Social awkwardness can often stray into late teens for many youngsters, but by the time Anand (name changed) was 17 years old, his ‘awkwardness’ worsened into a condition forcing him to remain within the confines of his home all day. He found it difficult to interact with people and avoided friends and teachers. He started skipping family events and feared even stepping out for shopping.
“He avoided traveling because he was too anxious to ask for tickets. He feared that he was being judged constantly,” recalls Lakshmi Sharanya, the therapist who treated Anand. A few days later, Lakshmi diagnosed him with Social Anxiety Disorder. Lakshmi says that with increasing awareness among parents, what would otherwise have been dismissed as a kid being introverted or shy, is now being treated in all its seriousness.
The fear of being judged
The DSM-5 (Fifth edition of the Diagnostic and Statistical Manual of Mental Disorders by the American Psychiatric Association, considered the principal authority on mental health discipline) explains that SAD is the “marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.”
At the core of SAD is the fear of being judged. An individual with SAD might fear that they will be evaluated negatively, and psychiatrists diagnose them with SAD only if this condition persists for more than six months.
DSM-5 lists out several symptoms of SAD, but there are two components: The psychological component includes the irrational fear of being judged, criticised or evaluated and being too conscious about what others might think; the physiological component is about the bodily responses - palpitations, tremors and dry mouth.
Often, the person anticipates what they would feel in a social setting and decides to keep away from them altogether. That’s why they are seen as shy or introverted.
The fear within: Understanding SAD
It is easy to confuse shyness with SAD, but what sets it apart are the physiological responses. Dr PV Bhandary, a psychiatrist based in Udupi says that a shy person will not usually have palpitations or tremors in a social setting, but a person with SAD will. A shy person might be uncomfortable initially but will nevertheless make an attempt to initiate and sustain conversations. However, a person with SAD, will entirely avoid social interaction. “Consider it as a spectrum with shyness on one end and SAD on the other and shyness can act as a precursor to SAD,” he says.
Lakshmi Sharanya, who is also a clinical psychologist at Amrita Institute of Medical Sciences in Kochi, says that SAD is very common in people with perfectionist traits. Their superior standards often work against them because they feel they cannot bear the public ‘embarrassment’ of their perceived shortcomings. Dr Bhandary adds that people with other personality traits, like anxious-avoidant or obsessive-compulsive, are also at high risk for developing SAD.
SAD also has its own variants. Every person with SAD need not have similar fears. For instance, one person might fear to attend a social event with too many people, while another person with SAD could feel more fearful at a public restroom with no one in it. In fact, those with SAD are not necessarily loners – they could also have mastered ways to cover it up. Dr Bhandary points to a client who suffered from SAD but was also a famous person who gave speeches in front of huge audiences.
However, Lakshmi Sharanya points out that there is also the risk of a misdiagnosis. “Sometimes an avoidant person is believed to be suffering from SAD when it could be something else. For instance, a person with Parkinson’s disease may avoid socializing out of reasons stemming from physical tremors and it has little to do with SAD.”
What causes SAD
While at least one study has found that genetics can play a role in SAD, psychiatrists say that early childhood experiences can play a significant role in triggering SAD. It could be an insulting experience at school or unfair criticism by parents, peers or people who hold a significant position in our lives. The young child internalizes these experiences and it could later manifest in SAD.
Anand’s case is an example of how childhood experiences can lead to SAD. In his psychological assessment, it was found that as a child he was initially the teachers’ pet. He worked hard to win praise and appreciation from his teachers, but when a teacher admonished him and called him a ‘fool’, for what he believes was no fault of his, he started building up anxiety. This was the first of many such incidents which pushed him into SAD.
Substance abuse and SAD
Individuals with SAD, especially men, are also known to take to substance abuse to cope with SAD, what Dr Bhandary refers to as self-medication hypothesis. Rather than addressing the problem first hand, they choose to mask it with alcohol or other substances.
Often men approach psychiatrists only when they end up becoming alcoholics, and only then is it detected that there is an underlying mental disorder which has led to the alcoholism. But often, doctors also don’t get to the root of the disorder.
Karan (name changed) hated to eat at social gatherings and would have bouts of nausea if he was forced to eat at one. So, he took refuge in alcohol. A single peg enabled him to stay calm and have his food. This coping mechanism soon transformed into alcoholism. He was repeatedly brought to the doctors for treatment and the doctors kept missing the root cause - Social Anxiety Disorder. Alcoholism took centre-stage in the treatment. It took several false starts to finally address the problem of SAD and get the right treatment.
Psychiatrists say that they have also noticed that technology, in the form of smartphones, video games or social media, could further worsen SAD.
A key strategy to deal with SAD is Cognitive Behavioural Therapy, in which the client is helped to change the way they think. It is a form of psychotherapy which focuses on modifying emotions, behaviour and thinking. It moves beyond root-cause analysis and finds solutions.
Therapists also employ graded-level exposure, where the client is slowly acclimatized to the various triggers of SAD. This is done with a good support system to help the client get through the discomfort and be able to adapt to it. Medication is also prescribed.