What are the diagnostic criteria for social anxiety disorder in adolescents and young adults?

Diagnostic Criteria for Social Anxiety Disorder

Social anxiety disorder is characterized by marked, persistent fear of social or performance situations involving unfamiliar people or possible scrutiny by others, with fears of acting in humiliating or embarrassing ways during social exposure, and recognition that the fear is excessive or unreasonable. 1

Core Diagnostic Requirements

The diagnosis requires meeting specific DSM-5 criteria that distinguish pathological anxiety from normal developmental concerns:

• Excessive fear or worry about being negatively evaluated by others in social situations must be present, causing the individual to fear they will act in ways that are humiliating or embarrassing 2

• The fear must be out of proportion to the actual threat posed by the social situation and developmentally inappropriate for the patient's age 1

• Duration of at least 6 months is required for diagnosis in adolescents and adults, ensuring symptoms are persistent rather than transient 1

• Clinically significant distress or functional impairment in social, academic, or occupational functioning must be present—normal social concerns without impairment do not qualify for diagnosis 1, 3

• The phobic social situations almost invariably provoke immediate fear or anxiety response, leading to active avoidance or endurance with intense distress 1

Distinguishing Features in Adolescents and Young Adults

Social anxiety presents with age-specific characteristics that must be recognized:

• Fear of negative evaluation by peers is particularly prominent in adolescents, often manifesting as avoidance of social situations with unfamiliar people 3

• Social and existential concerns are developmentally typical for adolescents but become pathological when excessive, persistent, and impairing 2, 3

• The disorder may present as selective mutism in younger adolescents, characterized by absence of speech in certain social situations despite presence of speech at home 2, 3

• Adolescents with social anxiety disorder demonstrate stable and high levels of self-reported arousal during social interactions, even when physiological habituation occurs 2

Critical Exclusion Criteria

Before confirming the diagnosis, systematically rule out alternative explanations:

• Medical conditions that mimic anxiety symptoms must be excluded, including hyperthyroidism, hypoglycemia, cardiac arrhythmias, and caffeine excess 1, 4

• Substance/medication-induced anxiety must be ruled out, including effects from stimulants, caffeine, illicit drugs, or alcohol withdrawal 1

• Other mental disorders that better explain the presentation must be excluded, particularly generalized anxiety disorder (which lacks the specific social focus), panic disorder, and depression 1, 4

• Normal developmental fears common in adolescence (such as age-appropriate social concerns) must be distinguished from pathological anxiety by assessing whether functional impairment is present 2, 1

Assessment Approach

The diagnostic evaluation requires a multi-faceted, developmentally sensitive approach:

• Multi-informant assessment is essential, obtaining reports from the adolescent, parents, and teachers to capture context-specific manifestations of anxiety 3

• Structured diagnostic interviews should be conducted separately with the patient and parents/guardians, using developmentally appropriate techniques including direct questioning, symptom rating scales, and behavioral observations 2

• Screening tools such as the GAD-7 (for patients ≥8 years) and SCARED can identify cases requiring comprehensive diagnostic evaluation, with GAD-7 scores ≥10 indicating moderate to severe anxiety 1, 3

• Collateral information from teachers, primary care clinicians, and other sources adds depth to diagnostic assessment, particularly regarding context-specific symptoms 2

• Assessment should be conducted in the patient's preferred language to avoid misdiagnosis associated with language barriers 2

Common Diagnostic Pitfalls

Several critical errors must be avoided:

• Dismissing symptoms as "just teenage drama" when functional impairment is actually present—social anxiety causes declining academic performance, withdrawal from peer relationships, and interference with family functioning 3

• Missing medical mimics such as hyperthyroidism, hypoglycemia, and cardiac conditions that present with anxiety-like symptoms 3, 4

• Overlooking comorbidities including depression (present in approximately one-third of cases), other anxiety disorders, ADHD, eating disorders, and substance use as self-medication 2, 1, 3

• Relying solely on observable signs rather than conducting thorough interviews about internal experiences of fear and worry 3

• Failing to assess for trauma history, particularly sexual harassment or assault, which commonly underlies anxiety presentations especially in young women 4

Red Flags Requiring Immediate Attention

Certain presentations demand urgent intervention:

• Suicidal ideation or self-harm behaviors require immediate safety assessment and intervention 3, 4

• Severe agitation or psychotic symptoms accompanying anxiety 3

• Comorbid depression, which significantly increases suicide risk, particularly when combined with generalized anxiety 3, 4

• Substance use as self-medication for anxiety symptoms 3