Social anxiety disorder

The 11th revision of the International Classification of Diseases (ICD-11) classifies social anxiety disorder as an anxiety or fear-related disorder. Cognitive aspects In cognitive models of social anxiety disorder, those with social anxiety disorder experience dread over how they will present to others. Those who have social anxiety disorder fear being judged by others in society. In particular, individuals with social anxiety are nervous in the presence of people with authority and feel uncomfortable during physical examinations. People who have this disorder may behave a certain way or say something and then feel embarrassed or humiliated after. As a result, they often choose to isolate themselves from society to avoid such situations. They may also feel uncomfortable meeting people they do not know and act distant when they are with large groups of people. In some cases, they may show evidence of this disorder by avoiding eye contact, or blushing when someone is talking to them. Comorbidity SAD shows a high degree of co-occurrence with psychiatric disorders. In fact, a population-based study found that 66% of those with SAD had one or more additional mental health disorders. SAD often occurs alongside low self-esteem and most commonly clinical depression. Clinical depression is 1.49 to 3.5 times more likely to occur in those with SAD. Research also indicates that the presence of certain social fears (e.g., avoidance of participating in small groups, avoidance of going to a party) are more likely to trigger comorbid depressive symptoms than other social fears. Anxiety disorders other than SAD are also common in people with SAD, in particular generalized anxiety disorder. Avoidant personality disorder is likewise highly correlated with SAD, with comorbidity rates ranging from 25% to 89%. To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to substance use disorders. It is estimated that one-fifth of people with social anxiety disorder also have alcohol use disorder. However, some research suggests SAD is unrelated to, or even protective against alcohol-related problems. Those who have both alcohol use disorder and social anxiety disorder are more likely to avoid group-based treatments and to relapse compared to people who do not have this combination. ==Causes==

Research into the causes of social anxiety and social phobia is wide-ranging, encompassing multiple perspectives from neuroscience to sociology. Scientists have yet to pinpoint the exact causes. Studies suggest that genetics can play a part in combination with environmental factors. Social phobia is not caused by other mental disorders or substance use. Generally, social anxiety begins at a specific point in an individual's life. This will develop over time as the person struggles to recover. Eventually, mild social awkwardness can develop into symptoms of social anxiety or phobia. Passive social media usage may cause social anxiety in some people. Genetics It has been shown that there is a two to a threefold greater risk of having social phobia if a first-degree relative also has the disorder. This could be due to genetics and/or due to children acquiring social fears and avoidance through processes of observational learning or parental psychosocial education. Studies of identical twins brought up (via adoption) in different families have indicated that, if one twin developed social anxiety disorder, then the other was between 30 percent and 50 percent more likely than average to also develop the disorder. To some extent, this "heritability" may not be specific – for example, studies have found that if a parent has any kind of anxiety disorder or clinical depression, then a child is somewhat more likely to develop an anxiety disorder or social phobia. Studies suggest that parents of those with social anxiety disorder tend to be more socially isolated themselves, and shyness in adoptive parents is significantly correlated with shyness in adopted children. Growing up with overprotective and hypercritical parents has also been associated with social anxiety disorder. Adolescents who were rated as having an insecure (anxious-ambivalent) attachment with their mother as infants were twice as likely to develop anxiety disorders by late adolescence, including social phobia. A related line of research has investigated 'behavioural inhibition' in infants – early signs of an inhibited and introspective or fearful nature. Studies have shown that around 10–15 percent of individuals show this early temperament, which appears to be partly due to genetics. Some continue to show this trait into adolescence and adulthood and appear to be more likely to develop a social anxiety disorder. Social experiences A previous negative social experience can be a trigger to social phobia, perhaps particularly for individuals high in "interpersonal sensitivity". For around half of those diagnosed with social anxiety disorder, a specific traumatic or humiliating social event appears to be associated with the onset or worsening of the disorder; this kind of event appears to be particularly related to specific social phobia, for example, regarding public speaking. As well as direct experiences, observing or hearing about the socially negative experiences of others (e.g. a faux pas committed by someone), or verbal warnings of social problems and dangers, may also make the development of a social anxiety disorder more likely. Social anxiety disorder may be caused by the longer-term effects of not fitting in, or being bullied, rejected, or ignored. or childhood bullying or harassment. In one study, popularity was found to be negatively correlated with social anxiety, and children who were neglected by their peers reported higher social anxiety and fear of negative evaluation than other categories of children. Socially phobic children appear less likely to receive positive reactions from peers, and anxious or inhibited children may isolate themselves. Parental influences Different parenting styles can also contribute to the development of social anxiety disorder. The common negative parenting styles, such as overcontrol and criticism can be detrimental for a child to be able to overcome difficult situations. More aggressive and harsh parenting styles that include both verbal abuse and physical punishment are linked with an insecure attachment and risk for social anxiety disorder. On the contrary, positive parenting that fosters a more supportive and warm environment for the child is correlated to a decreased risk of developing this disorder. On the biological level as well, there is strong evidence that states how children from parents with social anxiety disorder have significantly increased risk to the disorder. Cultural influences Cultural factors that have been related to social anxiety disorder include a society's attitude towards shyness and avoidance, affecting the ability to form relationships or access employment or education, and shame. One study found that the effects of parenting are different depending on the culture: American children appear more likely to develop social anxiety disorder if their parents emphasize the importance of others' opinions and use shame as a disciplinary strategy, but this association was not found for Chinese/Chinese-American children. In China, research has indicated that shy-inhibited children are more accepted than their peers and more likely to be considered for leadership and considered competent, in contrast to the findings in Western countries. Purely demographic variables may also play a role. Problems in developing social skills, or 'social fluency', may be a cause of some social anxiety disorder, through either inability or lack of confidence to interact socially and gain positive reactions and acceptance from others. The studies have been mixed, however, with some studies not finding significant problems in social skills while others have. What does seem clear is that the socially anxious perceive their own social skills to be low. It may be that the increasing need for sophisticated social skills in forming relationships or careers, and an emphasis on assertiveness and competitiveness, is making social anxiety problems more common, at least among the 'middle classes'. An interpersonal or media emphasis on 'normal' or 'attractive' personal characteristics has also been argued to fuel perfectionism and feelings of inferiority or insecurity regarding negative evaluation from others. The need for social acceptance or social standing has been elaborated in other lines of research relating to social anxiety. Substance-induced While alcohol initially relieves social phobia, excessive alcohol misuse can worsen social phobia symptoms and cause panic disorder to develop or worsen during alcohol intoxication and especially during alcohol withdrawal syndrome. This effect is not unique to alcohol but can also occur with long-term use of drugs that have a similar mechanism of action to alcohol such as the benzodiazepines which are sometimes prescribed as tranquillisers. Benzodiazepines possess anti-anxiety properties and can be useful for the short-term treatment of severe anxiety. Like the anticonvulsants, they tend to be mild and well-tolerated, although there is a risk of habit-forming. Benzodiazepines are usually administered orally for the treatment of anxiety; however, occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks. The World Council of Anxiety does not recommend benzodiazepines for the long-term treatment of anxiety due to a range of problems associated with long-term use including tolerance, psychomotor impairment, cognitive and memory impairments, physical dependence and a benzodiazepine withdrawal syndrome upon discontinuation of benzodiazepines. Despite increasing focus on the use of antidepressants and other agents for the treatment of anxiety, benzodiazepines have remained a mainstay of anxiolytic pharmacotherapy due to their robust efficacy, rapid onset of therapeutic effect, and generally favorable side effect profile. Treatment patterns for psychotropic drugs appear to have remained stable over the past decade, with benzodiazepines being the most commonly used medication for panic disorder. Many people who are addicted to alcohol or prescribed benzodiazepines when it is explained to them they have a choice between ongoing ill mental health or quitting and recovering from their symptoms decide on quitting alcohol or their benzodiazepines. Psychological factors Research has indicated the role of 'core' or 'unconditional' negative beliefs (e.g. "I am inept") and 'conditional' beliefs nearer to the surface (e.g. "If I show myself, I will be rejected"). They are thought to develop based on personality and adverse experiences and to be activated when the person feels under threat. Recent research has also highlighted that conditional beliefs may also be at play (e.g., "If people see I'm anxious, they'll think that I'm weak"). A secondary factor is self-concealment which involves concealing the expression of one's anxiety or its underlying beliefs. One line of work has focused more specifically on the key role of self-presentational concerns. The resulting anxiety states are seen as interfering with social performance and the ability to concentrate on interaction, which in turn creates more social problems, which strengthens the negative schema. Also highlighted has been a high focus on and worry about anxiety symptoms themselves and how they might appear to others. A similar model emphasizes the development of a distorted mental representation of the self and overestimates of the likelihood and consequences of negative evaluation, and of the performance standards that others have. Such cognitive-behavioral models consider the role of negatively biased memories of the past and the processes of rumination after an event (also known as post-event processing), and fearful anticipation before it. Studies have also highlighted the role of subtle avoidance and defensive factors, and shown how attempts to avoid feared negative evaluations or use of "safety behaviors" ==Diagnosis==

ICD-10 defines social phobia as fear of scrutiny by other people leading to avoidance of social situations. The anxiety symptoms may present as a complaint of blushing, hand tremor, nausea, or urgency of urination. Symptoms may progress to panic attacks. Standardized rating scales such as the Social Phobia Inventory, the SPAI-B, Liebowitz Social Anxiety Scale, and the Social Interaction Anxiety Scale can be used to screen for social anxiety disorder and measure the severity of anxiety. SAD is categorized into two main types: Generalized Social Anxiety Disorder: Affects nearly all aspects of a person's social life, making everyday interactions extremely stressful. Specific (Performance-Based) Social Anxiety Disorder: Individuals feel extreme nervousness in specific situations, like giving a speech or performing on stage. DSM-5 diagnostic criteria Although the DSM defines social anxiety disorder as an intense fear or anxiety of social situations, it makes clear a distinction to separate social anxiety disorder from simply social anxiety or social fear. Social situations • The anxiety must occur in a social setting under circumstances that are conducive to the possible scrutiny of others. • For children, the DSM-5 notes that the anxiety must be in a setting with other children and not with adults. • Social situations induce and are avoided due to the intense feelings of anxiety or fear. • Social situations must be the cause of anxiety or fear. The DSM-5 notes that for social anxiety disorder, the fear must be attributed or correlated to social situations and not another condition. Social anxiety disorder is often linked to bipolar disorder and attention deficit hyperactivity disorder (ADHD), leading to an assumption of a shared cyclothymic-anxious-sensitive disposition. The co-occurrence of ADHD and social phobia is common, especially when cognitive disengagement syndrome is present. ==Treatment==

Psychotherapies The first-line treatment for social anxiety disorder is cognitive behavioral therapy (CBT), with medications such as selective serotonin reuptake inhibitors (SSRIs) sometimes used in combination with CBT. Self-help based on principles of CBT is an alternative option for those unable to access in-person mental health services. Another treatment with a growing evidence base for social anxiety disorder is metacognitive therapy (MCT), which targets the underlying processes that maintain the disorder. More specifically, the aim of MCT is to identify and modify dysfunctional metacognitive beliefs that contribute to and sustain a perseverative style of thinking known as the cognitive attentional syndrome (CAS), which comprises worry and rumination, threat monitoring, self-focused attention, and maladaptive coping behaviors. Some studies have suggested that MCT may be superior to CBT for social anxiety disorder. There is emerging evidence for the use of acceptance and commitment therapy (ACT) in the treatment of social anxiety disorder. ACT is considered an offshoot of traditional CBT and emphasizes accepting unpleasant symptoms rather than fighting against them, as well as psychological flexibility – the ability to adapt to changing situational demands, to shift one's perspective, and to balance competing desires. ACT may be useful as an alternative treatment for the disorder in situations where CBT is ineffective or refused. Some studies have suggested social skills training can help with social anxiety. Examples of social skills that may be modified for social anxiety disorder include initiating conversations, establishing friendships, interacting with members of the preferred sex, constructing a speech, and assertiveness skills. However, it is not clear whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations. Social anxiety disorder may predict subsequent development of other psychiatric disorders, such as depression. Medications A comparison of the treatment effects on social anxiety disorder showed that using a medication is faster, while CBT is longer-lasting. Paroxetine and paroxetine CR, sertraline, venlafaxine XR and fluvoxamine CR (Luvox CR) are all approved and effective for treating social anxiety disorder. General side effects are common during the first weeks while the body adjusts to SSRI drugs. Symptoms may include headaches, nausea, insomnia and changes in sexual behavior. Other drugs Other prescription drugs are also used, if other methods are not effective. Before the introduction of SSRIs, monoamine oxidase inhibitors (MAOIs) such as phenelzine were frequently used in the treatment of social anxiety. RIMAs have been found to be less efficacious for social anxiety disorder than irreversible MAOIs like phenelzine. Propranolol, a beta blocker commonly used to control high blood pressure, is used for performance anxiety specifically. Gabapetin has been investigated for social anxiety disorder in preliminary long-term studies. Anticonvulsants, tricyclic antidepressants, antipsychotic drugs, and St. John's wort should not be used. Guidelines vary regarding whether benzodiazepines should be used. ==Epidemiology==

Social anxiety disorder is known to appear at an early age in most cases. Fifty percent of those who develop this disorder have developed it by the age of 11, and 80% have developed it by age 20. The National Comorbidity Survey of over 8,000 American correspondents in 1994 revealed 12-month and lifetime prevalence rates of 7.9 percent and 13.3 percent, respectively; this makes it the third most prevalent psychiatric disorder after depression and alcohol use disorder, and the most common of the anxiety disorders. According to US epidemiological data from the National Institute of Mental Health, social phobia affects 15 million adult Americans in any given year. Estimates vary within 2 percent and 7 percent of the US adult population. The mean onset of social phobia is 10 to 13 years. Onset after age 25 is rare and is typically preceded by panic disorder or major depression. Social anxiety disorder occurs more often in females than males. The prevalence of social phobia appears to be increasing among white, married, and well-educated individuals. As a group, those with generalized social phobia are less likely to graduate from high school and are more likely to rely on government financial assistance or have poverty-level salaries. Surveys carried out in 2002 show the youth of England, Scotland, and Wales have a prevalence rate of 0.4 percent, 1.8 percent, and 0.6 percent, respectively. In Canada, the prevalence of self-reported social anxiety for Nova Scotians older than 14 years was 4.2 percent in June 2004 with women (4.6 percent) reporting more than men (3.8 percent). In Australia, social phobia is the 8th and 5th leading disease or illness for males and females between 15 and 24 years of age as of 2003. Because of the difficulty in separating social phobia from poor social skills or shyness, some studies have a large range of prevalence. The table also shows higher prevalence in Sweden. ==History==

Literary descriptions of shyness can be traced back to the days of Hippocrates around 400 BC. Hippocrates described someone who "through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him". The first mention of the psychiatric term "social phobia" (phobie des situations sociales) was made in the early 1900s. Psychologists used the term "social neurosis" to describe extremely shy patients in the 1930s. After extensive work by Joseph Wolpe on systematic desensitization, research on phobias and their treatment grew. The idea that social phobia was a separate entity from other phobias came from the British psychiatrist Isaac Marks in the 1960s. This was accepted by the American Psychiatric Association and was first officially included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). ==Research==

Although social anxiety disorder has been under study for decades, the underlying neurobiology is not well understood. Neuroimaging technologies are in use to clarify brain regions involved. Parenting that is intrusive or controlling and stressful life events may increase the risk for SAD development during childhood, extending into adult years. Genetic factors may have a role, although genetic biomarkers are not specifically identified. ==See also==