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Features and Impact of Social Anxiety



Clinical Features

Key Feature

The key feature of SAD is an intense fear of negative evaluation by others. This fear may present as fear of social situations (e.g. dating, parties), fear of observation in social situations (e.g. eating, writing), or fears of performance (athletic performance, public speaking or dancing).


Behavioural Features

The key presenting behavioural features of SAD include social and occupational avoidance, delays in lifecycle transitions, self-medication with substances, and safety behaviours to hide physiological responses. Individuals meeting the diagnostic criteria for SAD may chronically avoid social situations and thus have a highly restricted social network due to behaviours such as repeatedly turning down invitations to social events or leaving social events early to escape feelings of anxiety. Occupationally, they may seek employment in jobs that require little social contact, acquiesce to unpleasant requests to avoid conflict, and be inadequately assertive. At social gatherings they may avoid eye contact, smiling and self-disclosure to discourage others from conversing with them. Additionally, they may speak very quietly, or occasionally be controlling of conversations due to their anxiety. Converse to the Skills Deficit Model of SAD, there is also evidence to suggest that affected individuals have the social skills required to interact appropriately, but do not perform these skills competently.

Those meeting the diagnostic criteria for SAD may also live at home longer and be delayed in marrying (usually men). Self-medication with substances is also common to cope with fears around social events. Moreover, Clinicians may observe off-putting safety behaviours, for example, clients may present with a dismissive attitude, ambivalence regarding commitment to treatment, limited eye contact, wearing a jacket in summer to hide perspiration, or excessive make up to hide blushing. These are employed to help minimise the physical signs and extent of anxiety.


Cognitive Features

The core feature of SAD according to cognitive models of SAD is the fear of negative evaluation from a perceived audience. Key associated beliefs include that the perceived audience will observe the individual’s behaviour, have a high standard for approval which the individual is not competent to meet, that the individual will be unable to control the resulting anxiety and that the audience will negatively evaluate the person at a high social cost. These beliefs are maintained by distorted cognitive processing before, during and after social events. Before events, the individual engages in negative catastrophic predictions. During the event, the person selectively attends to signs of possible deficient performance which increases anxiety and uses safety behaviours to manage this anxiety. Self-focus about their performance also causes individuals to miss important social cues, resulting in poorer social performance. After the event, they replay the event to reassure themselves, however due to the same negative information processing cognitive biases that informed their cognitions before and during the event, these replays serve to reinforce their negative beliefs. Studies supporting these patterns have shown that those with SAD interpret ambiguous stimuli negatively, have more negative thoughts than controls, and attribute events internally to global, stable traits.


Functional Impact

SAD is associated with high rates of social disability, including lower lifetime earnings, elevated rates of school dropout, and decreased wellbeing, employment, workplace productivity, socioeconomic status, and quality of life. The disorder is also correlated with being single, divorced, and not having children, particularly among men. SAD also impairs leisure activities, and caregiving or volunteering in older adults.


Maintenance Processes

Avoidance is a key maintaining factor of SAD and can be covert (over-preparing for a speech, limiting eye contact, other safety behaviours) or overt (cancelling social plans). Distorted cognitions play a significant role in the maintenance of SAD, particularly as painful feelings are often far more salient than awareness of cognitions for individuals. Frequent cognitive distortions include catastrophising, emotional reasoning and discounting the positive. Being unemployed is also a strong predictor for the persistence of the disorder.


References

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Simon, N. M., Otto, M. W., Wisniewski, S. R., Fossey M., Sagduyu, K., Frank, E., Sachs, G. S., Nierenberg, A. A., Thase, M. E., & Pollack, M. H. (2004). Anxiety disorder comorbidity in bipolar disorder patients: Data from the first 500 participant in the systematic treatment enhancement program for bipolar disorder (STEP-BD). The American Jounral of Psychiatry, 161(12), 2222-2229. https://doi.org/10.1176/appi.ajp.161.22.2222


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