Social Anxiety Disorder / Social Phobia

Some people have a very hard time in social situations because they fear them to the point where they can be diagnosed with Social Anxiety Disorder, also known as Social Phobia.

You could think of Social Phobia as more typical shyness turned up to 11. The big difference is that the anxiety becomes a lot more prominent. If a run of the mill shy person went to a party they may not talk much, and they may report feeling inhibited, tongue-tied, and insecure, but they often aren't outstandingly nervous. A socially anxious person may go to a party and be a shaky, frightened, nauseous mess for the first half of it.

Also, when someone is shy they may worry about being seen as quiet or boring. Someone with Social Anxiety Disorder may worry about that too, but also about coming across as obviously anxious and uncomfortable, which they believe that will lead to them being rejected and embarrassed. Because it's more severe, Social Anxiety Disorder also has much more of a negative effect on people's lives. Someone who is a little shy may not contribute much to a group conversation. A person with a bad case of Social Phobia may feel too nervous around people to be able to hold down a job.

Criteria for Social Anxiety Disorder / Social Phobia

Below are two sets of criteria for diagnosing someone with Social Anxiety Disorder. The descriptions below come from two sources, the Diagnostic and Statistical Manual, 5th Edition (DSM-5), and the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10). The DSM-5 is published by the American Psychiatric Association. The ICD-10 is based on classifications from the World Health Organization.

If you actually have Social Phobia you probably already know all about it. If not, this may be interesting reading. I'd caution anyone not to try to diagnose themselves or anyone else just based on some descriptions. A qualified professional has to make that call. Also, lots of people can read the criteria for various mental health issues and see little pieces of themselves in them, but that's usually a far cry from being officially diagnosable.

DSM-5 Criteria For Social Anxiety Disorder

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g, giving a speech).

Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating and embarrassing; will lead to rejection or offend others).

C. The social situations almost always provoke fear or anxiety.

Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J. If another medical condition (e.g., Parkinson's disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specify if: Performance only: If the fear is restricted to speaking or performing in public.

ICD-10 Criteria for Social Phobia:

Social phobias often start in adolescence and are centred around a fear of scrutiny by other people in comparatively small groups (as opposed to crowds), leading to avoidance of social situations. Unlike most other phobias, social phobias are equally common in men and women. They may be discrete (i.e. restricted to eating in public, to public speaking, or to encounters with the opposite sex) or diffuse, involving almost all social situations outside the family circle. A fear of vomiting in public may be important. Direct eye-to-eye confrontation may be particularly stressful in some cultures. Social phobias are usually associated with low self-esteem and fear of criticism. They may present as a complaint of flushing, hand tremor, nausea, or urgency of micturition, the individual sometimes being convinced that one of these secondary manifestations of anxiety is the primary problem; symptoms may progress to panic attacks. Avoidance is often marked, and in extreme cases may result in almost complete social isolation.

Diagnostic Guidelines

All of the following criteria should be fulfilled for a definite diagnosis:

(a) the psychological, behavioural, or autonomic symptoms must be primarily manifestations of anxiety and not secondary to other symptoms such as delusions or obsessional thoughts;
(b) the anxiety must be restricted to or predominate in particular social situations; and
(c) avoidance of the phobic situations must be a prominent feature.

Includes:

  • anthropophobia
  • social neurosis

Differential Diagnosis

Agoraphobia and depressive disorders are often prominent, and may both contribute to sufferers becoming "housebound". If the distinction between social phobia and agoraphobia is very difficult, precedence should be given to agoraphobia; a depressive diagnosis should not be made unless a full depressive syndrome can be identified clearly.

There are two sub-types of Social Anxiety Disorder. The first is generalized and much more detrimental. It's when someone is anxious in most social situations. The second is when someone functions well on the whole, but fears specific scenarios such as eating or writing in front of people.

Another thing I'll draw attention to is how depression or other anxiety problems often occur alongside social anxiety. It's totally understandable how someone could also be depressed if they were super nervous around people and their life suffered as a result. People with Social Anxiety Disorder may be anxious in other ways as well. They may have other fears, a general level of background anxiety, or worries about having panic attacks.

There's another way social phobics can be divided into two types. Some people with this problem don't feel great in social situations, but they manage to function in them anyway. They have a group of friends and do things with them. They may not be operating at 100%, but they get by. The second type don't have a satisfying social life because their nerves are too much for them to rein in. They're lonely and unhappy.

Additional effects

I don't think those two clinical-sounding symptom lists above capture the full extent of what having social anxiety is like. Sure, the crippling fear of social situations is the main feature, but social phobics are also often really insecure and miserable because of their condition. They can be really down on themselves because of how isolated they are and how they can't manage to overcome their nervousness. They also tend to spend a lot of their time worrying and over-analyzing things, which anxiety in general tends to make people do.



Treatments for Social Anxiety Disorder

There are effective treatments for Social Anxiety Disorder, though it's not something that can be fixed overnight. The approaches I cover below are often blended together and taught all at once. People can reduce on their social anxiety on their own, but working with a therapist, either one-on-one or in group sessions is often helpful. My own philosophy is that if you have access to that kind of resource then why not take advantage of it? Seeing a professional is also the only way to access medication, which some people find helpful in treating the condition.

Cognitive restructuring

People with social anxiety tend to think in ways that exaggerate the danger of social situations and downplay their ability to deal with them. Like they may believe that if they come off as the slightest bit timid or socially awkward, everyone will judge them harshly. If they learn to identify and debunk their maladaptive thoughts and beliefs they can reduce their nervousness. Covering this information is pretty mandatory in working with social anxiety. Even if no other interventions are attempted, there's evidence that this approach alone can be useful.

I wrote a couple of articles on this area:

Beliefs And Worries Which Sustain Shyness, Insecurity, And Social Anxiety
Challenging Maladaptive Thoughts
Accepting And Rolling With Maladaptive Thoughts

Exposure therapy

From what I've researched on the topic, the most effective treatment for Social Phobia is for people to gradually and systematically face their social fears. As I just noted, education in dealing with maladaptive thinking should be a component of this approach.

Facing their fears is something a person with Social Anxiety Disorder could do on their own, or with a counselor's guidance. They could also join a treatment group that would provide a safe environment and plenty of opportunities to get used to being in social situations, through structured role-plays, and by the members talking to and learning from each other.

I wrote two articles on the importance of facing fears and how to go about doing it.

Reduce anxiety and depression in general

Aside from handling their more specific social difficulties, it can help social anxiety sufferers to make lifestyle changes that turn down their overall anxiety levels. It can also be useful to learn general strategies for coping with anxious feelings. I discuss that in these articles:

Lifestyle Changes That Can Improve Mood
Overall Attitudes For Handling Anxiety
Coping With Anxiety In The Moment

Social skills training

This one depends on the individual. Like with shyness, some people with social anxiety have decent interpersonal skills. Their anxiety gets in the way and prevents them from deploying those skills effectively. Other people with social anxiety have rusty or underdeveloped communication skills. That they know they're awkward around people may contribute to their nervousness. Improving their people skills can help them feel more confident and capable in social situations. Naturally, I think this site is a good resource for advice on people skills.

The odd social deficit can be corrected simply by reading about a better way to act, but most of the time real-world practice is needed. Again, someone with social anxiety should be educated on how to handle their maladaptive thought processes and beliefs about socializing. They should also have an idea of how to manage any nervousness that comes up. If they don't have this foundation then throwing themselves into the social world to try to learn new skills may do more harm than good.