Social anxiety disorder can make it difficult for a person to attend school, find and keep a job, form healthy relationships, and otherwise enjoy a productive and satisfying life – and new information shows us that there may be a direct relationship between social anxiety disorder and specific aspects of brain structure and function.
Experts typically cite inherited genetic variations and personality traits as primary risk factors for this social anxiety disorder. However, new and advanced research efforts shed new light on the origin and cause of social anxiety disorder.
In late 2023 and early 2024, one study from South Korea and another from Australia explored the neurobiological aspect of social anxiety disorder. One study assessed differences in gray matter mass, while the other explored alterations in how certain areas of the brain communicate with each other.
With more than 800 million people throughout the world at risk of developing social anxiety disorder, advancements in the diagnosis and treatment of this condition have the potential to make a considerable global impact.
What Is Social Anxiety Disorder?
Social anxiety disorder, which clinicians refer to as both SAD and social phobia in addition to social anxiety disorder, is one of 11 anxiety disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
Generally speaking, all anxiety disorders involve excessive fear and worry. Many also have physical symptoms.
The criteria for a diagnosis of SAD include:
- Overwhelming fear or anxiety about social situations where that may involve scrutiny or judgment, such as meeting new people, dining in a restaurant, or giving a presentation at work.
- Fear of acting in a manner that results in humiliation, embarrassment, and/or rejection.
- Persistent fear that’s disproportionate to any actual chance of negative social repercussions
- Continued fear and worry – as in the three bullet points above – for six months or more.
- Consistent avoidance of events or circumstances that trigger the symptoms mentioned above
The symptoms of social anxiety disorder are more severe than typical nervousness that many of us feel when we meet new people or prepare to speak in public. A person with clinical social anxiety disorder will experience considerable distress, to the point that it undermines their ability to function in school, at work, or in other important areas of life.
Potential effects of untreated SAD include:
- Poor performance at work or in school
- Turning down job opportunities or promotions
- Financial problems
- Difficulty forming and maintaining healthy relationships
- Low self-esteem
- Withdrawal and isolation
- Diminished overall quality of life
- Elevated risk of substance abuse and addiction
- Suicidal thoughts
As researchers learn more about structural and functional differences in the brains of people with social anxiety disorder compared to people without SAD, their findings will hopefully lead to improvements in how clinicians diagnose and treat the condition.
Social Anxiety Disorder and Cortical Thickness
In June 2024, the journal Psychiatry Research: Neuroimaging published a study from South Korea that explored the relationship between SAD and altered brain structure.
Led by Dasom Lee, a PhD student at Seoul National University, the South Korean researchers conducted structural magnetic resonance imaging (MRI) on 78 adult participants. The participant group for this study included 36 people who received outpatient care for social anxiety disorder and 42 who didn’t.
The research focused on cortical thickness, which is the amount of gray matter in the outer layer of the brain. Previous research suggests cortical thickness in certain brain areas may be associated with intelligence.
The MRIs that Lee’s team conducted revealed that adults with SAD had elevated cortical thickness in four regions of the brain:
- Left insula, involved in emotion processing.
- Left superior parietal lobule, involved in attention, spatial orientation, and interpreting sensory information.
- Left superior temporal gyrus, associated with sensory perception, language comprehension, and auditory processing.
- Left frontopolar cortex, which contributes to information processing, problem solving, and other high level cognitive functions.
The MRIs also showed participants with SAD had decreased cortical thickness in two areas:
- Left superior/middle frontal gyrus, involved in spatial processing and working memory.
- Left fusiform gyrus, involved in recognizing faces and perceiving objects and words
These findings, the researchers wrote, provide insights into the neurobiological underpinnings of social anxiety disorder:
“The convergence of functional and structural evidence indicates that [social anxiety disorder] has distinct underlying neural mechanisms. These abnormalities may be further investigated as candidate biomarkers for diagnosing SAD.”
SAD and the Default Mode Network
About seven months before the South Korean study appeared in Psychiatry Research: Neuroimaging, the open access journal Translational Psychiatry published a report on a similar topic from the University of Melbourne in Australia.
The researcher team used functional MRI (fMRI) to assess brain activity in participants engaged in a computer-based tasks that involved:
- Direct self-appraisal: participants to identify words they’d use to describe themselves
- Reflected self-appraisal: participants selected words other people would use to describe them.
- External attention: participants answered questions about letters in certain words.
- Rest-fixation, or 10-second periods between other tasks when participants devoted their full attention to crosshairs on a screen.
This study involved 100 adolescents and young adults ages 16-25, including 38 people with SAD.
The researchers focused on the default mode network (DMN), which encompasses several brain regions, including:
- Inferior parietal lobe (IPL)
- Medial prefrontal cortex (MPFC)
- Posterior cingulate cortex (PCC)
The brain areas in the DMN typically become active when a person daydreams, reflects, or isn’t engaged in a specific cognitive function. Functions commonly controlled by the DMN include retrieving memories and imagining future activities.
The study participants showed the greatest differences in brain functions when engaged in reflective self-appraisal. During these periods, those with SAD exhibited:
- Greater excitatory connectivity between the PCC and the MPFC, compared to participants without SAD.
- Greater inhibitory connectivity from the left IPL to the MPFC, compared to participants without SAD.
These findings, the researchers concluded, may identify the neurological mechanism that causes people with social anxiety disorder to worry excessively about being judged by others. Here’s how the research team characterizes their results:
“The specificity of this finding for the reflected self-appraisal condition is consistent with the nature of [social anxiety disorder], whereby those with SAD show acute, anxiety-inducing preoccupation with the views that others hold of them.”
Participants with SAD also showed reduced connectivity when in a resting state. However, during periods of direct self-appraisal, when participants considered their own opinions of themselves, the fMRI revealed no significant connectivity differences between the two groups. Here’s how the research team described this aspect of their results:
“This supports the idea that for SAD participants reflected self-appraisal is more dependent on their constructed narrative self, in contrast to how this process functions in [participants without SAD].”
What Does This Mean for People With SAD?
It’s impossible to predict how current research into the neurobiology of social anxiety disorder will affect future efforts to help people diagnosed with SAD. Its benefits may include improvements in both diagnosis and treatment, such as:
- Greater understanding of brain differences in people with social anxiety disorder, combined with advances in imaging technologies, could help treatment professionals identify patients at greatest risk for SAD.
- As researchers build an evidence base, they may develop targeted medications to alleviate symptoms of SAD.
The good news is that people who have social anxiety disorder don’t have to wait for these potential future developments before they can achieve better health.
Treatment Options for Social Anxiety Disorder
Current treatment options, including medication, education, and therapy, empower people with social anxiety disorder to manage their symptoms and experience a better quality of life.
Most people who receive professional support for SAD participate in cognitive behavioral therapy (CBT) sessions and other forms of psychotherapy.
CBT helps people identify maladaptive thought and behavior patterns, then teaches them how to adopt healthier ways of thinking and acting. Research and case studies indicate that CBT is one of the most effective means of helping people learn to manage fears and worries characteristic of SAD.
No medication specifically treats social anxiety disorder. However, depending on the nature and severity of the symptoms, many treatment professionals prescribe antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).
At Crownview Psychiatric Institute, we offer comprehensive, personalized programming to help adults with social anxiety disorder and other complex mental health concerns.
Our dynamic approach incorporates psychotherapy, experiential therapy, medication, educational workshops, adjunct services, case management, and full wraparound support, all provided in a welcoming and supportive community-like environment.
To learn more about how we can help you or a loved one, or to schedule an assessment, please visit our Contact page or call us today.
Gianna Melendez
Jodie Dahl, CpHT