Individuals with social anxiety disorder may be inadequately assertive or excessively sub- missive or, less commonly, highly controlling of the conversation. They may show overly rigid body posture or inadequate eye contact, or speak with an overly soft voice. These in— dividuals may be shy or withdrawn, and they may be less open in conversations and dis- close little about themselves. They may seek employment in jobs that do not require social contact, although this is not the case for individuals with social anxiety disorder, perfor- mance only. They may live at home longer. Men may be delayed in marrying and having a family, Whereas women who would want to work outside the home may live a life as homemaker and mother. Self—medication with substances is common (e.g., drinking be- fore going to a party). Social anxiety among older adults may also include exacerbation of symptoms of medical illnesses, such as increased tremor or tachycardia. Blushing is a hall- mark physical response of social anxiety disorder.
The 12-month prevalence estimate of social anxiety disorder for the United States is ap- proximately 7%. Lower 12-month prevalence estimates are seen in much of the world us- ing the same diagnostic instrument, clustering around 0.5%—2.0%,' median prevalence in
Europe is 2.3%. The 12-month prevalence rates in children and adolescents are comparable to those in adults. Prevalence rates decrease with age. The 12-month prevalence for older adults ranges from 2% to 5%. In general, higher rates of social anxiety disorder are found in females than in males in the general population (with odds ratios ranging from 1.5 to 2.2), and the gender difference in prevalence is more pronounced in adolescents and young adults. Gender rates are equivalent or slightly higher for males in clinical samples, and it is assumed that gender roles and social expectations play a significant role in ex- plaining the heightened help-seeking behavior in male patients. Prevalence in the United
States is higher in American Indians and lower in persons of Asian, Latino, African Amer- ican, and Afro-Caribbean descent compared with non-Hispanic whites.
Median age at Onset of social anxiety disorder in the United States is 13 years, and 75% of individuals have an age at onset between 8 and 15 years. The disorder sometimes emerges out of a childhood history of social inhibition or shyness in US. and European studies. On- set can also occur in early childhood. Onset of social anxiety disorder may follow a stress- ful or humiliating experience (e.g., being bullied, vomiting during a public speech), or it may be insidious, developing slowly. First onset in adulthood is relatively rare and is more likely to occur after a stressful or humiliating event or after life changes that require new social roles (e.g., marrying someone from a different social class, receiving a job promo- tion). Social anxiety disorder may diminish after an individual with fear of dating marries and may reemerge after divorce. Among individuals presenting to clinical care, the disor— der tends to be particularly persistent.
Adolescents endorse a broader pattern of fear and avoidance, including of dating, compared with younger children. Older adults express social anxiety at lower levels but across a broader range of situations, whereas younger adults express higher levels of so- cial anxiety for specific situations. In older adults, social anxiety may concern disability due to declining sensory functioning (hearing, vision) or embarrassment about one’s ap- pearance (e.g., tremor as a symptom of Parkinson’s disease) or functioning due to medical conditions, incontinence, or cognitive impairment (e.g., forgetting people’s names). In the community approximately 30% of individuals with social anxiety disorder experience re- mission of symptoms within 1 year, and about 50% experience remission within a few years. For approximately 60% of individuals without a specific treatment for social anxiety disorder, the course takes several years or longer.