Social anxiety disorder (SAD), also referred to as social phobia, is characterized by an intense fear of public situations. It is the third most prevalent psychiatric disorder, following substance abuse and depression. 

Women and men are equally likely to develop SAD. SAD can be limited to only one type of situation, such as a fear of speaking in public, or it may be so broad that a person experiences symptoms almost any time they’re around other people. SAD can become so debilitating that it prevents people from going to work or school. 

In a survey of 191 women with SAD and an eating disorder, nearly one half were unable to complete high school (Hinrichsen, 2007). People with this problem have a hard time making friends and even associating with family. 

The symptoms of SAD include an intense fear of the following activities:

  • Asking questions in groups
  • Attending social gatherings
  • Being assertive
  • Being introduced
  • Being watched doing something (such as eating or writing)
  • Indirect evaluation (such as test taking or a job review)
  • Interacting with people deemed important
  • Making small talk
  • Meeting or talking with strangers
  • Public speaking or performing
  • Small group discussion
  • Using public restrooms
  • Using the telephone
  • Spending time after a social situation analyzing your performance and identifying flaws in your interactions
  • Expecting the worst possible consequences from a negative experience during a social situation 

Physical symptoms often accompany the intense anxiety of SAD and include blushing, trembling, nausea, profuse sweating, and difficulty talking. People with SAD are generally aware that their feelings are irrational. However, even if they manage to confront what they fear, they usually feel extremely anxious beforehand and intensely uncomfortable throughout. Afterward, anxious feelings tend to linger as they worry about what people are thinking about them. 

In a study of patients with SAD, about half reported that their disorder began in response to a specific embarrassing experience, while the others reported that it had been with them for as long as they could remember. SAD often co-occurs with other anxiety disorders as well as eating disorders, and increases a person’s risk of depression fourfold. 

Substance-related disorders frequently develop in individuals who attempt to self-medicate their SAD by drinking or using drugs. Approximately one half of patients with SAD have comorbid mental, drug or alcohol problems. Studies have shown that at least 16% of patients who present with SAD have alcohol abuse problems. 

Longitudinal data indicates that SAD precedes approximately 70% of these comorbid conditions, suggesting that these conditions arise in response to the disorder. 

Treatment of Social Anxiety Disorder 

Treatment depends on how much social anxiety disorder affects your ability to function in daily life. The two most common types of treatment for social anxiety disorder are psychotherapy (also called psychological counseling or talk therapy) or medications or both. 

Psychotherapy improves symptoms in most people with social anxiety disorder. In therapy, you learn how to recognize and change negative thoughts about yourself and develop skills to help you gain confidence in social situations. 

Cognitive behavioral therapy is the most effective type of psychotherapy for anxiety, and it can be equally effective when conducted individually or in groups. In exposure-based cognitive behavioral therapy, you gradually work up to facing the situations you fear most. This can improve your coping skills and help you develop the confidence to deal with anxiety-inducing situations. 

In psychotherapy, clients often participate in skills training or role-playing to practice social skills and gain comfort and confidence relating to others. Practicing exposures to social situations is particularly helpful to challenge the person’s worries.

Randi Fredricks, Ph.D.

References

Abramowitz JS, Moore EL, Braddock AE, Harrington DL. Self-help cognitive-behavioral therapy with minimal therapist contact for social phobia: a controlled trial. Journal of Behavior Therapy and Experimental Psychiatry. 2009;40:98–105.

Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Ruan WJ, et al. Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry. 2005;66:1205–15.

Acarturk C, Smit F, de Graaf R, van Straten A, Ten Have M, Cuijpers P. Economic costs of social phobia: a population-based study. Journal of Affective Disorders. 2009;115:421–9.

Koszycki D, Benger M, Shlik J, Bradwejn J. Randomized trial of a meditation-based stress reduction program and cognitive behavior therapy in generalized social anxiety disorder. Behaviour Research and Therapy. 2007;45:2518–26.

Adler LA, Liebowitz M, Kronenberger W, Qiao M, Rubin R, Hollandbeck M, et al. Atomoxetine treatment in adults with attention-deficit/hyperactivity disorder and comorbid social anxiety disorder. Depression and Anxiety. 2009;26:212–21.

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