SOCIAL ANXIETY DISORDER

The occasional experience of anxiety is a normal part of daily life. Perceived dangers or threats produce anxious apprehension or fear, which stimulates individuals to relieve feelings of anxiety.

Normally, anxiety is an adaptive process that elicits a behavioural reaction to reduce danger or injury (e.g., escape and avoidance). However, when individuals experience frequent, intense, sustained, and excessive feelings of anxiety, that interfere with normal daily functioning and produce distress and impairment, anxiety becomes a problem.

One form of anxiety is social anxiety disorder.

WHAT IS SOCIAL ANXIETY DISORDER?

Social anxiety disorder (also known as social phobia) is an anxiety condition characterised by an excessive fear of social situations, including contact with strangers and circumstances where there is potential criticism or scrutiny from others.

This condition is relatively prevalent, with 1 in 7 Australians being affected. It typically occurs during teenage years and is often chronic.

WHAT ARE THE SYMPTOMS OF SOCIAL ANXIETY DISORDER?

Individuals with social anxiety disorder can experience a variety of symptoms. These range from emotional and behavioural symptoms to physical symptoms.

Emotional and behavioural symptoms

A key feature of social anxiety disorder includes a fear of negative evaluation where individuals experience distress from being unfavourably evaluated by others. Because of these fears, individuals with social anxiety disorder use avoidance behaviours to reduce the likelihood of experiencing distress.

Examples of these fears and behaviours include:

Fear of being in situations where you may be judged or scrutinised.
Substantial fear of acting in a certain way that may lead to being negatively evaluated by others.
Fear of being rejected or offending others.
Almost always experiencing fear or anxiety when in social situations.
Avoidance of social situations. If social situations cannot be avoided, they are endured with intense anxiety, fear, and distress.
Avoiding activities, speaking to people, or interacting with strangers out of the fear of being embarrassed or criticised.
Anticipating social situations with dread and anxiety.
Expecting the worse to occur from negative experiences in social situations.

Avoidance and safety behaviours

A prominent feature of social anxiety disorder includes avoidance and safety behaviours. Avoidance behaviours refer to the avoidance of certain activities or situations that may be anxiety provoking. Conversely, safety behaviours (also referred to as safety-seeking behaviours) include behaviours that are used to reduce feelings of fear and anxiety.

Due to substantial fear, common day-to-day activities are often endured with great difficulty by individuals with social anxiety disorder. As a result, these individuals may engage in avoidance and safety behaviours to reduce feelings of fear and distress.

When placed in social situations, individuals with social anxiety disorder fear that they are being negatively evaluated by others. Additionally, they fear that they may act or present themselves in a way that would provoke negative judgment from people around them (e.g., being viewed as weak, stupid, unlikable, dirty, or boring). Individuals with social anxiety disorder may also fear offending others through their actions.

Examples of avoided activities include:

Shopping in a busy mall.
Dining out at restaurants.
Attending parties and social gatherings.
Interacting or engaging in conversation with unfamiliar people.
Going to work or school.
Dating.

Examples of safety behaviours include:

Averting eye contact during conversations.
Dressing in a certain way to avoid attracting attention to oneself.
Sitting or standing in obscured places to reduce attracting attention (e.g., sitting in the back of a lecture theatre).
Drug and/or alcohol use to decrease feelings of anxiety.

Physical symptoms

In addition to emotional and behavioural symptoms, individuals with social anxiety disorder also exhibit physical symptoms. These physical symptoms result from the dysfunctional psychological processes experienced by the sufferer.

Examples of physical symptoms include:

Excessive sweating.
Nausea or diarrhoea.
Trembling and shaking.
Tense muscles.
Rapid heartbeat.
Dizziness or light-headedness.
Blushing.
Shortness of breath.

MODELS OF SOCIAL ANXIETY DISORDER

To date, several models (also referred to as theories) have been developed to explain the psychological processes involved in social anxiety disorder. Some of these models include:

Self-presentation model: where people feel motivated to make a good impression but doubt their ability to do so. This then leads to individuals perceiving that they are being unsatisfactory evaluated by others, which results in social anxiety.

Cognitive model: where self-focused attention, negative social thoughts, safety behaviours, and rumination are argued to maintain social anxiety.

Cognitive-behavioural model: where maintenance of social anxiety is argued to be due to distorted/biased processing of social-evaluative information producing heightened anxiety in social situations.

Common factors in each of the abovementioned models include the role of cognitive and behavioural processes in social anxiety, along with a focus on fear of negative evaluation. In the self-presentation model, this can be seen through socially anxious individuals engaging in self-evaluation and being motivated to appear socially desirable. Likewise, in the cognitive and cognitive-behavioural models, individuals with social anxiety are argued to experience negative cognitions in relation to processing of social-evaluative information and overestimate the likelihood and consequence of negative evaluation.

A recently developed model of social anxiety is the bivalent fear of evaluation model. The bivalent fear of evaluation model expanded on previous models of social anxiety as it examined the role of fear of positive evaluation in addition to fear of negative evaluation. This model will be discussed further in the section below.

THE BIVALENT FEAR OF EVALUATION MODEL OF SOCIAL ANXIETY

The bivalent fear of evaluation model of social anxiety is a model developed to understand the psychological processes that contribute to social anxiety symptoms.

The original bivalent fear of evaluation model by Weeks and Howell (2012) consisted of fear of negative evaluation (distress in response to unfavourable evaluations of oneself by others; e.g., being afraid that others will not approve of you) and fear of positive evaluation (distress in response to favourable evaluations of oneself by others; e.g., being uncomfortable when receiving compliments). While fear of negative evaluation had traditionally been associated with social anxiety, Weeks and Howell argued that fear of positive evaluation also contributed to social anxiety symptoms where both fears contributed to a general fear of evaluation.

Most recently, Cook, Meyer, and Knowles (2018) extended the bivalent fear of evaluation model to include concerns of social reprisal and disqualification of positive social outcomes. Their extended model identified that while fear of negative and positive evaluation directly influenced social anxiety symptoms, the relationship between fear of negative and positive evaluation, and social anxiety symptoms were also affected by concerns of social reprisal and disqualification of positive social outcomes (see below for a diagram and summary of factors influencing social anxiety symptoms).

Fear of negative evaluation: Distress from being unfavourably evaluated by others (e.g., I am afraid that people will find fault with me).

Fear of positive evaluation: Distress from being favourably evaluated by others (e.g., I generally feel uncomfortable when people give me compliments).

Concerns of social reprisals: Fear of being evaluated too positively by others, and the resulting reprisal that may ensue (e.g., I could see making a good impression on others as being threatening to some people).

Disqualifications of positive social outcomes: Attributing positive experiences and success to external factors as opposed to one’s own ability or effort (e.g., When people tell me that they find what I’m saying to be interesting, I usually assume that they are just humouring me).

The extended bivalent fear of evaluation model of social anxiety
Cook, S., Meyer, D., Knowles, S.R. (2018). Relationships between psychoevolutionary fear of evaluation, cognitive distortions, and social anxiety symptoms: A preliminary structural equation model.
Australian Journal of Psychology

DYSFUNCTIONAL ATTITUDES ASSOCIATED WITH SOCIAL ANXIETY

Dysfunctional attitudes are pervasive negative attitudes towards oneself, the outside world, and the future. Regarding the mechanisms involved, dysfunctional attitudes distort reality by making the individual misinterpret what is going on in their environment (Wong, 2008). With interpretations are not supported by reasonable evidence, individuals with dysfunctional attitudes experience negative cognitions where they illogically evaluate themselves, others, and their environment (Tanaka et al., 2006).

Dysfunctional attitudes have been associated with the development of anxiety disorders generally (Mogg & Bradley, 1998; Wong, 2008) and social anxiety specifically (Kumari, Sudhir, & Mariamma, 2012; Noh & Kim, 2016; Rudaz et al., 2016; Wong & Sun, 2006). They have also been argued to give rise to emotions that lead to feelings of distress and harmful behaviours (Tanaka et al., 2006).

DIAGNOSIS AND TREATMENT OF SOCIAL ANXIETY DISORDER

Social anxiety disorder can be diagnosed by General Practitioners (GPs), psychologists, and psychiatrists. It is a good idea to see a GP if you are experiencing social anxiety symptoms as they can check for medical problems that may be contributing to your anxiety. In addition to making a diagnosis, GPs will also be able to discuss treatment options, prescribe an anxiolytic (anti-anxiety medication), and write a referral to a mental health specialist (e.g., a psychologist or psychiatrist).

A variety of treatments are available for social anxiety disorder. These treatments can be classified as being psychological or medical. Generally, psychological treatments will be the first line of treatment. However, in severe cases medication can also be delivered alongside psychological therapy. It should be noted that medical treatments can only be delivered by registered medical practitioners, such as GPs and psychiatrists. Psychologists can only conduct psychological treatment.

Psychological treatments

Cognitive Behavioural Therapy

Cognitive Behavioural Therapy (CBT) offers the most consistent evidence for the reduction of social anxiety and is therefore one of the most accepted treatment options. CBT is a short-term focused approach to changing unhelpful thoughts, habits, and behaviours, and replacing them with healthier ones.

Graduated Exposure Therapy

Graduated exposure therapy is a common treatment for anxiety conditions and involves individuals being gradually exposed to their feared object or situation within a safe context. Exposure to the feared stimulus is gradual, so that the individual gradually confronts their fear until they no longer experience distress to their feared object situation.

Hypnotherapy

In a hypnotherapy session, the therapist induces a state of deep relaxation in the patient. In this relaxed state, the brain can more readily replace unwanted thoughts and habits with those that are healthier and more useful.

Relaxation training

Relaxation training involves learning a technique that increases feelings of relaxation and calmness, while reducing negative feelings of stress and anxiety. A variety of relaxation techniques exist, with some of the most well know including deep breathing, mindfulness meditation, progressive muscle relaxation, tai chi, yoga, and other forms of exercise.

Other potential psychological approaches to treating social anxiety disorder

Mindfulness-Based Stress Reduction (MBSR)

Mindfulness-based stress reduction is an eight-week program that involves intensive mindfulness (directing attention to experiences occurring in the present moment) training. This program was developed to support individuals experiencing anxiety, depression, stress, chronic pain, and stress related to medical conditions. Mindfulness-based stress reduction assists individuals to become aware of stressful or unpleasant feelings and stress reactions they may be experiencing. It allows individuals with anxiety, depression, or other afflictions to recognise their feelings in the current moment and enables them to react in a positive way.

Acceptance and Commitment Therapy (ACT)

Acceptance and commitment therapy is a psychological treatment program that uses acceptance (the process of recognising and accepting negative or uncomfortable situations without trying to change them) and mindfulness (focusing ones attention to experiences that are occurring within the present moment) strategies, with behaviour-change and commitment strategies. The aim of acceptance and commitment therapy is to recognise, understand, and accept challenging feelings and situations as opposed to actively trying to eliminate or change them. Acceptance and commitment therapy allows individuals to open-up to unpleasant feelings they may be experiencing, learn to not avoid situations or circumstances that may elicit these feelings, and to learn not to overreact to them.

Medical treatments

Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are often the first type of medication prescribed to address social anxiety symptoms. SSRIs work by reducing the reabsorption of serotonin by nerve cells, which in turn leads to increased levels of serotonin within the brain. Serotonin is a naturally occurring neurotransmitter/chemical within the brain that is involved in the regulation of a variety of functions such as mood. In anxiety disorders, serotonin is in a state of imbalance. Through the stabilisation of serotonin levels, SSRIs may assist in decreasing anxiety symptoms. Your treating doctor may prescribe SSRIs under a variety of names such as paroxetine, fluoxetine, escitalopram, citalopram, and sertraline.

Benzodiazepines

Benzodiazepines are a type of medication known as central nervous system depressants (also referred to as sedatives). They work by reducing activity of the central nervous system (the brain and spinal cord) and slowing down the messages travelling between the brain and body. Benzodiazepines can help reduce anxiety symptoms and promote sleep. However, due to the addictive nature of benzodiazepines, they are only designed for short term use. Your treating doctor may prescribe benzodiazepines under a variety of names such as diazepam, temazepam, oxazepam, and alprazolam.

SUMMARY OF SOCIAL ANXIETY DISORDER

Social anxiety disorder is characterised by an excessive fear of social situations, including contact with strangers and circumstances where there is potential criticism or scrutiny from others. It is relatively prevalent with 1 in 7 Australians being affected. Individuals with social anxiety disorder experience a range of psychological and physical symptoms. Several models have been developed to explain social anxiety disorder, with the most recent model arguing that social anxiety results from a fear of negative and positive evaluation in addition to concerns of social reprisals and disqualifications of positive social outcomes. Diagnosis and treatment of social anxiety disorder can be conducted by GPs, psychologists, and psychiatrists, with a variety of psychological and medical treatments being available.