• Social anxiety disorder (SAD) is also known as social phobia.
• It is the most common anxiety disorder.
• The essential feature is a marked and persistent fear of one or more social or performance situations in which the person is exposed to possible scrutiny by others.
• The person with SAD fears that he/she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. be embarrassing or humiliating and which may lead to possible rejection by others).
• Feared situations are avoided or endured with great distress or anxiety
• The onset is usually between the ages of 15 and 20 years. Onset after the age of 25 years is relatively uncommon.
• Optimal treatment includes a combination of psychotherapy and medication.
What is social anxiety disorder (SAD)?
SAD is, as it’s name suggests, an anxiety disorder, and is also known as social phobia. A phobia is an irrational and excessive fear that usually results in deliberate avoidance of the specific feared object, activity or situation.
In SAD the intense and persistent fear is of being in the company of strangers or authority figures in some cases, scrutiny by others in a social situation, or a fear of behaving in a way that might cause embarrassment, humiliation and/or ridicule, and perhaps ultimately, rejection.
While it is normal for people to experience anxiety about certain social or performance situations such as job interviews or public speaking, the person with SAD experiences persistent, extreme anxiety out of proportion to the actual situation (i.e. “irrational fear”).
The person becomes anxious as he/she anticipates humiliation and embarrassment days or weeks before the dreaded event (anticipatory anxiety).
During the event he/she is extremely anxiety and uncomfortable throughout. After the event, the person may be plagued by concerns about their performance and how others judged them or thought of them. In this way a vicious circle is created.
The person may feel that everyone else is far more competent in public than they are. Small mistakes may appear much more serious than they really are and the person feels that his/her every move, reaction or perceived mistakes are noticeable to others.
Blushing is prominent in some people with SAD and may in itself be painfully humiliating to the person. SAD can be limited to speaking or performing in public.
However, in SAD the social fears are mostly generalised and include most social situations. Situations such as signing cheques or contracts before witnesses, using public toilets, eating and drinking in public, and talking on the phone are instances that may also cause extreme “social” anxiety.
The intense anxiety may lead to avoidance in patients with SAD. When the person is not able to avoid, and has to face the feared situation or person, it is endured with great anxiety and discomfort.
Adolescents and adults with SAD have good insight and mostly realise that their anxiety is irrational and excessive but are still unable to control it.
SAD shouldn’t be confused with shyness. Shy people may feel very uneasy around others but do not experience the same extreme anxiety in anticipation of the event and do not typically avoid social situations.
Shyness (or social reticence) is a common personality trait, and is not by itself regarded as pathological or problematic. But when the person (or significant others, for example) is concerned about his/her shyness and there is evidence that it has a detrimental effect on functioning, it can no longer be regarded as normal and a diagnosis of SAD is probable.
SAD may involve panic attacks during or before the feared situation. The anxiety cause great distress to the person and/or may be so intense and overwhelming that it significantly interferes with work or school, social life or other activities.
For example, a person may not reach his potential in his career because he is anxious in the presence of authority figures or colleagues, or too anxious to go for a job interview. As social situations are often avoided, many people with SAD do not develop important life and social skills.
In severe cases, people do not have friends, refrain from dating and in severe cases, never leave their parents’ home to live independently. SAD is often accompanied by other psychiatric disorders.
For example, as noted earlier, persons with SAD may have panic attacks in social or performance situations. Other conditions like depression, body dysmorphic disorder and obsessive compulsive disorder may also occur.
As people with SAD often “self-medicate” by drinking alcohol or taking drugs, they are at risk of developing substance abuse or dependence. SAD usually precedes these disorders.
Can children have SAD?
In children, SAD is diagnosed only when the anxiety occurs in peer settings and not just during interactions with adults. Also, in children, the excessive fear or anxiety may be expressed by crying, freezing, clinging, or even failing to speak in social situations. The insight that their anxiety is irrational and excessive is not always present in children however.
They may also not be able to avoid feared situations and may be unable to identify the nature of their anxiety. Children and adolescents with SAD often show a decline in school performance due to test anxiety or classroom participation, school refusal or avoidance of age-appropriate social activities.
What causes SAD? There are multiple possible causes for SAD, which may also interact with one another. Indeed, experts say that SAD may have both environmental and genetic causes.
For example, a person’s genetic make-up may render him/her more vulnerable, and combined with another environmental variable (e.g. childhood trauma / parents’ personality or childrearing styles), SAD may develop.
It is known that SAD is more common in families (i.e. hereditary). There is ongoing research which attempts to find out how much of this is genetic versus whether the symptoms have been acquired through learning (e.g. imitation of parents who are avoidant or anxious).
Some neurotransmitters (i.e. some of the chemicals in the brain) have also been linked with SAD. Specifically, serotonin may play a key role in the development of SAD (which may explain why SAD patients often respond to treatment with selective serotonin reuptake inhibitors (SSRIs)).
Some parts of the brain – e.g. the amygdala - may also play a role in fear response, resulting in an excessive reaction in some patients with an overactive amygdala.
Other factors have also been considered in the causality of SAD – e.g. some research suggests that culture or even the climate / weather may play a role. For example, people from Mediterranean countries have lower rates of SAD compared to those from Scandinavia.
Who gets SAD?
There are factors which may render a person more vulnerable to develop SAD. These are:
Gender: SAD is significantly more common among females than males. Notably though, females with SAD are more common in community studies, whereas males are more common in treatment settings.
Genetics (“nature”): The risk for SAD increases if a person's parents or siblings have the condition. Upbringing (“nurture”): SAD may also be learnt: Some person develop SAD because they have witnessed socially anxious behaviour in others. Parental styles may also play a role: there may be a link between SAD and over-protective parenting.
Adverse experiences: Children or adolescents who have been exposed to bullying, ridicule, humiliation or rejection may be more susceptible to social anxiety, compared to other people. Other traumatic factors, such as sexual abuse, may also play a role.
Personality / temperament: Children or adolescents who are withdrawn, restrained, shy or timid when confronted with a new situation may be more prone to developing SAD.
Other factors: SAD occurs in all societies and racial groups although it may manifest differently or at different rates across cultures, depending on social demands. In some cultures the fear may be more related to offending others rather than fear of embarrassment or ridicule.
What are the symptoms?
Symptoms can have a sudden onset but usually develop or increase over time. Apart from psychological feelings of anxiety and fear, people with SAD almost always experience somatic (physical) symptoms of anxiety such as heart palpitations, trembling, sweating and muscle tension. As noted earlier, panic attacks may occur in some cases.
SAD usually emerges in mid-adolescence. In some cases there is a childhood history of social inhibition or shyness.
If left untreated, SAD may become a chronic, relentless disorder. Severity may fluctuate – during stressful times symptoms may be worse than at other times. Symptoms may “disappear” if circumstances change – e.g. a person with a fear of public speaking who is promoted to a position where this is no longer required.
In severe cases, especially when other conditions such as depression are present, suicide becomes a risk.
How is SAD diagnosed?
The very “normality” (or high prevalence) of shyness and social anxiety has lead to the fact that SAD is often undiagnosed and untreated unfortunately.
A clinician (usually a general practitioner, psychologist or psychiatrist) should do a thorough assessment, including taking an in-depth history of the patient and his/her family. The input of people close to the affected person may also be valuable. A diagnosis is made according to the criteria set out in diagnostic manuals such as The Diagnostic and Statistical Manual of Mental Disorders (DSM).
As the symptoms of SAD closely resemble other psychiatric conditions such as avoidant personality disorder, body dysmorphic disorder or panic disorder, a thorough assessment is needed. Comorbid conditions must also be diagnosed and addressed in treatment.
When to see a mental health professional
A mental health professional should be seen when the social anxiety, avoidance and distress are significantly impacting on work, school or social life. Early diagnosis and treatment can prevent the negative impact of the disorder on social development and general functioning. It can also perhaps prevent the development of comorbid conditions, such as depression and alcohol abuse / dependence.
People with SAD should tell the doctor about when it first became a problem, the course of the disorder and previous treatment received, including what medication was prescribed, the dosage and duration, and how effective it was in relieving their symptoms.
If the person underwent psychotherapy, it is important to mention the kind of psychotherapy used (there are different types of psychotherapy – ask your therapist which she/he will use during treatment).
How is it treated?
The treatment goals for SAD are basically to reduce the fear, avoidance, physical distress, disability, and comorbidity. Treatment can greatly relieve the symptoms and improve quality of life of persons with SAD. About 80 % of people with SAD find relief from their symptoms when treated with psychotherapy and/or medication.
SAD is very seldom treated on an in-patient basis. In fact, generally treatment is underutilized in patients with SAD, and a long-term treatment approach may be needed to improve the likelihood of recovery from SAD.
Any co-existing disorder such as depression which may influence outcome should also be treated.
Several different medications can be used to treat SAD. These include antidepressants (like the SSRIs), beta-blockers and benzodiazepines.
- Anti-depressants are the first line of treatment.
- Selective Serotonin Reuptake Inhibitors (SSRI’s)
These antidepressants act on the neurotransmitter called serotonin and also treat depression which often co-exists with SAD. Examples of SSRI’s are sertraline (Zoloft) and fluoxetine (e.g. Lilly-Fluoxetine, Lorien or Nusac). Paroxetine (Aropax) and fluvoxamine (Luvox) have been registered for use in treating SAD in some countries.
A person will be started on a low dose which will gradually be increased until a therapeutic (optimal) dose is reached. The disadvantage of these antidepressants is that, unlike benzodiazepines, they take a few weeks before the person notices a relief of symptoms. Unfortunately, many people therefore stop taking medication prematurely.
Although SSRI’s have a favourable side-effect profile compared to older generation antidepressants, side-effects such as headaches, nausea or even increased anxiety may be experienced. Fortunately they will gradually disappear. If side-effects are difficult to tolerate, different medication may be prescribed. Monoamine Oxidase Inhibitors (MAOI’s)
An older generation class of antidepressant, Monoamine Oxidase Inhibitors (MAOI’s) is sometimes used. Parnate (tranylcypromine) is the only MAOI available in South Africa. MAOI’s inhibits the enzyme monoamine oxidase.
They are not widely used anymore because they may have a dangerous interaction with certain foodstuffs containing tyramine such as red wine and cheese. This interaction can lead to a potentially fatal rise in blood pressure.
Common side-effects include headaches, dizziness, agitation, insomnia and sexual problems.
Newer generation agents, the reversible inhibitors of monoamine oxidase A (RIMA) do not have this potentially dangerous interaction with food and drink, and may nevertheless be used for the treatment of SAD although evidence of their effectiveness is equivocal.
Benzodiazepines (tranquillizers), such as diazepam (Valium), are often preferred by people because of their almost immediate effect. However, these are not generally recommended because of side effects such as sedation, their addiction potential and because of problems that may be experienced during medication withdrawal.
Another disadvantage is that they only treat anxiety and not depression. It is important not to stop medication without medical supervision – the doctor will probably taper off the dosage to avoid “rebound” anxiety.
Drugs called beta-blockers such as propranolol (Inderal) have helped people with excessive anxiety in performance situations. These drugs are used on the day of a specific social situation (for example, about 30 minutes to an hour before a public speaking event).
Cognitive-behavioural therapy (CBT) is short-term, structured therapy which involves active participation by both therapist and patient. It is based on the theory that one’s feelings and behaviour are controlled by how one thinks and perceives the world.
In the case of SAD, CBT focuses on changing negative thought patterns that specifically pertains to self, self-image and interactions with other people. The therapist will challenge cognitive distortions such as catastrophizing, probability overestimation and all or nothing thinking and encourage the development of a positive mind-set.
Self-monitoring is an important part of CBT. The person is encouraged to pay closer attention to his/her thoughts and feelings and to identify those irrational or destructive thoughts (and resulting negative emotions and behaviour) that needs to be disputed and substituted by more functional or logical thoughts, feelings en behaviour.
Systematic desensitisation or exposure therapy has been used with great success. Three-quarters of people benefit significantly from this type of treatment. It involves drawing up a hierarchy of feared situations and gradually exposing the person to these situations starting from the least feared to the most anxiety-provoking situation.
The therapist also teaches relaxation and breathing techniques which are used to help the person cope in the dreaded situation.
In summary, there is good evidence in the literature for the effectiveness of exposure-based CBT in the treatment of SAD.
People with SAD usually feel that everyone else is far more competent in public and that they are the only ones not coping. Support groups can help the person to share his or her concerns with others and to learn different techniques to cope with the disorder.
In South Africa, the Depression and Anxiety Support Group (SADAG: ) has helped many people cope with anxiety disorders and depression. There are several groups throughout the country.
Organisations such as Toastmasters can also help people become more comfortable with public speaking.
Can SAD be prevented?
SAD cannot be prevented. However, there is growing awareness of social anxiety symptoms in children. One possibility is that early intervention for children with such symptoms can prevent the development of full-blown SAD.
What SAD research is being done in South Africa?
There is an ongoing SAD research project conducted at the MRC Research Unit on Anxiety Disorders (Dept. of Psychiatry, University of Stellenbosch).
The SAD project at the MRC Unit primarily focuses on investigation of the phenomenology (including blushing, anxiety and avoidance) as well as the role of genetic factors in the development of this condition.
Other factors that are also evaluated include age of onset, response to medication treatment, comorbidity, personality features, and family history of SAD and other psychiatric disorders.
Our focus now include investigation of brain structure and functioning in patients with SAD and the assessment thus includes both neuropsychological testing as well as brain imaging.
Participation entails a once-off consultation (and referral for treatment if required), is cost-free and takes approximately two to three hours.
If scanning and neuropsychological testing are involved (in addition to the initial comprehensive diagnostic interview), one additional session will be needed.
Blood will be drawn from participants and their parents (if possible, if not, saliva samples would be adequate) to get to the genetic material (also known as DNA). The MRC Unit is situated in the Western Cape.
Participation does not have to interfere with a patient’s current treatment regime, and feedback can be provided to his/her treating clinician if requested.
Appropriate referral for treatment can be discussed and organized however. At times, treatment trials are run at the MRC Unit.
At the moment, an ambitious study including genetics investigations, brain imaging and a treatment (pharmacotherapy) leg is being planned at Stellenbosch University and will most likely be launched before the end of 2014.
For more information, contact Prof Christine Lochner at the MRC Unit on Anxiety Disorders on 021 938 9179 (email: firstname.lastname@example.org).
Reviewed by Prof Christine Lochner, Clinical psychologist & Co-Director: MRC Unit on Anxiety and Stress Disorders, Department of Psychiatry, University of Stellenbosch.
Do you suffer from social anxiety disorder?
Stellenbosch University invites you to take part in an exciting research study to help researchers further understand this disorder.
Click here to read how to become a volunteer or, if you want more information or want to participate, please contact: Prof Christine Lochner 021 – 938 9179, e-mail: email@example.com or Ms Elsie Breet 021 – 938 9654, e-mail: firstname.lastname@example.org for more information.