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Social Anxiety Disorder

Imagine being paralyzed with fear in social situations. Your throat closes up, your heart races. Whether you are at a party, eating lunch, or giving a presentation, you feel as if all eyes are on you, scrutinizing every word and action, waiting to judge any mistake. At its worst, social anxiety can lead to panic attacks and overwhelming feelings of doom that lead people to quickly sequester themselves for fear of others seeing.

To the untrained eye, Social Anxiety Disorder appears like extreme shyness. In a social environment, people with Social Anxiety may appear tense, often with trembling hands which they try to hide from others’ view. They may stumble over their words, speak in soft tones, and avoid eye contact. People also sweat more (those with sweaty palms avoid shaking hands), blush, and avoid using public restrooms (this alone can be a major impediment to going out in public).

They attempt to avoid meeting new people and being in groups, even with people they already know. Children with social anxiety may freeze or hide in social situations and cling to their caregivers for support. Refusal to attend school is a hallmark for children with this disorder.

Social Anxiety Disorder often prevents people from starting relationships. They have trouble approaching others for whom they have romantic feelings. They also delay moving out of their parents’ home and tend to get married later.

They can also suffer significant anxiety leading up to social events that they can’t avoid, and those with performance-specific anxiety will agonize over every detail of their presentations. Performance anxiety can even apply to eating, drinking, test-taking, meeting authority figures, and job interviews, any situation in which the person feels under scrutiny. They avoid jobs that require much social interaction, and, if they have a financially supportive spouse, they may avoid employment altogether.

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Causes and Risk Factors

More common than you think

SAD is the third most common mental health disorder in the United States (after Major Depressive Disorder and the Substance Use Disorders), with a lifetime prevalence of roughly 12%.

Early onset

Social anxiety tends to start early, appearing in over half of would-be patients by age 11 and in over 80% by age 20. People with Social Anxiety Disorder tend to have a history of severe shyness in childhood and were more often victims of significant bullying and harsh social rejection.

Family trends

First degree relatives of people with Social Anxiety Disorder have a 2-6 times greater risk than average of also developing the disorder. A large study of roughly 1,700 participants estimated that social anxiety is about 50% heritable. However, smaller studies have only shown heritability to be based on a general personality trait (neuroticism, a risk factor for all anxiety disorders) and not specifically social anxiety.

Social anxiety and alcohol

Alcohol Use Disorder strikes one in five people with Social Anxiety Disorder. Alcohol reduces anxiety for patients during social situations. But this isn’t necessarily all due to the effects of alcohol. In fact, there is a significant placebo effect where patients expect that alcohol will decrease their tension and anxiety and increase their ability to be outgoing and socialize.

Tumultuous childhood

Traumatic childhood events like separation from either parent, marital problems between parents, and violence committed by family members increase the risk of developing Social Anxiety Disorder. Compared to the rest of the population, adults with Social Anxiety Disorder rated their parents as having been more emotionally cold and controlling and having administered punishments more frequently and more severely.

Brain wiring

Brain imaging of people with Social Anxiety Disorder has demonstrated significantly elevated activity in the brain area that processes fear (the amygdala) when viewing unfamiliar, emotionally expressive faces. Furthermore, the orbitofrontal cortex, which normally manages the brain’s fear assessments and determine the appropriate threat responses, has reduced connectivity with the amygdala. In short, their brains overreact in social situations and perceive danger where none is present.

Diagnosing Social Anxiety Disorder

Making the diagnosis

Social Anxiety Disorder is a paralyzing fear of any social situation in which the person interacts with or performs in front of others. In these situations, people’s minds are filled with frequent, paranoid thoughts about others judging them. In children, the anxiety must occur in the presence of similarly aged peers and not only with adults.

People with Social Anxiety Disorder are very self-conscious of their anxiety. They are typically nervous that any outward display of their anxiety will lead to ridicule by observers. Even though they know their anxiety is unnecessary, they continue to overestimate the amount of rejection they will encounter if others notice it.

Social encounters almost always produce anxiety, so they will go to great lengths to avoid them. The level of anxiety is significantly greater than is appropriate for the given situation. Additionally, it significantly interferes with functioning in school, work, and social situations. Symptoms last for at least 6 months.

Other possibilities

Many other disorders, such as Eating Disorders, Panic Disorder, and Developmental Disorders (autism, for example), can have social anxiety as a component and must be differentiated from Social Anxiety Disorder. Outwardly disfiguring medical conditions can also cause self-seclusion and can appear like social anxiety. However, the difference is that the embarrassment in social anxiety is far greater than would be expected.

Use of stimulants, such as amphetamines and cocaine, can cause social anxiety and paranoia both during immediate intoxication and as long-term effects, which can be mistaken for new-onset social anxiety. Some people with social anxiety only suffer from performance anxiety, where the only situations that cause anxiety are those involving speaking, presenting, or performing in front of an audience. These people do not have symptoms in other social situations and tend to be less severely impacted by the disorder.

Treating Social Anxiety Disorder

Cognitive Behavioral Therapy

Exposure-based CBT is the primary form of psychotherapy for Social Anxiety Disorder. First, the patients make lists of anxiety-provoking situations of increasing severity. Then, with the aid of the therapist, they face and engage in those experiences. By staying in the feared place long enough (this time is different across individuals) and by gradually increasing the levels of anxiety, people learn new responses that are not fear-based.

CBT also involves cognitive restructuring, where people identify automatic, negative thoughts about social situations, learn to rationally challenge them, and ultimately replace them with more useful reactions. Patients practice this in the security of a therapy session and then integrate it during the exposures.

Progressive Muscle Relaxation

PMR involves patients learning to identify the physical symptoms of anxiety. They then use focused relaxation of muscle groups to quickly release the physical tension that comes with anxiety. Though PMR by itself is not sufficient treatment for social anxiety, it can be combined with exposure therapy and patients eventually learn to regulate their bodies’ responses in anxiety-provoking situations.

Medications

The primary Food and Drug Administration-approved medications for treating SAD are the SSRIs, Paxil (paroxetine) and Zoloft (sertraline), and the SNRI, Effexor (venlafaxine). Although these medications take a few weeks to start working, they are generally preferable to benzodiazepines (usually, alprazolam and clonazepam). Benzodiazepines can lead to abuse and addiction and should only be prescribed for 6 weeks at most.

People with performance-specific anxiety benefit significantly from propranolol and clonidine, which are blood pressure medications that also inhibit the physical effects of anxiety. By reducing heart rate, tremors, and sweating, these medications enable patients to perform without fear of embarrassment. Furthermore, these medications are only taken as needed before performances, rather than every day like SSRIs.

Managing Social Anxiety Disorder

Don’t fear the treatment

The central part of exposure therapy based CBT is that patients need to actually face their fears. This may sound terrible to someone suffering from social anxiety. However, the key to this treatment is small steps, slowly increasing the exposure to new people and new places.

Preventing alcohol use

The best treatment for coexisting Social Anxiety Disorder and Alcohol Use Disorder includes educational programs about the relationship between the two disorders. CBT also addresses the use of alcohol in social situations as part of exposure therapy. Furthermore, early intervention when social anxiety is developing in adolescence significantly reduces the risk of also developing problems with alcohol.

Missed diagnosis

Because Social Anxiety Disorder tends to start young and the nature of the disorder precludes people from discussing their experience with an authority figure such as a doctor, patients usually do not have an objective view of their situation. When people finally get treatment, they often realize they have been suffering from social anxiety for several years.

Screening tools

If people often describe you as very shy, ask your doctor about Social Anxiety Disorder or take a short quiz which is based on the diagnostic criteria and provided by the Anxiety and Depression Association of America.

Types of Anxiety Disorders

Wondering about a possible disorder but not sure? Let’s explore your symptoms.

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References
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