Social Anxiety Disorder

Where the line with shyness actually falls

The material puts it in behavioural terms: the fear exceeds normal shyness because it produces excessive social avoidance and substantial impairment at work or in relationships. ICD-11 classifies it as an anxiety or fear-related disorder and asks for persistent symptoms over at least several months, with distress and impairment across personal, family, social, educational or occupational life.

The printed encyclopedia gives the more vivid version of the range. A social phobia may be confined to one act: a person who cannot write on a blackboard in front of others and manages every other social task without difficulty. At the other end are people who find it hard to speak to anyone outside their immediate family. Signing a name in public and using a public lavatory are named among the avoided activities.

What social anxiety does before and after events

The cognitive account describes two rehearsals rather than one reaction.

Before the event, the person reviews what could go wrong and how each unexpected turn might be handled. After it, they conclude the performance was unsatisfactory, and anything that could conceivably have been abnormal is reinterpreted as embarrassing. Those thoughts are described as continuing for weeks or longer.

The perceptual bias underneath is documented. Neutral or ambiguous conversations are read negatively, and socially anxious people recall more negative memories than less distressed people do. The self-presentation account holds the two together: the person is trying to produce a well-mannered impression and believes they are unable to.

Why social anxiety rarely arrives alone

Sixty-six per cent of people with social anxiety disorder in a population-based study had at least one additional mental health disorder. Depression is between 1.49 and 3.5 times more likely in people with it. Avoidant personality disorder overlaps at rates from twenty-five to eighty-nine per cent, which is a range wide enough to raise the question of whether the two are separable at all.

One finding in that material is more specific than the rest. Particular social fears, avoiding small-group participation and avoiding parties, are more likely than other social fears to bring depressive symptoms with them. It is not the severity of the fear that predicts the depression but which situations it removes.

Whether social anxiety leads to drinking

About one fifth of people with social anxiety disorder also have alcohol use disorder, and self-medication is described as common, particularly where the condition is undiagnosed or untreated.

Against that, some of the evidence indicates social anxiety disorder is unrelated to alcohol-related problems or even protective against them. The material carries both positions without resolving them. What is not in dispute is the consequence: people with both conditions are more likely to avoid group-based treatment and more likely to relapse.

Why social anxiety runs in families

The risk is two to threefold higher if a first-degree relative has it. Identical twins raised apart through adoption showed the second twin between thirty and fifty per cent more likely than average to develop it. Both figures are consistent with inheritance and neither isolates it, since children also acquire social fears by watching.

The heritability may not be specific. A parent with any anxiety disorder or clinical depression raises a child's risk of an anxiety disorder generally. Parents of people with social anxiety disorder tend to be more socially isolated themselves, and shyness in adoptive parents correlates significantly with shyness in adopted children, which is an environmental finding inside an adoption study.

Behavioural inhibition is the temperamental thread. Around ten to fifteen per cent of infants show an inhibited, watchful early temperament, partly genetic, and those who carry it into adolescence are more likely to develop the disorder. Overprotective and hypercritical parenting is associated with it, and adolescents rated as anxious-ambivalent in attachment as infants were twice as likely to develop an anxiety disorder by late adolescence.

What starts social anxiety

For around half of those diagnosed, a specific traumatic or humiliating social event is associated with the onset or the worsening of the condition. The association is strongest for the narrow presentations, public speaking in particular.

Indirect routes are also documented: witnessing or hearing about somebody else's social failure, or being warned verbally about social dangers. Bullying, rejection and long-term exclusion are named as causes in their own right.

How social anxiety disorder is treated

Attention to social anxiety disorder increased significantly from 1999, with the approval and marketing of drugs to treat it. That sentence is worth reading slowly, because it dates a rise in a diagnosis to a commercial event rather than a discovery, and the source states it without comment.

The approved medications are:

• the selective serotonin reuptake inhibitors paroxetine, sertraline and fluvoxamine
• the serotonin and noradrenaline reuptake inhibitor venlafaxine
• the monoamine oxidase inhibitor phenelzine

Propranolol, a beta blocker, is used off-label for performance anxiety.

Cognitive behavioural therapy is the first-line treatment with or without medication, and is most effective delivered individually rather than in a group, which is a notable finding for a condition defined by fear of groups. Metacognitive therapy and acceptance and commitment therapy are described as at least as effective.

Prevalence is described as rising, particularly among young people, and passive social media use is named as a possible cause in some. The 2008 printed encyclopedia gives the National Institute of Mental Health figure of about fifteen million affected adults in the United States.