multiple disorders, click here.
Demography Setting Base Rate Diagnostic Method
Rhode Island[1] The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project. Psychiatric outpatient practice sample (N=859) 27.8% SIDP-IV
Oakland, California[2] Representative probability within primary care group sample ages 18-70 (N=1001) 3% SCID
All of U.S.A.[3] National Comorbidity Survey Replication (NCS-R). Nationally representative household survey, community sample of adults ages 18+ (N=9282) 12.1% (lifetime)

7.1% (12-month)

WHO-CIDI Clinical Interview
All of U.S.A.[4] NCS Adolescent Supplement (NCS-A) for ages 13 to 17. Community sample, (N=6243). Females 11.2%

Males 6.2% Total 8.6%

WHO-CIDI Clinical Interview, modified to simplify language and use examples relevant to adolescents.
Western North Carolina.[5] The Great Smoky Mountains Study (GSMS). Longitudinal, community sample of children ages 9 to 16 (N=6674) Females 0.8%

Males 0.3% Total 0.5%

CAPA
Houston, Texas metropolitan area. Teen Health 2000 (TH2K). Community sample in large, metropolitan area, ages 11 to 17 (N=4,175) 1.6% DISC-IV
Puerto Rico[6] Representative household probability community sample, ages 4 to 17 (N=1886). 2.8% DISC-IV
Children referred to Anxiety Disorders clinic.[7] Child and Adolescent Anxiety Disorders outpatient research clinic, ages 8 to 13 with anxiety disorder diagnosis (N=199) 20% ADIS-C/P
All of U.S.A. – clinical settings[8] Meta-analysis of data collected across multiple clinical settings, 1995-2006 (N=15,967) 20% (SDI)

6% (unstructured interview)

Structured or Semi-Structure Diagnostic Interviews and unstructured clinical interviews.
Metanalysis of outpatient clinics[9] Outpatient clinic 6% Diagnosis as Usual (DAU)
Metanalysis of outpatient clinics)[10] Outpatient clinic 20% Structured Diagnostic Interviews (SDI)
Intended to apply to the entire United States [11] General Population 9%

Note: WHO-CIDI = World Health Organization Composite International Diagnostic Interview; NCS-A (lifetime prevalence); CAPA= Children and Adolescent Psychiatric Assessment (3-month prevalence); DISC-IV = Diagnostic Interview Schedule for Children, Version 4 (12-month prevalence); ADIS-C/P=Anxiety Disorders Interview Schedule for Children/Parents; SIDP-IV = Structured Interview for DSM-IV Personality; SCID=Structured Clinical Interview for DSM-IV; SDIs included in Rettew et al. (2009): CIDI, DAWBA, DICA, DISC, DIS, MINI, K-SADS-PL, SCAN-2, SCID, SCID-II.

  • Higher rates of social anxiety disorder are found in females than in males, with more pronounced differences in adolescence. Prevalence rates in children and adolescents are comparable to those in adults. Onset is typically in early adolescence (DSM-5, 2013).

Prediction phase

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Psychometric properties of screening instruments for social anxiety disorder

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The following section contains a list of screening and diagnostic instruments for social anxiety disorder. The section includes administration information, psychometric data, and PDFs or links to the screenings.

  • Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
  • For a list of more broadly reaching screening instruments, click here.
Measure Format (Reporter) Age Range Administration/

Completion Time

Where to Access
Liebowitz Social Anxiety Scale (LSAS)[12] Questionnaire (clinician administered, self-report) 7 years-adult 15 minutes
Social Phobia Inventory (SPIN)[13] Questionnaire (self-report) 12 years-adult 5-10 minutes
Social Phobia and Anxiety Inventory (SPAI)[14] *not free Questionnaire (self-report) 14 years-adult 20-30 minutes Purchase here
For Children and Adolescents Specifically
Revised Children’s Anxiety and Depression Scale (RCADS) Questionnaire (Child) 6-18 years 12 minutes

PDFs for RCADS

Subscales

Translations

Social Phobia and Anxiety Inventory for Children (SPAIC) *not free Questionnaire 8-14 years 20-30 minutes Purchase here

Note: Reliability and validity are included in the extended version here. This table includes measures with Good or Excellent ratings.

Likelihood ratios and AUCs of screening measures for social anxiety disorder

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  • For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
Screening Measure (Primary Reference) AUC (Sample Size) DiLR+ (Score) DiLR- (Score) Clinical Generalizability Where to Access
Liebowitz Social Anxiety Scale (LSAS)

[15]

[16] and [17]

0.94 - differentiating from subclinical patients

0.98 - differentiating from healthy controls

Not reported Not reported Printable PDF
Overall Anxiety Severity And Impairment Scale (OASIS)[18] .87[19] 3.07 (> or = cut score 8)
Cut-score of ≥ 8 to be optimal given that it successfully classified 87% of the sample with the most favorable balance of sensitivity (89%) and specificity (71%)

[19]

Not reported Unknown[19] Printable PDF
Social Phobia and Anxiety Inventory for Children (SPAI-C)
(Beidel, Turner, & Morris, 1995)

[20] and [21]

.65 (N=172) 3.55 (18+) .47 Purchase here
Screen for Child Anxiety and Related Emotional Disorders (SCARED)
[22][23] 		.72 (N=119) 1.9 (27+) .50 Printable PDF
Notes about the above table
  • Note: All studies used some version of ADIS-C, K-SADS or CAS administered by trained raters. “LR+” refers to the change in likelihood ratio associated with a positive test score, and “LR-” is the likelihood ratio for a low score. Likelihood ratios of 1 indicate that the test result did not change impressions at all. LRs larger than 10 or smaller than .10 are frequently clinically decisive; 5 or .20 are helpful, and between 2.0 and .5 are small enough that they rarely result in clinically meaningful changes of formulation (Sackett et al., 2000). AUC guidelines according to Swets and Pickett (1982)[24]: .50 to .70 (low accuracy), .70 to .90 (moderate accuracy), and greater than .90 (high accuracy).
  • Note: Silverman & Ollendick (2005)[25] suggest that the SPAI-C is the better instrument for identifying those children and adolescents who most likely meet DSM-IV criteria for social phobia, but that this measure may miss some adolescents who would meet criteria for social phobia. Child and Adolescent Social Anxiety Disorder Jacqueline Nesi 7 Although the MASC has evidence to support it, the current evidence only applies to screening for GAD in girls and anxiety comorbidities (p.404). Thus, for both of these measures, another assessment method is to be used as well, such as an interview schedule (pp 401-5). The SCARED, MASC, and FSSC-R may be helpful to discriminate between youth with social phobia versus other anxiety disorders (p. 404).

Interpreting social anxiety disorder screening measure scores

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Prescription phase

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Gold standard diagnostic interviews

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  • For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.
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Diagnostic instruments for social anxiety disorder
Measure Format (Reporter) Age Range Administration/

Completion Time

Where to Access
Anxiety Disorders Interview Schedule (ADIS)[26] Interview (clinician) 7 years-adult 90 minutes Purchase here
Structured Clinical Interview for DSM (SCID)[27] Semi-structured Interview Adults (Ages 18+) 1-2 hours Available for purchase from APA Publishing (Note: Not free)

Note: Reliability and validity are included in the extended version here. This table includes measures with Good or Excellent ratings.

Process phase

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The following section contains a brief overview of treatment options for social anxiety disorder and list of process and outcome measures for social anxiety disorder. The section includes benchmarks based on published norms for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

Outcome and severity measures

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This table includes clinically significant benchmarks for social anxiety disorder specific outcome measures

  • Information on how to interpret this table can be found here.
  • Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
  • For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
Benchmarks Based on Non-Referred Sample of Adolescents (Anderson et al., 2009)
Measure Subscale Cut-off scores Critical Change
(unstandardized scores)
A B C 95% 90% SEdifference
MASC (2009) Total 15.9 63.8 38.9 11.9 10.0 6.1
Social Anxiety Scale 3.5 19.9 11.8 7.8 6.6 4.0
SPAI-C (2009) Total 3.3 26.6 15.9 7.5 6.3 3.8
Benchmarks Based on Published Norms
Measure Subscale Cut-off scores Critical Change
(unstandardized scores)
A B C 95% 90% SEdifference
CBCL T-Scores (2001 Norms) Total 49 70 58 5 4 2.4
Internalizing n/a 70 56 9 7 4.5
TRF T-Scores (2001 Norms) Total n/a 70 57 5 4 2.3
Internalizing n/a 70 55 9 7 4.4
YSR T-Scores (2001 Norms) Total n/a 70 54 7 6 3.3
Internalizing n/a 70 54 9 8 4.8

Note: A = Away from the clinical range; B= Back into the nonclinical range; and C = Closer to the nonclinical than clinical mean.

Treatment

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The resources below concentrate on child and adolescent populations.

Information on therapy for social anxiety

According to Effective Child Therapy, no “Well-Established” treatments have been empirically validated for Social Phobia.

  • However, group Cognitive Behavioral Therapy, or Group CBT, for Anxiety has been identified as “Probably Efficacious” in treating Social Phobia.
  • According to Effective Child Therapy, the “Probably Efficacious” distinction marks a treatment as having “strong research support” but lacking the criteria that at least two large-scale randomized controlled trials have been conducted by “independent investigatory teams working at different research settings.” This prevents the treatment from moving into the “Well-Established” group.
  • Currently, however, CBT is identified as the most promising treatment for childhood and adolescent social phobia.

Cognitive Behavioral Therapy

  • Effective Child Therapy identifies the following core components of CBT for anxious youth, including those with Social Phobia: Emotions Education and Relaxation.
  • Parents and child are taught about the interrelated physiological, cognitive, and behavioral components of anxiety.
  • Activities help demonstrate different emotions, body postures, and cognitive and physiological correlates. Progressive relaxation training helps anxious children develop awareness and control over their own physiological and muscular responses to anxiety.

Cognitive restructuring

  • Cognitive restructuring helps children identify and replace distorted cognitions with more adaptive beliefs.
  • Basic cognitive strategies include identifying and reducing negative self-talk, generating positive self-statements, thought stopping, thought challenging (weighing evidence for and against), testing both dysfunctional and adaptive beliefs, and creating a coping plan for feared situations.

Imaginal and in-vivo exposure

  • The goals of exposures are to encourage approach behavior by positioning the child in a previously feared or challenging situation.
  • The child attempts to complete tasks in a graded "fear hierarchy" such that the child experiences early success before attempting greater challenges.
  • During individual exposures, a child is encouraged to use any number of coping skills, including relaxation exercises, coping thoughts (challenging anxious thoughts with more positive, realistic thoughts), concrete problem-solving, or rehearsal of desirable skills.

Parent Interventions

  • Parents may have their own preconceptions about the threatening nature of anxiety and they may not know how best to encourage a child to cope with anxiety.
  • CBT provides parents education about the risks of continued avoidance and guidance in managing their own anxiety
  • CBT may also impart basic parenting strategies (e.g., positive/negative reinforcement, planned ignoring, modeling, reward planning) to facilitate the practice of therapy skills in the home.

Sources: Effective Child Therapy page on Fear, Worry & Anxiety

Please refer to the Wikipedia page on Social Anxiety Disorder for more information on available treatment for social anxiety or go to Effective Child Therapy for a curated resource on effective treatments for anxiety disorders.

External resources

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  1. ICD-10 diagnostic criteria
  2. Find-a-Therapist
    • A curated list of find-a-therapist websites where you can find a provider
  3. NIMH
    • Go to this resource for more information on anxiety disorders
  4. OMIM (Online Mendelian Inheritance in Man)
  5. Effective Child Therapy page for Fear, Worry, & Anxiety
    • Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society for Clinical Child and Adolescent Psychology (SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.
  6. Society of Clinical Child and Adolescent Psychology
  7. Behavioral Health Virtual Resource
    • This resource has free PDFs of anxiety screenings, as well as information on diagnosing and treating different anxiety disorders
  8. www.abctcentral.org 
    • This is a website sponsored by the Association for Behavioral and Cognitive Therapies.
    • Use the “Find a Therapist” option to search for local therapists using CBT, an effective treatment for Social Anxiety.
  9. www.BravePracticeForKids.com
    • This website, created by Dr. Emily Becker-Haimes at the University of Pennsylvania, has information on conducting Exposure Therapy for anxiety disordered youth.

References

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Click here for references
  1. ↑ Zimmerman, Mark; Morgan, Theresa A.; Young, Diane; Chelminski, Iwona; Dalrymple, Kristy; Walsh, Emily (December 2015). "Does Borderline Personality Disorder Manifest Itself Differently in Patients With Bipolar Disorder and Major Depressive Disorder?". Journal of Personality Disorders 29 (6): 847–853. doi:10.1521/pedi_2014_28_169. ISSN 1943-2763. PMID 25248008. http://www.ncbi.nlm.nih.gov/pubmed/25248008. 
  2. ↑ Olfson, M; Kroenke, K; Wang, S; Blanco, C (March 2014). "Trends in office-based mental health care provided by psychiatrists and primary care physicians.". The Journal of clinical psychiatry 75 (3): 247-53. PMID 24717378. 
  3. ↑ Ruscio, AM; Brown, TA; Chiu, WT; Sareen, J; Stein, MB; Kessler, RC (January 2008). "Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication.". Psychological medicine 38 (1): 15-28. PMID 17976249. 
  4. ↑ Kessler, RC; Avenevoli, S; McLaughlin, KA; Green, JG; Lakoma, MD; Petukhova, M; Pine, DS; Sampson, NA et al. (September 2012). "Lifetime co-morbidity of DSM-IV disorders in the US National Comorbidity Survey Replication Adolescent Supplement (NCS-A).". Psychological medicine 42 (9): 1997-2010. PMID 22273480. 
  5. ↑ Mustillo, S; Worthman, C; Erkanli, A; Keeler, G; Angold, A; Costello, EJ (April 2003). "Obesity and psychiatric disorder: developmental trajectories.". Pediatrics 111 (4 Pt 1): 851-9. PMID 12671123. 
  6. ↑ Ortega, AN; Goodwin, RD; McQuaid, EL; Canino, G (NaN). "Parental mental health, childhood psychiatric disorders, and asthma attacks in island Puerto Rican youth.". Ambulatory pediatrics : the official journal of the Ambulatory Pediatric Association 4 (4): 308-15. PMID 15264963. 
  7. ↑ Verduin, TL; Kendall, PC (June 2003). "Differential occurrence of comorbidity within childhood anxiety disorders.". Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53 32 (2): 290-5. PMID 12679288. 
  8. ↑ Rettew, DC; Lynch, AD; Achenbach, TM; Dumenci, L; Ivanova, MY (September 2009). "Meta-analyses of agreement between diagnoses made from clinical evaluations and standardized diagnostic interviews.". International journal of methods in psychiatric research 18 (3): 169-84. PMID 19701924. 
  9. ↑ Rettew, David C.; Lynch, Alicia Doyle; Achenbach, Thomas M.; Dumenci, Levent; Ivanova, Masha Y. (2009-09). "Meta-analyses of agreement between diagnoses made from clinical evaluations and standardized diagnostic interviews". International Journal of Methods in Psychiatric Research 18 (3): 169–184. doi:10.1002/mpr.289. ISSN 1049-8931. http://dx.doi.org/10.1002/mpr.289. 
  10. ↑ Rettew, David C.; Lynch, Alicia Doyle; Achenbach, Thomas M.; Dumenci, Levent; Ivanova, Masha Y. (2009-09). "Meta-analyses of agreement between diagnoses made from clinical evaluations and standardized diagnostic interviews". International Journal of Methods in Psychiatric Research 18 (3): 169–184. doi:10.1002/mpr.289. ISSN 1049-8931. http://dx.doi.org/10.1002/mpr.289. 
  11. ↑ Kessler, R. C., Avenevoli, S., Costello, E. J., Georgiades, K., Green, J. G., Gruber, M. J., . . . Merikangas, K. R. (2012). Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry, 69(4), 372-380. doi:10.1001/archgenpsychiatry.2011.160
  12. ↑ Heimberg, R. G.; Horner, K. J.; Juster, H. R.; Safren, S. A.; Brown, E. J.; Schneier, F. R.; Liebowitz, M. R. (1999-1). "Psychometric properties of the Liebowitz Social Anxiety Scale". Psychological Medicine 29 (1): 199–212. ISSN 0033-2917. PMID 10077308. https://www.ncbi.nlm.nih.gov/pubmed/10077308. 
  13. ↑ Connor, Kathryn M.; Davidson, Jonathan R. T.; Churchill, L. Erik; Sherwood, Andrew; Weisler, Richard H.; Foa, Edna (2000/04). "Psychometric properties of the Social Phobia Inventory (SPIN): New self-rating scale". The British Journal of Psychiatry 176 (4): 379–386. doi:10.1192/bjp.176.4.379. ISSN 0007-1250. https://www.cambridge.org/core/journals/the-british-journal-of-psychiatry/article/psychometric-properties-of-the-social-phobia-inventory-spin/9E4A3EE20D2B1A6C222CDB5807AC086A. 
  14. ↑ Garcia-Lopez, Luis Joaquin; Hidalgo, Maria D.; Beidel, Deborah C.; Olivares, Jose; Turner†, Samuel (2008-01-01). "Brief Form of the Social Phobia and Anxiety Inventory (SPAI-B) for Adolescents". European Journal of Psychological Assessment 24 (3): 150–156. doi:10.1027/1015-5759.14.3.150. ISSN 1015-5759. http://dx.doi.org/10.1027/1015-5759.14.3.150. 
  15. ↑ Liebowitz, MR (1987). "Social phobia.". Modern problems of pharmacopsychiatry 22: 141-73. PMID 2885745. 
  16. ↑ Mennin, DS; Fresco, DM; Heimberg, RG; Schneier, FR; Davies, SO; Liebowitz, MR (2002). "Screening for social anxiety disorder in the clinical setting: using the Liebowitz Social Anxiety Scale.". Journal of anxiety disorders 16 (6): 661-73. PMID 12405524. 
  17. ↑ Santos, LF; Loureiro, SR; Crippa, JA; Osório, FL (2015). "Can the Liebowitz Social Anxiety Scale - self-report version be used to differentiate clinical and non-clinical SAD groups among Brazilians?". PloS one 10 (3): e0121437. PMID 25811489. 
  18. ↑ Campbell-Sills, Laura; Norman, Sonya B.; Craske, Michelle G.; Sullivan, Greer; Lang, Ariel J.; Chavira, Denise A.; Bystritsky, Alexander; Sherbourne, Cathy et al. (2009-1). "Validation of a Brief Measure of Anxiety-Related Severity and Impairment: The Overall Anxiety Severity and Impairment Scale (OASIS)". Journal of affective disorders 112 (1-3): 92–101. doi:10.1016/j.jad.2008.03.014. ISSN 0165-0327. PMID 18486238. PMC PMC2629402. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629402/. 
  19. ↑ 19.0 19.1 19.2 Campbell-Sills, Laura; Norman, Sonya B.; Craske, Michelle G.; Sullivan, Greer; Lang, Ariel J.; Chavira, Denise A.; Bystritsky, Alexander; Sherbourne, Cathy et al. (2009-1). "Validation of a Brief Measure of Anxiety-Related Severity and Impairment: The Overall Anxiety Severity and Impairment Scale (OASIS)". Journal of affective disorders 112 (1-3): 92–101. doi:10.1016/j.jad.2008.03.014. ISSN 0165-0327. PMID 18486238. PMC PMC2629402. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2629402/. 
  20. ↑ Inderbitzen-Nolan, H; Davies, CA; McKeon, ND (2004). "Investigating the construct validity of the SPAI-C: comparing the sensitivity and specificity of the SPAI-C and the SAS-A.". Journal of anxiety disorders 18 (4): 547-60. PMID 15149713. 
  21. ↑ Viana, AG; Rabian, B; Beidel, DC (June 2008). "Self-report measures in the study of comorbidity in children and adolescents with social phobia: research and clinical utility.". Journal of anxiety disorders 22 (5): 781-92. PMID 17888622. 
  22. ↑ Birmaher, B; Khetarpal, S; Brent, D; Cully, M; Balach, L; Kaufman, J; Neer, SM (April 1997). "The Screen for Child Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics.". Journal of the American Academy of Child and Adolescent Psychiatry 36 (4): 545-53. PMID 9100430. 
  23. ↑ Desousa, DA; Salum, GA; Isolan, LR; Manfro, GG (June 2013). "Sensitivity and specificity of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a community-based study.". Child psychiatry and human development 44 (3): 391-9. PMID 22961135. 
  24. ↑ Song, HH (March 1997). "Analysis of correlated ROC areas in diagnostic testing.". Biometrics 53 (1): 370-82. PMID 9147602. 
  25. ↑ Silverman, WK; Ollendick, TH (September 2005). "Evidence-based assessment of anxiety and its disorders in children and adolescents.". Journal of clinical child and adolescent psychology : the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53 34 (3): 380-411. PMID 16026211. 
  26. ↑ Hunsley, John; Mash, Eric J., eds (2018-06). "A Guide to Assessments That Work". Oxford Clinical Psychology. doi:10.1093/med-psych/9780190492243.001.0001. http://dx.doi.org/10.1093/med-psych/9780190492243.001.0001. 
  27. ↑ Hunsley, John; Mash, Eric J., eds (2018-06). "A Guide to Assessments That Work". Oxford Clinical Psychology. doi:10.1093/med-psych/9780190492243.001.0001. http://dx.doi.org/10.1093/med-psych/9780190492243.001.0001. 
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