What is Social Anxiety Disorder? – Health Matters

hi everybody I'm dr. David granite and welcome to health matters the topic on the table today is that of social anxiety disorder now at first glance it's going to sound like simple shyness but there's so much more to this it's really about how we all function and sometimes can't function in everyday settings and we have with us a true expert today dr. Marie Steen professor of psychiatry here at the University of California San Diego welcome thanks now when I was getting ready for the show I came across a quote that you have in one of the articles that you wrote from Mark Twain and I just loved it man is the only animal that blushes or needs to write and I thought that was great because we think about what our actions are like and we worry about what other people think about it I open the show by saying it sounds like shyness when you talk about social anxiety disorder but there's so much more to it can you define social anxiety disorder and as we go along we'll talk about why that's different than somebody who just is a little nervous sure the other term that people use in addition to social anxiety disorder sometimes they'll call it social phobia so people will see both terms being used and you're right it's it has an element of shyness at its core so the concern that people with social anxiety disorder have is that when they're in situations where they're around other people and there's the potential for other people to think badly of them that that's going to happen so they're afraid that if they're eating in a restaurant they're going to spill something on themselves other people are going to notice their handshake you're going to think badly of them and as a result they actually start avoiding those sorts of situations and what's different than shyness even though it has that element of shyness to it is really how severe it is for us to say somebody has social anxiety disorder these kinds of fears about being scrutinized by other people are at a point where it interferes with their life where they don't go out can't do things can't meet people can't progress in school because they reach a point where they have to present in front of groups and find out they can't do it and they actually divert and do something else so once it's the point where that severe shyness interferes with things that people do or things they want to do in the future then we say it's social anxiety disorder they're going to be people who are listening to what you said and say I get nervous before I go out when the waiter comes over and asks me what wine to order and I realize I don't know anything about wine and I'm on the spot I get a little nervous on my peer is going to judge me badly what do I do suck it up what's different about these people that it's not just that same moment that all of us have faced at one point in our lives or even face a little bit all the time I mean that's one of the things about social anxiety disorder I think on the bright side it sort of helps people understand it because we've all had experiences like that but it also can lead people to sort of say oh you know I've had that no big deal it's really a matter of severity and and pervasiveness people who have social anxiety disorder it'll be just about any situation where there's the opportunity for them to be self-conscious they are and the kinds of feelings they have anxiety can be so overwhelming that they literally just can't do it at all and so they learn that the best way for them to get by is often just to avoid completely but it is a matter of severity and that's one of the reasons I think it makes this particular disorder kind of hard to understand because people see some of themselves in it some people probably see themselves in that description because they really do have social anxiety to sort now the other thing I was struck by and preparing for the show is the sort of catch-22 of this being a little bit like what we've all touched leading to not getting diagnosed and and folks probably I there have been people who got berated or yelled at who have a problem and just felt like there was something wrong with them or that there was no help or it's gotten sort of that negative spiral that was going on and I would also think that someone who is worried about those types of situations is be less likely to to seek care to pick up the phone to make the appointment to go to the doctor to talk about these issues yeah a couple things been going on I mean we know for a fact that most people with social anxiety disorder never seek help for that problem so why is that well in part it's because often they've had it for so long most people with social anxiety disorder have had it ever since childhood they just see it as part of them it's just this is just me you know why would I go to a doctor to try and get help with this if this is just me and of course on the flip side for those people who have been brave enough and they go to their physicians and they say you know I really find I'm really uncomfortable around other people and it's stopping me from doing things up till now what most doctors would say is oh yeah we all get a little bit like that don't worry about it it's nothing so even if they've been courageous enough to seek help there hasn't been a lot of awareness in in the medical community that you know this actually is a problem for some people and it's something that we can treat I remember in medical school 20 years ago I was came across during my psychiatry rotations one of the psychiatrist said well there's Toastmasters that helps people get over those kinds of things and and those other books that have been written to help people to you know teach them look me in the eye and shake the hand and how to get up and perform we're past that what we're talking about right now or do those still have a role they do have a role I mean a lot of people will have sort of a milder form of social anxiety disorder where really can be just limited to sort of the public speaking sorts of things and in those cases Toastmasters where people learn skills and they get to practice and we're actually very good and most of the people you know that we see in our clinic and the people are participating in our research it's yes they may not be able to speak in public but that's just sort of the tip of the iceberg there is just so much of a more pervasive problem for them that Toastmasters is is not going to do the job there's a phrase I came across lost opportunity and it it touch me made me sad almost thinking about that that there are folks who just step away from opportunities because they don't even want to be in that situation yeah I mean the great example is somebody who has say the you know the academic talent to be able to go to college and they realize that because college is going to involve having to meet a whole bunch of new people getting out of maybe the the little niche of familiarity where they can function and then having to you know speak in class that they're going to be graded on that this side I'm not going to go to college and you know we've treated people who after they get treatment now maybe they're in their 40s or the 50s they get treated and there's this real sadness sort of saying I really wish I'd done this earlier on because my life would be different and we've actually even had people go back to college you know when they're 40 or 50 it's not the same for them there really is a lot of opportunity but that's one of the reasons we're trying to sort of get the word out about this problem so people know about it and seek treatment earlier I have to just give you a compliment you're very good writer and I read a lot of the things that you've written and you've written a lot about all this at one point is the Unabomber someone who you would say you know a recluse type person with social anxiety disorder and will you point out that these are people who want to actually want to be able to do it they don't want to be alone they want to have social interaction they crave it but they don't know how to do it there's a big difference between that and the the true social misfit or you know if you will right I mean there there is definitely a group of people who hate other people you know they want hurt other people and and their recluse is you know by choice because of that but people with social phobia they can be seen as being recluse is often the other way they're viewed by their peers as sometimes people will think they're snobs because you know here's somebody who doesn't sit with anybody else in the lunchroom at work doesn't seem to have very much to say very often people will say all the person's just stuck-up the truth may be that they're absolutely terrified to engage with other people in any way so there are a lot of misconceptions about this problem that continuing to talk about this disorder because I want to get to what we do about it in a little bit I grew up in a family of loud New York Jews that was what we all talked and everybody talked to their hands and did all that culturally we were sort of outgoing type of people but as I told you before the show started I would practice before all those situations to make sure I was ready for it now there are some cultures where people are generally more reserved and reticent to speak up do does the social anxiety run in families is there a cultural component to this and and and where you're raised in what part of the world you're raised and those cultural things make a big difference yeah so let me touch on the cultural part of it first we know that even in cultures where people are much more reserved so if you look at Japan there's all sorts of rules about when you speak up and what you say and when you say it even there the Japanese psychiatrists say oh we see social phobia and it turns out to be in about the same rate as it would be in America so even within these differences in cultural variations there's still some people where it's even in situations where they should be able to be open and they can't do that in terms of you say the same rate as America I'm sorry to interrupt you yeah how what percent sure so you know the rates vary a little bit depending on which study you look at but probably the most conservative the lowest rate is about 5% of people in the US have social anxiety disorder and that means that they have it at a level where it really is interfering with with their lives that's a substantial way it's one in 20 so if you look at the average classroom there's one kid sitting in that classroom it's going to have this problem yeah in fact I say to people when they try and sort of understand what this is I say think of your high school graduating class and think of the person who was the most shy person you knew the person you knew couldn't speak up in class maybe had a couple of close friends that was probably somebody with social anxiety disorder in terms of sort of the familial nature of this and really does run in families it's very clear it's also clear from twin studies that it has a strong genetic makeup to it and particularly in families where you'll see a parent with with social anxiety to sort very often they'll have one or more children with the problem well it strikes me if you have social anxiety disorder how do you go date I mean how do you even get to the point where you're married and have a child if the because the dating situation has to be somewhat nerve-wracking it is for anybody to go up to a pretty girl and talk to them and or a girl to go up to a guy and in a school situation or a social situation a bar you have to be there to meet someone how do they how do you do that yeah I mean that can be a huge problem for for people with social anxiety disorder when they're in high school and college often you know they they won't have a big social circle and they may actually not date much and we've seen people who literally married the first person they ever went out with because they said wow here's somebody who actually asked me out this is never going to happen again and you know sometimes things work out great sometimes they don't we've also seen people and you know pretty unhappy marriages were then afraid to leave them because you know if I leave know how now what that's that's a little spooky yeah the other part about the dating scene and you mentioned sort of going to to a bar or whatever the way some people with social anxiety disorder have managed to somewhat cope with the problem is they drink and they find that you know alcohol is a social lubricant it does reduce social anxiety to some extent and that's the way some people have coped and also the way that some people get into some serious problems with alcohol abuse as the internet changed this is it a safer place or a stranger place to sit and you know in the comfort of your own home and type on a computer I think what it's done is it's made it paradox thinking a little easier for people who are uncomfortable actually going out and meeting people to sit at home and stay on the Internet so I think there's been somewhat less of an impetus now for people with some people with social anxiety to sort of kind of go out meet people because it's more socially acceptable to just sit and talk on the internet and never really actually have any any face-to-face contact when you do some of your work and you know you're starting to look at the brain of folks who are in this situation what are you seeing you seeing different patterns or is there something that's truly different in the way they're processing information in their brain we know that so social anxiety disorders one of the anxiety disorders there are many others are panic disorder and generalized anxiety disorder and post-traumatic stress disorder one of heard recently is performance the formance anxiety is that in the same yes a performance anxiety gets categorized sort of within social anxiety disorder but it's it's a relatively small piece of it and most people with performance anxiety you know they wouldn't come to see me as a psychiatrist they would either go to Toastmasters or they'd take classes they might see you know sort of a coach to get over it but it is sort of a small piece of social anxiety disorder in terms of what we see in the brain we see in social anxiety disorder and some of the other anxiety disorders that some of the parts of the brain that are involved in emotion processing and emotion regulation called the limbic system and part of that includes pieces of the limbic system like the amygdala and the insula that these seem to be actually overactive and people with social anxiety disorder when they're processing emotional information and it's kind of like this emotional part of the brain doesn't have the brakes put on it in the way that it should so in dangerous situations we really want our amygdala to get activated it tells us something bad is going to happen it lets us sort of think about doing something or escaping but you don't want your brain doing that in a social situation where the danger is really only that other people you know might not like you and that seems to be one of the things that's going on and one of the areas of the brain that treatment is influenced by so it's not a choice you're hardwired this way you're certainly hardwired and we're all hardwired to be able to interact with other people and it's a good thing that were hardwired to be sensitive to what other people think otherwise we just you know I'll go out and it'd be every man for himself sometimes it feels that way sometimes it feels that way but you know we have this structure of the brain that helps us understand that it's important that we work together it's important that we affiliate but in people with social anxieties or it's like that part of the brain is just on turned on all the time and at a much higher gain that it should be now these the spectrum of social anxiety disorder from what I understand the onset is usually a teenager from 11 to 19 roughly there's sort of two groups there's about half of the people who weren't particularly shy as kids sometime in adolescence and adolescence is a time we're sort of everybody becomes more self-conscious and more self-aware and you think more about what other people think about you some people with social phobia that's where it turns on but there's about half and these are actually the people who have the most severe social anxiety disorder later in life they have always been that way let me ask them you know what stories do your parents tell you about yourself when you were a kid it's like oh well you know soon as people would come into the house you'd run upstairs and hide we couldn't get you to ever order in a restaurant you know we sort of had to bribe you to do that and it just continues for them and becomes pretty severe social anxiety disorder in adulthood do parents have trouble with their kids that way I mean if you're not one of those people who also had this sort of problem what in a household it's got to create an issue with a job it can even if the parent themselves went through it sometimes what we'll see is a parent who had social phobia and they remember how tough it was for them as kids so they try and protect their child from it and so they don't get their kids order in the restaurant and they talk to the teachers and say you know my my son has trouble speaking up in class can he just sort of get out of doing performances that's not a good thing because one of the important ways to overcome this is for people to really in sort of a very nurturing setting get pushed if they can't push themselves to do things so that they eventually become comfortable with them that's sort of part of what we do also in in that behavior therapy and that's that's exactly what I wanted to get to you next which is yeah which is what to do behavioral therapy let's start there because you just mentioned it we're finally getting around to we I hope and I really wanted to spend a good chunk of this talking convincing people that this is real because because I have a feeling that's the fear now let's tell not only is it real but there's something we can do behavioral therapy because that you'll hear the terms behavioral therapy or cognitive behavioral therapy basically this is a type of psychological treatment where people learn about the problem they get an explanation of you know why it is they feel that way when they're in social situations and they really learn the link between kind of how they feel and the way they think about social situations and how that then influences their behavior and so the big thing in social anxiety disorder is when you feel uncomfortable when you have these thoughts that people are going to think I'm stupid if I speak up you don't say anything and if you haven't done that for 10 years it becomes very difficult to overcome and so what a therapist will do in cognitive behavioral therapy is help people to kind of understand this pattern and then work with them to gradually overcome it to say okay I know you you have these thoughts when you're in these kinds of situations how realistic are the thoughts let's test it out let's ask some people whether when you say something the first thing they think is oh what an idiot and maybe those thoughts aren't that realistic and if they're not that realistic then maybe you could start practicing testing out some of these things and kind of unlearn some of the bad habits you've had and kind of learned that these things are safe to do and actually can be enjoyable that's the other part about social anxiety to sort of people even though they crave the social interaction because they know that's what people need it's been so hard for them to do that they've sometimes lost the enjoyment of doing it and part of it is them learning that hey I can actually get pleasure out of talking other people and getting to know them and then getting to know me and that makes sense what about the younger person who that kind of insight is very difficult for right so with the younger kids they don't know at all why they're not doing these things right they go to a birthday party and they can't talk to anybody and in fact I didn't mention earlier there's actually sort of a very early onset form of this disorder that's called selective mutism it can be so bad that the kids literally won't speak or can't speak at all outside of speaking to their parents and their siblings they'll go to school in kindergarten and won't say a word I have seen kids in my office as someone who specializes in pediatric field who they won't look at me they only look at their parents and they won't they won't say a word in the office I mean nothing and I'm pretty good with kids like nothing I do whoever gets them to come out they just won't even so kids like that they of course don't understand it's just you know overwhelming for them they don't know why they feel that way and so there is just more of the behavior therapy it's more okay we're going to gradually help the child feel comfortable speaking they're going to get positive feedback for it and work with them to overcome it even in those situations sometimes the behavior therapy alone doesn't work and we look at other treatments like other medical treatments and and so medical treatments start to imply medications yeah and there's a host of medications there are the old ones that I learned when I was in school that you know you take a beta blocker for stage fright quote-unquote but that's not necessarily the right thing to do for social anxiety disorder yeah so most of what people know if they hear about medications for social anxiety disorder its beta blockers and beta blockers have sort of a small role to play oftentimes performers musicians we use beta blockers reduced the racing heart if somebody has a lot of shaking it'll reduce that a little bit but for people with this more pervasive form of social anxiety disorder where even you know one on one they're uncomfortable beta blockers really don't work so what we have now and it's only been in the past 10-15 years prior to that we really didn't know how to treat social anxiety disorders so when I was doing my training as a resident in psychiatry we had really no clue how to treat this at all now we learned that some of the antidepressants work to treat social anxiety disorder and the interesting thing is a lot of people with social anxiety disorder do become depressed at some point in their lives in part because they're so they come socially impoverished they're just alone many will become very seriously depressed but we know that we can use medicines like selective serotonin reuptake inhibitors SSRIs medicines people might know include medicines like prozac or paxil actually work remarkably well for these severe kinds of social anxiety disorder so somebody sitting at home shouldn't feel like there's nothing that can be done there's actually a whole lot that can be done I mean one of the one of the reasons I like to work in this field is because we're able to help people make such dramatic changes in their lives with either the cognitive behavioral therapy or medication treatments or both it's actually really rewarding to see people change sometimes dramatically in very positive ways if you could control the world and the world at large and the medical world what would you like to see happen in this field over the next generation would be nice just for there to be more awareness about the problem I think people are starting to understand not only that this is a very common problem but for many people it's really very serious and because it affects people often so early in life it it leads it has a lot of repercussions in terms of sort of stopping people in their tracks in terms of marrying education career the lost opportunity lost opportunity and it wouldn't take a lot in terms of getting the word out about treatment we've also got to sort of learn more about the actual etiology the disorder get better treatments but sort of be at a point where people can feel confident that they could go to a doctor and ask for help and that helps going to be available for them in you and I are both professors in a medical school how much of this is taught to medical students these days I think now you know I mean I know I talk about the anxiety disorders to our medical students so they certainly hear about it and so I think things are better than they were 10 or 15 years ago and there's still you know more work to be done for someone who's sitting at home and I keep picturing somebody watching the show who do they go to first they go to their internist they go to a psychiatrist they go to a psychologist where do they turn for resources to get more information about all this yeah when most people just because of the way our healthcare system set up are going to go their primary care physician and you know they're best off if they go armed with some information because their primary care doc may or may not know something about this there are very good websites there's an organization called the anxiety disorders Association of America that has great information about social phobia and other anxiety disorders they can go to the National Institute of Mental Health website and get really good information then kind of go to their primary care doc and say you know I think I might have this is can we talk about this and or I think my child might have this or I think my child how early should a parent be thinking my four-year-old my six-year-old my 8 year old my 10 year old might have this and go to the pediatrician in this case yeah we don't have a good feel for some kids even if they're really really shy we'll just sort of outgrow it with sort of natural experiences we don't know which are the kids who really need something more intensive in the way of therapy so my recommendation is if you're concerned about your child being excessively shy go talk to your pediatrician about it pediatricians are you know generally very good at either saying let's wait and watch this or or let's do something sooner telling difference between a developmentally appropriate and developmentally inappropriate milestone yeah and sometimes it's just a matter of you know what I'm not concerned now but I do want to keep an eye on it let's come back in six months let's sort of see how things are going and see where they're at well I I can't thank you enough for coming and chatting about this because sometimes putting something in the light of day is all the difference in the world and for someone sitting at home who's not educated about this to hear about this can be the difference between them getting care or not so I appreciate you having me here thank you thanks for being out there making noise about it I hope everyone's been listening there is a line between what we all feel and what then becomes problematic when something begins to interfere with your function with your ability to do the things that you would want to do in life now it may be time to talk about getting help or chat with your physician about this in this day and age on the Internet we have great resources that you can read more about it we say it all the time here on health matters knowledge is power get armed with a knowledge about what's going on with your own health with your own attitudes with your own approaches to life and you can help yourself I'm dr. David granite and we'll look forward to seeing you again next time right here on health matters

37 thoughts on “What is Social Anxiety Disorder? – Health Matters

  • Unfortunately for me, I've learned to cope somewhat by disconnecting emotionally. I just noticed this a few weeks ago. When I talk and interact with people now it feels like I'm mimicking what I'm expected to act and respond but its not me. Hard to explain. Like I'm acting or something. And I can only do this for a max of 8.5 hours. After that I'm physically drained and literally can't function anymore 😪

  • This was super informative…I didn't even know I had SAD until my late 20's…it really has affected my life.

  • I have social anxiety disorder, have had it since I can remember. But, Cognitive Behavioral Therapy (CBT) saved my life, literally! I went from a depressed and suicidal socal recluse who was afraid of everything and everyone, to now having a steady job with a supportive boyfriend and family. If you ever get the opportunity, financial, or otherwise, take it! You won't regret it.

  • I enjoyed this. My husband has social anxiety disorder. Very informative. Please watch my videos as I am a mental health and wellness pastor. Minister Deanna Deloatch with Eloquent Speaking Consulting.

  • The main point of difference is avoidance. A shy person will go to a party, over time they will end up having fun. The person with SA wont even go to the party

  • I love these two guys! A very intelligent and compassionate discussion. Great information and very helpful ❤️

  • Having anxiety about your anxiety – this is the point where you know something has to be done. I recommend mindfulness meditation. How can we change our thoughts if we never even take the time to look at them. Observe your thoughts, know your enemy. Hypnosis can help as well. Good look to everyone.

  • The thing is tho Mr professional, human beings are cruel natured (not all) but my social Anxiety is so bad Evan when I try to face up to it like,sit in to eat my meal rather than paying and scarpering off lol people watch me and mock or laugh at me, (Not paranoia) so then I crack up worse, & yess this guy is right i dont go anywere i cant evan work its that bad,and my girl wants me to meet her family and go out places its fuckin so bad, + its like ino of other people in the area who have the right help but me oh no get to fuck,I'm close to doing something stupid but I think naa why would I want to spend my life in prison for little arseholes who will in good time receive their own karma! Speech over lol

  • Kudos for the Video! Excuse me for chiming in, I am interested in your opinion. Have you heard the talk about – Mahorrla Execute Shy Method (do a google search)? It is a good one off guide for beating social anxiety without the headache. Ive heard some interesting things about it and my friend Sam finally got astronomical success with it.

  • Even if I've finally learned to deal with situations like meeting whole groups of unknown people (with a smile on my face), it's still impossibly hard to actually appear like a professional representative of my "profession" to customers whose money demand it.

  • SAD (Social Anxiety Disorder) is the perfect acronym for this disorder that does cause sooooooo much sadness.

  • Humans learn to be social as children. Learning how to share, how to play, learning how to have conversation, etc when they are toddlers, in preschool and grade school. For some who were the only child or home schooled or badly abused at home they never develop the tools to be social with others. It is far more than not feeling comfortable with public speaking or being in crowds. It causes many of these sufferers to be isolated or feel as if they are isolated from the world, lonely, depressed, and suicidal. It causes issues with family and especially authority that can cause a person to do time in jail or prison. They desperately want to fit in and understand rules and boundaries but they lack the tools to do so. They want friends but do not know how to go from a simple introduction to a friendship and often say the "wrong" things or talk incessantly afraid of the possible uneasy silence that
    comes with some conversations. They desire friendship and to be accepted so badly that they make unwise choices in who they are "friends" with befriending those who actually CHOOSE them in order to manipulate, use or abuse because they are easy targets. Due to this they avoid other humans and sometimes live as hermits. They often lack even one friend but if they do have one they imprison that friendship with control, jealousy, and manipulation through guilt so they will be their "forever friend". They tend to have issues making meaningful long lasting relationships with other humans even though they desire it more than anything. This is a real problem that is normally dealt with when a person is a child and in the developmental stages. Dealing with this when the person is an adult and has had many more scars of abuse, neglect, loneliness, self loathing, etc is NOT something you can "cure" in a youtube video. There is a difference between having a minor social anxiety and Social Anxiety Disorders and there is no easy fix for the latter.

  • I've always been labelled as shy ever since I was little but I knew it was more than shyness. when I got to high school it got worse my friends told me I was boring and they kinda ignore me and I couldn't talk to someone to save my life, now I moved to a new high school and I'm flipping dying I don't even have any friends. If I tell my family they'll call me an idiot. My mother told me she hates hanging out with me because I suck the energy out of her because I'm not outgoing like her. social anxiety disorder flipping sucks.

  • I'm so happy I can finally name the problem I've been struggling with since 1st grade. Right now I'm following cognitive behavioral therapy. It really helps so everyone with social anxiety, please, get help.

  • That's me in a nutshell. I have clear S.A.D. and I can act, but I'll never get an Academy Award. I'll look into Dr. Murray Stein's solution. It seems he something new to bring to the table.

  • I know exactly what this is …my whole family has this …
    My father
    My mother
    My brother
    My sister
    I'm adopted …I'm a social butterfly !!!!!!!

  • I'm learning more about this Social Anxiety Disorder disease. it's crazy that I Learned more about myself. when I had psychology class for college and really exposed my behavior and I didn't even know it the whole time. Being so distant from others. I'm not paranoid like that. on certain things I can interact with other people. but it's very difficult because it's different from close Friends and opening up to them. then being hurt by bad relationships. is the nail bitter. I hate feeling Rejected from people it really sucks. and I play Football so it really don't help cuz I'm used to being around Teammates. Outside of it and talking to Pretty women I'm really nervous for totally different reasons

  • excellent interview and virtuos exposition about the subject. Thank you both…Dr. Romo (baja peninsula México)

  • what a wonderful video – even after i had retired – especially about those lost opportunities
    i sadly gave up as a medical student – even then i knew something could have been done but it was a real issue then as to who knows enough of this seriously handicapping problem to ask for help from. as i got older i developed some coping mechanisms that were only minimally effective unfortunately. it has not been really a complete loss but, boy, what if it was not there?

  • it's robbed me of my young life to the point of total exile, I can't even talk to family members without a high level of anxiety. it's a horrendous imperfection and I will on any fellow sufferers to seek help, people who falsy claim this disorder for being 'uncomfortable in front of large groups' etc are discrediting a serious condition

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