Social Anxiety Disorder: Understanding Symptoms, Causes & Treatment

Whenever I think of social anxiety, I am reminded of a nugget of advice an old friend offered me, which he had borrowed from his psychiatrist father: “When you’re feeling anxious in a social setting, pretend that there’s something you are smarter about than everyone else in the room.”

Over the years, this advice has helped me not only navigate social settings, but also identify the things I’m good at or feel smart about, and lead conversations with that.

Over the years, I’ve also learned another useful way of dealing with awkwardness in social settings: Ask questions. Whenever you’re engaged in a conversation and don’t know what to talk about, ask the other person questions about their life, or general topics such as travelling or pop culture so that the weight of sharing doesn’t fall on you.

While these two tips may be helpful for anyone who finds engaging in conversation challenging, social anxiety can be more complicated than cocktail conversations, having a deeper impact on one’s life and functioning.

Social anxiety disorder goes beyond feeling awkward in social interactions and is characterised by a fear of being scrutinised or negatively evaluated. This fear can make everyday interactions anxiety-provoking and lead to feelings of embarrassment or self-consciousness. When anxiety becomes extreme, one may want to avoid social situations altogether, contributing to the development of a phobic stance toward social interactions.

While social anxiety can be triggered even in everyday interactions - like feeling judged by a friend who’s always meant well - certain situations or settings can be extremely triggering.

Typically, social anxiety is triggered in situations that involve interaction, observation or performance. These include dates, interviews, presentations, public speaking or speaking in front of a large group, large social gatherings, family gatherings, or situations wherein one is expected to meet or network with strangers.

The terms social anxiety and social phobia are used interchangeably. Until the 1960s, social phobia was the preferred term for the condition wherein one fears being judged in social interactions. Post 1960s the term social anxiety became more popular, as it encapsulates the extreme nervousness or discomfort associated with the condition.

Worldwide, around 2 to 5% of adults are believed to suffer from social anxiety. Social anxiety disorder impacts both men and women equally and symptoms usually begin during adolescence. In adolescents, common manifestations of social anxiety include avoidance of performative activities such as participating in debates and school performances, avoidance of authority figures, and difficulties making new friends.

Some risk factors for the development of social anxiety disorder include family history, negative experiences such as bullying or harassment, conflict or instability at home, and concerns related to one’s appearance.

Social anxiety may be generalized or specific. In generalized social anxiety, most social interactions invoke a feeling of discomfort or nervousness and the fear of being judged. One may want to avoid socializing altogether or feel drained after having to engage with others for some time. In specific social anxiety, there are limited or specific situations that trigger anxiety. Usually, these are situations that involve some sort of a performative element like public speaking.

A lot of kids and adults out there are shy and may feel uncomfortable in social settings. While this may raise some concerns, it’s important to remember that shyness and social anxiety are quite distinct from one another.

While social anxiety is a diagnosable anxiety disorder that can impact one’s daily functioning, shyness is a personality trait. A shy person - child or adult - may feel slight discomfort in social settings but generally, is able to work through this and motivate themselves to participate when necessary.

A shy individual is someone who may take time to warm up to a new setting or a relationship but is likely to open up and get comfortable with time. On the other hand, someone with social anxiety disorder is likely to experience symptoms of anxiety (palpitations, sweaty palms, digestive issues, intrusive thoughts, excessive worry) when an encounter with a social interaction occurs.

Symptoms and Causes of SAD[social anxiety disorder]

Social anxiety is marked by anxiety being triggered by one or more social settings. This anxiety may show up as:

Emotional and behavioural symptoms:

One may experience intense worry or self-consciousness in a social setting. In some cases, this intense worry may lead one to avoid social interactions altogether.
When one does engage, one may find themselves overthinking the interaction
One may experience negative self-talk or criticism for the way they behaved
To manage or compensate for this extreme discomfort, one may either stay quiet and disengaged in social settings, or compensate by oversharing or other “fawning” or people-pleasing responses

Physical symptoms:

Anxiety is a mind-body event and is often accompanied by physical symptoms such as:

Sweaty palms
Rapid heartbeat
Dizziness or light-headedness
Blushing
Quiver in the voice or tremors in hands
Headaches

Comorbidity:

Social anxiety disorder is often accompanied by some other psychiatric or psychological condition. The most commonly co-occurring mental health conditions with social anxiety disorder are depression, PTSD and alcohol or substance abuse.

Social anxiety disorder may be precipitated by several factors including genetics and family history, social experiences, personality traits and thought patterns, and use of substances.

Genetics and Family Environment:

Studies show that social anxiety disorder is inheritable. However, when mediated by family and other social environments, the influence of heredity seems to change. In simple words, while one may have a strong genetic predisposition to social anxiety disorder, the social environment may either exacerbate or diminish its impact.

For example, despite a family history of social anxiety disorder, if one is provided with a nurturing, stable and safe environment at home and school, the chances of developing social anxiety may be reduced.

Social experiences that may precipitate the onset of a social anxiety disorder include bullying, harassment or trauma. Difficulties with peer groups or an unstable home environment may also contribute to the development of social anxiety disorder. Culturally, social norms, gender roles and role expectations, socially acceptable milestones and conduct are some factors that may cause feelings of anxiety in social settings.

Psychological factors:

While we may see perfectionism as something to be revered, perfectionistic traits in fact tend to contribute to social anxiety. This association is stronger when one is also concerned with a perfectionistic self-presentation - meaning when one doesn’t just want to achieve a high standard for themselves, but also wants to be seen in a positive light by others.

Other cognitive factors that contribute to social anxiety include poor social goals, low perceived emotional control or regulation, poor social skills and negative self-perception or low self-esteem.

Substance-induced:

Social anxiety and substance use, especially the use of alcohol, are correlated and commonly co-occur. One might say that those who are prone to social anxiety may lean on substances as a crutch to navigate social situations. However, the use of substances tends to make the anxiety worse.

How does SAD develop?

For any mental health condition, the development is not linear. Mental health conditions develop as a result of interactions between various different factors, including biology, social interactions, personal and interpersonal experiences, and even cultural factors.

While social anxiety disorder is influenced by one’s genetic pool, the likelihood of it developing in an individual is more deeply related to one’s social experiences. One’s personality traits and dispositions also interact with social situations in the development of social anxiety.

As discussed, one’s social experiences play a significant role in the development of social anxiety. One social experience that is relatively new, but impacts many of us is social media. Social media has become an invasive and unavoidable part of life for many people. While the emotional distance created by social media platforms can help facilitate communication and even create work-related opportunities for people with social anxiety, it has its downsides too.

Social media can allow one to compensate for deficits in their ability to interact with others. Having said that, social media is also a space where evaluation and comparison are ripe. If one is anxious about being evaluated negatively by others, social media can further fuel this. Comparing oneself to others on social media can also fuel social anxiety.

Social anxiety disorder can be diagnosed by a mental health professional like a clinical psychologist or a psychiatrist. A mental health professional would take a detailed history, and administer assessments that can help diagnose social anxiety. They would also refer to the DSM criteria for the diagnosis of social anxiety disorder.

The DSM criteria for the diagnosis of social anxiety disorder include:

The individual feels anxious about one or more social interactions or situations, fearing being negatively evaluated.
Social situations almost always provoke fear or anxiety
The fear or anxiety seems out of proportion
Avoidance of social situations
Fear or anxiety cause clinically significant distress, and symptoms last for at least 6 months
The fear or anxiety are not attributable to other factors such as substance use, or another existing medical or mental health condition

Social anxiety can be managed and treated. Depending on the intensity of the anxiety, one may benefit from medication, psychotherapy or a combination of the two. Self-help strategies like relaxation and mindfulness also help alleviate the symptoms of social anxiety.

Psychotherapy for SAD[social anxiety disorder]

CBT or cognitive behavioural therapy is a popular choice for the treatment of social anxiety disorder. CBT helps identify automatic negative thoughts and irrational beliefs, and reframe these into more positive and useful thoughts and beliefs that can help one feel more at ease in social situations.

CBT helps an individual learn strategies to approach social situations with more realistic evaluation and expectations. Over time and with practice, the fears may become subdued and one is able to engage in social situations more effectively.

Research shows that when combined with CBT, hypnosis can be an effective treatment for social anxiety disorder. Hypnosis puts the personal in a relaxed state and enables the processing of difficult memories or incidents.

In cases where symptoms of anxiety are extreme and unmanageable, medication can be helpful. Medication for social anxiety disorder is prescribed by a psychiatrist and includes SSRIs, SNRIs, Beta-blockers, and benzodiazepines.

SSRIs and SNRIs are anti-depressants that have been found useful for the treatment of anxiety as well. Beta-blockers can help control some of the physical symptoms of anxiety like rapid heartbeat. Easing these physical symptoms can, in turn, improve one’s mental state. And finally, benzodiazepines are anti-anxiety medications that work well for immediate relief.

All medication must be taken under the continued supervision of a psychiatrist. It’s important to keep in mind that consultation is recommended even when one wants to reduce the dosage or wean off the medication.

The amount of time it would take social anxiety medication to work would depend on the type of medication one is prescribed. While SSRIs and SNRIs take up to two weeks to work, benzodiazepines can be prescribed for quicker relief.

Online therapy can be a helpful resource for individuals with social anxiety who may find the intimacy of in-person sessions too daunting. The efficacy of online therapy is about the same as in-person sessions. But, online sessions come with the advantage of being in your comfort zone.

Self-help strategies such as journaling, relaxation activities, mindfulness exercises, and affirmations can be helpful in the management of social anxiety.

What questions should I ask my doctor about SAD?

If you suspect that you may be struggling with social anxiety disorder, and are planning to see a mental health professional, here are a few questions you can ask them:

What are some ways to stay calm during social situations I can’t avoid?
What is a good way to explain to my loved ones about what I’m experiencing?
How can my loved ones support me in this journey?
What are some emotional regulation skills I can use to feel better in social situations?
Can you give me a daily routine that might help me feel better overall?
How do I know if what I’m feeling is because of social anxiety or something else?
What are my treatment options?
How long will my treatment last?
Does social anxiety come back after it’s been treated?
How can I protect myself from future episodes of social anxiety, while being socially engaged?

Although in both conditions, one may exhibit similar symptoms of anxiety or avoidance, social anxiety, and agoraphobia are different.

While social anxiety is related to how one will be perceived by others, agoraphobia is related to the sense of safety one feels in places. In social anxiety, one fears social interactions. In agoraphobia, one fears being in public spaces or any space that is not familiar. One can have agoraphobia without having social anxiety, and vice versa.

In agoraphobia, the concern is more about one’s safety. Public places and new places are avoided because they are unfamiliar. A familiar and safe companion can ease these fears.

In social anxiety, the concern is about performance and engagement with others, and how one will be perceived. Social anxiety may be triggered in safe physical spaces, like at a house party or family gathering.

Conclusion:

Social anxiety disorder is an anxiety disorder characterized by extreme fear or worry about being negatively judged in social settings. Due to this fear, one may want to avoid social settings altogether. Although genetic predisposition plays a role in an individual’s susceptibility to social anxiety disorder, it can be precipitated by many different factors such as social experiences, cultural influences, and personality traits or thought patterns.

If you or someone you know are suffering from social anxiety, it’s advisable to get the right help. A trained mental health professional can help you navigate the challenges that come with having social anxiety. You can reach out to one of the qualified mental health professionals from our very own Therapy Club.