Defining Social Anxiety
Social anxiety disorder (formerly called social phobia) is characterized by extreme and persistent fear or anxiety and avoidance of social situations in which the person could potentially be evaluated negatively by others (APA, 2013). As with specific phobias, social anxiety disorder is common in the United States; a little over 12% of all Americans experience social anxiety disorder during their lifetime (Kessler et al., 2005).
The heart of the anxiety in social anxiety disorder is the person’s concern that they may act in a humiliating or embarrassing way, such as appearing foolish, showing symptoms of anxiety (such as blushing), or doing or saying something that might lead to rejection (such as offending others). The kinds of social situations that may cause distress include public speaking, having a conversation, meeting strangers, eating in restaurants, or using public restrooms. Although many people become anxious in social situations like public speaking, the fear, anxiety, and avoidance experienced in social anxiety disorder are highly distressing and lead to serious impairments in life.
Physical symptoms often accompanying social anxiety disorder include excessive blushing, excessive sweating, trembling, palpitations, and nausea. Stammering may be present, along with rapid speech. Panic attacks can also occur under intense fear and discomfort. Some sufferers may use alcohol or other drugs to reduce fears and inhibitions at social events. Adults with this disorder are more likely to experience lower educational attainment and lower earnings (Katzelnick et al., 2001); more likely to perform poorly at work and to be unemployed (Moitra, Beard, Weisberg, & Keller, 2011); and report greater dissatisfaction with their family lives, friends, leisure activities, and income (Stein & Kean, 2000).
When people with social anxiety disorder are unable to avoid situations that provoke anxiety, they typically perform safety behaviors: mental or behavioral acts that reduce anxiety in social situations by reducing the chance of negative social outcomes. Safety behaviors can include avoiding eye contact, rehearsing sentences before speaking, talking only briefly, and not talking about oneself (Alden & Bieling, 1998). Although these behaviors are intended to prevent the person with social anxiety disorder from doing something awkward that might draw criticism, these actions often exacerbate the problem because they do not allow the individual to disconfirm their negative beliefs, often eliciting rejection and other negative reactions from others (Alden & Bieling, 1998).
Social anxiety disorder
Worry and fear of social situations in which one may be negatively judged is a defining feature of social anxiety disorder. (credit: Freddie Peña)
DSM-5 Diagnostic Criteria
In order to be diagnosed with social anxiety disorder, a person must experience an intense fear in one or more social situations, marked specifically by the fear of embarrassment or humiliation. This anxiety—or efforts to avoid the anxiety-inducing situation—must cause considerable distress and an impaired ability to function in at least some parts of social, occupational, academic, or daily life. Symptoms must last at least six months in order for a diagnosis to occur, and the symptoms must not be better accounted for by the effects of substance use, a medical condition, or another mental illness.
Etiology
Research into the causes of social anxiety and social phobia is wide-ranging, encompassing multiple perspectives from neuroscience to sociology. Scientists have yet to pinpoint the exact causes. Studies suggest that genetics can play a part in combination with environmental factors. It has been shown that there is a two- to threefold greater risk of having social phobia if a first-degree relative also has the disorder; this could be due to genetics and/or due to children acquiring social fears and avoidance through observational learning.
As with specific phobias, it is highly probable that the fears inherent in social anxiety disorder can develop through conditioning experiences. For example, children who are subjected to early unpleasant social experiences (e.g., bullying at school) may develop negative social images of themselves that become activated later in anxiety-provoking situations (Hackmann, Clark, & McManus, 2000). Indeed, one study reported that 92% of a sample of adults with social anxiety disorder reported a history of severe teasing in childhood, compared to only 35% of a sample of adults with panic disorder (McCabe, Antony, Summerfeldt, Liss, & Swinson, 2003).
One of the most well-established risk factors for developing social anxiety disorder is behavioral inhibition (Clauss & Blackford, 2012). Behavioral inhibition is thought to be an inherited trait, and it is characterized by a consistent tendency to show fear and restraint when presented with unfamiliar people or situations (Kagan, Reznick, & Snidman, 1988). A recent statistical review of studies demonstrated that behavioral inhibition was associated with a greater-than sevenfold increase in the risk of development of social anxiety disorder, indicating that behavioral inhibition is a major risk factor for the disorder (Clauss & Blackford, 2012).
Treatment
The first-line treatment for social anxiety disorder is cognitive behavioral therapy (CBT), which has been shown to be effective in treating social phobias through both individual and group therapy. The cognitive and behavioral components seek to change thought patterns and physical reactions to anxiety-inducing situations.
The attention given to social anxiety disorder has significantly increased since 1999, with the approval and marketing of several drugs for its treatment. Prescribed medications include several classes of antidepressants: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs). Other commonly used medications include beta blockers and benzodiazepines.