“I have to present my report in front of all my colleagues tomorrow, I am so nervous!”
“I am going to meet my new classmates soon, what if they don’t like me?”
“I don’t want to eat in front of others. People might laugh at me.”
Statements like these are often made or heard in our daily life. Different people react to social circumstances differently; some people are very confident when facing the crowd, while some are shy and nervous when being exposed to social situation. At one end, there are individuals who experience extreme fear and anxiety when they are being exposed to social situation. Chances are, these individuals are displaying the symptoms of social anxiety disorder.
Social Anxiety Disorder: WHAT?
Social anxiety disorder (SAD) is also known as social phobia. Based on the latest edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5)1, an individual has to fulfil the following criteria to be diagnosed as SAD:
DSM-5 criteria Explanation and example
1. Individual experience intense fear or anxiety towards at least one social situation that expose him or her to potential judgement by other people. (Note: In children, the anxiety is not limited to interactions with adults, but also with peers.)
Individual might experience extreme anxiety and fear towards social situations such as:
a. having to socially interact (e.g. talking with others, meeting new people)
b. being observed by others (e.g. eating, drinking)
c. performing in front of others (e.g. giving speech, performing a play).
2. Feeling of fear that his or her actions or symptoms of anxiety will be negatively judged by other people.
In social situations, individual is afraid of:
a. being judged as anxious, crazy, stupid, unlikable etc.
b. showing symptoms such as sweating, blushing or shaky that leads to negative evaluation by others
c. being humiliated, feeling embarrassed, being rejected or offending other people.
3. That certain social situation(s) almost always trigger the fear or anxiety.
The similar social situation should consistently cause fear or anxiety. However, individuals might experience different degree and form of fear or anxiety across different occasions. For example, an individual might experience panic attack during the social situation, or he or she might experience anticipatory anxiety where the intense fear or anxiety occur far before the upcoming situations (e.g. worrying for weeks before attending a social event).
4. That certain social situation(s) is avoided or is endured with intense fear or anxiety.
Individual takes effort to avoid the situation. Avoidance can be subtle (e.g. over preparing for speech to avoid embarrassment) or extensive (e.g. refuse to eat in front of people at all to avoid being negatively judged). When inevitable, he or she undergoes the situation experiencing extreme stress, fear and anxiety. Physical symptoms such as trembling, stomach-ache, headache, or dry throat are often reported when individual is enduring the social situation.
5. The fear or anxiety is disproportionate to the actual threat presented in the social situation.
Individual with social anxiety disorder might overestimate the threat of the social situation and experiencing intense fear or anxiety that is excessive when compare to the actual threat posed in the situation. For example, individual is extremely afraid of being judged as “loner” when eating alone, when actually no one is looking at him or her. When the intense fear or anxiety is caused by the actual danger (e.g. being bullied by others) in the social situation, it is not considered as excessive.
6. The fear, anxiety, or avoidance of the social situation(s) is persistent for at least 6 months or more.
Individual experience the fear or anxiety towards the social situation consistently for at least 6 months. Mental health clinicians generally use the 6 months duration threshold as a guide, where some flexibility is allowed.
7. The fear, anxiety, or avoidance has leads to clinically significant distress or has caused dysfunctional in either social, occupation, or other important areas.
The fear and anxiety has caused significant distress that interfere with the individual’s functioning in the areas of academic, occupation, relationship, or daily routine. For example, the intense fear or anxiety leads to dizziness and panic attack, or individual choose to not go to work on every Monday because he is required to present his project ideas in front of everyone. An individual who experiences intense anxiety when doing public presentation would not be diagnosed as having social anxiety disorder if this activity is not routinely encountered in the individuals’ job or education.
8. The fear, anxiety, or avoidance is not caused by any substances or medical condition.
The fear and anxiety is not the effect of any drugs, medication, or medical conditions.
9. The fear, anxiety, or avoidance is not better explained by symptoms of another mental disorder.
The fear, anxiety, or avoidance is not better explained by other disorders (e.g. panic disorder, body dysmorphic disorder, autism spectrum disorder).
10. If the individual has another medical condition, the fear, anxiety or avoidance is clearly irrelevant or is excessive.
Even if the individual has medical condition such as Parkinson’s disease or obesity, the intense fear or anxiety is not caused by it.
Social Anxiety Disorder: WHEN and WHY?
Onset of social anxiety disorder can be at any age, but most of the time it emerges in early childhood or teenage years.2,3 Up to date, exact cause of SAD is yet to be confirmed. Onset of SAD can be insidious, developing slowly or can be due to previous lived experience. Certain genetic and biological factors were found to be related with or contribute to SAD. For example, research discovered that amygdala of participants with SAD was more active than participants without SAD when they were shown aversive facial expressions. Amygdala, which is a part of brain that is responsible for detecting fear, was found to be correlated with the severity of SAD.4 Neuroendocrine mechanisms like hypersensitivity of serotonin receptors and decreased in dopamine might also contribute to SAD.2 Besides that, research found that individuals with first-degree relative that met the criteria for SAD tend to have higher chances to have the disorder.5 Although the finding propose partial role of genetic transmission, evidence suggests that certain parenting style (e.g. overcontrolling, overprotective parents) also predicts the development of SAD.6 Other than that, some individuals develop SAD as a result of experiencing a traumatic, humiliating, or shameful event.