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Social anxiety disorder, as its name implies, is a disorder that causes people to be anxious about social interaction. The disorder is characterized by a fear of being judged negatively by others, which results in a desire to avoid interacting with others or drawing attention to oneself (Kashdan & Farmer, 2014, 629). Social anxiety disorder (also known as social phobia or SAD) affects people in multiple ways. It can have physical symptoms; for example, people with SAD may blush or tremble in situations that induce anxiety for them (Schneier, 2003, 516). The disorder also has several cognitive and behavioral systems, which will be discussed later. Some people with SAD only get anxious in specific situations such as public speaking, while others can get anxious in a broader range of social situations (Schneier, 2003, 516). SAD seems to have both genetic and environmental causes. Several genes have been found to have some association with social anxiety, and it is likely that these can contribute to the disorder (Stein & Stein, 2008, 1118). However, parenting styles that are “overprotective yet critical” may also contribute to the development of the disorder (Schneier, 2003, 516). It is possible that negative treatment from peers at a young age can also contribute; adolescents who experience “relational victimization”, or negative treatment in a social relationship, are more likely to have feelings of social anxiety later (Siegel et al., 2009, 1096). SAD can be treated with certain medications, such as selective serotonin reuptake inhibitors; it can also be treated with cognitive behavioral therapy (Stein & Stein, 2008, 1120).
Social anxiety disorder is quite common; it is the third most common psychiatric disorder in the United States (Schneier, 2003, 515-516). 10 to 15 percent of people in the U.S. experience SAD at some point in their lifetime (Farmer & Kashdan, 2015, 102). It usually sets in early in life; about 50% of people with SAD have it by age 11, and about 80% have it by age 20 (Stein & Stein, 2008, 1115).
The cognitive aspects of social anxiety disorder include feelings of low self-esteem and inferiority to others (Farmer & Kashdan, 2015, 104; Schneier, 2003, 516). People with SAD are prone to self-consciousness and easily embarrassed (Schneier, 2003, 516), and they tend to be quick to assume that others dislike them (Farmer & Kashdan, 2015, 104). In some cases, if a person with SAD believes he or she has made a mistake or been judged negatively during a social interaction, he or she may think about the event hours or even days after it has occurred (Farmer & Kashdan, 2015, 103). People with SAD often remember negative social experiences more than positive ones, and even friendly interactions can sometimes cause them anxiety (Farmer & Kashdan, 2015, 104). People with SAD tend to experience more stress than others (Farmer & Kashdan, 2015, 110). They expend a substantial amount of mental energy trying to avoid anxiety and the possibility of being disliked, which can be “cognitively taxing” (Kashdan & Farmer, 110). Compared to others, the self-esteem of people with SAD seems to be more dependent on their social experiences (Farmer & Kashdan, 2015, 111). As would be expected, people with SAD tend to have higher levels of introversion (Stein & Stein, 2008, 1118).
The behavioral aspects of social anxiety disorder include an avoidance of interacting with others, and of social events and activities (Schneier, 2003, 515). They especially avoid situations where they are likely to be evaluated. This avoidance behavior is usually the surest way to prevent their feelings of anxiety, although it is unlikely to be the best course of action for their mental health in the long run (Eggleston et al., 2003, 45).
Social anxiety disorder has several effects on the lives of those who have it. As would be expected, their reluctance to interact with others often prevents them from having positive social experiences, so they are less likely to develop friendly relationships and have meaningful social lives (Farmer & Kashdan, 2015, 104). In a work setting, it is more difficult for them to have smooth relationships with coworkers (Farmer & Kashdan, 2015, 103). They sometimes have certain “safety behaviors” that they engage in to try to mitigate their feelings of anxiety. These can include “unassertiveness, conflict avoidance, restriction of emotional expression, and interpersonal anxiety” (Farmer & Kashdan, 2015, 104). In an unfortunate vicious circle, these behaviors can seem unappealing to others and make them uncomfortable, fulfilling the person with SAD’s fears of being liked less (Farmer & Kashdan, 2015, 104).
Some of the potential effects of social anxiety disorder can be felt at a society-wide level. People with SAD often do not do as well as others in their education. They are also less likely to marry (Nardi, 2003, 1287). People with SAD are in greater danger of losing their job than others, and on average they have a lower economic status. Due to the difficulties that SAD can cause in education and work, the “financial burden” of SAD “rivals that of depression” (Farmer & Kashdan, 2015, 102).
Despite the frequency of social anxiety disorder, it often goes undiagnosed (Schneier, 2003, 516). Most people with SAD do not seek treatment, and 80 percent of people with the disorder do not get it. This number is much higher than for other mental disorders; for comparison, 40% of people with major depressive disorder and 50% of people with generalized anxiety disorder get no treatment (Anderson et al., 2015, 131). This is partly because the feelings of shame that people with SAD tend to experience can discourage them from seeking treatment (Schneier, 2003, 516). They are likely to worry about what other people would think about it (Anderson et al., 2015, 132).
As with many other mental disorders, there is a stigma surrounding social anxiety disorder in American society. In a study, some participants indicated that they would like to have more “social distance” between themselves and someone with the typical behaviors of SAD (Anderson et al. 2015, 131). For example, they expressed that they would rather not have such a person as a close friend, or as a coworker (Anderson et al., 2015, 133). These attitudes were more common among men and people who did not have experience getting mental health treatment (Anderson et al., 2015, 131). Stigma can be especially hurtful to people with SAD, due to their fear of other people thinking of them negatively (Anderson et al., 2015, 131).
Social anxiety disorder can be related to other behavioral health issues. There is “considerable comorbidity” between SAD and major depressive disorder (Farmer & Kashan, 2015, 108). SAD also seems to have a complex and not fully understood relationship with alcohol use. SAD and alcohol abuse occur together in many cases; 20-28% of people who seek treatment for SAD also meet criteria for an alcohol use disorder (Eggleston et al., 2003, 34). In others, however, exhibiting the symptoms of SAD was correlated with drinking less (Eggleston et al., 2003, 34). A possible explanation is that SAD can potentially push people in two different directions regarding alcohol, depending on how they view it. Some people with SAD may view drinking as a coping method that will help alleviate their anxiety and make it easier for them to be social (Eggleston et al., 2003, 45); these people would be more likely to abuse alcohol. Other people with SAD may be worried that they would act embarrassingly while under the influence of alcohol; these people would be more likely to drink less than average (Eggleston et al., 2003, 34-35).
As mentioned earlier, social anxiety disorder goes undiagnosed very often in the U.S., despite the fact that it is quite common and it can be treated. Social anxiety disorder is mainly treated in two ways: cognitive behavioral therapy and medication. Studies have shown that both of these treatment methods are generally effective against SAD, although the improvements from cognitive behavioral therapy (or CBT) seem to last longer (Stein & Stein, 2008, 1120).
In cognitive behavioral therapy, a therapist helps the patient learn to address the thought processes involved in SAD, and to act in a way that is not so inhibited by the disorder. The therapist helps the patient notice unhelpful thoughts – such as expectations that others will judge him or her – and think differently. Patients also learn to set constructive goals – such as initiating more social interactions – instead of just holding themselves to expectations that they find difficult to fulfill. The therapist may also teach the patient strategies for managing anxiety and relaxing (Schneier, 2006, 1030-1031). CBT also includes therapeutic exposure. The therapist may help the patient create a “hierarchy” of situations that he or she fears. Then the patient is gradually exposed to these, either through role-playing with the therapist, or in the real world through “homework assignments” (Schneier, 2006, 1031). CBT certainly works as a treatment for SAD. In a follow-up study, after five years, 89% of people who had done CBT had seen improvement, meaning that their social anxiety, avoidance of social situations, and life impairment had decreased to some extent (Schneier, 2006, 1031).
Because people with SAD are likely to be anxious when starting CBT, it is important for therapists to build positive relationships with their patients at the beginning of the therapy. This can decrease the possibility that patients will decide not to come to therapy appointments, which they may be inclined to do otherwise. One helpful action that the therapist can take at this stage is to ask if he or she can do anything to reduce the patient’s anxiety during their meetings (McNeil & Quentin, 2014, 273-274). Forms of CBT that are done in groups do not work as well in treating SAD as individual therapy (Stein & Stein, 2008, 1121). Cognitive behavior therapy is effective on children and adolescents who show signs of social anxiety disorder (Stein & Stein, 2008, 1121-1122). It can potentially “restor[e] normal social development” in such children and adolescents, preventing them from having SAD in the future (Schneier, 2006, 1034). Therefore, getting CBT for children and adolescents who fit the criteria for SAD could be a preventative approach to reducing its incidence.
The most prominent medications used against SAD are selective serotonin reuptake inhibitors (or SSRIs) and the related serotonin-norepinephrine-reuptake inhibitors (or SNRIs). These are now used as a “first-line pharmacotherapy” for the disorder, and their effectiveness has been established in studies (Schneier, 2006, 1031). Several other medications can also be used against SAD; these include benzodiazepines, monoamine oxidase inhibitors (or MAOIs), and certain other anticonvulsants and antidepressants (Schneier, 2006, 1032-1033). There is not as much evidence for the effectiveness of these medications as there is for SSRIs and SNRIs (Schneier, 2006, 1032-1033), but switching to one of them may be helpful for patients who do not see improvement on an SSRI or SNRI (Schneier, 2006, 1034).
Patients who take medication for SAD are advised to take it for 6 to 12 months, and after this they can progressively reduce the amount and then stop taking the medication. However, relapse will still be possible, and patients should start taking the medication again if it happens (Schneier, 2006, 1003). Medication has quicker results than cognitive behavioral therapy. It is a more feasible option for treatment in some situations; this includes if the patient is “too anxious or depressed” to start cognitive behavioral therapy, or does not do their homework for it (Stein & Stein, 2008, 1120).
One other form of treatment for SAD that has emerged recently is internet-based treatment (Andersson et al., 2014, 569). In this, patients use an online program that teaches them about SAD and how they can learn to be less affected by it. Many of these programs are similar to CBT in the material they present. Although the programs are usually self-guided, they involve some online contact with a therapist (Andersson et al., 2014, 569). This internet-based treatment appears to have a similar effectiveness to CBT that is done in person. However, more research would be helpful towards understanding how it could work best (Andersson et al., 2014, 581).
If more people with SAD were diagnosed, more of them could get treatment, which could reduce or alleviate their difficulties from the disorder. As mentioned earlier, one of the main reasons that so many people with social anxiety disorder are undiagnosed is that many of them never seek treatment. In some cases, this is simply due to a lack of awareness about the disorder; some people with SAD do not know that they have a condition that is shared by others and is treatable (Nardi, 2003, 1287). Therefore, raising awareness about would be one way to help those who have it ultimately get treatment. There have been educational campaigns in the media about anxiety disorders that have increased the number of people with these conditions who get treated (Nardi, 2003, 1287). Therefore, media campaigns that teach people about SAD would be an effective way to increase treatment for it.
The stigma associated with having a mental disorder is another reason that many people with SAD never seek treatment (Anderson et al., 2015, 131), so reducing this stigma could also help increase treatment for SAD. Doctors could carry materials about SAD that expose misconceptions and portray the disorder in a more respectful light. If these materials were shown to people with SAD when doctors recommend treatment to them, they might be more willing to get it (Anderson et al., 2015, 136).
SAD would also be diagnosed more frequently if primary care doctors recognized possible social anxiety more often, even in patients who did not come in for reasons related to it. Doctors could look out for possible signs of SAD, such as blushing and trembling (Zamorski & Ward, 2000, 251). If a doctor thinks that a patient might have SAD, he or she can ask the patient whether they experience social anxiety, initiating the process that could lead to diagnosis.
In medical settings, people with SAD may not want to talk much, and do not usually tell doctors about their difficulties without prompting. They are often reluctant to do so because they are embarrassed about their difficulties, do not think the doctor would take them seriously, or are not comfortable around authority figures (Stein & Stein 2008, 1116-1117). Therefore, doctors may need to ask patients about social anxiety specifically in order to get them to talk about it (Stein & Stein, 2008, 1117). Diagnosing a patient with SAD is likely to be easier if the doctor acts kind and understanding, rather than like a cold authority figure, and communicates that SAD is a common problem that he or she has knowledge of. Patients can also be given self-administered questionnaires that screen for the possibility of SAD, as in some cases this can help the doctor make a diagnosis (Stein & Stein, 2008, 1117). Patients should be encouraged to complement their treatment by trying to gradually increase their social activities (Schneier, 2006, 1034).
Doctors and psychologists who treat people with SAD should also be conscious of the ways in which it can interact with other disorders. Among people who have major depressive disorder, those who have SAD in addition may be more likely to attempt suicide (Schneier, 2006, 1030). Therefore, practitioners who have a patient with both of these disorders should connect him or her with suicide prevention resources. People who have both alcoholism and SAD are less likely to use group treatments, such as Alcoholics Anonymous, than other alcoholics; they may also be more likely to have a relapse (Schneier, 2006, 1030). Therefore, practitioners who have such a patient should inform him or her about other strategies for controlling addiction.
There is some controversy over the designation of social anxiety disorder; some people believe that it simply describes shyness, a normally occurring personally trait that should not be medicalized and called a disorder (Stein & Stein, 2008, 1117). In this view, what some call SAD is simply a personal issue, not a health problem that should be addressed with medical intervention. However, “social… anxieties exist on a continuum”, and the traits of SAD occupy a more extreme place on this continuum than standard shyness (McNeil & Quentin, 2014, 271). SAD causes a great deal of distress to people who have it, sometimes in measurable ways (Stein & Stein, 2008, 1117); as mentioned, many people with SAD have difficulty keeping a job. Classifying SAD as a disorder indicates that these problems deserve serious attention and should be addressed with treatment, which improves the lives of people who get it. Although it is true that there is some subjectivity involved in deciding what should be called a disorder, in this case it seems appropriate and beneficial to recognize SAD as one.
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