I’m sometimes asked about what social anxiety disorder (SAD) is and whether it’s the same as social phobia. Since SAD is one of the subtypes of the stage fear, let’s have a closer look at them in today’s post!
So, what is social anxiety disorder? Social anxiety disorder is a condition in which the fear of a situation where one has to make a presentation or where others are watching is very strong. Sometimes, the fear is so strong that such situations are avoided completely.
Usually, it’s feared that something mysterious, strange, or ridiculous will be said or made inadvertently. As a rule, a person fully understands that their fear is excessive.
SAD also manifests as the fear of situations that require communication – whether companies of new people, interviews with older, smarter, or more senior people, conversations in general, or parties.
We should start with what is the difference between social anxiety disorder (SAD) and social phobia. In fact, there’s no difference other than the use of the term ’social anxiety disorder’ today, while the term ’social phobia’ was used mainly until the mid-1990s.
- The term ’social phobia’ was used mainly to describe a diagnosis where a person was extremely awkward or afraid of performing in front of others.
- In the mid-1990s, it was decided that the term ’social anxiety disorder’ is more appropriate as it describes the diagnosis of an individual who feels awkward in a variety of social situations.
SAD is characterised by a strong fear of the situations where, for some reason, it is necessary to stay in the spotlight. The individual is anxious about a mere thought of saying or doing something that could humiliate or embarrass them. Such individuals are characterised as perceiving things from the inside, from the point of view of other people.
For example, a person is afraid of appearing as stupid, so they are imagining that everyone around them thinks they are stupid. These moments can be very brief, but awaken very strong feelings.
Therefore, SAD means constant fear of embarrassment or humiliation in which sufferers avoid attending events they believe can be stressful.
This includes public speaking, meetings, and social events (American Psychiatric Association, 1994). Social anxiety disorder can be reduced to only a few specific examples, such as formal public speaking, or extened to various situations, such as social gatherings or conversations.
Fear of failure
SAD is also characterised by a person’s fear of negative assessment, which they expect as a result of failure. For such a person, performance means:
- controlling their emotions
- carrying out daily activities (such as eating out, talking to a stranger or a group of strangers, communicating with the opposing sex)
- as well as all other activities performed by a person living in our society.
A person suffering from SAD believes that they behave unacceptably and, as a result, is abandoned by others.
It has been also described as the fear of social situations where a person has a strong fear of the negative evaluation of a failed performance.
Thoughts reflect how we value what’s happening around us
Everything that happens to us makes us think. Thoughts reflect how we interpret and value what’s happening around us. Sometimes, these evaluations are accurate, sometimes, over-optimistic. However, if a person is anxious, they tend to see everything in a negative light and to interpret it as a threat. We’re talking about compulsive thoughts such as:
- „I’m considered foolish and annoying“
- „Everyone’s looking at me and thinks I’m weird“
- „Others don’t like me, I only say bizarre things“.
Unfortunately, these are not the thoughts of others, but mere illusions of a person suffering from this disorder. If they only knew that very few people actually think about them, they would be seriously offended. One thing is certain, there’s no reason for panic.
Signs and symptoms
SAD can occur in many forms and at varying degrees, but every time you feel panic associated with communication or public speaking is not indicative of disease. Some people suffering from this disorder seem to feel inherently embarrassed, although some symptoms of anxiety can also occur in very sociable people.
It has been pointed out that when an individual experiences a situation that causes SAD, the individual usually recognises a variety of symptoms, the main ones including rapid heart beat, sweating, reddening, and disaster-thinking. These symptoms are manifested even if a person realises that these reactions are exaggerated or unreasonable.
However, the most common symptom of SAD is the stage fear (for example, making a speech), answering in a class, or making a presentation.
There also are the following signs:
- fear of reddening in a public place
- fear of eating out and the related inappropriate behaviour
- fear of using public lavatories
- fear of crowds
- fear of examinations
The distinct features can include:
- rapid heart beat
- accelerating breathing or holding one’s breath
- shaking voice or hands
Sometimes, anxiety manifests in anticipation or thought of a terrifying event, for example, through nausea or going to the toilet frequently.
Impact on four levels
The main symptoms that manifest in relation to social phobia impact a person on four levels – thinking, behaviour, body, and emotions.
Impact on thinking – worried about what others think; thinking about what might go wrong; mind feels completely empty, no words to say.
Impact on behaviour – the person avoids eye contact; speaks in a fast or quiet manner; avoids communication-related situations.
Impact on body – panic discomfort, which may include rapid heart beat, dizziness, nausea; signs of anxiety such as redness, sweating, shaking.
Impact on feelings – insecurity and inferiority; nervousness and dread; depressive thinking, as in nothing can be done.
What are the causes of SAD?
As with other mental disorders, there’s no single cause for it; a number of factors, such as brain chemistry disorders, heredity, and environmental factors, have to coincide.
Both genetic and psychological factors are considered to be the causes of this disorder. According to the cognitive model, a person suffering from it wishes to make a good impression, but, at the same time, they doubt their ability. As a result, social situations are viewed by the individual as a major source of danger, in which they think they’ll inevitably ruin something with their behaviour and remain without the support of others forever.
Social phobia is partly a genetic disorder, but along with genetic factors, obviously, other factors also play a major role. The genetic origin is that social phobia often runs in the family, and the affected person has beliefs that feed their fears and lower self-esteem.
It is also believed that social phobia is a dopamine dysregulation disorder – dopamine is a chemical compound that plays an important role in the manifestation and reoccurrence of anxiety; dopamine dysregulation results in mental disorders.
According to the established theories, people prone to social phobia have developed opinions that social situations automatically make them think they won’t be able to handle communication. Despite the fact that they can actually handle it, they’re afraid of negative judgment or of losing support from psychologically important key people.
Since the causes of social anxiety can be of both genetic and psychological nature, it’s not a good idea to envision that „it is an inherited disorder that can’t be overcome“.
Although this disorder is widespread, it is diagnosed officially only if avoiding certain situations impacts a person’s professional life, damages important relationships, or causes significant suffering. The signs of social anxiety and fear must have lasted for at least 6 months to suspect the manifestation of social phobia.
What is mainly used to identify SAD is a detailed survey, which looks at when and how often the symptoms occur. Just in case, I’ll also mention that, inasmuch as the physician must be convinced that anxiety, panic, and other symptoms of social phobia are not caused by any other problem (e.g., mental disorders, physical disorders, drugs, or use of some medication), they may ask a variety of questions.
How common is it?
Social anxiety is very common, with one in eight suffering from it. It can significantly reduce the quality of life, preventing building new relationships and negatively impacting studies and work.
As you can see, it is quite common; it’s considered one of the most common psychiatric disorders in every three people. The results of different studies vary in a range from 1.5 to 13%. According to population surveys, 50-70% of women suffer from social phobia, but mostly men ask for professional help.
Ruscio, Brown, Chiu, Sareen, Stein & Kessler (US National Library of Medicine, 2008) conducted a survey in the US in 2001-2003 involving 9,282 people. The study revealed that social anxiety disorder is quite common, but also undertreated, which results in significant functional impairment. According to the study, the stage fear or the fear of speaking in front of others is the worst of the remaining social fears.
When does it occur?
The signs of social phobia occur mainly already in adolescence, very rarely manifesting in adulthood. Anxiety may also manifest in a pupil, where answering in front of a class, doing a test, or meeting with new people may lead to the child wishing to leave school.
Anxiety and stress exhaust human energy and may result in the desire to separate, to be alone. It makes it difficult to build close relationships, including friendships. If being alone occurs more frequently than an anxious person wishes, it’s time to recognise the problem and deal with it.
There’s no efficient prevention for social anxiety disorder. Several studies have shown that to avoid reoccurrence, the effect of psychotherapy is somewhat more permanent than the use of medicine alone.
Activities that have a positive effect through escaping should be avoided, as they’re rather harmful in the long run. One of these activities is to seek comfort to boost one’s self-esteem.
Being praised is like sitting in a rocking chair. It gives you something to do, and a warm feeling, but it doesn’t get you anywhere. So, if you miss a friendly pat on your back and the words „You’ll make it“, „Don’t be afraid“, and „Everything’s fine?“, please remember that this is a temporary relief, not a solution. It’s much more better if you’re able to use your thoughts to reach the exact same state, without the help of others.
Another cunning tool as an anxiety reliever is alcohol. Alcohol plays a big role in social situations making people more talkative and courageous, but the idea of having a drink to be courageous is not for someone suffering from this disorder. Since in many cases alcohol has a depressive effect, it’s more likely to worsen the situation instead of making it better.
The effects of different conversational therapies have also been compared, and cognitive-behavioural therapy was found to be most efficient. The latter focusses on helping people cope with their irrational fears and overcome avoidance behaviour.
One way to treat social phobia is to use antidepressants. However, I’ll emphasise that antidepressants are prescribed in the case of a widespread social phobia. The positive effect usually accumulates slowly, over several weeks. The benefits of treatment have been marked at 35-50%.
Certain sedation medicine (benzodiazepines) has also been used, but their long-term use may be addictive, and the risk of reoccurrence of SAD at the end of use is likely.
Evan Mayo-Wilson, along with colleagues, analysed the data of 101 clinical trials (Mayo-Wilson et al 2014). The results were published by The Lancet Psychiatry on September 26, 2014. The study professionals collaborated with John Hopkins Bloomberg School of Public Health, Oxford University, and University College London.
There were a total of 13,164 participants in the study, all of which suffered from a long-term and severe social anxiety disorder. Approximately 9,000 of them received either placeboes or antidepressants (SSRI type). More than 4,000 participants went to psychotherapy. Some clinical trials also included a combination of medication and therapy, and there was no evidence that combined therapy was more effective than psychotherapy.
At this point, it’s worth pointing out that even if this disorder is not treated, it can still be alleviated, especially when a person gets positive communication experiences and learns ways to cope with anxiety.
Cognitive-behavioural therapy as a tool for treating SAD
In the 1950s and 1960s, behavioural therapy techniques were developed that proved useful in the treatment of social anxiety disorder and simple phobias (such as the fear of heights or flying). The purpose of behavioural therapy was to treat the symptoms (e.g., anxiety) instead of the root causes (e.g., a traumatic experience from childhood).
However, since behavioural therapy proved to be inadequate, it was supplemented in the 1970s with a special depression therapy called cognitive therapy. Cognitive-behavioural therapy is used both as a group and individual therapy.
At the beginning of treatment, the situations that a person avoids are identified; then, they are allowed to experience these situations or activities. It also seeks to identify negative thoughts that occur automatically in relation to problematic situations, to make them more realistic. It also seeks to detect false beliefs and negative thoughts that occur automatically in relation to problematic situations.
Studies have shown that cognitive-behavioural therapy is beneficial in the treatment of SAD and phobias, as well as other conditions, such as gambling, alcohol and drug addiction, and eating disorders. Often, there are specific mental patterns behind various psychological problems, but the services of a psychologist or psychiatrist are often expensive and not accessible to everyone.
Thus, a large number of people live hiding and suffering from their problems for many years, not sharing with anyone or asking for help. However, cognitive-behavioural therapy manuals have been widely published lately, presenting the fundamentals of the therapy and offering systematic action plans for self-help.
How to help yourself?
If visiting a therapist is not an option, but you’re willing to change, it’s a good idea to start with a cognitive-behavioural therapy book. Gillian Butler offers some effective tips in her book „Overcoming Social Anxiety & Shyness“. What helps tolerate or overcome anxiety is:
Changing one’s mindset helps you understand how a person thinks in a situation where anxiety manifests and what should be changed.
Changing one’s behavioural patterns teaches how to fight the fear, not avoiding situations or apodting defensive behaviour.
Reducing excessive self-awareness shows how deliberately concentrating on others helps suppress anxiety.
Boosting self-confidence helps you step out of the box, which will allow you to see yourself and the world.
Overcoming social anxiety disorder allows you to enjoy being yourself instead of being constantly afraid and to develop the qualities that may have stayed hidden for many years.
Reducing your general anxiety levels also helps. The simplest way to do this are relaxing exercises and activities. Physical activity is a great help for many.
Exercising through creating situations that lead to manifestation of social anxiety disorder is one of the most important pillars of overcoming it. It should be taken into consderation that when practising, it’s reasonable to choose problematic yet tolerable situations.
One thing to be sure of – fighting social anxiety disorder cannot be overcome simply avoiding it and social situations.
Social anxiety disorder as a form of the stage fear
If you compare the symptoms of the stage fear described in one of my previous posts with the symptoms of SAD, you’ll see a number of similarities.
For example, a practitioner of the Georgia Dias (2007) describes the stage fear as stress from the unreleased energy accumulated in the body, which becomes difficult to tolerate when entering the stage or a „danger zone“. An excessive amount of unreleased energy is interpreted by the body as fear and panic.
According to Witt and Benke (2006), the stage fear is primarily a fear of speaking in front of an audience. Just as public performance anxiety is divided into subtypes, the stage fear is also viewed in various public speaking contexts.
Brodsky (1996) describes the stage fear as fear before or during presentation, incapability of coping with the increasing stress during presentation. According to Barlow (2000), the fear of public speaking is the feeling of having no control over a major event in the future. However, the idea of failure can be drastic to an individual’s self-esteem.
Hart develops this idea further, adding that people react to situations related to the fear of public speaking with the fight-or-flight response. This means that our physiological system prepares us for either fighting or escaping. Although performing on stage doesn’t pose a physical danger, the possibility of failure is something that greatly affects the performer’s self-esteem. It brings out a similar reaction that occurs when one’s life stumbles.
Andrew (1994) et al. also state that the stage fear is one of the hidden forms of social anxiety disorder. Beck (2010) states the same and classifies the fear of public speaking as one of the specific types of social anxiety disorder. Fumark (2000) adds a bit to the point saying that the fear of public speaking is the most widespread form of social anxiety disorder. Moreover, Fumark describes one of the results of his own research, in which 77.1% of people suffering from social anxiety disorder were mainly prone to the fear of public speaking.
As discussed above, SAD is a rather common occurrence, which affects about 13% of people. It is quite often a major obstacle to building relationships and can significantly decrease the quality of life. It also negatively affects studies and work. SAD often manifests when you’re a teenager or a young adult – a critical developmental period, making life even more difficult and having very long-term consequences.
The good news is that it is possible to get effective help from therapy.
What is stage fright? Stage fright is a specific communication-based anxiety resulting in a person experiencing physiological excitement, negative feelings, or certain behavioural responses to the actual or expected act of public speaking
How many people are afraid of public speaking? The 2001 Gallup study (USA) revealed that 40% of people were afraid of public speaking. Tomas Fumark’s study of 2000 highlighted that the stage fear prevailed in 77.1% of the people suffering from SAD. Of 2,000 study participants, 24% of the respondents indicated that stage fright was an issue.
Does the level of the stage fear decrease with age? In general, the answer is yes. In my Master’s thesis, I also studied how people of three different generations cope with the fear of public speaking. To sum it up, 47.3% of baby boomers suffer from an average or a above average level of the stage fear. Those percentages are significantly higher for Generations X (64.6%) and Millenials (79.1%). Have a closer look here.