- Amygdala
- Insula
- Prefrontal cortex
- Anterior cingulate cortex

Brain Regions Involved in SAD

Functional magnetic resonance imaging (fMRI) is an effective tool for analyzing brain functionality. It is capable of tracking the functional response of the brain through Blood Oxygen Level Dependent (BOLD) contrast. Increased neuronal activity leads to local increase in energy and oxygen consumption. Essentially, the BOLD effect is a contrast caused by the relative decrease in the magnetic field irregularities due to relative increase in the oxyHb level contributed by the blood flowing in the brain region with increased activity.

Functional MRI

Functional connectivity (FC) is defined as the temporal coincidence of spatially distant neurophysiological events, wherein two regions are considered to show functional connectivity if there is a statistical relationship between the measures of activity recorded for them. Extensions of this include both static and dynamic FC.

Functional Connectivity

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.

Pomona College

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)

Boehme, S., Ritter, V., Tefikow, S., Stangier, U., Strauss, B., Miltner, W. H. R., & Straube, T. (2014). Brain activation during anticipatory anxiety in social anxiety disorder. Social Cognitive and Affective Neuroscience, 9(9), 1413–1418. https://doi.org/10.1093/scan/nst129

Brain activation during anticipatory anxiety in social anxiety disorder (2014)

Devinsky, O., Morrell, M. J., & Vogt, B. A. (1995) Contributions of anterior cingulate cortex to behavior. Brain, 118, 279-306. https://doi.org/10.1093/brain/118.1.279

Contributions of anterior cingulate cortex to behavior (1995)

Amir, N., Klumpp, H., Elias, J., Bedwell, J. S., Yanasak, N., & Miller, L. S. (2005). Increased Activation of the Anterior Cingulate Cortex During Processing of Disgust Faces in Individuals with Social Phobia. Biological Psychiatry, 57(9), 975–981. https://doi.org/10.1016/j.biopsych.2005.01.044

Activation of the anterior cingulate cortex during processing of disgust faces in individuals with social phobia (2005)

Somerville, L. H., Kelley, W. M., & Heatherton, T. F. (2010). Self-esteem modulates medial prefrontal cortical responses to evaluative social feedback. Cerebral Cortex (New York, N.Y.: 1991), 20(12), 3005–3013. https://doi.org/10.1093/cercor/bhq049

Self-esteem modulates medial prefrontal cortical responses to evaluative social feedback (2010)

Etkin, A., Egner, T., & Kalisch, R. (2011). Emotional processing in anterior cingulate and medial prefrontal cortex. Trends in Cognitive Sciences, 15(2), 85–93. https://doi.org/10.1016/j.tics.2010.11.004

Emotional processing in anterior cingulate and medial prefrontal cortex (2011)

Davidson, R. J. (2002). Anxiety and affective style: Role of prefrontal cortex and amygdala. Biological Psychiatry, 51(1), 68–80. https://doi.org/10.1016/s0006-3223(01)01328-2

Anxiety and affective style: role of prefrontal cortex and amygdala (2002)

Simmons, A. N., Stein, M. B., Strigo, I. A., Arce, E., Hitchcock, C., & Paulus, M. P. (2011). Anxiety positive subjects show altered processing in the anterior insula during anticipation of negative stimuli. Human Brain Mapping, 32(11), 1836–1846. https://doi.org/10.1002/hbm.21154

Anxiety positive subjects show altered processing in the anterior insula during anticipation of negative stimuli (2011)

Etkin, A., & Wager, T. D. (2007). Functional neuroimaging of anxiety: A meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia. The American Journal of Psychiatry, 164(10), 1476–1488. https://doi.org/10.1176/appi.ajp.2007.07030504

Functional neuroimaging of anxiety: A meta-analysis of emotional processing in PTSD, social anxiety disorder, and specific phobia (2007)

Egger, M., Ley, M., & Hanke, S. (2019). Emotion recognition from physiological signal analysis: a review. Electronic Notes in Theoretical Computer Science, 343, 35-55. https://doi.org/10.1016/j.entcs.2019.04.009

Emotion recognition from physiological
signal analysis: a review (2019)

Denny, B. T., Fan, J., Liu, X., Ochsner, K. N., Guerreri, S., Mayson, S. J., Rimsky, L., McMaster, A., New, A. S., Goodman, M., Siever, L. J., & Koenigsberg, H. W. (2015). Elevated amygdala activity during reappraisal anticipation predicts anxiety in avoidant personality disorder. Journal of Affective Disorders, 172, 1–7. https://doi.org/10.1016/j.jad.2014.09.017


Elevated amygdala activity during reappraisal anticipation predicts anxiety in avoidant personality disorder (2015)

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

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. 

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