Social Anxiety Disorder: WHO?
In the general population, the number of female with SAD is higher than the number of male with SAD.1 However, clinical samples show equal or higher rate of male with SAD than female with SAD. The frequency of male with SAD is underreported in general population, and it is believed that it is the gender role assumption and social expectation on male that lead to their reluctance to seek for help for their condition.
In the U.S., SAD is found to be affecting 7.1% of the population.7 On the other hand, studies conducted in East Asia found a lower prevalence rate of SAD, for example 0.8 in Japan8, 0.2% in China9, and 0.3% in Korea10.
Interestingly, there is a special manifestation of SAD which is more prevalent in Japan and Korea that is known as Taijin Kyofusho (TKS) (対人恐怖症).11 Individual with TKS displays symptoms of intense anxiety about being observed by others which leads to the avoidance of social situations. One major different of TKS from typical SAD is that individual with TKS is more concern on their action might offend or embarrass other people, while individual with typical SAD is more concern on embarrassing themselves.
Social Anxiety Disorder: HOW?
Over the years, extensive studies have focused on discovering efficacious and effective treatment for SAD. Cognitive behavioural therapy (CBT) is one of the well-researched treatments supported by scientific evidence for individuals with SAD.12 In CBT, practitioners aim to help clients overcome the fear and anxiety symptoms in social situation and change the beliefs that are maintaining the behaviour.13 Different techniques would be systematically implemented to modify the current behavioural repertoires of the individual with SAD. Some examples of the techniques are:
1. Applied relaxation14: A technique of replacing previous conditioned response (fear) with new conditioned response (relaxation). Client would be taught on progressive muscle relaxation (PMR) that can be used to manage physiological arousal elicited by anxiety. Once mastered, client would be exposed to anxiety-provoking social situation (graduated exposure) and practice PMR when they are anxious.
2. Graduated exposures2: A process of repeatedly and gradually exposing clients to the feared social situation to abate the conditioned anxiety. To use this method, practitioner and client first build a fear and avoidance hierarchy. The feared social situation is ranked based on the degree of anxiety they elicit. Exposure often begins with lower-ranked social situation (situation that triggers less fear and anxiety). Once client has habituated and felt less anxious towards the situation, the client can move up the hierarchy to higher-ranked social situation (situation that triggers more fear and anxiety), and eventually to the social situation that creates most anxiety.
3. Cognitive restructuring2: An approach of altering client’s dysfunctional beliefs about the feared social situation. In this approach, practitioner work with client to identify the negative beliefs (e.g. “Everyone will laugh at me when I talk”) and replace them with more rational, adaptive beliefs (e.g. “Look at the audience. How many of them are actually laughing at you?”).
Another option of SAD treatment is pharmacological treatment. Different medications have been explored; some showed inconsistent findings, while others produce good results but was associated with some limitations. Up to date, the use of selective serotonin reuptake inhibitors (SSRI) (e.g. escitalopram, sertraline) is recommended and has showed consistent efficacy for individuals with SAD.15,16
Although both CBT and pharmacological treatment were shown to be effective for SAD, there is inadequate evidence to conclude the combination of both treatment yield better outcome.17 When the treatment is implemented independently, pharmacological treatment seems to result in more rapid improvement, but CBT may lead to enduring outcome with less risk of relapse.18
Social Anxiety Disorder: Closing Note
SAD is a chronic condition that often gets unrecognized. Unlike normative shyness, which is a personality trait, SAD might adversely affect a person’s life. Unfortunately, individuals with SAD tend to avoid seeking for help, which might leads to increased SAD severity, comorbid mental disorders (e.g. general anxiety disorder, alcohol abuse, major depressive disorder), and higher risk of suicide.13 Seeking for help is a hard, yet important step. I will end this article with a statement by Ricky Williams, a famous American football player, who was diagnosed with SAD and has made great progress after receiving treatment. “I understand that a lot of people, especially men, look up to me because of my profession, so I have a chance to reach out to people and let them know what I’ve been through and how treatment has made my life so much better. If my story can help even one person to seek help, it will feel as though I’ve scored the game-winning touchdown.”
To read more about personal experience of individual with SAD:
//www.adaa.org/living-with-anxiety/personal-stories/ricky-williams-story-social-anxiety-disorder (Ricky Williams’s story)
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