According to the American Psychological Association (APA), social anxiety disorder (SAD) and major depressive disorder (MDD) are prevalent disorders that exhibit a high rate of co-occurrence. Furthermore, these disorders have been shown to be associated with each other, suggesting that the presence of one disorder increases risk for the other disorder.
Comorbidity in social anxiety disorder (SAD) refers to having another disorder in addition to SAD. Having SAD increases the chance that you will be diagnosed with another disorder, and also makes receiving treatment more complex. Many disorders are related to social anxiety disorder (SAD), including other anxiety disorders, depression, and personality disorders.
There is an established relationship between depression and social anxiety disorder – if you’ve been diagnosed with SAD, you are more likely to develop depression later in life. Furthermore, people who suffer from both depression and social anxiety disorder often only seek help for depression, even though they may have had severe social anxiety for many more years. There is evidence that this underlying vulnerability is genetic in nature and related to trait-like constructs such as positive and negative affect.
Unfortunately, treating depression without also treating the underlying social anxiety will not be as effective. This is why it is important to share all of your symptoms with your doctor, and for physicians to be alert to potential signs of social anxiety disorder.
If you live with social anxiety, it can be tempting to avoid social situations that might cause uncomfortable anxiety symptoms. As humans, we’re programmed to keep pain at bay, after all. So, what happens when you’re sitting at home alone after backing out of plans with your friends at the last minute? For some people with social anxiety, the isolation it brings can come with feelings of inadequacy, sadness, or even shame, sometimes mimicking or causing depression. Social anxiety that leads to a diagnosis like major depressive disorder (MDD) can sometimes mean dealing with anxiety and depression symptoms that are harder to treat. But a care approach that supports you in addressing social anxiety symptoms head-on while acknowledging and treating your depressive symptoms can help.
What is Social Anxiety?
When people bring up social anxiety, they usually mean social anxiety disorder, an anxiety disorder also called “social phobia.“ Fear around social situations is the main feature of social anxiety, according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5). But this fear can come up at different times, depending on what kind of social anxiety you have. For example, some people have “performance only” social anxiety, meaning their anxiety only flares up in situations where they must speak or perform in front of others. They might not experience anxiety at parties, their workplace, or the grocery store, as is common for other people with social anxiety. Since social anxiety causes fear in social situations, it’s not uncommon to become isolated if you live with the condition. While isolation doesn’t always cause loneliness, it often can – and this loneliness often leads to depression.
Social anxiety disorder (SAD) and major depressive disorder (MDD) are often co-present, up to 20 percent of the time, higher in some groups. Social anxiety starts earlier in life, affecting nearly 5 percent of people, foreshadowing future depression with a five-fold risk of depression for those with prior social anxiety (Ohayon & Shatzberg, 2010). Combined, they are more difficult to treat as the symptoms of each synergize with the other.
For example, anxiety and avoidance of social interactions in SAD worsen social withdrawal seen with depression. Negative feelings about oneself and often others in depression reinforce negative perceptions in social anxiety. The vicious cycle of negative perceptions of oneself, others, and the world can make recovery challenging, undermining relationships, including therapeutic ones.
Implications for Treatment and Recovery
Research suggests that depression with social anxiety and depression without social anxiety represent distinctly different groups in terms of the lived experience of patients as well as in terms of implications for evaluation, treatment, and recovery.
A primary distinguishing feature is the significantly higher incidence of childhood trauma in the SAD-MDD group, which dovetails with fearful attachment style in adulthood. In my experience as a psychiatrist and therapist for two decades, I have found that while social anxiety and depression are generally identified as current problems, it is not unusual for developmental factors and the impact of attachment style to receive less clinical attention.
Proper identification of core problems and an accurate diagnosis are necessary to guide effective treatment. This can be challenging, especially in psychiatry, as many symptoms overlap and biologically-based diagnostic models are in their infancy.
For instance, despite greater awareness, the role of developmental trauma remains under-recognized and often not fully addressed in treatment. In some cases, the diagnosis of social anxiety, while apt, may miss the broader role of posttraumatic stress symptoms persisting from early life.
Those in the SAD-MDD group required more intensive treatment—this is not surprising given both higher overall symptom severity and more profound underlying difficulties with attachment and trauma. In order to be most effective, it’s important for evaluation to identify and treatment to address the underlying drivers of functional difficulties.
The role of fearful attachment in social anxiety, particularly in social anxiety combined with depression, is a key finding from this research. In some ways, even more than developmental trauma – which while important may be harder to connect up with adult experiences in social and professional settings – fearful attachment makes the connection much clearer.
When we are generally afraid of other people, when our basic assumption is that social situations are inherently threatening or even outright dangerous, it is a serious barrier to satisfaction and productivity. Fearful reactions to others are less likely to meet the needs of the situation, whether friendship, family, romance, work, or school, leading to maladaptive ways of approaching interpersonal problems.
When we approach others with a fearful attitude, they are more likely to react negatively, compounding the problem and often reinforcing fearful assumptions. For example, if we are standoffish out of fear, others may interpret our behavior as aloof and superior, leading them to back off and confirming beliefs of our own unworthiness as well as others’ shortcomings as we misattribute their motives because our model of others’ inner states (“mentalization”) may be divergent from reality. Others may recognize fear as vulnerability to exploitation and take advantage.
Research offers clinically useful insights. Identifying the role of fearful attachment provides a key target for therapeutic and behavioral interventions. Self-knowledge is one of the four pillars of therapy – coming to terms with basic fears of others provides an opportunity to work on and improve attachment style, addressing potential underlying childhood trauma and learning how to cope more effectively with mistrust, revise distorted perceptions in social situations and in terms of our own sense of self, and over time make progress in addressing both anxiety and depression to enjoy more satisfying relationships with others – and with oneself.
This article is provided by Dr. Ralph Kueche (Child Psychologist). Dr. Kuechle is a Child and Adolescent Clinical Psychologist who specializes in treating children and their families who may be struggling with mood and behavioral issues. Learn more about Dr. Kuechle.
