Many people are uncomfortable when interacting with others or talking or performing in front of others. A number of entertainers and sports figures, from singer Barbra Streisand to baseball pitcher Zack Greinke, have described episodes of significant anxiety before performing. Social fears of this kind certainly are unpleasant, but usually the people who have them manage to function adequately.

People with social anxiety disorder, by contrast, have severe, persistent, and irrational anxiety about social or performance situations in which they may face scrutiny by others and possibly feel embarrassment (APA, 2013) (see Table 5-7). The social anxiety may be narrow, such as a fear of talking in public or eating in front of others, or it may be broad, such as a general fear of functioning poorly in front of others. In both forms, people repeatedly judge themselves as performing less competently than they actually do (see MindTech below). It is because of its wide-ranging scope that this disorder is now called social anxiety disorder rather than social phobia, the label it had in past editions of the DSM (Heimberg et al., 2014).

Social anxiety disorder can interfere greatly with one’s life (Cooper, Hildebrandt, & Gerlach, 2014; Ravindran & Stein, 2011). A person who cannot interact with others or speak in public may fail to carry out important responsibilities. One who cannot eat in public may reject meal invitations and other social offerings. Since many people with this disorder keep their fears secret, their social reluctance is often misinterpreted as snobbery, lack of interest, or hostility.

Surveys reveal that 7.4 percent of people in the United States and other Western countries (around 60 percent of them female) experience social anxiety disorder in any given year (see Table 5-8). Around 13 percent develop this disorder at some point in their lives (Kessler et al., 2012; Alfano & Beidel, 2011). It tends to begin in late childhood or adolescence and may continue into adulthood. At least one-quarter of individuals with social anxiety disorder are currently in treatment (NIMH, 2011).

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Research finds that poor people are 50 percent more likely than wealthier people to have social anxiety disorder (Sareen et al., 2011). Moreover, in several studies African Americans and Asian Americans, but not Hispanic Americans, have scored higher than white Americans on surveys of social anxiety (Melka et al., 2010; Polo et al., 2011; Stein & Williams, 2010). In addition, a culture-bound disorder called taijn kyofusho seems to be particularly common in Asian countries such as Japan and Korea. Although this disorder is traditionally defined as a fear of making other people feel uncomfortable, a number of clinicians now suspect that its sufferers primarily fear being evaluated negatively by other people, a key feature of social anxiety disorder.

The leading explanation for social anxiety disorder has been proposed by cognitive theorists and researchers (Iza et al., 2014; Heimberg, Brozovich, & Rapee, 2010; Hofmann, 2007). They contend that people with this disorder hold a group of social beliefs and expectations that consistently work against them. These include:

Cognitive theorists hold that, because of these beliefs, people with social anxiety disorder keep anticipating that social disasters will occur, and they repeatedly perform “avoidance” and “safety” behaviors to help prevent or reduce such disasters (Moscovitch et al., 2013). Avoidance behaviors include, for example, talking only to people they already know well at gatherings or parties. Safety behaviors include wearing makeup to cover up blushing.

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Beset by such beliefs and expectations, people with social anxiety disorder find that their anxiety levels increase as soon as they enter into a social situation. Moreover, because they are convinced that their social flaws are the cause of the anxiety, certain that they do not have the social skills to deal with the situation, and concerned that they cannot contain their negative arousal, they become filled with anxiety.

Later, after the social event has taken place, the individuals repeatedly review the details of the event. They overestimate how poorly things went and what negative results may take place. These persistent thoughts actually keep the event alive and further increase the individuals’ fears about future social situations.

Researchers have indeed found that people with social anxiety disorder manifest the beliefs, expectations, interpretations, and feelings listed here (Moscovitch et al., 2013; Rosenberg et al., 2010). At the same time, cognitive theorists often differ on why some individuals have such cognitions and others do not. Various factors have been uncovered by researchers, including genetic predispositions, trait tendencies, biological abnormalities, traumatic childhood experiences, and overprotective parent-child interactions during childhood (Heimberg & Magee, 2014; Rapee, 2014; Kuo et al., 2011).

Only in the past 15 years have clinicians been able to treat social anxiety disorder successfully (Rosenberg et al., 2010). Their newfound success is due in part to the growing recognition that the disorder has two distinct features that may feed upon each other: (1) sufferers have overwhelming social fears, and (2) they often lack skill at starting conversations, communicating their needs, or meeting the needs of others (Beck, 2010). Armed with this insight, clinicians now treat social anxiety disorder by trying to reduce social fears, by providing training in social skills, or both.

How Can Social Fears Be Reduced?Social fears are often reduced through medication (Pelissolo & Moukheiber, 2013; Ravindran & Stein, 2011). Somewhat surprisingly, it is antidepressant medications that seem to be the drugs of most help for this disorder, often more helpful than benzodiazepines or other kinds of antianxiety medications. At the same time, several types of psychotherapy have proved to be at least as effective as medication at reducing social fears, and people helped by such psychological treatments appear less likely to relapse than those treated with medications alone (Abramowitz et al., 2011). This finding suggests to some clinicians that the psychological approaches should always be included in the treatment of social fears.

One psychological approach is exposure therapy, the behavioral intervention so effective with phobias (Heimberg & Magee, 2014; Anderson et al., 2013; Antony & Roemer, 2011). Exposure therapists encourage clients with social fears to expose themselves to the dreaded social situations and to remain until their fears subside. Usually the exposure is gradual, and it often includes homework assignments that are carried out in the social situations. In addition, group therapy offers an ideal setting for exposure treatments by allowing people to face social situations in an atmosphere of support and caring (McEvoy, 2007). In one group, for example, a man who was afraid that his hands would tremble in the presence of other people had to write on a blackboard in front of the group and serve tea to the other members (Emmelkamp, 1982).

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Cognitive therapies have also been widely used to treat social fears, often in combination with behavioral techniques (Heimberg & Magee, 2014; Goldin et al., 2013, 2012). In the following discussion, cognitive therapist Albert Ellis uses rational-emotive therapy to help a man who fears he will be rejected if he speaks up at gatherings. The discussion took place after the man had done a homework assignment in which he was asked to identify his negative social expectations and force himself to say anything he had on his mind in social situations, no matter how stupid it might seem to him:

Studies show that rational-emotive therapy and other cognitive approaches do indeed help reduce social fears (Heimberg & Magee, 2014; Ollendick, 2014; Boden et al., 2012). And these reductions typically persist for years. On the other hand, research also suggests that while cognitive therapy often reduces social fears, it does not consistently help people perform effectively in social settings. This is where social skills training has come to the forefront.

How Can Social Skills Be Improved?In social skills training, therapists combine several behavioral techniques in order to help people improve their social skills. They usually model appropriate social behaviors for clients and encourage the individuals to try them out. The clients then role-play with the therapists, rehearsing their new behaviors until they become more effective. Throughout the process, therapists provide frank feedback and reinforce (praise) the clients for effective performances.

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Reinforcement from other people with similar social difficulties is often more powerful than reinforcement from a therapist alone. In social skills training groups and assertiveness training groups, members try out and rehearse new social behaviors with other group members. The group can also provide guidance on what is socially appropriate. According to research, social skills training, both individual and group formats, has helped many people perform better in social situations (Sarver, Beidel, & Spitalnick, 2014; Kim et al., 2011).