Social anxiety is nervousness in social situations. Some disorders associated with the social anxiety spectrum include anxiety disorders, mood disorders, autism, eating disorders, and substance use disorders. Individuals higher in social anxiety avert their gazes, show fewer facial expressions, and show difficulty with initiating and maintaining conversation. Trait social anxiety, the stable tendency to experience this nervousness, can be distinguished from state anxiety, the momentary response to a particular social stimulus. Nearly 90% of individuals report feeling symptoms of social anxiety (e.g. shyness) at some point in their lives. Half of the individuals with any social fears meet criteria for social anxiety disorder. The function of social anxiety is to increase arousal and attention to social interactions, inhibit unwanted social behavior, and motivate preparation for future social situations.
Some feelings of anxiety in social situations are normal and necessary for effective social functioning and developmental growth. Cognitive advances and increased pressures in late childhood and early adolescence result in repeated social anxiety. Adolescents have identified their most common anxieties as focused on relationships with peers to whom they are attracted, peer rejection, public speaking, blushing, self-consciousness, freaking out, and past behavior. Most adolescents progress through their fears and meet the developmental demands placed on them. More and more children are being diagnosed with social anxiety, and this can lead to problems with education if not closely monitored. Part of social anxiety is fear of being criticized by others, and in children, social anxiety causes extreme distress over everyday activities such as playing with other kids, reading in class, or speaking to adults. On the other hand, some children with social anxiety will act out because of their fear. The problem with identifying social anxiety disorder in children is that it can be difficult to determine the difference between social anxiety and basic shyness.
It can be easier to identify social anxiety within adults because they tend to shy away from any social situation and keep to themselves. Common adult forms of social anxiety include performance anxiety, public speaking anxiety, stage fright, and timidness. All of these may also assume clinical forms, i.e., become anxiety disorders (see below).
Criteria that distinguish between clinical and nonclinical forms of social anxiety include the intensity and level of behavioral and psychosomatic disruption (discomfort) in addition to the anticipatory nature of the fear. Social anxieties may also be classified according to the broadness of triggering social situations. For example, fear of eating in public has a very narrow situational scope (eating in public), while shyness may have a wide scope (a person may be shy of doing many things in various circumstances). The clinical (disorder) forms are also divided into general social phobia (i.e., social anxiety disorder) and specific social phobia.
Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by a significant amount of fear in one or more social situations causing considerable distress and impaired ability to function in at least some parts of daily life.:15 These fears can be triggered by perceived or actual scrutiny from others.
Physical symptoms often include excessive blushing, excess 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. It is common for sufferers of social phobia to self-medicate in this fashion, especially if they are undiagnosed, untreated, or both; this can lead to alcoholism, eating disorders or other kinds of substance abuse. SAD is sometimes referred to as an "illness of lost opportunities" where "individuals make major life choices to accommodate their illness". According to ICD-10 guidelines, the main diagnostic criteria of social anxiety disorder are fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating, avoidance and anxiety symptoms. Standardized rating scales can be used to screen for social anxiety disorder and measure the severity of anxiety.
The first line treatment for social anxiety disorder is cognitive behavioral therapy (CBT) with medications recommended only in those who are not interested in therapy. CBT is effective in treating social phobia, whether delivered individually or in a group setting. 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 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. It is the most common anxiety disorder with up to 10% of people being affected at some point in their life.
Signs and symptoms
Blushing is a physiological response unique to humans and is a hallmark physiological response associated with social anxiety. Blushing is the involuntary reddening of the face, neck, and chest in reaction to evaluation or social attention. Blushing occurs not only in response to feelings of embarrassment but also other socially-oriented emotions such as shame, guilt, shyness, and pride. Individuals high in social anxiety perceive themselves as blushing more than those who are low in social anxiety. Three types of blushing can be measured: self-perceived blushing (how much the individual believes they are blushing), physiological blushing (blushing as measured by physiological indices), and observed blushing (blushing observed by others). Social anxiety is strongly associated with self-perceived blushing, weakly associated with blushing as measured by physiological indices such as temperature and blood flow to the cheeks and forehead, and moderately associated with observed blushing. The relationship between physiological blushing and self-perceived blushing is small among those high in social anxiety, indicating that individuals with high social anxiety may overestimate their blushing. That social anxiety is associated most strongly with self-perceived blushing is also important for cognitive models of blushing and social anxiety, indicating that socially anxious individuals use both internal cues and other types of information to draw conclusions about how they are coming across. Individuals with social anxiety might also refrain from making eye contact, or constantly fiddling with things during conversations or public speaking.
Individuals who tend to experience more social anxiety turn their attention away from threatening social information and toward themselves, prohibiting them from challenging negative expectations about others and maintaining high levels of social anxiety. A socially anxious individual perceives rejection from a conversational partner, turns his or her attention away, and never learns that the individual is actually welcoming. Individuals who are high in social anxiety tend to show increased initial attention toward negative social cues such as threatening faces followed by attention away from these social cues, indicating a pattern of hypervigilance followed by avoidance. Attention in social anxiety has been measured using the dot-probe paradigm, which presents two faces next to one another. One face has an emotional expression and the other has a neutral expression, and when the faces disappear, a probe appears in the location of one of the faces. This creates a congruent condition in which the probe appears in the same location as the emotional face, and an incongruent condition. Participants respond to the probe by pressing a button and differences in reaction times reveal attentional biases. This task has revealed mixed results, with some studies finding no differences between socially anxious individuals and controls, some studies finding avoidance of all faces, and others finding vigilance toward threat faces. There is some evidence that vigilance toward threat faces can be detected during short but not longer exposures to faces, indicating a possible initial hypervigilance followed by avoidance. The Face-in-the-crowd task shows that individuals with social anxiety are faster at detecting an angry face in a predominantly neutral or positive crowd or slower at detecting happy faces than a nonanxious person. Results overall using this task are mixed and this task may not be able to detect hypervigilance toward angry faces in social anxiety.
Focus on the self has been associated with increased social anxiety and negative affect, however there are two types of self-focus: In public self focus, one shows concern for the impact of one's own actions on others and their impressions. This type of self-focus predicts greater social anxiety. Other more private forms of self-consciousness (e.g., egocentric goals) are associated with other types of negative affect.
Basic science research suggests that cognitive biases can be modified. Attention bias modification training has been shown to temporarily impact social anxiety.
Trait social anxiety is most commonly measured by self-report. This method possesses limitations, however subjective responses are the most reliable indicator of a subjective state. Other measures of social anxiety include diagnostic interviews, clinician- administered instruments, and behavioral assessments. No single trait social anxiety self-report measure shows all psychometric properties including different kinds of validity (content validity, criterion validity, construct validity), reliability and internal consistency. The SIAS along with the SIAS-6A and -6B are rated as the best. These measures include:
- Fear of Negative Evaluation (FNE) and Brief form (BFNE)
- Fear Questionnaire Social Phobic Subscale (FQSP)
- Interaction Anxiousness Scale (IAS)
- Liebowitz Social Anxiety Scale-Self Report (LSAS-SR)
- Older Adult Social-Evaluative Situations (OASES)
- Social Avoidance and Distress (SAD)
- Self-Consciousness Scale (SCC)
- Social Interaction Anxiety Scale (SIAS) and brief form (SIAS-6A and -6B)
- Social Interaction Phobia Scale (SIPS)
- Social Phobia and Anxiety Inventory (SPAI) and brief form (SPAI-23)
- Situational Social Avoidance (SSA)
- Asperger syndrome
- Avoidant personality disorder
- Highly sensitive person
- Major depressive disorder
- Obsessive-compulsive disorder
- Selective mutism
- Social inhibition
- Social isolation
- Social rejection
- Schneier, Franklin R; Blanco, Carlos; Antia, Smita X; Liebowitz, Michael R. "The social anxiety spectrum". Psychiatric Clinics of North America. 25 (4): 757–774. doi:10.1016/s0193-953x(02)00018-7.
- Spielberger, C.D. (1983). Manual for the state-trait anxiety inventory (STAI). Palo Alto: Consulting Psychologists Press.
- Zimbardo, P.G. (1977). Shyness: what it is, what to do about it. Reading (MA): Addison-Wesley.
- Ruscio, A. M.; Brown, T. A.; Chiu, W. T.; Sareen, J.; Stein, M. B.; Kessler, R. C. (2008-01-01). "Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication". Psychological Medicine. 38 (1): 15–28. doi:10.1017/S0033291707001699. ISSN 1469-8978. PMC 2262178. PMID 17976249.
- Albano, Anne Marie; Detweiler, Michael F. (2001). "The Developmental and Clinical Impact of Social Anxiety and Social Phobia in Children and Adolescents". In Hofmann, Stefan G.; DiBartolo, Patricia M. From Social Anxiety to Social Phobia: Multiple Perspectives. Allyn & Bacon. ISBN 978-0-205-28189-3.
- Adalbjarnardottir, Sigrun (December 1995). "How Schoolchildren Propose to Negotiate: The Role of Social Withdrawal, Social Anxiety, and Locus of Control". Child Development. 66 (6): 1739–1751. doi:10.1111/j.1467-8624.1995.tb00962.x. PMID 8556896.
- Harold Leitenberg (1990) "Handbook of Social and Evaluation Anxiety", ISBN 0-306-43438-5
- National Institute for Health and Clinical Excellence: Guidance. Social Anxiety Disorder: Recognition, Assessment and Treatment. Leicester (UK): British Psychological Society; 2013. PMID 25577940
- Stein, MD, Murray B.; Gorman, MD, Jack M. (2001). "Unmasking social anxiety disorder" (PDF). Journal of Psychiatry & Neuroscience. 3. 26 (3): 185–9. PMC 1408304. PMID 11394188. Retrieved 17 March 2014.
- Shields, Margot (2004). "Social anxiety disorder— beyond shyness" (PDF). How Healthy are Canadians? Statistics Canada Annual Report. 15: 58. Retrieved 17 March 2014.
- Pilling, S; Mayo-Wilson, E; Mavranezouli, I; Kew, K; Taylor, C; Clark, DM; Guideline Development, Group (May 22, 2013). "Recognition, assessment and treatment of social anxiety disorder: summary of NICE guidance". BMJ (Clinical research ed.). 346: f2541. doi:10.1136/bmj.f2541. PMID 23697669.
- Hofmann, S. G.; Smits, J. A. (2008). "Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials". The Journal of Clinical Psychiatry. 69 (4): 621–632. doi:10.4088/JCP.v69n0415. PMC 2409267. PMID 18363421.
- Blanco, C.; Bragdon, L. B.; Schneier, F. R.; Liebowitz, M. R. (2012). "The evidence-based pharmacotherapy of social anxiety disorder". The International Journal of Neuropsychopharmacology. 16 (1): 235–249. doi:10.1017/S1461145712000119. PMID 22436306.
- Craske, MG; Stein, MB (24 June 2016). "Anxiety". Lancet. doi:10.1016/S0140-6736(16)30381-6. PMID 27349358.
- Nikolić, Milica; Colonnesi, Cristina; de Vente, Wieke; Drummond, Peter; Bögels, Susan M. (2015-06-01). "Blushing and Social Anxiety: A Meta-Analysis". Clinical Psychology: Science and Practice. 22 (2): 177–193. doi:10.1111/cpsp.12102. ISSN 1468-2850.
- Leary, Mark R.; Toner, Kaitlin. Psychological theories of blushing. pp. 63–76. doi:10.1017/cbo9781139012850.007.
- Clark, D.M.; Wells, A (1995). "A cognitive model of social phobia". In R.G. Heimberg; M.R. Leibowitz; D.A. Hope; F.R. Schneier. Social phobia: Diagnosis, assessment, and treatment. New York, NY: Guilford Press. pp. 69–93.
- Staugaard, Søren Risløv (2010-08-01). "Threatening faces and social anxiety: A literature review". Clinical Psychology Review. 30 (6): 669–690. doi:10.1016/j.cpr.2010.05.001.
- Bögels, Susan M.; Mansell, Warren (2004-11-01). "Attention processes in the maintenance and treatment of social phobia: hypervigilance, avoidance and self-focused attention". Clinical Psychology Review. Social Phobia and Social Anxiety. 24 (7): 827–856. doi:10.1016/j.cpr.2004.06.005.
- Mor, Nilly; Winquist, Jennifer. "Self-focused attention and negative affect: A meta-analysis". Psychological Bulletin. 128 (4): 638–662. doi:10.1037/0033-2909.128.4.638.
- Heeren, Alexandre; Mogoașe, Cristina; Philippot, Pierre; McNally, Richard J. (2015-08-01). "Attention bias modification for social anxiety: A systematic review and meta-analysis". Clinical Psychology Review. 40: 76–90. doi:10.1016/j.cpr.2015.06.001.
- Modini, Matthew; Abbott, Maree J.; Hunt, Caroline (2015-04-21). "A Systematic Review of the Psychometric Properties of Trait Social Anxiety Self-Report Measures". Journal of Psychopathology and Behavioral Assessment. 37 (4): 645–662. doi:10.1007/s10862-015-9483-0. ISSN 0882-2689.
- Antony, M.M. (1997). "Assessment and treatment of social phobia". Canadian Journal of Psychiatry. 42 (8): 826–834.
- Leary, Mark R. (1983-09-01). "A Brief Version of the Fear of Negative Evaluation Scale". Personality and Social Psychology Bulletin. 9 (3): 371–375. doi:10.1177/0146167283093007. ISSN 0146-1672.
- Marks, I. M.; Mathews, A. M. (1979-01-01). "Brief standard self-rating for phobic patients". Behaviour Research and Therapy. 17 (3): 263–267. doi:10.1016/0005-7967(79)90041-X.
- Leary, Mark R.; Kowalski, Robin M. (1993-08-01). "The Interaction Anxiousness Scale: Construct and Criterion-Related Validity". Journal of Personality Assessment. 61 (1): 136–146. doi:10.1207/s15327752jpa6101_10. ISSN 0022-3891. PMID 8377098.
- Liebowitz, Michael R. Social Phobia. pp. 141–173. doi:10.1159/000414022.
- Gould, Christine E.; Gerolimatos, Lindsay A.; Ciliberti, Caroline M.; Edelstein, Barry A.; Smith, Merideth D. (2012-12-01). "Initial evaluation of the Older Adult Social-Evaluative Situations Questionnaire: a measure of social anxiety in older adults". International Psychogeriatrics. 24 (12): 2009–2018. doi:10.1017/S1041610212001275. ISSN 1041-6102.
- Turner, Samuel M.; Beidel, Deborah C.; Dancu, Constance V.; Stanley, Melinda A. "An empirically derived inventory to measure social fears and anxiety: The Social Phobia and Anxiety Inventory". Psychological Assessment. 1 (1): 35–40. doi:10.1037/1040-35220.127.116.11.
- Scheier, Michael F.; Carver, Charles S. (1985-12-01). "The Self-Consciousness Scale: A Revised Version for Use with General Populations1". Journal of Applied Social Psychology. 15 (8): 687–699. doi:10.1111/j.1559-1816.1985.tb02268.x. ISSN 1559-1816.
- Mattick, Richard P.; Clarke, J. Christopher (1998-04-01). "Development and validation of measures of social phobia scrutiny fear and social interaction anxiety1". Behaviour Research and Therapy. 36 (4): 455–470. doi:10.1016/S0005-7967(97)10031-6. PMID 9670605.
- Turner, Samuel M.; Stanley, Melinda A.; Beidel, Deborah C.; Bond, Lloyd. "The social phobia and anxiety inventory: Construct validity". Journal of Psychopathology and Behavioral Assessment. 11 (3): 221–234. doi:10.1007/BF00960494. ISSN 0882-2689.
- Ishiyama, F. (1999). "Development and validation of a situational social avoidance scale". Psychological Reports. 85 (1): 114–120. doi:10.2466/pr0.1918.104.22.168.