What is Social Anxiety 

Social Anxiety manifests mainly as fears primarily centred around negative social evaluation, rejection and humiliation from others. Those fears often lead to leads to anticipatory anxiety, panic and avoidance of certain people, activities or social situations.

Social Anxiety is often associated with reduced functioning, impaired performance and quality of life, comorbidity with other Anxiety Disorders or Depression.

According to the Diagnostic and Statistical Manual of Mental Disorders,5th Edition (DSM-V), the criteria for social anxiety disorder classification include:

• A persistent fear of one (or more) social or performance situation(s) involving exposure to unknown/less known people or possible scrutiny by others. People usually fear that they will act in an embarrassing or humiliating way.

•  The exposure to the feared situation leads to Anxiety, which may take the form of a situational bond or situationally pre-disposed panic attack.

•  The person is aware that this fear is excessive.

• The feared situation(s) is avoided or endured with intense anxiety and distress. 

• The avoidance, anxious anticipation, and distress of the feared situation(s) interfere significantly with the person's daily routine, functioning, social activities, and relationships.

• The fear, Anxiety, and avoidance behaviour persist for six months or more.

•  The problem is not due to the direct physiological effects of a substance(s), general medical condition or another mental disorder.

     The fear of negative social evaluation in Social Anxiety usually relates to :

• Strong beliefs about excessively high social performance standards ("I must appear funny/ intelligent /cool, etc.)

• Negative beliefs about the personal ability to meet these standards

•  Strong beliefs about drawing the attention of others ("I do things that lead people to attend me") 

• Fear of experiencing shame or humiliation through such attention (positive or negative) OR by appearing less than what is assumed that others expect

     The fear of social situations usually relates to:

• Fear of formal speaking 

• Fear of informal speaking

• Attending meetings/parties 

• Speaking to/infront of authority figures

• Speaking to strangers or not well-known people

• Initiating and/or maintaining conversations 

• Dating 

• Eating in public

• Using public toilets

• other

     The experience of high anxiety and possible panic usually relates to:

• Feelings or beliefs of display of visible physical symptoms of anxiety - twitching, shaking limbs and/or blushing, sweating, gastric motility (which may or may not be observable)

• Panic attacks in anticipation of or during social exposure

  Avoidance and safety behaviours -Some examples:

• Use of excessive make-up (to hide blushing)

• Hiding hands (to hide shaking)

• Avoiding eye contact 

• Wearing lots of clothes (hide sweating)

• Controlling breathing (to hide Anxiety)

•  Holding face and body stiff or leaning on objects (to avoid shaking)

• Drinking beforehand

• Staying silent/being monosyllabic (to avoid attracting attention)

• Making lots of "jokes" (to appear cool)

• Always ask lots of questions (to keep the focus off oneself)

• Sitting in the back of the room (not to attract attention)

• Engaging in activities to reduce interactions (e.g., checking phone or pretending- to look for something)

• Wearing neutral clothing (to avoid others attention)

• Avoiding certain things associated with Anxiety, e.g., drinks, food, etc.

• Other

Prevalence 

In the UK, according to the National Institute of Health and Clinical Excellence (NICE), Social Anxiety is the most common anxiety diagnosis, with a life prevalence of 12%, which is the highest compared to generalised anxiety disorder (GAD)- around 6%, panic disorder (PD)- around 5%; post-traumatic stress disorder- around 7% and obsessive-compulsive disorder – around 2%.

Research data show that Social Anxiety affects equally men and women but is slightly more prevalent for women (2:3); males and females are relatively equal in seeking treatment; the prevalence and presentation are culturally influenced; SA has a significant impact on educational, career, financial status, and general wellbeing. Early age onset predicts severity and chronicity.

Reports show significant comorbidity between Social Anxiety and Depression (19%), Substance Use Disorder (17%), Generalised Anxiety Disorder (5%), Panic Disorder(6%) and PTSD(3%).

SA has an early median age of onset (13 years) and is the most persistent of all anxiety disorders. Only about half of people struggling with symptoms associated with social Anxiety seek treatment.

Cognitive Model of Social Anxiety

The cognitive model of social Anxiety distinguishes three interrelated phases, each characterised by specific dynamic and maintaining mechanisms. They are:

      1. Anticipatory Phase

Upon anticipation of a feared social situation, different cues/triggers are activated, and they provoke anxiety and avoidance. The intensity of both anxiety and avoidance increases with the time approaching the situation. Those cues are contextual and can be informational, situational, or biased beliefs and assumptions. Usually, the affected person starts planning to avoid the situation or engages in preparation—rehearsal or mental rehearsal.

• The mind is preoccupied with painful and detailed rumination of a future event (s), which activates beliefs about social inability.

• The attention is focused on what is perceived as a potential threat, especially social judgements and experiences of shame or humiliation. Memory retrieval is biased and selective in treating and coping with problems and consequences. The preoccupation with the event increases anxiety and, respectively, the avoidance urge.

         2. Situational Exposure Phase

• At the time of the exposure to the fired social event, the anxiety levels and cognitive biases (maladaptive self-schemes) are at their highest level.

• The activated self-schemas create internal and external selective attention to treat cues. Cues for safety are ignored or minimised.

• The person is processing self as a negative social object and engages in automatic inhibitory behaviours (e.g., stiff posture, tight face, staring eyes, shaky voice, etc.).

      3. Post-event Processing Phase

• Social phobics engage in detailed post-mortem recalls and evaluations of past social performance and its outcomes with biased recall and interpretations.

  Most common beliefs that a socially anxious person may hold:

• Deflated negative beliefs about self - "I am boring", "I do not fit in", etc.

• Radical beliefs about disapproval - "To be disapproved is terrible."

• Beliefs about social performance standards- "I must never show weakness"; "I must always sound intelligent."

• Believes about anxiety and its effects -" showing anxiety equals weakness", "people radiculate anxiety in others."

Treatments for Social Anxiety

The UK National Institute for Health and Care Excellence (NICE) guidelines recommend CBT as a first-line treatment for Social Anxiety. Many research studies show that CBT is the most effective treatment. However, the treatment may involve questions of comorbidity.

Medical treatments for Social Anxiety Disorder are typically recommended as a second-line treatment if CBT is refused. 

References:

American Psychiatric Association. (2022). Bipolar and related disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.) https://doi.org/10.1176/appi.books.9780890425787.x05_Anxiety_Disorders 

Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pp. 69–93). New York: Guildford Press

Holmwood, Chris. "Comorbidity of Mental Disorders and Substance Use: A Brief Guide for the Primary Care Clinician." 2008, https://core.ac.uk/download/14931391.pdf. 

Ingraffia, Michelle. "An Examination of the Relationship Between Fear of Evaluation, Social Anxiety, and Depression." 2022, https://core.ac.uk/download/541430876.pdf.

International Classification of Diseases, Eleventh Revision (ICD-11), World Health Organization (WHO) 2019/2021 https://icd.who.int/browse11. Licensed under Creative Commons Attribution-NoDerivatives 3.0 IGO licence (CC BY-ND 3.0 IGO).

National Institute for Health and Care Excellence (NICE: 2013). Social anxiety disorder: recognition, assessment, and treatment. Retrieved from: https://www.nice.org.uk/guidance/cg159/resources/socialanxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397