State University of New York at Albany

Social anxiety disorder (SAD) affects about 4% of the worldwide population and is slightly more common in women. Also known as social phobia, it is defined as a persistent,and potentially debilitating fear of meeting new people, being watched, or criticized by others. Some with social anxiety may attempt to avoid anxiety-triggering situations by self-isolating or cancelling plans. It is a profound fear of the judgement of peers, particularly public humiliation. It is NOT shyness or introversion but can sprout from childhood shyness. In a social sense, social anxiety is not just feeling nervous or shy in certain social situations like starting a new job or the first day of school. Social anxiety disorder is a disorder that interferes with everyday life and relationships due to fearing situations where you can be embarrassed or viewed negatively and intense fear of situations where a person with SAD expects the worst. 

Social Anxiety Disorder (Social Phobia)

Autism Spectrum Disorder is a neurodevelopmental disorder that affects communication and behavior. It displays symptoms such as impaired communication, lack or impairment in social skills and interactions, and repeated patterns of behaviors that interfere with an individual's ability to cognitively function. These symptoms are almost always present in early development, and are considered to be on a 'spectrum' because of the differences in severity of these symptoms.


Although autism can be diagnosed at any age, it is said to be a “developmental disorder” because symptoms generally appear in the first two years of life. Boys tend to be diagnosed more often than girls by approximately 4x. There is also an overrepresentation of transgender or gender nonconforming people with ASD.

Autism Spectrum Disorder

Neff, M. (n.d.). Social anxiety vs autism. Neurodivergent insights. https://neurodivergentinsights.com/misdiagnosis-monday/social-anxiety-or-autism#:~:text=People%20with%20social%20anxiety%20are,people%20(Cuncic%2C%202021).

Autism and Social Anxiety Disorder Reference

Social phobia, more commonly known as social anxiety disorder (SAD), can potentially limit a person's ability to socialize and interact with others without extreme fear. However, the specific longterm effects that SAD has on a person's life, especially their academic success, are not well-known. A longitudinal study  followed students who did not have diagnosed social anxiety but did possess high trait social anxiety. The students' performance during their first two years of college was examined. Findings suggested that while social anxiety traits were common among the participating college students, coping with said anxiety seemed possible enough to not result in high transfer rates, and only studying the first two years is not long enough to begin observing very negative, clear effects on academic performance. 

The effects of social anxiety and social skills on academic performance

An association exists between individuals with social anxiety disorder (SAD) and risk for developing marijuana dependence, appearing especially vulnerable to marijuana use disorders (MUD). Research indicates that social anxiety disorder and marijuana dependence share an especially prevalent relationship, wherein the rate of marijuana dependence is greater than twice more likely to occur in individuals with SAD as opposed to any other anxiety disorder. Furthermore, adolescents with SAD have approximately five times greater the risk of developing marijuana dependence. Evidence strongly suggests social anxiety is a risk factor of MUD. 



Risk of marijuana dependence

 Common social triggers for Hyperhidrosis include: 
- Being in public, such as at work or school 
- Eating at a restaurant
- Spending time with friends 
- Thinking about hyperhidrosis 



Social Triggers for Hyperhidrosis

About 69% have said they faced conflict from others due to their condition, resulting in a constant sense of worry whether an individual is sweating or not.
This condition is thought to be a possible symptom of Social Anxiety disorder.

Conflicts Faced with Hyperhidrosis

Through MBSR research, it was found that MBSR attacks social anxiety disorder on a behavioral level and a neural level.  Patients found that they had less negative emotions when focusing on breath work.  In the neural networks it was found that focusing on breathing allowed attention regulation from an explicit to implicit process.  This means that breath works allows a patient with social anxiety disorder to rewire their brain to be more focused when breathing, thus limiting the symptoms of social anxiety.

MBSR and Social Anxiety

Functional neuroimaging has identified several brain regions and circuits involved in pathological anxiety, such as the amygdala, insula, and prefrontal cortex. Neural dysfunction associated with SAD varies from reduced regional volume to increased or decreased activation and functional connectivity.

The Neural Basis of Social Anxiety Disorder

There are mixed findings for the role of oxytocin in psychological disorders such as autism spectrum disorder, PTSD, and social anxiety disorder. Hoge et al (2008) found a positive correlation between anxiety and plasma oxytocin levels, while Schneider et al (2021) found that high basal oxytocin predicted less anxiety. Hoge et al hypothesize that oxytocin in individuals with anxiety may increase to compensate for dysfunctional oxytocin receptors.

Oxytocin and psychopathology

Social anxiety disorder is the most common disorder when it comes to anxiety. Through the use of neuroimaging, it was confirmed that there is hyperactivation in the fear areas in relation to social anxiety disorder. The lobes that were activated, specifically are the amygdala, insula, anterior cingulate, and prefrontal cortex. It was found that insular activity is often involved with anxiety. The insula becomes a part of the default-mode-network in humans, especially healthy humans. The introduction of state anxiety might explain why there isn't a significant difference in studies observing social anxiety disorder. The disturbance of normal homeostatic network systems might be similar to an imbalance in heightened emotional arousal and enhanced perception of fear stimuli. The role of the parietal and occipital lobes has a heavy emphasis on anxiety disorders. The meta-analysis study shows that the medical parietal regions play an important role in most anxiety disorders.

Neuroimaging in social anxiety disorder -- A meta-Analytic review resulting in a neurofunctional model

Social Anxiety Disorder Library

When around others:
- Blushing, sweating, trembling
- Rapid heart rate
- "Mind blank"
- Feeling sick
- Rigid posture
- Overly soft voice when speaking
- Challenging to maintain eye contact 
- Difficult to communicate with people even if they want to
- Self-conciseness or fear of judgment
- Avoid crowded places or locations with people
- Worry over fear or embarrassment 
- Intense fear of interacting or talking 
- Fear others will notice the appearance of anxiety
- Shaky voice
- Anxiety in anticipation of event or place
- Analysis of performance and perceived flaws in interactions
- Expecting the worst outcome
- Nausea
- Trouble catching breathe
- Muscle tension
- Avoidance of common social interaction

Symptoms of Social Anxiety

The conditions that are commonly and significantly linked with social anxiety disorder are mood disorders, such as depression, substance abuse disorders, and other anxiety disorders.

Disorders Strongly Associated with Social Anxiety Disorder

- Genetic and temperamental factors
- Cognitive aspects
- Family environment
- Cultural & societal influences
- Adverse life events
- Gender roles

The Etiology of Social Anxiety Disorder

Social Anxiety Institute. Retrieved July 1st, 2023, from https://socialanxietyinstitute.org/

Social Anxiety Institute

- Fear of at least one social or performance situation
- Exposure to situation provokes anxiety
- Recognition of the fear being unreasonable
- Situation is avoided or endured with distress
- Interferes with routine, occupational functioning, social life, or distress in having said phobia
- Distress is present for 6 or more months
- Distress is not due to a substance or medical condition

DSM-5 Social Anxiety Criteria

Cognitive behavioral therapy is used as a treatment for social anxiety disorder, but a portion of patients may still have symptoms after the initial therapy. This variation between different patients is not well understood but it is important to comprehend because it may be the key to understanding the etiologies of disorders and improving therapies for them. Functional magnetic resonance imaging (fMRI) may offer essential indications of patient variation using neuromarkers. The use of neuromarkers is a technique that allows following brain activations viewed during an fMRI.

Predicting Treatment Response in Social Anxiety Disorder from Functional Magnetic Resonance Imaging: Using Neuromarkers to Understand Patient Variation.

References for Predicting Treatment Response in Social Anxiety Disorder from Functional Magnetic Resonance Imaging

Social Anxiety Disorder and Autism Comparison

Reference for Autism and Social Anxiety Disorder

Reference for Causes and Consequences of Social Anxiety Disorder

Several factors can increase the risk of developing social anxiety disorder. These include:
* **Behavioral inhibition**: An inherited trait characterized by fear and restraint in unfamiliar situations.
* **Childhood temperament**: Being shy or withdrawn in childhood.
* **Attention-drawing conditions**: Having a physical condition or appearance that attracts attention.
* **Adverse childhood experiences**: A history of being bullied or abused.
* **Family history**: Having relatives with social anxiety disorder.
* **New life demands**: Facing novel occupational or social challenges.

Risk Factors for Social Anxiety Disorder

Behaviors that reduce the risk of developing social anxiety disorder:

* Getting help early if anxiety occurs.
* Setting priorities in life and engaging in enjoyable activities.
* Avoiding the consumption of unhealthy substances such as nicotine, caffeine, drugs, or alcohol.
* Keeping track of personal life in a journal in order to make the process of recognizing the stressors later easier.


Social Anxiety Disorder Prevention

Social anxiety disorder is a widespread condition in the United States. It is estimated that just over 12% of the American population will experience it at some point during their lifetime.

Prevalence of Social Anxiety Disorder

When left unaddressed, social anxiety disorder can lead to significant impairments across various aspects of an individual's life. Adults with this condition often have lower levels of educational achievement and reduced earnings. They may also exhibit poorer performance in the workplace and face a higher likelihood of unemployment. Furthermore, the disorder is associated with greater reported dissatisfaction with personal relationships, including family and friends, as well as with leisure activities and overall income.

Life Impairments Associated with Social Anxiety Disorder

Virtual reality offers an immersive and controlled environment for the assessment and treatment of social anxiety disorder. Virtual reality exposure therapies have shown effective results for improving symptoms post treatment in comparison to control groups like in vivo exposure therapy.  However, use of virtual reality for assessment of social anxiety disorder is less reliable and valid. 

Virtual Reality for Social Anxiety Disorder

References for Virtual Reality for SAD

Verbal

Gestures

Pictures

Text

Drawing

Communication Styles

A 1981 epidemiological study conducted by Lorna Wing to examine sex ratios in children diagnosed with autism revealed the following:
- difference b/w men and women in language and social impairments, and in the way they reacted to their respective environments
- prompted further sex ratio research

Ehlers and Gillberg (1998):
- study on epidemiology of Asperger's syndrome
- found smaller male:female ratio than expected

Matille et. al, (2007):
- hypothesizied that women with autism display superficial social skills and this is what causes them to be misdiagnosed

Koenig and Tsatsanis (2005):
- found that most autism research stemmed from male experiences alone
- Hartrung and Widiger (1998): concluded that when a disorder's symptoms change based on gender, diagnosis will be skewed towards those who outwardly express symptoms that are out of the social norm



Gender Bias in Autism and Asperger's Syndrome

When diagnosed with ASD, one is further classified as level 1, 2, or 3. These classifications correspond with severity of symptoms and dependency, particularly indicating how much support is necessary for that individual’s daily functioning. 

- ASD Level 1
- ASD Level 2
- ASD Level 3
- Limitations of the ASD Levels

Three Functional Levels of ASD

The most common co-occurring disorders with Autism Spectrum Disorder include epilepsy/seizures, sleep disorders, gastrointestinal disorders, ADHD, anxiety, depression, and bipolar disorder. Often, these can go undetected due to the overlapping symptoms of ASD and/or inability to communicate these symptoms. This inability to communicate other discomforts can often result in coping mechanisms consisting of inappropriate behaviors, thus a shift in behavior can indicate presence of a comorbid disorder. 

- ASD and Epilepsy

ASD Co-morbidity with Other Disorders

As our understanding of Autism Spectrum Disorder has evolved, our definition and explanations have evolved as well, modifying diagnostic criteria and labels. Most likely, it will continue to adapt and evolve as we learn more about it, as our current understanding is incomplete. 

ASD Definitions Through Time

There is no medical test for ASD. Rather, experts must study an individual's development and behavior and, using their best logic and existing criteria, suggest a diagnosis. Generally, diagnoses are more likely to be accurate by age 2 or older. 

ASD Diagnosis Techniques

People with autism and those with intellectual disability often experience stigma and barriers to forming intimate romantic relationships due to deficits in complex social skills, despite often having the same needs for intimacy and sexuality as typically-developing people.

Forming romantic relationsihps as an individual with ASD

Fragile X syndrome is perhaps the most common genetic form of intellectual disability. It results when the trinucleotide repeats (i.e., CGG repeats) in the long arm of the X chromosome number more than 200 repeats, as opposed to the normal 6-50 repeats. This extension of repeats leaves this region of DNA fragile, or prone to breakage. Specifically, the overexpansion causes methylation and transcriptional repression of the Fragile X Mental Retardation 1 gene (*FMR1*), which encodes an important RNA-binding protein that inhibits RNA translation into proteins known as fragile X retardation protein (FMRP). The condition affects 1 in 3600 males and 1 in 8000 females. The reason for this large discrepancy between incidences in biological sexes is due to the fact that genetic females have two X chromosomes rather than one X like genetic males do. Generally speaking, females have one normally functioning *FMR1* on the non-mutated chromosome in each cell, which allows their symptoms to be milder since the amount of abnormal *FMR1* is more variable than in males.

Fragile X Syndrome

- About 50-60% of transition-age youth and adults with autism spectrum disorder obtain work opportunities following participation in vocational rehabilitation programs, mainly working part-time and for low wages
- Programs primarily focus on modifying behavior as opposed to modifying work environments and practices
- The structures of VR programs, availability of services, eligibility criteria, and funding differ greatly by state, as well as how tailored they are to individuals with ASD
- A shift to a knowledge-based economy makes VR services for individuals on the autism spectrum a necessity

Vocational Rehabilitation for Individuals on the Autism Spectrum

Many autistic individuals have at least one other co-occuring psychological condition. Some common co-morbidities of Autism Spectrum Disorder include: 

- Attention-Deficit Hyperactivity Disorder 
- Obsessive-Compulsive Disorder 
- Depression 
- Anxiety Disorders 

Co-occuring Psychological Conditions in Autism Spectrum Disorder 

Applied behavioral analysis, or ABA therapy, is rooted in understanding learning and behavior. This therapy is intended to help people with ASD learn skills and behaviors to help them live more fulfilling lives. Such as:

- coping mechanisms
- social skills
- communication skills
- self-care
- play, leisure activities
- motor skills

ABA Therapy

The DSM-5 criteria for children with ASD includes deficits in sensory processing, specifically sensory modulation. Any sensory modality may be affected but some evidence suggests that individuals with ASD have a greater frequency of sensory deficits in the domains of taste and smell, as well as tactile sensitivity. 

- neurobiology of sensory symptoms in ASD

Sensory Processing Deficits in Autism Spectrum Disorder

- mental/speech deficits or impairment
- sleep difficulties
- if smiling, laughing, and/or head flapping is a repetitive behavior this could also be a symptom of autism since repetitive behaviors are a part of autism.

Angelman Syndrome and Autism Spectrum Disorder: Common Symptoms

Avoidant Personality Disorder and Autism Comparison

Neff, M. (n.d.). Avoidant Personality Disorder vs Autism. Neurodivergent insights. https://neurodivergentinsights.com/misdiagnosis-monday/avoidant-personality-disorder-vs-autism




Avoidant Personality Disorder and Autism Comparison Reference 

Autism Spectrum Disorder (ASD) is a category of neurodevelopmental disorders defined by core challenges in social interaction and communication, alongside the presence of restricted and repetitive patterns of behavior.

Autism Spectrum Disorder (ASD) Core Deficits

The capacity for independent living among adults with Autism Spectrum Disorder varies. While individuals with more developed language and intellectual skills may be able to live and work on their own, this is not the reality for the majority. For many, the persistence of ASD symptoms creates significant impairments in various life domains, making it difficult to manage essential daily tasks like personal hygiene, finances, and meal preparation.

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