How SAD Happens: The Development of Social Anxiety Disorder

Social anxiety disorder may be an extreme form of "trait social anxiety."

Posted Feb 23, 2020

You often hear people proclaim that they "do their own thing" and "don’t care what other people think or say." This, of course, is silliness. For one, the things we do are never wholly our own; the brain itself is a social organ, shaped by social interaction. Your internal experience, your thought and feeling processes, are cast in a social mold. I may write my own story, but society gave me language, writing, and the concept of "story."

Society even gave me the very concept of "me." Our sense of self—the “I” in “I do my own thing”—is largely constructed socially, in the process of comparing ourselves to others and gauging others’ responses to us. To wit: Are you a kind person? If yes, how do you know that? Most likely, you know you’re kind because 1. You figured out what behaviors are defined as kind in society and engaged regularly in those behaviors, and 2. People have commented on your kindness and referred to you as a kind person.

The truth is we all care about what others say and think. Humans are social creatures. We survive and thrive only in well-coordinated groups. We need to belong, and so we have to care about what others say and think about us, how they perceive us, and how they treat us. Our lives, quite literally, depend on it.

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Given this, it is clear why our antennas are well-tuned to pick up and react strongly to others’ criticism or negativity. From an evolutionary perspective, such concern is adaptive, because it helps us maintain our standing within the group, thus enhancing our chances for successful survival and reproduction.

However, every adaptation comes at a cost and every strength creates its own vulnerabilities. When our (adaptive) concern with negative social judgment becomes pervasive, extreme and all-consuming to the point of hindering our ability to function, the psychological adaptation becomes a psychopathology known as Social Anxiety Disorder (SAD). SAD manifests differently in different people, but it has certain commonly seen characteristics:

“Individuals with social anxiety disorder are typically shy when meeting new people, quiet in groups, and withdrawn in unfamiliar social settings. When they interact with others, they might or might not show overt evidence of discomfort (e.g., blushing, not making eye contact), but invariably experience intense emotional or physical symptoms, or both (e.g., fear, heart racing, sweating, trembling, trouble concentrating). They crave the company of others, but shun social situations for fear of being found out as unlikable, stupid, or boring. Accordingly, they avoid speaking in public, expressing opinions, or even fraternizing with peers; in some situations, this can lead to such individuals being mistakenly labeled as snobs. People with social anxiety disorder are typified by low self-esteem and high self-criticism.”

Anxiety disorders are the most prevalent disorders, and SAD is one of the most prevalent anxiety disorders. NIH data suggest that the past year prevalence of SAD among U.S. adults aged 18 or older is 7.1 percent (it is more common in females). An estimated 12.1 percent of U.S. adults experience SAD at some time in the course of their lives. SAD does not usually appear alone. In fact, it is highly co-morbid with other anxiety disorders, depression, and substance use disorders. Up to 90 percent of people who are diagnosed with SAD in their lifetimes will be diagnosed with another mental health disorder. SAD has an early age of onset: by age 11 in about 50 percent and by age 20 in approximately 80 percent of individuals.

The development of SAD is not yet fully understood, and appears to involve several possible pathways. But recent research suggests that the disorder may not be an entity in itself but rather an extreme and debilitating form of what is known as trait social anxiety, a tendency to feel anxious in a wide range of social situations. Trait social anxiety, it turns out, is strongly predicted by what is known as behaviorally inhibited temperament in infancy. Behaviorally inhibited infants show high negative affect in unfamiliar situations and act cautiously around unfamiliar people, objects, and events. Behavioral inhibition is strongly heritable, and tends to persist throughout childhood, often manifesting as shy, socially avoidant, and nonassertive behavior.

Behavioral inhibition, which predisposes infants toward anxious reactions, may be necessary for trait social anxiety to develop, but it is not sufficient. Certain environmental conditions must be present if the infant’s genetic predisposition is to end up expressing itself as a fully formed adult personality trait. In the case of trait social anxiety, such environmental conditions may be related to parental and peer environments. For example, parental (and peer) rejection has been shown to predict the development of social anxiety in behaviorally inhibited children, often through the consequent development of anxious "relational schemas"—cognitive representations that prime individuals to perceive themselves as socially inadequate, others as judgmental, and social interactions in general as negative.

This elastic process—by which the early environment shapes the development of specific genetic traits that are adaptive in it—is called conditional adaptation. Trait social anxiety appears to be one such conditional adaptation, in which “cues of social threat in the early environment promote the development of trait social anxiety as a protective, damage-limiting strategy.”

Alas, trait social anxiety may not be protective in situations where early and late environments are misaligned. In other words, a childhood rife with social threats could trigger the development of trait social anxiety in behaviorally inhibited children as a protective mechanism. This would be adaptive in situations where continuity between the childhood and adulthood environments in fact existed. Yet for many children in modern societies, early environments are not necessarily predictive of later ones. This mismatch manifests in two primary ways. First, social threats in general are now less likely to have dire life-or-death consequences than in prehistoric times. Second, as social life has become more complex and dynamic (and as childcare has become less of a collective effort), the social environment of childhood often does not represent the social environment of adulthood. The mismatch is where SAD may emerge from trait social anxiety.

By way of analogy, a mind trained inside a war zone will be ill-suited to a peaceful environment. Growing up in a war zone, a child’s duck-and-cover reaction to loud noises and fear of strangers, for example, would be adaptive, as the noises are likely to be bombs and strangers on the street may be hostile and unpredictable. However, if the child ends up later living in a peaceful city, where loud noises are unlikely to be bombs and where street crowds are mostly peaceful tourists, then these same fear habits would be maladaptive and ineffective—in other words, disordered.

In sum, if this new thinking about SAD finds further empirical support, it may eventually help point us in the direction of developing preventative measures, by which early intervention with socially inhibited infants and children may reduce their odds of developing a full-blown disorder in adulthood.

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