Social Anxiety Disorder

Key Facts About Social Anxiety Disorder (SAD):

  • Social anxiety disorder (SAD) is characterized by significant anxiety in reaction to social situations and a fear of being judged. It can seriously impact an individual’s social and professional life.
  • SAD is often difficult to diagnose. The symptoms can be mistaken for shyness or traits related to temperament. SAD is one of the most widespread psychiatric disorders, after depressive disorders and substance use disorders, but it is often difficult to diagnose due to its interaction with cultural, gender, and contextual factors.
  • SAD treatment generally involves cognitive-behavioral therapy (CBT), which includes gradual exposure techniques and cognitive restructuring, as well as pharmacological interventions.
  • Recent research on nasal anxiolytics offers promising perspectives for rapid treatment of anxiety-inducing situations, complementing traditional psychotherapy approaches and medication.

 

How does SAD manifest?

Julien, 24 years old, a university student, seeks help for high anxiety in social situations. Since childhood, he has felt uncomfortable in family gatherings, despite a loving and supportive environment. At school, he struggled with group presentations, recalling symptoms of panic such as palpitations and confuse thoughts. To avoid being in the spotlight, he has taken on supportive roles, such as taking notes for the group and preparing slides.

He prefers to avoid direct social interactions. In this way, he feels that he is still participating and that his work is appreciated, without being exposed to others’ scrutiny. He has also faced other challenges when trying to ask someone out or when he struggled to order food in front of other people at a restaurant. He prefers to text rather than call when given the opportunity. He finds it difficult to introduce himself to people and he feels his voice tremble when giving oral presentations.

Julien feels that his symptoms severely impact his social and professional life, preventing him from forming relationships and pursuing his studies. He uses alcohol and sometimes cannabis to reduce his anxiety.

Definition and Prevalence of Social Anxiety Disorder (SAD)

SAD is characterized by significant anxiety in response to social situations such as social interactions (e.g., conversing with strangers, meetings), performing (e.g., speaking in front of people), and being observed (e.g., eating or writing in front of people). A certain level of anxiety in social situations can be congruent with the context (for example, a major presentation that could be determinant for a promotion), but the core of SAD is the underlying layer of negative thoughts suggesting to the person that they will be judged, ridiculized, or perceived negatively by others.

Social Anxiety Disorder (SAD) is the most common anxiety disorder in the population, with a prevalence rate of around 7%. This disorder affects women twice as often as men. The typical age for the onset of symptoms is around 13 years old (between 8 and 15 years old).

A traumatic experience in social contexts is not necessarily a precursor for SAD, and the disorder causes impairment in several areas of life. A duration of 6 months is required for a diagnosis of SAD. Symptoms can include a performance subtype, where the fear is limited to speaking or performing in public. SAD also includes paruresis, which is the fear of urinating in a public restroom.

For example, in a child, SAD may present as refusal to go to school, which raises the possibility of separation anxiety disorder. In an adolescent or young adult, SAD may interfere with romantic date requests or engagement with new friends (e.g., when starting a new sport or transitioning to secondary school or university).

Avoidance of the feared situation is a common feature of SAD. Less severe manifestations include high levels of anticipatory anxiety, excessive preparation, or participation in the event only with a companion or assistance.

Management of SAD

SAD is typically treated through psychotherapy and/or pharmacotherapy.

Psychotherapeutic Intervention

  • Cognitive-behavioral therapy (CBT) is the first-line treatment, aimed at gradually exposing individuals to feared situations while modifying negative perceptions. For young people, parental involvement is often necessary to support the treatment. Typically, 15 to 20 sessions of CBT are recommended.
  • There are also therapies based on mindfulness and acceptance, including acceptance and commitment therapy (ACT), mindfulness-based stress reduction (MBSR), and in vivo exposure— all aimed at providing evidence against the erroneous cognitive perceptions related to social expectations and apprehensions.

Pharmacological Interventions

  • First-line pharmacotherapies that have clearly demonstrated efficacy in reducing social anxiety and improving quality of life include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) such as paroxetine, sertraline, fluvoxamine, and venlafaxine. 
  • Citalopram, escitalopram, and vilazodone have also shown promising results and appear to be more effective than fluoxetine. 
  • A minimum treatment duration of 4 to 6 weeks is necessary for notable benefits.
  • Paroxetine and sertraline seem to be the most helpful medications in the treatment of SAD. 
  • Recent research on nasal anxiolytics, such as PH94B, shows promising results for rapid treatment of anxiety-provoking situations.

Combining CBT with medication can be particularly effective, although this approach is not always utilized.

SAD is a significant disorder that causes silent suffering and can greatly impact quality of life. It contributes to depression, substance abuse disorders, underemployment, and a general lack of ability to reach one’s full socio-educational potential. Increased recognition and a combined approach of psychotherapy and pharmacotherapy can offer valuable support to those affected.

References :

  • Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The Efficacy of Cognitive Behavioral Therapy: A Review of Meta-analyses. Cognitive Therapy and Research, 36(5), 427-440. DOI: 10.1007/s10608-012-9476-1
  • Stein, M. B., & Stein, D. J. (2008). Social anxiety disorder. The Lancet, 371(9618), 1115-1125. DOI: 10.1016/S0140-6736(08)60488-8
  • Rapee, R. M., & Spence, S. H. (2004). The etiology of social anxiety disorder. Annual Review of Clinical Psychology, 1, 389-407. DOI: 10.1146/annurev.clinpsy.1.102803.143916
  • Kessler, R. C., Berglund, P., Demler, O., Jin, R., Koretz, D., & Merikangas, K. R. (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 593-602. DOI: 10.1001/archpsyc.62.6.593
  • Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In Social phobia: Diagnosis, assessment, and treatment (pp. 69-93). Guilford Press.
  • Liebowitz, M. R. (1987). Social phobia. Modern Problems of Pharmacopsychiatry, 22, 141-173. DOI: 10.1159/000414022
  • Cuijpers, P., Karyotaki, E., Weitz, E., Andersson, G., & Hollon, S. D. (2016). The effects of psychotherapies for major depression in adults on remission, recovery and improvement: a meta-analysis. Journal of Affective Disorders, 202, 511-517. DOI: 10.1016/j.jad.2016.04.027
  • Muroff, J. (2006). Pharmacological treatments for social anxiety disorder: A review. Expert Opinion on Pharmacotherapy, 7(11), 1505-1515. DOI: 10.1517/14656566.7.11.1505
  • Fales, C. L., & Schaefer, H. S. (2022). Novel pharmacological treatments for social anxiety disorder: Current status and future directions. Journal of Anxiety Disorders, 86, 102587. DOI: 10.1016/j.janxdis.2021.102587
  • Stein, M. B., & Goldin, P. R. (2020). The efficacy of novel treatments for social anxiety disorder. Current Psychiatry Reports, 22(8), 63. DOI: 10.1007/s11920-020-01178-3