Speaking About Social Anxiety Disorder

Years ago, I was asked to give a speech at a friend’s wedding. As I stood at the mic, trying to get the crowd’s attention, my shaky hands dropped my drink. The first words of what was supposed to be a funny, heartfelt speech were instead “I’m pretty nervous.” Public speaking can be tough for a lot of people, myself included, but for some people it - and other social situations - can be crippling. Social anxiety disorder is an intense fear of social situations.^[1] Social anxiety disorder is felt as a fear of humiliation, embarrassment, rejection, or offending in a situation where a person is being scrutinized, judged, or evaluated by others.^[2] This fear is out of proportion to the actual threat posed and causes avoidance of social situations.^[2] In addition to being distressing, social anxiety disorder can increase the risk of other mental disorders like depression, anxiety, and substance use, and can make existing disorders more severe.^[1]

Social anxiety disorder affects somewhere around 12-13% of the U.S. population.^[1,3] For unknown reasons, the rate in the United States is higher than in other countries.^[3] The typical age of onset is much younger than most wedding speech writers, averaging around 13 years old.^[1] Genetics, environmental, and behavioral factors all seem to influence the risk of developing social anxiety disorder.^[1] It seems to run in families, with genetics making people more vulnerable, though parental behavior may also play a role.^[1] Young and low-income people are at the highest demographic risk, while Asian, Hispanic, and Black Americans who live in urban areas may have lower rates of social anxiety disorder.^[4]

Balancing humor, relationship history, insults, affection, and embarrassing stories is a true art in wedding speeches. When one of these aspects (especially embarrassing stories) gets out of hand, the whole thing can fall apart. This mirrors what happens in the brain with social anxiety disorder. Parts of the brain that deal with fear, including the amygdala, insula, hippocampus, and frontal lobe, have increased activity.^[5] Signaling molecules like serotonin that control the activity levels in these brain regions get out of whack.^[6] It’s unclear how these molecular imbalances cause issues; both increases and decreases in serotonin levels are associated with social anxiety disorder, which complicates treatment.^[6]

The first-line treatment for social anxiety disorder is cognitive behavioral therapy, a goal-oriented talk therapy.^[1] Some doctors may also recommend exposure therapy.^[1] Medications for social anxiety disorder have limited success, and only around 35% of patients get specific medications that work for them.^[1] Selective serotonin reuptake inhibitors (SSRIs) like paroxetine have been successful for around 30-40% of patients, though they may take weeks to take full effect.^[7,6,5] Unfortunately, for patients who do not respond to SSRIs (perhaps because they don’t have excessive serotonin levels), clinical trials have found that other medications have no or minor advantages over placebo.^[7] There is a clear need for more social anxiety disorder treatment options.

One possible treatment that has been working its way through the clinical trial process with some success is a pheromone sprayed into the nose.^[8] Previously, scientists thought the vomeronasal organ - which senses pheromones, had no function.^[9,10] There is now evidence that some pheromones cause a rapid effect in the brain, including in the amygdala and other fear-related regions.^[8,10]  Scientists are investigating medications that may activate the vomeronasal organ to suppress fear and anxiety.^[9] Early clinical trials found that some patients who sprayed a pheromone-like medication into the nose had decreased anxiety for tasks like public speaking.^[9]  More clinical trials need to be done to investigate the effectiveness of this new delivery method for social anxiety disorder medications. If they prove to be effective, we may see a new marriage between disorder and treatment. 

Creative Director Benton Lowey-Ball, BS, BFA

References:

[1] Leichsenring, F., & Leweke, F. (2017). Social anxiety disorder. New England Journal of Medicine, 376(23), 2255-2264. https://www.nejm.org/doi/abs/10.1056/NEJMcp1614701

[2] American Psychiatric Association. (2013). Social anxiety disorder. In Diagnostic and statistical manual of mental disorders (5th ed.). 

[3] Stein, D. J., Lim, C. C., Roest, A. M., De Jonge, P., Aguilar-Gaxiola, S., Al-Hamzawi, A., ... & WHO World Mental Health Survey Collaborators. (2017). The cross-national epidemiology of social anxiety disorder: Data from the World Mental Health Survey Initiative. BMC medicine, 15, 1-21. https://link.springer.com/article/10.1186/s12916-017-0889-2

[4] Grant, B. F., Hasin, D. S., Blanco, C., Stinson, F. S., Chou, S. P., Goldstein, R. B., ... & Huang, B. (2005). The epidemiology of social anxiety disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Journal of Clinical Psychiatry, 66(11), 1351-1361. https://pubmed.ncbi.nlm.nih.gov/16420070

[5] Fox, A. S., & Kalin, N. H. (2014). A translational neuroscience approach to understanding the development of social anxiety disorder and its pathophysiology. American Journal of Psychiatry, 171(11), 1162-1173. https://psychiatryonline.org/doi/full/10.1176/appi.ajp.2014.14040449

[7] Williams, T., McCaul, M., Schwarzer, G., Cipriani, A., Stein, D. J., & Ipser, J. (2020). Pharmacological treatments for social anxiety disorder in adults: a systematic review and network meta-analysis. Acta Neuropsychiatrica, 32(4), 169-176. https://doi.org/10.1017/neu.2020.6

[8] Kaminski, R. M., Marini, H., Ortinski, P. I., Vicini, S., & Rogawski, M. A. (2006). The pheromone androstenol (5α-androst-16-en-3α-ol) is a neurosteroid positive modulator of GABAA receptors. The Journal of pharmacology and experimental therapeutics, 317(2), 694-703. https://jpet.aspetjournals.org/article/S0022-3565(24)32659-X/abstract

[9] Liebowitz, M. R., Salman, E., Nicolini, H., Rosenthal, N., Hanover, R., & Monti, L. (2014). Effect of an acute intranasal aerosol dose of PH94B on social and performance anxiety in women with social anxiety disorder. American Journal of Psychiatry, 171(6), 675-682. https://pubmed.ncbi.nlm.nih.gov/24700254/

[10] Monti-Bloch, L., Jennings-White, C., Dolberg, D. S., & Berliner, D. L. (1994). The human vomeronasal system. Psychoneuroendocrinology, 19(5-7), 673-686. https://www.sciencedirect.com/science/article/abs/pii/0306453094900493