The essential feature of social anxiety disorder is a marked, or intense, fear or anxiety of social
situations in which the individual may be scrutinized by others. In children the fear or
anxiety must occur in peer settings and not just during interactions with adults (Criterion
A). When exposed to such social situations, the individual fears that he or she will be negatively
evaluated. The individual is concerned that he or she will be judged as anxious,
weak, crazy, stupid, boring, intimidating, dirty, or unlikable. The individual fears that
he or she will act or appear in a certain way or show anxiety symptoms, such as blushing,
trembling, sweating, stumbling over one’s words, or staring, that will be negatively evaluated
by others (Criterion B). Some individuals fear offending others or being rejected as
a result. Fear of offending others—for example, by a gaze or by showing anxiety symptoms—
may be the predominant fear in individuals from cultures with strong collectivistic
orientations. An individual with fear of trembling of the hands may avoid drinking, eating,
writing, or pointing in public; an individual with fear of sweating may avoid shaking
hands or eating spicy foods; and an individual with fear of blushing may avoid public performance,
bright lights, or discussion about intimate topics. Some individuals fear and
avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or
“shy bladder syndrome”).
The social situations almost always provoke fear or anxiety (Criterion C). Thus, an individual
who becomes anxious only occasionally in the social situation(s) would not be diagnosed
with social anxiety disorder. However, the degree and type of fear and anxiety
may vary (e.g., anticipatory anxiety, a panic attack) across different occasions. The anticipatory
anxiety may occur sometimes far in advance of upcoming situations (e.g., worrying
every day for weeks before attending a social event, repeating a speech for days in advance).
In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, or
shrinking in social situations. The individual will often avoid the feared social situations.
Alternatively, the situations are endured with intense fear or anxiety (Criterion D). Avoidance can be extensive (e.g., not going to parties, refusing school) or subtle (e.g., overpreparing
the text of a speech, diverting attention to others, limiting eye contact).
The fear or anxiety is judged to be out of proportion to the actual risk of being negatively
evaluated or to the consequences of such negative evaluation (Criterion E). Sometimes,
the anxiety may not be judged to be excessive, because it is related to an actual
danger (e.g., being bullied or tormented by others). However, individuals with social anxiety
disorder often overestimate the negative consequences of social situations, and thus
the judgment of being out of proportion is made by the clinician. The individual’s sociocultural
context needs to be taken into account when this judgment is being made. For example,
in certain cultures, behavior that might otherwise appear socially anxious may be
considered appropriate in social situations (e.g., might be seen as a sign of respect).
The duration of the disturbance is typically at least 6 months (Criterion F). This duration
threshold helps distinguish the disorder from transient social fears that are common,
particularly among children and in the community. However, the duration criterion
should be used as a general guide, with allowance for some degree of flexibility. The fear,
anxiety, and avoidance must interfere significantly with the individual’s normal routine,
occupational or academic functioning, or social activities or relationships, or must cause
clinically significant distress or impairment in social, occupational, or other important areas
of functioning (Criterion G). For example, an individual who is afraid to speak in public
would not receive a diagnosis of social anxiety disorder if this activity is not routinely
encountered on the job or in classroom work, and if the individual is not significantly distressed
about it. However, if the individual avoids, or is passed over for, the job or education
he or she really wants because of social anxiety symptoms, Criterion G is met.