Even the most emotionally healthy and balanced among us know what it is to occasionally feel like a wallflower, to be on the outside looking in, or shy in an unfamiliar social situation. But for sufferers of social anxiety disorder (SAD), the problem goes far beyond the occasional tense social scenario.
People afflicted with SAD understand the world to be a frightening, judgmental place fraught with people ready to point out their shortcomings, where seemingly benign social interactions are potentially soul-crushing experiences. And while shyness, social anxiety, and unsociability are terms used interchangeably to describe inhibited behavior in social situations, not all people who are shy meet the criteria for SAD, despite the overlapping nature of either condition1.
Social anxiety disorder is among the most common mental disorders, and its symptoms often lead to major life-altering fears such as eating or drinking in public, using public restrooms, and even being seen writing in public. Symptoms of less severe forms of the disorder often include fear of public speaking, fear of being assertive and avoidance of parties, and other common social functions 2. Left undiagnosed and untreated, SAD can contribute to any number of health, family, and financial problems, which can then lead to thoughts of suicide3, increased drinking (specifically when alone)4, and long-term disability (usually defined as lasting more than four years and impairing mobility), self-care, social interactions, and general life activities5.
Compounding what is already a debilitating disorder on its own, SAD is often comorbid (commonly occurring with other psychiatric disorders) with situational panic attacks6, intermittent explosive disorder7, selective mutism8, or the inability to speak in select social settings, and others.
The causes of SAD are understood to be an interplay between factors such as an individual’s genetic, biological and cognitive processes, and social skills, as well as environmental factors like parental influence, aversive social experiences, and negative life events9. As an illness that usually becomes evident early on in a person’s life, its effects on the already fragile adolescent years can be especially damaging, increasing the risk of both depression10 and alcohol and cannabis dependence in early adulthood11. And that’s not to mention its seriously compromising educational progress and completion at the high school level12, and serious avoidance and school difficulties during the college years13.
Despite the illness’s far-ranging effects, a recent meta-analysis indicates that social anxiety disorder responds well to treatment, even though there are some lingering effects once the acute treatment phase has concluded. The most effective psychological intervention is cognitive behavioral therapy (CBT), which studies showed has a greater effect when compared to psychodynamic psychotherapy, interpersonal psychotherapy, mindfulness, and supportive therapy. Among the pharmacotherapy interventions, the most effective treatment for adults is the use of SSRIs14.
An important step, however, is simply to approach the illness and those affected by it with knowledge and compassion. Share information on the whys and hows of SAD and communicate that it is both common and treatable. Encourage those suffering to seek treatment and to see the process through to completion while gently helping them find ways to engage socially, but never pushing too hard15.
1. Poole, K. L., Van Lieshout, R. J., & Schmidt, L. A. (2017). Exploring relations between shyness and social anxiety disorder: The role of sociability. Personality & Individual Differences, 110, 55-59. doi:10.1016/j.paid.2017.01.020
2. Crome, E., & Baillie, A. (2014). Mild to severe social fears: Ranking types of feared social situations using item response theory. Journal of Anxiety Disorders, 28(5), 471-479.
3. Vriends, N., Bolt, O. C., & Kunz, S. M. (2014). Social anxiety disorder, a lifelong disorder? A review of the spontaneous remission and its predictors. Acta Psychiatrica Scandinavica, 130(2), 109-122. doi:10.1111/acps.12249
4. Buckner, J. D., & Terlecki, M. A. (2016). Social anxiety and alcohol-related impairment: The mediational impact of solitary drinking. Addictive Behaviors, 587, 7-11. doi:10.1016/j.addbeh.2016.02.006
5. Hendriks, S. M., Spijker, J., Licht, C. M., Hardeveld, F., de Graaf, R., Batelaan, N. M., & … Beekman, A. F. (2016). Long-term disability in anxiety disorders. BMC Psychiatry, 161, 1-8. doi:10.1186/s12888-016-0946-y
6. Potter, C. M., Wong, J., Heimberg, R. G., Blanco, C., Liu, S., Wang, S., & Schneier, F. R. (2014). Situational panic attacks in social anxiety disorder. Journal Of Affective Disorders, 167, 1-7. doi:10.1016/j.jad.2014.05.044
7. Keyes, K. M., McLaughlin, K. A., Vo, T., Galbraith, T., & Heimberg, R. G. (2016). Anxious and aggressive: The co-occurrence of IED with Anxiety Disorders. Depression & Anxiety 33(2), 101-111. doi:10.1002/da.22428
8. Gensthaler, A., Maichrowitz, V., Kaess, M., Ligges, M., Freitag, C. M., & Schwenck, C. (2016). Selective mutism: The fraternal twin of childhood social phobia. Psychopathology, 49(2), 95-107.
9. Spence, S. H., & Rapee, R. M. (2016). The etiology of social anxiety disorder: An evidence-based model. Behaviour Research & Therapy,8650-67. doi:10.1016/j.brat.2016.06.007
10. Beesdo, K., Bittner, A., Pine, D. S., Stein, M. B., Hofler, M., Lieb, R., et al. (2007).
Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Archives of General Psychiatry, 64(8), 903–912.
11. Buckner, J. D., Schmidt, N. B., Lang, A. R., Small, J. W., Schlauch, R. C., & Lewinsohn, P. M. (2008). Specificity of social anxiety disorder as a risk factor for alcohol and cannabis dependence. Journal of Psychiatric Research, 42(3), 230–239.
12. Ranta, K., La Greca, A., Kaltiala-Heino, R., Marttunen, M., & La Greca, A. M. (2016). Social Phobia and Educational and Interpersonal Impairments in Adolescence: A Prospective Study. Child Psychiatry & Human Development, 47(4), 665-677. doi:10.1007/s10578-015-0600-9
13. Dell’Osso, L., Abelli, M., Pini, S., Carlini, M., Carpita, B., Macchi, E., … & Massimetti, G. (2014). Dimensional assessment of DSM-5 social anxiety symptoms among university students and its relationship with functional impairment. Neuropsychiatric disease and treatment, 10, 1325.
14. Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), 368-376.
Cinzia Cottù Di Roccaforte earned a Doctoral Degree in Clinical Psychology from Alliant International University Los Angeles in 2019. She received a Bachelor of Arts in psychology from UCLA in 2011 and her Master of Arts in clinical psychology with emphasis in Marriage & Family Therapy from Pepperdine University in 2014. Dr. Roccaforte has been working with Dr. Alexander Bystritsky at the UCLA Anxiety Disorders Program. Dr. Roccaforte and Dr. Bystritsky also collaborated writing articles for Anxiety.org.