About 15 million American adults, or about 7 percent of the population, have social anxiety disorder, making it one of the most common mental disorders in the United States1. Often referred to as SAD, and sometimes as social phobia, it is characterized by a fear in one or more social situations. To be clear, SAD is different from shyness; studies have found that only 12 percent of shy teenagers meet the criteria for this disorder2.
SAD is diagnosed when social anxiety disrupts daily life. Common examples are avoiding social situations such as going to parties or eating in front of people. Socially anxious people have different reasons for avoiding certain situations, but most often it comes from an overwhelming fear of being judged or embarrassed. Being in these situations can cause rapid heart rate, lightheadedness, or some other physical discomforts3.
Like several other types of anxieties, social anxiety can fall into a vicious self-perpetuating cycle. Let's say I have SAD and a friend persuades me to go to a party. I agree, and at first I'm excited about attending. But as the party date approaches I start thinking negatively about the social situation: "I'm going to embarrass myself; there are too many strangers." As these thoughts float around in my head, my heart starts to race and maybe I feel a little queasy. I still have the option to bail, so I text my friend that I can't make it. I avoid the party, and my body calms down, which reinforces my habit of avoiding parties. This is part one of the cycle.
Here is the other part: I decide to go to the party, and when I show up I'm worried about embarrassing myself. I pay too much attention to myself, causing me to sweat, so I hide in the corner, which is not a very enjoyable experience. Afterward I go home and have negative thoughts about the party, which reinforce the idea that I should avoid all parties.
This cycle of avoiding anxious situations or being made uncomfortable by anxious situations is a common hallmark of most anxiety disorders, and it is known as the cognitive avoidance model4. It can be particularly self-destructive with SAD because it causes further isolation from social groups, which can, in turn, make symptoms worse.
Although SAD is the most common mental disorder in the United States, many people spend years with their symptoms before consulting a therapist, psychiatrist, or other mental health provider. As many as 36 percent of those with social anxiety report having had symptoms for 10 years or longer before they seek help1. How do you cope with those symptoms before getting help? Alcohol, mostly.
Alcohol, a depressant familiar to many, causes feelings of euphoria when taken in low doses. It also decreases anxiety and inhibition, which usually increases sociability. These qualities make alcohol the most common form of self-medication for SAD. But this carries a few negative consequences. For one, almost 28 percent of people formally diagnosed with SAD also meet the criteria for alcohol use disorder at some point in their lifetime5. In addition to the high risk of addiction, depending on alcohol for social situations will worsen general anxiety symptoms. Self-medicating SAD with alcohol is not a viable long-term course of action.
The longer your dependence on alcohol, the more likely you are to develop heart or liver disease, depression, stroke, cancer, irritable bowel syndrome, or many other potential health problems.6
Getting professional help is key to your future well-being. Cognitive behavioral therapy (CBT) and behavioral activation (BA) are two recommended psychological approaches to breaking free of social anxiety. Both are evidence-based and equally effective in treating social anxieties10. If depression is associated with social anxiety, BA is more effective. As with all therapies, it is best to find a therapist you feel most comfortable with. This process may take some time.
Medication is often recommended only for those who are not interested in therapy7. Occasionally medication can help facilitate therapy, with the goal of discontinuing it while still in therapy. The most common classes of medications prescribed for social anxiety are selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs). The medications known as beta-blockers and benzodiazepines are not recommended as long-term treatment options8-9. As for any mental disorders, finding the right medication at the correct dosage may require some trial-and-error. It is important to find a psychiatrist you feel comfortable with so you can discuss all your symptoms and side effects.
It may take time to set up treatment options with therapists or psychiatrists. In the meantime, you can start by taking two steps to incorporate into your daily life to end your social anxiety cycle.
1. Get in a good mood before social situations. This is one of the mechanisms taught in behavioral activation treatment. Social anxieties may begin to take form before you ever get to a social engagement. Negative thoughts can cause doubts and you may simply leave. Or they can make you too self-conscious when you do arrive.
Take some time to prepare yourself emotionally to put yourself in a good mood. This might be watching TV, listening to music, or playing video games. Engaging in activities you enjoy can help release endorphins that will make you feel more relaxed and positive.
2. Reframe your negative thoughts. Reframing is one of the first techniques taught in CBT. "I am just shy." "People are going to judge me." These are the types of thoughts that can cause a self-fulfilling prophecy. When you believe these things so fundamentally within yourself, it becomes difficult to act in any other way.
A therapist will help guide you through the reframing process, but it is something you can try to do yourself. When you are thinking negative thoughts, acknowledge them, write them down, and reframe them. Here's how:
a. Stop defining yourself! "I am a quiet person." Instead of defining yourself as quiet, reframe your thought as the action "I acted quietly tonight." Acknowledge your behavior without defining yourself; this becomes something you can change instead of something that is a part of you.
b. Change your perspective. "People are going to judge me and think I'm boring." You cannot assume to know what others are thinking. Instead, reframe the thought: "People haven't gotten a chance to know me." Then follow up with an actionable thought: "I will try to express myself."
Try these activities to help ease your social anxiety and control your symptoms. Eventually, and with the help of a mental health professional, you may find that what you worried about most rarely actually took place.
Recommended For You
1. Understanding the Facts: Social Anxiety Disorder. Retrieved from https://www.adaa.org/understanding-anxiety/social-anxiety-disorder
2. Burnstein, M., Ameli-Grillon, L., and Merikangas, K.R. (2011). Shyness versus social phobia in US youth. Pediatrics. 128(5), 917-925.
3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
4. Stapinski, L.A., Abbott, M.J., and Rapee, R.M. (2010). Evaluating the cognitive avoidance model of generalised anxiety disorder: impact of worry on threat appraisal, perceived control and anxious arousal. Behaviour Research and Therapy. 48(10), 1032-1040.
5. Schneier, F.R., Foose, T.E., Hasin, D.S., et al. (2010). Social anxiety disorder and alcohol use disorder co-morbidity in the National Epidemiologic Survey on Alcohol and Related Conditions. Psychological Medicine. 40(6), 977-988.
6. Physical Health Consequences of Alcoholism. Retrieved from http://americanaddictioncenters.org/alcoholism-treatment/physical-health/
7. Pilling, S., Mayo-Wilson, E., Mavranezouli, I., et al. (2013) Recognition, assessment and treatment of social anxiety disorder: summary of NICE guidance. BMJ (Clinical research ed.) 346, 2541.
8. Blanco, C., Bragdon, L. B., Schneier, F. R., and Liebowitz, M. R. (2012). The evidence-based pharmacotherapy of social anxiety disorder. The International Journal of Neuropsychopharmacology. 16(1), 235–249.
9. Allgulander, C., Bandelow, B., Hollander, E., et al. (2003). WCA recommendations for the long-term treatment of generalized anxiety disorder. CNS Spectr. 8(8 Suppl 1), 53–61
10. Soleimani, M., Mohammadkhani, P., Dolatshahi, B., et al. (2015). A Comparative Study of Group Behavioral Activation and Cognitive Therapy in Reducing Subsyndromal Anxiety and Depressive Symptoms. Iran Journal of Psychiatry. 10(2), 71-78.
Date of original publication: August 15, 2017