Social anxiety disorder: a complete guide

You have a presentation tomorrow. You are feeling jitters in your tummy. Your palms are sweaty and your heart feels like it will jump out of your chest at any moment. But when the time comes to present, you get on the stage, give your presentation and get through the process. Talking in front of strangers or public speaking does not come easily to most people. However, most of us can slog through. Unfortunately, if you have a social anxiety disorder or social phobia, the stress put on you due to such situations can be very high.

Social anxiety can make life difficult

People who suffer from social anxiety disorder prefer to avoid any and all kinds of social gatherings that can act as triggers. These gatherings or may include speaking in front of a large audience or meeting up a few friends in a café. Everything that is normal in our eyes may be impossible for a person who suffers from social anxiety disorder. Because of this, not only does your work-life fall apart, your social and personal life as well goes along with it.

In the United States alone, social anxiety disorder affects around 5.3 million people. The average age at which social anxiety disorder manifests its symptoms are between 11 and 19 years (teenagers). Studies show that social phobia is the third most common mental health problem that people suffer from. This comes after alcoholism and depression. Social anxiety is an extremely debilitating condition. It can limit your engagement in all aspects of your life. People suffering from severe social anxiety disorder stop stepping out of their house because they are afraid that they will have to talk to others. They will not go grocery shopping or even engage with their neighbors.

Since social anxiety disorders are a very common mental health issue, there has been a lot of research. Many treatment options are also available. If you feel that you are suffering from social anxiety disorder, you need to ask for help. In this article, I will be discussing how to identify if you are suffering from social phobia and whether you need to see a doctor for the same or not.

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What exactly is social anxiety disorder?

Social phobia or social anxiety disorder is an overwhelming and persistent fear of being in social situations. This is more than just a feeling of shyness or jitter. If you suffer from major social anxiety disorder, you will not even want to step out of your house because you feel that everyone on the road, on the bus, on the subway, etc will be judging you. This extreme level of self-consciousness forces such people to even stop engaging in basic day-to-day activities.

The unfortunate part is that the fear and anxiety that they face are not even closely proportional to the threat. The constant fear of judgment, ridicule, and rejection have a massive negative impact on the person’s social, interpersonal, and work-life. If the anxiety remains, eventually the sufferer may find it hard to even step outside their own home.

Social anxiety stops you from doing things that you wish to engage in. It’s extremely invasive and makes you fear almost every part of your daily routine. As I mentioned before, social anxiety disorder usually starts during the adolescent stages and affects those who have an inherently low self-esteem

Those suffering from social anxiety do understand that their brain expands the fear beyond control. However, the anxiety still continues to persist. They may be dealing with their everyday fears for example talking to colleagues, discussing projects with the boss etc. However, the persistent voice in the back of the head still remains that they are constantly being judged.

How the world views social anxiety disorder?

Most often, social phobia is viewed by others as the person being

• Shy
• Cold
• Unfriendly
• Quiet
• Uninterested

Even if you are successful in making friends and hanging out with them, your social anxiety can stop you from engaging with your friends to your heart’s content.

When does social phobia occur?

In the case of those suffering from social anxiety disorder, the fear is normally limited to a few situations like initiating a conversation, talking to strangers, speaking in public, etc. However, those having severe social phobia may feel anxious in any or all situations. For them, even stepping out of their home can become a nightmare.

Every person who suffers from social phobia can experience it in a different manner. However, there are some common situations that people with social phobia struggle with:

• Talking to strangers
• Dating
• Entering large crowded rooms
• Speaking in public
• Establishing eye contact
• Attending parties
• Using public restrooms
• Going to their workplace or school
• Initiating a conversation

There is a chance that all of us may be facing difficulty in one of the above-mentioned situations. For example, giving a speech in front of the public may be a very hard task for you. Alternatively, attending parties may seem like nightmares since everybody might judge you. However, if you do not suffer from social phobia, your anxiety is not crippling. You can still go out and give a speech if needed. However, if you are suffering from social anxiety, giving a speech would initiate panic attacks. Even the thought of standing in front of a large crowd or audience would cause heart palpitations, sweating, and all other signs of anxiety. You may have nightmares before your presentation and feel sick to your stomach.

Causes behind social anxiety disorder

Every person who suffers from social phobia has a reason for feeling that way. However, in general, these overwhelming feelings can be narrowed down to the fear of

• Being watched or judged by others in any social settings
• Being humiliated or embarrassed in the past
• Afraid of being humiliated or embarrassed.
• Accidentally causing someone to feel offended
• Becoming the center of attention

So far, I have given you an overview of what social anxiety disorder looks like. However, now it is time to break it all down. Let’s start with checking out the symptoms of social phobia

Symptoms of social phobia

The symptoms of social phobia falls under four different symptom types. These are

Cognitive symptoms

Cognitive symptoms cover the negative worry and thoughts that you experience when you suffer from social phobia. These thoughts may focus on

• Humiliating yourself in front of others by engaging in an embarrassing act
• Everything that can possibly go wrong in the social setting
• Being made fun of, ridiculed or criticized
• Being judged negatively by your peers
• Others being able to see your anxiousness
• Sounding stupid, boring or incompetent. You already view yourself negatively and you are worried that others will also feel that.
• Afraid of rejection
• Constantly thinking about the upcoming social situation, from weeks before the actual date.
• Afraid of offending or upsetting others
• Discussing a matter with those in authority. You may believe that people who hold higher positions than you are superior to you in every way and you are inferior to them.
• Picking apart your performance at the social setting later. Constantly thinking about where you went wrong, what should not have been done, and instead what you should have said etc. For example, “why did I even talk about it. It was such a stupid thing to say. I should have never even initiated that conversation. How am I ever going to face that person again.”
• Afraid of becoming the center of attention
• Feeling that everyone in the room is watching and judging you when you walk into a crowded social setting.

Physical symptoms of social phobia

The physical symptoms in the case of social phobia are pretty much similar to the symptoms that you would face if you have any kind of anxiety. This is because the body triggers the same stress response across all anxiety types. When the mind senses that you are under stress or feeling extremely anxious, it causes the body to release stress hormones.

These stress hormones include adrenaline and cortisol. These stress hormones are used to prepare us to respond to any threat or danger like running away if someone comes at you with a knife. These hormones also cause the production of physically unpleasant signs like hyperventilation, muscle tension, increased heart rate, etc.

Evolution of physical symptoms of social phobia

Studies have shown that the physical symptoms of anxiety have an evolutionary background. During prehistoric times, humans had to deal with many dangerous situations on a regular basis. Thus, these hormones put the person in a fight or flight response state. However, if you suffer from social anxiety, the specific social situation which you are afraid of is perceived as a threat by the brain. Therefore, the brain starts to release stress hormones and produce the same physical symptoms that it would in case there is someone running at you with a knife.

The most common physical symptoms in case of social phobia include

• Palpitations or increase in heart rate
• Painful or tight chest
• Shaking
• Dry mouth and throat
• Blushing
• Jittery feeling or butterflies in the stomach
• Shaky voice
• Having to repeatedly go to the toilet
• Tingling in toes and fingers or numbness
• Difficulty in swallowing
• Nausea
• Feelings of Lightheadedness or dizziness
• Twitching muscles in the facial region and neck

Emotional symptoms of social phobia

In case of social phobia, the most common emotional symptoms that you may feel are

• Fearful
• Scared
• Self-conscious
• Embarrassed
• Anxious
• Nervous
• Insecure
• Vulnerable

Behavioral symptoms

A few of the behavioral symptoms I have already discussed before like complete avoidance of social situation. However, the other symptoms are:

• Avoidance of the specifically feared situation like avoiding going to events that have large crowds or leaving jobs that need a person to engage in public speaking.
• Misuse of alcohol or drugs to reduce the symptoms of anxiety
• Avoiding eye contact
• Absence of assertiveness
• Impaired performance at work and underachievement
• Escaping quickly from social situations
• Engaging in safe behaviors. These are specific behaviors that people exhibit to make themselves feel safe in social settings like putting on makeup to hide the blush, not initiating any conversation, taking a friend along to parties
• Difficulties in interpersonal relationships

What are the causes behind social anxiety disorder?

As has been observed with many mental health conditions, social phobia also stems up from a combination of environmental and genetic factors. However, this in no way means that if you have a dysfunctional family or if your parents or parent have an anxiety disorder, you will end up with the same problem.

Genetics

Anxiety tends to run in families. If there is a close family member who suffers from anxiety, there are chances that you may suffer from anxiety too. So far, the relationship between learned behavior and genetics has not been scientifically established.

Style of parenting

A child is like a mold. The way the parents influence the child has a huge effect on who the child grows up to become. If parents constantly demoralize the child, ridicule, embarrass him, or intentionally make him feel small, there’s a high chance that the child may develop social anxiety disorder later in life. Furthermore, parents who tend to worry a lot over every simple thing can also affect their child’s ability to cope with minor problems. This in turn can lead to social anxiety disorder later in life.

Kids who suffer from social phobia generally describe their parents as:

• Not affectionate enough
• Overprotective
• Exaggerating the challenge of the upcoming situation
• Constantly demoralizing and making the child feel like they cannot do anything by themselves.
• Placing an over-emphasis on grooming and mannerisms.
• Constantly worrying over the child displaying wrong behavior

Negative experiences

There’s a chance that your social anxiety may be completely unrelated to your genetics or parenting style. If you have faced embarrassment, humiliation, or ridicule in the past (in a social setting), that can also trigger social anxiety disorder. For example, you have been bullied or embarrassed in a previous social situation. You were giving a presentation in front of a large crowd. You mispronounced or forgot a few words and everyone laughed at you. Your brain may feel that a similar situation might present itself in the future as well. Thus, you start to fear public speaking completely.

How does social phobia affect your life?

Social phobia can prevent you from living a full life. You will start to avoid any and every situation where your phobia might be triggered. These situations are those that are considered normal by everyone else. You may find it difficult to understand how can others handle such situations so easily. Eventually, as you start to avoid social settings completely, it will take a toll on your personal relationships as well. Social phobia can also cause

• Negative thoughts
• Depression
• Loself-esteemem
• Poor social skills
• Extreme sensitivity to any kind of criticism

Why do people find it hard to overcome social anxiety?

In certain cases, people gain confidence as they advance in age. This allows them to overcome their social phobia. However, this is not necessarily possible in every case. In some cases, the social phobia stays and eventually grows.

Long term beliefs

If you are a victim of social phobia for many years now, it is most likely that the anxiety is stemming from a long-term belief. This long-term belief may be that you are simply bad at being in social situations. However, research has implicated that those who suffer from social phobia have similar social skills as everyone else. But, they do not have the faith in themselves. They do not believe that they can behave properly in a social situation.

Avoidance

Sometimes, people who suffer from social anxiety completely try to avoid situations where they are afraid to be. If complete avoidance is not an option, they will try to get out of the situation as soon as possible. This use of avoidance tends to become the preventative factor in helping the person overcome social anxiety.

When you start to avoid uncomfortable situations, you do not even give yourself a chance to go and find out if you are truly uncomfortable or not. If you allow yourself to go out and explore difficult situations, you may notice that they are not that difficult or challenging after all.

Fear is an emotion that only increases if you avoid facing the fear. When you face your fears, you will feel anxious. However, when you repeatedly face your fear, your anxiety will start to reduce gradually. It is not possible for anyone’s body to constantly keep producing the stress hormones that cause the physical symptoms. They will eventually fade out.

Focusing on oneself too much

Since people who suffer from social anxiety believe that they are the center of attention whenever they are in a social setting, they tend to watch their own behavior too closely. They already have a negative image of themselves in their minds. When they start to focus on themselves in social situations, they may exaggerate a minor behavior and feel that they are becoming the center of attention. For example, if you blush in social situations, you may be afraid that you are blushing too much and everyone who looks at you notices your blush.

This self-focused tendency continues to increase with increase in anxiety. This also means that you will not be able to peacefully focus on a conversation because you are busy reinforcing the belief that you might behave poorly in the social setting.

Afraid of feeling fearful

You are already afraid of being in a social situation. Thus, you start predicting the symptoms that you may feel. For example, “I know I’m going to tremble.” Having these thoughts before you have even encountered the social setting only fuels your anxiety. Your increase in anxiety may even bring upon the physical symptoms that you are afraid of. Thus, establishing a positive feedback loop where the fear contributes to anxiety and the anxiety contributes to fear.

Safe behaviors

Sometimes, social situations cannot be avoided. Under such circumstances, people may resort to using safe behavior. Safe behavior is specific behavioral patterns that help a person feel safe in social situations. Some examples of such behavior are:

• Speaking very quietly on not speaking at all
• Taking your friend along
• Pretending to be busy on the phone
• Drinking more alcoholic beverages than normal
• Attempting to hide the visible anxiety signs like putting a shawl on your hand to cover up the fact that your hand is trembling.
• Avoid sharing any and all personal information. This can be done by asking the other party a lot of questions and preventing them from asking you anything.

In short term, safe behaviors can prove to be beneficial. However, in the long term, they can prevent you from learning social cues. When your mind notices that your safe behavior allows you to navigate the social setting without much difficulty, it reinforces that behavior. For example, if you think that you could only survive the social situation by consuming alcohol, this may increase your chances of drinking at every social event you attend.

What to do if you are suffering from social phobia?

As I’ve mentioned countless times before, the first step to healing your mental health is understanding that you have a problem and the second step is getting help. If you have read the article to this point, either you or someone close to you is probably suffering from a social anxiety disorder. In that case, they need treatment. If you are worried about whether you should go to a psychologist or psychiatrist, you can visit either of them. Alternatively, you can also go to your General Medical practitioner. They will be able to direct you to a psychologist or psychiatrist depending on your case.

Social anxiety tests

There are many tests that are available online to find out if you have social anxiety symptoms. These tests are mostly based on questionnaires. The test scores are calculated depending on the answers that you pick. These scores are used to determine whether a person is suffering from social phobia or not. However, these tests are not completely reliable. If you feel that you might have social phobia, the best bet is to consult a mental health practitioner.

Diagnosis procedure

Your mental health practitioner will first determine whether there are underlying medical conditions that may be contributing to the anxiety or whether you have social phobia along with any other mental or physical health issue.

Diagnosis will be based on

• A physical examination to understand the presence of an underlying medical condition that may be causing anxiety symptoms.
• Discussion of the symptoms, what triggers them, how often do they occur, and how do you cope
• Self-report questionnaires to understand if you have anxiety
• Discussion of the situations that may make you anxious

Finally, the therapist will check the diagnostic and statistical manual of mental disorders (DSM- 5 ). This diagnostic manual is published by the American Psychiatric Association and is used by psychologists to identify most the mental health issues.

Criteria for social anxiety disorder (as per DSM-5)

• Intense and constant fear or anxiety about a certain social situation. This occurs because you feel that you will be judged in a negative manner, humiliated, ridiculed, or embarrassed.
• Complete avoidance of any social situation that can cause anxiety. If a person has to be in such a social situation, they will endure them with extreme anxiety and fear
• Anxiety levels are completely out of proportion to the situation at hand.
• Anxiety that is causing interference with the daily activities of the person.
• Anxiety or fear that is not explained by any underlying medical condition, substance abuse or medication.

Treatment options for social phobia

The treatment of social phobia depends on how much the anxiety disorder is affecting the person’s ability to function in their daily lives. The most common approach used by psychologists is psychotherapy (talk therapy or psychological counseling), medications, or in certain instances, both might be used. The specific therapy to be used depends on the severity of the person’s anxiety.

Psychotherapy

In most cases of social phobia, psychotherapy is enough to improve the symptoms. The psychologist tells the patient how to recognize and modify the negative thoughts that the person has towards themselves. The psychologist also works with the patient and helps the patient develop the skills needed to boost confidence in social settings.

The most common therapy used for the treatment of social anxiety is cognitive behavioral therapy. This has been observed to be the most effective for the treatment of anxiety disorders. It can either be used one on one or in group settings.

Exposure based CBT

In exposure-based CBT, the psychologist prepares the patient to face the situations that are extremely challenging for him. They will train the patient in breathing techniques, relaxation techniques etc. They will also work with the patient to boost self-confidence. The patient may participate in role-playing or skills training to gain more self-confidence and comfort in social settings. Once the therapist sees a certain level of progress in the patient, the patient is exposed to different social situations that may trigger the anxiety.

Medication options

Even though there are several medication types available for treating anxiety disorders, selective serotonin reuptake inhibitors (SSRIs) are the first drug that is provided by the clinician to curb persistent symptoms of social phobia. Your mental health practitioner may either prescribe sertraline or Paroxetine. The serotonin and norepinephrine reuptake inhibitor (SNRI) is another option that is used in the case of social phobias. To reduce side effects risk, your psychiatrist may start you at low doses and increase them if the need arises. The symptoms may start to show improvement within the period of a few weeks to several months depending on the severity of your anxiety disorder.

Other medications

Other medications that are in effect for the treating social anxiety symptoms are:

Antidepressants

Your practitioner may have to test out several different types of antidepressants with you to find out which one works best for you with the least side effects.

Anti-anxiety medications

Benzodiazepines reduces anxiety levels in people. Even though they tend to work very quickly, they can be sedating and habit-forming. Therefore, they are only prescribed for short periods by psychiatrists.

Beta-blockers

These medications normally work by blocking the epinephrine effect. They cause a reduction in heart rate, pounding of the heart, blood pressure, reuse the shakiness in your limbs and boys. Due to this, these are usually used on an SOS basis. They are not a general recommendation for anxiety disorder treatment.

Never stop your medications on your own

Anxiety disorder or any other mental health issue takes time to heal. If you do not see results in a week, do not stop your medications. It may take you several weeks to months to start seeing a difference. A combination of the right medication and skill training can help manage your anxiety. However, finding the right medication may take time for both you and your mental health practitioner. Therefore, if you do not notice a reduction in symptoms, do not stop your medication. If you have any concerns, discuss the same with your psychiatrist. Such medications should usually be tapered off and stopped. They must never be stopped suddenly. If stopped immediately, they can cause adverse side effects.

To make sure that you are getting the maximum out of your treatment, go to every appointment, discuss any self-care tips that you may have found with your practitioner. Remember to take all the medications on time. Practice the relaxation therapy and breathing exercises that your practitioner has taught you. Try mild exposure therapy by yourself to identify if you are progressing. If there is any change in your condition, discuss the same with your medical health care practitioner.

Conclusion

We all face anxiety at some point or the other. However, if your anxiety becomes unbearable and starts to interfere with your daily life, it is time to seek treatment. As I have mentioned before, understanding the problem and getting help is winning half the battle. Even if someone says, it’s not big deal, do not listen to them. Listen to your own heart. If you feel you need help, get it. You owe yourself that much.

Stick to your medications, go to regular therapy appointments and practice everything that your therapist asks you to. Social anxiety takes time to overcome. It is not impossible but it is time-consuming. The problem will also not go away in a week or a month. It may take you a long time depending on your severity level. Be patient with yourself and give yourself time. As much of it as you need.

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See you in my next blog post

Dr. Shruti