Monthly Archives: June 2022

Social Anxiety Disorder: A Definitive Guide

Dr. Robert F. Mullen

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Social Anxiety Disorder

Social anxiety disorder (SAD) is one of the most common mental disorders, negatively impacting the emotional and mental well-being of roughly 40 million U.S. adults and adolescents who find themselves caught up in a densely interconnected network of fear and avoidance of social situations. As the third-largest mental health care problem in the world, SAD is culturally identifiable by the persistent fear of social and performance situations.

Social anxiety makes us feel helpless and hopeless, trapped in a vicious cycle of fear and anxiety, and restricted from living a ‘normal’ life. We feel alienated and disconnected – loners filled with uncertainty, hesitation, and trepidation. Our fear of criticism, ridicule, and rejection is so severe, that we avoid the life experiences that interconnect us with others and the world. The irony is, that we have far more to fear from our distorted perceptions than the opinions of others. Our imagination takes us to dark and lonely places.

We fear the unknown and unexplored. We obsess about upcoming events and how we will reveal our shortcomings. We experience anticipatory anxiety for weeks before a situation and anticipate the worst. We feel like we are under a microscope, and everyone is judging us negatively. We worry about what we say, how we look, and how we express ourselves. We worry about what we will say, how we will look, and how others perceive us. We feel undesirable and worthless. 

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Roughly 40 million U.S. adults will experience SAD this year. The National Institute of Mental Health estimates that roughly 10% of adolescents currently experience symptoms. Statistics are imperfect for LGBTQ+ persons; the Anxiety and Depression Association of America estimates the community is twice as likely to contract it than their straight or gender-conforming counterparts. Statistics are fluid, however; a high percentage of persons who experience SAD refuse treatment, fail to disclose it, or choose to remain ignorant of its symptoms. 

SAD is ostensibly the most underrated, misunderstood, and misdiagnosed disorder. It is nicknamed the ‘neglected anxiety disorder’ because few therapists want or have the expertise to tackle it, and the massive number of revisions, substitutions, and changes in defining SAD result in the probability of misdiagnosis. Debilitating and chronic, SAD attacks on all fronts, negatively affecting our entire lived-body. It manifests in mental confusion, emotional instability, physical dysfunction, and spiritual malaise. Emotionally, we are depressed and lonely. In social situations, we are subject to unwarranted sweating,  trembling, hyperventilation, nausea, and muscle spasms. Mentally, our thoughts are discordant and irrational. Spiritually, we define ourselves as inadequate and insignificant. 

The commitment-to-remedy rate for those experiencing SAD is unexemplary ― reflective of symptoms that manifest perceptions of worthlessness and futility. SAD’s poor recovery rates mirror a general inability to afford treatment due to employment instability. Over 70% of us are in the lowest economic group.

SAD is a pathological form of everyday anxiety. Feeling anxious or apprehensive in certain situations is normal; most of us are nervous speaking in front of a group and anxious when visiting our dentist. The typical individual recognizes the normality of a situation and accords it with appropriate attention. We anticipate it, personalize it, dramatize it, and obsess about its negative implications. We make mountains out of molehills.

We are inordinately apprehensive others will think us incompetent, stupid, or undesirable. There is persistent anxiety and fear of social situations such as dating, interviewing for a position, answering a question in class, and dealing with authority. Often, mere functionality in perfunctory situations―eating in front of others, riding a bus, using a public restroom—can be unduly stressful. 

The fear that manifests in social situations can seem so fierce that many believe it is beyond our control, which manifests in perceptions of helplessness and hopelessness. Negative self-evaluation interferes with our desire to pursue a goal, attend school, or do anything that might precipitate our anxiety. We often anguish over things for weeks before they happen and negatively predict the outcomes. We avoid situations where there is the potential for embarrassment or ridicule. After a situation, our imagination creates false scenarios, and we obsess about our prior behavior.

The overriding fear of being found wanting manifests in our self-perspectives of inferiority and unattractiveness. We are unduly concerned we will say something that will reveal our ineptitude. We walk on eggshells, supremely conscious of our awkwardness, surrendering to the GAZE―the anxious state of mind that comes with the fear we are the center of attention. Our social interactions are often clumsy, small talk inelegant, and attempts at humor embarrassing. Our anticipation of repudiation motivates us to dismiss relationship overtures to offset any possibility of rejection. SAD is repressive and intractable, imposing self-destructive thoughts and behaviors. SAD establishes its authority through defeatist measures produced by distorted and unsound interpretations of reality that govern our perspectives of attractiveness, intelligence, and desirability. 

Maladaptive Self-Beliefs

Maladaptive is a term created by Aaron Beck, the pioneer of cognitive-behavioral therapy. A unique characteristic of SAD, a maladaptive self-belief is a reaction or perspective unsupported by reality. We can find ourselves in a supportive and approving environment, but SAD tells us we are unwelcome and the subject of ridicule and disparagement. SAD distorts our perception, and we adapt negatively (maladapt) to a positive situation. To analogize, if the room is sunny and welcoming, SAD tells us it is dark and unapproving. 

We circle the block endlessly before entering a situation, then end up avoiding it entirely. We try to hide in the classroom, our hearts pounding, hands sweaty, hoping we will not be asked to contribute. We lie awake at night, consumed by all the stupid things we said and did during the day. We are inordinately concerned about the visibility of our anxiety and are often preoccupied with sexual performance or arousal.

We crave companionship but shun social situations for fear others will find us unattractive or stupid. We avoid speaking in public, expressing opinions, or even fraternizing with peers. We are prone to low self-esteem and high self-criticism due to childhood disturbance which precipitates a disruption in our natural physiological and psychological development, allowing the onset of SAD. 

Then to top it off, we consistently beat ourselves up. We blame ourselves for our lack of social skills. We feel shame for our inadequacies. We guilt ourselves when we avoid getting close to someone, terrified of rejection. We know these feelings are irrational; we know we are not responsible for our emotional dysfunction. But our social anxiety compels us to self-loath and self-destruct. How did this happen to me, we ask ourselves? It originated with our Core Beliefs.

Core and Intermediate Beliefs

Core beliefs are determined by our childhood physiology, heredity, environment, information input, experience, learning, and relationships.

Negative core beliefs are generated by any childhood disturbance that interferes with our optimal physical, cognitive, emotional, and social development. Cumulative evidence that a toxic childhood is a primary causal factor in lifetime emotional instability has been well-established. Any number of things can generate a negative core belief. Our parents are controlling or do not provide emotional validation. Perhaps we were subject to gender bullying or a broken home. The disturbance can be real or imagined, intentional or accidental. A toddler who finds their parental quality time interrupted by a phone call can feel a sense of abandonment, which can generate core beliefs of unworthiness and insignificance. This is important when it comes to attributing blame or accountability for our SAD because of the possibility no one is responsible; certainly not the child. 

SAD senses our vulnerability and onsets in adolescence. A combination of genetic and environmental factors drives SAD. Researchers recently discovered a specific serotonin transporter gene called ‘SLC6A4’ that is strongly correlated with susceptibility to the disorder. SAD can linger in our system for years or even decades before asserting itself. 

Core beliefs remain as our belief system throughout life. They mold the unquestioned underlying themes that govern our perceptions. Even if a core belief is irrational or inaccurate, it still defines how we see the world. When we decline to question our core beliefs, we act upon them as though they are real and true.

Core beliefs are more rigid and exclusive in individuals with social anxiety because we tend to store information consistent with negative beliefs and ignore evidence that contradicts them. SAD generates a cognitive bias—a subconscious error in thinking that leads us to misinterpret information, impacting the rationality and accuracy of our perspectives and decisions. 

Negative core beliefs fall within two categories: self-oriented (I am unlovable, I am stupid) and other-oriented (You are unlovable, you are stupid). Individuals with self-oriented negative core beliefs view themselves in one of four ways: 

  • Helpless (I am weak, I am incompetent)
  • Hopeless (nothing can be done about it)
  • Undesirable (no one will like me)
  • Worthless (I don’t deserve to be happy).

These beliefs can lead to fears of intimacy and commitment, an inability to trust, debilitating anxiety, codependence, aggression, feelings of insecurity, isolation, a lack of control over life, and resistance to new experiences.

We are not defined by our social anxiety,
but by our character strengths, virtues, and attributes.

Individuals expressing other-oriented negative core beliefs view people as demeaning, dismissive, malicious, and manipulative. We tend to blame others for our condition, avoiding personal accountability (I can’t trust anyone). This generates serious anxiety towards situations we perceive as potentially dangerous, causing us to avoid them in anticipation of harm. (A ‘situation’ is defined as the set of circumstances ̶ the facts, conditions, and incidents affecting us at a particular time in a particular place. For social anxiety disorder, situations are the places that generate discomforting anxiety or stress such that it impacts our emotional well-being and quality of life.)

So, we accumulate negative core beliefs due to childhood disturbance and other early-life experiences. They influence our intermediate beliefs which develop our adolescence. The onset of SAD aggravates our negative self-beliefs and images, which generate the fears and anxieties of a situation that form our automatic negative thoughts (ANTs). A corresponding intermediate confirmation of the core belief, I am undesirable, might be,  I am unattractive and fat. A corresponding irrational intermediate resolution might be, If I diet and have my nose fixed, I will be desirable

The negative cycle we are in may have convinced us that there is
something wrong with us. That is untrue. The only thing we may be
doing wrong is viewing ourselves and the world inaccurately.

Intermediate beliefs are the go-between our core beliefs and our automatic negative thoughts (ANTs). Despite similar core beliefs, we have varying intermediate beliefs; they develop by way of ousocial, cultural, and environmental experiences ― the same things that make up our personality.

Intermediate beliefs establish our attitudes, rules, and assumptions. Attitude refers to our emotions, beliefs, and behaviors. Rules are the principles or regulations that influence our behaviors. Our assumptions are what we believe to be true or real which, in SAD, are irrational and cognitively distorted. Dysfunctional assumptions caused by our negative intermediate beliefs, and consequential to our negative core beliefs, generate our ANTs. Even when we know our fears and apprehensions are irrational, their emotional impact is so great, that our dysfunctional assumptions run roughshod over any healthy, rational response. 

Automatic Negative Thoughts

Automatic Negative Thoughts (ANTs) are the involuntary, anxiety-provoking thoughts that occur in anticipation of or reaction to a feared-situation. They are unpleasant expressions of our anxieties and apprehensions ― manifestations of our irrational self-beliefs about who we are and how we relate to others, the world, and the future. (I am incompetent; No one will talk to me; I’ll say or do something stupid; they’ll reject me.) They are our predetermined assumptions of what will happen in a situation. 

ANTs are the expressions of our dysfunctional assumptions and distorted beliefs about a situation that we accept as true. For example, the Situational automatic negative thought I am ugly and fat and no one will like me might result from the core belief I am undesirable, and the intermediate belief I am unattractive. This negative self-appraisal can elicit an endless feedback loop of hopelessness, worthlessness, and undesirability, leading to substance abuse, eating disorders, anxiety, depression, and low self-esteem. 

ANTs are cognitively distorted emotions that can lead to maladaptive behaviors. 

Cognitive Distortions

Cognitive distortions are the exaggerated, or irrational thought patterns involved in the onset or perpetuation of anxiety and depression. They are thoughts that cause us to view reality inaccurately. We all engage in cognitive distortions and are usually unaware of doing so. Cognitive distortions reinforce or justify our negative thoughts and behaviors. SAF convinces us these false and inaccurate reactions are the truth of a situation. 

Cognitive distortions define the ANT. I am ugly and fat and no one will like me is a distorted and irrational statement. It is Jumping to Conclusionsassuming we know what another person is feeling and thinking, and why they act the way they do. There is also Personalization, and Labeling-Mislabeling distorting the statement. Cognitive distortions tend to blend and overlap like the symptoms and characteristics of many dysfunctions. 

Thirteen Definitive Cognitive Distortions

Prevalent in social anxiety disorder, ANTs are irrational, perceptual, and self-destructive. To challenge them, we need to interrogate them to understand their structure. Why do we have these self-destructive thoughts and where did they come from? Without a clear inventory of the causes and consequences of our negative thoughts and behaviors, we do not have a chance of defeating them.

Anxiety is an abstraction; it has no power on its own.
We fuel it, giving it strength and power.

Love and Friendship

In unambiguous terms, the desire for love is at the heart of social anxiety disorder because of our inability to establish and maintain healthy relationships. Our fear of rejection makes social interconnectivity challenging. Our compunction to reject to offset the possibility of rejection is borne by our perception of undesirability. We crave companionship but shun the possibility due to the fear of appearing unlikeable, stupid, or annoying, which limits our potential for comradeship. Our low self-esteem and high self-criticism keep us from fraternizing with peers, and this avoidance prevents the enjoyment of being with others who share our hobbies and interests. 

Friendship. Aristotle called philia one of the most indispensable requirements of life. A healthy friendship is a bonding of individuals with mutual experiences―a platonic affection that subsists on shared experience and personal disclosure. A core symptom of SAD is the fear of revealing something that will make us appear stupid or undesirable. Even the anticipation of interaction causes physical and emotional anxiety because of our anticipation of being found wanting.

Physical/Emotional. Eros is reciprocal feelings of shared arousal between people physically attracted to each other, the fulfillment expressed by the sexual act. Our dysfunctional self-image of unlikability, coupled with fears of intimacy and rejection, challenges our ability to establish and maintain romantic relationships. Studies show that, due to our fear of intimacy and sexual incompetence, we experience less sexual satisfaction than non-anxious individuals 

Unconditional. Through the universal mandate to love thy neighbor, the concept of agape embraces unconditional love that transcends and persists regardless of circumstance. To love unequivocally, one must self-love in the same fashion, a quality challenged by our symptomatic self-disparagement and lacuna of self-esteem.

Family. The disruption in our natural human development due to childhood disturbance and subsequent onset impedes satisfaction of physiological safety and belongingness and love. As a result, familial love and protection, vital to the healthy development of the family unit is severely impacted, challenging our ability or willingness to recognize and embrace the family unit. 

Playful and Provocative: Our conflict with the provocative playfulness of ludus is evident in our fears of criticism and rejection. We do not find social interaction pleasurable, always expecting the worst. Our self-perceptions of inadequacy generally manifest in awkward and inappropriate social behavior 

Practical relationships are formed by mutual interests and goals securing a working and endurable partnership. They endure through rational behavior and expectation―a balanced and constructive quality counterintuitive to someone whose modus operandi is discordant thought and behavior. The pragmatic individual deals with relationships sensibly and realistically, conforming to typical standards of conduct. Our symptomatic fears are irrational and cognitively distorted 

There is a large body of research linking healthy relationships with positive mental and physical health outcomes. Productive associations lead us to the recognition of our value to society and motivate us toward building communities for the welfare of others. These relationships are developed through social connectedness ― a central psychological requirement for better emotional development and wellbeing. Social connectedness is strongly associated with our level of self-esteem.

Comorbidity and Misdiagnosis

SAD is routinely comorbid with depression and substance abuse. It shares symptoms and characteristics with avoidant personality, panic, generalized anxiety, bipolar personality, obsessive-compulsive, dependent personality, histrionic personality, post-traumatic stress, and eating disorders.

Coupled with the discrepancies and disparity in SADs definition, epidemiology, assessment, and treatment, mainstream medical authorities point to the poor reliability of conventional psychiatric diagnosis. A recent Canadian study reported, that of 289 participants in sixty-seven clinics meeting DSM-IV criteria for SAD, 76.4% were misdiagnosed. The Anxiety Institute in Phoenix reports an estimated 8.2% of clients had generalized anxiety, but just 0.5% were correctly diagnosed. Experts cite the mental health community’s difficulty distinguishing the symptoms and traits of dysfunctions or identifying specific etiological risk factors due to the DSM’s failing reliability statistics. 

The DSM changes drastically from one edition to the next, while the American Psychiatric Association swears by its credibility. Criteria change with each edition, often without evidence that the new approach is better than the prior one. The abundant revisions, substitutions, and changes from one edition to the next is never universally accepted. Psychiatrists, psychologists, and researchers who specialize in or survive by funding are justifiably protective of their territory. Even under the best circumstance with a knowledgeable and caring clinician, it is difficult to get a proper diagnosis. 

But there is hope. We can learn to moderate those fears and anxieties that impact our emotional wellbeing and quality of life. A comprehensive recovery program guides us through the process of proactive neuroplasticity to restructure our neural network from the years of negative self-beliefs to an appreciation of our value and significance. An integration of science and east-west psychologies is necessary to capture the diversity of human thought and experience in recovery. Science gives us proactive neuroplasticity and psychobiography; cognitive-behavioral self-modification and positive psychology’s optimal functioning are western-oriented; eastern practices provide the therapeutic benefits of Abhidharma psychology and the overarching truths of ethical behavior. Included are targeted approaches to help us rediscover and reinvigorate our self-esteem.

Recovery takes persistence and perseverance to endure the deliberate, repetitive input of information necessary to compensate for years of negative core and intermediate self-beliefs. However, once we begin the process, progress is exponential. It is physiologically and psychologically felt as we implement and experience the tools and techniques of recovery.

SAD Symptoms, Fears, and Apprehensions

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