Update on the diagnosis and treatment of social anxiety disorder.

Social anxiety disorder is characterized by marked fear of performance, excessive fear of scrutiny, and fear of acting in a way that will be embarrassing. Although the incidence of social anxiety disorder is approximately 13%, this disorder has been termed "the neglected anxiety disorder" because it is often missed as a diagnosis. Social anxiety disorder has an early onset in most patients and tends to manifest during adolescence. However, many patients do not receive therapy until a comorbid disorder (e.g., panic) is diagnosed later in life. There are 2 distinct subtypes of social anxiety disorder, generalized and nongeneralized, that differ in terms of symptoms, course of illness, morbidity, pathophysiology, and response to treatment. Both pharmacologic and psychotherapeutic treatments are effective, and the 2 modalities have complementary strengths. The selective serotonin reuptake inhibitors may be considered first-line therapy for the generalized subtype of social anxiety disorder because of proved efficacy and well-tolerated adverse effect profiles. Other agents may be useful for treatment-refractory patients. However, there is a substantial rate of relapse even after prolonged treatment. There is evidence that patients who receive cognitive-behavioral therapy may have lower rates of relapse. Early and aggressive treatment of social anxiety disorder may prevent development of comorbid disorders and can substantially improve patients' quality of life.