Adults with ASD and Social Anxiety Disorder

Social Anxiety Disorder (SAD), also called social phobia, is diagnosed when individuals become overwhelmingly anxious and excessively self-conscious in everyday social situations. ASD (high functioning autism) adults with SAD have an intense, persistent fear of interacting with others (especially in groups). They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.

It's normal to feel nervous in some social situations. For example, going on a date or giving a presentation may cause that feeling of butterflies in your stomach. But in SAD, everyday interactions cause irrational anxiety and self-consciousness.

While many ASD adults with SAD realize that their fears about being with others are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.

SAD can be limited to one situation (e.g., talking to others, eating or drinking, writing on a blackboard in front of others, etc.) or may be so broad that the individual experiences anxiety around almost anyone other than close family members.

 

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Symptoms—

Emotional and behavioral SAD signs and symptoms include:

• Anxiety that disrupts your daily routine, work, school or other activities
• Avoiding doing things or speaking to others out of fear of embarrassment
• Avoiding situations where you might be the center of attention
• Difficulty making eye contact
• Difficulty talking
• Fear of situations in which you may be judged
• Fear that others will notice that you look anxious
• Intense fear of interacting with strangers
• Worrying about embarrassing or humiliating yourself

Physical SAD signs and symptoms include:

• Blushing
• Cold, clammy hands
• Confusion
• Diarrhea
• Fast heartbeat
• Muscle tension
• Nausea
• Shaky voice
• Sweating
• Trembling or shaking
• Upset stomach

Worrying about having symptoms:

When adults on the spectrum have SAD, they realize that their anxiety or fear is out of proportion to the situation. Yet they’re so worried about developing SAD symptoms that they avoid situations that may trigger them. This type of worrying creates a vicious cycle that can make symptoms worse.

When to see a doctor:

See your doctor or mental health provider if you fear and avoid normal social situations because they cause embarrassment, worry or panic. If this type of anxiety disrupts your life, causes severe stress and affects your daily activities, you may have SAD or another mental health condition that requires treatment to get better.

Feelings of shyness or discomfort in certain situations aren't necessarily signs of SAD, particularly in kids. Comfort levels in social situations vary from individual to individual due to personality traits and life experiences. Some people are naturally reserved and others are more outgoing. What sets SAD apart from everyday nervousness is that its symptoms are much more severe, causing the  individual to avoid normal social situations.

Common, everyday experiences that may be difficult to endure when the ASD adult has SAD include:

• Being introduced to strangers
• Entering a room in which individuals are already seated
• Initiating conversations
• Interacting with strangers
• Making eye contact
• Ordering food in a restaurant
• Returning items to a store
• Using a public restroom or telephone
• Writing in front of others

SAD symptoms can change over time. They may flare up if you're facing a lot of stress or demands, or if you completely avoid situations that would usually make you anxious, you may not have symptoms. Although avoidance may allow you to feel better in the short term, your anxiety is likely to persist over the long term if you don't get treatment.

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Causes—

Like many other mental health conditions, SAD likely arises from a complex interaction of environment and genes. Possible causes include:

• Brain chemistry: Natural chemicals in your body may play a role in SAD. For instance, an imbalance in the brain chemical serotonin may be a factor. Serotonin is a neurotransmitter that helps regulate mood and emotions, among other things. Individuals with SAD may be extra-sensitive to the effects of serotonin.
• Brain structure: A structure in the brain called the amygdale may play a role in controlling the fear response. Individuals who have an overactive amygdala may have a heightened fear response, causing increased anxiety in social situations.
• Inherited traits: Anxiety disorders tend to run in families. However, it isn't entirely clear how much of this may be due to genetics and how much is due to learned behavior.
• Negative experiences: Kids who experience teasing, bullying, rejection, ridicule or humiliation may be more prone to SAD. In addition, other negative events in life, such as family conflict or sexual abuse, may be associated with SAD.

Risk factors—

SAD is one of the most common mental disorders. It usually begins in the early to mid-teens, although it can sometimes begin earlier in childhood or in adulthood. A number of factors can increase the risk of developing SAD, including: 

• Environment: SAD may be a learned behavior. That is, the ASD person may develop the condition after witnessing the anxious behavior of others. In addition, there may be an association between SAD and moms and dads who are more controlling or protective of their kids.
• Family history: You're more likely to develop SAD if your biological moms and dads or siblings have the condition.
• Having a health condition that draws attention: Facial disfigurement, stuttering, Parkinson's disease and other health conditions can increase feelings of self-consciousness and may trigger SAD in some individuals.
• New social or work demands: Meeting new individuals, giving a speech in public or making an important work presentation may trigger SAD symptoms for the first time. These symptoms usually have their roots in adolescence, however.
• Temperament: Kids who are shy, timid, withdrawn or restrained when facing new situations or individuals may be at greater risk.

Complications—

Left untreated, SAD can be debilitating. Your anxieties may run your life. They can interfere with work, school, relationships or enjoyment of life. You may be considered an "underachiever," when in reality it's your fears holding you back, not your ability or motivation. In severe cases, you may drop out of school, quit work or lose friendships. SAD can cause:

• Hypersensitivity to criticism
• Low self-esteem
• Negative self-talk
• Poor social skills
• Trouble being assertive

SAD can also result in:

• Excessive drinking, particularly in men
• Isolation and difficult social relationships
• Low academic achievement
• Poor work record
• Substance abuse
• Suicide

Preparing for a doctor’s appointment—

You may start by seeing your family doctor. After your initial appointment, your doctor may refer you to a mental health provider who can help make a firm diagnosis and create the right treatment plan for you.

What you can do:

• Ask a trusted family member or friend to be present for your appointment, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down all of your medical information, including other physical or mental health conditions with which you've been diagnosed. Also write down the names of any medications you're taking.
• Write down any symptoms you've been experiencing, and for how long. SAD often first appears in your teens. Your doctor will be interested to hear how your symptoms may have waxed or waned since they began.
• Write down questions to ask your doctor.
• Write down your key personal information, especially any significant events or changes in your life shortly before your symptoms appeared. For example, your doctor will want to know if your social anxiety seemed to be triggered by a promotion, meeting new individuals, or another new work or social demand.

Questions to ask your doctor at your initial appointment may include:

• Are there any other possible causes?
• How will you determine my diagnosis?
• Should I see a mental health specialist?
• What do you believe is causing my symptoms?

Questions to ask if you are referred to a mental health provider include:

• Am I at increased risk of other mental health problems?
• Are effective treatments available for this condition?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?
• Is my condition likely temporary or chronic?
• With treatment, could I eventually be comfortable in the situations that make me so anxious now?

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In addition to the questions that you've prepared in advance, don't hesitate to ask questions at any time during your appointment.

A doctor or mental health provider who sees the person for possible SAD may ask:

• Do you avoid activities in which you are the center of attention?
• Do you drink alcohol or use illegal drugs? If so, how often?
• Do you ever have symptoms when you're not being observed by others?
• Does anything seem to make your symptoms better or worse?
• Does fear of embarrassment cause you to avoid doing things or speaking to individuals?
• Have any of your close relatives had similar symptoms?
• Have you been diagnosed with any medical conditions?
• Have you been treated for other psychiatric symptoms or mental illness in the past? If yes, what type of therapy was most beneficial?
• Have you ever thought about harming yourself or others?
• How are your symptoms affecting your life, including your work and personal relationships?
• When are your symptoms most likely to occur?
• When did you first notice these symptoms?
• Would you say that being embarrassed or looking stupid is among your worst fears?

Tests and diagnosis—

When you decide to seek treatment for SAD symptoms, you may have a physical exam and your doctor will ask a number of questions. The physical exam can determine if there may be any physical causes triggering your symptoms. Answering questions will help your doctor or mental health provider find out about your psychological state.

There's no laboratory test to diagnose SAD, however. Your doctor or mental health provider will ask you to describe your signs and symptoms, how often they occur and in what situations. He or she may review a list of situations to see if they make you anxious or have you fill out psychological questionnaires to help pinpoint a diagnosis.

To be diagnosed with SAD, an individual must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Criteria for SAD to be diagnosed include:

• Persistent fear of social situations in which the individual believes he/she may be scrutinized or act in a way that's embarrassing or humiliating.
• These social situations cause you a great deal of anxiety.
• You avoid anxiety-producing social situations.
• You recognize that your anxiety level is excessive or out of proportion for the situation.
• Your anxiety or distress interferes with your daily living.

SAD shares symptoms with other psychological disorders, including other anxiety disorders. Your mental health provider will want to determine whether one of these other conditions may be causing your social anxiety, or if you have SAD along with another mental health disorder. Often, social anxiety occurs along with other mental health conditions, such as substance abuse problems, depression and body dysmorphic disorder.

Treatments and drugs—

The two most common types of treatment for SAD are medications and psychotherapy. These two approaches may be used in combination.

Psychotherapy:

Psychological counseling (psychotherapy) improves symptoms in most individuals with SAD. In therapy, you learn how to recognize and change negative thoughts about yourself. Cognitive behavioral therapy is the most common type of counseling for anxiety. This type of therapy is based on the idea that your own thoughts — not other individuals or situations — determine how you behave or react. Even if an unwanted situation won't change, you can change the way you think and behave.

Cognitive behavioral therapy may also include exposure therapy. In this type of therapy, you gradually work up to facing the situations you fear most. This allows you to become better skilled at coping with these anxiety-inducing situations and to develop the confidence to face them. You may also participate in skills training or role-playing to practice your social skills and gain comfort and confidence relating to others. Your mental health professional may help you develop relaxation or stress management techniques. 

 

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First choices in medications:

Several types of medications are used to treat SAD. However, selective serotonin reuptake inhibitors (SSRIs) are often the first type of medication tried for persistent symptoms of social anxiety. SSRIs your doctor may prescribe include:

• Fluoxetine (Prozac, Sarafem, others)
• Fluvoxamine (Luvox)
• Paroxetine (Paxil)
• Sertraline (Zoloft)

The serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor) also may be an option for SAD.

To reduce the risk of side effects, your doctor will start you at a low dose of medication and gradually increase your prescription to a full dose. It may take up to three months of treatment for your symptoms to noticeably improve.

Other medication options:

Your doctor or mental health provider may also prescribe other medications for symptoms of social anxiety.

• Anti-anxiety medications: A type of anti-anxiety medication called benzodiazepines may reduce your level of anxiety. Although they often work quickly, they can be habit-forming. Because of that, they're often prescribed for only short-term use. They may also be sedating. If your doctor does prescribe anti-anxiety medications, make sure you try taking them before you're in a social situation so that you know how they will affect you.
• Beta blockers: These medications work by blocking the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs. Because of that, they may work best when used infrequently to control symptoms for a particular situation, such as giving a speech. They're not recommended for general treatment of SAD. As with anti-anxiety medications, try taking them before you need them to see how they affect you.
• Other antidepressants: The person may have to try several different antidepressants to find which one is the most effective and has the fewest unpleasant side effects.

Don't give up if treatment doesn't work quickly. The ASD adult can continue to make strides in psychotherapy over several weeks or months. And finding the right medication for your situation can take some trial and error. For some individuals, the symptoms of SAD may fade over time, and medication can be discontinued. Others may need to take medication for years to prevent a relapse. To make the most of treatment, keep your medical or therapy appointments, take medications as directed, and talk to your doctor about any changes in your condition.

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Lifestyle and home remedies—

Although SAD generally requires help from a medical expert or qualified psychotherapist, the individual can try some self-help techniques to handle situations likely to trigger symptoms.

First, consider your fears to identify what situations cause the most anxiety. Then gradually practice these activities until they cause you less anxiety. Begin with small steps in situations that aren't overwhelming.

Situations to practice may include:

• Asking a retail clerk to help you find an item
• Calling a friend to make plans
• Eating with a close relative, friend or acquaintance in a public setting.
• Getting directions from a stranger
• Giving someone a compliment
• Making eye contact and returning greetings from others, or being the first to say hello
• Showing an interest in others — ask about their homes, kids, grandkids, hobbies or travels, etc.

At first, being social when you're feeling anxious is challenging. As difficult or painful as it may seem initially, don't avoid situations that trigger your symptoms. By regularly facing these kinds of situations, you'll continue to build and reinforce your coping skills. The following techniques can help

one begin to face situations that make him/her nervous:

• Adopt stress management techniques.
• Focus on personal qualities you like about yourself.
• Pay attention to how often the embarrassing situations you're afraid of actually take place. You may notice that the scenarios you fear usually don't come to pass.
• Practice relaxation exercises.
• Prepare for conversation. For instance, read the newspaper to identify an interesting story you can talk about.
• Set realistic goals.
• When embarrassing situations do happen, remind yourself that your feelings will pass, and you can handle them until they do.

Avoid using alcohol to calm your nerves. It may seem like it helps, but in the long run it can make you feel more anxious.

Alternative medicine—

Certain supplements may help relieve anxiety, although it isn't clear about how much they help or what possible side effects they might have. Some supplements used to treat anxiety include:

• Vitamin B and folic acid: These nutrients may relieve anxiety by affecting the production of chemicals needed for your brain to function (neurotransmitters).
• Valerian: Most commonly used as a sleep aid, valerian has a sedative effect and may also relieve anxiety.
• Kava: This herb is reported to relax you without making you feel sedated. Some studies have linked kava to liver problems, so it isn't a good idea to take it if you have a liver condition, drink alcohol daily or take medications that affect your liver.

Talk to your doctor before taking herbal remedies or supplements to make sure they're safe for you and won't interact with any medications you take.

Coping and support—

Some coping methods that may help ease your anxiety include:

• Doing pleasurable activities, such as exercise or hobbies, when you feel anxious
• Eating a well-balanced diet
• Getting enough sleep
• Joining a group that offers opportunities to improve communication and public speaking skills, such as Toastmasters International
• Joining a local or Internet-based support group
• Reaching out to others with whom you feel comfortable

Over time, these coping methods can help control your symptoms and prevent a relapse. Remind yourself that you can get through anxious moments, that your anxiety is short-lived, and that the negative consequences you worry about so much rarely come to pass.

Prevention—

There's no way to predict for certain what will cause someone to develop an anxiety disorder in the first place, but the person  can take steps to reduce the impact of symptoms if anxious:

• Avoid unhealthy substance use. Alcohol and drug use and even caffeine or nicotine use can cause or worsen anxiety. If you're addicted to any of these substances, quitting can make you anxious. If you can't quit on your own, see your doctor or find a support group to help you.
• Get help early. Anxiety, like many other mental health conditions, can be harder to treat if you wait.
• Keep a journal. Keeping track of your personal life can help you and your mental health provider identify what's causing you stress and what seems to help you feel better.
• Prioritize your life. You can reduce anxiety by carefully managing your time and energy.

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Best Comment:

This is very true, other people can't see that it's a constant battle before, during and after. THis is totally draining. However I think it's vital that Aspergers be diagnosed for a person first before SAD can be addressed. I was treated for SAD which made it worse because they made out I was behaving irrationally, had I known I had Aspergers it would have been OBVIOUS why I feel and act like I do. The reason we suffer from SAD is because of people who don't accept us and don't tune in to our needs.