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Some people are afraid to leave their homes. Others are stuck in dead-end jobs. Too many are too afraid to participate in the simplest of social encounters. Hearts race and pulses pound from the constant fear of judgement, embarrassment and humiliation.
This is the reality of social anxiety disorder, one of the most common — yet misunderstood — anxiety problems.
Social anxiety disorder affects an estimated 15 million Americans. New evidence shows that a gene that transports serotonin — a brain chemical that helps with stabilizing mood, appetite and sleep — was associated with the disorder, according to a study published in the journal Psychiatric Genetics. Although more work needs to be done, researchers hope ongoing research will help with earlier diagnosis.
More Than Shyness
Most of us have felt some anxiety in a social encounter, whether at work or at a party. But for those with SAD, the anxiety is overwhelming and layered with the constant and irrational thoughts of not being good enough and not being accepted. For a species that needs to connect with others, social anxiety can make life incredibly tough.
“Humans are mammals and by nature we are social creatures who want to belong, so having high levels of distress around social situations can be horribly debilitating,” psychiatrist Dr. Niranjan Karnik of Rush University Medical Center in Chicago told TODAY.
“Very simply, social anxiety disorder is not shyness,” said Dr. Stefan Hofmann, a professor of psychology and director of the Social Anxiety Program at Boston University’s Center for Anxiety and Related Disorders. “Being shy is a personality trait, not a mental health disorder.”
Indeed the symptoms of SAD are extreme. Minds buzz with self-doubts, and fear of humiliation and embarrassment. People worry about offending others and over-analyze social situations. Some may have panic or anxiety attacks.
These unfounded fears can affect everything from careers to the most common of social interactions like enjoying a meal at restaurant or even returning something to a store.
“They think they are being judged and feel stupid, worthless and powerless,” Hofmann said.
Early onset, late diagnosis for many
Although SAD generally begins in adolescence, about 36 percent of people don’t report symptoms for 10 or more years, according to the Anxiety and Depression Association of America.
“Speaking as a clinician and having worked with many socially anxious people, a later diagnosis is overwhelmingly their story,” Larry Cohen, a cognitive behavioral therapist practicing in Washington, D.C. told TODAY.
Part of the issue is that often parents and other adults may view the angst of adolescence as just a normal part of growing up. Compounding that issue is that school and social situations are highly structured, even throughout the college years. It’s when people enter the job market they realize their fears are holding them back, said Cohen, director of socialanxietyhelp.com.
For a diagnosis, a child’s fear of humiliation during social encounters must be so severe it interferes to a high degree with normal functioning, according to the ADAA. And like adults, kids with the disorder will go to great lengths to avoid situations causing anxiety, said cognitive behavioral therapist Jennifer Shannon, author of Don’t Feed The Monkey Mind, The Anxiety Survival Guide For Teens and The Shyness and Social Anxiety Workbook for Teens.
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This can be especially tough during adolescence, since “it’s a time when children move from their parents to their peers and then from their peers to the big world,” Shannon, whose daughter developed severe SAD during middle school, told TODAY. Unless they get help, kids with SAD “are going to be delayed in that way."
What causes anxiety disorders
Although researchers are unraveling more clues, they agree that both genetics and environment play a role. Since anxiety disorders often run in families, it may be inherited. But scientists don’t yet fully know how much of this heritability is due to genes or learned behavior.
The brain structure called the amygdala also can play a role since it controls the fear response. And kids who may have experienced bullying, rejection or other negative situations may also be at greater risk of developing SAD, according to the Mayo Clinic.
At greater risk for other issues
Having SAD does put a person at risk for other conditions, especially other anxiety disorders like generalized anxiety disorder or panic disorders. It can also increase risk for substance abuse. But by far the most prevalent problem is depression, though not everyone who has SAD becomes depressed.
Effective treatment — facing your anxiety
While some cases of SAD may require medication — generally selective serotonin reuptake inhibitors like Paxil — most patients benefit from cognitive behavioral therapy (CBT.)
In fact, CBT used alone, may be a more effective long-term treatment for social anxiety disorder than medication alone or a combination of the two, according to a study published in the journal Psychotherapy and Psychosomatics.
In about 12 to 16 sessions CBT therapists will work with patients to develop goals and then their way of thinking is put to the test with patients being gradually exposed to situations that make them anxious.
One important exposure is the so-called “mishap” exposure, which happens later in treatment. These often-scripted social exercises are worst-case scenarios like going to a drugstore and asking for the smallest size condom, going to a bookstore and asking for a book on sex, or even singing in public, among others tailored to a person’s fears, Hofmann said.
What patients discover can be life-changing.
“Patients worry about people noticing them or thinking they’re stupid and what they find out is that sometimes people don’t even look at them when they are doing something odd or awkward or they find out people can be very kind,” he said. "Patients with SAD don’t need to suffer. There is such effective treatment.”
All photographs featuring model Emily Terrett are by Jasmine Kate Blanchard, 19, as part of a series exploring what it feels like to live with anxiety and panic disorders. For more go to Jasmine Kate Photo.