6.4 Social Anxiety Disorder (Social Phobia)

As Earl Campbell’s anxiety increased, he became concerned about what other people might think of him if they knew about his problem. As noted earlier, he was very aware of when people were looking at him. He also avoided crowds. Could Campbell have developed social anxiety disorder?

What Is Social Anxiety Disorder?

Social anxiety disorder, also called social phobia, is an intense fear of or anxiety about being scrutinized by others when in social situations, (see TABLE 6.9; American Psychiatric Association, 2013). Such social situations fall into three types: social interactions (such as a conversation); being observed (such as when eating or using public restrooms); and performing (such as giving a speech). People with social anxiety disorder may avoid making eye contact and avoid their feared social situations whenever possible. As noted in TABLE 6.9, a DSM-5 criterion is that the fear or anxiety is disproportional to the danger actually posed.

When a social situation cannot be avoided and must be endured, the person with social anxiety disorder experiences fear or anxiety, sometimes including symptoms of upset stomach, diarrhea, sweating, muscle tension, and heart palpitations. DSM-5 distinguishes between a social phobia that is limited to specific social performances where the person is the center of attention—such as making a presentation—and a more generalized social phobia, which leads a person to fear and avoid all social situations, as does Rachel in Case 6.4. TABLE 6.10 lists additional facts about social anxiety disorder.

People who have social anxiety disorder also tend to be very sensitive to criticism and rejection and to worry about not living up to the perceived expectations of others. Thus, they often dread being evaluated or taking tests, and they may not perform up to their potential at school or work. Their diminished performance challenges their self-esteem, increasing their anxiety during subsequent performances or tests. Similarly, achievement at work may suffer because they avoid social situations that are important for advancement on the job, such as making presentations. People with social anxiety disorder are less likely to marry or have a partner than people who do not have this disorder.

Sometimes, a clinician or researcher cannot easily distinguish whether a person’s symptoms indicate that he or she has social anxiety or agoraphobia. However, there are two key features that distinguish these disorders:

1. People with social anxiety disorder fear other people’s scrutiny.
2. People with social anxiety disorder rarely have panic attacks when alone.

In contrast, people who have agoraphobia do not exhibit these features.

Understanding Social Anxiety Disorder

Because of the very nature of this disorder, social factors are prominent contributors to it. Neveretheless, as we’ll see, all three types of factors play a role and contributed to Campbell’s problems.

Why does social anxiety disorder exist at all? Evolutionary psychologists speculate that social anxiety disorder may have its origins in behaviors of animals that are lower on a dominance hierarchy: Less powerful animals fear aggressive action from those more dominant and therefore behave submissively toward them. It is possible that social phobias arise when this innate mechanism becomes too sensitive or otherwise responds improperly (Hofmann et al., 2002). Key facts about the brains of people with social anxiety disorder are consistent with this conjecture, as we see in the following section.

What is your amygdala doing when you see this negative facial expression? The amygdalae of people with social anxiety disorder are more active when seeing negative facial expressions, such as this one here, compared to people without the disorder.

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Brain Systems and Neural Communication

Social anxiety disorder involves fear, and researchers have shown repeatedly that the amygdala is strongly activated when animals—including humans—are afraid (Rosen & Donley, 2006). Thus, it’s no surprise that the amygdala is more strongly activated when people with social anxiety disorder see faces with negative expressions (such as anger) than when they see happy faces and that this difference is greater than observed in control participants who do not have the disorder (Del Casale et al., 2012; Phan et al., 2006). Indeed, the more symptoms of social anxiety disorder a person has, the more strongly the amygdala is activated when the person views faces with negative expressions.

In addition, neurotransmitters may function abnormally in people who have social anxiety disorder (Li, Lindenberger, & Sikström, 2001). In particular, researchers have found that patients with social anxiety disorder show less activation in brain areas that rely on dopamine than do control participants. Furthermore, people with social anxiety disorder have too little serotonin, which may suggest why SSRIs have sometimes helped these patients (Gorman & Kent, 1999; Lykouras, 1999).

GETTING THE PICTURE

Which one of these children is more likely to be diagnosed with social anxiety disorder as an adult? Answer: The child on the right, who seems shy and may have a behaviorally inhibited temperament.

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Genetics

As is the norm for anxiety disorders, social anxiety disorder appears to arise from both genetic factors and environmental factors (Mathew et al., 2001; Stein, Jang, & Livesly, 2002). The heritability of social anxiety disorder is about 37% on average (Beatty et al., 2002; Fyer, 2000; Li et al., 2001; Neale et al., 1994).

We noted earlier that some people with social anxiety disorder were extremely shy as children; they had what is called a shy temperament, or behavioral inhibition (Biederman et al., 2001; Kagan, 1989), which has a genetic component. These patients cannot really be said to have developed a phobia, since they always had a basic level of discomfort in particular social situations (Coupland, 2001).

Three types of psychological factors influence the emergence and maintenance of social anxiety disorder: cognitive biases and distortions, classical conditioning, and operant conditioning.

Cognitive Biases and Distortions

People who have social anxiety disorder have particular biases in attention and memory (Ledley & Heimberg, 2006; Lundh & Öst, 1996; Wenzel & Cochran, 2006). In particular, people with social anxiety disorder tend to pay more attention to—and hence better remember—faces that they perceive as critical, which in turn feeds into their fears about being evaluated.

Similarly, cognitive distortions about the world can lead people with social anxiety disorder to see it as a very dangerous place; they then become chronically hypervigilant for potential social threats and negative evaluations by others (Beck & Emery, 1985; Joorman & Gotlib, 2006; Rapee & Heimberg, 1997). People with social anxiety disorder also use distorted emotional reasoning as proof that they will be judged negatively: They evaluate the impression they made on others based on how anxious they became during the interaction, regardless of what actually transpired. Furthermore, people with social anxiety disorder interpret ambiguous cues as negative, which becomes proof that they were correct in their concerns. For instance, an anxious woman giving a talk may interpret the fact that some audience members in the front row are leaning forward in their seats during her talk as proof that they are “waiting for me to falter or make a jerk out of myself” rather than that they might be leaning in to hear her better or might be stretching their backs.

Culture can influence the nature of the symptoms of social anxiety disorder. In Korea, for example, social fears called taijin kyofusho involve the possibility of offending others, perhaps through body odor or blushing. The social anxieties of Westerners, in contrast, involve fears of being humiliated by their own actions.

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Classical and Operant Conditioning

In some cases, classical conditioning can contribute to the development of social anxiety disorder: A social situation (the conditioned stimulus) becomes paired with a negative social experience (such as public humiliation) to produce a conditioned emotional response (Mineka & Zinbarg, 1995). The conditioned response (fear or anxiety) may generalize to other, or even all, types of social situations.

Operant conditioning principles apply to social anxiety disorder as well: Like a person with agoraphobia, a person with social anxiety disorder might avoid social situations in order to decrease the probability of an uncomfortable experience. The avoidant behavior does decrease anxiety and is thus reinforced (Mowrer, 1939). Campbell’s avoidance of crowds does not appear to have been related to social anxiety but rather to his attempting to avoid places where he might have a panic attack.

Extreme overprotection by parents is associated with childhood anxiety (Hudson & Rapee, 2001; Wiborg & Dahl, 1997); such overprotection may lead children to avoid certain situations to cope with their anxiety (Barrett et al., 1996).

In addition, different cultures emphasize different concerns about social interactions, and these concerns influence the specific nature of social anxiety disorder. For example, in certain Asian cultures, such as those of Korea and Japan, a person with social anxiety disorder may be especially afraid of offending others; in particular, he or she may fear that his or her body odor or blushing will be offensive. In Japan, this fear is known as taijin kyofusho (Dinnel et al., 2002; Guarnaccia, 1997a). This contrasts with a fear among North Americans and Europeans of being humiliated by something they say or do (Lee & Oh, 1999). This difference in type of social fears is consistent with the collectivist orientation of Asian countries compared to the individualist orientation of Western countries (Norasakkunit et al., 2012). The results from one study suggest that social phobias are becoming more common over time, and a higher proportion of people in more recent birth cohorts will develop the disorder (Heimberg et al., 2000).

A genetic or other neurological vulnerability, such as a shy temperament, can predispose people to developing social anxiety disorder (Bienvenu et al., 2007). The neurological vulnerability both contributes to and is affected by distorted thinking and conditioning to social situations (psychological factors). In addition, the anxiety and cognitive distortions may be triggered by a negative social event (social factor) and are then perpetuated by negative self-evaluations and avoidance of the feared social interactions (Antony & Barlow, 2002). Based on these psychological factors, people with social anxiety disorder may interact with others in ways that lead other people to rebuff them (Taylor & Alden, 2006), confirming their own negative view of themselves and of social interactions.

Treating Social Anxiety Disorder

Various forms of treatment are effective for social anxiety disorder; although these treatments typically target a single type of factor, as usual, they indirectly affect the other types of factors.

For people whose social fears are limited to periodic performances—such as a business presentation, a class presentation, or an onstage performance—a beta-blocker, such as propranolol (Inderal), is the medication of choice (Rosenbaum et al., 2005). Beta-blockers bind to some of the brain’s receptors for epinephrine and norepinephrine and hence make these receptors less sensitive. Both of these neurotransmitters are released during the fight-or-flight response. Thus, if the person perceives a “threat” and more epinephrine or norepinephrine is released as part of the fight-or-flight response, he or she will not experience its physical effects, such as increased heart rate, as strongly after taking a beta-blocker.

For those whose social anxiety arises in a wider and more frequent set of circumstances, the medication of choice is the SSRI paroxetine (Paxil) or sertraline (Zoloft). Other SSRIs and SNRIs, such as venlafaxine (Effexor) and nefazodone (Serzone), and NaSSAs, such as mirtazapine (Remeron), can also help treat social anxiety disorder (Rivas-Vazques, 2001; Van der Linden, Stein, & van Balkom, 2000). These medications affect the amygdala and the locus coeruleus, decreasing their activation. As with panic disorder, medication may be effective in treating social anxiety disorder in the short run (Federoff & Taylor, 2001), but symptoms generally return when medication is discontinued; thus, CBT is often also appropriate.

GETTING THE PICTURE

Which photo best captures the type of situation that would be part of exposure treatment for social fears about public speaking? Answer: The photo on the left.

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© Steve Hix/Somos/Corbis

The cognitive aspects of CBT help people to identify irrational thoughts about social situations, develop more realistic thoughts and expectations, and test predictions about the consequences of engaging in specific behaviors (Antony & Barlow, 2002; Clark et al., 2006). In addition, the behavioral method of exposure can be very effective in treating people with social anxiety disorder: When people put themselves in social situations in order to habituate to their anxiety symptoms, their anxiety diminishes (Taylor, 1996).

Because the anxiety symptoms relate to social interactions, group therapy is the preferred mode of exposure treatment. Such therapy immerses people in the very type of experience that is associated with anxiety. Cognitive-behavioral group therapy uses exposure and cognitive restructuring in a group setting. This setting allows patients to try out their new skills immediately (Heimberg et al., 1990, 1998). Moreover, the exposure involved in group therapy helps to extinguish the conditioned bodily arousal (learned alarm) that arises in social situations. Cognitive-behavioral group therapy is as effective as medication (Davidson et al., 2004) and has the added benefit that the positive effects continue after treatment ends (Aderka et al., 2011; Furukawa et al., 2013).

In addition to therapy groups, there are self-help organizations for people who are afraid of speaking in public, such as Toastmasters, which give people an opportunity to practice making both spontaneous speeches and planned ones. (For more information, go to www.toastmasters.org.)

Research indicates that CBT has effects on the brain that are comparable to those of some medications; both sorts of treatments actually reduce the activity in certain key brain areas. For example, one study investigated two kinds of treatments with participants who had untreated social anxiety disorder (Furmark et al., 2002). The study began by scanning the participants’ brains as they performed a public speaking task—which made them all anxious. Each participant was then randomly assigned to one of three groups: After the first scan, members of one group received the SSRI citalopram, members of another received CBT, and members of the third group were placed on a waiting list.

Nine weeks after the first scan, patients in the two treatment groups had improved by the same amount; however, patients in the waiting list group had not improved. At this point, all participants received a second brain scan, again while they performed the public speaking task. Comparison of the before and after brain scans revealed that a host of brain areas had less activity after treatment, particularly those involved in fear (and related emotions) and memory. Specifically, the amygdala, the hippocampus, and related areas were activated less strongly during the second scan, and the activation decreased comparably for the participants in the two treatment groups. The patients who responded best to treatment showed the greatest decrease in activation. And perhaps most striking, 1 year later the people who had the greatest reduction in activation from the first scan to the second scan were the most improved clinically. This means that the brain scans indicated how well the treatment worked for people with social anxiety disorder.

However, when medication is discontinued, symptoms of social anxiety disorder often recur. Such relapse is less likely after CBT. From a neuropsychosocial approach, CBT changes the way a patient thinks about and behaves in social situations (psychological factors). Viewing these situations more realistically and with less anxiety means that the patient does not get as physically aroused (neurological factor). This lowered arousal, along with positive or neutral expectations about the previously feared social situations, leads the patient to enter more willingly into a social situation (social factor), with less negative expectations. When such social experiences are positive, the patient feels increasing mastery (psychological factor) and less arousal (neurological factor) and perhaps receives reinforcement from others (social factor) for these changes.