October 18, 2022
Rajesh* decided to finally meet a psychiatrist! He was 32 years of age, had finished his MBA and was working for a reputed bank. All these years he was refusing marriage. Earlier his parents thought that he wanted to retain his freedom, or maybe he wanted to settle down financially first. Then they thought maybe he had a girlfriend from a different community, his colleagues thought he was gay and his teachers thought he had still not recovered from his college-sweethearts’ heartbreak. The truth was something else! Rajesh had social anxiety disorder! He just couldn’t face strangers! He was brilliant but unable to deliver presentations that he so meticulously made. The thought of meeting a girl for alliance was sending shivers down his spine. How could he smile on stage in front of hundreds of people? His reception scene was his recurring nightmare. His elder sister got him to me to improve his confidence.
The defining feature of social anxiety disorder, also called social phobia, is intense anxiety or fear of being judged, negatively evaluated, or rejected in a social or performance situation.
People with social anxiety disorder may worry about acting or appearing visibly anxious (e.g., blushing, stumbling over words), or being viewed as stupid, awkward, or boring. As a result, they often avoid social or performance situations, and when a situation cannot be avoided, they experience significant anxiety and distress.
Here I would like to mention that this should not be confused with being an introvert. Clients want to socialise but can’t. Unlike introverts who may not like to socialise at all.
Many people with social anxiety disorder also experience strong physical symptoms, such as a rapid heart rate, nausea, and sweating, and may experience full-blown panic attacks when confronting a feared situation. Although they recognize that their fear is excessive and unreasonable, people with social anxiety disorder often feel powerless against their anxiety.
How common is this condition?
Social anxiety disorder affects approximately 15 million adults and its prevalence is almost 10% in young adults. It is the second most commonly diagnosed anxiety disorder following specific phobia. The average age of onset for social anxiety disorder is during the teenage years. Many patients report how a very strict parenting may have resulted in their lack of “socialising power “.
Another important feature to note that though these individuals are labelled as “shy”, they tend to compensate lack of real socialisation with increased online socialising as that they find less threatening.
A person with social anxiety disorder feels symptoms of anxiety or fear in certain or all social situations, such as meeting new people, dating, being on a job interview, answering a question in class, or having to talk to a shopkeeper in a store.
Doing everyday things in front of people—such as eating or drinking in front of others or using a public restroom—also causes anxiety or fear. The person is afraid that he or she will be humiliated, judged, and rejected. “People will laugh at me" is the common thought.
Without treatment, social anxiety disorder can last for many years or a lifetime and prevent a person from reaching his or her full potential.
Physical and behavioural symptoms
When having to perform in front of or be around others, people with social anxiety disorder tend to:
• Blush, sweat, tremble, feel a rapid heart rate, or feel their “mind going blank”
• Feel nauseous or sick to their stomach
• Show a rigid body posture, make little eye contact, or speak with an overly soft voice
• Be very self-conscious in front of other people and feel embarrassed and awkward
• Stay away from places where there are other people
DSM-5 criteria for social anxiety disorder include:
• Persistent, intense fear or anxiety about specific social situations because you believe you may be judged, embarrassed or humiliated
• Avoidance of anxiety-producing social situations or enduring them with intense fear or anxiety
• Excessive anxiety that's out of proportion to the situation
• Anxiety or distress that interferes with your daily living
• Fear or anxiety that is not better explained by a medical condition, medication or substance abuse
The most important part of the treatment is to reassure the client that he is not alone. There are so many people who suffer from this condition. The good news is that it can be treated.
Treatment depends on how much social anxiety disorder affects their ability to function in daily life.
Milder cases improve with therapy alone. Moderate to severe cases do require medication. This is in addition to counselling.
Psychotherapy improves symptoms in most people with social anxiety disorder. In therapy, clients are taught how to recognize and change negative thoughts about themselves and develop skills to gain confidence in social situations.
Cognitive behavioural therapy is the most effective type of psychotherapy for anxiety, and it can be effective when conducted individually or in groups.
In exposure-based cognitive behavioural therapy, clients gradually work up to facing the situations they fear most. This happens in small steps from least anxiety provoking to most anxiety provoking. This can improve coping skills and help develop the confidence to deal with anxiety-inducing situations. Some therapists specialise in role playing and modelling techniques which provide clients more confidence in facing real life challenges.
Typical homework assignments
First, identify what situations that cause anxiety. In a progressive fashion practice these activities, until they cause less anxiety.
Begin with small steps, by setting daily or weekly goals in situations that aren't overwhelming.
• Eat with a close relative, friend or acquaintance in a public setting
• Purposefully make eye contact and return greetings from others, or be the first to say hello
• Give someone a compliment
• Ask a shopkeeper to find you an item.
• Get directions from a stranger
• Show an interest in others — ask about their homes, children, grandchildren, hobbies or travels, for instance
• Call a friend to make plans
Prepare for social situations
Prepare small talk and greetings for those who may be present. Reward yourself when you can socialise.
At first, being social, when you're actually feeling so anxious, is indeed challenging. As difficult or painful as it may seem initially, don't avoid situations that trigger your symptoms. By regularly facing these kinds of situations, you'll continue to build and reinforce your skills.
These strategies can help you to face situations that make you nervous. When you face them, it will build your confidence
Though several types of medications are available, selective serotonin reuptake inhibitors (SSRIs) are often the first type of drugs given for persistent symptoms of social anxiety.
Serotonin and norepinephrine reuptake inhibitor (SNRI) are also an option for social anxiety disorder.
To reduce the risk of side effects, starting doses are low dose of and gradually increased to a full dose. It may take a few weeks of treatment for symptoms to noticeably improve. But they surely do. Being patient is very important.
Certain medications such as benzodiazepines for short-term use and Beta blockers to reduce panic attacks are given.
Although social anxiety disorder generally requires help from a psychiatrist, one can try some of these techniques to handle situations that are likely to trigger symptoms:
• Learn stress reduction skills and relaxation exercise.
• Do regular physical exercise.
• Get enough sleep
• Eat a healthy, well-balanced diet
• Avoid alcohol and substances of abuse.
• Limit or avoid caffeine
• Participate in social situations by reaching out to people with whom one feels comfortable
Defeating social anxiety is a team effort between the client and the mental health experts - psychiatrist, psychologist and social worker.
When efforts are consistently put, clients gradually live up to more and more socially challenging situations. Treatment is highly rewarding. Patients often thank us with a Kannada saying “ili ge huli madidera doctore” (meaning treatment has metamorphosed a meek person to a strong one).