It is a long term; overwhelming worry or fear of social situations that usually starts during teenage years. Social Anxiety Disorder (or Social Phobia) is a very common condition.
Social Anxiety Disorder is a persistent fear or anxiety about a social situation that is out of proportion to the actual threat. It is a fear of being judged, negatively evaluated or rejected. People with social anxiety disorder worry about human interactions before and after the incident.
Telling Social Anxiety Disorder apart from Shyness
Social anxiety is different from shyness which is short term and not disruptive. Shyness by definition is not debilitating and shouldn’t impact life. Social anxiety on the other hand gets in the way of school, work and making connections with people.
Overlap between Social Anxiety Disorder
There is significant overlap between Social Anxiety Disorder and other mental health conditions. The latest NICE guidelines (UK) on the topic suggest comorbidities of depression (19%), substance use (17%), panic disorder (6%).
Women appear to experience Social Anxiety Disorder more than men. It is often diagnosed in adolescence. Oftentimes people diagnosed with Social Anxiety Disorder report extreme shyness as children. However, as touched on above these are two different experiences.
Sadly, only about half of those experiencing the condition seek treatment. Often people wait 10+ years before getting professional help.
How common is it?
It’s thought of that over 10% of the population experiences Social Anxiety Disorder at some point in their lives. About 5% of the people have the condition in any given year. It is the second most common anxiety disorder after phobias.
How social anxiety presents differs from person to person – age, cultural backgrounds, communities we belong in, work and life situations all play a part.
Common physical symptoms include:
- Blushing, excessive sweating or trembling
- Nausea, lightheadedness or difficulty speaking
- Unable to do things in public, fear of being watched and judged by others
Physical symptoms worsen anxiety as people worry that others will notice. This can lead to a vicious or compounding cycle that is hard to get out of.
Common psychological symptoms include:
- Worrying intensively about a situation, days or weeks in advance.
- Avoiding social, work or school situations or trying to blend into the background when attending
- Fear of embarrassing yourself, making a mistake or appearing silly.
- Needing to drink alcohol to calm nerves
- Worry about everyday situations like shopping, speaking on the phone or meeting new people
- Eating in groups.
- Using public bathrooms
Social anxiety symptoms can be situation specific. For example the anxiety might come out when eating in a public space or at supermarket checkouts. Social Anxiety Disorder is a chronic condition, symptoms can fluctuate in intensity depending on other life stressors.
Anticipatory anxiety is a key part of social anxiety disorder. It is the worry pre-event. For instance worrying about going shopping the day prior, over thinking about a friend’s birthday party to the point you don’t go. There is also anxiety after the incident. Playing it on repeat in your mind, going over the details and being critical on yourself.
Social anxiety disorder by it’s very definition gets in the way of living life. It is restrictive, gets in the way of making relationships and impairs functioning outside the home.
Social anxiety symptoms in children
Children show their anxiety symptoms different to adults. In children social anxiety can present in different ways:
- Cry, freeze or go numb and be detached from a situation
- Finding it difficult or outright refusal to go to class or speak up in the classroom.
- Shying away from optional activities like school performances, attending parties or going to clubs.
How is Social Anxiety Disorder diagnosed?
Social anxiety disorder can be diagnosed by your family doctor or an experienced mental health clinician. At Epsychiatry, both our psychologists and psychiatrists can assess for Social Anxiety Disorder.
A history will be taken focusing on aspects of anxiety; symptoms, duration, triggers, past treatments etc. They will want to know about anticipatory fears, post-event processing patterns plus if there are any safety seeking behaviors.
Given the frequent overlap between anxiety and other mental health concerns, questions about depression, trauma, alcohol use etc. are asked. They may also look for personality disorders, psychosis or autism as these conditions can present initial as avoidance or social anxiety.
Sometimes you will be asked to fill out a questionnaire. Oftentimes it takes a couple of sessions to complete an assessment. There are no blood or brain scans for social anxiety. Diagnosis is made based off responses to questions asked during an assessment.
Social anxiety disorder is one of the most prevalent anxiety disorders. Sadly people wait 10+ years before seeking help.
Asking for help with social anxiety can feel embarrassing. Fortunately most doctors and health clinicians will try to put you at ease. Sometimes it help to have a support person, in the room with you when you are first explaining how you feel.
Like most mental health conditions the underlying drivers of social anxiety are complex. Here are some factors that can trigger, contribute or work together to make social anxiety a problem.
- Bullying – some people with social anxiety disorder to being treated poorly, publicly shamed or humiliated
- Learned behavior – children learn by observing their parents and caregivers. If parents behave such as the world is a frightening, critical place, a child will internalize that.
- Genetics – It is possible that there is a genetic component to social anxiety. Currently researchers are of the view that multiple genes possibly contribute to anxiety.
- Temperament or nature – It is possible that being timid, shy or clingy as a child might mean an underlying anxious temperament. Our underlying nature or ways might put at risk of developing social anxiety disorder.
- Not having corrective experiences – whilst shyness is a different entity to social anxiety disorder, often people with social anxiety disorder describe themselves as shy. Maybe the lack of learning or corrective experiences for these shy children lead to them developing social anxiety disorder in their teenage years.
- Family conflict or sexual abuse – Feeling unsafe as a child, having traumatic or bad experiences as a child might lead to feelings that the world is unsafe. This might lead to understandably self protective behavior and distancing. Opportunities as missed to feel safe again, leading to anxiety with others and in the community.
- Controlled or over protective households – this is similar to learned behavior in that it involves copying adult behavior. It however also prevents children from developing confidence and feeling a sense of mastery by themselves.
Where treatment is conducted, cultural factors, presence of any other mental health conditions, age and individual preferences are all considered in determining treatment. It is important to talk about these things with your therapist.
Learning about Social anxiety disorder is a starting place. It is a complex condition. You can learn about social anxiety by reading articles online, watching videos and joining forums on social anxiety disorder.
Ask your doctor or mental health clinician for information sheets or brochures. Ask questions, at the start and through the treatment journey.
Oftentimes people with social anxiety disorder view it as a personal flaw, failing and are vulnerable to self stigmatization. Self stigmatization is when people are aware of others negative views, internalize and blame themselves. It’s important over time to challenge some of these beliefs.
Changing clinicians or doctors can be challenging for people with social anxiety; sharing personal stories raises anxiety, building trust takes time. Disruptions should be avoided. Telehealth psychology means therapists and clients are not as geographically limited.
Cognitive behavioral therapy for social anxiety disorder forms the basis of treatment. In this type of treatment your therapist will focus on negative or unhelpful thought patterns about yourself and others. They will teach you ways to challenge these. Behavioral or confidence building exercises also form part of this therapy.
Graded exposure is used in treating different anxiety conditions such as OCD. It also can form part of social anxiety treatment. Breaking down social anxiety, tackling less provoking situations for example, doing click and collect shopping first. Once at ease picking up items from a supermarket, the next step would be to shop in the aisles.
Psychological treatment should be structured around or based on treatment manuals for Social Anxiety Disorder. A manual written by Debra Hope and colleagues in 2010, or the Clarks and Wells model are two example.
The client and therapist need to feedback to each other on how they feel therapy is going. Often with anxiety people have questions about therapy and how they are progressing. It is important that these questions are addressed.
During therapy a psychologist can teach ways to focus externally as opposed to being too internally focused. They help to “re-script” bad memories of social trauma. Psychologist at the end teach ways to prevent relapse and to notice early warning signs of social anxiety returning to the fore.
The NICE guidelines on Social Anxiety Disorder (2013) note the possible challenges people face attending crowded clinics for assessment and treatment. Self check in, private space and the use of telehealth psychology are different ways to reduce this initial anxiety.
Guided Self Help
This involves working through online material or worksheets to help. There are various Australian and International resources available online; some free and others for a fee. A quick search on Google or recommendation from a friend might be the way to go.
Social anxiety by its very nature is isolating. Being part of a group, working through some of these issues together can help. People can learn from other’s experience of social anxiety. Also to realize that social anxiety is common condition, impacting a lot of people in very different ways.
The guidelines on treating social anxiety disorder suggest medications are second line options. Doctors will want to explore refusal of treatment, try address concerns about therapy before turning to medication.
At times selective serotonin reuptake inhibitors (SSRIs) are used to treat social anxiety disorder, but they come with side effects. It is important to be aware of activating properties ( increased anxiety, jitteriness, agitation) during the first 2 weeks on these medications. These expected short term side effects are often blamed for medications making things worse.
Our Epsychiatry team are experienced in treating people with social anxiety. We believe we are well suited to help with our online, telehealth psychologists and psychiatrists. Feel free to send us any questions you have. You can reach us via webchat, email or by phone. Our details are at the bottom of this page.