Social Anxiety Disorder – Causes, Signs and symptoms

Social Anxiety Disorder

Also called: Social Phobia


Social anxiety disorder –  also known as social phobia – is a type of anxiety disorder in which a person feels extremely anxious in certain social situations and has a chronic fear of being judged by others. People with this condition also have an intense fear of embarrassing themselves. About 15 million adult Americans ages 18 and older suffer from social anxiety disorder, according to the National Institute of Mental Health.

Some people with social anxiety disorder may experience the phobia only in certain situations. Others with social anxiety disorder feel intense anxiety in almost any social situation, making it difficult to form and maintain relationships. Social anxiety disorder often begins in childhood or early adolescence and usually lasts throughout a person’s lifetime.

Patients with social anxiety disorder usually experience various symptoms when confronted with an anxiety-provoking social situation. Such symptoms include blushing, profuse sweating, trembling, heart palpitations, muscle tension, nausea, diarrhea and difficulty talking. In some cases, symptoms may progress to a full-blown panic attack.Typically, social anxiety disorder is a condition that flares up in cyclical fashion throughout a patient’s lifetime. A combination of medications and psychotherapy can help patients to control their symptoms and lead more productive, fulfilling lives.

About social anxiety disorder

Social anxiety disorder, also known as social phobia, is a type of anxiety disorder in which a person experiences extreme anxiety in some social and public situations. It is among the most common mental disorders that affect adults. People with this disorder have an intense and chronic fear of embarrassing themselves or being perceived by others as anxious, weak, crazy or stupid. Such fears are so intense that they may prevent patients from performing their job duties or engaging in other day-to-day activities.

About 15 million adult Americans ages 18 and older suffer from social anxiety disorder, according to the National Institute of Mental Health(NIMH). The disorder affects men and women equally. Social anxiety disorder should not be confused with shyness, stage fright or typical anxiety. These are normal emotions that people experience in situations that may be unusual, new or otherwise stressful. Social anxiety disorder causes anxiety that is especially intense and that is typically considered irrational given the social circumstances that are present. People fear what they perceive as the scrutiny and judgment of others who watch them in the anxiety-provoking situation.

Some people with social anxiety disorder may find that their symptoms only occur in certain situations. For example, a person may be at ease with people most of the time, but experience discomfort in certain situations such as eating in front of others or giving a presentation. Patients may fear using public restrooms or talking on the phone or writing while others watch. In other cases, people with social anxiety disorder will feel intense anxiety in almost any social situation.

People with social anxiety disorder will go to great lengths to avoid social situations that make them uncomfortable, or will find themselves worrying for days or weeks in advance of a dreaded social situation. Patients in an anxiety-provoking situation may experience symptoms related to panic attacks, sudden brief episodes of fear and anxiety. Social anxiety disorder often begins in childhood or early adolescence, typically around age 13 and usually lasts throughout a person’s lifetime. Patients may find it difficult to make and maintain relationships, and may avoid school, work or other day-to-day situations. The type of social anxiety disorder that a patient suffers from may depend on gender. For example, fear of blushing may be more prevalent among women. In other cases, fears may be based on experience. Fear of eating in front of others is more likely in someone who has had a past embarrassing episode of choking in public.

Risk factors/causes of social anxiety disorder

The exact cause of social anxiety disorder is unknown. Feelings of inferiority and low self-esteem appear to be at the root of social anxiety disorder. Patients with the disorder tend to believe that showing anxiety is a sign of weakness, and they believe that other people are more confident or competent than they really are.

The disorder may have a genetic component and runs in families. Researchers also believe that biochemical factors may influence development of anxiety disorders. A neurotransmitter called serotonin helps regulate mood and emotions, and it is believed that an imbalance may help cause social anxiety disorder in patients who are more sensitive to serotonin’s effects.

The composition of the brain may also be partly responsible for social anxiety disorder. A structure deep in the brain called the amygdala appears to be responsible for controlling the fear response. People with an overactive amygdala may have heightened anxiety in circumstances where it does not seem reasonable.

Certain factors may increase the risk of developing social anxiety disorder. These include:

  • Environment. Some experts believe that aspects of social anxiety disorder may be based in learned behaviors that result from watching how others with the disorder react in social situations.

  • Genetics. Research indicates there may be a genetic component to social anxiety disorder.

  • Age. Social anxiety disorder usually begins in childhood or early adolescence, commonly around age 13, and seldom develops after age 25.

  • History of mental illness. Individuals with other mental health conditions, including depression or other anxiety disorders, are more likely to have social anxiety disorder.

  • Negative experiences. Children may develop social anxiety disorder after they have been teased, bullied, rejected, ridiculed or humiliated. Family conflict and sexual abuse are also sources of psychological trauma that may lead to social anxiety disorder.

  • Temperament. Children who are shy or withdrawn in new situations or when meeting new people may be at increased risk for social anxiety disorder.

  • Substance abuse. People with substance abuse problems (e.g., drugs, alcohol) have social anxiety disorder more than the general population. However, it is uncertain if substance abuse is a risk factor for the disorder or a result of it. However, if the symptoms of social anxiety disorder are believed to be related to substance abuse, social anxiety would not be diagnosed.

Signs and symptoms of social anxiety disorder

People with social anxiety disorder experience overwhelming anxiety and heightened self-consciousness in some or most social situations. They tend to have performance fears, exaggerating their own mistakes and believing that all eyes are on them, watching to see them sweat, blush or otherwise show fear. They are also sensitive to criticism and rejection and believe that others are ready to pass judgment when they fail.

Although symptoms associated with social anxiety disorder differ on a case-by-case basis, there are some typical signs and symptoms associated with the disorder. Fears of speaking in public, dating or talking to people in positions of authority are hallmarks of this condition. Patients are likely to feel intensely uncomfortable in situations where they do not know people. In addition, many patients with this phobia are aware that their anxiety is excessive, but still are unable to control their symptoms.

When patients with social anxiety disorder are in situations that provoke anxiety, they may experience symptoms such as blushing, profuse sweating, trembling, rapid heartbeats, muscle tension, nausea, diarrhea and difficulty talking. In some cases, this may progress to a full-blown panic attack. Patients who manage to get through anxiety-provoking social situations may feel lingering unpleasant feelings afterward and may worry about how others have judged them.

Social anxiety disorder is often associated with other anxiety disorders and depression. Many patients may abuse recreational or prescription drugs and alcohol in attempts to control the anxiety, which eventually causes substance abuse problems. Children who have social anxiety disorder may not be aware of the cause of their fears and may not be able to verbalize how they feel. Symptoms associated with social anxiety disorder in children include crying, tantrums, clinging to familiar people and shying away from social interaction. They may also struggle in school or try to avoid going to school. Children with social anxiety disorder may show discomfort even when feared social situations occur at home. This differs from children who have separation anxiety, as these children usually are comfortable in social settings in their own home.

Diagnosis of social anxiety disorder

Treatment may not be necessary in situations where social anxiety disorder is minor or where people are able to overcome their fears and do not limit their interactions. However, patients who find that anxiety brought on by social anxiety disorder is interfering with their ability to live or work should see a physician, preferably a mental health professional.

Before diagnosing social anxiety disorder, a physician should perform a complete physical examination and compile a thorough medical history. Patients will be asked to describe their symptoms and to explain what triggers them and how often they occur. Questions that a physician may ask a patient include:

  • Do they feel intense fear in situations where they do not know people?

  • Do they fear situations in which they may be judged?

  • Do they fear being embarrassed or humiliated?

  • Do they fear displaying physical signs of anxiety, such as sweating or trembling?

  • Does anxiety disrupt their work, school or other activities?

There are no laboratory tests used to diagnose social anxiety disorder. However, a physician may also want to rule out other medical conditions that could be causing symptoms, such as a heart problem or an overactive thyroid gland. In such cases, blood tests or other procedures may be used to rule out a medical illness. Children may not be diagnosed with social anxiety disorder until they have experienced symptoms for at least six months. A patient who appears to have social anxiety disorder may be referred to a psychiatrist or other mental health professional who can help make a specific diagnosis, and provide treatment and regular follow-ups. Patients may be asked to fill out questionnaires or self-assessments that can help pinpoint a diagnosis. In many cases, social anxiety disorder is accompanied by other anxiety disorders or mental illnesses such as depression, substance abuse or eating disorders.

Treatment options for social anxiety disorder

In situations where social anxiety disorder is minor, or where people are able to overcome their fears so they do not limit their interactions, treatment may not be necessary. However, social anxiety disorder typically does not resolve on its own and more severe cases may require treatment. Psychotherapy, use of medications or a combination of both approaches may be used to treat social anxiety disorder.

Psychotherapy is likely to focus on reducing anxieties and fears and managing reactions to fear-inducing stimuli. Treatment sessions may be in individual or group settings. Group therapy is known to be particularly effective for those with social anxiety disorder.

Cognitive behavior therapy is used to treat social anxiety disorder. It involves learning new skills that enable the person to react differently to situations that typically trigger anxiety. Patients also learn more about negative thought patterns that increase anxiety and ways to redirect such thinking. In addition, patients may be gradually exposed to situations that are frightening and in which they can test new coping skills with the help of a professional. This is known as exposure therapy.

Medications may also be prescribed to help reduce the anxiety that patients feel. Some antidepressants are effective in treating anxiety disorders, even in patients who are not depressed. These drugs usually take several weeks to work, so patients should not become discouraged if they do not notice immediate improvement. The U.S. Food and Drug Administration (FDA) recently noted that antidepressants may increase the risk of suicidal thinking and behavior in children and adolescents, and that people being treated with these drugs should be closely monitored for unusual changes in behavior. However, the benefits of these medications may outweigh the potential risks.

Anti-anxiety medications may also be prescribed. Many anti-anxiety medications, such as benzodiazepines, should be used only for short periods of time because of their addictive potential. Patients should not stop using anti-anxiety medications unless under the close supervision of a physician because they may experience withdrawal symptoms. Mild to moderate withdrawal symptoms may include anxiety, restlessness, insomnia or nightmares. More serious symptoms can include seizures, high fever, psychosis and even death.

Beta-blocker medications, which are typically used to treat heart conditions, are also sometimes effective in treating social anxiety disorder. These medications work by blocking the stimulating effect of the hormone adrenaline. Patients who know in advance that they soon will be in an anxiety-provoking situation – such as giving a speech in public – may use beta-blockers to reduce symptoms, such as a pounding heart or trembling hands.

Prevention methods for social anxiety disorder

Although there is no known method to prevent social anxiety disorder, individuals can use positive coping methods to help minimize symptoms. Getting enough sleep, engaging in exercise and eating a well-balanced diet can help people feel healthier and more relaxed. Relaxation techniques and other stress-management practices can also reduce anxiety levels.

Patients who feel anxious should also try to engage in hobbies and other pleasurable activities, and to reach out to others with whom they who feel comfortable. Patients should not use recreational drugs or alcohol to help them cope with uncomfortable social situations, as this is likely to have adverse consequences in the future.

Support groups can also help relieve anxiety. These are sessions in which people with social anxiety disorder share their experiences and offer encouragement and understanding to one another. Although the notion of sharing feelings with strangers can be intimidating, especially to those with social anxiety disorder, many patients find these groups to be extremely beneficial. Finally, confronting situations that trigger anxiety can be one of the best techniques for successfully reducing symptoms. Exposure therapy allows patients to gradually work up to facing situations that have been causing them great fear. Although this approach may cause anxiety initially, patients who regularly face these types of situations will learn to use coping skills that eventually may significantly diminish symptoms related to their social anxiety disorder.

Questions for your doctor about social phobia

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to social anxiety disorder, also known as social phobia:

  1. What makes you suspect I have social anxiety disorder?
  2. What is causing my social anxiety disorder? Could it be related to self-esteem or medications I am taking?
  3. How is social anxiety disorder diagnosed? Will I need to see a mental health professional? Can you recommend one?
  4. I do not experience fear in all social situations. Can I still have social anxiety disorder?
  5. What type of social anxiety disorder do I have?
  6. What are my treatment options? How effective are treatments?
  7. Are there any medications that may help me with my social anxiety disorder? What are the benefits and risks?
  8. What therapy options are available to me? How do I find qualified providers?
  9. How soon after beginning treatment will I see improvement in my condition?
  10. How can I prevent symptoms associated with social anxiety disorder?
  11. If I have social anxiety disorder, what is the likelihood that any of my children will develop the disorder?
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