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Social Anxiety Disorder (SAD)

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Social Anxiety Disorder

Social anxiety is a form of anxiety disorder that leads to severe anxiety, fear and distress in social situations. Individuals with this disorder are afraid that they may be judged and negatively evaluated by others. The condition can impair their ability to function in daily life, if left untreated.

What Is Social Anxiety?

A type of mood and anxiety disorder, social anxiety is also known as social phobia and social anxiety disorder (SAD). It is associated with severe anxiety and fear in social settings, such as public gatherings, meetings, social events, public performances, etc. People suffering from social phobia are always apprehensive about negative scrutiny, public humiliation, attending social events, or forming new relationships. It can manifest itself as anxious and fearful behavior in social settings triggered by excessive fear of humiliation, embarrassment and/or rejection. It can also involve a number of physical and mental symptoms, such as blushing, sweating, shaking, etc.

A 2001 study 1 defines social anxiety as a “marked and persistent fear of social or performance situations” that induces symptoms such as blushing, sweating, palpitations, shaking, and respiratory distress. When forced to participate in a social gathering, a person with SAD will tend to focus their attention on their social phobia instead of socializing with others.

They tend to have a negative perception of themselves when in a social setting, have emotion regulation problems, and believe they lack proper social skills. They may also “overestimate the negative consequences of a social encounter.” One 2007 study states “In order to avoid social mishaps, individuals with SAD revert to maladaptive coping strategies, including avoidance and safety behaviors, followed by post-event rumination, which leads to further social apprehension in the future.”

This distressing & persistent mental illness is often misunderstood and confused with shyness or introverted tendencies. Hence, it remains the most commonly treatable yet underdiagnosed and impairing of anxiety disorders. SAD has a worldwide prevalence of 5 to 10% 2 and a lifetime prevalence of 8.4 to 15%. Women are more commonly affected than men.

Read More About Anxiety Here

Symptoms Of Social Anxiety Disorder (SAD)

Symptoms of Social Anxiety
Social Anxiety Disorder (SAD)

Social anxiety symptoms involve physiological, biological, behavioral, and cognitive signs of severe anxiety and fear. These include:

1. Behavioral Symptoms

Severe anxiety disorders cause its sufferers to be ‘excessively shy’, as well as overtly self-conscious in their personal perception and assessment. They are burdened by dreads of scrutiny, criticism, judgment, and underperformance in distress-inducing social contexts. Because of which, they display the following ‘fight-or-flight’ behavioral symptoms:

  • Avoidance behavior (such as avoiding eye contact, physical contact, making conversation, etc.)
  • Awkward self-presentation
  • Withdrawal
  • Self-isolation
  • Low self-esteem
  • Insecure, nervous, and unconfident behavior
  • Behavioral disruption stemming from sleep deprivation

2. Cognitive Symptoms

The symptoms of social anxiety also involves a number of cognitive distortions, which include the following:

  • Dreading
  • Self-defeating thoughts
  • Harboring self-conscious inferior perceptions
  • Anticipating negative evaluation from others
  • Ambiguous actions
  • Disjointed speech (such as stuttering, mumbling, etc.)
  • Negative interpretations of neutral conversations
  • Awkward self-presentation
  • Harboring feelings of embarrassment, shame, guilt, shyness, and pride
  • Developing psychiatric disorders 3 (such as anxiety-disorders 4, depressive disorders 5, substance-abuse disorders 6, stress disorders 7, avoidant personality disorder 8, etc.)

Read More About Guilt Here

3. Physiological Symptoms

Social phobia induces a fight-or-flight response in its sufferers and this gets manifested into a number of physiological responses. These include:

  • Blushing
  • Excessive sweating
  • Palpitations
  • Nausea
  • Shaking
  • Respiratory distress
  • Panic attacks
  • Fainting
  • Gait abnormality
  • Crying
  • Disjointed speech
  • Comorbidities such as heart diseases, stress-induced physiological disorders, etc.

4. Biological Symptoms

Research 9 has attributed the pathological causes of social phobia to neurotransmitters (such as dopamine, glutamate, serotonin) and increased activity of paralimbic and limbic circuitry. One 2007 meta-analysis 10 states that individuals with SAD have hyperactivation in the amygdala, the dorsal anterior cingulate, and insula areas—which are frequently associated with fear and negative emotional processing.

Social Anxiety vs Panic Attack

The anxiety-related symptoms of social phobia sometimes take the form of a panic attack. However, panic disorders 11 are also characterized by recurrent unexpected panic attacks. In contrast, symptoms of the former can be differentiated by their consistent relation to social cues and are confined to situational encounters 12.

Read More About Panic Disorder Here

Causes Of Social Phobia

Causes of Social Anxiety
Social Anxiety Disorder (SAD)

SAD has been examined from multiple perspectives—ranging from psychiatry and neuroscience to sociology and cultural studies. However, research is yet to uncover its exact causes. However, the factors mentioned below are believed to influence the onset of social fear:

1. Genetics

Like any other ‘learnt’ 13 behavioral disorder, SAD shows great heritability. This behavior can be easily ‘transmitted’ via observational learning or parental psychosocial education. Research 14 shows that a person is at a two- or three-fold greater risk of having social fear if a first-degree relative already has it.

2. Psychological Causes

A person’s temperament may harbor personality and behavioral inhibitions that make him/her prone to social fear and anxiety. One 2007 study 15 states that people who are personality-wise inclined to inhibited shyness, unexpected bursts of emotions, lack of internal control, avoidant behavior, and interpersonal sensitivity are susceptible to SAD. The ones with poor social skills and/or cognitive abilities often experience social phobia as well.

3. Socio-cultural Contexts

First-hand negative social experience or public criticism and humiliation are potential triggers for social fear. This may lead to long-term anticipatory fear before any social event, with self-deprecating thoughts and demoralization in its aftermath. ‘Indirect’ experiences of social problems and dangers, garnered from testimonies or verbal warnings, make it more likely for social phobia to set in.

Experiences of bullying, embarrassment, harassment, and trauma also cause social withdrawal and anxiety. Research 16 shows that peer and parental pressure in children 17 and adolescents 18 cause social phobia. Moreover, cultural norms associated with modesty, avoidance, and social fluency affect socializing abilities and trigger SAD. Emotional abuse involving intimidation, gaslighting, competitive berating, and negative appraisal also cause social phobia.

4. Substance-induced Causes

Habit-forming intoxicants with long-term impact, such as alcohol and recreational drugs, may also cause social withdrawal. Research 19 shows that medical drugs, such as anticonvulsants, tranquilizers 20, prescribed benzodiazepines, etc. cause withdrawal symptoms.

Read More About Addiction Here

Diagnosis Of Social Anxiety

Lack of clearly-defined care pathways and a deficit in understanding the severity and complexities of SAD makes its recognition in children, adults, and the elderly difficult. Other comorbidities also push addressing social phobia to the backseat. Moreover, the service users’ avoidance of talking about the problem and stigma also contribute to its unchecked prevalence.

Addressing SAD involves evidence-based differential diagnosis 21 before undergoing full-fledged treatment strategies. Psychiatrists, psychologists, and general practitioners may examine self-reported data, patient history, symptoms, and other behavioral patterns 22. In clinical practice, assessment of SAD involves instruments such as

  • Social Phobia Inventory (SPIN)
  • Mini-SPIN
  • Liebowitz Social Anxiety Scale (LSAS)
  • Liebowitz Self-Rated Disability Scale
  • Disability Profile
  • Brief Social Phobia Scale (BSPS)
  • Social Phobia Safety Behaviors Scale
  • Self Statements During Public Speaking Scale

Treatment Of Social Anxiety

Social phobia can be treated in a number of ways and some of the most effective treatment approaches are mentioned below –

1. Psychotherapies

Social anxiety therapies are available to help with psychological flexibility and resilience. These include:

1. Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy (CBT) is currently considered the “gold standard” 23 psychological treatment approach for social phobia. For patients suffering from SAD, such a therapy enhances their cognitive reappraisal. Studies show that CBT induces healthy self-focused attention and self-perception and leads to reduction 24 of social withdrawal symptoms 25. About 56% to 95% patients find respite by CBT in SAD, states one 2015 study 26.

Read More About Cognitive Behavioral Therapy (CBT) Here

2. Group therapy

Cognitive behavior group therapy for social phobia (CBGT) is the most validated approach to treating severe social anxiety. It is both an educational and supportive therapy. It enhances social skills while addressing problems faced in socialization by people suffering from SAD. Studies 27 show that 63% of SAD patients respond more to ACT than any other prescribed therapy.

3. Acceptance and commitment therapy (ACT)

Acceptance and commitment therapy (ACT) teaches 28 mindfulness 29 and enables patients to practice self-acceptance and meaningful communication. A 2014 study 30 states that ACT has predicted better outcomes post-treatment in over 39% SAD patients.

4. Social Self-Reappraisal Therapy

Social self-appraisal therapy, much like group therapy, takes place in a group setting. It focuses on addressing issues 31 of social skills and self-perceptions via discussions, video feedback, audio feedback, mirror exposure, and group feedback.

2. Medications

For the treatment of social anxiety disorder, selective serotonin reuptake inhibitors (SSRIs) 32, a second-generation of antidepressants 33, are the first choice 34 of medication. SSRIs like Paroxetine 35 and paroxetine CR, Sertraline, Escitalopram 36, Venlafaxine XR, Fluvoxamine CR (luvox CR) 37, escitalopram, and sertraline are all approved for SAD. Research 38 shows that SSRIs help reduce general anxiety 39, hostility, and frenzied behavior.

In most cases, a combination of psychotherapy and SSRIs are used to treat severe social anxiety.

3. Psychoeducation

Psychoeducation 40 and mental health awareness programs and campaigns should help destigmatize mental health concerns in the long-run and normalize seeking help for any mental disorder, not just SAD.

Myths About Social Anxiety

SAD is an unrecognized and under-diagnosed anxiety disorder, a fact that can be attributed to the misunderstanding surrounding it:

1. SAD Is Not Shyness

Social anxiety is sometimes confused with shyness, introverted personality, or performance anxiety. Yet, the differences lie in the former’s severity and pervasiveness.

The 10th version of the International Classification of Diseases (ICD-10) classifies social phobia as a mental and behavioral disorder. Studies further show that social phobia is far from trivial; it substantially compromises the quality of life of the individuals suffering from it.

2. Sad Is Different From Other Phobias

Social anxiety, though synonymously termed as “social phobia”, should be differentiated from specific phobias like agoraphobia, hydrophobia, and alike. According to a 2003 study 41, differentiation of SAD from other phobic disorders is validated by its characteristic age of onset in the mid-teens and greater ratio of men to women.

Read More About Phobia Here

3. Sad Is Different From Other Mental Disorders

The International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) prescribe specific criteria for the diagnosis of social phobia. SAD must be differentiated from other disorders, such as:

  • Neurodevelopmental disorders
  • Spectrum disorders
  • Panic disorder
  • Phobias
  • Depressive disorders
  • Substance-related and addictive disorders
  • Body dysmorphic disorder
  • Personality disorders, etc.

Read More About Major Depressive Disorder (Depression) Here

4. Social Anxiety Accompany Other Mental Disorders

One 2013 study 42 claims that four-fifths of adults with a primary diagnosis of social anxiety disorder are bound to experience at least one other psychiatric disorder during their life. SAD occurs alongside mental disorders, such as:

  • Anxiety disorders
  • Affective disorders
  • Substance-abuse disorders
  • Nicotine dependence
  • Depressive disorders, etc.

5. The “fear” In Social Anxiety Is Very Distinct

The most common symptom of social anxiety disorder (SAD) is extreme and persistent fear of embarrassment and humiliation while participating in social and public activities. This fear 43 often results in self-defeating thoughts and ambiguous actions, cognitive distortions, and awkward self-presentation. However, this fear must not be attributed to the effects of substance abuse or medical condition or the symptoms of a different mental disorder.

What To Do If You Have Social Phobia

SAD can be effectively tackled by availing the following steps:

  1. Recognize the symptoms of social anxiety disorder (SAD)
  2. Read and be informative about the disorder
  3. Seek therapy and/or medication
  4. Implement healthy self-help coping strategies and focus on mindfulness. These may include:
    1. Participating in small support groups, like clubs, travel groups, support groups, etc.
    2. Volunteering
    3. Practicing small-scale networking to broaden social horizons at a healthy and acceptable pace
    4. Availing stress management techniques, such as yoga 44, meditation 45, deep breathing exercises, muscle relaxation techniques, body scan 46, etc.
    5. Developing leisure activities like journaling, taking long walks, engaging in art 47, taking to a new interactive hobby, etc.
    6. Working 48 on interactive social skills training 49, such as conversation-making, etc.
  5. Practice small-scale socialization to broaden your social horizons at a healthy and acceptable pace
  6. Be patient with yourself in coping with social phobia

Takeaway

Social phobia is a very common behavioral and mood disorder. It is also one of the most under-diagnosed anxiety disorders. If not timely treated, it can lead to severe physical and mental disorders and interfere with the patient’s quality of life, reputation, career, and social circle. Early diagnosis and effective treatment for social anxiety (involving therapies, medication, self-help strategies, etc.) can help manage and overcome the debilitating consequences of SAD.

Social Anxiety At A Glance

  1. Social anxiety or social phobia is the anxiety and fear linked to being in social settings.
  2. Its causes are wide-ranging—with genetic, psychological, biological, and socio-cultural causes.
  3. Severe social anxiety manifests in feeling negative emotions, avoidance and safety behaviors, fight-or-flight mindset and actions, disjointed speech, etc.
  4. The symptoms of social anxiety involve blushing, palpitation, excessive sweating, breathing problems, fainting, etc.
  5. If untreated, social phobia creates a number of severe physical and mental health conditions.
  6. Social anxiety disorder (SAD) also has negative effects on the afflicted person’s quality of life, reputation, career, and relationships.
  7. The treatment for social anxiety includes psychoeducation, psychotherapies, medication, and self-help coping strategies.

Frequently Answered Questions (FAQs)

Is social anxiety a mental illness?

Social anxiety is a form of anxiety disorder that leads to severe distress and anxiety in social situations. People with social anxiety disorder (SAD) are fearful of negative scrutiny, public humiliation, attending social events, or forming new relationships.

Do I have social anxiety?

The signs of social anxiety are easily recognizable. You have social anxiety if you dread social interaction and are afraid of negative scrutiny, public humiliation, embarrassment, etc. This is very different from shyness or having an introverted personality.

What does it mean to have social anxiety?

A person has social anxiety if he/she fears social interaction or social events. A social context triggers social phobia, resulting in symptoms such as blushing, sweating, breathing problems, fainting, etc.

Can social anxiety be cured?

Social phobia is a very common anxiety disorder that can be easily cured. Treatment involves psychotherapies, medication, self-help coping strategies, exercise, natural remedies, and psychoeducation. If left untreated, it leads to a number of physical and mental health problems.

How do we help someone with social anxiety?

The key to help someone dealing with social anxiety involves free communication, patience, and understanding. Focus on their feelings and body language and listen patiently. Try distraction techniques (such as laughter, games & discussing hobbies) to ease their social stress.

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