Social phobia was accorded official psychiatric diagnostic status in the United States less than 20 years ago, but has been described in the medical literature for centuries. Hippocrates described such a patient: “He dare not come in company for fear he should be misused, disgraced, overshoot himself in gestures or speeches or be sick; he thinks every man observes him.”1
This observation was made more than 2,000 years ago. Yet social anxiety disorder (SAD) was left largely unstudied until the mid-1980s.2 An estimated 20 million people in the U.S. suffer from this disorder.
What causes some people to break into a cold sweat at the thought of the most casual encounter with a checkout clerk, a coworker, or an acquaintance? Limited evidence points to underlying biological abnormalities in SAD, but there have been no conclusive findings.
Two main subtypes of SAD exist (Box 1). Roughly 25% of sufferers have discrete or nongeneralized SAD, that is, circumscribed social fears limited to one or two situations, such as speaking in public or performing before an audience. The remaining 75% suffer from generalized SAD, the more severe subtype in which all or nearly all interpersonal interactions are difficult.
Generalized SAD often begins early in life, with a mean onset at about age 15, but 35% of the time SAD occurs in individuals before age 10.3 This subtype appears to run in families, while the nongeneralized subtype does not, suggesting that a genetic inheritance is possible. From an etiological perspective, the possible effects of parenting styles of socially anxious parents, or acquisition of social anxiety conditioned by experiencing extreme embarrassment, may also contribute to the development of SAD in some people. Approximately twice as many females as males are affected, and almost all are affected before age 25.3,4 When social fears interfere with social, occupational, or family life, the affected individual is not suffering from normal "shyness," but rather a treatable anxiety disorder.
“The mind is a wonderful thing. It starts working the moment you are born, and never stops until you get up to speak in public.”
–Toastmasters slogan
DIFFERENCES AMONG SOCIAL ANXIETY DISORDER SUBTYPES
Generalized
- Most social interactions
- Early onset
- Social skills deficit
- High comorbidity
- Lower achievement
- Remission rare
Nongeneralized
- Limited fears
- Later onset
- Social skills normal
- Less comorbidity
- Less Impairment
- Remits often
The National Comorbidity Survey (NCS) estimated lifetime prevalence of SAD at 13.3% and 12-month prevalence at 7.6%, making it the third most common psychiatric disorder, following only major depression and alcohol abuse/dependence.5 Despite this high rate, SAD remains woefully underdiagnosed.
Anyone who has had to speak in public, play a musical instrument at a recital, or perform in some way under the watchful expectation of an audience has experienced anxiety as he or she anticipates the "big moment” (Box 2). Once the performance is under way, the anxiety usually lessens to a more manageable level for most people. In fact, nearly one in three Americans will admit to moderate or great fear of speaking in public.
THE CASE OF THE INHIBITED TEACHER
Mr. L, a 40-year-old eighth-grade teacher, consulted a psychiatrist because he was scheduled to be evaluated by a state education accreditation committee while teaching class. Though he had always passed these before, he had been worried sick for weeks and was experiencing panic attacks each time he thought about the accreditation visit.
He lived with his mother, had never dated, and had few friends. He was extremely inhibited outside the classroom, brought cash to stores to avoid being observed while writing a check or signing credit card slips, and avoided social gatherings outside of his church, which he attended with his mother and tolerated with distress.
Further history revealed that he had quit medical school during his third year because he had so much difficulty presenting cases to the attending on ward rounds that he chose to leave the profession in order to avoid feeling sick each morning and afternoon.
Enough people encounter the fear of public speaking to support the weekly Toastmasters meetings in most U.S. cities. Many people overcome their social anxiety about public speaking or performing with continued practice. However, those with nongeneralized SAD, who are among the most severely affected, may remain so fearful of speaking or performing under scrutiny that they avoid it at any cost—even if it means passing up a job or promotion or even choosing to change professions.
The majority (75%) of those with SAD—representing approximately 15 million individuals in the U.S.—suffer from generalized SAD, a much more severe, potentially disabling subtype. These unfortunate individuals fear and avoid most or all social interactions outside their home except those with family or close friends. When they encounter or even anticipate entering feared social situations, individuals with generalized SAD experience severe anxiety. Blushing, tremulousness, and sweating can be noticed by others, and thus are particularly distressing to those with SAD.