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.

4.4.1 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 might be evaluated by others (e.g., giving a presentation). 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 their 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 and embarrassing themselves. Additionally, one may be concerned about sweating in social situations and limit physical contact with others, for instance by refusing to shake hands.

Unfortunately, for those with social anxiety disorder, all or nearly all social situations provoke intense fear. Some individuals even report significant anticipatory fear days or weeks before a social event is set to occur. This anticipatory fear often leads to avoidance of social events; however, some will attend social events with a marked fear. These fears cause significant distress and often significantly impact the individual’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. In this instance, social anxiety disorder would not be diagnosed as the negative evaluation and threat are real.

4.4.2 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 U.S. population diagnosed with social anxiety disorder in a given year. Similarly, within the U.S. prevalence is also lower in individuals of Asian, Latinx, and African American descent compared to non-Hispanic whites. One-year prevalence rates in adolescents are about half those in adults and prevalence rates show a significant decrease after the age of 65. With regards to gender, there is a higher diagnosis rate in women than men. This gender discrepancy appears to be larger in children/adolescents than adults.

4.4.3 Comorbidity

Among the most common comorbid diagnoses with social anxiety disorder are other anxiety-related disorders, major depressive disorder, and substance use disorders. Generally speaking, social anxiety disorders will precede other psychological disorders, with the exception of separation anxiety disorder and specific phobia, which are more commonly diagnosed in childhood (APA, 2022). Social anxiety disorder can result in chronic social isolation that can provoke major depressive disorder. The high comorbidity rate among anxiety disorders and substance use disorders is likely related to efforts of self-medicating with drugs. 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.

4.4.4 Treatment

4.4.4.1 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 they can practice social interactions in a safe, controlled environment (Rodebaugh, Holaway, & Heimberg, 2004). As the client becomes habituated to the interaction 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.

4.4.4.2 Social Skills Training 

This treatment is specific to social anxiety disorder as it focuses on social skill deficits or inadequate social interactions displayed by the client that stem from their fears and contribute to 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 their behavioral interactions (Rodebaugh, Holaway, & Heimberg, 2004). By incorporating the clinician’s feedback into their social repertoire, the client can engage in more positive social interactions outside of the treatment room in hopes to improve social experiences and reduce ongoing social anxiety.

4.4.4.3 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 (e.g., “I’m going to look stupid!). 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).