Social Anxiety Disorder

Social anxiety disorder is an intense fear of being criticized, judged, rejected, embarrassed, or offending others. It is the most common anxiety disorder affecting up to 12 percent of adults at some point in their life.[1, 2] Performance anxiety and stage fright are the most common types of social anxiety. Social anxiety limits your life in many ways: you have difficulty with personal interactions, social settings, and being assertive at work.

Fortunately, social anxiety disorder is a very treatable condition. You can get better. A good place to begin is with an overview of anxiety including the symptoms, causes, and treatment.

Five Symptoms of Social Anxiety

These are some of the symptoms you might experience in a social setting, or if you’re worried you might be judged:

• You blush, sweat, tremble, or go rigid
• Your heart begins to race
• You feel nauseous or sick to your stomach
• You make little eye contact, or speak with a soft voice
• You mind goes blank

Social anxiety disorder usually starts early in life. About 75 percent of individuals with social anxiety disorder developed the symptoms between the ages of 7 and 15 years old.[3]

Definition of Social Anxiety Disorder

Social anxiety disorder criteria based on the DSM-5 [3]

• Do you feel anxious in at least one social setting, worrying that you might be judged? For example;
• Conversations
• Being around people
• Eating in public
• Speaking up at work
• Speaking in front of others or performing
• Does that social setting almost always make you feel anxious?
• Do you either avoid that social setting or reluctantly endure it?
• Do you worry that people will see your anxiety and judge you?
• Do other people consider you worry out of proportion to the actual threat posed by that social situation?
• Have your symptoms lasted for at least six months?
• Has your worry had a significant negative impact on your life (relationships, work, social life, or emotional life)?
• Your symptoms are not due to medication, substance abuse, or any other medical condition (e.g., hyperthyroidism).
• Your symptoms are not due to another mental health condition such as generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, or post-traumatic stress disorder.

If you answered yes to all of the above criteria, you may meet the DSM definition of social anxiety disorder.

Tests

Medical Tests

Your health care provider can determine if your social anxiety disorder is caused by an underlying medical condition, such as heart disease or thyroid problems. This may require blood tests and an electrocardiogram (ECG). A complete assessment should also include questions about your caffeine and alcohol consumption, and any substance use, which can contribute to an anxiety disorder.

Standardized Screening Test for Social Anxiety Disorder

The Social Phobia Inventory (SPIN) has been proven to be effective for the diagnosis of social anxiety disorder.[4] There are also a number of screening tests for anxiety in general. [5]

Causes of Social Anxiety

Before looking at the treatment of social anxiety disorder, it helps to understand the causes because that can help guide you to the appropriate treatment.

Negative Thinking

If you have social anxiety, you probably engage in at least one of these types of negative thinking:

• You feel you are different, an outsider, less than.
• You don’t think you have what it takes to cope well with social situations.
• You are hard on yourself.
• You overestimate the consequences of making a mistake or not being perfect.
• You think that other people cope better than you do.
• You believe you have little control over your thoughts or emotions.
• You feel as if you are swept along by your emotions.
• You think it is easier to avoid social situations rather than confront your fears.

The result of these kinds of negative thinking is that you excessively worry about being criticized, judged, rejected, or embarrassed. But negative thinking is learned thinking, therefore it can be unlearned, and healthier thinking can be relearned in its place. You can change your thinking with a combination of cognitive behavioral therapy (CBT) and mindfulness methods.

Parental Factors

Some parenting traits are known to contribute to social anxiety disorder by contributing to negative thinking. These include anxiety, overprotection, lack of warmth, criticism, shaming, and overcontrol.[6]

Parents often struggle with their own lack of coping skills or mental health issues. One study found that parents who had an anxiety disorder were less nurturing and more controlling than parents who did not have an anxiety disorder.[7] Although parents can contribute to social anxiety, it is important to not let a discussion of parental factors turn into “parent bashing,” which helps no one. Parents are generally doing the best they can with the tools they have.

A child learns not only from what parents say but also from what parents do. Parents can contribute to negative thinking by what they “show and tell.” Socially anxious parents are more likely to avoid social situations or become resentful if they have to go. They may go grudgingly, but then emphasize how much they disliked the situation afterwards. They may even encourage you to avoid social situations like school events by providing excuses for you.

Destructive Criticism

What is the most common fear people have? Most people would say fear of death or fear of failure. But if you were really honest, your biggest fear is being judged or criticized. You worry about what other people think about you. You worry if they like you, or if they think you’re incompetent. It affects everything you do. It affects everything from what you say to the clothes you wear.

Destructive criticism sounds like; “Don’t be silly.” “Can’t you do anything right?” “You’ll never amount to anything.” “Don’t be stupid.” Destructive criticism doesn’t offer any constructive help. Everyone has heard it before. Small doses of it are normal. Parents do the best they can, and nobody is perfect. But the more you hear destructive criticism, the more you begin to believe it. Eventually you’re afraid of doing things in front of other people, because you fear you’ll be judged.

Social anxiety disorder can be self-fulfilling. Suppose you are nervous about an upcoming social situation or work event. The more nervous you are, the less likely you will perform well or enjoy the event. This makes it more likely that you will anticipate the next social event with even more anxiety, which sets up a vicious cycle.

Overcontrolling Family

How does an overcontrolling parent contribute to social anxiety disorder? The show and tell messages you receive from a controlling parent imply the following:

• The world is a dangerous place.
• I am watching out for you, because you’re always messing up.
• You can’t deal with the world on your own.

If you heard those messages growing up, you probably didn’t get the chance to explore your environment or learn new skills on your own. This makes you feel that you’re ill-equipped to face the world. You feel that you need a guardian or protector, and without one you don’t have what it takes to cope with social situations.

Life Events

A number of stressful childhood events are known to contribute to social anxiety.[6]

• changing schools
• bullying
• poor academic performance
• childhood illness
• feeling different due to cultural or class differences
• separation from parents
• death or illness of parents
• parental marital problems or divorce
• family violence
• physical or sexual abuse

All these factors contribute to social anxiety because they can lead to the types of negative thinking, associated with social anxiety.

• You feel you are different, an outsider, less than.
• You don’t think you have what it takes to cope with social situations well.

Take for example, separation from parents, or parental marital problems. Children usually assume that family problems are somehow their fault. Therefore if these problems do occur, your first reaction is to assume that you are not good enough.

Substance Use

Tobacco, caffeine, drugs, and alcohol can all increase anxiety and the risk of developing social anxiety disorder. If you suffer from an anxiety disorder, the quickest thing you can do to reduce your anxiety is quit smoking tobacco and reduce your caffeine use.

Long-term substance abuse of drugs or alcohol leads to increased anxiety. Even drugs that are initially calming, such as tranquilizers, alcohol, and marijuana will eventually cause increased anxiety.

Genetics

Recent studies have begun to look at genetic predisposition towards social anxiety. The more genetically predisposed you are, the easier it is for environmental factors to push you into social anxiety.

An amazing study on genetic predisposition has shown that a child’s behavior at four months old can predict whether they will develop social anxiety symptoms when they are seven years old. A child is considered “highly reactive” at four months old if it shows vigorous motor activity and crying at unfamiliar stimuli. Children who are highly reactive at four months old are more likely to be shy in preschool and develop social anxiety symptoms at seven years old.[8]

One study followed 1,700 twins for 8 years, and found that genes contributed up to 50 percent of the chance of developing social anxiety disorder.[9]

Medical Causes

A number of medical conditions can cause anxiety symptoms. These include an overactive thyroid, hypoglycemia, mitral valve prolapse, anemia, asthma, COPD, inflammatory bowel disease, Parkinson's disease, and dementia among others. Your physician may perform certain tests to rule out these conditions. But it is important to remember that anxiety is more often due to poor coping skills or substance abuse than any medical condition.

Treatment of Social Anxiety Disorder

The three main treatments for social anxiety disorder are cognitive behavior therapy, mindfulness-meditation, and anti-anxiety medications.

Five Things You Can Do About Your Social Anxiety Disorder

• Avoid smoking, alcohol, and caffeine, which can cause anxiety symptoms.
• Review your over-the counter medications such as diet pills and cold medications that can contain stimulants, which may trigger anxiety.
• Learn relaxation and stress-management techniques and make them part of your life. Develop healthy coping skills.
• Rule out any medical causes for your symptoms.
• Ask for help. Talk with a health professional about your anxiety. Review your thought patterns, and identify any negative thinking that can contribute to your anxiety.

Cognitive Behavior Therapy for Social Anxiety Disorder

If you don’t change the underlying negative thinking that causes your anxiety, then any other treatment will probably have only temporary benefits.

Cognitive behavioral therapy (CBT) changes your inner dialogue. It is a step-by-step method for identifying the negative thinking that contributes to your anxiety disorder and replacing it with healthier ways of thinking. Numerous studies have shown that cognitive behavioral therapy is effective for treating all forms of anxiety.[10]

MRI studies have shown that the benefits of cognitive behavioral therapy are not just temporary. It has lasting benefits, because you change your own brain pathways through CBT, and they begin to reflect your new way of thinking.[11, 12]

Besides changing your thinking, cognitive behavioral therapy also has a behavioral component. The idea is to take small steps into your anxiety-provoking situations as you develop healthier thinking patterns. In this way you get to exercise your new coping skills and see that you can safely negotiate social situations. (Learn more about cognitive behavioral therapy)

Stress Management, Meditation and Mindfulness for Anxiety

Stress management methods such as meditation and mindfulness are being incorporated into medicine. The evidence is overwhelming that these methods are effective in treating anxiety disorders.[13, 14] There are a number of stress management techniques to choose from. All are effective, and which one works for you is largely a matter of personal choice. Start slowly with ten minutes a day, and see how you will reduce your anxiety and change your life. (Learn more about stress management and mindfulness)

Social anxiety is treatable. The most important step you can take is reaching out and asking for help. You can change your life.

References

1. National Comorbidity Survey, Lifetime Prevalence of DSM-IV Disorders.  https://www.hcp.med.harvard.edu/ncs/ftpdir/NCS-R_Lifetime_Prevalence_Estimates.pdf.
2. Ruscio, A. M., Brown, T. A., Chiu, W. T., Sareen, J., et al., Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychol Med, 2008. 38(1): p. 15-28. PMC2262178.
3. American Psychiatric Association, DSM-5 The Diagnostic and Statistical Manual of Mental Disorders. 5 ed, ed. D. Kupfer: American Psychiatric Association.
4. Connor, K. M., Davidson, J. R., Churchill, L. E., Sherwood, A., et al., Psychometric properties of the Social Phobia Inventory (SPIN). New self-rating scale. Br J Psychiatry, 2000. 176: p. 379-86.
5. Beidas, R. S., Stewart, R. E., Walsh, L., Lucas, S., et al., Free, brief, and validated: Standardized instruments for low-resource mental health settings. Cogn Behav Pract, 2015. 22(1): p. 5-19. PMC4310476.
6. Brook, C. A., & Schmidt, L. A., Social anxiety disorder: a review of environmental risk factors. Neuropsychiatr Dis Treat, 2008. 4(1): p. 123-43. PMC2515922.
7. Lindhout, I., Markus, M., Hoogendijk, T., Borst, S., et al., Childrearing style of anxiety-disordered parents. Child Psychiatry Hum Dev, 2006. 37(1): p. 89-102.
8. Kagan, J., Childhood predictors of states of anxiety. Dialogues Clin Neurosci, 2002. 4(3): p. 287-93. PMC3181685.
9. Kendler, K. S., Karkowski, L. M., & Prescott, C. A., Fears and phobias: reliability and heritability. Psychol Med, 1999. 29(3): p. 539-53.
10. Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T., The empirical status of cognitive-behavioral therapy: a review of meta-analyses. Clin Psychol Rev, 2006. 26(1): p. 17-31.
11. Beutel, M. E., Stark, R., Pan, H., Silbersweig, D., et al., Changes of brain activation pre- post short-term psychodynamic inpatient psychotherapy: an fMRI study of panic disorder patients. Psychiatry Res, 2010. 184(2): p. 96-104.
12. Linden, D. E., How psychotherapy changes the brain--the contribution of functional neuroimaging. Mol Psychiatry, 2006. 11(6): p. 528-38.
13. Manzoni, G. M., Pagnini, F., Castelnuovo, G., & Molinari, E., Relaxation training for anxiety: a ten-years systematic review with meta-analysis. BMC Psychiatry, 2008. 8: p. 41. PMC2427027.
14. Vollestad, J., Nielsen, M. B., & Nielsen, G. H., Mindfulness- and acceptance-based interventions for anxiety disorders: a systematic review and meta-analysis. Br J Clin Psychol, 2012. 51(3): p. 239-60.