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Social Anxiety Disorder (SAD)

INTRODUCTION

Social anxiety disorder (SAD), once called social phobia, is the most common anxiety disorder that continues to be under-diagnosed. SAD is characterised by a marked, persistent fear and/or avoidance of one or more social situations. The individual is fearful of being exposed to unfamiliar people and/or to possible scrutiny by others. On exposure to the feared situation, intense anxiety (Table 1) or panic attacks (Table 2) may occur, events that for some are perceived as humiliating or embarrassing.

Those with SAD seek to be perfect. In the feared situation, they dislike being observed always believing that others are evaluating them unfavourably. While avoidance of the feared situation is the norm, some penetrate the feared situation experiencing anxiety or a panic attack. For the diagnosis of SAD, sufferers must recognise their fear is excessive and unreasonable, and that the condition significantly impairs life.

Anticipatory anxiety is a striking feature of SAD. This anxiety occurs prior to entering the feared situation, often surfacing well in advance of the upcoming social event. For some, this anxiety is often as distressing as the anxiety and panic that may occur while in the situation. Underlying this anxiety are fearful thoughts that one’s performance will not be perfect and an unfavourable evaluation will occur. Often those with SAD, following entry into the feared situation, will undertake a post mortem analysis commonly evaluating their performance unfavourably.

TABLE 1 Symptoms of anxiety common in SAD
  • Palpitations
  • Sweating
  • A sick feeling in the stomach
  • Blushing
  • Trembling
  • Tense muscles
  • Dry mouth or throat
  • Pressure in the chest

SOCIAL AVOIDANCE

For some with SAD, certain social situations may always be avoided, others minimise their exposure by behaving in ways that limit scrutiny. See Table 3.

COURSE, ONSET AND GENDER

Unfortunately, for most, SAD is a chronic, unremitting illness. Spontaneous remission is rare. SAD strikes young; 40% have SAD prior to the age of ten and 95% by the age of twenty. The disorder is more prevalent in females than males.


TABLE 2 Symptoms of a panic attack
(Four symptoms required for a diagnosis)
  • Palpitations, pounding heart or accelerated hear rate
  • Sensations of shortness of breath or smothering
  • Feelings of choking
  • Nausea or abdominal distress
  • De - realisation (feeling of unreality) or depersonalisation
    (being detached from oneself)
  • Paraesthesia (numbness or tingling sensations)
  • Sweating
  • Trembling or shaking
  • Chest pain or discomfort
  • Feeling dizzy, unsteady, light - headed or faint
  • Fear of losing control or going crazy
  • Fear of dying
  • Chills or hot flushes


TABLE 3 Behaviours undertaken to limit scrutiny in SAD
  • Limited eye contact or gaze
  • Shyness
  • Daydreaming
  • Head held in a lowered position
  • Turning away
  • Avoiding conversing with others
  • Showing disinterest
  • Positioning one - self to minimise social contact
  • Speaking softly

TYPES OF SOCIAL INTERACTION

Social phobic situations can be broadly defined as performance or interactive (See table 4) In performance situations, the individual engages in behaviour while being observed often by more than one person, i.e., presenting a report to a group. Interactive situations involve inter-change with another i.e., addressing your employer. Regardless of type, an unfavourable evaluation is feared.

TYPES OF SAD

Non - generalised SAD
Non-generalised SAD is when only a limited number of social situations are feared or avoided. Therefore, one may be fearful only of and avoid public speaking, the most common type of SAD and the most common phobia.

Generalised SAD
In generalised SAD, multiple interaction and performance situations are feared and/or avoided; in fact, some may feel uncomfortable in most social situations. Generalised SAD has an earlier age onset, is more common and leads to greater impairment than non - generalised SAD.


TABLE 4 The most common situations avoided in SAD
Performance situations Interactive situations
  • Public speaking
  • Using public toilets
  • Eating in front of others
  • Writing in front of others
  • Speaking in front of others
  • Drinking in front of others
  • Entering a room where others are seated
  • Playing an instrument
  • Playing sports
  • Negotiating with another
  • Purchasing items
  • Dating
  • Speaking to a stranger
  • Conversing on the telephone
  • Addressing an authority figure
  • Asking for help

SAD DOES NOT OCCUR ALONE

Up to 80% of those with SAD have a further psychiatric diagnosis; 70% experience an additional anxiety disorder, 70% experience either depression or dysthymia and 20% abuse alcohol. The most common illnesses to co - occur with SAD are listed in Table 5; SAD often precedes the onset of these illnesses. Up to 16% with SAD will attempt suicide, moreover, para-suicidal feelings are common, examples of which are listed in Table 6.


TABLE 5 Common psychiatric illnesses to co-occur with SAD
  • Specific Phobias
  • Generalised Anxiety Disorder
  • Major Depression
  • Alcohol and drug abuse/dependence
  • Panic Disorder with agoraphobia
  • Obsessive Compulsive Disorder
  • Dysthymia

Refer to the Panic Anxiety Mood Guide home page to learn more about the above psychiatric illnesses.
TABLE 6 Para - suicidal feelings that can occur with SAD
  • Frequent thoughts about death
  • Feelings of wanting to commit suicide
  • Feelings of wanting to die
  • Feeling that life is not worth living

IMPACT

Those with SAD, particularly of the generalised sub - type experience significant social, occupational and economical impairment. In one study, 85% considered that their academic and educational chances were affected with 50% failing to complete high school. It was also shown that 20% were dependent on welfare and 50% were single, divorced or separated. Anti-social behaviours during childhood and adolescence are common, 35% acknowledge truancy at least twice in one year and 40% repeated school years.

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