Social Anxiety Disorder
- Social anxiety disorder is also known as social phobia
- The essential feature is a marked and persistent fear of social or performance situations in which embarrassment may occur
- 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 psychotherapy and medication
What is social anxiety disorder (SAD)?
Social anxiety disorder (SAD), is as its name suggests an anxiety disorder, and is also known as social phobia. A phobia is an irrational fear resulting in a conscious avoidance of the specific feared object, activity or situation.
In SAD the intense and persistent fear is of being in the company of unfamiliar people, scrutiny by others in a social situation, or a fear of behaving in a way that might cause embarrassment, humiliation and/or ridicule.
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. The very normality of social anxiety has meant that SAD is often undiagnosed.
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 immediately anxious and extremely 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 and that he/she is not. Small mistakes may appear much more serious than they really are and the person feels that his/her every move or reaction is noticeable to others. Blushing may in itself be painfully humiliating to the person.
SAD can be limited to only specific situations. The most common anxiety-provoking social situation is public speaking. However, other situations such as signing cheques or contracts before witnesses, using public toilets, eating and drinking in public, and talking on the phone may also cause anxiety.
In some cases, fears are more generalised and include most social situations.
The intense anxiety may lead to avoidance behaviour. Children may not be able to avoid feared situations and may be unable to identify the nature of their anxiety. When the person faces the feared situation, it is endured with great anxiety and discomfort.
Adolescents and adults with SAD realise that their anxiety is irrational and excessive but are unable to control it. This is not, however, always the case in children.
SAD shouldn’t be confused with shyness. Shy people may feel very uneasy around others but do not experience the same anxiety in anticipation of the event and do not typically avoid social situations. People with SAD are not necessarily shy. They may be completely at ease in social situations most of the time and the anxiety only surfaces in certain situations.
Anxiety can take the form of panic attacks during or before the feared situation.
The fears and 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.
In children, there may be a decline in school performance due to test anxiety or classroom participation, school refusal or avoidance of age-appropriate social activities.
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 and refrain from dating.
SAD is often accompanied by another psychiatric disorder, especially another anxiety disorder such as panic disorder or obsessive compulsive disorder, or depression. 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.
What causes SAD?
The exact cause is not known. However, SAD appears to run in families. As in the case of other anxiety disorders, this disorder seems to be underpinned by various brain circuits. For example, work by the MRC Unit on Anxiety Disorders in Cape Town has shown that activity in an area of the brain, called the cingulate, is normalized during treatment of SAD.
Who gets SAD?
SAD occurs in all societies and racial groups although it may manifest differently across cultures, depending on social demands. In some cultures the fear may be more related to offending others, rather than embarrassment.
It is estimated that up to 13% of people suffer from SAD.
Although the disorder can have its onset in childhood, the average age of onset is between 15 and 20 years. It is, however, not uncommon to experience the first symptoms in early adulthood.
Women with SAD are more common in community studies, but men present more commonly for treatment.
What are the symptoms?
Symptoms can have a sudden or insidious onset. 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. In severe cases, panic attacks are present.
Children may express anxiety through crying, tantrums, refusing to participate in group play, freezing or shrinking from social situations with unfamiliar people.
SAD usually emerges in mid-adolescence. In some cases there is a childhood history of social inhibition or shyness.
In many cases a traumatic social event triggered the development of SAD. In other cases, no precipitating event is evident. If left untreated, SAD is a chronic, relentless disorder.
Severity may fluctuate – during stressful times symptoms may be worse than at other times. Symptoms may disappear if life 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 may result.
How is SAD diagnosed?
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 the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).
As the symptoms of SAD closely resemble other psychiatric conditions such as Avoidant Personality Disorder or Panic Disorder, additional diagnoses may be necessary.
When to see a mental health professional
A mental health professional should be seen if social anxiety is causing distress or 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 co-morbid conditions, such as depression and alcohol abuse.
People with SAD should tell the doctor about when it was first noticed, 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 symptoms. If the person underwent psychotherapy, it is important to mention the kind of psychotherapy used.
How is it treated?
Treatment can greatly relieve the symptoms and improve quality of life. About 80 percent of people who suffer from SAD find relief from their symptoms when treated with psychotherapy and/or medication. SAD is very seldom treated on an in-patient basis.
Any co-existing disorder should also be treated.
Several different medications can be used to treat SAD. These include antidepressants, beta-blockers and benzodiazepines.
Anti-depressants are the first line of treatment.
Selective Serotonin Reuptake Inhibitors (SSRI’s)
These antidepressants act on the neurotransmitter serotonin and also treat depression which often co-exists with SAD. Examples of SSRI’s are sertraline (Zoloft) and fluoxetine (Lilly-Fluoxetine). 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 dose is reached. The disadvantage of these antidepressants is that, unlike benzodiazepines, they take a month or longer before the person notices a relief of symptoms. 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 and nausea may be experienced. Fortunately they will gradually disappear after a while. 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 interaction, 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, because of their addiction potential and because of problems 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 a specific form of SAD called performance anxiety. These drugs are used on the day of a specific social situation (for e.g. 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 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.
CBT focuses on changing negative thought patterns. The therapist will challenge cognitive distortions such as catastrophising, probability overestimation and all or nothing thinking and encourage the development of a positive mindset.
Self-monitoring is an important part of CBT. The person is encouraged to pay closer attention to thoughts and feelings.
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.
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 has helped many people cope with anxiety disorders and depression. There are several groups throughout the country. They can be contacted at (011) 262 6396. Organisations such as Toastmasters can help people become more comfortable with public speaking.
Can SAD be prevented?
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. However, at present this is a theoretical idea.
For more information on SAD and other anxiety disorders, the book “False Alarm: How to Conquer the Anxiety Disorders” is available from the MRC Unit at (021) 938 9229 or the Mental Health Information Centre at (021) 938 9229.
Reviewed by Dr Soraya Seedat, psychiatrist and co-director, MRC Unit on Anxiety Disorders.