Epidemiology, genetics, neuroimaging, clinical features, and treatment between overall and performance-only social anxiety disorder: a narrative review.

Social anxiety disorder (SAD) is a common psychiatric condition marked by a significant fear of social evaluation. To better identify a meaningful subgroup, the DSM-5 introduced a "performance-only" specifier, replacing the generalised specifier in the DSM-IV. We conducted a narrative review comparing overall SAD (including generalised and performance-only forms) and performance-only SAD across epidemiology, genetics, neuroimaging, clinical characteristics, and treatment. Overall SAD affects 5-13% of the population, whereas performance-only SAD has been reported in about 0.3-0.7%. Overall SAD typically emerges in early adolescence and is more prevalent among females, whereas performance-only SAD tends to begin in mid-adolescence and is relatively more prevalent among males. Family studies indicate stronger familial aggregation in overall SAD, suggesting greater genetic contribution compared with performance-only SAD, although direct heritability estimates for the latter remain limited. Neuroimaging studies of overall SAD reveal alterations in fronto-limbic and default mode networks, whereas neurobiological data on performance-only SAD are limited and suggest more localised, context-dependent neural responses. Clinically, performance-only SAD is linked to fewer psychiatric comorbidities, less functional impairment, and higher socioeconomic status. Treatments for overall SAD typically include CBT and pharmacotherapy, such as SSRIs or SNRIs. In contrast, performance-only SAD is commonly managed with exposure-based CBT and, in some cases, beta-blockers for situational symptom relief. These findings suggest that performance-only SAD may represent a distinct subtype within the SAD spectrum, although empirical research on this specifier remains limited.