What is Social Anxiety?

Social anxiety is the fear of social situations and the interaction with other people that can automatically bring on feelings of self-consciousness, judgment, evaluation, and inferiority.

Put another way, social anxiety is the fear and anxiety of being judged and evaluated negatively by other people, leading to feelings of inadequacy, embarrassment, humiliation, and depression.

The anxiety becomes worse when the person fears that they are going to be singled out, ridiculed, criticized, embarrassed, or belittled. On occasions, the anxiety is so high that panic attacks develop in response to some specific social event (e.g. giving a speech).

People with social anxiety realize that their fear is exaggerated, but they still cannot control it. They tend to avoid situations in which they need to perform in front of others, and this tends to interfere with life adjustment in some way. As you would expect, people with social anxiety disorder have an elevated rate of relationship difficulties and substance abuse. They also feel their self-worth is low, feel inadequate and have difficulty being assertive.

As many as 10 percent of the population may experience social anxiety to some degree, although they all do not seek treatment. Many people are fearful of public speaking, but manage to avoid it and cope well within a slightly more limited life sphere. Some individuals have more severe social anxiety, and are even fearful of talking to strangers in any capacity. These people have more serious adjustment problems, and are more likely to seek treatment. Social anxiety tends to develop during teen years, but often in children described as excessively shy.

Symptoms of Social Anxiety Disorder

Physical symptoms often accompany the intense anxiety of social phobia and include blushing, profuse sweating, palpitations, intense fear, dry mouth,  panic attacks, trembling, and other symptoms of anxiety, including difficulty talking and nausea or other stomach discomfort. These visible symptoms heighten the fear of disapproval and the symptoms themselves can become an additional focus of fear. Fear of symptoms can create a vicious cycle: as people with social phobia worry about experiencing the symptoms, the greater their chances of developing the symptoms.

People with social anxiety disorder usually experience significant emotional distress in the following situations:

• Being introduced to other people

• Being teased or criticized

• Being the centre of attention

• Being watched while doing something

• Meeting people in authority ("important people")

• Most social encounters, especially with strangers

• Going around the room (or table) in a circle and having to say something

• Fear of using public bathrooms or writing in public

• Interpersonal relationships, whether friendships or romantic

This list is certainly not a complete list of symptoms -- other feelings have been  associated with social anxiety as well.

Treatment of Social Phobia

1. Cognitive Behavioural Therapy (CBT and REBT)

In repeated trials, sponsored by the National Institutes of Mental Health, cognitive-behavioural therapy has proven the most effective treatment for social phobia. 

Rational Emotive Behavioural Therapy (REBT) helps people deal with anxious situations. It involves understanding the problem and developing coping strategies such as changing thinking patterns in social situations, learning to focus attention on effective social behaviours. CBT usually begins with a study of the disorder, examining the situations that provoke the anxiety and the accompanying somatic symptoms.  This educational process sets the understanding for training in skills to alleviate and eventually conquer social phobia.  These skills include assertiveness training, relaxation techniques, diaphragmatic breathing, the cognitive restructuring of distorted and negative thinking that contribute to social anxiety, and a programmatic hierarchical exposure to situations that precipitate anxiety.

Recent research indicates that approximately 70% of people who complete a short term treatment program (10 to 15 sessions) are judged to be much or very much improved. The amount of improvement appears to be related to the amount of time and energy the person devotes to developing new coping strategies.

Combining pharmacotherapy with cognitive-behavioural strategies is usually the most effective treatment.

2. Medications

SSRIs such as paroxetine, 20-40 mg/day (FDA approved for the treatment of social anxiety disorder), sertraline  50-100 mg/day, or citalopram 20-40 mg/day are first line medications for social phobia.

Benzodiazepines, such as clonazepam (Klonopin) 0.5 - 2 mg per day may be used if SSRIs are ineffective or in combination with SSRIs during the early phase of treatment before the SSRI takes full effect. Benzodiazepines may be used on a PRN basis especially in patients with non-generalized social phobia that is limited to certain settings.

Social phobia with performance anxiety, such as public speaking, responds well to beta- blockers. The effective dosage can be very low, such as 10-20 mg of propranolol. It may also be used on a prn basis; 20-40 mg given 30-60 minutes prior to the anxiety provoking event. A "test dose" trial should be given several days prior to the speaking event.

Monoamine oxidase inhibitors such as phenelzine also have significant efficacy in treating the anxiety associated with social phobia, but concerns regarding dietary restrictions and potential for hypertensive crisis prevents significant usage.

Silvia Buet provides psychological treatment for social anxiety, using techniques appropriate to the presenting symptoms. This depends what triggers the anxiety, whether the individual has panic attacks, and the severity of the symptoms. Most often a combination of behavioural interventions is used with cognitive therapy. The behavioural treatment may include relaxation training and systematic desensitization, as well as flooding. Cognitive therapy helps you to develop cognitive blocking mechanisms when the anxiety begins to build, and also helps you understand why the social anxiety symptoms occur. This allows you to develop different ways of coping by changing the way you perceive the social situations triggering your anxiety.

References:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994.

Hidalgo, R.B., Barnett, S.D., and Davidson, J.R.T. Social Anxiety Disorder in Review: Two Decades of Progress. Int J of Neuropsychopharm 2001, 4, 279-298.

Kaplan H, Sadock B. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. Seventh Edition, Baltimore, Williams & Wilkins, 1999.

Pollack M.H. Co-morbidity, neurobiology, and pharmacotherapy of social anxiety disorder. J Clin Psychiatry 2001;62 Suppl 12:24-9