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SJHH ... / Mental Health & Addiction Services/ Mental Health Services/ Anxiety Treatment and Research Clinic (ATRC)/ Definitions and Useful Links/ Social Anxiety Disorder

Social Anxiety Disorder (Also Known As Social Phobia)

What is Social Anxiety Disorder?

Everyone at some point in time has experienced anxiety during some social or performance situation. In fact, in one survey only 5% of people said that they had never been shy at any time in their life. Social anxiety disorder is the most extreme form of social anxiety or shyness. In order to be diagnosed with social anxiety disorder, an individual must experience excessive levels of social anxiety, severe enough to bother him or her significantly, or to cause interference in his or her daily routine (e.g., work, school, relationships). Often, individuals with social anxiety disorder avoid the social situations that they find uncomfortable.

Official Criteria for Social Anxiety Disorder

Based on criteria from the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013)

The individual experiences excessive and persistent fear of one or more social or performance situations. Examples are listed in the next section.
The individual experiences feelings of anxiety, fear, or panic immediately upon encountering the feared social situation.
The fear is out of proportion to the actual risk in the situation.
The individual tends to avoid the feared social situation, or if he or she doesn’t avoid, the situation is endured with intense anxiety or discomfort.
The individual’s fear, anxiety, or avoidance causes significant distress (i.e., it bothers the person that he or she has the fear) or significant interference in the person’s day to day life. For example, the fear may make it difficult for the person to perform important tasks at work, meet new friends, attend classes, or interact with others.
The fear, anxiety, or avoidance is persistent (usually lasting as least 6 months).
It must be established that the anxiety symptoms are not being caused by a medical condition (e.g., thyroid condition, diabetes, heart condition) or by a drug or substance (e.g., cocaine use, caffeine, withdrawal from alcohol). In addition, if the individual has a medical condition with visible symptoms (e.g., stuttering, shaking from Parkinson’s disease), the fear must not be only of others noticing these medical symptoms.
If the person's fear is restricted to speaking or performing in public, it should be described as performance only.

What do People with Social Anxiety Disorder Fear and Avoid?

Generally, people with social anxiety disorder fear and avoid social situations that fall into two broad categories, performance situations (e.g., situations that involve performing in front of others or being observed by other people) and social interaction situations (e.g., situations that involve engaging or interacting with one or more people). Most people with social anxiety disorder fear situations from both of these categories.

Examples of Feared Performance Situations in Social Anxiety Disorder:

Public speaking
Talking in meetings or classes
Participating in sports or working out in front of others
Performing music or acting on stage
Writing in front of others
Eating or drinking in front of others
Using public restrooms when other people are nearby
Making mistakes in front of others
Being in public areas such as a shopping mall or a bus

Examples of Feared Social Interaction Situations in Social Anxiety Disorder:

Going to a party
Initiating or maintaining conversation
Talking to strangers
Inviting friends over for dinner
Talking on the phone
Expressing personal opinions
Being assertive (e.g., refusing to give in to unreasonable requests, asking others to change their behavior)
Being in intimate situations
Talking to people in authority (e.g., employer, professor, doctor)
Returning items to a store or sending food back in a restaurant

Causes of Social Anxiety Disorder

Biological Factors

Brain Activity – Researchers are only now beginning to uncover the underlying brain mechanisms associated with social anxiety disorder. The few studies that have examined social anxiety disorder using positron emission tomography (PET) or functional magnetic resonance imaging (fMRI) neuroimaging techniques have generally found that people with social anxiety disorder show increased activity in the amygdala (i.e., a structure deep inside the brain that generally shows more activity in response to threatening or fearful events), and show decreased activity in cortical areas (i.e., the outer portion of the brain that is involved in planning and the complex interpretation of events). However other studies have found conflicting results. For example, other studies have found that people with social anxiety disorder generally show increased right brain activity in response to a threatening social event. It is unclear however how to exactly interpret these different findings, and more research is needed to definitively understand how brain activity is related to social anxiety disorder.
Neurotransmitters – Studies examining the relationship between social anxiety disorder and neurotransmitters (i.e., chemicals used by nerve cells to communicate with one another) have been generally inconsistent. The two neurotransmitters that appear to be most likely involved in the development and maintenance of social anxiety disorder are dopamine and serotonin. For example, studies have found that people who are very sociable tend to have increased levels of dopamine, and drugs that act on levels of serotonin and dopamine in the brain generally help to improve and reduce the symptoms of social anxiety disorder. It should be stressed, however, that although some studies suggest involvement of dopamine and serotonin, other studies have not supported the idea that these two neurotransmitters are related to social anxiety disorder.
Genetics – As with the other biological factors discussed earlier, evidence that one’s genetic make-up may play a role in the development of social anxiety disorder has been inconsistent. On the one hand, some studies have found that the generalized form of social anxiety disorder (i.e., a fear of most social and performance situations) tends to run in families, whereas the nongeneralized form (i.e., fear of relatively few social and performance situations) does not. Furthermore, some studies have found that the pattern of social anxiety disorder across identical and fraternal twins suggests a role for genetics in the transmission of social anxiety disorder across family members. However, other twin studies have found that individual environmental experiences play a larger role in the development of social anxiety disorder than a shared genetic history. Interestingly, some studies examining personality traits that are related to social anxiety, specifically neuroticism (e.g., a tendency to feel or become easily distressed and anxious) and introversion (e.g., a tendency to be socially withdrawn), have been found to be highly heritable. Although there is some evidence that genetic factors are involved in the development of social anxiety disorder, environmental influences cannot be discounted.

Psychological Factors

Learning and Personal Experiences – A person’s personal experiences are thought to influence the development of social anxiety disorder. For example, a history of negative experiences in social situations (e.g., being teased at school) may cause a person to subsequently fear or avoid social situations if being around people becomes associated or linked with the negative experience. In addition, an individual who is exposed to others with extreme social anxiety (e.g., growing up with parents who have social anxiety disorder) may learn to fear the same situations just through observation. The messages children receive from parents, teachers, friends, and the media (e.g., it’s important to always make a good impression) may also affect the development of social anxiety disorder in some individuals. Of course negative social experiences alone are not enough to cause social anxiety disorder, and only a small percentage of people who have such experiences go on to develop the problem.
Attention and Memory – Generally people with social anxiety disorder tend to pay more attention to, and remember more accurately, socially threatening information than people without social anxiety. For example, people with social anxiety disorder appear to be particularly good at remembering faces, especially negative or critical faces, compared to people without social anxiety disorder. Although the data demonstrating a tendency to pay closer attention to socially threatening information in social anxiety disorder are fairly well established, studies on memory biases in social anxiety disorder have been somewhat less consistent in their findings.
Beliefs and Interpretations about Social Situations – People with social anxiety disorder tend to hold beliefs and interpret social events in such a way as to maintain or increase their anxiety. For example, people with social anxiety disorder are especially worried about others reactions to their behavior and to noticing their symptoms of anxiety (e.g., blushing, shaking, sweating). Furthermore, they also tend to make more negative evaluations of their performance in social situations compared to people who are not socially anxious. Finally, compared to individuals without social anxiety disorder, people with social anxiety disorder tend to interpret neutral facial expressions negatively, and expect that negative consequences of social events will be more likely and more costly.
Avoidance and other Anxious Behaviors – Avoidance of social situations prevents people with social anxiety disorder from learning that social and performance situations are not as “dangerous” as they feel. In addition, certain anxious behaviors (e.g., avoiding eye contact, standing far away from others, speaking quietly) may lead some people with social anxiety disorder to actually be judged more negatively by others, thereby maintain the anxious beliefs.

Effective Treatments for Social Anxiety Disorder

Biological Treatments

There are a number of medications that have proven useful for treating social anxiety disorder. These medications include antidepressants, which are also commonly used to treat depression, and antianxiety medications. In addition, some recent studies have suggested that gabapentin (Neurontin) may be useful for reducing symptoms of social anxiety disorder. Although beta-adrenergic blockers or “beta blockers” (e.g., propanolol [Inderal] and atenolol [Tenormin]) are sometimes used for treating stage fright in actors and musicians, there are no studies supporting the use of these medications in social anxiety disorder. Examples of effective antidepressants and antianxiety medications for social anxiety disorder are listed below:

Type of Medication	Generic Name	Brand Name
SSRI Antidepressants	Citalopram Fluoxetine Fluvoxamine Paroxetine Sertraline	Celexa Prozac Luvox Paxil Zoloft
Other Antidepressants	Nefazodone Venlafaxine	Serzone Effexor
Antianxiety Medications	Alprazolam Clonazepam	Xanax Klonapin or Rivotril

The decision to take medication and which medication to use should be based upon a number of factors, and should be discussed with a doctor first. Factors including the individual’s past treatment history, the individual’s medical history, the presence of additional psychological or medical problems, and additional medication or substances being taken should be considered when choosing a medication.

Psychological Treatments

Currently, the best established form of psychotherapy for social anxiety disorder is cognitive-behavioral therapy (CBT), although other forms of treatment (e.g., interpersonal psychotherapy) may be useful as well, based on preliminary research. The CBT strategies with the most research support include:

Cognitive Therapy – Involves learning to identify one’s anxious thoughts and to replace them with more realistic thoughts. For example, if an individual is afraid of writing in front of others because of possibly being judged for having shaky hands, he or she might be encouraged to examine realistically the likelihood that others will in fact notice the shaky hands and the likelihood that if others do notice, they will think terrible things about the individual. The person might also be encouraged to create a little experiment to test out the validity of the beliefs. For example, the person might try writing in front of others, while purposely having his or her hands shake, just to see what happens.
Exposure to Feared Situations – this technique, also called in vivo exposure , involves confronting a feared situation repeatedly, until the situation no longer triggers fear. For example, someone who identifies talking to people of authority as a fearful situation might purposefully go to a professor and ask questions about homework, or go to a pharmacist and ask questions about medication he or she is taking. Exposure works best when it occurs frequently (e.g., several times per week), and lasts long enough for the fear to decrease (up to two hours).
Exposure Role Plays – Role plays are similar to the exposure practices described above, except that they are simulated practices instead of practicing the real thing. For example, someone who is anxious about going to a job interview might practice a simulated interview with a friend, family member, or therapist. When the role play practices become easier, the individual may then move on to practice exposure in the real situation.
Social Skills Training: After avoiding certain social situations for an extended time, it is not surprising that some people with social anxiety disorder might develop some bad habits in social situations, including making poor eye contact, and engaging in other anxious behaviors. They may also find it difficult to think of what to say during a conversation or date. Or, they may lack certain basic public speaking skills. If this is the case, CBT may include social skills training as a component. Examples include teaching an individual how to make the best impression during a job interview, how to be more assertive, and how to use nonverbal communication (e.g., body language, eye contact) more effectively.

Combined Treatments

Generally medications and CBT work about equally well in the short term, although some people may respond better to one approach or the other. For many people, the combination of medication and CBT probably does not work any better than either approach alone, although there is relatively little research on combined treatments for social anxiety disorder. Once treatment has stopped, individuals who have been treated with CBT are thought to be less likely to experience a return of their symptoms than are individuals who have been treated with medication.

Did you know ...?

The typical age of onset for social anxiety disorder appears to be mid- to late- teens and is slightly more common in women than men.
Estimates of the prevalence of social anxiety disorder vary widely across studies. Examining the pattern across studies, social anxiety disorder probably affects about 7% of the general population.