Social anxiety disorder

Definitions & Key takeaways

Social anxiety disorder (SAD), also known as social phobia, is a mental health condition characterized by intense fear in one or more social situations causing considerable distress and impaired ability to function in at least some parts of daily life. Common symptoms of SAD include fear of being scrutinized or judged by others, fear of embarrassment, and avoidance of social situations. Treatment for SAD may include psychotherapy, medication, and lifestyle changes.

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I Social anxiety disorder is a condition where a person experiences excessive and persistent fear during social situations because they worry about being embarrassed, judged, or humiliated.
Normally everyone feels a little nervous sometimes, like seeing your crush and suddenly forgetting how to walk, talk, or even breathe properly.
However, in social anxiety disorder, fear is excessive and out of proportion to the actual situation. It's intense enough to interfere with daily functioning, including school, work, and relationships.
You can think of it as targeted anxiety because it's tied specifically to social situations. Social anxiety disorder is specific to situations like when meeting new people, talking to others, or speaking in public.
This makes it different from generalized anxiety disorder, where a person experiences excessive worry about many areas of everyday life, not just social interactions.
Now imagine landing your dream job. You walk into a room full of new coworkers and suddenly fear circuits in the brain kick in.
The almond shaped structure called the amygdala acts as an alarm system. It perceives the situation as threatening and screams, Stranger danger!
Immediately it alerts the hypothalamus, which flips on the sympathetic nervous system. Your heart starts beating fast, your breathing speeds up, your hand starts shaking, and your mouth goes dry.
To make things worse, the locus cerelius in the brain stem releases norepinephrine to flood the amygdala, acting like a turbo booster and pushing it into a state of hyperarousal.
Once the body enters this hyperaroused state, your internal sensor called the insula wakes up. It passes the information to the anterior cingulate cortex and the dorsoedial prefrontal cortex, which act like supervisors, deciding whether the situation is something you should worry about.
When these two recognize that there's no actual threat and everyone is happy to meet you, they stimulate the ventromedial prefrontal cortex.
The ventral medial prefrontal cortex works like a brake system. It uses the inhibitory neurotransmitter GABA to directly silence the amygdala.
At the same time, it stimulates the raffe nuclei to release serotonin, which indirectly calms the amygdala even further.
As this brake system kicks in, you gradually settle down and regain the confidence to introduce yourself to new coworkers.
But in social anxiety disorder, the brain's fear system is misfiring, staying active even when there's no real danger. First, the normal brake system between the ventromedial prefrontal cortex and the amygdala is not working properly.
There is not enough gaba and serotonin to keep the amygdala calm, while the locus cerilius is working overtime and flooding it with norepinephrine.
This combination keeps the amygdala stuck in a hyperactive state. Next, the insula becomes disregulated and starts misinterpreting normal bodily sensations such as a faster heartbeat as signs of danger, further amplifying the fight or flight response.
Meanwhile, the anterior cingulate cortex and the dorsomedial prefrontal cortex mistakenly interpret normal external situations as threatening, which further increases the anxiety.
Finally, the striatum, which is part of the basal ganglia, is like the brain's escape button. It triggers the urge to escape the anxiety provoking situations.
Sometimes their brain convinces them that the only way to feel safe is to just leave the room. That's why these individuals avoid eye contact and stay silent.
For example, they might leave the room before even saying their own name. Now, there are many risk factors associated with developing social anxiety disorder.
First up is a lack of healthy social modeling from parents. For example, if parents are constantly arguing or avoiding social situations themselves, a child might never learn effective ways to interact with others.
Next up are traumatic social experiences in childhood such as freezing up during a class presentation and being ridiculed by classmates.
Temperament also plays a role because some children are naturally more sensitive or shy. They might cling to their parents on the first day of school or avoid talking to new classmates.
Over time, repeated avoidance can reinforce anxiety and contribute to the development of social anxiety disorder. Now, moving on to clinical manifestations, which can be subdivided into psychological and physical features.
Psychological manifestations mainly come from hyperactivity of the amygdala. These include excessive and out of proportion anxiety about being embarrassed, judged, or negatively evaluated during social situations.
For example, a medical student with social anxiety disorder might struggle to speak up during a group discussion because they worry about stumbling over their words or blushing.
Anxiety can also affect performance situations. The day before presentation, they might call in sick despite being well prepared because they're afraid of looking incompetent or being humiliated by their supervisors.
And if anxiety appears only in performance situations, we're talking about performance-only social anxiety disorder. Even everyday situations can feel overwhelming.
While eating with their colleagues, their hands might shake or they might spill something. Suddenly they can't stop worrying that everyone is watching and judging.
Things that could happen to anyone feel like a disaster. Because of these fears, individuals with social anxiety disorder often avoid social situations altogether, and if they do attend, they usually go through interactions with intense fear and anxiety.
On the other hand, physical manifestations happen because the sympathetic nervous system kicks into overdrive. Common manifestations include a racing heartbeat, sweating all over the body, facial blushing, and trembling, especially in the hands.
On top of that, a person experiencing these symptoms is also worried that others will notice and judge negatively, which makes anxiety worse.
Now, that's all about adults, but in children, social anxiety looks a bit different. It has to appear during interactions with peers, not just adults.
During these interactions, kids often show their anxiety by crying, freezing, clinging tightly to a parent, or even hiding behind them.
To diagnose a social anxiety disorder, we need to check several key boxes. First, the person must report an intense fear of being embarrassed, judged, or negatively evaluated during social situations.
Second, fear must be out of proportion to the actual situation. Next, the symptoms should last at least 6 months and cause them to avoid social situations.
On top of that, fear must cause significant difficulties at work, school, or in social life. But before calling it social anxiety disorder, we must be sure that the fear is not caused by something else like another medical condition, substance use, or even a medication.
Only after ruling those out can we confidently make the diagnosis. Next up is treatment, which can be subdivided into two.
First, during acute episodes, like just before giving a presentation, benzodiazepines can provide temporary relief. These medications work by boosting GABA effects in the brain, calming overactive fear circuits.
For physical symptoms, beta blockers can help calm down the racing heart and tremors caused by sympathetic overactivity.
Second, long-term management involves psychotherapy and medications. Psychotherapy helps a person gradually face and manage their social fears.
It includes options such as cognitive behavioral therapy, exposure therapy, and acceptance and commitment therapy. For medications, the first line option involves selective serotonin reuptake inhibitors or SSRIs, which increase serotonin levels in the brain, calming down overactive fear circuits.
Another option includes serotonin norepinephrine reuptake inhibitors or SNRIs, which boost both serotonin and norepinephrine.
All right, as a quick recap, in social anxiety disorder, the normal brake system between the ventromedial prefrontal cortex and the amygdala isn't working properly, leaving the amygdala stuck in a hyperactive state.
At the same time, the insula, anterior cingulate cortex, and dorsoedial prefrontal cortex misinterpret signals as threats triggering the fight or flight response.
The ultimate result is excessive anxiety during social interactions. On top of that, the sympathetic nervous system kicks in, causing physical symptoms like a racing heart, shaking hands, and sweating.