Therapy of Social Anxiety Disorder
Dr Jonathan Haverkampf
Social anxiety disorder (SAD) is also known as social phobia. Individuals feel great social stress in social situations and are inhibited in their day to day life. It is more than just shyness. According to ICD-10 guidelines, the main diagnostic criteria of social anxiety disorder are fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating, avoidance and anxiety symptoms. . It is the most common anxiety disorder with up to 10% of people being affected at some point in their lives. 
In adults, it may be tears as well as blushing, excessive sweating, nausea, difficulty breathing, shaking, and palpitations as a result of the fight-or-flight response.
Common is the fear that everyone is looking at me and thinking about what I think and how I feel. Interestingly, people with social anxiety disorder are concerned what others see in their inner life. What they feel on the inside they believe they communicate to the outside world. Individuals with social anxiety are often very sensitive, although their perception tends to be more negative than in someone not suffering from this condition. Depression with anxiety can mask as the ‘pure’ social anxiety disorder.
Interesting is that studies suggest that socially anxious individuals remember more negative memories than those less distressed. This may either have a biological explanation or be a learned phenomenon. However, since social anxieties do seem to run in families at least partially, there may be a biological explanation to it. A 2006 study found that the area of the brain called the amygdala, part of the limbic system, is hyperactive when patients are shown threatening faces or confronted with frightening situations. They found that patients with more severe social phobia showed a correlation with the increased response in the amygdala.
An important question is why I as a socially anxious person feel as the center of attention if it is not what I want, or is it? Many people with social anxieties actually want to have good relationships and are often fond of people. The problem is how they see themselves or that in many cases they cannot really see who they are. Sometimes there may also be an ambivalence in one’s relationship with people, which might be a result of personal life experiences or some unresolved conflicts from another source.
The search for identity lies at the heart of any form of social anxieties. Often, if some fundamental questions about oneself can be answered the social anxiety decreases. Fundamental questions are:
An important method in therapy to have the client imagine a situation and run through it. This helps break down the distinction between reality and the imagined world. Many people suffering from social anxieties are very sensitive, which also contributes to the symptoms. Physical symptoms often include excessive blushing, excess sweating, trembling, palpitations, and nausea. There may even be stammering and rapid speech. Panic attacks can also occur under intense fear and discomfort.
Many people with social anxieties have difficulties imagining the future because it is too painful. Here it helps to identify emotions and feeling that underlie the negative thoughts. Often the tensions and anxieties have underlying processes that need to be identified.
It is also important to deal with the losses sich SAD is also referred to as the “disorder of lost opportunities”. People avoid situations where the social anxieties cause the symptoms. In more severe cases this can mean that the individual has no romantic relationships and does not take up jobs that could be interesting and enjoyable. Here the first step it to acknowledge the problem and realize that while the person did not do what he/she might have liked, social anxiety is often a problem of not knowing what one really wants. Finding this out can be a tremendous chance.
Medication can help. From clinical experience the selective serotonin reuptake inhibitors (SSRIs), such as escitalopram or paroxetine, should be the first line. Paroxetine was for a long time seen as the preeminent drug. However, I have seen many patients doing much better on escitalopram with lower side effects.
People with social anxiety often set high standards for themselves for social situations. Since they believe they cannot reach these standards they have a lot of negative thoughts about how they do in those situations and the outcomes. The sense of failure can be reinforced in the situation by very minor mishaps, such as a stutter or notices sweating. This leads to even greater self-consciousness and the likelihood actually of sweating or stuttering increases. Anxiety can increase to panic attacks.
There is also the sense of being judge. The judgment by others gets a relatively high significance. People with social anxieties can be very competitive in professional or academic situations. It seems easier to believe the judgment of others. A good way to counter this is to explore one’s own personality a little more.
Many see the self-consciousness as a problem, being more alert to anything other people may see or perceive, but the fundamental problem is that the person does not trust what he communicates to the world, that there is not some communication that may give away something negative, and this might lead to the ultimate fear that people turn away. The ultimate fear in social anxiety is not of social situations but that relationships may turn negative or even break down. Loss of relationships and loss of control is often at the heart of social anxiety. Helping people with social anxiety means exploring new ways of communicating, so that they learn that communication and relationships are actually something quite stable.
The setting can also play a problem and may be worthwhile to thematize. Instead of making a new friend at a bar, a person with social anxiety might find this task easier to accomplish via an online friendship or dating site. As people develop a greater understanding of their wants, needs and aspirations, they should also develop a better understanding of how they interact and communicate with their environment. In an empathic and understanding therapeutic environment various angles can be explored, reflected on and discussed.
Selective Serotonin Inhibitors (SSRIs) are often used in generalized social anxiety disorders, if psychotherapy does not help fast enough or as a support. Historically, paroxetine and fluoxetine have often been used, but newer SSRIs, such as escitalopram, seem also to work. In clinical experience, some people benefit significantly from SSRIs, while others do not. One explanation is that it depends on the presence of other symptoms and psychiatric disorders, as well as how generalized the symptoms are, or how specific they apply to certain situations. Overall, there can be many different reasons, especially psychodynamic ones, that make up this diverse diagnosis, and they need to be carefully explored to increase the chances of therapeutic success.
© Dr Jonathan Haverkampf
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This paper is solely a basis for discussion and no medical advice is given. Always consult a professional if you believe you might suffer from a medical condition.
 National Institute for Health and Clinical Excellence: Guidance. Social Anxiety Disorder: Recognition, Assessment and Treatment. Leicester (UK): British Psychological Society; 2013. PMID 25577940
 Harold Leitenberg (1990) “Handbook of Social and Evaluation Anxiety”, ISBN 0-306-43438-5
 Stein, Murray B.; Gorman, Jack M. (2001). “Unmasking social anxiety disorder” (PDF). Journal of Psychiatry & Neuroscience. 3. 26: 185–9. Retrieved 17 March 2014.
 Blanco, C.; Bragdon, L. B.; Schneier, F. R.; Liebowitz, M. R. (2012). “The evidence-based pharmacotherapy of social anxiety disorder”. The International Journal of Neuropsychopharmacology. 16 (1): 235–249.doi:10.1017/S1461145712000119. PMID 22436306.
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