Key Points
- Social anxiety is common, correlated with childhood trauma, and predicts future depression.
- Depression with and without social anxiety is different in symptom presentation, severity, and treatment.
- Addressing underlying factors is likely to improve treatment outcomes and quality of life for those with combined social anxiety and 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.
Is Depression With Social Anxiety Different From Depression Alone?
A recent study in the Journal of Psychiatric Research (2022) compared patients with SAD alongside those with combined (“comorbid”) MDD and SAD. The goal of this research by Elling and colleagues was to understand areas of overlap and differentiation between the two groups, with a focus on childhood adversity and attachment style.
It’s relevant that people with SAD have higher rates of childhood trauma, including a greater likelihood of a history of bullying or “peer victimization” (Pontillo et al., 2019), also associated with depression (Mei, 2021).
While research to date has not explicitly looked at how depression fits in with social anxiety and adverse childhood experiences, based on the current understanding, there is reason to believe that there are important differences between the two groups with implications for treatment and recovery.
Regarding attachment style, researchers observed that attachment can be viewed as how one sees oneself and others. In secure attachment, people have a positive model of themselves and a positive model of others.
With insecure attachment subtypes, those with fearful attachment have a negative model of oneself and a negative view of others, those with preoccupied attachment have a negative model of oneself and a positive model of others, and those with dismissive attachment have a positive model of the self and a negative model of others.
Social anxiety is expected to be correlated with a negative model of oneself and may be associated with negative or positive assumptions about others.
Head-to-Head Comparison
To look more closely at the relationships among depression, social anxiety, childhood trauma, and attachment, researchers recruited 612 patients for a study comparing those with SAD-MDD with those with MDD alone. Participants completed several measures, in addition to formal diagnostic testing: the Social Phobia Inventory (SPIN), the Beck Depression Inventory (BDI), the Adverse Childhood Experiences Scale (ACE), and the Attachment Style Questionnaire (ASQ).
The initial analysis found significant differences between the two groups. SAD-MDD participants reported fewer relationships and overall lower education levels. They had a greater number of additional anxiety problems, including panic, generalized anxiety, and agoraphobia; increased suicidal thinking; and had received more treatment with medication and therapy.
Those in the SAD-MDD group had significantly higher ACE scores, reflecting more severe childhood adversity. SAD-MDD participants were significantly less likely to have secure attachment and more likely to show the insecure fearful attachment style. Furthermore, this fearful attachment was associated with greater social anxiety, predicting over 15 percent of symptoms severity. Likewise, increased childhood adversity was statistically associated with greater social anxiety severity, both directly and via insecure attachment style, including both fearful and preoccupied attachment.
Implications for Treatment and Recovery
This 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.
This 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.1
Originally published in Psychology Today on January 22, 2022
References
Note
1. It’s unusual to take a literal approach to self-relationship, in which we might think of our relationship with ourselves in just the same way we think about how we relate to an actual other person. However, this weird perspective shift can be a powerful tool for awareness, tilting the landscape of what we think is OK for ourselves compared with others. This is especially important for people with negative self-attributions who may treat themselves and others according to different standards, with a tendency at times to hold lower standards for oneself in spite of sometimes seeming to preference oneself in other ways.
For example, it’s not unusual for me to encounter people who apply more stringent moral standards in how they treat others, for example respecting others’ basic human rights more than their own, or feeling apparently greater compassion for others than oneself. It can be a useful exercise to consider this aspect of self-relationship, including more basic behaviors around emotional and physical self-care and daily practice. Co-authors and I call the dysfunction in self-reflexive attitudes and behaviors “self-irrelationship” and write about how to make our natural inner contradictions – which can make us feel “crazy” – work for us.
Ohayon MM, Schatzberg AF. Social phobia and depression: prevalence and comorbidity. J Psychosom Res. 2010 Mar;68(3):235-43. doi: 10.1016/j.jpsychores.2009.07.018. PMID: 20159208.
Christina Elling, Andreas J. Forstner, Laura-Effi Seib-Pfeifer, Martin Mücke, Jutta Stahl, Franziska Geiser, Johannes Schumacher, Rupert Conrad, Social anxiety disorder with comorbid major depression – why fearful attachment style is relevant, Journal of Psychiatric Research, 2022, ISSN 0022-3956, https://doi.org/10.1016/j.jpsychires.2022.01.019.
Pontillo M, Tata MC, Averna R, et al. Peer Victimization and Onset of Social Anxiety Disorder in Children and Adolescents. Brain Sci. 2019;9(6):132. Published 2019 Jun 6. doi:10.3390/brainsci9060132
Mei S, Hu Y, Sun M, et al. Association between Bullying Victimization and Symptoms of Depression among Adolescents: A Moderated Mediation Analysis. Int J Environ Res Public Health. 2021;18(6):3316. Published 2021 Mar 23. doi:10.3390/ijerph18063316
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Grant H. Brenner, MD
Psychiatry
Grant Hilary Brenner, M.D., a psychiatrist and psychoanalyst, helps adults with mood and anxiety conditions, and works on many levels to help unleash their full capacities and live and love well.
