Social Anxiety Disorder

What Causes Social Anxiety Disorder?

Scientists don’t yet fully understand what causes social anxiety disorder. However, an individual’s risk for developing social anxiety disorder is probably due to a complex interaction of genetic and environmental factors.

Risk factors for anxiety include:

• Poor development of social behavior skills in childhood
• Experiencing trauma, abuse, bullying, or humiliation
• Introduction to new social or professional situations
• Family history of anxiety or other mental illnesses

Is Social Anxiety Disorder Hereditary?

People with a family history of anxiety or associated mental disorders have a higher risk of developing SAD themselves, suggesting an inherited component to anxiety. However, scientists have not yet identified a single gene definitively associated with anxiety or anxiety disorders. Instead, anxiety is likely the result of a coincidence of multiple genetic and environmental factors.

How Is Social Anxiety Disorder Detected?

SAD usually begins around adolescence, but it may start earlier in childhood. Many people with SAD were extremely shy children, but the symptoms of SAD are more intense and debilitating than typical shyness. Early warning signs of SAD include:

• Extreme clinginess to parents
• Crying or tantrums during social situations
• Refusing to speak to strangers
• Poor eye contact
• Avoidance of school activities
• Sweating, nausea, or other physical symptoms in social situations

How Is Social Anxiety Disorder Diagnosed?

Diagnosis of SAD begins with determining that the patient has a cluster of symptoms that meet the diagnostic criteria for the disorder. A doctor will start with a physical exam to rule out biological problems that may be causing symptoms. This exam may include lab tests.

After these exams, if the doctor suspects that SAD or another anxiety disorder is the cause of the symptoms, they may recommend a psychological or psychiatric assessment to solidify the diagnosis further.

Diagnostic steps may include:

• A physical exam. This exam will be aimed at ruling out physical conditions that could be causing the symptoms.
• Blood tests. These tests will look at the patient’s blood chemistry for potential causes of the symptoms. Screenings for drugs and alcohol may also be conducted to rule out symptoms caused by substance abuse.
• Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.

The results of the psychological assessments will be compared to the diagnostic criteria for anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria for social anxiety disorder include:

• Anxiety involves fear of being embarrassed, humiliated, or judged. Children experience anxiety around other children, not just around adults.
• Social situations almost always cause anxiety.
• The anxiety is out of proportion to the situation.
• Anxiety-producing situations are avoided or endured under distress.
• The anxiety lasts for six months or more.
• The symptoms cause significant distress or impairment.
• Another mental illness does not explain the symptoms.
• The anxiety is not caused by medication, substance abuse, or a medical condition.

PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.

How Is Social Anxiety Disorder Treated?

A combination of medications and psychotherapy is often used to treat the symptoms of SAD.

Medication

Several different medications may be used to treat and manage social anxiety. Individual medication plans depend on the patient’s age, responsiveness to treatments, and the severity of their symptoms.

• Benzodiazepines. These anti-anxiety medications work relatively quickly to control symptoms. However, they may lose their effectiveness over time.
• Selective serotonin reuptake inhibitors (SSRIs). These drugs work by increasing the levels of serotonin, a neurotransmitter chemical in the brain. Common SSRIs include citalopram, escitalopram, fluoxetine, paroxetine, sertraline, and vilazodone.
• Serotonin-norepinephrine reuptake inhibitors (SNRIs). These drugs work similarly to SSRIs in that they increase serotonin levels, but they also increase the level of norepinephrine, another neurotransmitter.
• Beta-blockers. These medications are commonly used to treat high blood pressure, but they may be effective at controlling the physical symptoms of anxiety.

Psychotherapy

A combination of medication and psychotherapy is often the most effective approach to controlling social anxiety. The most common therapeutic approach is cognitive-behavioral therapy (CBT). This process focuses on helping the patient identify a pattern of harmful thoughts and construct strategies and solutions for dealing with them.

How Does Social Anxiety Disorder Progress?

Social anxiety disorder can cause significant harm over the long term. Anxiety and avoidance of anxiety-triggering situations can lead to complications, including:

• Depression
• Relationship problems
• Problems at school or work
• Isolation
• Substance abuse
• Suicide or suicide attempts

How Is Social Anxiety Disorder Prevented?

There is no known way to prevent social anxiety disorder, but some self-directed strategies may help control or prevent episodes of anxiety:

• Avoid using alcohol or drugs.
• Stay physically active, and eat a nutritious diet.
• Seek help from a mental health professional.

Social Anxiety Disorder Caregiver Tips

Anxiety has many root causes, and it often exists alongside other mental health conditions, a situation called co-morbidity. Here are a few of the disorders commonly associated with social anxiety disorder:

• Depression and SAD are common comorbid mental disorders, and people with both disorders tend to have more severe SAD symptoms.
• Alcoholism and SAD are commonly comorbid.
• Bipolar disorder is commonly comorbid with SAD.
• People with SAD may have other anxiety disorders as well.
• Obsessive-compulsive disorder (OCD) and SAD are often associated with one another.
• Attention-deficit/hyperactivity disorder (ADHD) is associated with anxiety disorders in about half of adults with ADHD.
• Post-traumatic stress disorder (PTSD) shares many symptoms with other anxiety disorders, and veterans with PTSD have a high rate of SAD.

Social Anxiety Disorder Brain Science

Scientists believe that anxiety symptoms come from activity in the parts of the brain that control emotions and our reactions to them. These parts of the brain are collectively called the limbic system. The limbic system is associated with anxiety in several ways:

• The amygdala, the part of the brain responsible for detecting threats, may be hyperactive and may misidentify causes for fear or worry when none exist. In the case of social anxiety, other people’s behavior may be misinterpreted as threatening, causing an inappropriate anxiety response.
• An overactive amygdala may persistently cause the hypothalamus to trigger the hormonal response that produces the physical symptoms of anxiety.
• Communication between the amygdala and the prefrontal cortex (PFC) may be impaired. The PFC is responsible for triggering a rational response to threats, and it may not be able to do so when it is unable to communicate with the amygdala effectively.
• The hippocampus, the part of the brain responsible for processing long-term memory, may be underdeveloped or dysfunctional in the case of anxiety. As a result, it may have a preference for retaining stress-related memories rather than more rational memories.

Social Anxiety Disorder Research

Title: Efficacy of an Attention Guidance VR Intervention for Social Anxiety Disorder

Stage: Recruiting

Contact: Michael J. Telch, PhD

University of Texas

Austin, TX 

Social anxiety disorder (SAD) is a prevalent mental health concern that impacts approximately 12% of the population. One mechanism thought to maintain SAD is avoidance of faces (i.e., avoidance of negative evaluative threat). However, research on attentional processes in SAD has been confined to paradigms presented on computer monitors. To investigate attentional processes more naturally, the investigators developed an immersive, 360º-video virtual reality environment using real actors as part of a pilot study. Participants with a range of social anxiety symptoms (from none to severe) completed a 5-minute speech in this virtual reality environment while their eye movements were recorded. Results from the study showed that greater symptoms of social anxiety were associated with avoidance of looking at faces (i.e., fewer fixations on faces). While existing treatments for SAD are moderately effective, a large number of individuals do not experience meaningful reductions in their symptoms. The overarching goal of this project is to inform future treatment research for SAD. The investigators will test a brief attention guidance intervention for SAD that specifically targets avoidance of faces as a potential mechanism maintaining the disorder. The proposed research will use the eye-tracking hardware and naturalistic virtual reality environment from the pilot study. The investigators will also collect eye-tracking data before the intervention to investigate potential heterogeneity in the attentional processes of SAD. The investigators will test the hypotheses that (a) the attention guidance intervention, compared to the control intervention, will result in a greater reduction in symptoms of social anxiety, and (b) this effect will be mediated by the number of fixations on faces during a brief public speaking challenge following the intervention. These results will provide causal evidence related to a hypothesized mechanism maintaining SAD.

Title: Targeting Attention Orienting to Social Threat to Reduce Social Anxiety in Youth

Stage: Recruiting

Principal investigator: Wendy K. Silverman, PhD

Yale Child Study Center Program for Anxiety and Mood Disorders

New Haven, CT 

This two-site study tests Attention Bias Modification Treatment (ABMT) among 260 youths ages 10 to 14 years with social anxiety disorder. One-half of participants will receive eight sessions of computer-administered ABMT, and the other half of participants will receive eight sessions of computer-administered Neutral Control Task (NCT). The investigators hypothesize that a biomarker of attention to social threat measured using electroencephalography (EEG) and ratings of social anxiety severity will be lower in participants who receive ABMT compared to participants who receive NCT.

Title: Optimizing Exposure Therapy for Anxiety Disorders (OptEx)

Stage: Recruiting

Contact: Michelle G. Craske, PhD

University of California, Los Angeles

Los Angeles, CA

A substantial number of individuals fail to achieve clinically significant symptom relief from exposure-based therapies or experience a return of fear following exposure therapy completion. The prevailing model of exposure therapy for phobias and anxiety disorders purports that fear reduction throughout exposure therapy (i.e., habituation) is reflective of learning and critical to overall therapeutic outcomes. However, the amount by which fear – indexed by self-report, behavioral, and biological correlates of fear expression – reduces by the end of an exposure trial or series of exposure trials is not a reliable predictor of the fear level expressed at follow-up assessment.

Developments in the theory and science of fear extinction, and learning and memory, indicate that ‘performance during training’ is not commensurate with learning at the process level. Inconsistent findings regarding fear reduction are paralleled by findings based in associative learning laboratory paradigms with animals and human samples, specifically that outward expression of fear on the one hand and conditional associations indicative of underlying learning, on the other hand, may not always change in concordance. Instead, ‘inhibitory learning’ is recognized as central to extinction, rather than fear during extinction training.

The current proposal will compare the ‘emotional processing’ or habituation-based model of exposure therapy to the competing inhibitory model of exposure that emphasizes learning theory principles. No study has directly compared these approaches to determine which provides optimal symptom relief and return of fear or mediators and moderators that may contribute to these outcomes.

To address this gap, the current study plans to recruit participants for a treatment trial consisting of two psychotherapies: (a) habituation-based exposure therapy and (b) inhibitory learning-based exposure therapy. The primary goal of this study is to determine if one theoretical approach to exposure outperforms the other in reducing symptoms.

This study is conducted with individuals meeting diagnostic criteria for social anxiety disorder or panic disorder. Participants will be randomized to either treatment condition and receive nine individual psychotherapy sessions focused on either of these disorders. If an individual meets diagnostic criteria for both disorders, treatment will be focused on the primary presenting disorder. Participants will complete four assessments throughout the study, at pre-treatment, mid-treatment, post-treatment, and three-month follow-up. Pre-treatment, mid-treatment, and post-treatment assessments occur over two days, while three-month follow-up requires only a single day and is conducted remotely.

These assessments will include semi-structured interviews, self-report questionnaires, and laboratory paradigms designed to examine fear learning processes.