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Social Anxiety Disorder (Social Phobia)

Definition :
Everyone feels nervous from time to time. Going on a first date or giving a speech often causes that butterflies-in-your-stomach feeling, for example. Or maybe you feel shy at a party among a group of strangers, but then slowly warm up to them and have a great time.

For some people, though, this normal nervousness is magnified into extreme anxiety, fear and self-consciousness. Everyday social activities, even the most mundane, are virtually impossible. You may avoid dating, giving speeches or attending parties altogether. You may not even be able to eat with others or write a check at the grocery store.

When your anxiety is so extreme that it disrupts your life and you avoid certain situations, you may have social anxiety disorder. Social anxiety disorder is a chronic condition that causes an irrational anxiety or fear of activities or situations in which you feel others may be watching you or judging you. You also fear that you'll embarrass or humiliate yourself.

Social anxiety disorder, a type of anxiety disorder, is one of the most common mental disorders. Up to 13 percent of people in Western countries experience the condition at some point in their lives. Social anxiety disorder can be so debilitating that it interferes with work, school and other routine activities.

The good news is that effective treatment — cognitive behavioral therapy and medication — can improve your quality of life and open up opportunities that the anxiety and fear had closed off.

Causes:
Social anxiety disorder typically begins in the midteens, although it can begin earlier in childhood. It rarely begins in adulthood.

Like many other conditions, social anxiety disorder likely arises from a complex interaction of your environment and your genes. Researchers are still hunting for precise causes. Some possible causes under study include :

  • Genes. Specific genes may affect anxiety and fearfulness. However, researchers are still unraveling the mystery of which specific genes may be involved in social anxiety disorder. In addition, social anxiety disorder seems to have a hereditary component, which means it tends to run in families. But it's not clear whether that hereditary component is related to genetics or to behavior you learn from other family members.
  • Biochemistry. Researchers are exploring the idea that natural chemicals in your body may play a role in social anxiety disorder. For instance, an imbalance in the brain chemical serotonin (ser-oh-TOE-nin) could be a factor. Serotonin, a neurotransmitter, helps regulate mood and emotions, among other things. People with social anxiety disorder may be extra sensitive to the effects of serotonin.
  • Fear responses. Some research suggests that a structure in the brain called the amygdala (uh-MIG-duh-luh) may play a role in controlling the fear response. People who have an overactive amygdala may have a heightened fear response, causing increased anxiety in social situations.

Risk Factor :
Risk factors are things that increase the likelihood that you'll get a particular disease or condition.

Risk factors for social anxiety disorder include :

  • Your sex. About twice as many women as men have social anxiety disorder.
  • Family history. Some research indicates that you're more likely to develop social anxiety disorder if your biological parents or siblings have the condition.
  • Environment. Your environment may influence the development of social anxiety disorder in a number of ways. Some experts theorize, for instance, that social anxiety disorder is a learned behavior. That is, you may develop the condition after witnessing others with symptoms. In essence, you may be learning social anxiety disorder by example. In addition, there may be an association between social anxiety disorder and parents who are more controlling or protective of their children.
  • Negative experience. Children who experience teasing, bullying, rejection, ridicule or humiliation may go on to develop social anxiety disorder. In addition, other negative events in life, such as family conflict or sexual abuse, may be associated with social anxiety disorder.
  • Temperament. Children who are shy, timid, withdrawn or restrained when facing new situations or people may be at greater risk of social anxiety disorder.
  • New social or work demands. Meeting new people, giving a speech in public or making an important work presentation may trigger the signs and symptoms of social anxiety disorder. These signs and symptoms usually have their roots in adolescence, however.

When to seek medical advice :
Feeling shy at parties or nervous about giving a speech doesn't necessarily mean you have social anxiety disorder. If your fears or anxieties don't really bother you, you may not need treatment. For instance, you may not like making speeches but you do it anyway without being overwhelmed by anxiety.

On the other hand, if anxiety disrupts your life, causes you distress or affects your activities, you may benefit from medical or psychological treatment. Similarly, if you dread events for weeks beforehand or if you find yourself avoiding situations you believe may cause extreme anxiety, talk to your doctor or mental health professional.

Common, everyday experiences that may be difficult to endure when you have social anxiety disorder include :

  • Using a public restroom or telephone
  • Returning items to a store
  • Interacting with strangers
  • Writing in front of others
  • Making eye contact
  • Entering a room in which people are already seated
  • Ordering food in a restaurant
  • Being introduced to strangers
  • Initiating conversations

Don't allow yourself or others to trivialize your anxieties just because they may be associated with everyday occurrences. Also, remember that being anxious is not a sign of weakness or inferiority. Social anxiety disorder doesn't typically go away on its own — unless you're able to completely avoid the situation that triggers your symptoms.

Symptoms :
Social anxiety disorder, sometimes called social phobia, isn't the same as shyness or stage fright. In fact, it's perfectly reasonable to be anxious in some situations.

What sets social anxiety disorder apart from everyday nervousness is the severity and persistence of its signs and symptoms. Social anxiety disorder can have both emotional and physical signs and symptoms.

Emotional signs and symptoms of social anxiety disorder include :

  • Intense fear of situations in which you don't know people
  • Fear of situations in which you may be judged
  • Anxiety about being embarrassed or humiliated
  • Fear that others will notice you showing physical signs of anxiety
  • Anxiety that disrupts your daily routine, work, school or other activities

Physical signs and symptoms of social anxiety disorder include :

  • Blushing
  • Profuse sweating
  • Trembling
  • Nausea
  • Stomach upset
  • Difficulty talking
  • Muscle tension
  • Confusion
  • Palpitations
  • Diarrhea

When you have social anxiety disorder, you know that your anxiety or fear is out of proportion to the situation. Yet you're so worried about developing these signs and symptoms that you avoid social situations that may trigger them. Indeed, simply worrying about having any of these signs and symptoms can cause them or make them worse.

Signs and symptoms of social anxiety disorder can fluctuate over time. They may flare up if you're facing a lot of stress or demands. Or if you avoid situations that would usually make you anxious, you may not have signs or symptoms. Although such avoidance may allow you to feel better in the short term, your anxiety is likely to persist over the long term.

In addition, you may have signs and symptoms in only one type of situation, such as eating in front of others. In more severe cases, you may have signs and symptoms any time you're around another person at all.

Diagnosis :
When you decide to seek treatment for your signs and symptoms, you may have both a physical and psychological evaluation. The physical exam can determine if there may be any physical causes triggering your signs and symptoms.

There's no laboratory test to diagnose social anxiety disorder. Your doctor or mental health professional will ask you to describe your signs and symptoms, how often they occur and in what situations. He or she may review a list of situations to see if they make you anxious.

If you're seeing a primary care doctor, he or she may refer you to a psychiatrist or psychologist for further evaluation. You may fill out psychological questionnaires or self-assessments to help pinpoint a diagnosis.

Complications :
Many people live with social anxiety disorder for years without seeking help. They may not realize they have a medical condition, or they may be too embarrassed to seek help.

But left untreated, social anxiety disorder can be debilitating. Your anxieties may run your life. They can interfere with your work, schooling, relationships or enjoyment of life. In severe cases, you may drop out of school, quit work or lack friendships.

Social anxiety disorder can also lead to other health problems, such as substance abuse or excessive drinking in an attempt to cope. And it can also increase your risk of depression and suicide.

Treatment:
Social anxiety disorder typically persists for life, often waxing and waning. But treatment can help you control it. The two most effective types of treatment are medications and a form of psychotherapy called cognitive behavioral therapy. The two are often used in combination.

Psychotherapy
Cognitive behavioral therapy is the only type of therapy that has been shown to be effective in treating social anxiety disorder. This type of therapy is based on the premise that your own thoughts — not other people or situations — determine how you behave or react. Even if an unwanted situation won't change — you still have to give that presentation to management, for instance — you can change the way you think and behave in a positive way.

Cognitive behavioral therapy may also include exposure therapy. In this type of therapy, you gradually work up to facing the situations you fear most. This allows you to become better skilled at coping with these anxiety-inducing situations and to develop the confidence to face them. You may also participate in skills training or role-playing to practice your social skills and gain comfort and confidence relating to others.

Medications
Several types of medications can be used to treat social anxiety disorder. However, the Food and Drug Administration has specifically approved only three medications, all antidepressants, to treat social anxiety disorder.

Those antidepressants are :

  • Paroxetine (Paxil, Paxil CR)
  • Sertraline (Zoloft)
  • Venlafaxine (Effexor)

But your doctor or mental health professional may also prescribe other medications that haven't been specifically approved for social anxiety disorder. This is called off-label use.

Other medications your doctor may recommend include :

  • Anti-anxiety medications. A type of anti-anxiety medication called benzodiazepines (ben-zo-di-AZ-uh-penes) may reduce your level of anxiety. Although they often work quickly, they can be habit-forming. Because of that, they're often prescribed for only short-term use. They may also be sedating. Examples include diazepam (Valium), chlordiazepoxide (Librium) and lorazepam (Ativan).
  • Beta blockers. These medications work by blocking the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs. Because of that, they may work best when used infrequently to control symptoms for a particular situation, such as giving a speech. They're not recommended for general treatment of social anxiety disorder. They include propranolol (Inderal LA, Innopran XL).

Don't give up if one of these medications isn't effective enough or has intolerable side effects. It may take some trial and error to find the best medication for you.

For some people, the symptoms of social anxiety disorder may fade over time, and medication can be discontinued. Others may need to take medication for years to prevent a relapse.

 
Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.
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