Facts about Social Anxiety
Prevalence

SAD is the third largest mental health care problem in the world today (after depression and alcohol dependence), affecting 7% to 8% of the population at any given time, with a lifetime prevalence of about 13%.1, 2 An estimated 19.2 million Americans have social anxiety disorder. That's a lot of people! SAD is more common in women than in men3 (though men are more likely to seek help), and more common in younger people.4, 5

SAD most often surfaces in adolescence or early adulthood, but can occur at any time, including early childhood.6 The mean onset of social phobia is from 10-136 to 15 years.4 Onset after age 25 is uncommon.4,6 36% of people with social anxiety disorder report symptoms for 10 or more years before seeking help. The majority (about 70%) have another mental health concern.5,7

Causes

While the exact cause of social anxiety disorder remains a mystery, research studies suggest that its development may be related to the complex interaction of environment and genes and involve a number of biological, psychological, and environmental factors. There are several subtypes of SAD, and causes and risk factors vary for each. Possible causes of SAD include:6

  • Biological: Anxiety disorders tend to run in families, suggesting a genetic component. Overactivity in certain brain structures, such as the amygdala (may cause a heightened fear/anxiety response in social situations for people with social anxiety8,9
  • Psychological: Cognitive distortions and biases in thinking
  • Environmental: However, SAD may also be a learned behavior. This can refer to parental/family interactions, other negative life events and experiences in other environments
  • Some researchers have suggested that SAD may play an adaptive role when considered in an evolutionary framework

Here are some common scenarios:6,10

  • Having biological parents or siblings with the disorder
  • Parental style, especially having parents who are overly controlling or protective, distant, or rejecting11-13
  • Some individuals with SAD perceive their parents as having isolated them from social experiences and as being more avoidant of social situations themselves
  • Having a childhood temperament that is shy, timid, or withdrawn. Behavioral inhibition (BI), defined as a temperamental style characterized by the tendency for children to display fear, avoidance, or quiet restraint in unfamiliar situations is associated with SAD14-16
  • Having a health condition that draws attention and increases self-consciousness (stuttering, Tourette's Syndrome, facial disfigurement)
  • Witnessing the anxious behavior of others, especially one's parents (SAD may be a learned behavior)
  • Facing increased demands at work or in social situations (e.g., giving a speech or making a presentation)
  • Experiencing a socially traumatic event involving rejection or humiliation, bullying or teasing; being criticized or humiliated in front of the class; making a presentation; blushing
  • Someone whose parents didn't have many friends and didn't socialize (lack of role model)
  • Some people have been shy all their lives and don't remember a time when they were comfortable around strangers or even loved ones
  • Emotional or physical abuse
    • Having a family that criticizes or condemns your ideas, or your right to have ideas
    • Lack of acceptance by your family

    Diagnosis

    If you fear and avoid normal social situations because they cause embarrassment or panic, you may have SAD or another mental health condition that requires treatment in order to get better. When seeking help, we recommend looking for a doctor or mental health professional who specializes in social anxiety and who understands the problem and how to treat it.

    According to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM - 5), published in May 2013, Social Anxiety Disorders can be diagnosed with the following criteria:

    1. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation), being observed (e.g., eating or drinking), or performing in front of others (e.g., giving a speech).

    2. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (e.g., be humiliated, embarrassed, or rejected) or will offend others.

    3. The social situation(s) almost always provoke fear or anxiety. (Note: in children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failure to speak in social situations.)

    4. The social situation(s) are actively avoided or endured with marked fear or anxiety.

    5. The fear or anxiety is out of proportion to the actual threat posed by the social situation. (Note: "Out of proportion" refers to the sociocultural context.)

    6. The fear, anxiety, or avoidance is persistent, typically lasting six or more months.

    7. The fear, anxiety, and avoidance cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

    8. The disturbance is not attributable to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

    9. The disturbance is not better accounted for by another mental disorder (e.g., anxiety about having Panic Attacks in Panic Disorder, agoraphobia situations in Agoraphobia, separation from attachment figures in Separation Anxiety Disorder, public exposure to perceived physical flaws in Body Dysmorphic Disorder, or social communication problems in Autism Spectrum Disorder. Failure to speak is not better accounted for by stuttering or expressive language problems in Communication Disorders, or refusal to speak due to opposition in Oppositional-Defiant Disorder.

    10. If another medical condition (e.g., stuttering, Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is unrelated or is out of proportion to it.

    Copyright 2013, The American Psychiatric Association

    Prevention

    Unfortunately, at this time there is no known way to prevent SAD. However, being aware of the risk factors and symptoms, and seeking help as soon as the symptoms appear, can help you to minimize the impact of this disorder. Like so many other conditions, "early detection" leads to improved treatment effectiveness.

    Prognosis

    Left untreated, remission rate is low.17,18 Social anxiety disorder can be debilitating. SAD symptoms may ruin a person's life, interfering with work, school, relationships, or the ability to enjoy life. In severe cases, people may drop out of school, quit work, lose friendships, or confine themselves to their home.

    With treatment, the outcome for social anxiety disorder is generally good. Many people improve significantly and enjoy more productive lives.

    Comorbidities

    See Comorbidities

    References

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    2. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Arch Gen Psychiatry. 1994;51(1):8-19.

    3. Furmark T. Social phobia: overview of community surveys. Acta Psychiatr Scand. 2002;105(2):84-93.

    4. Schneier FR, Johnson J, Hornig CD, Liebowitz MR, Weissman MM. Social phobia. Comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry. 1992;49(4):282-288.

    5. Ohayon MM, Schatzberg AF. Social phobia and depression: prevalence and comorbidity. J Psychosom Res. 2010;68(3):235-243. doi:10.1016/j.jpsychores.2009.07.018.

    6. Rapee RM, Spence SH. The etiology of social phobia: empirical evidence and an initial model. Clin Psychol Rev. 2004;24(7):737-767. doi:10.1016/j.cpr.2004.06.004.

    7. Crome E, Grove R, Baillie AJ, Sunderland M, Teesson M, Slade T. DSM-IV and DSM-5 social anxiety disorder in the Australian community. Aust N Z J Psychiatry. 2014. doi:10.1177/0004867414546699.

    8. Fox AS, Kalin NH. A Translational Neuroscience Approach to Understanding the Development of Social Anxiety Disorder and Its Pathophysiology. Am J Psychiatry. 2014. doi:10.1176/appi.ajp.2014.14040449.

    9. Brühl AB, Delsignore A, Komossa K, Weidt S. Neuroimaging in social anxiety disorder-A meta-analytic review resulting in a new neurofunctional model. Neurosci Biobehav Rev. 2014. doi:10.1016/j.neubiorev.2014.08.003.

    10. Dalrymple KL, Herbert JD, Gaudiano BA. Onset of Illness and Developmental Factors in Social Anxiety Disorder: Preliminary Findings from a Retrospective Interview. J Psychopathol Behav Assess. 2006;29(2):101-110. doi:10.1007/s10862-006-9033-x.

    11. Arrindell WA, Emmelkamp PM, Monsma A, Brilman E. The role of perceived parental rearing practices in the aetiology of phobic disorders: a controlled study. Br J Psychiatry J Ment Sci. 1983;143:183-187.

    12. Arrindell WA, Kwee MG, Methorst GJ, van der Ende J, Pol E, Moritz BJ. Perceived parental rearing styles of agoraphobic and socially phobic in-patients. Br J Psychiatry J Ment Sci. 1989;155:526-535.

    13. Lieb R, Wittchen HU, Höfler M, Fuetsch M, Stein MB, Merikangas KR. Parental psychopathology, parenting styles, and the risk of social phobia in offspring: a prospective-longitudinal community study. Arch Gen Psychiatry. 2000;57(9):859-866.

    14. Schwartz CE, Snidman N, Kagan J. Adolescent social anxiety as an outcome of inhibited temperament in childhood. J Am Acad Child Adolesc Psychiatry. 1999;38(8):1008-1015. doi:10.1097/00004583-199908000-00017.

    15. Biederman J, Hirshfeld-Becker DR, Rosenbaum JF, et al. Further evidence of association between behavioral inhibition and social anxiety in children. Am J Psychiatry. 2001;158(10):1673-1679.

    16. Leung AW, Heimberg RG, Holt CS, Bruch MA. Social anxiety and perception of early parenting among American, Chinese American, and social phobic samples. Anxiety. 1994;1(2):80-89.

    17. Yonkers KA, Dyck IR, Keller MB. An eight-year longitudinal comparison of clinical course and characteristics of social phobia among men and women. Psychiatr Serv Wash DC. 2001;52(5):637-643.

    18. Massion AO, Dyck IR, Shea MT, Phillips KA, Warshaw MG, Keller MB. Personality disorders and time to remission in generalized anxiety disorder, social phobia, and panic disorder. Arch Gen Psychiatry. 2002;59(5):434-440.

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    20. Belzer K, Schneier FR. Comorbidity of anxiety and depressive disorders: issues in conceptualization, assessment, and treatment. J Psychiatr Pract. 2004;10(5):296-306.

    21. Rapee RM, Heimberg RG. A cognitive-behavioral model of anxiety in social phobia. Behav Res Ther. 1997;35(8):741-756.

    22. Hope DA, Burns JA, Hayes SA, Herbert JD, Warner MD. Automatic Thoughts and Cognitive Restructuring in Cognitive Behavioral Group Therapy for Social Anxiety Disorder. Cogn Ther Res. 2007;34(1):1-12. doi:10.1007/s10608-007-9147-9.

    23. Troy AS, Wilhelm FH, Shallcross AJ, Mauss IB. Seeing the silver lining: cognitive reappraisal ability moderates the relationship between stress and depressive symptoms. Emot Wash DC. 2010;10(6):783-795. doi:10.1037/a0020262.

    24. Wild J, Clark DM. Imagery Rescripting of Early Traumatic Memories in Social Phobia. Cogn Behav Pract. 2011;18(4):433-443. doi:10.1016/j.cbpra.2011.03.002.

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