Are you SAD? An overview of Social Anxiety Disorder

Society is an important part of our lives. Maslow places the social belongingness needs above security needs and physiological needs in his famous Need Hierarchy Theory.

Imagine a situation when you’re in a crowd and you feel like everyone around you has their eyes fixed on you. At times, you’re so nervous that you can feel it in your legs and stomach and you are scared to embarrass yourself by doing or saying something weird.

Such kind of overwhelming anxiety in crowded situations is labelled as Social Anxiety Disorder.

Anxiety is very detrimental to our emotional , psychological and social well being and seriously impairs the way we think, act and feel.

According to a study done by National Institute of Mental Health & Neurosciences (NIMHANS), at least 13.7 percent of India’s general population has been estimated to be suffering from a variety of mental illnesses; and 10.6 percent of this population requires immediate intervention.

Social Anxiety Disorder (SAD)/Social Phobia is one of the largest mental health problem in the world today. The World Health Organisation estimates that 15 percent of the world’s population will suffer from an anxiety disorder at some point in their lifetime. The epidemiological literature reports lifetime prevalence rates of Social Anxiety Disorder in Western countries ranging between 7% and 12% of the population (Furmark, 2002; Kessler, Berglund, Demler, Jin, & Walters, 2005). In most of the cases people do not even know that they suffer from social anxiety.

Being a social animal people seek social support and affection, so ostracism from the social group negatively impacts a variety of health related variables, including one’s self-esteem and sense of belonging (Baumeister & Leary, 1995) and this further leads to social isolation and loneliness and in some cases drug abuse.

SAD affects men and women relatively equally, with the average female to male ratio ranging between 1:1 (Moutier & Stein, 1999) and 3:2 (Kessler et al., 2005) in community studies. It often begins in the mid-teens, but can also occur in early childhood. During childhood, SAD is often associated with shyness, behavioral inhibition, overanxious disorder, mutism, school refusal, and separation anxiety. If the problem is left untreated, it typically follows a chronic, unremitting course and leads to substantial impairments in vocational and social functioning (Stein & Kean, 2001).

The physical symptoms of social anxiety disorders include blushing, excessive sweating, trembling, and other symptoms of anxiety, such as difficulty in speaking and nausea or other stomach discomfort and increased heart rate, poor eye contact and dizziness in social situations.

According to DSM-V diagnostic criteria for SAD includes:

• Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech)
• In children, the anxiety must occur in peer settings and not just during interactions with adults.
• The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).
• The social situations almost always provoke fear or anxiety. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
• The social situations are avoided or endured with intense fear or anxiety.
• The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
• The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
• The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
• The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmoφhic disorder, or autism spectrum disorder.

There is a considerable degree of variance among individuals with SAD in the number and type of situations they fear. A number of genetic influences, neurochemicals (e.g. serotonin, thyroid hormone, GABA, Epinephrine/Norepinephrine, Dopamine) and environmental factors (e.g. past experiences, family conflicts, trauma, bullying, sexual abuse) are responsible for SAD. Specific personality characters also contribute to SAD, for e.g., people with low self esteem are more likely to perform poorly in social situations. They might feel that everyone is paying close attention to them and scrutinising what they are doing/saying or they might believe that they are boring or have nothing interesting to contribute. Of course, such thinking patterns lead to high levels of social anxiety.

Mental health professionals can help one overcome social anxiety. Cognitive Behaviour Therapy is one of the most widely used psychotherapies which focuses on changing individual’s faulty thought patterns and suggests coping strategies. It is an evidence based therapy which uses both cognitive and behavioural psychological principles. The cognitive part of the therapy focuses on replacing the older faulty thought patterns and replacing them with new thought patterns. Further Learning Principles are applied to train the brain to make the new thought processes automatic and habitual. The behavioural component of CBT involves participation in an active, structured therapy group with people who also suffer from the same disorder. In the behavioural group, people voluntarily engage in practical activities that are mildly anxiety-causing, and proceed in a flexible, steady, scheduled manner to systematically desensitise themselves from anxiety-causing stimulus. This is practiced regularly till the new behaviour is learned. Such a group setting provides each participating individual with an opportunity to have genuine interactions without any fear of judgement, with the people who are empathetic and non-judgemental. This therapy works on building self esteem, confidence and positive practices which fosters personal growth of the individual.

Other psychotherapies include exposure therapy, group therapy, virtual therapy and mindfulness-based therapies which have been proven to be a great help in treating social anxiety.

On individual’s part it is important to reach out to family members and friends, talk to them, challenge anxious thoughts and see situations in a more realistic way. Also he/she must actively work towards reducing tendency of focusing on his/her own self during social interactions and removing the use of avoidance and safety behaviours and gradually confronting the fears. Keeping a stress journal, describing the triggers of social anxiety and one’s reactions to them, helps in getting a deeper understanding of the issue and is therapeutic in itself. Regular exercise and maintaining a healthy diet is also suggested.

In severe cases, medications (antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as drugs known as high-potency benzodiazepines etc.) are used to treat such kind of anxiety disorders.

SAD is curable. We need to be more kind to ourselves and others. We need to be more empathetic and more considerate and try to understand other people’s perspectives. All of us need each other. Try and be there for someone else and see how beautiful it feels to be there when someone else needs you.

“If you want others to be happy, practice compassion. If you want to be happy, practice compassion.” — Dalai Lama