Social anxiety - nothing remarkable or pathological

Some people want to interact  but don't dare. They are shy or actually have a phobia of other people's judgements and thus avoid social contact. But why are we the way we are  and can we change our social needs and fears?

The majority of people may feel uncomfortable or anxious in certain social situations. This sensation is commonly known as shyness. A more clinical term for it is social anxiety. According to psychologist Erik Hedman, a researcher at the Department of Clinical Neuroscience, there is nothing remarkable or pathological about this at all. It is a sensation that stems from a fear of being judged (and in the worst case condemned) by other people. It probably has an evolutionary explanation.

"Social anxiety is one of our most widespread anxieties. In principle, everyone has felt a fear of being scrutinised by others or of making an appearance in front of a group. This stems from a fear that we will somehow do something to exclude us from the group. For our ancestors, belonging to the group was something that increased their chances of survival, as it still is for us today," says Erik Hedman.

When looked at from this perspective, social anxiety is functional. But for some, the anxiety becomes so powerful that it develops into a phobia. The discomfort then becomes so severe that it causes limitations to daily life. This may involve not getting an education or declining exciting job offers for fear of being required to talk in front of others. It can also involve involuntarily living alone because it is so hard to make contact with a potential partner. 'Safety behaviours' are also characteristic of social anxiety disorder and include such things as memorising word for word what you plan to say or drinking alcohol before daring to make social contact.

Social anxiety disorder is strongly connected to feelings of shame, a condemnation of oneself. This is indicated by a study that Erik Hedman has conducted together with his colleagues. The study shows that when people with social anxiety disorder receive cognitive behavioural therapy (CBT), their feelings of shame decrease.

There are other studies that describe how shame may be an important factor in social situations. For example, individuals are perceived more sympathetically if they are ashamed of their behaviour when they have violated social rules in some way, perhaps by burping loudly. Appearing unconcerned after having burped makes someone appear unpleasant. Other studies show that if we stand with only one half of our face towards an audience, that side of the face blushes more than the side the audience cannot see.

"Blushing or otherwise indicating shame is clearly important in showing that we accept the social rules and acknowledging that we have violated them. This is something that appears to be stronger in individuals with social anxiety disorder," says Erik Hedman.

Internet treatment effective

It is possible to effectively treat social anxiety disorder with CBT. Interestingly enough, it works even if the patient does not meet the psychologist face-to-face. Therapy via the internet is just as effective as standard group therapy with CBT. And the results are long-lasting, according to a five-year follow-up study conducted by Erik Hedman.

"Increasing age is connected to improved outcome. The therapy is best suited to those who are older, and presumably more mature, who can take a large amount of responsibility for their own treatment. Naturally, the therapy is most effective if it is actually conducted as intended, i.e., if the patient dares to challenge their own social fears," says Erik Hedman.

Internet therapy involves the patient and the psychologist communicating via a secure, e-mail-like system through an online account that is similar to that of an online bank. This is where the patient receives information from the psychologist and where they determine what the patient wants to achieve, and how, but the patient must carry out the exposure on their own. This may involve daring to talk in front of a group or doing so without security behaviours. In this way, what used to be incredibly frightening becomes controllable.

From the perspective of learning theory, the mechanism of CBT is purely a rehash of old ideas. The phenomenon that people who have learned to associate an object or situation with an emotion such as anxiety can learn to associate it with a new emotion following new exposure has been studied extensively. Thus, if we are afraid of dogs, but get the chance to meet and pet a friendly dog, then our fear may dissipate.

Learning mechanisms can also partly explain why certain people end up with social anxiety disorder. There is, however, a clear genetic component, which may explain about 50 per cent of the onset.

Different people thus have a varying genetic sensitivity to the environmental factors that can lead to social anxiety disorder. Some do not develop social anxiety disorder at all after long-term bullying, while more minor unpleasant experiences are enough for others. Certain people cannot remember any negative treatment in social situations at all.

From a physiological perspective, what happens when someone develops social anxiety disorder is less well known, despite certain pieces of the jigsaw having fallen into place. For example, it has been proven that, in certain situations, people with social anxiety disorder have extra strong reactivity in their amygdala; the part of the brain that deals with threats and fears, and which prepares us for flight.

"Social desirability"

About ten years ago, a Swedish study was conducted in which people with social anxiety disorder were investigated with a PET scanner while they read a text in front of an audience. Blood flow was measured by injecting radioactive markers into it, which provides information about which areas are active. A great deal of activity was seen in the amygdala. Once these people had been successfully treated with CBT or pharmaceuticals, they were asked to make another public appearance; this time there was less activity in the amygdala.

However, these studies do not give an indication of which biochemical processes took place in the brains of the study subjects. Consultant psychiatrist Simon Cervenka, researcher at the Department of Clinical Neuroscience, is looking for the answer to this question. He has investigated the dopamine systems of healthy research subjects and patients with social anxiety disorder. These studies are also conducted with a PET scanner, but this time with the help of tracer compounds that bind to certain receptors in the brain, something that makes it possible to measure the density of receptors in different parts of the brain. Simon Cervenka and his colleagues have so far mainly been interested in the dopamine receptor D2.

Simon Cervenka describes an American study that left a big impression on him when it appeared in 2002. This study investigated the incidence of D2 receptors in monkeys. When monkeys lived alone in individual cages, they all had about the same levels of D2 receptors. But when they were transferred into a single group in one cage, some of them gained additional D2 receptors  these were the dominant, aggressive leaders.

"This study made me very interested in what kind of biological basis there is for social behaviour. I wanted to see if it was possible to investigate the role of dopamine systems in humans," says Simon Cervenka.

The first results were published a few years ago. They describe the incidence of D2 receptors in relation to a certain character trait: "social desirability". This is a character trait that involves a smooth behaviour, with the individual striving for harmony in the group.

"Social conformity was probably important for our ancestors in certain contexts. This is linked to the extent we attempt to be liked by the group. There is an element of submissiveness, but I also believe that there are parts that touch on social skills," says Simon Cervenka.

The results of the study were along the same lines as those in the monkey study. People with high values on the scale of social conformity, i.e., very compliant people, had few D2 receptors. A more dominant, cold and aggressive temperament implied a greater number of D2 receptors.

In a later study, nine people with social anxiety disorder were investigated before and after they were treated with CBT. The patients who were cured of their anxiety disorder gained additional D2 receptors. The greater the effectiveness of the treatment, the greater the increase in the radioactive compounds' binding to the receptors.

Thus, on one end of the scale there are the D2-deficient and extremely compliant individuals, who gladly help others and who are courteous even towards an unpleasant person. The basis for this is a desire to be accepted by people around them, which is similar to the fear of criticism found in people with social anxiety disorder.

At the other end of the scale are those with abundant D2, whose characteristics include dominance, aggressiveness and coldness.

At the extreme of this group we find people who display psychopathic traits. A psychopath is also what you would find when looking for the opposite of someone with social anxiety disorder.

"A person with social anxiety disorder has an exaggerated sensitivity and a fear of how they will be perceived. Psychopaths, on the other hand, do not care about this at all, instead they are indifferent to others' view of them as long as their own goals are not threatened," says Erik Hedman.

Consequently, a psychopath will most likely never ask for treatment for their behaviour, something that people with social anxiety disorder do if they dare.

Text: Annika Lund. First published in Medicinsk Vetenskap 4/2013.