Social Anxiety Disorder

It's normal to get nervous before you go on a first date or speak in front of a group. But imagine if you broke out in a heavy sweat or vomited when you were about to meet someone new. What if you were so afraid of embarrassing yourself that returning a phone call was an ordeal? Or you couldn’t use a public restroom because people could hear you use the toilet? What if you never went to restaurants because you couldn’t stand for anyone to see you eat? Or you worried for weeks afterwards about how you came across in a brief interaction with a stranger?

If you have social anxiety disorder (also known as social phobia) your intense fear that everyone is watching and judging you often wins out over normal life. Jobs that require contact with the public, going to meetings, or managing people may be out of the question. You may never learn the ropes of dating or having relationships.

This anxiety disorder can be limited to one type of situation, or so generalized that you feel very anxious around almost anyone except your family.

What are the symptoms of social anxiety disorder?

Symptoms like these usually start between ages 10-13, and rarely after age 25.

• Constant, intense anxiety
• Much more than normal distress when you meet people, speak in front of others, are being observed, get teased, or do nearly anything in public
• Avoiding work, school or social activities
• Blushing, heavy sweating, trembling, trouble talking, stammering, dry mouth, dizziness, nausea or racing heart in social situations
• In adults, knowing that your anxiety isn't reasonable yet being unable to stop it
• In children, crying, having tantrums, and freezing or shrinking from social situations

Many people with social anxiety disorder have other problems, too.

• Substance abuse may develop if people try to self-medicate their symptoms with alcohol, tobacco or drugs.
• Depression and other anxiety disorders (like panic disorder) are common.

How common is it?

It’s hard to get good data since most people with the disorder are too embarrassed to seek help. But it’s more common than you might guess. Some studies estimate that about 2% to 7% of American adults have it. Since it usually begins in childhood or the early teens, many younger people suffer, too.

Many people with social anxiety disorder have never heard of it and don't know that treatment can help.

Isn't it just another term for being shy? What's so bad about that?

It’s not the same thing. In an in-person 2011 survey of over 10,000 teens, 47% said they were somewhat or very shy. But only 9% of the total met the criteria for social anxiety disorder. (Sadly, only 20% of the kids with it had tried to get treatment.) So most shy people don’t have it.

The difference is that fear and avoidance dominate and limit the lives of people who have the disorder. They’re haunted by much more intense fear of being judged and humiliated. They worry that people will see them sweating, shaking, breathing hard or blushing, or hear their stomachs growl. They avoid normal activities. And they worry long in advance about being around people in the future. So even when they're alone they may be consumed by anxiety. 

What causes social anxiety disorder?

Brain scans show differences in the brain function of people with the disorder. When they look at pictures of angry or disapproving faces, they have a hyperactive response in the part of the brain that controls fear responses (amygdala). So a critical or hostile look is much more upsetting to them. They may even misread a neutral look.

The prospect of confronting a slightly tense social situation, like being evaluated by another teen in an online chat room, also caused a stronger fear response in the brains of teens with social anxiety disorder than in normal kids.

These abnormal brain responses are probably caused by a combination of genes and environment.

• Genes: Social anxiety disorder can run in families. And identical twins raised separately are more likely to both either have it or not. So we know genes are involved. Scientists have identified one called RGS2 that is linked to anxiety disorders in animals and humans. Another gene, 5-HTT, is linked with brain reactions to angry faces.
  
• Environment: The disorder builds on itself. If you're terribly nervous, avoiding social situations feels better, so you get in the habit of avoidance. And you may sweat and stammer in public more than you would otherwise. If someone comments on it, you become even more self-conscious. People with social phobia may also be genetically more likely to develop fears from observing the behavior and consequences of others.

How is it treated?

There are two effective kinds of treatment.

• Medicines include several types of antidepressants, benzodiazepine tranquilizers and beta-blockers.
   
• Cognitive-behavior therapy (CBT) has proved very useful in treating children, teens and adults. It may be done individually or in groups. A specially trained therapist helps people gradually get more comfortable with scary social situations. The cognitive part of the treatment helps people look at the thoughts that trigger anxiety. For instance, they:
  • Learn to think more logically about the chances that everyone is watching or judging them
  • Learn social skills for various situations
  • Work on accepting not knowing what will happen in a social situation
  • Look at their fear of disapproval more realistically
  • Describe their worst fears and figure out ways to respond to them
  • Stop identifying so closely with their condition

The behavioral part of CBT often involves a technique called exposure therapy. Patients practice relaxing their bodies with skills like deep breathing. They gradually practice doing the things that trigger anxiety.

Some research hints that the cognitive part of therapy may work better than the behavioral part for this disorder. To learn more about CBT you can search the Cover Story Archives for our article Cognitive Behavior Therapy.

Social anxiety disorder prevents many people from giving their best at work and in relationships. Consider getting help if you think you might have it.  Facing your fears isn't easy, but it’s better than living a life that’s limited by them.

Updated on 1/3/2012 by Jennifer Johnson, BA English composition, Northwestern University. Reviewed by Steve Silverstein, MD. Published on 1/30/2012.

References:
1. Anxiety Disorders at www.nimh.nih.gov .
2. Eley TC et al. Therapygenetics: The 5-HTTLPR and response to psychological therapy. Mol Psychiatry 2011 Oct 25
3. Ougrin D. Efficacy of exposure versus cognitive therapy in anxiety disorders: systematic review and meta-analysis. BMC Psychiatry. 2011 Dec 20;11(1):200.
4. Nelson E. C., Grant J. D., Bucholz K. K., Glowinski A., Madden P. A. F., Reich W. et al.  (2000). Social phobia in a population-based female adolescent twin sample: Co-morbidity and associated suicide-related symptoms. Psychological Medicine 30 (4): 797–804.
5. Ko CH, et al. Predictive values of psychiatric symptoms for Internet addiction in adolescents. Arch Pediatr Adolesc Med 2009; 163(10): 937-43.
6. Burstein M, et al. Shyness versus social phobia in U.S. youth.  Pediatrics 2011; 128: 917-925. 
7. Roy-Byrne P, et al. Delivery of evidence-based treatment for multiple anxiety disorders in primary care: A randomized controlled trial. JAMA 2010; 303: 1921-28. 

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Page last updated: January 27, 2012