4.4: Social Anxiety Disorder

Section Learning Objectives

• Describe how social anxiety disorder presents itself.
• Describe the epidemiology of social anxiety disorder.
• Indicate which disorders are commonly comorbid with social anxiety disorder.
• Describe the treatment options for social anxiety disorder.

Clinical Description

For social anxiety disorder (formerly known as social phobia), the anxiety is directed toward the fear of social situations, particularly those in which an individual can be evaluated by others. More specifically, the individual is worried that they will be judged negatively and viewed as stupid, anxious, crazy, unlikeable, or boring to name a few. Some individuals report feeling concerned that their anxiety symptoms will be obvious to others via blushing, stuttering, sweating, trembling, etc. These fears severely limit an individual’s behavior in social settings. For example, an individual may avoid holding drinks or plates if they know they will tremble in fear of dropping or spilling food/water. Additionally, if one is known to sweat a lot in social situations, they may limit physical contact with others, refusing to shake hands.

Unfortunately, for those with social anxiety disorder, all or nearly all social situations provoke this intense fear. Some individuals even report significant anticipatory fear days or weeks before a social event is to occur. This anticipatory fear often leads to avoidance of social events in some individuals; others will attend social events with a marked fear of possible threats. Because of these fears, there is a significant impact on one’s social and occupational functioning.

It is important to note that the cognitive interpretation of these social events is often excessive and out of proportion to the actual risk of being negatively evaluated. There are instances where one may experience anxiety toward a real threat such as bullying or ostracizing. In this instance, social anxiety disorder would not be diagnosed as the negative evaluation and threat are real.

Epidemiology

The overall prevalence rate of social anxiety disorder is significantly higher in the United States than in other countries worldwide, with an estimated 7% of the US population diagnosed with social anxiety disorder. Within the US, the prevalence rate remains the same among children through adults; however, there appears to a significant decrease in the diagnosis of social anxiety disorder among older individuals. With regards to gender, there is a higher diagnosis rate in females than males. This gender discrepancy appears to be larger in children/adolescents than adults.

Comorbidity

Among the most common comorbid diagnoses with social anxiety disorder are other anxiety-related disorders, major depressive disorder, and substance-related disorders. Generally speaking, social anxiety disorders will precede that of other mental health disorders, with the exception of separation anxiety disorder and specific phobia, seeing as these two disorders are more commonly diagnosed in childhood (APA, 2013). The high comorbidity rate among anxiety-related disorders and substance-related disorders is likely related to the efforts of self-medicating. For example, an individual with social anxiety disorder may consume larger amounts of alcohol in social settings in efforts to alleviate the anxiety of the social situation.

Treatment

Exposure 

A hallmark treatment approach for all anxiety disorders is exposure. Specific to social anxiety disorder, the individual is encouraged to engage in social situations where they are likely to experience increased anxiety. Initially, the clinician will engage in role-playing of various social situations with the client so that he/she can practice social interactions in a safe, controlled environment (Rodebaugh, Holaway, & Heimberg, 2004). As the client becomes habituated to the int4.5: Agoraphobiaeraction with the clinician, the clinician and client may venture outside of the treatment room and engage in social settings with random strangers at various locations such as fast food restaurants, local stores, libraries, etc. The client is encouraged to continue with these exposure based social interactions outside of treatment to help reduce anxiety related to social situations.

Social Skills Training 

This treatment is specific to social anxiety disorder as it focuses on skill deficits or inadequate social interactions displayed by the client that contributes to the negative social experiences and anxiety. The clinician may use a combination of skills such as modeling, corrective feedback, and positive reinforcement to provide feedback and encouragement to the client regarding his/her behavioral interactions (Rodebaugh, Holaway, & Heimberg, 2004). By incorporating the clinician’s feedback into their social repertoire, the client can engage in positive social behaviors outside of the treatment room in hopes to improve overall social interactions and reduce ongoing social anxiety.

Cognitive Restructuring 

While exposure and social skills training are helpful treatment options, research routinely supports the need to incorporate cognitive restructuring as an additive component in treatment to provide substantial symptom reduction. Here the client will work with the therapist to identify negative, automatic thoughts that contribute to the distress in social situations. The clinician can then help the client establish new, positive thoughts to replace these negative thoughts. Research indicates that implementing cognitive restructuring techniques before, during, and after exposure sessions enhances the overall effects of treatment of social anxiety disorder (Heimberg & Becker, 2002).