Diseases and Disorders

Social Anxiety Disorder: An Overview

Victoria Man


Introduction

Social anxiety disorder is a disorder in which an individual has excessive fears regarding their social performance. This disorder has neurological and psychological causes where countless children, adolescents, adults, and elderly can unknowingly suffer from it [1][3][4]. During the COVID-19 pandemic, many are isolating themselves to stay safe thereby reducing the amount of social interaction one receives. Due to this, social anxiety disorder may arise in individuals more actively. This paper will outline the disorder in regards to what the disorder is, how the disorder is diagnosed, research on treatments for the disorder, and also certain neuroimaging discoveries for social anxiety disorder.
 

What Is Social Anxiety Disorder?

Social anxiety disorder is a very common mental health condition that is usually identified as the extreme distress of being in social situations or as “social phobia.” While shyness is a regular character trait, social anxiety disorder is distinguished by unusual anxiety and fear that disrupts an individual’s everyday routine. Behavioral restraint or unusual shyness tends to show up in children during the early stages of social anxiety disorder  [3][6]. This behavioral inhibition may potentially manifest a particular change in one’s personality or even develop into dysfunctional behavior later on in an individual’s life [3]. Social Anxiety Disorder can stem from genetics, negative social experiences, and from delicate mental states such as mental illness or emotional instability [1][5].

While social anxiety disorder affects an individual's entire body with symptoms such as excessive perspiration or dry mouth, Social Anxiety Disorder predominantly affects the brain [1][3][6]. Parts of the brain affected include the frontal lobe and the cerebral cortex, as they correspond with emotion, cognitive control, the processing of one’s ego and superego, and motivation. Social anxiety disorder most heavily affects the amygdala,  the part of the brain that receives threat or fear signals and reacts to them, causing panic most of the time (refer to figure 1, also refer to figure 2 to see the fear circuitry’s effect on the body) [2][3][4][6]. Furthermore, social anxiety can be characterized by reduced testosterone levels and higher cortisol responses. This is because lowered testosterone levels create stress responses that increase cortisol levels, ultimately leading to an increase in blood pressure [3][4]. Both have direct relationships with anxiety and with certain circumstances, this change in hormones within the body could add to an individual’s social anxiety. Additionally, altered patterns of connectivity, such as reduced amygdala-prefrontal coupling can present themselves. Reduced amygdala-prefrontal coupling could heighten negative feelings and cause the individual with social anxiety disorder to become more isolated [4]. Despite the steady advancement in research to uncover the primary neurobiological component of social anxiety disorder, there is still much to be learned as Social Anxiety Disorder appears to emerge differently in each individual [3].

 

Figure 1. Amygdala’s role in the fear circuitry inside the brain [4]

 

Diagnostics

Doctors diagnose patients with normal performance anxiety frequently because it is quite common. However, the patient may also be tested for social anxiety disorder based on the five following criteria [5]:

  1. Persistent intense fear about social situations where an individual might be afraid of being humiliated and/or judged.

  2. Avoidance of social situations and/or not partaking in social situations with unbearable anxiety affecting their performance such as speech.

  3. Anxiety that is disproportionate to the actual gravity of the social situation.

  4. Distress that interferes with an individual doing regular tasks.

  5. Immense fear that cannot be attributed to other mental conditions, medication, or abuse of substances.

From the test, the doctor (or specialist) may or may not diagnose a patient with social anxiety disorder. The patient could be advised to pursue two different types of treatments: psychotherapy or pharmacotherapy [2][5]. If an individual suffering from social anxiety disorder does not go on to receive treatment, complications could arise, such as self-negativity, hypersensitivity to criticism, self-isolation, difficulty forming social bonds, low academic and employment achievements, substance abuse, and depression. All the following complications could be extremely damaging to one’s emotional and physical health [5].

 

Social Anxiety Disorder and the Brain

As mentioned previously in the first section of this paper, the amygdala is the part of the brain most affected by social anxiety disorder [3]. The amygdala is interconnected with the hippocampus, thalamus, and hypothalamus. When someone has social anxiety disorder, their amygdala becomes hyperactive [4]. This would immediately lead to a number of physical symptoms: an increase in heart rate, developing ulcers, difficulty breathing, and more (refer to figure 2). While there are plenty of physical conditions that arise due to social anxiety disorder, there is also much occurring within the brain, in the amygdala.

Neuroimaging has been able to break down borders and peer into the brain of someone suffering from a social anxiety disorder. Amygdala hyperactivity has been implicated in the disorder’s symptoms by experiments in amygdala stimulation [4][6]. When testing patients diagnosed with social anxiety disorder, it has been demonstrated that when receiving unpleasant social cues or observing negative facial expressions, the subjects display bilateral amygdala activities proportionate to the severity of the disorder. This means that for those who suffer from the disorder, their amygdala goes into overdrive, which interrupts the passage of signals within the brain as the entire body shuts down from the amygdala’s fear response [4]. When confronting social situations, people with social anxiety disorder are found to have increased activity in the subcortical and limbic brain systems [3][4]. This indicates the heightening of automatic emotional processes. Lowered activity in the anterior cingulate cortex and the prefrontal cortex suggests that individuals with social anxiety disorder may under-perform in cognitive thinking and understanding, resulting in nervous breakdowns or disruption in social situations as the brain does not know how to react [1][4]. Neuroimage analyses have brought to light the fact that the inhibited activities in the brain for an individual with social anxiety disorder correspond with negative emotions and social cue misinterpretation [3][4]. Investigation and studies of social anxiety disorder has been and still is going on through neuroimaging.

 

Figure 2. List of common symptoms that occur when the amygdala is excited [4]

 

Treatment and Surrounding Research

There are a variety of effective treatments available for children and adults, such as psychosocial and pharmacological treatments [1][2]. Psychosocial treatment, better known as cognitive-behavioral treatment, is the more common treatment of the two, but still is under-researched [2][3][4][6]. 

Though there is not much research on psychosocial treatments, the research that has been done demonstrates effectiveness. Research on psychotherapy for social anxiety disorder discovered that children who suffer from the disorder do not engage in cognitive challenges. Therefore, the approach to psychosocial treatments has shifted from restructuring one’s cognitive thinking skills to pinpointing the root cause of one’s childhood social anxiety [2]. In therapy, the patient learns to improve self-esteem and develop skills that would help the patient gain confidence when dealing with social situations. While psychosocial therapy is the most successful form of treatment when it comes to social anxiety disorder, it is still a difficult path to pursue because social phobia begins differently for every individual in their childhood [2][5]. There are also different factors that may trigger social anxiety disorder such as an individual experiencing trauma, leading them to become afraid of socializing or being in public events. Moreover, everyone’s cognitive skills differ. This complexity could be why psychosocial treatments are rather under-developed [2].

There have been only seven notable clinical trials for social anxiety disorder using pharmacotherapy methods. Within those, three studies were conducted with placebos in double-blind studies. In the open-label trials, children who suffered from social anxiety showed improvement on Selective Serotonin Reuptake Inhibitors (SSRI) [2][4][5]. However, two of the three double-blind experiments were unsuccessful in replicating results from the effective placebos. There is some uncertainty with pharmacological treatments when it comes to social anxiety disorder [1][2]. There is only a 50 to 80 percent rate of effectiveness when using pharmacological treatments, which is rather low relative to the benchmark for treatments [1][2][5]. More research for pharmacotherapy is currently being pursued in order to successfully provide conclusive evidence in support of them {2]. Other alternatives to SSRIs are also undergoing research for social phobia, promising agents include: venlafaxine, gabapentin, bupropion, and nefazodone [1].

Though seemingly effective, there are some limitations with both types of treatments. To make sure the treatments are beneficial and effective, there must be optimal integration and dissemination of the therapy, which cannot be guaranteed at times [4][6]. 30 to 40 percent of people who suffer from social anxiety disorder do not benefit from the treatments. This can be expected from treatments that fixate on neurological/psychological improvements because treatments may be different for all individuals [1][5][6]. 

 

Conclusion

Social anxiety disorder is particularly peculiar because of the fact that many people do not know that they suffer from it. The disorder may turn out to be mild but can also be very severe. Social anxiety disorder is not as popularly researched as other neurological and psychological disorders [3][4][6]. With a higher proportion of younger individuals being isolated during COVID-19 isolation, anxiety levels are increasing. Social anxiety disorder might be more prevalent than most believe and it may be beneficial to encourage more research in order to support future sufferers. Without more information about this very common disorder, future generations may find it difficult to communicate with others, which could affect individuals’ ability to regulate bodily functions and facilitate human interaction. As social anxiety disorder begins to impact more of the human population, without a clear understanding and solution, there may be outcomes that could potentially lead to social turmoil and affect the functions of social civilization.

 

Key Vocabulary


References


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  2. Beidel, D. C., et.al. (2001). The treatment of childhood social anxiety disorder. The Psychiatric clinics of North America, 24(4), 831–846. https://doi.org/10.1016/s0193-953x(05)70266-5. Retrieved: 14/04/2021.

  3. Cremers, Henk, & Karin Roelofs. (30/05/2016). Social anxiety disorder: a critical overview of neurocognitive research. Wiley interdisciplinary reviews. Cognitive science, 7(4), 218–232. https://doi.org/10.1002/wcs.1390. Retrieved: 14/04/2021.

  4. Martin, Elizabeth, et.al. (2009). The neurobiology of anxiety disorders: brain imaging, genetics, and psychoneuroendocrinology. The Psychiatric clinics of North America, 32(3), 549–575. https://doi.org/10.1016/j.psc.2009.05.004. Retrieved: 13/04/2021.

  5. Mayo Clinic Staff. (29/08/2017). Social anxiety disorder (social phobia) - Diagnosis and treatment - Mayo Clinic. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/social-anxiety-disorder/diagnosis-treatment/drc-20353567. Retrieved: 15/04/2021.

  6. Stein, Murray, & Dan Stein (29/05/2008). Social anxiety disorder. Lancet (London, England), 371(9618), 1115–1125. https://doi.org/10.1016/S0140-6736(08)60488-2. Retrieved: 14/04/2021.

Victoria Man

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