Summary –

Social Anxiety, Social Anxiety Disorder (SAD) or Social Phobia is a common anxiety disorder. Individuals with SAD tend to have a reserved personality, they become shy and quiet in unfamiliar social settings. They avoid interacting with new people and may or may not show visible symptoms of discomfort and anxiety. It can be confused with normal shyness, or having an introverted personality however it can be differentiated by its persistent and intense nature affecting other aspects of the individual’s life. Studies for treatment show improvement in the symptoms through cognitive-behavioral therapy (CBT).

 Key definitions –

Social anxiety disorder, also known as social phobia, is a mental health condition causing intense fear and anxiety in social situations due to a deep fear of being judged, scrutinized, or embarrassed by others, leading to significant distress and avoidance of social interactions, affecting daily life, work and relationships. It is characterized by intense fear, overwhelming anxiety, worrying about being judged and avoidance of social situations.

Cognitive Behavioral Therapy is a practical, goal oriented talk therapy helping the individual understand themselves better by identifying patterns and behaviors and to formulate new ways to cope with these situations better. It focuses on the connections between the individual’s thoughts, feelings and actions.

 Article –

What is Social Anxiety?

Social Anxiety Disorder or social phobia is a common anxiety disorder that has a debilitating impact on the life of the affected individual. It is not only limited to how it makes the individual feel, but how it also affects their relationship with everything around them. It hampers their work, daily life and interpersonal relationships, all of which can further lead to a negative effect on their overall mental health.

It has an early age of onset, with symptoms often appearing by the age of 11 in about 50% individuals and by 20 in 80% individuals (Stein et al., 2008). Since it begins at an early age, it can often be mistaken for shyness as the child may refrain from meeting others and not be very social. However, shyness, or social reticence is a common personality trait and is not accompanied by the detrimental aspects seen with social anxiety.

People with social anxiety fear and avoid the scrutiny of others because they feel like they will say or do something which will result in embarrassment or humiliation. Based on the findings of Amanda Morrison and Richard Heimberg, this process begins with the perception of an audience having the potential to judge an individual, whether or not they actually do so. This then stimulates a mental representation of oneself in the mind of others, however, this imagery is fed by a history of negative social experiences or a distorted self-perception. This causes the person with SAD to conclude that their image in the mind of the audience is poor, or on the contrary, the expectations are so high that they see it as an unattainable standard for their performance (Morrison et al., 2013).

How does an individual with SAD present in a clinical scenario?

Listed below are some of the common symptoms seen in a person with social anxiety disorder:

(i)   The individual appears shy, quiet and withdrawn in social settings. This may create an image of them being ‘snobbish’ in the eyes of the audience.

(ii)  They may show physical evidence of discomfort like blushing or avoiding eye contact with other, especially unknown, parties in the situation

(iii) They experience symptoms not visible to others like extreme fear, palpitations ‘racing heart’, sweating and trembling

(iv)They tend to have low self-esteem and often have trouble concentrating

(v)  They also show a fidgety, avoidant behavior when they experience discomfort/distress.

 Since Social Anxiety Disorder (SAD) presents with a set of symptoms which are not specific to the disease, it can often be confused with other conditions leading to false diagnoses. Some of the differential diagnoses for SAD are listed below:

(i)   Normal shyness – a personality trait, which is not by itself considered pathological.

(ii)   Panic disorder – panic attacks are sudden presentations of severe anxiety, characterized by tachycardia, breathlessness

(iii)   Agoraphobia – avoidance of situation where an individual fears a panic attack might occur.

-      To differentiate, we must inquire about their cognitions experienced by the individual. A person with SAD is keenly aware of the source of anxiety ie scrutiny by others, however, those with agoraphobia have no explanation for the cause of their symptoms (sudden, unexpected symptoms)

(iv)  Major depression – SAD frequently co-occurs with major depression; it is also a significant risk factor for subsequent onset of major depression.

-      SAD should not be diagnosed if social avoidance is confined to depressive episodes.

(v)   Other psychiatric disorders – schizophrenia, bipolar disorder, eating disorder etc.

It is important to understand the underlying cause of the individual’s actions to be able to provide them with an accurate diagnosis and further treatment.

 How to treat this condition?

The most well-researched as well as the most effective form of therapy for social anxiety disorder is cognitive-behavioral therapy (CBT) (Rodebaugh et al., 2004). CBT comprises of several practical ways to identify and change unhelpful thinking patterns and behaviors in individuals to improve mood and cope better with challenging situations such as –

(i)   Exposure: As the name suggests, exposure therapy encourages the participant to enter and remain in a distressing situation intentionally. This method does not lead to unlearning fear responses, but it generates new, more ambiguous learning that competes with the original fear response. (Bouton, 2002; Bouton and King, 1986)

-      The client is instructed to stay in the feared situation, with the expectation that it would produce new learning or habituation and cause reduced anxiety in that situation.

(ii)  Applied Relaxation Progressive Muscle Relaxation: PMR is a well-known technique for management of physical symptoms of anxiety. However, PMR by itself, is considered to be insufficient as a treatment. It forms the underlying basis for applied relaxation which shows some efficacy in the treatment of SAD.

-      Clients are trained to practice relaxation in daily activities. With frequent practice, they are able to confront fearful situations effectively.

(iii)  Social Skills Training: This model is taken into action when it is understood that the social anxiety stems from the lack of confidence or experience of the individual in social interaction skills. To combat this problem, a combination of modeling, behavioral rehearsal, corrective feedback and positive reinforcement is brought in. This gently encourages the person with SAD to engage in social situations confidently thus reducing or reversing their social anxiety.

-      Social skills training also inevitably includes exposure therapy as well since the development of social interaction skills cannot take place without a social setting.

(iv)   Cognitive Restructuring: This model is based on the understanding that the cause of social anxiety is not the situation, but the thoughts of the person with SAD.

-      “Automatic thoughts” i.e. negative, inaccurate, distressing thoughts are identified and are disputed. This is often paired with exposure therapy and performed before, during and after a situation to challenge these automatic thoughts and getting out of the loop of habit.

 In the broad perspective, the aim of all CBT practices is to facilitate the person with SAD to view the situation in a different light by focusing on different anxiety-inducing aspects. Due to the main goal of the therapy being common, it is difficult to assess any difference in the efficacy of the various methods. However, a combination of 2 or more of these tend to show a better result either in the sense of a greater stride of improvement, or a shorter duration required to see an impact.

References:

1.     Stein, M. B., Stein, D. J., University of California San Diego, Veterans Affairs San Diego Healthcare System, & University of Cape Town. (2008). Social Anxiety Disorder. In Seminar (Vol. 371, pp. 1115-1116) [Seminar]. The Lancet. https://www.thelancet.com

2.     Morrison, A.S., Heimberg, R.G., & Department of Psychology, Temple University, Philadelphia, Pennsylvania 19122. (2013). Social anxiety and social anxiety disorder. In Annu. Rev. Clin. Psychol. (pp. 249-274). https://doi.org/10.1146/annurev-clinpsy-0502120185631

3.               Rodebaugh, T. L., Holaway, R. M., Heimberg, R. G., & Adult Anxiety Clinic of Temple University. (2004). The treatment of social anxiety disorder. In Clinical Psychology Review (Vol. 24, pp. 883-908). https://doi.org/10.1016/j.cpr.2004.07.00



Author: Riya Agarwal
Riya Agarwal is an MBBS student, currently in her third year at GMERS Medical College, Ahmedabad. 
She is deeply curious about understanding the human mind, brain function, and the biological basis of behavior and disease. Through her academic journey, she aims to explore the intersection of clinical medicine and neuroscience, with a long-term vision of contributing meaningfully to research and patient care in the field of mental health.