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For many people, having to give a speech in public is daunting but doable - and meeting new people or attending events is awkward but a necessary part of socialising.

But for others so intense is their fear of possible humiliation that it prevents them from being able to do what do what should come naturally - communicate and socialise.

Social anxiety disorder (SAD) is, according to the Social Anxiety Association, the third largest mental health-care problem in the world today.

More than just being labelled as an “introvert” or even being “shy”, it is the fear of social situations that involve interaction with other people.

“Social anxiety disorder - also known as social phobia - is an intense fear of being observed while performing,” says clinical psychologist Colinda Linde.

“This can be specific where there are only a few particular situations causing the anxiety, such as public speaking, or more general across a range of situations including not eating in front of others or not wanting to be the centre of attention in a work or social setting.”

According to the South African Depression and Anxiety Group (Sadag), it is also the most common anxiety disorder, with the onset being usually between 15 and 20 years.

In SAD the intense and persistent fear is of being in the company of strangers or authority figures in some cases, scrutiny by others in a social situation, or a fear of behaving in a way that might cause embarrassment, humiliation and/or ridicule, and perhaps ultimately, rejection, Sadag says.

It often goes undiagnosed or undetected because being shy or introverted is considered “normal”.

But Linde says the condition is not the same as just being shy.

“In the case of SAD, the person often would like to engage but the fear of somehow embarrassing themselves holds them back,” she says.

“Introverts tend to prefer their own company or one-on-one conversation with familiar people, and take a while to ‘warm up’ when entering an unfamiliar situation where they don’t know many people. Extroverts on the other hand, derive energy from social interaction and can engage anyone, stranger or not.”

While it is normal for people to experience anxiety about certain social or performance situations such as job interviews or public speaking, the people with SAD experience persistent, extreme anxiety out of proportion to the actual situation.

If social, occupational and interpersonal functioning become affected, and someone starts to withdraw or avoid performance situations, they may well be dealing with SAD, the psychologist says.

Substance abuse is also common. Alcohol tends to lower the anxiety levels when going into a social situation, and when someone needs to drink before they can face people, it’s a serious warning sign.

“Alcohol may be a quick-fix, but lowers inhibition to the point where decision-making and functioning are impaired, and lead to their own problems.”

The condition is treatable. Research has revealed a combination of medication and cognitive behavioural therapy (CBT) works best.

“CBT is a short-term, research-based therapy, which addresses the core fears preventing the person from engaging, teaches social and presentation skills, and gradually exposes the person to the feared situation in specific ways to desensitise them. We do group CBT, which works quickly as well as effectively.”

Linde warns that certain medi- cations, such as tranquillisers, should be avoided, as they are highly addictive.

“There are agents called beta- blockers that work well for presentations - they keep heart rate steady and prevent shaking.

“Certain antidepressants also drop anxiety levels and if the person learns CBT skills while feeling less extreme levels of anxiety, the skills tend to stick better.”

Who gets SAD?

There are factors which may render a person more vulnerable to develop SAD. These are:

Gender: SAD is more common among females than males. Notably, though, females with SAD are more common in community studies, while males are more common in treatment settings.

Genetics (nature): The risk for SAD increases if a person’s parents or siblings have the condition.

Upbringing (nurture): SAD may also be learnt. People develop SAD because they have witnessed socially anxious behaviour in others. Paren- tal styles may also play a role: there may be a link between SAD and over-protective parenting.

Adverse experiences: Children or adolescents who have been exposed to bullying, ridicule, humiliation or rejection may be more susceptible to social anxiety. Other traumatic factors, such as sexual abuse may also play a role.

Personality/temperament: Children or adolescents who are withdrawn, restrained, shy or timid when confronted with a new situation may be more prone to developing SAD.

Other factors: SAD occurs in all societies and racial groups although it may manifest differently or at different rates across cultures, depending on social demands.

In some cultures the fear may be more related to offending others rather than fear of embarrassment or ridicule.

What are the symptoms?

Symptoms can have a sudden onset but usually develop or increase over time. Apart from psychological feelings of anxiety and fear, people with SAD almost always experience somatic (physical) symptoms of anxiety such as heart palpitations, trembling, sweating and muscle tension. As noted earlier, panic attacks may occur in some cases.