Peter (not his real name) was a smart, savvy businessman with a PhD and a bright future. He had quickly climbed the corporate ladder, but when he was offered another promotion -- one that would put him at the top of his division -- he turned it down, jeopardizing his career. Why? The thought of being the center of attention in a major meeting, required in the new position, threw Peter into a blind, desperate panic, complete with physical symptoms like flushing, sweating, and heart palpitations.
Peter had what psychiatrists call circumscribed social anxiety disorder (SAD) -- an intense, irrational, and persistent fear of being scrutinized or negatively evaluated by other people. People with SAD, also known as social phobia, tend to be sensitive to criticism and rejection, have difficulty asserting themselves, and suffer from low self-esteem. Social anxiety disorder can be "circumscribed," like Peter's (he only feared being scrutinized at work), or "generalized" -- a much more debilitating condition that can make everything from walking to a table at a restaurant to attending your best friend's wedding a cause for sheer terror.
In February, two antidepressant drugs, Effexor and Zoloft, were added to a list of about a dozen approved medications for social anxiety disorder, sparking renewed interest in this little-known condition. Is social anxiety disorder just another name for being really shy?
Putting the Brakes on Life
Not at all, say many leading psychiatrists. "Many people are a little bit shy. If you're shy, you might be somewhat uncomfortable in situations such as going to a party where you don't know anyone, but you do it. You give yourself a push, you go to the party, after a while you relax and talk to people," says Rudolf Hoehn-Saric, MD, who heads the Anxiety Disorders Clinic at Johns Hopkins University School of Medicine. "The social phobic person, at the prospect of the same party, would be overwhelmed by such anxiety that [he or she] would have a physical reaction -- perhaps nausea, sweating, heart racing, dizziness -- and would avoid it if at all possible. It's a matter of degree."
In other words, being shy can complicate your life. Having social phobia can stop it in its tracks. "The hallmark of social anxiety disorder is that it causes impairment in your function," explains Sy Atezaz Saeed, MD, chair of the department of psychiatry and behavioral medicine at the University of Illinois College of Medicine at Peoria and co-director of the University's Anxiety and Mood Disorders Clinic. A high school student -- many adolescents have social anxiety disorder -- might be so overwhelmed by the fear of standing up to give a report that he can't complete assignments and fails classes. For Peter, the businessman, social anxiety disorder endangered his career advancement.
"I've treated patients who are very competent, but have jobs well below their capacity because they're afraid of asking for a promotion or going out and looking for a better job," says Hoehn-Saric. This might explain why some 70% of people with SAD are on the lower end of the socioeconomic scale and nearly 50% fail to complete high school.
More Common Than You Think
How common is social anxiety disorder? Figures vary, but according to the most recent studies, about 8% of the population experiences social phobia in a given year -- making it the third most common psychiatric disorder, trailing only major depression and substance abuse. It's also widely underdiagnosed, says Saeed. "In one study, less than 1% of the patients with SAD were diagnosed and treated."
Part of the problem: SAD often accompanies major depression, in a which-came-first cocktail of mental health conditions, so psychiatrists may diagnose and treat the depression without taking note of the social anxiety disorder.
When it is diagnosed and treated, though, people with social anxiety disorder can look forward to major improvements in their lives. Saeed's patient, Peter, has seen his career take off after treatment for SAD. Hoehn-Saric describes a high school student whose social phobias were so great that he couldn't even enter the cafeteria at school; after struggling at several colleges, with treatment he found a small New England institution that understood his needs and is excelling academically and socially.
Most experts advocate a combined approach, using both approved medications and what's called cognitive behavioral therapy, to treat SAD. "Medication does decrease the general anxiety and also the depression that is frequently present in people who don't function so well socially," says Hoehn-Saric. "It can combat the surge of anxiety when you go into a social situation, and if you can diminish the initial responses -- chin quivering, hands shaking and sweating, face flushing -- if you take away those triggers, the person doesn't get into a vicious cycle of embarrassment."
But that's usually not enough. Cognitive behavioral therapy for social anxiety disorder usually involves "exposure" -- confronting the patient's fears. "First, people imagine the situation, and look at it as an outsider. How realistic are their fears? They're taught to reorganize their thinking, and then they expose themselves to social situations to decrease their anxiety," says Hoehn-Saric.
Group therapy often works particularly well for social anxiety disorder, since people with SAD are usually uncomfortable in groups and being exposed to other people. "They see that other people are like them, and they're doing better now, so there's some hope for them too. And as they start to feel more comfortable in a therapeutic group setting, they can transfer that to other social situations."
It's a long process. Don't expect social anxiety disorder to disappear after eight weeks of treatment, says Saeed -- closer to eight months or a year may be more realistic. "One of the difficulties with SAD is that since people have had it for so long, they've had to start avoiding things," he says. "Even when the symptoms are under control, unless you go out and engage in the activities you've been fearing, you won't know what your response is. So ultimately you have to face your fears."