Social Anxiety

           Fear is an adaptive response to threats that allows humans to learn from their mistakes and avoid dangerous or potentially dangerous situations. One of the most common fears is the fear of public speaking, followed by the fear of death and/or dying. From that information, it can be inferred that people rather die than speak publically. The fear and worry of scrutiny from others can be so intense that it significantly impairs the individual’s daily life. Excessive and debilitating worry over the embarrassment from and the judgement of others is classified as Social Anxiety Disorder, formerly known as Social Phobia.

Description

           Social Anxiety Disorder (SAD), as defined by the Diagnostic Statistical Manual 5, is a fear lasting for at least six months that is centered on potential embarrassment and scrutiny from others, causing clinically significant distress and impairment in an individual’s life. The key aspect of this description is clinically significant distress and impairment. The individual’s fear is usually out of proportion to the actual threat the situation presents (American Psychiatric Association, 2013). Most individuals have feared the judgement of others at least once in their lives; however, it is the intensity of the fear that leads to a lifestyle change through avoidance or modifying behaviors that affects the individual’s life as a whole. The prevalence of SAD for all ages is about 6.8 percent with higher rates found in females (Mahaffey, Wheaton, Fabricant, Berman, & Abramowitz, 2013). Although the prevalence is the same for all ages, older individuals’ social anxiety is less severe with a wider range of feared scenarios, and younger individual’s social anxiety is more severe with a narrower range of feared scenarios.

 Signs and Symptoms

           Cognitive symptoms. Those with Social Anxiety Disorder (SAD) tend to have erroneous cognitions that are centered on a perceived danger. The cognitions of SAD can be categorized into two types of thoughts: The individuals are less socially skilled than others around them, and the individuals will behave in a way that will make them appear socially incompetent (Koerner, Antony, Young, & Mccabe, 2013). The majority of these cognitions stem from the individuals’ observance of their own somatic sensation, such as heart beat, sweating, blushing, and muscle rigidity. In other words, the individuals are hypersensitive to their anxious symptoms. The anxiety then increases when the individuals try to hide their anxious symptoms because they believe that they are now more of a target to others around them (Brown et al., 2014).

Somatic symptoms. The signs and symptoms associated with Social Anxiety Disorder (SAD) include the diagnostic criteria, such as extreme fear in certain social settings, and other somatic symptoms. More than 95 percent of adolescents with SAD have experienced at least one somatic symptom. These somatic symptoms include headaches, sleep disturbances, stomachaches, muscle rigidity and/or pain, shaking, labored breathing, increased heart rate, sweating, blushing, and tiredness. These types of symptoms tend to be more common in female adolescents ranging from 12 to 17 years old. Those with SAD and somatic symptoms are more likely to be comorbid with other disorders. Additionally, somatic symptoms tend to decrease the affected individual’s confidence of competence in other important areas of functioning (Crawley et al., 2014).            

Associated Features

Other factors that can accompany Social Anxiety Disorder (SAD), other than symptoms, are associated features. Some associated features of SAD listed in the Diagnostic Statistical Manual 5 are overly submissive behavior, a lack of eye contact, insufficient social skills, withdrawn and reclusive patterns, and speaking in soft and rigid tones (American Psychiatric Association, 2013).  A study by Festa and Ginsburg in 2011 discovered that over controlling parents, low perceived social validation, and acceptance were common associated features of SAD. When parents are overprotective, the children are never given the opportunity to venture out and socialize on their own, thus stunting their social skills and perpetuating the anxiety and avoidance. Similarly, if the individuals do not feel accepted by their peers, they will not engage in social activities, once again furthering the progression of the disorder. Because of this particular associated feature, those with SAD have lower self-esteem and tend to need more validation and approval from others than what is considered normative.

Self-esteem. Peer opinions and behaviors greatly affect an individual’s self-image. Likewise, self-image plays a major role in self-esteem. Individuals who see themselves as inept, unlikable, and socially awkward are more likely to have lower self-esteems. Valentiner, Skowronski, McGrath, Smith, and Renner concluded in a 2011 that Social Anxiety Disorder (SAD) is stronger correlated with low social self-esteem than with low general self-esteem. Peers can recognize anxiety in individuals and tend to act negatively toward the affected individuals (Settipani & Kendall, 2013). Therefore, positive, edifying social interactions for those with SAD are fewer than those without SAD. This lowers the individuals’ perceptions of their social competence and social self-esteem, thus diminishing social interactions altogether and increasing solitary and isolating behaviors.

Self-medication. A common event that often goes together with isolating behaviors is alcohol and/or drug consumption. Individuals with Social Anxiety Disorder (SAD) tend to engage in self-medication when not seeking professional treatment. Alcohol and drug use are the most common forms of self-medication in anxiety disorders. Alcohol has an altering effect on behavior that lowers the anxiety levels of those with SAD. For this reason, alcohol use, specifically, begins in adolescence to early adulthood. However, on the other hand, SAD has been proven to deter the onset of alcohol and drug use, possibly because of the situations the individuals would have to be in, such as a party or social gathering, in order to receive those substances. It was found that when the initiation of alcohol use was delayed, cognitions of the possible positive effects on the individual’s behavior and anxiety still developed. Consequently, the shift from cognitions of alcohol to actions with alcohol was quicker and smoother than someone without SAD. Moreover, individuals with SAD have a greater tendency and inclination towards alcohol use to help alleviate the symptoms of their anxiety and any comorbidity that may join it (Tomlinson & Brown, 2012).  

Comorbidities

           Depression. The comorbidities, or co-occurrences, of other disorders are highly common in Social Anxiety Disorder (SAD). The most common comorbidity is depression (Cummings, Caporino, & Kendall, 2014). One of the links between SAD and depression is negative self-evaluation. If the individuals are constantly harping on negative qualities or convolutedly believing that they are worthless and incapable, then depression can take root in the solitary and negative environment that SAD has created (de Jong, Sportel, de Hullu, & Nauta, 2012). According to the Diagnostic Statistical Manual-5, depression may also be comorbid with social anxiety because of the long-term seclusion that can occur (American Psychiatric Association, 2013). Comorbidity of depression and SAD tends to be most common in adults, but it has a larger possibility of occurring within youths. However, research has shown that early intervention in youths with SAD can put off the co-occurrence of depression (Cummings, Caporino, & Kendall, 2014).

           Addiction. As mentioned earlier with the self-medication and tendency for individuals with Social Anxiety Disorder (SAD) to resort to alcohol for treatment, individuals with SAD also have a comorbidity of addiction. Alcoholic individuals with SAD tend to have a higher dependence of alcohol and higher depression than those without SAD. In general, having a comorbidity of alcoholism with SAD increases the complexity of the disorder and makes treatment more difficult. On average, individuals with SAD that were comorbid with substance abuse, who sought treatment for their addiction rather than for their SAD had less severe SAD. However, unfortunately because the most used treatment for addiction is group therapy, the individual with SAD will most likely not benefit from the therapy due to their anxiety in social settings (Book, Thomas, Smith, & Miller, 2012).

           Body dysmorphia. Another common comorbidity that exists with Social Anxiety Disorder (SAD) is Body Dysmorphic Disorder (BDD). The BDD is characterized by false perception of physical distortions or defects. Both SAD and BDD have similar distorted cognitions that fuel the distinctive actions that are associated with each disorder. Like SAD, individuals with BDD frequently mistake neutral cues as negative cues. This type of thinking causes a spiral train of thought that does not end until a corrective action is taken. The BDD becomes intertwined with SAD through SAD’s poor psychosocial functioning. The hallmark symptoms of SAD, such as fear and dodging of social events and interactions, are significant aspects that contribute to the difficulties that individuals with BDD experience in their psychosocial functioning (Kelly, Walters, & Phillips, 2010).  

 Possible Etiologies

Cognitive-Behavioral Theory

           Cognitions. The most prevalent theory for Social Anxiety Disorder (SAD) is the cognitive-behavioral theory. This theory combines the distorted cognitions and reinforcing behaviors that hallmark SAD. The onset of anxiety in a social situation begins with the affected individuals believing that those around them have the opportunity to judge them. This is a result of the individuals viewing themselves through the critical lens of an outsider. The overall perceptions the individuals gather are based on previous social interactions, environmental cues, somatic cues, and the individuals’ perceptions of themselves, which results in a generally negative perception. The final cognitive phase is comparing the individuals’ negative perceptions to the expectations of those around them and the imagined likely and exaggerated consequences to this disparity (Singh & Hope, 2009).  

           Behaviors. Once the distorted cognitions are in full effect, the individuals partake in compensatory and reinforcing behaviors. Behaviors range from safety behaviors to avoidance behaviors. Safety behaviors are actions that individuals believe will prevent negative assessment from others. These actions include only talking to people the individuals already know at a social function and/or constant rehearsal of factual information or talking points to avoid looking foolish when speaking (Piccirillo, Dryman, & Heimberg, 2016). The other type of behavior is avoidance behavior. Avoidance behavior is actions that remove the individual from social interactions such as not attending social functions, avoiding eye contact, or not socializing at events (Singh & Hope, 2009). The combination of the inaccurate thoughts and resulting behaviors encompasses this disorder..  

Parental Factors

           Although the basis of peer evaluation has a prominent role in Social Anxiety Disorder (SAD), parental evaluation also plays a role in the development and onset of SAD (Festa & Ginsburg, 2011). It has been found that SAD runs in families. Additionally, if one parent has or had SAD, the child is 4.7 times more likely to also have SAD. However, according to the diathesis-stress model, the individual with the genetic predisposition must have a triggering, stressful event to initiate the onset of the disorder. An adoption study was used to determine the nature versus nurture aspect of SAD. It was found that individuals who had a biological parent with SAD but were raised by responsive and supportive adopted parents did not develop SAD. On the other hand, individuals who had a biological parent with SAD and were raised by unresponsive and unsupportive adopted parents did develop SAD (Knafo et al., 2013). This confirms the diathesis-stress model in regards to SAD.

Treatment

Cognitive-Behavioral Therapy

           Cognitive-behavioral therapy (CBT) utilizes the cognitive-behavioral theory in regards to social anxiety disorder to decrease the symptoms. Three things that CBT focuses on in sessions are social skills shortfalls, negative beliefs, and amplified social attention. These three focal points are targeted through roleplays, Socratic dialogue, and concentration training. At the beginning of treatment, a goal is set by the clinical psychologist and the affected individuals. Ideally, after each subsequent session, the affected individuals get closer to confronting their fears and meeting their goals through the guidance of the therapist and the techniques learned from the therapist (Bogels, Wijts, Oort, & Sallaerts, 2014).

           Cognitive-behavioral therapy can be broken up into five steps of phases. The first step is educating the affected individuals on their diagnosis and disorder. The second step is teaching the individuals to recognize and deny their distorted cognitions. Next, the individuals partake in in vivo exposures to their feared stimuli. This can be instituted during sessions with therapist scaffolding or outside the sessions as homework for the individuals. Once in these exposures, the individuals practice altering their previous negative beliefs into more realistic, positive beliefs. Lastly, the individuals are taught how to maintain the learned techniques once treatment has ended to avoid a relapse (Bruce, Heimberg, Goldin, & Gross, 2013).

Exposure therapy. The most common method of treatment for individuals with social anxiety disorder is exposure therapy from the cognitive-behavioral theory. Exposure therapy consists of the affected individuals confronting the feared stimulus, in this case, social settings and interactions. During these exposures, the individuals practice techniques learned in previous sessions such as biofeedback, deep breathing, and emotional processing (Hayes, Hope, & Heimberg, 2008). These techniques allow the individuals to be aware of their somatic symptoms and accurately assess them. During the in vivo experience, the individuals practice being aware of their cognitions, denying the fallacies in their perceptions, and eradicating compensatory safety or avoidance behaviors (Goldin et al., 2014). This ensures that the individuals will be able to utilize the techniques learned in therapy outside of the office. Completion of exposure therapy has shown improvements in the individuals’ quality of life and symptoms for up to 12 months after treatment ends (Watanabe et al., 2010).

Virtual exposure therapy. One subset of exposure therapy that is growing in creditability is virtual exposure therapy. Virtual exposure therapy uses virtual technology to simulate a social setting for the affected individuals such as a classroom, auditorium, or conference room. Individuals might be asked to give a speech or presentation to the virtual characters. The limitation with this type of exposure therapy though is the specificity of simulating public speaking rather than social fears in general. Virtual exposure therapy still requires more research and versatility; however, this specific form of treatment is proving to have significant positive long-term effects for the individuals who partook in it (Anderson, Edwards, & Goodnight, 2017).

Conclusion

           Social Anxiety Disorder (SAD) is a disorder that is often glossed over and considered just to be shyness or introversion; however, the distorted cognitions and maladaptive behaviors can significantly impair individuals’ daily lives functioning. Additionally, individuals with SAD have a greater chance of developing comorbidities such as depression, addiction, and body dysmorphia, which further impairs their functioning. The cognitive-behavioral model of etiology and treatment is the leading theory in SAD and has proven to be effective and long-lasting in its methods. Advancements are being made in exposure therapy that will hopefully improve the treatment and decrease the symptoms of those with SAD. With this advancement and many more in the field of SAD, the quality of life for the affected individuals is greatly increasing.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). Arlington, VA: American Psychiatric Association

Anderson, P. L., Edwards, S. M., & Goodnight, J. R. (2017). Virtual reality exposure group therapy for social anxiety disorder: Results from a 4-6 year follow-up. Cognitive Therapy and Research, 41 (2), 230-236. doi: 10.1007/s10608-016-9820-y

Bogels, S. M., Wijts, P., Oort, F. J., & Sallaerts, S. J. M. (2014). Psychodynamic psychotherapy versus cognitive behavioral therapy for social anxiety disorder: An efficacy and partial effectiveness trial. Depression and Anxiety, 31 (5), 363-373. doi: 10.1002/da.22246

Book, S. W., Thomas, S. E., Smith, J. P., & Miller, P. M. (2012). Severity of anxiety in mental health versus addiction treatment settings when social anxiety and substance abuse are comorbid. Addictive Behaviors, 37 (10), 1158-1161. doi: 10.1016/j.addbeh.2012.04.016 

Brown, H. M., Waszczuk, M. A., Zavos, H. M. S., Trzaskowski, M., Gregory, A. M., & Eley, T. C. (2014). Cognitive content specificity in anxiety and depressive disorder symptoms: A twin study of cross-sectional associations with anxiety sensitivity dimensions across development. Psychological Medicine, 44 (16), 3469-3480. doi: 10.1017/S0033291714000828

Bruce, L. C., Heimberg, R.G., Goldin, P. R., & Gross, J. J. (2013). Childhood maltreatment and response to cognitive behavioral therapy among individuals with social anxiety disorder. Depression and Anxiety, 30 (7), 662-669. doi: 10.1002/da.22112

Crawley, S. A., Caporino, N. E., Birmaher, B., Ginsburg, G., Piacentini, J., Albano, A. M., …Kendall, P. C. (2014). Somatic complaints in anxious youth. Child Psychiatry and Human Development, 45 (4), 398-407. doi: 10.1007/s10578-013-0410-x

Cummings, C. M., Caporino, N. E., & Kendall, P. C. (2014). Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychological Bulletin, 140 (3), 816-845. doi: 10.1037/a0034733

de Jong, P. J., Sportel, B. E., de Hullu, E., & Nauta, M. H. (2012). Co-occurrence of social anxiety and depression symptoms in adolescence: differential links with implicit and explicit self-esteem?. Psychological Medicine, 42 (3), 475-484. doi: 10.1017/S0033291711001358

Festa, C. C., & Ginsburg, G. S. (2011). Parental and peer predictors of social anxiety in youth. Child Psychiatry and Human Development, 42 (3), 291-306. doi: 10.1007/s10578-011-0215-8

Goldin, P. R., Lee, I., Ziv, M., Jazaieri, H., Heimberg, R. G., & Gross, J. J. (2014). Trajectories of change in emotion regulation and social anxiety during cognitive-behavioral therapy for social anxiety disorder. Behaviour Research and Therapy, 56 (1), 7-15. doi: 10.1016/j.brat.2014.02.005

Hayes, S. A., Hope, D. A., & Heimberg, R. G. (2008). The pattern of subjective anxiety during in-session exposures over the course of cognitive-behavioral therapy for clients with social anxiety disorder. Behavior Therapy, 39 (3), 286-299. doi: 10.1016/j.beth.2007.09.001

Kelly, M. M., Walters, C. & Phillips, K. A. (2010). Social anxiety and its relationship to functional impairment in body dysmorphic disorder. Behavior Therapy, 41 (2), 143-153. doi: 10.1016/j.beth.2009.01.005

Knafo, A., Jaffee, S. R., Natsuaki, M. N., Leve, L. D., Neiderhiser, J. M., Shaw, D. S.,…Reiss, D. (2013). Intergenerational transmission of risk for social inhibition: The interplay between parental responsiveness and genetic influences. Development and Psychopathology, 25 (1), 261-274. doi: 10.1017/S0954579412001010

Koerner, N., Antony, M. M., Young, L., & Mccabe, R. E. (2013). Changes in beliefs about the social competence of self and others following group cognitive-behavioral treatment. Cognitive Therapy and Research, 37 (2), 256-265. doi: 10.1007/s10608-012-9472-5

Mahaffey, B. L., Wheaton, M. G., Fabricant, L. E., Berman, N. C., & Abramowitz, J. S. (2013). The contribution of experimental avoidance and social cognitions in the prediction of social anxiety. Behavioural and Cognitive Psychotherapy, 41 (1), 52-65. doi: 10.1017/S1352465812000367

Piccirillo, M. L., Dryman, M. T., & Heimberg, R. G. (2016). Safety behaviors in adults with social anxiety: Review and future directions. Behavior Therapy, 47 (5), 675-687. doi: 10.1016/j.beth.2015.11.005

Settipani, C. A., & Kendall, P. C. (2013). Social functioning in youth with anxiety disorders: Association with anxiety severity and outcomes from cognitive-behavioral therapy. Child Psychiatry and Human Development, 44 (1), 1-18. doi: 10.1007/s10578-012-0307-0

Singh, J. S., & Hope, D. A. (2009). Cognitive-behavioral approaches to the treatment of social anxiety disorder. The Israel Journal of Psychiatry and Related Sciences, 46 (1), 62-69. Retrieved from https://www.ncbi.nlm.nih.gov/labs/articles/19728574/

Tomlinson, K. L., & Brown, S. A. (2012). Self-medication or social learning? A comparison of models to predict early adolescent drinking. Addictive Behaviors, 37 (2), 179-186. doi: 10.1016/j.addbeh.2011.09.016

Valentiner, D. P., Skowronski, J. J., McGrath, P. B., Smith, S. A., & Renner, K. A. (2011). Self-verification and social anxiety: Preference for negative social-feedback and low social self-esteem. Behavioural and Cognitive Psychotherapy, 39 (5), 601-617. doi: 10.1017/S1352465811000300

Watanabe, N., Furukawa, T. A., Chen, J., Kinoshita, Y., Nakano, Y., Ogawa, S.,…Noda, Y. (2010). Change in quality of life and their predictors in the long-term follow-up after group cognitive behavioral therapy for social anxiety disorder: A prospective cohort study. BMC Psychiatry, 10 (1), 81-90. doi: 10.1186/1471-244X-10-81