Social phobia (social anxiety disorder)

The main characteristic of social phobia is the intense fear or anxiety of social situations in which the subject may be observed by other people. In fact, people with social phobia experience intense emotional reactions related to certain social contexts in which the subject is afraid of being judged negatively. Typically, the fear associated with social phobia is that of being seen as weak, anxious, unbalanced, stupid, boring, or otherwise negatively judged. The fear leads to avoidance of places and situations that might activate the anxious symptoms. Thus, the person increasingly reduces daily activities, places, and situations, triggering a vicious cycle that leads to a worsening of the phobic picture and a significant reduction in quality of life.

Public speaking is the most common and widespread specific social phobia. However, any social situation can become phobic. The phobia often manifests itself in very different ways. For example, people with social phobia may complain of anticipatory anxiety, which is characterized by a constant state of anxiety that lasts for many weeks before a feared social event. Or it may present in a more intense but less prolonged way, such as a severe panic attack related to a feared social situation.

Usually, the situations that people with social phobia (or social anxiety) dread the most are those that involve doing something in front of other people, such as giving a report or even just signing, making a phone call, or eating; sometimes it can cause social anxiety just to enter a room where people are already sitting, or to talk to one’s friend.

Social phobia is characterized by:

  • an intense fear of being in situations where one is subject to the judgment of others.
  • a fear of not measuring up
  • a tendency to evaluate oneself negatively for experiencing symptoms in the feared situations.

The criteria for social anxiety disorder according to DSM-5 are:

  • severe fear or anxiety about the possible judgment of others
  • feelings of humiliation and embarrassment: The individual fears that he or she will display anxiety symptoms that will be judged negatively and lead to rejection or offense by others (social performance anxiety).
  • fear of social situations, which can lead to insecurity, anxiety, or anxiety attacks
  • avoidance or endurance with high discomfort of the feared situations.

Social anxiety experienced in specific situations may be followed by secondary phobias. Consider a child with a specific learning disorder (SLD) and reading difficulties. In a setting such as school, where reading aloud is required, this child may feel exposed to the judgment of others and experience strong anxiety at the sight of written words, especially those that are more difficult to decode. This child is likely to develop not only social anxiety, but also a phobia of long words.

Social phobia is a fairly common disorder in the population. According to some studies, the percentage of people who suffer from it ranges from 3% to 13%. Also, according to these studies, it seems that social anxiety affects women more than men.

Social phobia, age of onset, and prevalence

Social phobia is more common than other psychiatric disorders. In fact, it is estimated that approximately 7-13% of people will experience symptoms of this disorder during their lifetime (Keller MB, 2003Schneier, 2006). Social phobia can occur in comorbidity with other psychiatric disorders, particularly other anxiety disorders and depressive disorders.

Social phobia typically begins in early adolescence (Stein, 2008) and is more prevalent in females (approximately 60 percent) than males (Ruscio et al., 2008). Social anxiety, like many other anxiety and mood disorders, is associated with social problems (e.g., reduced work productivity) and reduced quality of life (Stein, 2005).

Social anxiety in children and teens

Social anxiety can occur at any age. For example, social anxiety in children may manifest as crying fits or outbursts, immobility, fear of being observed (scopopophobia), clinging to the adult figure or withdrawal, or inability to speak during social interactions. We find the same behaviors in adolescent social anxiety, which can also manifest as FOMO, the fear of being cut off from peer experiences and the resulting fear of judgment. For adolescents whose bodies are changing at this stage of life, the fear of being bodyshamed is also common.

Some of the more serious consequences of social phobia in adolescence can be alcohol or drug use, eating disorders, and complete withdrawal (think of the phenomenon of hikikomori, in which anxiety and social withdrawal are the immediate manifestations of the person’s psychological distress).

DSM-5 symptoms and diagnosis

Social phobia appears in the DSM-5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, in the chapter on anxiety disorders. It is defined by intense fear and anxiety associated with one or more social situations. Often, social phobia may be related to social interactions with unfamiliar people, situations in which one may be observed, or performing in front of an audience (such as speaking in front of a group of people).

According to DSM-5 the symptoms of social phobia or social anxiety disorder are as follows:

  • Marked fear or anxiety about one or more social situations in which the individual is exposed to possible judgment by others.
  • The individual fears that he or she will show symptoms of anxiety and be judged negatively (humiliation, embarrassment).
  • Social situations almost always cause fear or anxiety.
  • Social situations are avoided or endured with intense fear or anxiety
  • Fear or anxiety is disproportionate to the actual threat posed by the social situation and socio-cultural context
  • The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

According to the DSM-5, in order to make a diagnosis of social phobia, the phobic reaction must have been present for some time (at least six months), be intense, and be disproportionate. In addition, the disorder must cause a significant decline in the individual’s functioning (e.g., through avoidance behaviors) and quality of life.

DSM-5 also defines two types of social anxiety disorder. If the symptoms occur only when the individual has to perform in public (e.g., public speaking), it is called “performance-related social anxiety disorder”. Usually this type of disorder can be diagnosed in musicians, dancers, athletes, etc. However, in cases where the disorder also occurs in other social settings, the simple term “social anxiety disorder” is used.

The causes that lead to the development of social anxiety disorder can be defined as multifactorial. According to the scientific literature, the etiopathogenesis of social phobia is based on a combination of genetic-biological and experiential-psychological factors, which may constitute risk and protective factors regarding the onset and maintenance of the disorder. In terms of biological risk factors, there would be a tendency to have more fearful reactions, which is associated with a greater reactivity of the limbic system, a set of nerve structures that are responsible for emotional regulation.

In general, it has been observed in the literature that anxiety disorders tend to have a transgenerational transmission, although it is still unclear how much of this transmissibility is related to purely genetic factors and how much to environmental factors of social attachment that play out in the child’s interaction with the anxious parent.

In this sense, other factors that may influence the development of social phobia (or social anxiety disorder) include environmental-psychological factors that bring into play each person’s subjective experience and specific ways of regulating emotions and relating to the world and others that we learn from childhood in our life context.

Risk factors that may facilitate the onset of social anxiety disorder include: family history (whether a parent or sibling has social anxiety disorder); personality trait of marked shyness; negative experiences of bullying, ridicule, humiliation, and social rejection and criticism (even sexual abuse).

Consequential avoidances

Symptoms of social phobia may cause the person to avoid eating, drinking, or writing in public for fear of embarrassment if others see his or her hands shaking.

Obviously, these people try very hard to avoid such situations or, if forced into them, endure such situations with a great deal of discomfort.

Anticipatory anxiety

Another typical feature of this disorder is a pronounced social anxiety that precedes feared situations and is called anticipatory anxiety. This means that even before facing a social situation (e.g., going to a party or a business meeting), people begin to worry about such an event.

As is often the case with phobic disorders, people with this disorder realize when they are away from the feared situations that their fears are only completely unreasonable, excessive, and silly. In this way, they come to blame themselves for the symptoms of social phobia and for their own avoidance behaviors.

Differential diagnosis, consequences and comorbidity of social phobia (or social anxiety disorder)

Although it is possible to try to detect the presence of typical symptoms and phenomena of social phobia in order to seek help, it is important to seek the help of mental health specialists in order to establish a clear diagnosis and treatment plan. In fact, it is important to make a differential diagnosis of social anxiety disorder or social phobia with respect to other anxiety disorders.

First of all, it is important to determine whether the social phobia is accompanied by panic attacks; if this is the case, it should be differentiated from panic disorder, in which the panic episodes do not occur exclusively in social situations.

In addition, it is important to exclude the presence of a generalized anxiety disorder in which the fear of being judged negatively in certain situations is still present, but this fear is not the core of the individual’s concerns in the case of a generalized anxiety disorder.

Avoidance of social situations and lack of social interactions and relationships are also phenomena found in some personality disorders. For example, even in Avoidant Personality Disorder, the person is very sensitive to the judgment of others, has a negative self-perception, and avoids social situations; however, in Avoidant Personality Disorder, the fear is a more pervasive and generalized fear of social relationships (although this may also be typical of Generalized Social Phobia). One aspect that may be differential is the sense of foreignness and non-belonging that is typical of avoidant personality disorder. However, the differential diagnosis between the two psychopathological frameworks is not straightforward and requires consultation with an experienced mental health professional.

Social isolation is also found in other psychopathologies, such as depression or schizoid personality disorder; in the case of depression, social isolation is the result of mood swings rather than anxious avoidance; while in the case of schizoid personality disorder, there is a lack of desire and interest in having relationships with others, an aspect that is maintained in social phobia or social anxiety.

In the medium to long term, if left untreated, social phobia or social anxiety disorder impoverishes the life of the individual, who often leads a withdrawn life with few friendships and few opportunities for recreation; it can also affect school and/or work careers, with consequent damage to image and self-esteem.

Consequently, the problems experienced by those with social phobia may contribute to the development of sadness and a sense of dissatisfaction with themselves and their lives, and in some cases a depressive mood disorder may develop.

Another phenomenon that may accompany social phobia is substance abuse and/or alcohol abuse as dysfunctional strategies to cope with high levels of anxiety in feared social situations (think of a social phobic at a party) as well as to alleviate the sadness and suffering associated with a general sense of dissatisfaction and inadequacy of the self in the social sphere.

Social phobia at the cognitive, behavioral, and emotional levels

The pathological core of social phobia (or social anxiety disorder) is represented by a marked sensitivity to the judgment of others; the social phobic fears being observed and becoming the object of ridicule by others, or that his or her own performance may expose him or her to negative evaluations.

At the cognitive level, the social phobic is characterized by being highly critical of himself and perceiving himself as weak, incompetent, and ridiculous, while the other person is seen as skilled, superior, and competent.

On the behavioral level, the phobic subject, in order to avoid exposure to painful experiences, adopts behaviors of avoidance and postponement, renunciation and withdrawal; in his relationship with the other, he adopts protective behaviors and communication of the anaxertive and submissive type.

At the emotional level, the person with a social phobia lives with a general feeling of anxiety and worry that increases as the feared situation approaches, anxiety, alertness, and a feeling of humiliation at the moment of being in the phobic situation.

The exaggerated fear of others’ judgment prevents self-exposure, and the more generalized the avoidance behaviors become, the more disabling the disorder becomes: feelings of inadequacy and inferiority develop, which in turn reduce self-esteem and increase the tendency to perceive oneself as incapable and others as critical and rejecting.

In cases where the social phobic person exposes himself or herself to the feared situations, anticipatory anxiety (which may occur even many days before the event) is usually present. Before facing the feared situation, the subject tends to brood for a long time about the future situation; such thoughts and mental images have a negative tenor and are accompanied by a high and intense level of anxiety. This dysfunctional anxiety creates a vicious cycle in which actual performance in the feared situation may be impaired by the excessive level of anxiety that interferes with cognitive processes. For example, in terms of attention, the person may focus on the other person’s nonverbal cues and/or their own signs and symptoms of anxiety rather than on the conversation that is taking place. As a result, the communicative interaction is compromised, and further shame, embarrassment, and feelings of inadequacy arise, which in turn may promote avoidance, anticipatory anxiety, or protective behaviors.

The person with social anxiety uses what are called protective behaviors to avoid the feared consequences that he or she persistently worries about. Such protective behaviors are strategies that the person uses in the belief that he or she can better “control” phobic symptoms. In reality, such behaviors are not helpful because they increase symptoms, perpetuate the individual’s fear and belief that he or she is being negatively evaluated, and negatively interfere with the performance or activity that the phobic person fears. For example, holding a cup very tightly in an attempt to control a slight hand tremor can interfere with normal movements by making the movement extremely awkward; similarly, mentally repeating what one intends to say before speaking makes conversation more tiring and difficult, or avoiding eye contact so as not to attract the other person’s attention is a signal that does not facilitate interaction with the other person.

Thus, protective behaviors – which vary from case to case – interfere with the feared social situation and actually make the person seem more awkward, clumsy, or less available for interaction. Finally, in cases where the feared consequences have not occurred, the person mistakenly attributes the absence of negative, catastrophic consequences to the implementation of the protective behaviors, making it difficult to disconfirm their dysfunctional beliefs.

During exposure to feared situations, the person with social anxiety focuses attention on himself or herself and adopts a self-observation perspective, both of his or her own image during performance and of his or her physiological and emotional feelings that are “internal” and not visible to others, as well as of the performance itself. Such self-observations have a high degree of subjectivity and lead to distorted self-images: for example, if the subject feels slightly hot, he may think he sees a trickle of sweat on his face. This is a signal that he believes will be judged negatively by his interlocutors and/or others observing his behavior.

In addition to anticipatory anxiety, the social phobic engages in a process of retrospective examination of the situation, which often results in a negative evaluation of self and performance. Even in the face of objectively adequate performance, the social phobic begins to ruminate on his own behavior and formulates a “usually negative a posteriori self-evaluation of himself and his performance in the social situation.

Social anxiety or phobia, shyness, and introversion

The distinction between shyness, introversion, and social phobia (also called social anxiety disorder) is a question often asked by those who are uncomfortable in social situations. In fact, the emotional experiences, cognitive, and behavioral aspects involved in shyness, introversion, and social anxiety are similar.

First, it should be emphasized that it is quite common-and not necessarily pathological and dysfunctional-to experience worry, anticipatory anxiety, shame, and fear of others’ judgment in certain social situations. One need only think of the situation of public speaking, in which the person finds himself or herself publicly exposed in front of a (more or less large) group of people. Even in everyday social situations, the person may experience shame and anxiety during a social interaction; however, such emotional phenomena may refer to a condition of shyness, an individual personality trait that is certainly not as disabling and limiting as a true social anxiety disorder. Social anxiety disorder involves a constant and disproportionate fear of social relationships, a state of intense psychophysical discomfort that forces the individual to avoid social situations for fear of being judged inadequate by others.

This is not the case with shyness. Social anxiety and shyness differ in the intensity and type of emotions (dysfunctional and more intense in the case of social anxiety), cognitive aspects of content and process, and the prevalence of avoidance behaviors and protective factors that do not interfere with the shy person’s relationship and work functioning and the normal course of daily life.

For example, shy people who do not have social anxiety disorder tend to brood to a lesser extent and only just before the onset of the anxiety-provoking situation, experience less anxiety during the situation itself, and exposure to the feared situation does not worsen symptomatology but rather reduces the likelihood of future avoidance. Thus, while shyness causes discomfort for the individual, it does not interfere with the individual’s social and occupational functioning.

Although the two terms are often used interchangeably in common parlance, there is an important distinction to be made between shyness and introversion, both of which can be defined as personality traits and therefore not pathological in themselves.

While the shy person desires social relationships but feels uncomfortable in social situations, feels uninvestigated, and fears judgment from others, the introvert shows less interest in cultivating social relationships, does not avoid opportunities for social interaction, but does not actively and constantly seek them out, and is generally not egodystonic (i.e., does not pose a problem for the individual). Among the most prominent psychologists in the literature who have studied personality traits, Eysenck identified two personality super-factors: extroversion-introversion and neuroticism (to which he later added psychoticism). According to his theory, introverts, due to a high level of internal arousal, tend to avoid external stimulation in order to avoid overstimulation. Extroverts, who have a low level of arousal, seek new or more intense external stimulation to maintain or achieve an optimal level of stimulation.

However, the personality traits of shyness and introversion do not necessarily preclude social anxiety: while it is true that being introverted does not mean being socially phobic, it is also true that it is possible for social anxiety disorder to develop in introverted or shy individuals. Conversely, it is not necessarily the case that people with social anxiety disorder are necessarily introverted.

Treatment of social phobia

As with other anxiety disorders, cognitive behavioral psychotherapy has generally been very effective in treating social phobia. Some medications may also be helpful.

Cognitive behavioral psychotherapy

Cognitive behavioral psychotherapy focuses on the “here and now,” on treating the symptom directly. It aims to modify dysfunctional thoughts and to provide the person with better skills and abilities to cope with the feared situation.

Dysfunctional or irrational beliefs are thoughts that people have about events in which they find themselves involved, which in turn are derived from rigid and non-adaptive cognitive patterns. For example, the belief that showing fear is a sign of weakness, or the belief that we are always being watched by others.

Such thoughts only come into play, so to speak, when a person has to face a social situation. That is, he or she must expose himself or herself to possible judgment by others, which triggers anxiety and the subsequent feeling of losing control.

The treatment of social phobia aims to modify such assumptions during the psychotherapeutic work, on the one hand, and to teach skills for better coping with social situations, on the other.

Such skills usually include both techniques (such as relaxation training) for managing anxiety and techniques for managing verbal interaction.

Cognitive-behavioral therapy for social phobia can be done very well in individual sessions. This does not detract from the fact that group treatment has significant advantages whenever possible, starting with the obvious fact that one is already in a social situation.

Pharmacological therapy

Pharmacological treatment of social phobia, although generally ineffective, is based on two classes of drugs: benzodiazepines and antidepressants.

The prescription of benzodiazepines alone is rarely definitive. In the case of social anxiety, however, both alprazolam and clonazepam have shown some efficacy.

Nevertheless, the use of these molecules should always be carefully evaluated because of the potential for addiction and abuse. As well as the possible difficulties (such as the development of “rebound” anxiety) that can be generated when they are discontinued.

Among the tricyclic antidepressants, the most commonly used molecule in this class is imipramine. However, the use of these drugs in the treatment of social phobia does not appear to be particularly promising.

Among the selective serotonin reuptake inhibitors (SSRIs), the following have been used to treat social anxiety: fluvoxamine, fluoxetine, sertraline, and paroxetine.

Some more, some less, all have shown some efficacy in symptomatic remission, although it should be noted that the results are not always maintained when the medication is discontinued. Finally, these molecules have a lower level of side effects than other classes of drugs.

The role of shame in social anxiety disorder (SAD)

Shame is a common experience for everyone and is an emotion experienced when one believes that one’s image is compromised and is the subject of negative evaluation by others. It plays an important role in social anxiety disorder. Those who feel embarrassed get red, tend to make themselves small and want to disappear, shirk and avoid certain situations.

For the person with social anxiety disorder, however, shame is seen as a weakness. In this case, one has a problem of meta-shame: one is ashamed of the very fact of feeling this emotion and is afraid of being judged for it.

Feeling shame is not wrong: only by accepting the risk of making a bad impression can one learn to tolerate it, and as a result feel less ashamed.

Social anxiety, depression and the world of work

When a person suffers from social anxiety, his or her life is affected by feelings of shame and fear of being judged to the point of shutting down or experiencing anticipatory anxiety. Social phobia, in fact, is a discomfort that can be experienced even before the event occurs. In severe cases, social anxiety is compounded by panic attacks and depression.

Consider the world of work. A person may have to attend a meeting or speak on stage at a conference. If he or she suffers from social anxiety, he or she will probably prefer to give up and isolate himself or herself, losing the opportunity to bond with colleagues, meet other professionals, and create or expand his or her network of contacts.

The result will be a deterioration in the quality of life, a loss of self-esteem, an overly strong attachment to a few people. Above all, the feeling of helplessness will be strong. This is why depression can occur in response to social anxiety. Together, depression and social anxiety will contribute to further closure to the outside world.

The difference between social phobia and avoidant personality disorder

As we have seen, people who suffer from social anxiety are afraid of being judged by others and, as a result, tend to withdraw into themselves. However, they can establish social relationships, albeit with difficulty. This is where social phobia and avoidant personality disorder differ.

Those who suffer from avoidant personality disorder will be unable to relate to others, will not be able to read their emotions, and will tend to shut themselves off completely, sinking into painful loneliness. It is no longer the fear of being judged that holds him back, but the feeling of not belonging to the relevant social group.


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