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DEPRESSION AND ANXIETY 31:472–479 (2014)
Review
SOCIAL ANXIETY DISORDER IN DSM-5
Richard G. Heimberg, Ph.D.,1∗Stefan G. Hofmann, Ph.D.,2Michael R. Liebowitz, M.D.,3Franklin R.
Schneier, M.D.,4Jasper A. J. Smits, Ph.D.,5Murray B. Stein, M.D., M.P.H.,6,7 Devon E. Hinton, M.D., Ph.D.,8
and Michelle G. Craske, Ph.D.9
With the publication of DSM-5, the diagnostic criteria for social anxiety disorder
(SAD, also known as social phobia) have undergone several changes, which have
important conceptual and clinical implications. In this paper, we first provide
a brief history of the diagnosis. We then review a number of these changes,
including (1) the primary name of the disorder, (2) the increased emphasis on fear
of negative evaluation, (3) the importance of sociocultural context in determining
whether an anxious response to a social situation is out of proportion to the actual
threat, (4) the diagnosis of SAD in the context of a medical condition, and (5)
the way in which we think about variations in the presentation of SAD (the
specifier issue). We then consider the clinical implications of changes in DSM-5
related to these issues. Depression and Anxiety 31:472–479, 2014. C2014
Wiley Periodicals, Inc.
Key words: DSM-5; social anxiety disorder; social phobia; diagnostic criteria;
diagnosis; classification; specifiers
1Department of Psychology, Adult Anxiety Clinic, Temple Uni-
versity, Philadelphia, Pennsylvania
2Department of Psychology, Boston University, Boston, Mas-
sachusetts
3Department of Psychiatry, Columbia University College of
Physicians and Surgeons and the Medical Research Network,
New York, New York
4Anxiety Disorders Clinic, New York State Psychiatric Institute
and Department of Psychiatry, Columbia University College of
Physicians and Surgeons, New York, New York
5Department of Psychology and the Institute for Mental Health
Research, University of Texas at Austin, Austin, Texas
6Department of Psychiatry, University of California at San
Diego, La Jolla, California
7Department of Family & Preventive Medicine, University of
California at San Diego, La Jolla, California
8Department of Psychiatry, Harvard University, Cambridge,
Massachusetts
9Department of Psychology, University of California at Los
Angeles, Los Angeles, California
∗Correspondence to: Richard Heimberg, Adult Anxiety Clinic, De-
partment of Psychology, Temple University, Weiss Hall, 1701 N.
13th St., Philadelphia, PA 19122. E-mail: heimberg@temple.edu
Received for publication 07 September 2013; Revised 09 November
2013; Accepted 28 November 2013
DOI 10.1002/da.22231
Published online 2 January 2014 in Wiley Online Library
(wileyonlinelibrary.com).
With the publication of the fifth edition of the Diag-
nostic and Statistical Manual of Mental Disorders (DSM-5),
there have been changes to the diagnostic criteria for sev-
eral disorders, additions of new disorders, and deletion of
some for which time has runs its course.[1] The Anxiety
Sub-Workgroup of the DSM-5 Anxiety, OC Spectrum,
Posttraumatic, and Dissociative Disorders Workgroup
devoted many long hours to consideration of the diag-
nostic criteria for, and even the name of, social anxiety
disorder (SAD, the disorder previously known as social
phobia). In this paper, after a brief history, several of
us who have devoted considerable energy to the study
of SAD examine the primary changes in the diagnos-
tic criteria and the implications these may have for the
recognition, assessment, and treatment of SAD. Keep in
mind that any statements contained herein do not rep-
resent the views or opinions of the American Psychiatric
Association and are purely those of the authors.
A BRIEF HISTORY OF SAD
(SOCIAL PHOBIA)
Much of our thinking about the classification of pho-
bic disorders derives from the 1966 work of Marks and
Gelder.[2] Citing distinctions in clinical features and
family history, they divided the phobic disorders into
three principal types—agoraphobia, specific phobias,
and social phobia. They defined social phobia broadly
as an exaggerated fear of scrutiny or evaluation by
C2014 Wiley Periodicals, Inc.
Review: Social Anxiety Disorder in DSM-5 473
others that led to distress and/or avoidance when en-
gaging in performance or social interactions.
DSM-III[3] defined social phobia in a way that, at first
glance, did not seem to differ markedly from Marks and
Gelder’s typology. DSM-III required affected individu-
als to manifest “a persistent, irrational fear of, and com-
pelling desire to avoid, a situation in which the individual
is exposed to possible scrutiny by others, and fears that
he or she may act in a way that will be humiliating or em-
barrassing” [3, p. 228]. However, it limited the diagnosis
in several ways, all without strong empirical support. Im-
portantly, it excluded from the diagnosis of social pho-
bia individuals whose symptoms were due to avoidant
personality disorder (APD), a newly created category
characterized by “hypersensitivity to potential rejection,
humiliation, or shame; an unwillingness to enter into re-
lationships unless given unusually strong guarantees of
uncritical acceptance; social withdrawal in spite of a de-
sire for affection and acceptance; and low self-esteem”
[3, p. 323]. In practice, this excluded those individuals
with widespread interpersonal fears, leaving the category
to those with more discrete and specific concerns such
as performance anxiety. This was reinforced in the text,
which stated that an affected individual generally had
only one social phobia. DSM-III also opined that social
phobia was relatively rare and not typically the source of
great disability.
Liebowitz and colleagues[4] challenged the DSM-III
view of social phobia on several grounds, arguing most
strongly against the APD exclusion. They reasoned that
individuals with widespread interpersonal fears often
suffered from an anxiety (phobic) disorder amenable
to cognitive-behavioral or medication approaches. Fur-
thermore, regardless of the definition, social phobia did
not appear to be rare or associated with only limited
impairment and disability. DSM-III-R[5] expanded the
DSM-III definition of social phobia by creating a “gen-
eralized subtype” for individuals who feared most social
situations. The APD exclusion was removed; individu-
als could meet criteria for both diagnoses. Interestingly,
the generalized subtype has been the more common vari-
ant of social phobia in many clinical settings, and many
clinicians have regarded the comorbid presentation of
social phobia and APD as the most impaired presenta-
tion of social phobia rather than a true manifestation of
two disorders. Although expanding the range of social
phobia, DSM-III-R limited it in another way, namely,
by creating an exclusion for individuals whose social or
performance fears were related to an Axis III disorder,
such as stuttering or a tremor due to Parkinson’s disease.
DSM-IV[6] added “SAD” as an alternative name, an is-
sue discussed further below. The DSM-IV Anxiety Dis-
orders Workgroup also recommended changes to the ex-
clusion for individuals whose fears were related to an Axis
III condition, but this recommendation was not accepted
by the DSM-IV leadership group. This exclusion, which
has been modified in DSM-5, is also described below.
The diagnosis of social anxiety in children also under-
went considerable change across editions of the DSM.
In DSM-III and DSM-III-R, socially anxious children
most commonly received a diagnosis of avoidant disor-
der of childhood or adolescence. This diagnostic cat-
egory was eliminated in DSM-IV, reflecting the high
degree of overlap with SAD. DSM-IV also restricted
the diagnosis of SAD to children who are capable of
age-appropriate peer relations who show anxiety in peer
interactions rather than solely when interacting with
adults. Further, DSM-IV stipulated that, unlike adults
with SAD, children did not have to recognize that their
fears were excessive or unreasonable.
THE DSM-5 ANXIETY
SUB-WORKGROUP
The Anxiety Sub-Workgroup addressed a large num-
ber of issues related to the diagnosis of SAD over the
course of its deliberations. In addition to consideration
of each specific criterion, they focused on the name of the
disorder, the advantages and disadvantages of the gener-
alized specifier versus various alternative specifiers, the
relationship between SAD and APD and whether the
two should be retained as separate diagnostic entities in
DSM-5, whether selective mutism (SM) and test anxiety
should be considered variants of SAD, the minimum du-
ration of the disorder, and whether the diagnosis is valid
for children and adolescents and from what age. Many
of these issues are discussed in their 2010 paper[7].
Briefly, with respect to topics not covered further here,
the Anxiety Sub-Workgroup concluded that there was
insufficient evidence to recommend that SAD and APD
be considered a single disorder, although they are highly
overlapping. Of interest is recent research suggesting
that APD may be part of a schizophrenia spectrum.[8,9]
Regarding SM, the Sub-Workgroup also concluded that
it was not possible to state that SM is identical to SAD,
although the two are strongly related. Continuing to
classify SM as a separate disorder could allow for the
diagnosis in a child who does not clearly appear to suf-
fer from SAD, but the Sub-Workgroup acknowledged
that the absence of social anxiety in children with SM
is rare. Conversely, including SM as a young child’s
variant of SAD could lead to the use of more effica-
cious treatments for this behavior. In the end, although
failing to speak in social situations was listed as one
means by which children may express social anxiety in
SAD, SM is classified as a distinct anxiety disorder in
DSM-5. The Sub-Workgroup recommended that test
anxiety be considered as an exemplar of SAD if fear of
negative evaluation by others is the core issue, but it
might be considered a manifestation of generalized anx-
iety disorder if worry about the nonsocial consequences
of failing an examination is more prominent. The Sub-
Workgroup also asserted that SAD is a proper diagnosis
for children, that it can be reliably diagnosed in children
as young as age 6, that the same diagnostic criteria can be
used to identify cases across age groups, and that a min-
imum duration of 6 months, regardless of age, is appro-
priate. Few changes were made in the SAD criteria that
Depression and Anxiety
474 Heimberg et al.
were specific to children. In the remainder of this paper,
we examine (1) the name of the disorder, (2) the role of
fear of negative evaluation in SAD, (3) whether the fear
or anxiety is out of proportion to the actual threat and
the importance of sociocultural context in making that
determination, (4) diagnosis of SAD in the context of a
medical condition, (5) and the specifier issue. We then
consider the clinical implications of changes in DSM-5
related to these issues.
SOCIAL PHOBIA VERSUS SAD:
WHAT IS IN A NAME?
SAD was an alternative name in DSM-IV, but it
has become the primary name in DSM-5. Those of us
involved with the DSM-IV Anxiety Disorders Work-
group were concerned that the label “social phobia”
contributed to the mistaken impression held by many
in mental health and primary care settings that the dis-
order was neither frequent nor impairing.[10] Data were
accumulating that social phobia was rarely brought up by
patients, largely because they feared negative evaluation
by providers[11] and that it was just as rarely recognized
by providers who apparently did not consider it suffi-
ciently important unless accompanied by other problems
such as depression or substance use.[12–14] In 2000, we[10]
recommended making SAD the primary name because
it more strongly conveys the sense of pervasiveness and
impairment than does social phobia, it has no histori-
cal baggage to suggest that the disorder is unimportant,
and it is better differentiated from specific phobia. The
DSM-5 Anxiety Sub-Workgroup expressed similar sen-
timents in its 2010 paper.[7] However, until recently,
there were no data to empirically tip the scales in either
direction.
In 2012, Bruce and colleagues conducted a study
of whether the name of the disorder influenced per-
ceived need for treatment in a sample of 806 commu-
nity residents.[15] Respondents heard a brief vignette
describing a person who experiences discomfort in social
situations and often avoids social events. These symp-
toms were labeled as either social phobia or SAD, and
respondents indicated whether the person should seek
treatment. The percentage of respondents recommend-
ing the person seek treatment was larger if the symptoms
were labeled as SAD rather than social phobia. Of course,
there is much room for further study of this issue, and
it is especially needed in samples of mental health and
primary care service providers.
THE ACKNOWLEDGED ROLE OF
FEAR OF NEGATIVE
EVALUATION IN SAD
In earlier editions of the DSM, the primary fear in
SAD was that the person would act in a way or show
anxiety symptoms that would be humiliating or embar-
rassing. In DSM-5, this criterion has been substantially
broadened: “The individual fears that he or she will act in
a way or show anxiety symptoms that will be negatively
evaluated (i.e., will be humiliating or embarrassing; will
lead to rejection or offend others)” [1, p. 202]. This is a
significant change. However, it is unclear whether it will
lead to the identification of new cases of SAD or whether
it will simply bring the criteria more in line with the un-
derstanding of SAD that has developed since the initial
work of Marks and Gelder,[2] as represented in several
prominent models of SAD.[16–19]
The focus on humiliation and embarrassment was sim-
ply too narrow. Clearly, humiliation and embarrassment
are significant concerns for many persons with SAD,
but not in every case. Fear of rejection, as well as fear
of offending others, can be central concerns, leading to
substantial distress and avoidance, and thus functional
impairment, in the absence of humiliation and embar-
rassment. A few examples related to fear of negative eval-
uation or rejection may make the point (fear of offend-
ing others is discussed in the following section). What
better way to invoke negative evaluation from others
than to become highly angry toward them? Erwin and
colleagues[20] demonstrated that persons with SAD were
angrier than nonanxious controls. They were also much
more likely to suppress the expression of anger toward
others, and anger suppression was correlated with fear
of negative evaluation. In another study,[21] participants
high in social anxiety reported greater ambivalence about
emotional expression and more negative beliefs about
emotional expression than less anxious persons. Believ-
ing that emotional expression is a sign of weakness and
will be met with social rejection partially mediated the
association between social anxiety and emotional sup-
pression. Being humiliated or embarrassed may be an
important part of SAD, but it is not the only part.
FEAR OR ANXIETY IS OUT OF
PROPORTION TO THE ACTUAL
THREAT AND THE
SOCIOCULTURAL CONTEXT
DSM-IV stated that the person must recognize that
the fear is excessive or unreasonable. In DSM-5, the cri-
terion is tied to the judgment of the clinician rather
than that of the patient based on the well-replicated
findings that socially anxious individuals underestimate
the quality of their behavioral performance and over-
estimate the likelihood of negative outcomes in social
situations.[22–24] Because the judgment of the clinician
rather than the patient is emphasized, the statement that
children need not recognize their fears as excessive or
unreasonable was removed. However, whether the fear
or anxiety is, indeed, disproportionate to the actual risk
may be difficult to determine. DSM-5 recommends that
“the individual’s sociocultural context needs to be taken
into account when this judgment is being made. For ex-
ample, in certain cultures, behavior that might otherwise
appear socially anxious may be considered appropriate in
Depression and Anxiety
Review: Social Anxiety Disorder in DSM-5 475
certain social situations (e.g., might be a sign of respect)”
[1, p. 204]. DSM-5 [1, p. 749] further states:
Culture refers to systems of knowledge, concepts,
rules, and practices that are learned and transmit-
ted across generations. Culture includes language,
religion and spirituality, family structures, life-cycle
stages, ceremonial rituals, and customs, as well as
moral and legal systems. Cultures are open, dynamic
systems, that undergo continuous change over time;
in the contemporary world, most individuals and
groups are exposed to multiple cultures, which they
use to fashion their own identities and make sense of
experience. These features of culture make it crucial
not to overgeneralize cultural information or stereo-
type groups in terms of fixed cultural traits.
Culture differs from race, which distinguishes groups
based on various superficial physical attributes, and eth-
nicity, which distinguishes groups based on shared char-
acteristics, such as a common history, geography, lan-
guage, or religion. DSM-5 describes cultural syndromes
(clusters or groups of co-occurring and relatively invari-
ant symptoms specific to a particular culture) as one ex-
ample of how culture influences the presentation and
course of DSM disorders (also see the work of Hinton
and colleagues[25] on how cultural syndromes specifi-
cally influence the anxiety disorders). DSM-5 discusses
taijin kyofusho (TKS), believed to be particularly preva-
lent in Japanese and Korean cultures, as an example of
a cultural syndrome [1, p. 205]. In contrast to SAD as
typically expressed in Western cultures, which is char-
acterized by fear of embarrassing oneself, a person with
TKS is concerned about doing something, or presenting
an appearance, that will offend or embarrass the other
person.[26–30] An example of this so-called offensive sub-
type of TKS may be a person who fears that he or she
would offend others by emitting offensive odors, blush-
ing, staring inappropriately, and presenting an improper
facial expression or physical deformity.[26] Some forms
of TKS are more closely associated with delusional dis-
order and body dysmorphic disorder.[1] However, char-
acteristics of the offensive subtype of TKS are common
among patients with SAD in the United States as well
as those from East Asia,[27] a finding which provided an
important impetus for the inclusion of fear of offending
others in the DSM-5 criteria for SAD.
Of particular relevance to TKS and other cul-
tural syndromes described in DSM-5 is individualism/
collectivism, which describes the relationship between
members of social organizations. In collectivistic cul-
tures, group harmony is the highest priority and
individual gain is considered less important than
improvement of the broader social group, whereas
in individualistic societies, individual achievements,
and success receive the greatest reward and social
admiration.[31,32] For example, in Asia, South America,
the Pacific Islands, and southern European countries,
strict social rules dictate what behavior is appropriate
in certain social situations.[33] Individuals who deviate
from social rules are threatened with sanctions, such as
exclusion from the group. Therefore, it is important for
individuals in such countries that their social behavior be
evaluated as appropriate and positive.[34] Thus, it is pos-
sible that the match between a person’s cultural orien-
tation and cultural norms contributes to SAD and other
emotional disorders.[35]
Our review of sociocultural issues is of necessity brief,
and TKS and individualism/collectivism are presented
as examples only. However, it is important to emphasize
that cultural differences might help explain the differ-
ences in prevalence and expression of social anxiety/SAD
in different countries as well as within different cultural
groups within the same country. Asian samples typically
show the lowest rates, whereas Russian and United States
samples show the highest rates, of SAD.[35]
SAD IN THE CONTEXT OF A
MEDICAL CONDITION
An important boundary issue involves how to distin-
guish SAD from social anxiety symptoms that are a con-
sequence of a medical disorder. Medical disorders such
as hyperhidrosis or essential tremor cause symptoms that
are also common in SAD and may trigger fears of nega-
tive evaluation. Other medical conditions, such as obe-
sity or facial disfigurement, may draw unwanted scrutiny
from others and lead to embarrassment and social
avoidance.
Prior criteria conservatively restricted the diagnosis
of SAD to persons whose symptoms could not be at-
tributed to another psychiatric or medical condition.
Furthermore, the social fears were required to be un-
related to the other condition (e.g., not fear of tremor
in Parkinson’s disease). The objective was to maintain a
relatively homogeneous category of SAD, because so-
cial anxiety secondary to other conditions might dif-
fer in symptom profile, pathophysiology, demographics,
course, and treatment outcome (personal communica-
tion, Robert Spitzer).
DSM-5 retains many of these comorbidity exclusions
but allows the diagnosis of SAD in the presence of an-
other medical condition when the social fear, anxiety,
or avoidance is unrelated to the medical disorder or “is
excessive” [1, p. 203]. The intention of this change is
to recognize that social anxiety secondary to a medical
condition, but with severity beyond the usual fear, anxi-
ety, and avoidance experienced by most persons with the
medical condition, deserves clinical and research atten-
tion and that persons with secondary social anxiety may
benefit from treatments developed for SAD.[7]
In an early study in a speech disorders clinic sample,
Stein et al.[36] found that social anxiety was not an in-
evitable consequence of stuttering and severity of social
anxiety was unrelated to the severity of stuttering. Subse-
quent research, reviewed by Iverach and colleagues,[37]
has come to the consensus that, in a subset of persons
Depression and Anxiety
476 Heimberg et al.
with stuttering, social anxiety is clinically significant and
impairing, and in such cases, a specific focus on treat-
ing the social anxiety may be beneficial. Similar find-
ings have been reported for Parkinson’s disease,[38]
hyperhidrosis,[39] hyperkinesias,[40] obesity,[41] essential
tremors,[42] and psoriasis.[43]
SUBTYPE OR SPECIFIER:
CHANGES IN THE WAY WE
THINK ABOUT VARIATIONS
IN SAD
DSM-5 includes a new specifier, performance only, ap-
plied if the fear is restricted to speaking or performing in
public. It replaces the DSM-IV generalized specifier (also
known as the generalized subtype). This change elicited
more debate within the Anxiety Sub-Workgroup than
any other change proposed for SAD. Central to the de-
bate was whether or not the DSM-IV generalized spec-
ifier, which simply stated that the individual fears “most
social situations,” was adequately operationalized for use
in research and clinical practice and whether a more pre-
cise specifier should be substituted.
The generalized specifier focuses on quantity rather
than content (i.e., most social situations, as defined in
DSM-IV). However, there was concern that different re-
search groups were using different cutoffs for what con-
stitutes “most” social situations. Furthermore, research
in this area (see[7] for a review; [44–46]) converges on the
conclusion that a dimensional severity scale or a simple
count of the number of situations feared captures the
heterogeneity of subgroups of patients with SAD better
than the categorical (generalized/nongeneralized) spec-
ifier, suggesting that the intent of the generalized spec-
ifier would be better operationalized by the use of a
dimensional severity measure. It was also noted that
some investigators made distinctions based on type of
feared situation, such as anxiety limited to public speak-
ing versus social interaction anxiety, which may have
merit but which may also result in confusion in research.
Consensus for an improved description or operational-
ization of the generalized specifier could not be reached,
which led to the search for an alternative.
The majority of Sub-Workgroup members expressed
the idea that it would be easier to reliably decide on
what constitutes a more limited variant of SAD. The
creation of the performance-only specifier is supported
by evidence that patients who suffer exclusively from per-
formance fears (e.g., certain musicians, individuals who
speak publicly on the job or give presentations in classes
or meetings) appear to be a distinct group. Epidemiolog-
ical studies also indicate that some individuals who meet
criteria for SAD report only performance fears.[44,47,48]
Other studies, however, question the existence of this
subtype in clinical samples.[49] Some studies suggest
that individuals who report performance-only fears are
more likely to display heightened physiological response
(i.e., higher heart rate) when confronted with the feared
situation relative to other individuals with SAD,[50–52 ]
although this observation arises from a relatively small
set of studies. Furthermore, compared to more perva-
sive social anxiety, performance-only social anxiety has
not been shown to have a genetic basis, has a later
age-of-onset, and is less strongly related to personality
characteristics such as shyness or behavioral inhibition.
Moreover, some patients with performance-only so-
cial fears respond to beta-adrenergic blocking agents,
whereas patients with other types of SAD do not.[7,53]
CLINICAL IMPLICATIONS
Although the DSM-5 does not provide specific treat-
ment guidelines, there are clinical implications attached
to the changes in the criteria for SAD. To begin, the
move to the primary name SAD may raise awareness
of the seriousness of the disorder among both patients
and providers, making it easier for patients to discuss
their concerns and more likely that providers will ask
about it. The broader focus on fear of negative evalua-
tion rather than the previous more narrow focus on hu-
miliation and embarrassment may capture a larger group
of patients who may benefit from evidence-based treat-
ments for SAD.
The criterion shift away from patient recognition that
the fear is excessive or unreasonable to the judgment of
the clinician that the fear or anxiety is out of proportion
to the actual threat can have a number of potentially
positive consequences. Because patients tend to under-
estimate the quality of their social behavior and overes-
timate the likelihood and severity of negative social con-
sequences, the clinician is better situated to make this
judgment. However, the clinician should be informed
by this shift that sole reliance on patients’ report of how
they performed or how others reacted to them in a so-
cial situation may be a poor choice and should be sup-
plemented by other assessment methods. Utilization of
informants if available or behavioral tests in which the
specific behaviors in question can be sampled[54] can con-
textualize patient report and help the clinician to deter-
mine whether a greater or lesser emphasis on shaping
cognitions or behavior is indicated. It is worth noting,
however, that the previous requirement that the patient
judge his or her fear to be excessive or unreasonable was
intended to discriminate between patients with SAD ver-
sus those with psychotic disorders such as paranoia. The
DSM-5 Anxiety Sub-Workgroup concluded that it may
not be necessary to make these disorders mutually ex-
clusive because psychotic patients with a comorbid di-
agnosis of SAD may benefit from the treatment of their
social anxiety.[7] However, this might still make us wary
of the paranoid patient who appears to the clinician to be
overly anxious about others’ opinions when the patient
does not feel that way at all.
DSM-5 emphasizes that cultural and contextual fac-
tors must be considered when determining the de-
gree to which an individual overestimates the threat of
a stimulus, recognizing that social anxiety can be an
Depression and Anxiety
Review: Social Anxiety Disorder in DSM-5 477
appropriate emotional response, that social reticence can
be an appropriate behavioral response, and that neither
automatically indicates a mental disorder or requires in-
tervention. Most importantly, the clinical relevance of
patterns of behavior, cognition, and emotion displayed
by an individual person must be evaluated in context. An
important corollary is that individuals who live in mul-
tiple cultures (e.g., immigrant persons who interact at
some times within their local immigrant communities
and at other times in the larger culturally different com-
munity) may have troubling symptoms of social anxiety
in some circumstances but not in others.
An important change is the removal of the exclusion
when the person’s fears are related to a medical disorder,
and this change will potentially result in the increased
recognition of SAD as a treatment target. This impact
may be most noticeable in nonpsychiatric medical set-
tings (e.g., a movement disorders clinic). A challenge
for clinicians working in these settings will be to deter-
mine when social anxiety symptoms are “excessive” for a
given medical condition. In the absence of objective in-
formation, patient distress and impairment from social
anxiety symptoms should be considered. Treatment of
SAD should be considered particularly when the under-
lying condition cannot be adequately treated. Additional
research will help clarify whether and how the underly-
ing condition will alter the approach to the treatment of
SAD for this population.
DSM-5 replaced the generalized specifier from
DSM-IV with the performance-only specifier. Whether
the performance-only specifier will be easier to opera-
tionally define and more helpful for treatment planning
remains to be seen. Accumulating research indicates that
this specifier is not highly prevalent in the general popu-
lation, and particularly in the treatment-seeking popula-
tion, thus calling its clinical utility into question.[49,55,56]
There is also little research as yet on the relative
efficacy of different psychological and pharmacological
interventions for SAD with and without the
performance-only specifier,[57] although it is likely
that such research will be forthcoming and may
ultimately tell us whether the new specifier is an
improvement over prior efforts.
A minority of the Sub-Workgroup and advisors ex-
pressed significant concerns about the performance-only
specifier, only some of which are noted here. Concerns
were raised that changing specifiers would require clini-
cians to adapt to the changing labels, and this might lead
to confusion about the proper medication for a particu-
lar patient. Also, it is not clear whether the patient group
designated by the generalized specifier in DSM-IV is the
same patient group who would not meet criteria for the
DSM-5 performance-only specifier, which may accen-
tuate confusion in referencing the extant treatment lit-
erature. Finally, concern was expressed that, in focusing
on the new specifier, clinicians may overlook nonperfor-
mance (other) social fears in patients who present with
predominantly performance fears. This is a serious con-
cern as patients with SAD may present with performance
fears initially because of fear that telling the provider of
more pervasive social fears will be judged negatively.
CONCLUDING COMMENTS
With the publication of DSM-5, a number of changes
have been made to the way we define SAD. It is rec-
ognized that the typical person in clinical settings with
SAD has multiple social fears and is broadly impaired,
although there may be patients who fear only speaking or
performing in public. It is acknowledged that SAD is not
only about humiliation and embarrassment, but other
social consequences, such as rejection by others, may be
feared as well. The importance of cultural considerations
has been emphasized, and this is particularly important
since SAD and culture are essentially social phenom-
ena. It is now recognized that social anxiety secondary
to another medical condition can be very disabling in its
own right, and affected persons may now receive the di-
agnosis. We believe that these changes have significant
clinical implications, and we will see whether that is true
in the months and years to come.
Conflict of interest.Dr. Schneier reports personal
fees from GlaxoSmithKline, outside the submitted work;
Dr. Craske reports grants from NIH, NIMH, other from
Oxford University Press, other from APA Books, outside
the submitted work; Dr. Hofmann reports grants from
NIH, other from Journal and book publishers, outside
the submitted work; Dr. Stein reports a patent use of
5HTTLPR genotyping to identify patients with social
phobia likely to respond to SSRIs issued. None of the
other authors have any specific disclosures to make.
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