Commentary: ‘Dropping out of school, refusing to leave home’ - social anxiety can be crippling

SINGAPORE: Imagine being called on by your teacher or boss to present a project to a room full of people. Your heart begins to race, your palms grow clammy. And yet, despite it all, you push through - with a huge sigh of relief as soon as it’s over. This is common for most people.

For those with social anxiety disorder, however, the experience is akin to stepping into a battlefield, stripped of armour and weapons, with weights tied to your ankles. The fear is excruciating and crippling.

The mother of 18-year-old Peter* recently shared with me her son’s extreme challenges.

Peter’s life took a drastic turn after a distressing incident in primary school, leaving him struggling with everyday activities such as leaving the house alone, using public transport or making purchases without assistance. His anxiety became so overwhelming that he could not continue his education and eventually had to drop out altogether after primary school.

Peter's difficulties were not merely a case of shyness; he was battling social anxiety disorder, also known as social phobia. This disorder is widely prevalent yet often overlooked and carries substantial economic and personal costs, including educational underachievement, decreased work productivity, increased dependency and frequent comorbidities, such as depression and alcohol dependence.

With Singapore making mental health a key priority in its national agenda, it is encouraging to see progress being made. However, there is still much work to be done in terms of raising awareness, reducing stigma, and ensuring accessible and effective treatment options for those in need.

THE NATURE OF SOCIAL PHOBIA

Social anxiety disorder extends far beyond shyness, representing a debilitating mental health condition characterised by an intense fear of social situations. Unlike shyness - a personality trait where individuals may feel awkward but can still participate in social interactions - social phobia leads to profound avoidance behaviours.

Individuals with social phobia feel such intense anxiety of judgement or scrutiny that it interferes with daily functioning, leading them to avoid social situations, affecting work, school and personal relationships.

Social anxiety disorder displays globally diverse characteristics, shaped significantly by cultural norms and societal expectations. In Japan, this is reflected in the unique form known as taijin kyofusho, where the fear centres not on one's own potential embarrassment, but on offending or embarrassing others. This contrasts with the fears typical in Western cultures, where the anxiety is about oneself being negatively judged.

In a 2020 study involving nearly 7,000 respondents from seven countries, a staggering 36 per cent globally met the threshold for social anxiety disorder.

It doesn’t just affect regular people. Celebrities such as Nicole Kidman, Kim Basinger and Ed Sheeran - whose very jobs require performing for people - have admitted to having social anxiety.

According to a World Mental Health Survey Initiative involving more than 140,000 respondents across low- to high-income nations, the global prevalence of social phobia ranges from 2 per cent to 12 per cent, with variations largely influenced by cultural factors and diagnostic criteria.

Other studies have shown that about 80 per cent of individuals with social anxiety disorder report onset at the age of 18, and it is more commonly reported in females than in males.

There are no recent studies about the extent of social phobia in Singapore to my knowledge, although a recent study led by the National University of Singapore showed that about one-third of Singapore adolescents reported mental health symptoms such as depression, anxiety and loneliness.

IMPACT ON DAILY LIFE

Social anxiety disorder can severely disrupt daily functioning due to the intense fear and avoidance of social interactions.

Routine activities most people take for granted become sources of profound distress. For example, buying food from hawker stalls can be overwhelming due to the fear of interacting with others or being observed by other diners.

In severe cases, individuals may avoid eating or drinking in public settings entirely, as was the case with a patient of mine. She stopped eating in school altogether as she could not bear the perceived scrutiny, skipping both recess and lunchtime.

Some may become virtually mute in social settings due to overwhelming anxiety. This level of social avoidance and ensuing isolation can have significant repercussions on personal development, educational achievement, and overall quality of life.

UNRAVELLING THE CAUSES OF SOCIAL PHOBIA

The causes of social anxiety disorder are multifaceted, involving biological, environmental, psychological, and increasingly recognised, digital influences.

Genetic factors play a significant role. Individuals with social anxiety disorder often have an overactive amygdala, a part of the brain that intensifies their response to social threats, making them more susceptible to social anxiety.

Social anxiety disorder is also influenced by environmental factors, such as upbringing and personal experiences. For example, children who grow up with overprotective or critical parents and those who experience bullying can struggle to feel confident in social situations, which might increase their risk of developing social phobia.

Personal traits also play a role; those who are naturally introverted or particularly sensitive to criticism may be more susceptible to this disorder.

In today's digital world, extensive use of smartphones and social media can exacerbate anxiety. Constant connectivity can lead to an overreliance on digital communication, reducing face-to-face interactions and potentially weakening the individual’s social skills.

Additionally, constant exposure to idealised images of others' lives may increase feelings of inadequacy and anxiety. The pressure to be constantly available and to manage one's digital persona can create and reinforce anxiety, particularly in social contexts.

STRATEGIES FOR MANAGING SOCIAL PHOBIA

Effectively managing social anxiety disorder starts with psychoeducation, which is crucial for clearing up misconceptions and helping with early detection.

Learning about social phobia can help patients and their caregivers spot early signs, like a child refusing to go to school or not speaking in certain situations.

Therapy, particularly cognitive-behavioural therapy (CBT), is essential in treating social anxiety disorder across all ages, from very young children to adults. CBT focuses on identifying and changing negative thought patterns and behaviours that contribute to anxiety.

In severe cases, some may consider medications like selective serotonin reuptake inhibitors (SSRIs). But as with all medications, there can be side effects and the decision to medicate should be made after a thorough evaluation by a psychiatrist, who will consider how severe the anxiety is, how it affects everyday life and the benefits versus the risks of the medication.

Support from schools and families is essential; they play a big role in providing the necessary support systems.

Schools can contribute by training teachers and staff to be aware of mental health issues and by creating an inclusive learning environment. Including mental health education in the curriculum can significantly improve how students understand and manage their mental health.

Families should keep an open dialogue about mental health, normalise seeking help when necessary, and encourage the development of social skills from an early age.

Peter's story is just one among many, but it's a reminder that behind every statistic is a real person struggling with real challenges.

By working together to address social anxiety disorder and other mental health issues, we can create a more inclusive and supportive society where everyone has the opportunity to thrive.

*A pseudonym was used in this commentary.

Dr Jared Ng is Senior Consultant and Medical Director at Connections MindHealth. He was previously chief of the department of emergency and crisis care at the Institute of Mental Health.