By Grant H. Brenner
Social anxiety disorder (SAD) and major depressive disorder (MDD) are often co-present, up to 20% of the time, higher in some groups. Social anxiety begins earlier in life, affecting almost 5% of people, foreshadowing future depression with a fivefold increase in depression risk for people with previous social anxiety (Ohayon and Shatzberg, 2010). Combined, they are more difficult to treat because the symptoms of each synergize with each other.
For example, anxiety and avoidance of social interactions in SAD worsen the social withdrawal seen with depression. Negative feelings about self and often others in depression reinforce negative perceptions in social anxiety. The vicious circle of negative perceptions of self, others, and the world can make recovery difficult and undermine relationships, including therapeutic relationships.
Is depression with social anxiety different from depression alone?
A recent study in the Psychiatric Research Journal (2022) compared patients with SAD to 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 is 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).
Although research to date has not explicitly examined how depression integrates with social anxiety and negative childhood experiences, based on current knowledge, there is reason to believe that it There are important differences between the two groups with implications for treatment and recovery.
Regarding attachment style, researchers have observed that attachment can be thought of as how a person views themselves and others. In secure attachment, people have a positive model of themselves and a positive model of others.
With the insecure attachment subtypes, those with fearful attachment have a negative self-model and negative view of others, those with preoccupied attachment have a negative self-model and a positive other-model, and those with who have a dismissive attachment have a positive model of self and a negative model of others.
Social anxiety should be correlated with a negative model of self and can be associated with negative or positive assumptions about others.
To take a closer look at the relationships between 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 tests: 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 revealed significant differences between the two groups. SAD-MDD participants reported fewer relationships and lower levels of education overall. They had a greater number of additional anxiety issues, including panic, generalized anxiety and agoraphobia, an increase in suicidal thoughts, and 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 a secure attachment and more likely to show the insecure fearful attachment style. Additionally, this fearful attachment was associated with greater social anxiety, predicting more than 15% of symptom severity. Similarly, increased childhood adversity was statistically associated with greater severity of social anxiety, both directly and via insecure attachment style, including 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 assessment, treatment and recovery.
A main distinguishing feature is the significantly higher incidence of childhood trauma in the SAD-MDD group, which is consistent 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 commonly identified as current issues, it is not unusual for developmental factors and impact of attachment style receive less clinical attention.
Proper identification of root problems and an accurate diagnosis are necessary to guide effective treatment. This can be difficult, especially in psychiatry, because many overlapping symptoms and biology-based diagnostic models are in their infancy.
For example, 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 appropriate, may miss the larger role of lifelong persistent posttraumatic stress symptoms.
Those in the SAD-MDD group required more intensive treatment – not surprising given both the overall severity of symptoms and the deeper underlying difficulties with attachment and trauma. In order to be most effective, it is important that assessment identifies and treatment addresses the underlying drivers of functional difficulties.
The role of fearful attachment in social anxiety, particularly social anxiety combined with depression, is a key finding of this research. In some ways, even more so than developmental trauma – which, while important, can be more difficult to connect to adult experiences in social and professional contexts – fearful attachment makes the connection much clearer.
When we are generally afraid of others, when our basic assumption is that social situations are inherently threatening or even downright dangerous, this is a serious impediment to satisfaction and productivity. Fear reactions toward others are less likely to meet the needs of the situation, whether it be friendship, family, romance, work, or school, leading to maladaptive ways of address interpersonal issues.
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 indifferent out of fear, others may interpret our behavior as aloof and superior, causing them to back off and confirm beliefs of our own unworthiness as well as the shortcomings of others while we misattribute their motivations because our model of other inner states (“mentalizing”) may be divergent from reality. Others may recognize fear as a vulnerability to exploitation and take advantage of it.
This research offers clinically useful information. Identifying the role of fearful attachment provides a key target for therapeutic and behavioral interventions. Self-awareness is one of the four pillars of therapy – accepting the core fears of others provides an opportunity to work on and improve attachment style, address potential underlying childhood trauma, and learn to deal more effectively with distrust, revise distorted perceptions in social situations and in terms of our own sense of self, and over time make progress in dealing with anxiety and depression to enjoy more satisfying relationships with others – and with oneself 1.