Source: socialanxietyinstitute.org
Melissa is a 21 year old college student who failed her first year exams as she was unable to complete an oral presentation. Over the past year, she has had increasing difficulty participating in group discussions as she feels “stupid”. She notes that she flushes red, is unable to look at her professors and stammers when asked questions in class. She has also stopped going out for meals with her friends as she feels she will embarrass herself while eating in the restaurant and say something “dumb”. This greatly distresses Melissa as she longs to be able to make friends and “fit in” while her parents are concerned about her academic performance.
The above scenario is not uncommon, yet people like Melissa are frequently dismissed as just being “shy”. However, there may be an underlying disorder that requires detection and treatment. Left untreated, this may cause her severe distress and may be debilitating.
What is Social Anxiety Disorder?
Social Anxiety Disorder (SAD) was previously known as social phobia or pathological shyness among the general public. SAD, although neglected by the medical community, can be debilitating but is highly treatable. It is a relatively common condition that can affect up to 12% of the population. SAD is more commonly seen in women.
The Diagnostic and Statistical Manual (DSM – 5) diagnoses SAD when an individual presents with
- A persistent fear that lasts more than 6 months, of social situations where the person is exposed to scrutiny by other people
- This exposure leads to excessive anxiety which interferes in ones’ normal routine
- These symptoms are not caused by a medical condition
What causes SAD?
Like most anxiety disorders, the causes of SAD are multifactorial. This includes hereditary and environmental factors. SAD has also been attributed to abnormalities in the neurotransmitters in the brain, such as serotonin.
Do I have SAD?
Some of the screening questions that clinicians use are:
- Do you avoid activities that make you the centre of attention?
- Do you avoid speaking to people for fear of embarrassment?
- Is your primary fear worrying that you will look “stupid” and be embarrassed?
This test, known as the Mini- Social Phobia Inventory (MINI-SPIN) is sensitive enough to pick up SAD in almost 90% of cases.
In some instances, the individual may also experience panic attacks, although careful history shows they only occur in the context of a feared social situation.
If you feel that you may have the above symptoms, consult a GP who may provide detailed screening tests and refer you to a psychiatrist if necessary.
Can SAD be managed?
There are several effective treatments for SAD, including both pharmacological and Cognitive Behavioural Therapy.
Medications like Selective Serotonin Reuptake Inhibitors (SSRI’s) are used as first line treatments for SAD. These help to increase the amount of the neurotransmitter serotonin and allay anxiety. There is light at the end of the tunnel as up to 80% of patients respond after 12 weeks of treatment. Your doctor may also prescribe a Benzodiazepine for a short term duration for their anti-anxiety effects.
Use of psychological treatments are increasingly popular. Cognitive Behavioural Therapy in particular is effective as it helps the patient address and overcome anticipatory negative thoughts like “people will think I’m crazy” or “I will embarrass myself”. Then, avoidance behaviour is targeted and the patient is given constructive behavioural goals such as “I will talk to at least 2 people at the party today”. This is a form of social skills training.
Melissa consulted her GP who conducted screening tests and referred her to a psychiatrist. She was started on a low dose of Escitalopram, an SSRI, and given Alprazolam for 1 week to use if she developed anxiety. Her symptoms started reducing with medication and she was able to resume her studies after 6 weeks of treatment but still continues follow-up visits.
This article is written by Dr. Sumeet Kaur, a psychiatrist from the Early Career Psychiatrists (ECP) Chapter of the Malaysian Psychiatrist Association (MPA).
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]
References
- American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5thedition). Washington, DC: American Psychiatric Association.
- Connor, K., Kobak, K., Churchill, L., Katzelnick, D. and Davidson, J. (2001). Mini-SPIN: A brief screening assessment for generalized social anxiety disorder. Depression and Anxiety, 14(2), pp.137–140.
- Schneier, F. (2006). Social anxiety disorder. New England Journal of Medicine, 355(10), pp.1029–1036.
- Stein, M. and Stein, D. (2008). Social anxiety disorder. The Lancet, 371(9618), pp.1115–1125.