Social anxiety disorder

Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impairing ability to function in at least some aspects of daily life.^[4]: 15 These fears can be triggered by perceived or actual scrutiny from others. Individuals with social anxiety disorder fear negative evaluations from other people.

Physical symptoms often include excessive

Literary descriptions of shyness can be traced back to the days of Hippocrates around 400 B.C. Hippocrates described someone who "through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him."^[14]

The first mention of the psychiatric term "social phobia" (phobie des situations sociales) was made in the early 1900s.^[15] Psychologists used the term "social neurosis" to describe extremely shy patients in the 1930s. After extensive work by Joseph Wolpe on systematic desensitization, research on phobias and their treatment grew. The idea that social phobia was a separate entity from other phobias came from the British psychiatrist Isaac Marks in the 1960s. This was accepted by the American Psychiatric Association and was first officially included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. The definition of the phobia was revised in 1989 to allow comorbidity with avoidant personality disorder and introduced generalized social phobia.^[16] Social phobia had been largely ignored prior to 1985.^[17]

After a call to action by psychiatrist

Social anxiety disorder is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that they may do something or act in a way that will be humiliating or embarrassing. It exceeds normal "shyness" as it leads to excessive social avoidance and substantial social or occupational impairment.[19] Feared activities may include almost any type of social interaction, especially small groups, dating, parties, talking to strangers, restaurants, interviews, etc.

Those who have social anxiety disorder fear being judged by others in society. In particular, individuals with social anxiety are nervous in the presence of people with authority and feel uncomfortable during physical examinations.^[20] People who have this disorder may behave a certain way or say something and then feel embarrassed or humiliated after. As a result, they often choose to isolate themselves from society to avoid such situations. They may also feel uncomfortable meeting people they do not know and act distant when they are with large groups of people. In some cases, they may show evidence of this disorder by avoiding eye contact, or blushing when someone is talking to them.^[20]

According to psychologist

People with SAD avoid situations that most people consider normal. They may have a hard time understanding how others can handle these situations so easily. People with SAD avoid all or most social situations and hide from others, which can affect their personal relationships. Social phobia can completely remove people from social situations due to the irrational fear of these situations. People with SAD may be addicted to social media networks, have sleep deprivation, and feel good when they avoid human interactions.^{[medical citation needed]} SAD can also lead to low self-esteem, negative thoughts, major depressive disorder, sensitivity to criticism, and poor social skills that do not improve.^[24] People with SAD experience anxiety in a variety of social situations, from important, meaningful encounters, to everyday trivial ones. These people may feel more nervous in job interviews, dates, interactions with authority, or at work.^[25]

Problematic digital media use

Comorbidity

SAD shows a high degree of

Anxiety disorders other than SAD are also very common in patients with SAD, in particular generalized anxiety disorder.^[59][60] Avoidant personality disorder is likewise highly correlated with SAD, with comorbidity rates ranging from 25% to 89%.^[55][61][62]

To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to

Research into the causes of social anxiety and social phobia is wide-ranging, encompassing multiple perspectives from neuroscience to sociology. Scientists have yet to pinpoint the exact causes. Studies suggest that genetics can play a part in combination with environmental factors. Social phobia is not caused by other mental disorders or substance use.^[67] Generally, social anxiety begins at a specific point in an individual's life. This will develop over time as the person struggles to recover. Eventually, mild social awkwardness can develop into symptoms of social anxiety or phobia. Passive social media usage may cause social anxiety in some people.^[68]

Genetics

It has been shown that there is a two to a threefold greater risk of having social phobia if a first-degree relative also has the disorder. This could be due to

A related line of research has investigated 'behavioural inhibition' in infants – early signs of an inhibited and introspective or fearful nature. Studies have shown that around 10–15 percent of individuals show this early temperament, which appears to be partly due to genetics. Some continue to show this trait into adolescence and adulthood and appear to be more likely to develop a social anxiety disorder.^[76]

Social experiences

A previous negative social experience can be a trigger to social phobia,

Problems in developing social skills, or 'social fluency', may be a cause of some social anxiety disorder, through either inability or lack of confidence to interact socially and gain positive reactions and acceptance from others. The studies have been mixed, however, with some studies not finding significant problems in social skills^[90] while others have.^[91] What does seem clear is that the socially anxious perceive their own social skills to be low.^[92] It may be that the increasing need for sophisticated social skills in forming relationships or careers, and an emphasis on assertiveness and competitiveness, is making social anxiety problems more common, at least among the 'middle classes'.^[93] An interpersonal or media emphasis on 'normal' or 'attractive' personal characteristics has also been argued to fuel perfectionism and feelings of inferiority or insecurity regarding negative evaluation from others. The need for social acceptance or social standing has been elaborated in other lines of research relating to social anxiety.^[94]

Substance-induced

While

The World Council of Anxiety does not recommend benzodiazepines for the long-term treatment of anxiety due to a range of problems associated with long-term use including tolerance, psychomotor impairment, cognitive and memory impairments, physical dependence and a benzodiazepine withdrawal syndrome upon discontinuation of benzodiazepines.^[97] Despite increasing focus on the use of antidepressants and other agents for the treatment of anxiety, benzodiazepines have remained a mainstay of anxiolytic pharmacotherapy due to their robust efficacy, rapid onset of therapeutic effect, and generally favorable side effect profile.^[98] Treatment patterns for psychotropic drugs appear to have remained stable over the past decade, with benzodiazepines being the most commonly used medication for panic disorder.^[99]

Many people who are addicted to alcohol or prescribed benzodiazepines when it is explained to them they have a choice between ongoing ill mental health or quitting and recovering from their symptoms decide on quitting alcohol or their benzodiazepines.^[100] Symptoms may temporarily worsen however, during alcohol withdrawal or benzodiazepine withdrawal.^[100]

Psychological factors

Research has indicated the role of 'core' or 'unconditional' negative beliefs (e.g. "I am inept") and 'conditional' beliefs nearer to the surface (e.g. "If I show myself, I will be rejected"). They are thought to develop based on personality and adverse experiences and to be activated when the person feels under threat.^[101] Recent research has also highlighted that conditional beliefs may also be at play (e.g., "If people see I'm anxious, they'll think that I'm weak").^[102]

A secondary factor is

Studies have also highlighted the role of subtle avoidance and defensive factors, and shown how attempts to avoid feared negative evaluations or use of "safety behaviors"^[106] can make social interaction more difficult and the anxiety worse in the long run.^[102] This work has been influential in the development of cognitive behavioral therapy for social anxiety disorder, which has been shown to have efficacy.

Mechanisms

There are many studies investigating neural bases of social anxiety disorder.^[108][109] Although the exact neural mechanisms have not been found yet, there is evidence relating social anxiety disorder to imbalance in some neurochemicals and hyperactivity in some brain areas.

Neurotransmitters

Sociability is closely tied to dopaminergic neurotransmission.^[110] In a 2011 study, a direct relation between social status of volunteers and binding affinity of dopamine D2/3 receptors in the striatum was found.^[111] Other research shows that the binding affinity of dopamine D2 receptors in the striatum of people with social anxiety is lower than in controls.^[112] Some other research shows an abnormality in dopamine transporter density in the striatum of those with social anxiety.^[113][114] However, some researchers have been unable to replicate previous findings of evidence of dopamine abnormality in social anxiety disorder.^[115] Studies have shown high prevalence of social anxiety in Parkinson's disease and schizophrenia. In a recent study, social phobia was diagnosed in 50% of Parkinson's disease patients.^[116] Other researchers have found social phobia symptoms in patients treated with dopamine antagonists like haloperidol, emphasizing the role of dopamine neurotransmission in social anxiety disorder.^[117]

Some evidence points to the possibility that social anxiety disorder involves reduced serotonin receptor binding.^[118] A recent study reports increased serotonin transporter binding in psychotropic medication-naive patients with generalized social anxiety disorder.^[113] Although there is little evidence of abnormality in serotonin neurotransmission, the limited efficacy of medications which affect serotonin levels may indicate the role of this pathway. Paroxetine, sertraline and fluvoxamine are three SSRIs that have been approved by the FDA to treat social anxiety disorder. Some researchers believe that SSRIs decrease the activity of the amygdala.^[108] There is also increasing focus on other candidate transmitters, e.g. norepinephrine and glutamate, which may be over-active in social anxiety disorder, and the inhibitory transmitter GABA, which may be under-active in the thalamus.^[108][119]

Brain areas

The amygdala is part of the limbic system which is related to fear cognition and emotional learning. Individuals with social anxiety disorder have been found to have a hypersensitive amygdala; for example in relation to social threat cues (e.g. perceived negative evaluation by another person), angry or hostile faces, and while waiting to give a speech.^[120] Recent research has also indicated that another area of the brain, the anterior cingulate cortex, which was already known to be involved in the experience of physical pain, also appears to be involved in the experience of 'social pain',^[121] for example perceiving group exclusion.^[122] Recent research also highlighted the potent role of the prefrontal cortex, especially its dorsolateral part, in the maintenance of cognitive biases involved in SAD.^[123] A 2007 meta-analysis also found that individuals with social anxiety had hyperactivation in the amygdala and insula areas which are frequently associated with fear and negative emotional processing.^[124]

Diagnosis

ICD-10 defines social phobia as fear of scrutiny by other people leading to avoidance of social situations. The anxiety symptoms may present as a complaint of blushing, hand tremor, nausea, or urgency of micturition. Symptoms may progress to panic attacks.^[8]

Standardized rating scales such as the

DSM-5 defines Social Anxiety Disorder as a marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others.[130]

DSM-5 Diagnostic Criteria with Diagnostic Features:

• 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). Note: 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). When exposed to such social situations, the individual fears that they will be negatively evaluated. The individual is concerned that they will be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable. The individual fears that they will act or appear in a certain way or show anxiety symptoms, such as blushing, trembling, sweating, stumbling over one's words, or staring, that will be negatively evaluated by others.
• The social situations almost always provoke fear or anxiety. Thus, an individual who becomes anxious only occasionally in the social situation(s) would not be diagnosed with social anxiety disorder. 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. Alternatively, the situations are 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 or anxiety is judged to be out of proportion to the actual risk of being negatively evaluated or to the consequences of such negative evaluation. Sometimes, the anxiety may not be judged to be excessive, because it is related to an actual danger (e.g., being bullied or tormented by others). However, individuals with social anxiety disorder often overestimate the negative consequences of social situations, and thus the judgment of being out of proportion is made by the clinician.
• The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. This duration threshold helps distinguish the disorder from transient social fears that are common, particularly among children and in the community. However, the duration criterion should be used as a general guide, with allowance for some degree of flexibility.
• The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The fear, anxiety, and avoidance must interfere significantly with the individual's normal routine, occupational or academic functioning, or social activities or relationships, or must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. For example, an individual who is afraid to speak in public would not receive a diagnosis of social anxiety disorder if this activity is not routinely encountered on the job or in classroom work, and if the individual is not significantly distressed about it. However, if the individual avoids, or is passed over for, the job or education they really want because of social anxiety symptoms, criterion is met.
• The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., an addictive substance, 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 dysmorphic disorder, or autism spectrum disorder.
• If another medical condition (e.g., Parkinson disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

If the fear is restricted to speaking or performing in public it is performance only social anxiety disorder.

Differential diagnosis

The DSM-IV criteria stated that an individual cannot receive a diagnosis of social anxiety disorder if their symptoms are better accounted for by one of the

The first-line treatment for social anxiety disorder is cognitive behavioral therapy (CBT), with medications such as selective serotonin reuptake inhibitors (SSRIs) used only in those who are not interested in therapy.^{[4]: 191 [9]} According to research studies, combining the use of CBT with escitalopram (a type of SSRI) in contrast to using CBT with a placebo reduced anticipatory speech-state anxiety and increased reductions of social anxiety symptoms, revealing the potential of combining various treatment methods.^[138] Self-help based on principles of CBT is a second-line treatment.^{[4]: 191 [139][140]}

There is some emerging evidence for the use of

Some studies have suggested social skills training (SST) can help with social anxiety.[143]^[144] Examples of social skills focused on during SST for social anxiety disorder include: initiating conversations, establishing friendships, interacting with members of the preferred sex, constructing a speech and assertiveness skills.^[145] However, it is not clear whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations.^[146]

There is some evidence that expressive therapies (e.g. painting, drawing or musical therapy) can be effective for treating social anxiety disorder in certain contexts. A 2019 study, for example, found that art therapy produced an "increase in subjective quality of life (both with large effects) and an improvement in accessibility of emotion regulation strategies" in adult women with anxiety.^[147] Both VAGA and the American Art Therapy Association run specific workshops for social anxiety disorder.

Furthermore, error-related brain activity varies in accordance to factors that affect the motivational significance of behavioural performance, such as social contexts and personality traits, suggesting that understanding how individuals appraise the relevance of incentives in a given context is crucial for designing interventions to ameliorate or prevent maladaptive patterns of performance evaluation, particularly with regards to social anxiety disorder and substance abuse.^[148]

Given the evidence that social anxiety disorder may predict subsequent development of other psychiatric disorders such as depression, early diagnosis and treatment is important.

Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are the first choice of medication for generalized social phobia but a second-line treatment.[4]^: 191 Compared to older forms of medication, there is less risk of tolerability and drug dependency associated with SSRIs.^[152]

Paroxetine and paroxetine CR, sertraline, escitalopram, venlafaxine XR and fluvoxamine CR (Luvox CR) are all approved for SAD and are all effective for it, especially paroxetine.^[10] All SSRIs are somewhat effective for social anxiety except fluoxetine which was equivalent to placebo in all clinical trials.^[153] Paroxetine was able to change personality and significantly increase extraversion.^[154][155]

In a 1995

Citalopram also appears to be effective.[159]

General

In addition, studies show that more socially phobic patients treated with anti-depressant medication develop hypomania than non-phobic controls. The hypomania can be seen as the medication creating a new problem.^[163][164]

Other drugs

Other prescription drugs are also used, if other methods are not effective. Before the introduction of SSRIs,

Certain anticonvulsant drugs such as gabapentin and pregabalin are effective in social anxiety disorder and may be a possible treatment alternative to benzodiazepines.^{[169][170][171][172]} However there is concern regarding their off-label use due to the lack of strong scientific evidence for their efficacy and their proven side effects.^[173]

Social anxiety disorder is known to appear at an early age in most cases. Fifty percent of those who develop this disorder have developed it by the age of 11, and 80% have developed it by age 20.[198] This early age of onset may lead to people with social anxiety disorder being particularly vulnerable to depressive illnesses, substance use, and other psychological conflicts.^[199]

When

It has also been referred to as anthropophobia,[211]^[212] meaning "fear of humans", from Greek: άνθρωπος, ánthropos, "human" and φόβος, phóbos, "fear". Other names have included interpersonal relation phobia.^[211] A specific Japanese cultural form is known as taijin kyofusho.^[177] There is also another cultural form of social phobia, Aymat zibur,^[213] in the Ultra-Orthodox Jewish community which is mostly rooted in a fear of embarrassment in the performance of religious duties.

See also

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• Avoidant Personality Disorder
• Alexithymia
• Agoraphobia
• Asociality
• Highly sensitive person
• Impostor syndrome
• Obsessive-compulsive disorder
• Scopophobia
• Selective mutism
• Social inhibition
• Social rejection

References