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Social anxiety disorder is an overwhelming fear about social situations that can have a significant impact on your life. There are a range of triggers, causes, risk factors and co-existing conditions but once diagnosed it can be successfully treated.

It is quite common to feel nervous about social situations but if you feel overwhelming fear or dread about social (or performance) situations, you may be diagnosed with social anxiety.

Social anxiety disorder is also used interchangeably with the term social phobia, although some argue that they are two distinct conditions. Social phobia concerns the fear of scrutiny and judgment whilst carrying out a task in public; whereas social anxiety refers to intense feelings of nervousness and overwhelming self-consciousness that are experienced in one-to-one and group situations. The symptoms mentioned above for both — social anxiety and social phobia — are now covered under the umbrella-term of social anxiety disorder, which is the official diagnosis for those suffering from excess social anxiety in a wide range of scenarios.

Social anxiety is not just being shy. It causes an overwhelming fear that doesn't abate and which impacts upon all areas of a person's lie. It is not unusual to be apprehensive or nervous on occasion in regards to social situations, but someone with social anxiety has a heightened sense of fear before during and after such situations. The sufferer will typically be fearful of embarrassment or fear negative evaluation by others. The individual may tolerate social situations but in a state of extreme discomfort or they may avoid situations altogether.

You may have social anxiety if you:

  • Are highly apprehensive about everyday encounters, which may include having to meet people you don't know, initiating conversations, or having a telephone conversation

  • Agonize about social activities, such as group conversations, eating with others or parties

  • Perpetually fret about doing something embarrassing, or appearing incompetent

  • Feel incredibly uncomfortable doing things when others are watching

  • Dread being criticized, avoid eye contact or have self-esteem issues

  • Frequently experience nausea, perspiring, shaking or palpitations

  • Experience panic attacks.

Common triggers

  • Eating in public (in front of others)

  • Speaking in public

  • Being the focus of attention

  • Talking to people you don't know

  • Meeting new people

  • Going to interviews

  • Going to school or work

  • Having to look other people in the eye

  • Using public toilets

Causes of social anxiety disorder

As with most mental health conditions, the exact cause of social anxiety disorder (social phobia) is still unclear. However, studies suggest (as with most things) that both nature and nurture play a role. Both environmental factors and genetics are likely to be involved and while childhood abuse or other early-life psychological adversity cannot be proven to cause social anxiety disorder, they can be regarded as risk factors.

Genetics may possibly play a role in the development of social anxiety as behavioral traits involved in the process are genetically shaped. Social anxiety disorder is often found in families – studies indicate that close-knit relatives have a two to six times greater likelihood of experiencing a social anxiety disorder. This is likely to be because patterns of behavior are often adopted across individuals in groups and so, for example, if your parent displays social anxiety then you are likely to grow up feeling that social situations are to be feared.

Those with a tendency to behavioral inhibition and also fear of judgment will necessarily be predisposed to social anxiety disorder. Behavioral inhibition is a term used to describe a personality style or temperament type, characterized by a cautious and someone reluctant approach; it concerns the tendency to become easily distressed by and/or withdraw from unfamiliar situations, people, or environments. Children who exhibit this personality temperament tend to retain this trait throughout childhood and tend to be more likely to go on to develop social anxiety disorder as adults.

Whether it is cause or effect, there do appear to be differences in brains and brain chemistry in those with social phobia. One study showed increased blood flow in the amygdala (part of the limbic system associated with fear) in those with social anxiety disorder and those without the disorder seemed to have greater blood flow to the area of the brain responsible for thinking and/or evaluation. Interestingly, people with a social anxiety disorder also appear to have imbalances in neurotransmitters also seen in those with agoraphobia and panic disorder.

Diagnosis of social anxiety disorder

Social anxiety disorder is diagnosed through an interview and using psychometric measures or self-report questionnaires. A clinician will want the person to describe what symptoms they are experiencing and discuss situations where they arise. The diagnostic criteria for social anxiety disorder in the DSM-5 includes:

  • Considerable fear or anxiety about social situations (lasting for 6 months or more) where the person individual is exposed to situations where scrutiny by others may be possible

  • Significant anxiety around exposing difficulties that could be negatively evaluated by others. In children, the anxiety must arise when among age-peers

  • The situations invariably result in fear and anxiety

  • The situations are either avoided or tolerated but experienced adversely (with intense fear)

  • The anxiety is disproportionate to the actual threat

  • It leads to significant functional impairment

  • It can not be attributed to another condition or medication.

Comorbidity and Risk Factors

Social anxiety is a common problem that often emerges in teenage years but typically resolves as the person ages. However, for some people, it becomes more and more entrenched over time and becomes pathological or a “disorder”. Social anxiety disorder is believed to affect approximately 15 million people or around seven percent of adults in the United States and is more common in women than men. Many children and adolescents also experience social anxiety symptoms - the condition often develops at a relatively young age in comparison with other mental health conditions (average age of onset is 13).

Social phobia is the most common anxiety disorder experienced after specific phobia. Many people with a social anxiety disorder also have other mental health issues, such as depression, panic disorder, PTSD, bipolar disorder, personality disorders, and alcohol dependence; it has extremely high morbidity with specific phobias. Studies also suggest that social anxiety disorder is a risk factor for other disorders developing, such as severe depression. It is also commonly found to co-occur with many medical conditions such as irritable bowel syndrome, stuttering, obesity, and major burns victims.

Treatments of social anxiety disorder

Despite effective treatments being widely available, less than five percent of people with social anxiety disorder seek treatment and more than 30 percent of people report symptoms in excess of 10 years before seeking help.

Treatment for most anxiety disorders consists of two possible elements: psychological therapy and medication.

  • Psychological therapies: the therapy with the strongest evidence base is Cognitive-Behavioral Therapy or CBT. This works by focusing on how your thoughts affect how you feel and behave and looks to challenge dysfunctional thoughts and understand core self-beliefs (the assumptions we have about ourselves and others as well as the world around us) to change behavior. With Social Anxiety Disorder, there must be a strong element of cognitive restructuring for the approach to be successful. Other possible approaches include Eastern-based approaches such as Mindfulness or Acceptance and Commitment Therapy or, on occasions, for more deep-seated issues, Psychodynamic Psychotherapy.

  • Medication: the first point of call with medication tends to be to prescribe an anti-depressant, often of the SSRI (Specific Serotonin Re-uptake Inhibitor) or SNRI (Specific Noradrenaline Re-Uptake Inhibitor) varieties.

Things you can try if suffer from social anxiety disorder

Self-help strategies are unlikely to be sufficient to cure social anxiety, but they can reduce their severity and so may be a useful first step.

  • It is important to learn to understand your anxiety. Therefore thinking about what is in your mind and your response in social situations can enable you to reach a clearer understanding of your difficulties.

  • Where you identify that beliefs are disproportionate or “unrealistic” you can try to replace them with more proportionate or “rational” ones.

  • Try not to ruminate over how you are seen by others; you could focus on others instead. It is worth reminding yourself that and your anxiety symptoms are unlikely to be obvious to other people.

  • Recommence activities that have previously been avoided. This is often challenging but if you approach it gradually, then progress can slowly be made.

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