Social anxiety disorder (SAD), previously known as social phobia, is an anxiety disorder characterized by high levels of anxiety and self-consciousness in social situations, resulting in significant distress and an impaired ability to function in daily life. The defining feature of social anxiety disorder is a persistent fear of negative or positive evaluation by others. These fears can be triggered by perceived or actual scrutiny from others. Recent data suggest the prevalence of social anxiety disorder is rising, particularly among young people.
Physical symptoms often include excessive blushing, excessive sweating, trembling, palpitations, muscle tension, shortness of breath, and nausea. Panic attacks can also occur under intense fear and discomfort. Some affected individuals may use alcohol or other drugs to reduce fears and inhibitions at social events. It is common for socially anxious individuals to self-medicate in this fashion, especially if they are undiagnosed, undertreated or untreated. This results in a heightened risk of alcohol use disorder, eating disorders, or other substance use disorders among sufferers. According to ICD-11 guidelines, an individual meets the criteria for social anxiety disorder if they experience persistent symptoms for at least several months, resulting in significant distress and impairment in personal, family, social, educational, occupational, or other important areas of functioning.
The first line of treatment for social anxiety disorder is cognitive behavioral therapy (CBT) with or without medication. CBT is most effective when delivered individually, though it can be offered in a group format. The cognitive and behavioral components seek to change thought patterns and physical reactions to anxiety-inducing situations. Metacognitive therapy and acceptance and commitment therapy are alternative options with efficacy at least as high as CBT.
The attention given to social anxiety disorder has significantly increased since 1999, with the approval and marketing of drugs for its treatment. Approved medications include the selective serotonin reuptake inhibitors (SSRIs) paroxetine, sertraline, and fluvoxamine, the serotonin–norepinephrine reuptake inhibitor (SNRI) venlafaxine, and the monoamine oxidase inhibitor (MAOI) phenelzine. Propranolol, a beta blocker, is sometimes used off-label for performance anxiety.
Signs and symptoms The 11th revision of the International Classification of Diseases (ICD-11) classifies social anxiety disorder as an anxiety or fear-related disorder.
Cognitive aspects In cognitive models of social anxiety disorder, those with social anxiety disorder experience dread over how they will present to others. They may feel overly self-conscious, pay excessive attention to themselves, or have high performance standards for themselves. According to the social psychology theory of self-presentation, an affected person attempts to create a well-mannered impression towards others but believes they are unable to do so. Many times, before the potentially anxiety-provoking social situation, they may deliberately review what could go wrong and how to deal with each unexpected case. After the event, they may have the perception that they performed unsatisfactorily. Consequently, they will perceive anything that may have possibly been abnormal as embarrassing. These thoughts may extend for weeks or longer. Cognitive distortions are a hallmark and are learned about in CBT (cognitive-behavioral therapy). Thoughts are often self-defeating and inaccurate. Those with social phobia tend to interpret neutral or ambiguous conversations with a negative outlook and many studies suggest that socially anxious individuals remember more negative memories than those less distressed.
Behavioral aspects Social anxiety disorder is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that they may do something or act in a way that will be humiliating or embarrassing. It exceeds normal "shyness" as it leads to excessive social avoidance and substantial social or occupational impairment.
Those who have social anxiety disorder fear being judged by others in society. In particular, individuals with social anxiety are nervous in the presence of people with authority and feel uncomfortable during physical examinations. People who have this disorder may behave a certain way or say something and then feel embarrassed or humiliated after. As a result, they often choose to isolate themselves from society to avoid such situations. They may also feel uncomfortable meeting people they do not know and act distant when they are with large groups of people. In some cases, they may show evidence of this disorder by avoiding eye contact, or blushing when someone is talking to them.
Physiological aspects Physiological effects may include excessive sweating, nausea, difficulty breathing, shaking, palpitations, and increased heart rate.
Social aspects People with SAD avoid situations that most people consider normal. People with SAD avoid all or most social situations and hide from others, which can affect their personal relationships. Social phobia can completely remove people from social situations due to the irrational fear of these situations. People with SAD may be addicted to social media networks, have sleep deprivation, and feel good when they avoid human interactions. SAD can also lead to low self-esteem, negative thoughts, major depressive disorder, sensitivity to criticism, and poor social skills that do not improve. People with SAD experience anxiety in a variety of social situations, from important, meaningful encounters to common situations. These people may feel more nervous in job interviews, dates, interactions with authority, or at work and school.
Comorbidity SAD shows a high degree of co-occurrence with psychiatric disorders. In fact, a population-based study found that 66% of those with SAD had one or more additional mental health disorders. SAD often occurs alongside low self-esteem and most commonly clinical depression. Clinical depression is 1.49 to 3.5 times more likely to occur in those with SAD. Research also indicates that the presence of certain social fears (e.g., avoidance of participating in small groups, avoidance of going to a party) are more likely to trigger comorbid depressive symptoms than other social fears.
Anxiety disorders other than SAD are also common in people with SAD, in particular generalized anxiety disorder. Avoidant personality disorder is likewise highly correlated with SAD, with comorbidity rates ranging from 25% to 89%.
To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to substance use disorders. It is estimated that one-fifth of people with social anxiety disorder also have alcohol use disorder. However, some research suggests SAD is unrelated to, or even protective against alcohol-related problems. Those who have both alcohol use disorder and social anxiety disorder are more likely to avoid group-based treatments and to relapse compared to people who do not have this combination.
Causes Research into the causes of social anxiety and social phobia is wide-ranging, encompassing multiple perspectives from neuroscience to sociology. Scientists have yet to pinpoint the exact causes. Studies suggest that genetics can play a part in combination with environmental factors. Social phobia is not caused by other mental disorders or substance use."Social anxiety disorder." CareNotes. Truven Health Analytics Inc., 2012. Health Reference Center Academic. Web. 15 Nov. 2012. Generally, social anxiety begins at a specific point in an individual's life. This will develop over time as the person struggles to recover. Eventually, mild social awkwardness can develop into symptoms of social anxiety or phobia. Passive social media usage may cause social anxiety in some people.
Genetics It has been shown that there is a two to a threefold greater risk of having social phobia if a first-degree relative also has the disorder. This could be due to genetics and/or due to children acquiring social fears and avoidance through processes of observational learning or parental psychosocial education. Studies of identical twins brought up (via adoption) in different families have indicated that, if one twin developed social anxiety disorder, then the other was between 30 percent and 50 percent more likely than average to also develop the disorder. To some extent, this "heritability" may not be specific – for example, studies have found that if a parent has any kind of anxiety disorder or clinical depression, then a child is somewhat more likely to develop an anxiety disorder or social phobia. Studies suggest that parents of those with social anxiety disorder tend to be more socially isolated themselves, and shyness in adoptive parents is significantly correlated with shyness in adopted children.Daniels and Plomin, 1985.
Growing up with overprotective and hypercritical parents has also been associated with social anxiety disorder. Adolescents who were rated as having an insecure (anxious-ambivalent) attachment with their mother as infants were twice as likely to develop anxiety disorders by late adolescence, including social phobia.
A related line of research has investigated 'behavioural inhibition' in infants – early signs of an inhibited and introspective or fearful nature. Studies have shown that around 10–15 percent of individuals show this early temperament, which appears to be partly due to genetics. Some continue to show this trait into adolescence and adulthood and appear to be more likely to develop a social anxiety disorder.
Social experiences A previous negative social experience can be a trigger to social phobia,Athealth.com.Social phobia. 1999. Retrieved February 24, 2006. perhaps particularly for individuals high in "interpersonal sensitivity". For around half of those diagnosed with social anxiety disorder, a specific traumatic or humiliating social event appears to be associated with the onset or worsening of the disorder;Mineka S, Zinbarg R (1995) Conditioning and ethological models of social phobia. In: Heimberg R, Liebowitz M, Hope D, Schneier F, editors. Social Phobia: Diagnosis, Assessment, and Treatment. New York: The Guilford Press, 134–162 this kind of event appears to be particularly related to specific social phobia, for example, regarding public speaking. As well as direct experiences, observing or hearing about the socially negative experiences of others (e.g. a faux pas committed by someone), or verbal warnings of social problems and dangers, may also make the development of a social anxiety disorder more likely.Beidel, D.C., & Turner, S.M. (1998). Shy children, phobic adults: The nature and treatment of social phobia. American Psychological Association Books. Social anxiety disorder may be caused by the longer-term effects of not fitting in, or being bullied, rejected, or ignored. Shy adolescents or avoidant adults have emphasized unpleasant experiences with peers or childhood bullying or harassment. In one study, popularity was found to be negatively correlated with social anxiety, and children who were neglected by their peers reported higher social anxiety and fear of negative evaluation than other categories of children. Socially phobic children appear less likely to receive positive reactions from peers, and anxious or inhibited children may isolate themselves.
Parental influences