Social anxiety is more than being shy, an introvert or having a certain personality type. It is a serious condition that causes significant distress and impairment. In some cases, it can even be life-threatening.
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What Is Social Anxiety Disorder?
Also known as social phobia, social anxiety disorder (SAD) is one of the anxiety disorders listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the reference guide used by mental health professionals to make formal psychiatric diagnoses.
To be diagnosed with SAD, a person must have ongoing fears of one or more social situations that involve exposure to people they don’t know or possible social judgment. The person’s symptoms must meet the following criteria:
- Anxiety nearly always arises in response to social scenarios
- The situation is either avoided or endured with intense distress
- This anxious distress or avoidance causes significant functional impairment or anguish
- Social anxiety and related avoidance reactions persist for six months or longer
- The affected person recognizes that their anxiety is irrational or excessive
For some people with social anxiety disorder, these symptoms have a negative impact on their ability to achieve meaningful personal goals. They might be too anxious to go to a job interview, attend a best friend’s event or give a required presentation for a class. Some people experience such severe social anxiety they fail to engage in activities necessary for their health or safety.
People can become so afraid of social encounters they won’t leave their homes, even to get food or other necessities. The clinical term for this is agoraphobia, which is listed as a separate disorder in the DSM and can arise as a secondary condition for SAD and other anxiety disorders.
Types of Social Anxiety Disorders
While there is only one SAD diagnosis listed in the DSM, there are two different types of the disorder.
Generalized Social Anxiety
Generalized social anxiety is the standard SAD diagnosis. It is the most severe form of the disorder and involves an all-encompassing fear of a wide variety of social situations.
Research shows that generalized SAD is a distinct and valid diagnosis. People with generalized SAD are more likely to be single, to have more social fears and to be diagnosed with comorbid depression and alcohol use disorders.
Performance Only Social Anxiety
Performance-only social anxiety disorder has the same diagnostic criteria as generalized SAD but only arises in situations that involve performing in public. Just as generalized SAD is not simply shyness or introverted personality traits, performance-only SAD is not just a fear of public speaking, which is the most common fear in America.
Performance-only SAD is a full psychiatric disorder that causes significant distress for people who have it. People with this condition don’t just get jitters before speaking. They are likely to avoid it altogether, even if it means missing important social or professional opportunities. Still, performance-only SAD is less severe than generalized SAD. Research shows that it represents a milder form of SAD, with a later age of onset, less severe anxiety symptoms and lower rates of comorbid depression.
Symptoms of Social Anxiety Disorder
Social anxiety symptoms can manifest in many ways, including physically, cognitively and emotionally. Sometimes anxious thoughts trigger physical changes like rising heart rate, while at other times, bodily changes cause people to start having anxious thoughts. A clinician may diagnose SAD when these symptoms arise in the context of social situations.
Symptoms of SAD include the following common physical effects of anxiety when they emerge during or in anticipation of feared social scenarios:
- Rapid breathing
- Increased heart rate
- Shaking or trembling
- Exhaustion and lethargy
- Motor agitation or restlessness
- Sweating without physical exertion
- Digestive or gastrointestinal problems
- Sleep disturbances, especially difficulty falling asleep
At times, SAD or the disorder’s symptoms are mental rather than physical. Cognitive SAD symptoms include the following:
- Anxious rumination or worry, especially about social situations
- Difficulty concentrating on anything other than objects of anxiety
- Thinking obsessively about past experiences that were embarrassing
- Imagining future situations in which humiliation or rejection occur
- Negative self-talk about reasons for being judged or rejected
These anxiety symptoms may drive people with SAD to avoid social situations altogether. In extreme cases, they can even lead to agoraphobia, suicidal ideation or suicide attempts.
Causes of Social Anxiety Disorder
What causes social anxiety disorder? According to psychologists, it is most significantly rooted in biological factors including temperament, genetics and processes in the brain. Research shows a connection between SAD and increased activity in the amygdala, the part of the brain responsible for emotional arousal and threat processing, which may be more active in people with sensitive temperaments.
It is unlikely that SAD is caused by these brain differences alone, as people with similar differences in brain function don’t always develop the disorder. As with most other mental health conditions, SAD derives from a combination of biological factors and life experiences.
Social anxiety disorder is more common in people who had negative social experiences early in their lives, such as being bullied, humiliated in public or emotionally abused by their parents. In some cases, people develop the condition after growing up with parents who exhibited fear in social situations or who were overprotective.
While social anxiety disorder is not known to be caused by medical conditions, health problems can trigger social anxiety symptoms. Changes in brain chemistry and heart rate, as well as anything that triggers the release of adrenaline, can make people feel anxious. When these changes occur in social contexts, they can lead to the development of social anxiety.
Health conditions known to trigger anxiety include the following:
- Heart disease
- Thyroid problems
- Irritable bowel syndrome
In addition to these health problems, rarer medical conditions can cause anxiety, including Lyme disease, other infectious diseases and tumors. Excessive vitamin deficiencies, such as low B12, can cause severe anxiety and occasionally even panic attacks.
Substance abuse sometimes triggers anxiety symptoms. Stimulants, even mild legal stimulants like caffeine and nicotine, activate the sympathetic nervous system, which is responsible for the fight-or-flight response.
The anxiety that naturally arises in charged survival scenarios motivates people to take action. However, when this response arises without an environmental cause, there is no way for the mind to know when the body can relax. As a result, people may experience lingering anxiety after using stimulants.
In high doses, marijuana can trigger paranoia and anxiety, as can hallucinogens. Alcohol, opiates and sedatives including benzodiazepines can all have the effect of reducing anxiety; however, people who use them often experience a recurrence of anxiety as the effects of these substances wear off. The result of long-term use of these substances is that the brain produces fewer of the neurochemicals that instill calm, causing an overall increase in anxiety.
Most of the time, social anxiety disorder is not caused solely by medical conditions or substance use. Usually, genetic, physical and neurochemical causes combine with difficult life circumstances to cause anxiety.
A distorted personal belief system may underpin a fear of social situations. People with SAD may believe they have something wrong with them or that the world is a hostile place. These beliefs may be responses to life experiences, especially events that happened in childhood.
How Is Social Anxiety Disorder Diagnosed?
Diagnosing social anxiety disorder can be more straightforward than diagnosing other mental health conditions. A clinical assessment is required to determine if a temporary reaction, medical condition or recent substance use is causing the anxiety. If so, this rules out a SAD diagnosis.
Mental health professionals know how to diagnose SAD using clinical interviews. They explore whether social scenarios trigger anxiety symptoms, then determine how severe the social anxiety symptoms are and how long they have been occurring. Clinicians especially focus on a patient’s history, including whether they have any co-occurring conditions.
Clinicians also examine whether a person had any negative or humiliating experiences in their childhood that affected how they see themselves or other people. Once a mental health professional establishes that a person is not experiencing secondary anxiety and that their symptoms meet all of the DSM criteria, they can formally diagnose someone with SAD.
Who Is at Risk for Social Anxiety Disorder?
During the diagnostic process, clinicians evaluate people for risk factors for SAD, which include:
- A family history of mental illness
- A shy or sensitive temperament
- A history of other mental or behavioral health conditions
- A history of negative social experiences, including bullying or abuse
- A recent increase in stress, especially in work or social situations
Clinicians may examine certain cognitive factors connected to an increased risk of developing SAD, including negative self-image and internalized shame.
Social Anxiety Disorder Statistics
- SAD affects 7 percent of people in the United States every year.
- About 50 percent of people with SAD have the condition by the age of 11 years old.
- Nearly 80 percent of people with social anxiety develop SAD by the age of 20 years old.
- Approximately 20 percent of people with SAD have a comorbid alcohol use disorder.
- About two-thirds of people with SAD say they have symptoms for ten or more years before asking for help.
Untreated SAD can lead to substance abuse and addiction. If you or someone you know has SAD and is misusing substances to cope, don’t wait to get help. Treatment can provide immediate relief from severe symptoms and long-term recovery from substance use disorders and co-occurring social anxiety. To learn more about available treatment options, contact a representative at The Recovery Village today.
Medical Disclaimer: The Recovery Village aims to improve the quality of life for people struggling with a substance use or mental health disorder with fact-based content about the nature of behavioral health conditions, treatment options and their related outcomes. We publish material that is researched, cited, edited and reviewed by licensed medical professionals. The information we provide is not intended to be a substitute for professional medical advice, diagnosis or treatment. It should not be used in place of the advice of your physician or other qualified healthcare provider.