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Social Anxiety Disorder

Most people experience social anxiety, such as the nervousness commonly experienced speaking in front of an audience (stage fright), feeling anxious talking to strangers, or feeling uncomfortable whilst being observed working on a task. For most people this anxiety and discomfort is manageable and does not interfere significantly with personal functioning. Shyness is common too, and this does not necessarily constitute Social Anxiety Disorder (SAD).

In Social Anxiety Disorder (SAD) nervousness, anxiety and avoidance of social situations causes significant personal distress and impairment in social and occupational functioning.

The primary feature of SAD is persistent fear of acting in a way that is humiliating or embarrassing in social or performance situations. This typically means fear of showing particular symptoms, signs of anxiety or failed performance. The person with SAD may be very concerned about blushing in front of others, sweating noticeably, shaking, appearing boring, sounding stupid or being seen as weird or abnormal. Anxiety almost always occurs on exposure to the situation and it can take the form of panic attacks.

Two sub-types of SAD can be distinguished: generalized SAD and specific (non-generalised) SAD. The generalized type refers to fear of a wide range of social situations, whilst the specific type refers to fear of a particular situation such as using telephones or public lavatories or speaking in front of a group.

In some cases SAD emerges out of shyness and timidity in childhood but in other cases it can occur suddenly after a humiliating experience. The problem can diminish at times if the person is no longer exposed to the feared social situation. It may be activated by changes in lifestyle such as promotion to a position that requires public speaking.

There can be complications with SAD such as substance or alcohol misuse as the person tries to self-medicate. Drugs, alcohol and caffeine can however contribute to the symptoms of SAD such as blushing, sweating and trembling.

In order to diagnose SAD it is necessary to rule-out other causes of anxiety and specific symptoms which may be due to drugs or medication. Some medical conditions can give rise to symptoms that are similar to those in SAD and possible underlying medical causes should be explored. For instance, some tumours, cardio-vascular problems, hormonal factors, diabetes and diseases such as Parkinsonism can give rise to persistent symptoms such as blushing, sweating or trembling. See your doctor to rule-out possible underlying medical causes of your symptoms.

Treatment

Different treatments have been applied to SAD. These include social skills training, anxiety management, group and individual cognitive-behaviour therapy (CBT). Group and individual CBT are the most effective of this list of treatments. They reduce avoidance and anxiety in social situations. However, it has been observed that they decrease fear of negative evaluation and worry about social situations only a modest amount. Individual and group CBT combine techniques such as relaxation training, exposure methods, social skills training and challenging of negative thoughts about performance and anxiety.

More recently Metacognitive theory has been used to develop more effective treatment and is being actively researched at MCT-I. In this newer form of metacognitive-focused CBT the focus is on reducing patterns of worry before and after social situations, modifying the focus of attention in social situations, and examining distorted internal images that patients have of themselves. The newer form of treatment is effective and produces large decreases in fear of negative evaluation and worry about social situations. The approach has been evaluated in several trials.

Drug treatment has also been used in SAD. Some types of antidepressants within the Selective Serotonin Reuptake Inhibitors (SSRI’s) and the Mono-amine Oxidase Inhibitors (MAOI’s) have been found beneficial in some cases. However, these drugs can produce side effects and not everyone can take them. In a recent study the newer metacognitive-based treatment was superior to treatment by SSRI’s. In specific subtypes of social anxiety (e.g. anxiety in performing musicians) beta-blockers have been used and some patients report benefit from their occasional use but this effect is not clearly established. Your doctor will be able to advise you. Drug treatments should not be used without appropriate medical consultation and monitoring.

Metacognitive-based CBT or standard CBT is recommended for the treatment of SAD.

References

Clark DM, Ehlers A, McManus F et al (2003). Cognitive therapy versus fluoxetine in generalized social phobia: A randomized placebo-controlled trial. Journal of Consulting and Clinical Psychology, 71, 1058-1067.

Heimberg, RG, Liebowitz MR, Hope DA (1998). Cognitive-behavioral group therapy versus phenlezine therapy for social phobia: 12-week outcome. Archives of General Psychiatry, 55, 1133-1141.

Nordahl, HM, Vogel, PA., Morken, G., Stiles, T., Sandvik, P., & Wells, A. (2016). Paroxetine, Cognitive therapy or their combination in the treatment of Social Anxiety Disorder with and without avoidant personality disorder: A randomized clinical trial. Psychotherapy and Psychosomatics, 85, 346-356.

Wells A, White J & Carter K (1997). Attention training: Effects on anxiety and beliefs in panic and social phobia. Clinical Psychology and Psychotherapy, 4, 226-232.

Wells A & Papageorgiou C (1998). Social phobia: Effects of external attention on anxiety, negative beliefs and perspective taking. Behavior Therapy, 29, 357-370.

Wells A & Papageorgiou C (2001). Brief cognitive therapy for social phobia: A case series. Behaviour Research and Therapy, 39, 713-720.

Wells A & McMillan D (2004). Psychological treatment of social phobia. Psychiatry, 3:5, 56-60.