Social Anxiety Disorder Overview

Social Anxiety Disorder (SAD)

• SAD is a severe, persistent fear of social or performance situations.
• Anxiety is pervasive, impacting daily life and leading to comorbidities (e.g., other mood/anxiety disorders and substance abuse).
• Individuals fear negative evaluation by others, leading to avoidance of social situations.
• Symptoms include palpitations, sweating, gastrointestinal discomfort, muscle tension, blushing, confusion. In severe cases, panic attacks may occur.
• Safety behaviors, such as avoiding eye contact, are common.
• SAD leads to underperformance at work/school, impaired relationships, lower productivity, lower life satisfaction, and increased suicidal ideation and risk of depression.
• Lifetime prevalence is 4-13% in Western societies. Women are affected more frequently and often have more severe fears, especially performance-related.
• Age of onset is typically early to mid-teens, prior to age 18. New cases after late adolescence are usually related to another disorder.
• Remission rate is low. Prevalence estimates in East Asian countries are lower possibly due to cultural differences in how SAD is expressed.

Etiology of Social Anxiety Disorder

• SAD is distinct from specific phobias, partly due to unique cognitive biases in sufferers.
• Genetic factors: Twin studies indicate a moderate genetic influence on development. Submissiveness, anxiousness, social avoidance, and behavioral inhibition (BI) are heritable aspects. A general predisposition to anxiety disorders may be inherited, not just social phobia.
• Familial and developmental factors: Offspring with SAD are more likely to have parents (especially mothers) with similar difficulties. BI, a heritable trait with estimates of 50-70% heritability, is a risk factor, but not a guarantee of development. Early parent-child interactions might play a role. Controlling parents, less warmth, less sociability, and shame-based discipline are possible factors, but causal relationships are unclear.
• Cognitive factors: SAD sufferers make negative predictions about future social events; perceive the probability of negative outcomes to be higher than those with other anxiety disorders or healthy controls. This fosters avoidance. They intensely scrutinize social cues & perceive situations as extremely threatening. They tend to underestimate their social skills and find it difficult to interpret positive social feedback. They have unrealistically high standards for social performance (e.g., needing everyone to like them). Self-focus attention intensifies their anxiety during social encounters.

Treatment

• Pharmacological: SSRIs, SNRIs, benzodiazepines, and beta-blockers are effective, but symptoms often return after cessation, emphasizing a need for continued support like CBT.
• CBT (Cognitive Behavioral Therapy): Effective with component elements:
  • Exposure therapy: Gradual exposure to feared social situations, either in vivo or through role-playing.
  • Social skills training: Addresses individual deficits to improve interactions.
    • Modeling: Demonstrates desired behaviors.
    • Rehearsal: Practice of new skills.
    • Feedback: Corrective feedback and encouragement.
  • Cognitive restructuring: Challenges and changes negative thought patterns and reduces self-focus.
  • Mindfulness-based interventions (similar to CBT): Enhance acceptance, values, and awareness of thoughts and reactions.
  • Group therapy: Allows natural social interaction and exposure.

Agoraphobia

• Agoraphobia is a fear of places where escaping or getting help is difficult when anxious. Common locations include public transport, open spaces and shops.
• 50% of agoraphobia cases are preceded by panic attacks. The remaining percentage are linked to other anxiety disorders, somatic symptoms disorders or depression.
• Typically starts during the 20s and is more frequent in females than males.
• Avoidance of spaces and social situations is common.
• Substance abuse is sometimes used as a coping mechanism.

Panic Disorder

• Occasional panic attacks during stressful times are common and do not necessarily indicate a disorder.
• Panic disorder is characterized by frequent, unprovoked panic attacks causing worry and behavioral changes in response.
• Fear of a potentially life-threatening illness, thoughts of losing control, or "going crazy" are often symptoms.
• Chronicity and comorbidity with generalized anxiety, depression, and alcohol abuse are common.
• Suicidal ideation and suicide attempts are more likely with co-occurring substances abuse or depression.
• Biological vulnerabilities might exist (dysregulation of norepinephrine systems in the locus ceruleus).
• Interoceptive conditioning: associating bodily cues (conditioned stimulus) with panic attacks.
• Increased interoceptive awareness and fear of perceived danger of bodily sensations may contribute.

Cognitive Mediation of Panic Attacks

• Biological challenge tests (infusions of sodium lactate or yohimbine, CO2 inhalation) reliably induce panic attacks in patients.

• An alternative explanation is that panic attacks result from misinterpreting benign bodily sensations.

• Mediators (of biological challenge tests inducing panic response):

  • Expected affect: Predicted distress.
  • Interpretation: Explanations of sensations.
  • Perceived control: Control over sensations.

• Catastrophic cognitions: An overestimation of the dangerousness of body sensations.

Cognitive Models of SAD

• Cognitive models propose that cognitive processes during socially threatening events mediate social anxiety.
• Dysfunctional beliefs: Overly high social performance standards, conditional beliefs about social evaluation, and unconditional beliefs about the self.
• Triggered expectations of negative evaluation: Triggers anxiety leading to:
  • Attentional shift towards self and feared responses: Focus on anxious responses, self-monitoring, and negative self-imagery.
  • Negative self-representations: Negative representations of self as a social object.
  • Safety behaviors: Reliance on internal/external behaviors to avoid negative evaluation.
• Maintaining cycle: Post-event rumination reinforces negative social self-perception, leading to anticipatory processing.
• Models overlap, but not completely: While comorbidity with depression may enhance certain rumination traits, distinct rumination patterns exist for each disorder.

Interpretation and Judgmental Biases in Social Phobia

• Interpretation bias: Interpreting ambiguous events as negative, specifically social events. This bias involves content specificity (only social events) that is not seen in other anxiety disorders.
• Judgmental bias: Overestimating the cost and/or probability of negative outcomes in a social context.
• SAD patients have higher negative ratings of social events compared to control groups, without this bias being evident in non-social situations.