Exploring the Recent Rise of Social Anxiety Disorder

The Telltale Signs

An uncomfortable flutter of the heart…sweaty palms…an uneasy turning of the stomach... Although they present with similar symptoms, experiencing anxiety and having an anxiety disorder are two different things. For example, someone might experience a jolt of nervousness when standing in a large, bustling crowd - but not every person who feels that jolt will have social anxiety disorder. While there are a variety of specific differences that set the two conditions apart, one of the main determinants is how frequently and consistently one’s anxiety is experienced. For a person to be diagnosed with social anxiety disorder (SAD), their anxiety surrounding social situations must persist for at least six months and cause them significant distress or impairment; they must also show other qualifying symptoms, such as fear that their behavior will be judged or cause them humiliation, and that social situations are either avoided or endured with great fear.[1] Notably, recent studies have found that the number of people meeting this criteria/who do have social anxiety disorder has been steadily increasing. 

THE RISE OF SOCIAL ANXIETY DISORDER

Not only is social anxiety disorder becoming increasingly common each year, its prevalence is growing fast. Approximately 15 million adults in the United States are diagnosed with social anxiety disorder every year, totaling about 7.1% of the population.[2] As staggering as that number is, it’s likely that the number of individuals afflicted with social anxiety disorder is even higher than the number of those officially diagnosed. While the afore-mentioned statistic only represents adults, social anxiety disorder is actually more common among teens and adolescents. According to the Anxiety and Depression Association of America (2022), in most cases of social anxiety disorder, the individual began experiencing symptoms when they were only around 13 years old.[3] Furthermore, 36% of those who have social anxiety disorder report that they experienced symptoms for ten years or more before seeking help.[4] Combined with the fact that many people never get their social anxiety disorder diagnosed,[5] it’s likely that the number of people with social anxiety disorder is much higher than currently on record.

Jeffries and Ungar (2020) conducted a self-reported study of nearly 7,000 individuals, aged 16-29, across seven countries selected for their cultural and economic diversity: Brazil, China, Indonesia, Russia, Thailand, the United States, and Vietnam. They found that 36% of participants met the threshold for social anxiety disorder.[6] Despite previous research showing the U.S. had a 12% lifetime prevalence rate of SAD in 2005,[7] just fifteen years later Jeffries and Ungar found that participants in the U.S. reported the highest rate of this disorder - nearly 58%. Conversely, participants in Indonesia reported the lowest rates in the study, at 22.9% (which is still remarkable at nearly 1/4 of that cohort).[8] 

It’s necessary to emphasize that Jefferies and Ungar’s study did not only ask participants whether or not they had social anxiety; they were also asked to rank statements describing common thoughts and fears experienced by those with SAD, based on how true the statement was for them. For example, statements participants were asked to rank included:[9]

• “I get nervous if I have to speak with someone in authority.” 

• “I feel tense if I’m alone with just one other person.” 

• “I feel I’ll say something embarrassing when talking.” 

As such, they were not only able to consider the amount of people who recognized themselves as having SAD, but also determine how many people did not consider themselves as having SAD yet still met the benchmarks to qualify. According to their findings, 18% of those interviewed claimed that they did not have SAD, but still exceeded the threshold needed to qualify. This statistic highlights the prevalence of SAD and how people may be experiencing it, but don’t recognize it, or view themselves as someone who does not have it.[10] Possible universal reasons for this situation include: 1) a lack of understanding what SAD is and/or how it presents and 2) cognizance of a perceived lack of societal acceptance of the disorder and subsequent denial of the condition.

WHY IS IT RISING?

There is no simple answer for what’s causing social anxiety disorder to increase in prevalence the way it has been, as dozens of factors are at play. One of the most prominent among these is the rise of social media. Because social media inherently offers us so many methods for connection that don’t require any face-to-face interaction, our over-reliance on it is causing us to become more socially anxious every year.[11] This is especially relevant when it comes to younger generations, who have increasingly liberal access to social media at younger and younger ages. With this shift toward virtual interaction during stages of life where we are developing our social functioning skills and abilities, the growing prevalence of social anxiety disorder in children and adolescents seems to be a natural consequence.

Fischler (2021) notes that another potential contributor to the rise of social anxiety disorder is that, for much of the population, there is less of a pressure for survival than there have been in previous generations. While not true in every case, it is generally (comparatively) easier to access food, water, and other necessities than it has been within the last few generations. Because of this, people’s attention has tended to shift more toward material goods, since there is, at large, less concern about where the essentials will come from.[12] Fischler adds this higher emphasis on material goods, money, and social appearance have a documented link to anxiety and depressive symptoms, and thus can be linked to the increase in SAD.[13]

The recent pandemic has also contributed to the growing prevalence of SAD. Much like the increasing commonality of social media, extended quarantine situations enacted during the pandemic resulted in people either not being able to normally socialize, or having to socialize through technology, such as via Zoom meetings or social media. People have grown accustomed to not having to interact in person; now that the public is starting to open again and business are returning to on-ground work policies, many are struggling to acclimate.[14] This is especially true of children who have, to some degree, grown up in the pandemic, since they had less opportunity to socialize than children in the generations before them.[15] Medina (2021) notes it is expected that young students who are experiencing in-person education for the first time will have much higher levels of anxiety about their schooling than previous generations, mainly because of the increased socialization required.[16]

WHO DOES IT AFFECT?

While there is no one clearly defined profile for the type of person who will develop social anxiety disorder, research has found that certain demographics have a higher likelihood of developing this disorder than others. Jefferies & Ungar (2020) note that those who are unemployed, have lower educational levels, and/or live in rural areas are more-likely to present with SAD. Conversely, the prevalence rates of social anxiety disorder are the lowest in low-income countries, and the highest in high-income countries,[17] despite the fact that it’s more common in individuals who are unemployed and have lower educational levels.

Gender, too, can play a role in the development of social anxiety. Females are more likely to qualify for social anxiety disorder than males[18] and report a higher number of social fears.[19] Further, the ways in which social anxiety manifests are often also affected by gender. Women are more apt to experience social anxiety in a professional setting than men are; they’ll be more likely to be anxious about speaking to authority figures or going through the process of interviews.[20] Men, on the other hand, are more likely to have social anxiety around issues such as dating.[21] There is also a difference in comorbidity based on gender, with men more likely to have comorbid externalizing (observable) disorders, while women are more likely to have comorbid internalizing disorders.[22]

However, possibly the clearest trend in the increase in prevalence of social anxiety disorder is age. On average, younger demographics, such as children and teens, are more likely to meet the benchmark for social anxiety disorder than older adults. Jefferies & Ungar (2020) found that 90% of new cases of social anxiety were reported to have occurred by the time the individual reached 23 years old,[23] with additional contributing factors comprising a higher reliance on the individual’s family unit as well as greater emphasis on peer acceptance.[24]

HOW CAN WE TREAT IT?

In most cases, social anxiety disorder is treated through talk therapy, medication, or a combination of the two. Most commonly, cognitive behavioral therapy (CBT) is used as the primary method of treatment.[25] Through CBT, the individual learns different ways of thinking about the difficulties that they face and find different (generally more productive) ways of behaving and reacting to troubling situations. Although it isn’t a quick-fix solution, CBT is considered to be the most effective treatment option for those with social anxiety disorder. In cases where an individual is prescribed medication to help mitigate symptoms of their social anxiety, they will be in the form of antidepressants, beta blockers, or anti-anxiety medications.[26]

If you are experiencing symptoms of anxiety or social anxiety, please reach out to a licensed mental health professional for guidance and treatment options.

Contributed by: Jordan Rich

Editor: Jennifer (Ghahari) Smith, Ph.D.

1 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental 

disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

2 Anxiety and Depression Association of America. (2022, October 28). Anxiety Disorders - Facts and Statistics. https://adaa.org/understanding-anxiety/facts-statistics

3 Ibid.

4 Ibid.

5 Jefferies, P., & Ungar, M. (2020). Social anxiety in young people: A prevalence study in seven countries. PLoS ONE, 15(9), 1–18. https://doi-org.baypath.idm.oclc.org/10.1371/journal.pone.0239133

6 Ibid.

7 Kessler, R.C., Berglund, P., Demler, O., Jin, R., Merikangas, K.R., Walters, E.E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry, 62(6), 593-602. 

8 Jefferies & Ungar (2020)

9 Ibid.

10 Ibid.

11 Ibid.

12 Fischler, S. (2021). The Rise Of Anxiety Over The Past 100 Years. CBT Baltimore. 

https://www.cbtbaltimore.com/the-rise-of-anxiety-over-the-past-100-years/

13 Ibid.

14 Medina, E. (2021). How Young People’s Social Anxiety Has Worsened in the Pandemic. The New York Times. https://www.nytimes.com/2021/09/27/us/social-anxiety-pandemic.html

15 Ibid.

16 Ibid.

17 Stein, D. J., Lim, C. C. W., Roest, A. M., de Jonge, P., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Benjet, C., Bromet, E. J., Bruffaerts, R., de Girolamo, G., Florescu, S., Gureje, O., Haro, J. M., Harris, M. G., Yanling He, Hinkov, H., Horiguchi, I., Chiyi Hu, & Karam, A. (2017). The cross-national epidemiology of social anxiety disorder: Data from the World Mental Health Survey Initiative. BMC Medicine, 15, 1–21. https://doi-org.baypath.idm.oclc.org/10.1186/s12916-017-0889-2

18 Jefferies & Ungar (2020)

19 Asher, M., & Aderka, I. M. (2018). Gender differences in social anxiety disorder. Journal of Clinical Psychology, 74(10), 1730–1741. https://doi-org.baypath.idm.oclc.org/10.1002/jclp.22624

20 Ibid.

21 Ibid.

22 Ibid.

23 Jefferies & Ungar (2020)

24 Ibid.

25 National Institute of Mental Health. (2022). Social Anxiety Disorder: More Than 

Just Shyness. https://www.nimh.nih.gov/health/publications/social-anxiety-disorder-more-than-just-shyness

26 Ibid.

Seasonal Affective Disorder: Weathering the Storm in the PNW

Seasonal Affective Disorder

It’s that time of year again – Daylight Saving Time has ended and winter is a stone’s throw away, prompting the skies to gray and darken earlier. Along with the seasonal and time shifts, tend to come bleaker moods.

Seasonal affective disorder (SAD) is a form of depression also known as seasonal depression or winter depression. The Diagnostic Manual of Mental Disorders (DSM-5) identifies SAD as “Major Depressive Disorder with Seasonal Pattern.”[1] This disorder is particularly commonplace in the Pacific NorthWest, with its relentless rain and gray skies so famous that paint manufactured dubbed one hue “Seattle Gray.” If you’re curious what it looks like – just glance to the sky most days in winter in the PNW and you’ll know. Notably, the National Oceanic and Atmospheric Administration (NOAA) finds Seattle has some of the cloudiest weather in the country, with an annual average of 71 clear days, 93 partly cloudy and 201 cloudy.[2]

SAD is more than just “dreary winter blues.” Symptoms can be distressing and overwhelming to the point that they interfere with daily functioning. Roughly five percent of adults in the U.S. experience SAD, with durations lasting typically 40 percent of the year; symptoms tend to peak in January and February.[3]

Research has found shorter daylight hours and less sunlight in winter is linked to a biochemical imbalance in the brain. People can experience a shift in their biological internal clock/circadian rhythm that can cause them to be out of sync with their daily schedule.[4] The sleep-related hormone, melatonin, also has been linked to SAD as one’s body naturally increases melatonin production when it's dark; as days become shorter and darker, people have comparatively high levels of melatonin during normal wake-hours.[5] But for our sleep-wake cycle, it's important to pay attention to the fundamentals to those processes that regulate sleep. We have a circadian system that under normal circumstances, is very effective in promoting sleep at nighttime and wakefulness during the daytime.[6] In areas of higher latitudes (note: the PNW) where daylight hours wane in the winter, this disorder is more prevalent.[7] 

SYMPTOMS AND DIAGNOSIS

According to the American Psychiatric Association[8], the two main/common symptoms of SAD include:

• fatigue (even with increased sleep)

• weight gain associated with overeating and carbohydrate cravings.

Additional symptoms of SAD are similar to those of major depression and can vary from mild to severe, such as:

• Feeling sad or having a depressed mood

• Loss of interest or pleasure in activities once enjoyed

• Changes in appetite; usually eating more, craving carbohydrates

• Change in sleep; usually sleeping too much

• Loss of energy or increased fatigue despite increased sleep hours

• Increase in purposeless physical activity (e.g., inability to sit still, pacing, handwringing) or slowed movements or speech (these actions must be severe enough to be observable to others)

• Feeling worthless or guilty

• Difficulty thinking, concentrating, or making decisions

• Thoughts of death or suicide

SAD may begin at any age, but it typically starts when a person is between ages 18 and 30, with risk increasing with age.[9] Further, demographically, this condition is more common among women than men.[10,11]

A diagnosis of SAD may be made after a careful mental health exam and medical history is conducted by a psychiatrist or other mental health professional.

TREATMENT

SAD can be effectively treated in several ways, including: light therapy, antidepressant medications, talk therapy or a combination of these methods. While symptoms will generally improve on their own with the change of seasons, symptoms can improve more quickly utilizing treatment.

Light therapy - This involves sitting in front of a light therapy box that emits a very bright light (and filters out harmful ultraviolet (UV) rays). According to the American Psychiatric Association, this method usually requires 20 minutes or more per day, typically first thing in the morning, during the winter months. Most people see some improvements from light therapy within one or two weeks of beginning treatment. To maintain the benefits and prevent relapse, treatment is usually continued through the winter. Anticipating the return of symptoms in late autumn, some people may begin light therapy in early autumn to prevent symptoms from arising.[12] 

Those wishing to try light therapy, should speak to a specialist about which type of light is most effective. Dr. Lorin Boynton, a psychiatrist practicing at the University of Washington Medical Center-Roosevelt, notes, “You need 10,000 lux, so talk to a provider about what to get. Some people who have sensitive eyes shouldn’t use white light. They now make bright light therapy with green light that’s friendlier for the eyes.”[13]

Spending time outdoors - For some people, increased exposure to sunlight can help improve symptoms of SAD. Boynton suggests, “If you’re working out indoors, at home or at a gym, try to be in a brightly lit area, exercising outside whenever you can.” Further, research has shown that being in nature has a positive impact on health. “Natural daylight, even when it’s cloudy like it often is here, is much better for your brain and for all your hormones that control mood than artificial light.”[14]

Talk therapy, particularly cognitive behavior therapy (CBT) – Talk therapy has been shown to effectively treat SAD. Cognitive-behavioral or interpersonal therapy can help change distorted views one may have of themselves and the environment around them. Further, it can help improve interpersonal relationship skills, and identify things that cause stress as well as how to manage them[15.16]; this is particularly important as SAD leads to depressive symptoms.

Selective serotonin reuptake inhibitors (SSRIs) – This type of antidepressant is most commonly prescribed to treat SAD. SSRIs can help correct chemical imbalances that may lead to SAD.[17,18]

Maintain Health & Wellness – Ensuring your general health and wellness is optimized can also help. This includes: regular exercise, healthy eating, getting enough sleep, and staying active and connected (such as volunteering, participating in group activities and getting together with friends and family).[19]

Maintain your sleep routine - Dr. Ramanpreet Toor, a UW Medicine psychiatrist, notes that “Getting out of bed in the morning when it’s still dark out may be difficult, but maintaining a sense of normalcy by sticking to a regular sleep schedule will help your body better adjust to the lack of daylight.” Toor adds, “I wouldn’t recommend slowing down more or sleeping more; if someone is at risk of depression, that’s going to worsen symptoms.”[20]

The practice of good sleep hygiene is essential, including: keeping the bedroom cool and dark, avoiding caffeine near bedtime and putting blue light-emitting devices like smartphones and laptops away.[21] David Neubauer, of Johns Hopkins Medicine discussed sleep hygiene in an interview with Seattle Anxiety Specialists, PLLC: “We should be active in the daytime outside if possible. Sunlight is a good thing to help with the robustness of our circadian system, exercise, other physical activity.” Adding, “For our sleep-wake cycle, it's important to pay attention to the fundamentals to those processes that regulate sleep. We have a circadian system that under normal circumstances, is very effective in promoting sleep at nighttime and wakefulness during the daytime.”[22]

Keep variety in your diet - Once winter sets in, people tend to crave carb-rich and sugary foods become less inclined to cook. Boynton notes this is normal but should try to be avoided. Opt for healthy “comfort food” options like homemade soups or stews full of veggies and lean meats. Further, try to make meals colorful as possible by using different fruits and veggies to counter the dreariness of the weather. Aim to eat a diet which focuses on fruits, vegetables and whole grains.[23]

Johns Hopkins Medicine notes the following methods can further help relieve symptoms of SAD:[24]

• Get help. If you think you may be depressed, see a healthcare provider as soon as possible.

• Set realistic goals in light of the depression. Don't take on too much. Break large tasks into small ones, set priorities, and do what you can as you can.

• Try to be with other people and confide in someone. It is usually better than being alone and secretive.

• Do things that make you feel better. Going to a movie, gardening, or taking part in religious, social, or other activities may help. Doing something nice for someone else can also help you feel better.

• Get regular exercise.

• Expect your mood to get better slowly, not right away. Feeling better takes time.

• Eat healthy, well-balanced meals.

• Stay away from alcohol and drugs. These can make depression worse.

• Delay big decisions until the depression has lifted. Before deciding to make a significant transition—change jobs, get married or divorced—discuss it with others who know you well and have a more objective view of your situation.

• Remember: People rarely "snap out of" a depression. But they can feel a little better day-by-day.

• Try to be patient and focus on the positives. This may help replace the negative thinking that is part of the depression. The negative thoughts will disappear as your depression responds to treatment.

• Let your family and friends help you.

If you feel you have symptoms of SAD, seek the help of a trained medical professional. Just as with other forms of depression, it is important to make sure there is no other medical condition causing symptoms. SAD can be misdiagnosed in the presence of hypothyroidism, hypoglycemia, infectious mononucleosis, and other viral infections, so proper evaluation is key. A mental health professional can diagnose the condition and discuss therapy options. With the right treatment, SAD can be a manageable condition.[25]

If you feel your depression is severe or are having suicidal thoughts, consult a doctor immediately, seek help at the closest emergency room or dial 911.

For more information, click here to access an interview with Psychiatrist David Neubauer on insomnia & anxiety.

 Contributed by: Jennifer (Ghahari) Smith, Ph.D.

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 “Seasonal Affective Disorder (SAD),” American Psychiatric Association. (accessed 11-6-21) www.psychiatry.org/patients-families/depression/seasonal-affective-disorder

2 NOAA's National Centers for Environmental Information (NCEI). (accessed 11-6-21)

www1.ncdc.noaa.gov/pub/data/ccd-data/clpcdy18.dat  

3 “Seasonal Affective Disorder (SAD),” American Psychiatric Association.

4 Ibid.

5 “Seasonal Affective Disorder,” Johns Hopkins Medicine. (accessed 11-5-21)

www.hopkinsmedicine.org/health/conditions-and-diseases/seasonal-affective-disorder

6 Naubauer, D., & Ghahari, J. (2021, August 24). Psychiatrist David Neubauer on Insomnia & Anxiety. Seattle Psychiatrist Magazine. (accessed 11-8-21) seattleanxiety.com/psychology-psychiatry-interview-series/2021/8/24/anxiety-and-insomnia

7 “Seasonal Affective Disorder (SAD),” American Psychiatric Association.

8 Ibid.

9 “Seasonal Affective Disorder,” Johns Hopkins Medicine.

10 Ibid.

11 “Seasonal Affective Disorder (SAD),” American Psychiatric Association.

12 Ibid.

13 “How to Survive - and Thrive - in the Pacific Northwest's Cold, Dark Months,” Right as Rain by UW Medicine. (accessed 11-5-21) rightasrain.uwmedicine.org/mind/mental-health/winter-motivation-tips    

14 Ibid.

15 “Seasonal Affective Disorder (SAD),” American Psychiatric Association.

16 “Seasonal Affective Disorder,” Johns Hopkins Medicine.

17 Ibid.

18 “Seasonal Affective Disorder (SAD),” American Psychiatric Association.

19 Ibid.

20 “How to Survive - and Thrive - in the Pacific Northwest's Cold, Dark Months,” Right as Rain by UW Medicine.

21 Ibid.

22 Psychiatrist David Neubauer on Insomnia & Anxiety.

23 “How to Survive - and Thrive - in the Pacific Northwest's Cold, Dark Months,” Right as Rain by UW Medicine.

24 “Seasonal Affective Disorder,” Johns Hopkins Medicine.

25 “Seasonal Affective Disorder (SAD),” American Psychiatric Association.