Social Anxiety Disorder and Role of Mental Health Professionals

By Wasim Kakroo

NORMAL shyness is not the same as social anxiety disorder, as normal shyness is not connected with handicap or interference in most aspects of life. Social anxiety disorder can lead to educational underachievement as such children and adolescents are at a higher risk of dropping out of school early and earning lower-educational credentials. According to one study, patients with social anxiety disorder earned 10% less than the non-clinical group. Thus we can understand that the social life of such children and adolescents suffer as a result. Individuals with social anxiety disorder have fewer friends and have a harder time getting along with them on average. They have a lower likelihood of marrying, more likelihood of divorce, and are less likely to have children. Social fears can make it difficult to do things like go shopping, buy clothes, get a haircut, or use the phone. The majority of patients with social anxiety disorder do a job; but, due to their symptoms, they report taking more days off work and being less productive. People may avoid or quit jobs that require them to give speeches or perform before the public.

Social Anxiety Disorder inflicts significant economic costs on individuals, their families and carers, as well as society due to functional handicap, low educational success, loss of work productivity, social impairment, greater financial dependency, and impairment in quality of life. These expenses are much higher for those who have comorbid disorders, which are quite common in people who have social anxiety. At least one other psychiatric disease, such as another anxiety disorder, depression, or a substance-use disorder, is present in 50 to 80 percent of patients with social anxiety disorder who seek professional help.

Despite its devastating nature, social anxiety disorder is frequently misdiagnosed and undertreated, with little knowledge on its resource implications for individuals, healthcare providers, and society. Furthermore, because of its early onset and chronic nature, an untreated individual’s lifetime cost is relatively high due to the detrimental impact on productivity.

How easily is Social Anxiety Disorder diagnosed by professionals?

General physicians (GPs) frequently fail to recognise social anxiety disorder in children, adolescents and adults. This could be due to GPs failing to recognise the condition and a general lack of understanding of its severity and complexity among other factors. However, it could also be due to the general public’s lack of awareness of the problem, their avoidance of talking about their social anxiety, and the stigma related to mental health issues in general.

Because of the early age of onset and the implications on educational attainment, recognition of social anxiety disorders in educational settings is imperative. In addition to underachievement, children with social anxiety disorder may be more prone to be bullied and teased at school. Teachers and other educational professionals may be unfamiliar with how to recognise the disorder and supervise its treatment. If such people are unable to receive treatment at earliest, they may fall prey to more severe conditions and may develop comorbidities such as depression. In nutshell, social anxiety disorder may lead to significant decrease in the quality of life and thus its treatment needs to be understood in light of clinical psychology and psychiatry.

How is Social Anxiety Disorder treated by mental health professionals?

The two major modes of treatment used to treat Social Anxiety Disorder include Psychotherapy and Pharmacotherapy.

Psychotherapy:

Various behavioral and cognitive behavioral therapies have been developed through research and are used by psychologists to treat social anxiety disorder. These interventions focus on strategies that entail real-life confrontation with social settings.

1. Exposure in vivo: The concept behind in vivo exposure is that avoiding fearful circumstances is one of the most important aspects in maintaining social anxiety. The treatment entails creating a hierarchy of feared events (from least to most dreaded) and encouraging the individual to frequently expose oneself to the situations, beginning with fewer fear-provoking situations and progressing to more difficult situations as confidence grows. Within treatment sessions and through systematic homework assignments, exposure exercises involve confronting real-life social issues through role plays and out-of-office exercises. Many persons with social anxiety disorder discover that they can’t entirely avoid feared social events, so they try to manage by holding back (for example, not talking about themselves, remaining silent, or remaining on the periphery of a group) or otherwise avoiding within the setting. As a result, exposure therapists spend a lot of time during therapy detecting subtle, within-situation avoidance patterns (safety-seeking behaviours) and pushing the person to do the opposite, i.e., to work on those social avoidance patterns and expose themselves to such situations so that their mind learns how to deal with the anxiety in such situations.

2. Applied relaxation: Applied relaxation is a type of relaxation training that focuses on teaching people how to relax in everyday social situations. The treatment begins with muscle relaxation training and progresses through a number of phases that allow people to relax on cue in everyday situations. The final level of treatment involves a lot of practice with the relaxation techniques in real-life social situations.

3. Social Skills Training: Social skills training is based on the assumption that people are anxious in social situations partly because they are deficient in their social behavioural skills and need to improve these skills in order to behave successfully and achieve positive results in their social interactions. Systematic training in nonverbal social skills (for example, greater eye contact, friendly posture, and so on) as well as verbal social skills (for example, how to start a conversation, how to give others positive feedback, how to ask questions that promote conversation, and so on) is part of this training. The therapist helps the patient through role plays in therapy sessions and by providing and assessing homework assignments so that the client practices the skills that have been identified during the sessions with the therapist.

4. Cognitive restructuring: Cognitive restructuring is a strategy that is employed as a part of a variety of therapies. The therapist works with the person and helps them to identify the major fear provoking thoughts they have in anxiety-provoking social situations, as well as some of the general beliefs about social interactions that may provoke those thoughts. The person is then taught mostly verbal skills for creating alternative, less anxiety-provoking thoughts (‘rational replies,’) which they are encouraged to practise before and during social interactions. To help them in recovery, their therapist encourages them to keep thought records, which are shared with therapists during treatment sessions so that their therapist monitors the change in the thoughts and beliefs related to social situations as the therapy proceeds.

5. Cognitive behavioural interventions: It includes well recognized and manualized approaches such as cognitive behavioural interventions (CBT). Most cognitive behavioural therapies include in-vivo exposure and cognitive restructuring. Some programmes also incorporate relaxation methods training as well as social and conversational skills training. In CBT and related cognitive behavioral interventions, therapists focus on various strategies used by clients that maintain Social Anxiety Disorder in their life. These avoidance patterns include self-focused attention, distorted self-imagery, and the various safety-seeking behaviours. Techniques that aim to address these maintaining factors include training in externally focused and/or task-focused attention, and demonstrations of the unhelpful consequences of safety-seeking behaviours and replacing them with some healthy behaviors.

6. Interpersonal psychotherapy: In this type of therapy, treatment is based on a biopsychosocial model based on the proposition that the temperament that an individual is born with, interacts with early and later life experiences and may cause and sustain social anxiety disorder. The treatment is divided into three stages. In the first phase, the person is encouraged to view social anxiety disorder as an illness that must be managed rather than an indication of weakness or insufficiency in the person’s personality. In the second phase, the therapist works with the individual to address specific interpersonal issues, such as role shift and role conflicts that might have caused an impact on a person’s understanding of self and relations. During the therapy, the therapist does role plays with the client to encourage the expression of emotions and accurate communication. Patients are also encouraged to form a social network of tight, trustworthy relationships. In the third phase, the therapist and the patient discuss the progress in the therapy, discuss the conclusion of the therapeutic relationship so that the patient understands his/her role in interpersonal relations and so that the patient prepares himself for future situations and experiences.

7. Psychodynamic psychotherapy: Psychodynamic psychotherapy views Social Anxiety Disorder as the result of basic relationship conflicts, which are mostly based on early experience, especially childhood and adolescence. The goal of therapy is to assist the person recognise the link between their childhood conflicts and their present symptoms. The therapy interaction serves as a key conduit for insightful awareness and change. The symptoms of Social Anxiety Disorder are linked to the person’s underlying core conflicts in relationship with themselves as well as others. Suggestion, reassurance, and encouragement are used to help patients to work on the conflicts. Outside of therapy sessions, clients are advised to expose themselves to fearful social settings. Inner dialogues that are self-affirming are also encouraged.

8. Mindfulness training: Mindfulness training is a psychological intervention derived from the Buddhist tradition that helps people to gain psychological distance from their worries and unpleasant emotions by viewing them as observers rather than participants in their mental world. The first step in treatment is to educate yourself about stress and social anxiety. The participants then attend weekly meetings where they are taught how to meditate.

Pharmacotherapy: 

Pharmacotherapy, that is the use of medicines to treat Social Anxiety Disorder is a good option for those cases whose SAD conditions have gone beyond moderate levels or those who don’t have psychological mindedness and just want their symptoms to be treated without putting much effort into understanding the reasons behind it.

Though there are a variety of drugs available, selective serotonin reuptake inhibitors (SSRIs) are frequently used to treat chronic social anxiety symptoms. Sertraline (Paxil) or paroxetine (Paxil) may be prescribed by your psychiatrist (Zoloft). Venlafaxine (Effexor XR), a serotonin and norepinephrine reuptake inhibitor (SNRI), may also be used to treat social anxiety disorder. Your psychiatrist may start you on a low dose of medication and gradually raise your prescription to a full dose to lessen the chance of side effects. It may take several weeks to months of treatment to noticeably improve your symptoms.

If you are dealing with Social Anxiety Disorder at mild to moderate levels, your condition can be dealt with by clinical psychologist alone, however, psychotherapy is advisable even if you have severe Social Anxiety Disorder, because taking help from both psychotherapy as well as pharmacotherapy for Social Anxiety Disorder can make you understand the reasons behind it, equip you with the skills and techniques to deal with it, while medicines help you to deal with the symptoms so that the symptoms don’t bother you while you are putting efforts in psychotherapy, so that you are able to make best use of your potential and live your life productively.

The author is a licensed clinical psychologist (alumni of Govt. Medical College Srinagar). He works at Kashmir Life Line, a free mental health counseling service. Author can be reached at [email protected]

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