By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
When you are nervous or extremely uncomfortable in social situations you probably are suffering from Social Anxiety Disorder. It is also called by the name ‘social phobia’. It is one of the most common mental disorders. It is also a type of anxiety disorder that causes fear in social settings. This can be a chronic mental health condition. Learning coping skills in psychotherapy, taking medications regularly would boost up one’s confidence and ability to interact with others.
Most of us might have gone through these uncomfortable situations like
Nervous meeting someone new or
Having sweating palms and thumping heart before making a presentation at conference or meeting
Speaking in public
Walking into a roomful of strangers etc
These symptoms indicates social anxiety disorder. People with social anxiety disorder do understand many times that their fears may be unreasonable but they feel helpless. They think that they do not have the power or courage to overcome them.
It is different from shyness which is usually short-term and doesn’t meddle with our life. On the other hand, social anxiety is debilitating and persistent. It would affect one’s ability to work, attend school or gatherings, meet people and develop relationships out of family.
ADAA (Anxiety and Depression Association of America) – states that approximately 15 million American adults have this disorder and the symptoms of the same might start around 13 years of age.
Avoiding people, things and situations is one of the main characteristic features of people suffering from social anxiety disorder. They find stress associated with these situations very difficult to handle. Things which are ‘just normal’ for other people like making a small initiative in speaking or making an eye-to-eye contact seems to be very uncomfortable for people suffering from social anxiety disorder. People even hesitate to ask for help and this is serious trouble. If the social silence goes beyond limits of ‘just shyness’ one needs to see the doctor and seek medical attention and help.
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Table of Contents
The exact cause for this problem is unknown. It is said to be caused by a combination of environmental factors and genetics. Negative experiences like family conflicts, bullying and sexual abuse might contribute. The most common causes are –
Inheritance – Anxiety and related disorders tend to run in families. Therefore, any person having a family member with this disorder would be more prone of getting this disorder.
Structure of Brain – Amygdala is a structure in the brain which plays an important role in controlling the fear responses. When this part of the brain is overactive, it may cause increased fear response leading to anxiety in social situations.
Serotonin imbalance – Serotonin is a chemical in the brain which helps in regulation of mood. Serotonin imbalance may also cause these disorders.
Environment – This disorder may be learned behavior. This condition may be developed after an unpleasant or embarrassing social situation. It is also common in those kids whose parents display anxious behavior in social situations or are more controlling / overprotective of their children.
History of abuse, bullying or teasing is also linked to this disorder. ‘Shy children’ and ‘children having controlling parents’ are more likely to become socially anxious adults in future years.
Developing a health condition affecting one’s appearance or voice could also lead to triggering of social anxiety. This disorder puts one’s life into disarray and prevents one from leading a normal life.
People suffering from this condition would avoid confronting those situations which are otherwise considered as normal by most people. These people would often wonder how others are able to handle those situations so easily.
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Is shyness or being reserved equal to ‘social anxiety disorder’?
Shyness or feeling discomfort in certain situations seems to be anxiety but they need not necessarily be signs of ‘social anxiety disorder’. Shyness and situation discomfort is common in children. There are other people who are basically reserved by nature and others are more outgoing in nature. So, shyness or being reserved is not equal to ‘social anxiety disorder’ but these two conditions when one progresses to beyond limits and when one cannot get over them, they may gradually transform into ‘social anxiety disorder’.
This condition usually begins in early teens or middle teens. It may also start in younger children or in adults.
Feeling nervous everyday
Fear, anxiety and avoidance (these interfere with relationships, daily routines, work, school and other activities)
Fear of being judged negatively
Worry that one might embarrass or humiliate self
Extreme fear of interacting with new people / strangers
Fears that other people might notice their anxious nature
Fear of getting embarrassed due to physical symptoms such as sweating, blushing, trembling, having shaky voice
Avoiding doing things out of fear of embarrassment
Avoiding situations wherein one might be the center of attraction
Getting anxious in wait of a feared event or activity
Extreme fear / anxiety during social situations
Fear of offending someone accidentally
Fear of analysis of their performance or if anyone would point out at flaws in interactions following a social situation
Expecting worst consequences from a negative experience during a social situation
Speaking in public,
Attending social gatherings/ parties/work/ job interviews
Going for shopping/ school
Talking on phone
Making eye to eye contact
Entering rooms having people seated in them
Eating in front of / in presence of others
Returning things to a store
Using public restroom
Behavior in children having social anxiety disorder
Have issues interacting with adults or peers
Display this anxiety by crying,
Displaying temper tantrums,
Clinging to parents or by refusing to speak in social situations
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Performance oriented social anxiety disorder
This type of social anxiety disorder will be limited to certain situations. One would experience extreme fear and anxiety while speaking or performing in public. They may not experience the same anxiety in other types of more general social situations.
Trembling / shaking
Difficulty in speaking
Increased / fast heartbeat
Tensions in muscles
Nausea / stomach upsets
Feeling blank headed
Trouble catching up with breath
Sensation as if one is out of his / her body
One would get these symptoms and get anxious immediately before an event. One may also worry about it for many weeks.
Intense worry about social situations
Worry about an event, many days or weeks before it occurs
Avoiding social situations
Worry about embarrassing self in social settings
Worry about being noticed by other people (that people may find out that you are stressed or nervous)
Feeling need of alcohol in order to face social situations
Missing school or work
Avoidance of common social situations
There may also be variants. Some people might find it easy to give a speech but consider going to a party a nightmare. A person may be good in face to face confrontation and conversation with one person but finds it extremely uncomfortable stepping in and speaking to a crowded classroom.
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The symptoms of this condition keep changing from time to time. There may also be flare-ups if the patient is facing demands, stress or a lot of unexpected changes in life. People may feel better when they avoid situations that produce anxiety. But the relief will be short lived. If this condition is not treated promptly the condition will progress and might have anxiety for life.
Symptoms may not occur in all situations and all time. You may also have limited / selective anxiety. If it is an extreme case, you will have symptoms in all social gatherings.
Effects of avoiding social situations
Disturbed personal relationships
Poor social skills
Sensitiveness to criticism
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When to seek medical attention
You may prefer seeing a doctor or specialist / mental healthcare professional if you fear and avoid normal social situations because they cause panic, worry or embarrassment.
Negative experiences like being victim of –
Negative events in life such as conflicts in family, abuse, trauma
Temperament – Those children who are shy, timid, withdrawn or restrained while they are facing new people or situations
New work demands or social demands – Typically this disorder being in teen years of one’s life. Meeting new people, giving public speech or making an important presentation at workplace may trigger the symptoms for the first time and that is when one gets alerted about this condition.
Having an ‘attention drawing’ appearance or condition – Example, in some people the social anxiety disorder might get triggered due to facial disfigurement, stuttering or tremors (as in Parkinson’s Disease) etc by increasing feelings of self-consciousness.
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If social anxiety disorder is not treated the disease will meddle with life and will seriously interfere with work, school, relationships or enjoyment of life. The below mentioned can be caused as complications of this condition –
Poor school skills
Becoming victims of substance abuse (example – taking too much alcohol)
Making attempts to suicide
Low achievement at academics and employment
Difficult social relationships
Becoming hypersensitive to criticism
Having trouble being assertive
Along with ‘social anxiety disorder’ one may also have other anxiety disorders and other accompanying mental health disorders, mainly major depressive disorder and substance abuse problems.
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Getting early help – If you suspect having this disorder you need to take help immediately without delaying. Delaying can increase problems and intensify symptoms.
Keeping journals – Keep a check and track on life activities and events. This will not only help you and your mental health professional / doctor to identify what factors bring stress and what help you to feel better and relieved.
Setting your life priorities – Chose what you want to do often and enjoy doing them. Make a priority list and follow your heart. Do only those activities and visit those places and people with whom you are comfortable with, those which can keep you relaxed and entertained. Important is to keep doing things that you enjoy the most. Reduce your anxiety levels by properly managing time and energy.
Keep away from unhealthy substance use – Your anxiety can be caused or worsened by alcohol and drug use, use of caffeine or nicotine. If you suddenly quit these substances to which you are addicted you may get more anxious. Take time and gradually quit the substances. Most often it is difficult to quit these habits and may need help from healthcare provider. You may also prefer to take help from support groups.
Doctor will diagnose this condition after a thorough interview and examination. They will try to find if you have this condition along with another physical or mental health disorder. Diagnosis is done on the basis of –
Physical exam – to find out medical conditions or medications which might trigger anxiety symptoms
Interview – to discuss your symptoms in detail, frequency of symptoms and situations in which they appear
Review / follow up – of many conditions, factors and situations (causes or triggers) to see if they are making anxiety worse
Self-report questionnaires (which includes symptoms of social anxiety)
Criteria listed in DSM-5 published by the American Psychiatric Association
DSM-5 criteria for social anxiety disorder include –
1. Fear – you will have persistence and intense fear of anxiety about specific social situations. This is because you believe that you may be judged negatively, embarrassed or humiliated.
2. Avoidance – you will avoid social situations which produce anxiety and those situations which will endure you with intense fear, panic or anxiety.
3. Excessive Anxiety – You may have severe anxiety that is blown out of proportion to the given situations.
4. Interference – Your anxiety or distress may interfere with daily living.
5. Unexplained fear – You may have a fear or anxiety which cannot be explained by a medical condition, medication or substance abuse.
The choice of treatment will totally depend on the quantity of social anxiety disorder affecting your ability to function in daily life and also the severity of symptoms.
Most common treatment options-
1. Psychotherapy / Talk Therapy / Psychological counseling
3. Combination of psychotherapy and medications
Treatment would differ from person to person. Some may need one type of treatment and others may need treatments in combinations. Your doctor or health care provider may refer you to a mental health provider or psychiatrist for an opinion or better treatment.
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This therapy improves symptoms in most people. While in the process of therapy you will learn to recognize and also to change the negative thoughts about yourself. It will also help you to develop skills to enable you to gain confidence in social situations.
Cognitive Behavioral Therapy (CBT) – It can be conducted individually or in groups. CBT helps to control anxiety through methods of relaxation and breathing. It will also help to replace negative thoughts with positive ones.
Exposure based CBT – You would gradually work up and learn to face situations which you had feared the most. You can improve your coping skills. This therapy will also help you to develop confidence to deal with anxiety inducing situations. Herein you may also participate in skills training or role-playing.
Group Therapy – This helps to learn social skills and techniques which will further enable you to interact with people in social settings and gatherings. Others in the group may also have the same problems and fears as you have, about the same things and situations. Participating in this therapy alongside others who have similar problems as yours will make you feel less alone and boost up your confidence.
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SSRI – Selective Serotonin Reuptake Inhibitors are the first choice of drugs for treating persistent symptoms of social anxiety. SNRI (Seratonin and Norepinephrine Reuptake Inhibitor) is also an option for this condition. It may take weeks to months of treatment for improvements in the symptoms of the disease to be noticeably good.
Other medications –
Even if the given treatment do not work quickly as per your expectations you need to hang on and adhere to the treatment and wait for results. It takes time for you to learn new skills to manage your anxiety.
In some, the symptoms will reduce and fade over period of time. In these conditions medication can be discontinued. For many others medication may be needed for months or years so as to prevent relapses.
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Lifestyle Changes, Home Remedies
These measures help to handle situations that are likely to trigger symptoms.
Exercise – exercise regularly
Sleep – You need to get good quality and quantity of sleep as recommended for your age. Deficit sleep might increase anxiety and worsen symptoms of social phobia.
Eat health foods, well balanced diet
Limit use of caffeine or avoid it (coffee, chocolate, soda etc are stimulants)
Participate in social situations, reach out to people with whom you are comfortable with
Try to identify and list out the causes and situations that bring about anxiety in you. After doing so you may practice the below mentioned activities until they make your anxiety levels less.
Make small initiations. Set yourself with small daily or weekly goals in situations that are not overwhelming. The more you practice, the less anxious you will start feeling.
Eat foods of your choice with a close friend, relative or acquaintance in a public setting
Make purposeful eye to eye contact with others
Greet – try to return the greetings from others
Hello – take initiation to tell hello or introduce self to others, communicate and exchange pleasantries
Compliment – truly compliment someone
Directions – try to get directions to go to a place from a stranger
Plan – make plans with the help of your friends
Ask – when you are at a shop, talk to helpers to help you to find an item you want to purchase
Interest – show interest in others, speak, ask about their home, children, hobbies, travels etc and tell them your stories
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Prepare for social situations
It is no doubt a challenging scenario for you every time to ‘try being social’ in spite of having an anxious mind. Though it is tough, try not to avoid ‘trigger situations’ and try to be there and make a practice of it. You can beat your demons only with small fightbacks. Tell yourself ‘all is well’ or ‘everything will be okay!’. When you face these situations on a regular basis you will continue to reinforce your coping skills and will help yourself a lot. No one can help you better than yourself in coping up and making a practice of being in social situations.
The below mentioned strategies may help you to take a kick-start –
Practice relaxation techniques, yoga, meditation
Prepare self with conversations, try with family and friends to begin with
Explore the best qualities and nature you have by looking deep into self and explore
Manage – try to understand your stress and triggers, master them, and learn management techniques
Set smart and realistic social goals, small ones to begin with
Count – take an account of the frequency of occurrence of ‘embarrassing situations that you are afraid of and prepare self to combat them
Ensure self that your feelings in embarrassing situations will pass out for sure and that you can handle them until they pass away
Try to enroll yourself in a local or recognized support group, online or offline, whatever you are comfortable with
You may also try to join groups that gives you with good opportunities to improve your communication and public speaking skills
Indulge yourself in relaxing and pleasurable activities such as hobbies whenever you feel anxious
These methods will help in controlling your symptoms and also to prevent relapses of the symptoms when you practice them consistently.
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Outlook for Social Anxiety Disorder
According to ADAA – about 33% people with social anxiety disorder do not speak to healthcare providers until they have had symptoms for at least 10 years.
People suffering from this problem often rely on drugs and alcohol. This would help them to cope up with anxiety triggered by social interaction. If social phobia is not promptly treated it can lead to other high-risk behaviors. They include –
Young people at risk of SAD – Study relating social anxiety in young people (prevalence study done in 7 countries) reveals that the levels of social anxiety may be rising among young people and those aged 18-24 may be at more risk. Public health initiatives are needed to raise awareness of social anxiety, the challenges associated with it and effective means of combating them.
Another study shows that individuals with social anxiety disorder show large differences in personality traits.
Yet another study establishes link between ‘social anxiety disorder’ and alcoholism. It tells that SAD may have a direct effect on alcoholism.
One more study tells that psychotherapy normalizes brain changes linked to social anxiety disorder.
Study – Social anxiety increases visible anxiety signs during social encounters but does not impair performance.
Study found high magnitude of social anxiety disorder in school adolescents.
Social Anxiety Disorder is a type of anxiety disorder. ‘Fear’ is the main component of this disorder. Bhaya or fear increases vata and this vata causes disturbances in the body and mind causing symptoms of anxiety disorder. Therefore, aggravated vata should be treated to bring vata and its symptoms into control.
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The entire set of ‘anxiety disorders’ are correlated to ‘chittodvega’ explained in Ayurveda. Principles of treating this condition too should be adopted in treating social phobia. Other treatment principles –
Line of treating the mind disorders shall be considered
Line of treating the ‘contamination of mind carrying channels’ shall also be considered