What does social anxiety disorder feel like? Essentially, it’s a fear of being judged, criticized, or rejected by others and the extreme desire to avoid disappointing others and escape the possibility of being judged if they do things “right”. You may be hypersensitive to perceived social interactions and may have low self-esteem, poor social skills, and trouble being assertive.1 For example, after making a mild mistake, such as standing within the appropriately socially distanced space of another and being asked to move away, may result in feelings of embarrassment that are distorted or out of proportion with the actual situation.
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), published by the American Psychiatric Association, defines social anxiety disorder as having a marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others.2 This can include fears of being negatively evaluated, like being judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikeable. Social anxiety disorder is linked to significant distress and impairment in education, employment, financial independence, and the development of professional, peer and intimate relationships.3
How Does Social Anxiety Disorder Lead to Drinking?
Social anxiety is challenging, especially when people around you cannot understand it. Social anxiety is not merely shyness or introversion; rather, it is associated with disability and interference with most areas of life. Studies have shown that the onset of anxiety disorders often happens before a substance use disorder (thus becoming “comorbidities”) .4 It is believed that some people turn to alcohol, which reduces inhibition, to self-medicate feelings of loneliness and sadness related to a lack of social relationships associated with social anxiety. Drinking regularly for the anxiety-relieving effects of alcohol can lead to excessive drinking.
SIGNS AND SYMPTOMS OF SOCIAL ANXIETY DISORDER
The DSM-5 uses the following ten criteria, in usual social situations such as public speaking, speaking in meetings, attending social events or parties, introducing oneself to others, having conversations, giving and receiving compliments, making requests of others, and eating and writing in public. The criteria determine the severity of an individual’s social anxiety disorder by measuring the frequency of:
Feeling of sudden terror, fear, or fright in social situations
Feeling anxious, worried, or nervous about social situations
Having thoughts of being rejected, humiliated, embarrassed, ridiculed, or offending others
Feeling a racing heart, sweaty, trouble breathing, faint, or shaky in social situations
Feeling tense muscles, on the edge or restless, or having trouble relaxing in social situations
Avoiding, or not approaching or entering, social situations
Leaving social situations early or participate only minimally (e.g. say little, avoid eye contact)
Spending a lot of time preparing what to say or how to act in social situations
Distracting themself to avoid thinking about social situations
Needing help to cope with social situations (e.g. alcohol or medications, superstitious objects)
Causes of Social Anxiety Disorder
The causes of social anxiety disorder are varied and not well understood. For instance, there are several factors that may increase the risk of developing social anxiety, including family history, negative experiences (especially during childhood – experiences like bullying, humiliation, etc.), temperament, new social or work demands, or having an appearance or condition that draws attention (positive or negative).5 Like other mental health disorders, a social anxiety disorder may also result from the interaction of inherited traits (genetics), brain structure (physiology), and an individual’s environment.
TREATING SOCIAL ANXIETY DISORDER
Therapy
While therapy sessions for social anxiety disorder are especially useful. During such sessions, the therapist may guide the patient in practicing exposure therapy by, say, approaching strangers. However, the COVID-19 pandemic has forced a movement to online therapy.6 Fortunately, there is a litany of secure, heavily encrypted, and HIPAA-compliant platforms specific to healthcare use that therapists conduct sessions through.
Support Groups
Under non-pandemic conditions, talking to other people who “get it” can alleviate feelings of loneliness that come with a social anxiety disorder. It may be quite helpful to learn how others with social anxiety disorder approach and overcome their symptoms.
Medications
Two Types of Dependence
In the case that social anxiety has debilitating effects on your ability to function normally, pharmacological intervention may be a good treatment (at least to start with). Benzodiazepines are a class of drugs (e.g. Xanax, Klonopin, Valium, Ativan) that produce calming effects by inhibiting the activity of neurons that make up networks involved in anxiety.7 However, there are serious downsides of benzodiazepines, including the potential to lead to tolerance and physical dependence, and ultimately, withdrawal.8
Antidepressants & SSRI’s
In some situations, antidepressants, which typically take 4-6 weeks to have an effect, will be prescribed instead. Antidepressants of the SSRI type (e.g. Prozac, Zoloft, Lexapro) are used to treat a range of anxiety disorders and work by limiting the reuptake of the neurotransmitter serotonin, which is thought to lead to other changes that ultimately produce the effects of SSRIs.9
Other Medications
Lastly, there are additional medications with demonstrated efficacy in social anxiety, including beta-blockers, which reduce symptoms of anxiety, including heart rate, blood pressure, heart ‘pounding’, and shaking voice and/or limbs, by blocking the effects of epinephrine (adrenaline) on beta receptors, which prevents the body from entering a fight-or-flight response.10 As they only affect physical symptoms of anxiety, beta-blockers (e.g. propranolol) are particularly useful for anxiety in specific instances, such as a performance or speech.11
TREATING ALCOHOL ADDICTION
Detox
Detox from alcohol is the first step in treating alcohol addiction. The period of detox, as well as the type and severity of withdrawal symptoms, varies depending on factors like the frequency and amount of alcohol consumption and co-occurring mental health issues. Minor (e.g. anxiety, sweating, nausea, headache) and major alcohol detox withdrawal symptoms usually go away over two weeks.
Rehab
Rehab is the second step in treating an alcohol use disorder. When multiple serious mental and physical problems are present (involving substance abuse), the traditional approach has been to treat each issue sequentially. However, the development of Dual Diagnosis, when a person has two or more co-occurring disorders (for instance, social anxiety disorder and substance use disorder) encourages medical professionals to address both medical conditions at the same time. This is especially important for combined alcohol addiction and social anxiety disorder, since symptoms of anxiety may cause a person who has quit drinking to relapse.
Sober Living
You may be surprised at how embedded alcohol is in most cultures. That fact, combined with the residual mental and physical effects of an alcohol use disorder, makes sober living all the more challenging. Here are a few ways to avoid drinking:12
Build drink refusal skills
Plan to handle the urge to drink
Determine and avoid that which triggers the urge to drink
MENTAL CHANGES TO REDUCE SOCIAL ANXIETY
Develop the following practices to safeguard your mental health while navigating social situations.
Identify and Challenge Negative Thoughts
Being able to recognize negative thoughts and respond to them as they arise can be useful in managing social anxiety. For example, remembering that anxiety isn’t as visible as it may feel, and that negative thoughts do not mean that one has done something wrong, and are in fact natural and common, can help alleviate feelings of shame or embarrassment.
Focus on Others to Reduce Your Negative Thoughts
Directing one’s focus externally may help turn one’s mind away from anxious thoughts. Helping others in some way, or attentively listening to a conversation, may help you stay engaged in the present moment.
Controlled Breathing and Mindfulness
Developing the skills to direct one’s focus internally in a useful way can be helpful when anxiety spikes. The key is to learn how to control that internal focus (since it may sometimes feel as though anxiety is beyond one’s control).
Face Your Fears
Facing one’s fears may sound intimidating, but exposure is one of the best medicines for social anxiety disorder. Entering a social situation is the perfect opportunity to put your newly learned mental changes to the test. In addition, doing so may help you pinpoint triggers for anxiety, what you can handle, and what is non-negotiable. Start in small doses!
LIFESTYLE CHANGES TO REDUCE SOCIAL ANXIETY
The following are some of the best nonmedical solutions to reduce social anxiety.
Reduce Caffeine
The FDA cites 400 mg per day as the limit for caffeine consumption without dangerous, negative effects, but this limit may vary from person to person.13 For instance, while caffeine does not cause anxiety, it can worsen symptoms of anxiety. Caffeine, the active ingredient in coffee (and in tea, energy drinks, soda, and even chocolate), can cause unwanted side effects including restlessness, shakiness, rapid or abnormal heart rhythm, and dizziness when over-consumed.14, 15 Additionally, maximizing the time period between caffeine consumption and going to bed can set you up for a good night’s rest.
Exercise
Exercise (particularly aerobic exercise) may reduce social anxiety in several ways, by:16
Diverting one’s focus from the source or sensation of anxiety
Increasing heart rate, which causes an increase in the availability of anxiolytic (anxiety-inhibiting) neurotransmitters
Relieving bodily tension
Improving the mind-body connection
Omega-3 Fats
Omega-3 fats are an especially beneficial type of ‘healthy fat’ which may reduce symptoms of anxiety when administered in daily doses of at least 2000 mg (2 grams).17, 18 Research suggests that a lack of omega-3 fatty acids in the brain may induce disorders, both behavioral and psychiatric.
Don’t Smoke
Smokers without social anxiety find it a difficult habit to quit due to the addictive nature of nicotine. That said, research suggests that smokers with social anxiety who are using the habit as a means to cope may feel more intense cravings to smoke during periods of social stress.19 In this case, smoking may be a “false safety behavior” employed to relieve anxiety, but only successful in the short term, and may ultimately indicate avoidance of the source of anxiety. In the long term, anxiety may actually increase as a result, so it is helpful to quit smoking.
Get ‘Good’ Sleep
Since social anxiety can lead to insomnia, and sleep deprivation can make anxiety worse, getting enough and quality sleep can make a world of difference, both on anxiety levels and overall health.20 Cognitive-behavioral therapy for anxiety or insomnia, as well as practicing good sleep hygiene (e.g. avoiding exposure to blue light, staying hydrated, developing a relaxing winding-down-for-sleep routine), may help to break the cycle.
WHAT ARE THE BEST JOBS FOR PEOPLE WITH SOCIAL ANXIETY?
People with social anxiety tend to avoid jobs that involve giving performances or presentations. Retail and service jobs, which involve face-to-face interaction with a great number of people, are similarly unattractive. Other aspects that may be of importance include low stress and noise levels, and minimal interruptions. Jobs that require physical presence with minimal social interaction include:
Delivery Drivers
As a delivery driver, most of the workday is spend independent from other people (at most, they may need to obtain a signature from a package recipient). Education beyond a high school level isn’t required.
Janitorial/Housekeeping Positions
While potentially a bit labor-intensive, janitorial or housekeeping positions offer ample alone-time and a quiet environment.
Outdoor Jobs
In addition to limited social interaction, working as a gardener or landscaper has the added benefit of exposure to the outdoors—and fresh air, sunlight, and greenery all have therapeutic effects themselves. Some background knowledge of plants/plant care may be required.
Animal Care
Working as a pet groomer involves little to no contact with pet owners and requires no formal education beyond a high school level. There’s often a period of training, but past that, the majority of time is spent focusing on animals (and by the way, there’s ample evidence that the presence of animals can relieve anxiety!).21 Perhaps even these minimally social jobs aren’t feasible. Fortunately, those with social anxiety may reap the benefits of living in the modern era by using technology, such as in the following jobs:
Online Freelance Work
Freelance sites like Upwork or Fiverr offer a means to work from the comfort of one’s own home (or anywhere with an Internet connection) and offer flexible work hours (but can be unsteady income without long-term clients). Whether you can write, do graphic design, program, or just use office software, there is always a job that you can do using the skills you already have. In addition, there are various online sources you can use to further develop and learn new skills.
Transcriptionist
Transcription involves converting audio recordings into a written format and is frequently needed in the healthcare and legal fields.22 Depending on the field, certification may be required, and having the right tools for the job is usually advised, but minimal social interaction is needed.
Programmer
Many programming positions require formal education—either a bachelor’s or master’s degree in computer science, or a similar area—but there are plenty of freelance opportunities for those who can code expertly. Programming doesn’t require much face-to-face communication, involves mostly individual tasks, and pays well.
