Social Anxiety Disorder:

What you should know

1

Anxiety, as such, is a normal (and common) feeling that most of us

experience at some time in our daily lives. In fact, anxiety has an important

adaptive function, allowing us to overcome stressful events and to cope with

dangerous situations. Anxiety could be job-related or perhaps due to health, dangerous situations. Anxiety could be job-related or perhaps due to health,

social, family or fi nancial matters. However, in general, these feelings are

manageable and eventually they subside as the body’s natural tendency to

reduce its stress levels takes over and the situations seem less catastrophic

than once thought.

However, for some people, anxiety associated with social situations becomes

a major negative contributor to life – an uncontrollable sensation of deep

anxiety and extreme distress in relation to social or performance-related events

(eg, attending a party, or speaking in public). This is known as Social Anxiety

Disorder. Those who suffer from Social Anxiety Disorder will often go to great

lengths to avoid the anxiety-causing situation.

Social Anxiety Disorder is a recognised medical condition. If you have Social

Anxiety Disorder, you understand fi rst-hand its debilitating effects on your life.

This booklet contains information about Social Anxiety Disorder and its

treatment, and the positive steps you can take to seek help. It is a resource

designed to help you, your family and friends to understand your illness.

Knowing more about the disorder will enable you to get the most out of

your treatment.

Introduction

2

In a word – yes. It is very diffi cult, if not impossible, to lead a life free of anxiety.

Most of us have or will at one time or another, experience a feeling of worry and

unease, which may occur for any number of reasons – such as a major project

deadline, anticipation of speaking in public, or before a job interview, important deadline, anticipation of speaking in public, or before a job interview, important

meeting, or exam. Also, it is quite normal to feel a sense of apprehension or

anticipation when going on, say, a fi rst date, or to a party where you don’t know

many people, and most people, if asked, would say they would be embarrassed

to perform on stage.

Apart from social or performance anxiety, there could be a number of other

reasons for anxiety: fi nancial obligations, the health of a family member, or

numerous other situations in our day-to-day lives.

Typically, the experience of anxiety is the body’s normal reaction to a challenging

situation. It keeps us alert in times of crisis or demand. The body may respond

with accelerated heartbeats, sweating or a fl ushed face, but mostly we manage

to calm ourselves by realising that the situation is not as dire as it seems.

Could social/performance anxiety be normal?

3

In short – yes. When harnessed properly, anxiety can lead to a positive

experience or outcome.

For example:

• the anxious feeling before a job interview or meeting with your superior at the anxious feeling before a job interview or meeting with your superior at

work may lead to better preparation, and therefore, a successful outcome

• prior to a major event, an athlete may use his or her nervousness to

advantage by training harder and using the “nerves” to kick-start a

better performance

• the discomfort associated with speaking in public can urge a person to give

their best effort on the day, and because anxiety often encourages diligent

preparation, the speaker may be able to answer diffi cult questions and

impress the audience

• fi rst-date nerves can become the subject of discussion and even laughter

during the date to help ease tension.

These are just some examples of how and why the normal experience

of social or performance-related anxiety, when managed well, can be a

positive experience.

Is anxiety useful?

4

If anxiety is normal and even useful, the question remains: when does anxiety

become a problem? In some people, the feeling of anxiety is heightened and

pervades all aspects of their lives. This extreme anxiety may occur for a very

minor or no apparent reason, or may be related to specifi c situations such as minor or no apparent reason, or may be related to specifi c situations such as

social gatherings or public performance.

When extreme anxiety becomes a signifi cant part of daily life, seems

uncontrollable or even catastrophic, leads to avoidance behaviour, and begins

to hinder the ability to work or lead a healthy life – this is a problem. In medical

terms this is known as an anxiety disorder, which can take many different

forms (see below).

Anxiety as a problem

Generalised Anxiety Disorder

An excessive and persistent worry or anxiety that does not fi t the person’s life circumstance.

Social Anxiety Disorder

An extreme fear of humiliation or embarrassment in social or performance situations and the avoidance of these situations.

Agoraphobia

Anxiety about being in places or situations such as in a crowd or in open spaces, outside the home, from which escape or egress is feared to be impossible. The situation is avoided or endured with marked distress, sometimes including the fear of having a panic attack.

Panic Disorder

Unexpected, spontaneous and recurrent panic attacks, accompanied by the fear of future attacks and avoidance of situations that are thought to have triggered a previous attack.

Obsessive-Compulsive Disorder

Repetitive, intrusive or distressing thoughts, images or impulses (obsessions), and repetitive behaviours that a person feels driven to perform (compulsions).

Post-traumatic Stress Disorder

Specifi c symptoms of stress and/or anxiety that are precipitated by exposure to a traumatic event that causes intense fear, helplessness or horror.

5

Social Anxiety Disorder is a medical condition that typically involves excessive,

uncontrollable anxiety and fear of humiliation or embarrassment in social or

performance situations, and avoidance of such situations. Examples of these

situations include public speaking, attending meetings or social events, meeting situations include public speaking, attending meetings or social events, meeting

with authority fi gures, entering a room occupied by others, or meeting with

strangers. Some people even fi nd it diffi cult to eat at a restaurant or to interact

with the attendant at the supermarket.

The extent of Social Anxiety Disorder ranges from fear of a single, discrete setting

(eg, public speaking) to a fear of virtually all forms of interpersonal contact.

Consequently, two types of Social Anxiety Disorder have been identifi ed:

(a) Generalised/diffuse social anxiety disorder – which is the fear of most social

and performance situations

(b) Non-generalised social anxiety disorder – fear of only two or three social or

performance situations

Symptoms of Social Anxiety Disorder are specifi cally related to the actual social

or performance situation or when a person remembers or anticipates such

situations. Symptoms include:

• self-consciousness or fear • palpitations

• panic • excessive sweating

• blushing • shortness of breath

• twitching • abdominal discomfort (feelings

• stammering of emptiness, butterfl ies in the

• muscle tension stomach, gas pains, diarrhoea)

What is Social Anxiety Disorder?

6

Self-consciousness or fear may occur in isolation or along with one or more

of the other symptoms.

People with Social Anxiety Disorder also exhibit avoidance behaviours.

These may include subtle “safety” behaviours during the social or performance These may include subtle “safety” behaviours during the social or performance

situation (eg, avoiding eye contact) to more extreme avoidance of all forms

of interpersonal contact outside of the immediate family.

This self-perpetuating cycle of intense anxiety and avoidance behaviours has a

strong negative effect on a person’s emotional health – making it very diffi cult

to interact well with others – and relationships and work begin to suffer.

Social Anxiety Disorder may coexist with other forms of anxiety disorders

or mental health conditions. Assessment by a healthcare professional

(GP or psychiatrist) is necessary to determine if you suffer from more than

one medical condition, eg, depression.

What is Social Anxiety Disorder?

7

The exact cause of Social Anxiety Disorder is unknown but the interaction

between genetics and the environment is believed to play a major role. Family

members of those with Social Anxiety Disorder are more likely to also suffer

from this condition. Additionally, research has shown that specifi c environmental from this condition. Additionally, research has shown that specifi c environmental

infl uences faced by individuals with Social Anxiety Disorder are associated with

the development of this condition.

The concept of an imbalance in brain chemicals possibly causing Social Anxiety

Disorder is the subject of research. The brain chemical serotonin helps transmit

nerve signals to regulate mood and emotions – an imbalance in the level of

serotonin or sensitivity to serotonin could conceivably be involved in Social

Anxiety Disorder.

Some research suggests that people with Social Anxiety Disorder may have

an overactive amygdala (the part of the brain that controls the fear response)

and therefore have an overactive fear response.

If you suffer from Social Anxiety Disorder, you are certainly not alone.

It reportedly affects up to 13% of the population at any given time. Social

Anxiety Disorder generally starts at a young age (at 10–15 years of age or

sometimes earlier). Most people wait about 15 years before seeking treatment.

What causes Social Anxiety Disorder?

8

The following risk factors may increase a person’s chance of developing

Social Anxiety Disorder. However, not everyone who has these risk factors will

develop the condition.

• Family history – greater likelihood if parents or siblings have Social Family history – greater likelihood if parents or siblings have Social

Anxiety Disorder.

• Sex – Social Anxiety Disorder is more common in females than in males.

• Environment – a number of environmental infl uences may be involved in

the development of Social Anxiety Disorder, eg, controlling or overprotective

parents, constant exposure to social anxiety in others around you, family

confl ict, or childhood sexual abuse.

• Timid temperament – children who are very shy or withdrawn and fi nd it

diffi cult to assimilate with other children are at greater risk of developing

Social Anxiety Disorder.

• Negative social or performance experience – children who are ridiculed,

bullied or teased in school, or humiliated after a performance, may be at

greater risk of developing Social Anxiety Disorder.

• Social or work demand – being burdened with the responsibility of a new or

intense social or work demand (eg, public speaking, organising a school play)

during adolescence, or a negative experience with this demand, may lead to

extreme anxiety and distress associated with the specifi c situation.

While stress has not been implicated as the cause of Social Anxiety Disorder, the

apprehension and worry regarding social/performance situations may worsen

during times of stress.

Risk factors for Social Anxiety Disorder

9

Excessive anxiety and fear of humiliation or criticism can be extremely

distressing and debilitating. The continued avoidance of the feared situation

means that over time you become even less able to face these situations.

Undoubtedly the anxiety begins to hinder the ability to lead an active and Undoubtedly the anxiety begins to hinder the ability to lead an active and

fulfi lling life. Work and family relationships suffer and you may fi nd yourself

becoming increasingly socially isolated.

While your circumstance may seem overwhelming and hopeless – it is not.

Social Anxiety Disorder is a medical condition. Treatments such as medication

and psychotherapy are available to help control your anxiety so that it is not the

major emotional contributor to your daily living.

Sufferers are often ashamed of their anxiety and this may be one reason

for the reluctance to seek help. However, it is important to regain perspective

and recognise that what you have is a medically defi ned illness – just as you

wouldn’t look down upon a person with, say, arthritis or asthma, so too you

shouldn’t be hard on yourself. Everyone deserves the best help available for

any medical condition and to be provided with the tools to try and live a

healthy and active life.

Good mental health is the key to good physical health and also determines your

ability to work and interact with others. Seeking help is the fi rst step in

the treatment strategy for Social Anxiety Disorder.

Seeking help for Social Anxiety Disorder

10

Two important questions regarding Social Anxiety Disorder are:

• what types of treatments are available and

• who should I ask for help?

There are a number of approaches to treatment (generally used in combination),

and also a variety of professionals and others who may be able to help you.

Treatment options for Social Anxiety Disorder include:

• medications

• psychotherapy

• self-help techniques

Pharmacological agents (ie, medications) are used along with psychotherapy in

the treatment of Social Anxiety Disorder.

Who can help

• GP

• Psychiatrist

• Psychologist

• Counsellor

• Family and friends

Your GP should be the fi rst point of contact. He or she may determine the type

of treatment appropriate for you and will likely recommend other healthcare

professionals as needed.

Treating Social Anxiety Disorder

11

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is a type of psychotherapy that is effective

in the treatment of Social Anxiety Disorder. CBT should be conducted by a

qualifi ed healthcare professional. qualifi ed healthcare professional.

The basic premise of CBT is the realignment of a person’s thinking to help

him or her to see the feared situation for what it really is (ie, perhaps not as

threatening as it seems). CBT also helps you to regain perspective because social

or performance situations are unlikely to change – ie, facing the fact that the

project presentation or speech will need to be performed, and exploring how this

can be done effectively by managing or controlling the associated anxiety.

CBT equips you with a number of skills:

• cognitive restructuring skills (to enable you to identify and ‘restructure’ the

catastrophic thoughts associated with the feared situation)

• social skills/training in which you are taught skills that will help you

to function in social situations

• behavioural skills that involve gradual re-entry into the feared social

situations

Relaxation training helps relieve some of the physical symptoms of anxiety such

as muscle tension, sweating, palpitations, etc. Cognitive restructuring is a tool

that assists with “clear thinking” – it allows you to restructure your thought

processes when they become catastrophic.

Exposure therapy is a key element of CBT for Social Anxiety Disorder.

Here you gradually work up to facing the situations that cause you extreme

anxiety, at fi rst perhaps through imagery, and later via actual exposure to

the situation. In this way, you become less sensitive to the anxiety-causing

circumstances and are better able to cope with them.

Psychotherapy forSocial Anxiety Disorder

12

Professional counselling

Counselling may also be helpful for Social Anxiety Disorder. Counselling

(conducted by a trained psychologist or counsellor) may be useful to help

explore the environmental issues (eg, family history, past traumatic experiences, explore the environmental issues (eg, family history, past traumatic experiences,

etc) that may have contributed to your condition or impact on your anxiety.

Counselling provides the opportunity to talk to a trained professional about your

problems, and receive objective guidance and support.

Sometimes your counsellor may suggest family or relationship counselling as

part of your therapy. The impact of Social Anxiety Disorder extends beyond

the person affected to those near and dear, who may need to understand how

you feel and come to terms with your illness. This communication is often best

achieved through interaction with a professional counsellor.

Psychotherapy forSocial Anxiety Disorder

13

Several types of drugs are available for the treatment of Social Anxiety Disorder.

Medications that may be prescribed include:

• Antidepressants

• Beta-blockers (generally for discrete circumstances of

performance-related anxiety)

After careful consideration of your symptoms, medical history, family history,

current state of health, other medications you’re taking, any allergies you may

have, your doctor will choose the treatment that best suits you, and the duration

of therapy that is appropriate.

Remember to follow your doctor’s instructions carefully. Most drugs will not

show an immediate effect and may need to be taken for weeks or months to

get the best results. To get the most out of your treatment, it is important to

discuss your expectations with your doctor. He or she will be able to inform you

realistically about the treatment and clarify any myths and misconceptions.

All medications have the potential to cause mild or serious side effects. The

experience of side effects may vary based on the individual and the medication.

If you have any concerns, discuss these with your doctor and report any side

effects that you encounter.

Finally, the treatment strategy for Social Anxiety Disorder is multi-dimensional.

Medications are not used in isolation. Drug treatments need to be combined

with psychotherapy to achieve best outcomes.

Medications forSocial Anxiety Disorder

14

While you receive treatment under the guidance of professionals, you may fi nd

it helpful to enact certain behaviours that help to re-introduce some safe social

contact into your life. Some examples of these behaviours are:

• Eat at a public venue (restaurant, café or park) with a close friend Eat at a public venue (restaurant, café or park) with a close friend

or relative

• Keep up-to-date on news or current affairs and use your knowledge to

engage in a short social conversation with a co-worker during a tea break

• Take phone messages on behalf of others and give these to them

• Make a conscious effort to contribute an idea or to ask a question

during a meeting

• Make eye contact when speaking with people or greeting them

• Ask a shop attendant a question

• Walk around outdoors and greet passers-by.

Self-help behaviours in Social Anxiety Disorder

15

There are some additional positive steps that you can take to manage your anxiety. Most anxiety-reducing self-help techniques involve calming the body and the mind. Some of these (eg, yoga, meditation and Tai Chi) originated in ancient times in Eastern cultures and are now increasingly being recognised in the Western world as benefi cial to overall health and wellbeing. Deep, controlled

breathing techniques are particularly useful in quelling anxiety.

Relaxation

Self-relaxation techniques can be learned through classes, or performed via the help of guided relaxation tapes. Consciously relaxing the body and mind helps to relax muscles and release tension from the body. This in turn calms the mind and

reduces mental worry and tension.

Meditation

This is a process of mental quietness and contemplation that may help to achieve a sense of calmness and mental poise. Find a reputable practitioner with whom you can practice guided meditation or use a guided meditation tape at home.

Yoga

Originating many thousands of years ago in India, yoga has now found a fi rmplace in the Western world. Yoga teaches you to focus on strengthening andstretching your body, strengthening the breath through deep breathing techniques, and calming the mind through meditation. You may fi nd that this helps alleviate symptoms such as fatigue, muscle tension, shortness of breath, etc.

Tai Chi

The benefi ts of this ancient Chinese practice are increasingly being recognised in the West. Tai Chi involves slow, deliberate, dance-like movements that develop strength and mental focus. Benefi ts include strengthening and mobilising joints and muscles and calming the breath.

Self-help techniques forreducing anxiety

16

Your GP, after excluding other physical causes for your symptoms (eg, thyroid

problems), may make an initial diagnosis and start treatment. Alternatively, he

or she may refer you to a psychiatrist for the initial diagnosis and treatment.

If medication is to be used, the choice of drug will be infl uenced by a number If medication is to be used, the choice of drug will be infl uenced by a number

of factors, including your symptoms, medical and family history, allergies,

concurrent medical conditions or medications, and your wishes.

It is important to take your medication as instructed by your doctor and to

discuss with him or her any concerns about your illness or its treatment.

Your doctor needs to be fully informed of your needs and concerns for you

both to be able to make a genuinely collaborative decision about the best

treatment option for you.

Most likely your GP will refer you to other healthcare professionals such as a

psychiatrist or psychologist, and/or a trained counsellor. These professionals can

help in different ways to address the core issues surrounding your anxiety and

equip you with the skills and techniques to combat your anxiety symptoms.

Your GP will want to see you regularly throughout your treatment. These

consultations provide an opportunity to:

• discuss how you are feeling and your response to treatment

• air any concerns regarding your condition or the medication, including

any side-effects

• consider whether you require any changes to treatment

• discuss any other issues or concerns including aspects of your life that may

be infl uencing your response to treatment.

What your GP can do

17

Your GP may refer you to a psychiatrist for a thorough evaluation of your

symptoms and to confi rm the diagnosis of Social Anxiety Disorder. Don’t be

alarmed if you receive a referral to a psychiatrist. He or she is a doctor who

specialises in treating mental health conditions – just as a cardiologist specialises specialises in treating mental health conditions – just as a cardiologist specialises

in problems associated with the heart.

The psychiatrist will need to know about all your symptoms and feelings, and

the length of time over which they’ve occurred. Also, he or she will take a

thorough medical and family history, and will use the information you provide

to arrive at a diagnosis of Social Anxiety Disorder (with or without other mental

health conditions). In consultation with you, the psychiatrist may prescribe

the medication that he or she determines is appropriate for you. Sometimes,

your psychiatrist may provide CBT and/or counselling as part of your therapy.

Alternatively, the psychiatrist may recommend a qualifi ed psychologist to

provide these services.

Don’t be afraid to discuss with the psychiatrist your needs or concerns

regarding your illness or treatment. You will need to return to the psychiatrist

for regular visits. Additionally your GP and psychiatrist may share responsibility

for your management.

What your psychiatrist can do

18

A psychologist is a trained healthcare professional specialising in psychotherapy

for mental health conditions. Psychotherapy used alongside pharmacological

treatments is an important part of the treatment for Social Anxiety Disorder.

A psychologist would likely initiate CBT (cognitive behavioural therapy – see A psychologist would likely initiate CBT (cognitive behavioural therapy – see

page 11) to teach you the coping, cognitive and behavioural skills required to

fi ght morbid anxiety. Additionally, the psychologist may provide psychotherapy –

where you explore and deal with the issues (such as past trauma or family

history) that may have contributed to your condition.

It is important to attend your sessions regularly and to discuss openly all aspects

of your history and illness with your psychologist. You may fi nd that you receive

‘homework’ – ie, exercises that you can practice to readjust your thinking and

behaviour. Make every effort to practice these exercises diligently and to use the

techniques you have learned whenever anxiety grips you.

Your commitment to the therapy may be a key determinant in your long-term

health and wellbeing.

What a psychologist can do

19

You may choose to see a professional counsellor (ie, someone with a

qualifi cation in counselling), or sometimes, people may turn to their minister,

pastor, religious or spiritual advisor for some preliminary counselling.

Alternatively, your psychologist may be able to provide counselling along Alternatively, your psychologist may be able to provide counselling along

with CBT.

Counselling can help identify some of the reasons for your anxiety and will likely

help your recovery and reduce the chance of your condition deteriorating.

It helps to talk to a professional about your thoughts, feelings and concerns and

to deal with any grief or trauma that you may have suffered previously.

Contrary to what some people believe, counselling is not a ‘soft option’. It takes

courage to seek help and to admit your feelings or relive past trauma. Many

people fi nd that they feel better after having discussed these things.

When receiving counselling, attend your sessions regularly so you can work

through your experiences with your counsellor and make the journey towards

better mental health.

What your counsellor can do

20

Your anxiety can be distressing for your family and friends. They may not

understand the way you react to a particular scenario and may think that

you are simply being unnecessarily shy or over-dramatic. It is confusing and

upsetting for them to see someone they care about become withdrawn. If they upsetting for them to see someone they care about become withdrawn. If they

do not realise you are ill, they may feel hurt or rejected when you refuse their

invitations to social activities, or if you exit a social situation unexpectedly.

Your family and friends need to understand that Social Anxiety Disorder is an

illness. It is a complex condition that requires different modes of treatment

to help with recovery. They also need to be aware that it may take some time

before you feel well, and that you cannot simply “snap out of” the feelings of

overwhelming anxiety. Their support and understanding will be an immense help

while you are receiving treatment.

If they are having diffi culty understanding your condition or want to learn more,

you may want to take a family member or close friend to the GP with you. They

can then help by:

• reminding you to take your medication

• encouraging you to attend psychotherapy sessions

• recommending reputable teachers for meditation/yoga/Tai Chi, etc

• accompanying you to a café or a park (when you feel ready) so you can

gradually re-integrate into society.

As you begin to feel better, you may feel like socialising again – but your friends

should realise that you will need to do things gradually, and should not feel hurt

if you decline some of their invitations. They will understand this better if you

talk to them openly about your progress and the way you feel.

What your family and friends can do

21

You may fi nd it helpful to join an anxiety support group to talk to others who

are in a similar situation – either those who currently suffer from Social Anxiety

Disorder, or those that are managing their condition well through successful

treatment. It can be reassuring to know that you are not alone and it is an treatment. It can be reassuring to know that you are not alone and it is an

opportunity to exchange ideas about techniques that can help you to feel better.

Your GP, psychologist or counsellor may be able to provide information about

support groups in your local area.

If you have access to the Internet, you will fi nd there are a number of websites

dedicated to Social Anxiety Disorder. Some of these have been developed by

people with anxiety disorders. These may be useful for information about your

illness and hints on how to manage it.

However, not all information from the Internet is reliable – discuss what you

may fi nd with your GP or your psychologist.

Patient support groups

22

Use this page to list useful addresses and telephone numbers – eg, your GP,

psychiatrist, psychologist or support group. You may also want to include

reputable Internet addresses.

Name ...................................................................................................................................................

Contact details .................................................................................................................................

Name ...................................................................................................................................................

Contact details .................................................................................................................................

Name ...................................................................................................................................................

Contact details .................................................................................................................................

Name ..................................................................................................................................................................................................................

Contact details ........................................................................................................................................................................................

Name ..................................................................................................................................................................................................................

Contact details ........................................................................................................................................................................................

Useful contacts

23

Anxiety Australia www.anxietyaustralia.com.au

HealthInsite www.healthinsite.gov.au

Panic Anxiety Disorder Association www.panicanxietydisorder.org.au

Serenity NSW www.serenitynsw.com.au

Anxiety Self Help Association

of Western Australia www.cnswa.com/asha

Additional resources

24

Please use the space below to note any questions or comments you may have

for your GP, psychiatrist, psychologist, or counsellor about your illness or the

treatment that has been prescribed.

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Notes

This patient information leafl et is published with the support of The Lundbeck Institute, Taastrup, Denmark.

Lundbeck would like to thank Professor David Castle for his valuable comments on this booklet.

©2006 Lundbeck. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form by any means, electronic, mechanical, photocopying, recording or otherwise without written permission from Lundbeck.

June 2006

This medical information booklet has been prepared by

Lundbeck Australia Pty Ltd

ABN 86 070 094 290

Unit 1/10 Inglewood Place

Norwest Business Park

Baulkham Hills NSW 2153

W60314 0406