Said to be the most common of the anxiety disorders, impacting people from all walks of life, SAD is estimated to affect tens of millions of people worldwide. The nature of the condition, however, makes it difficult for people to speak up about their problem, so experts suspect that up to 80 percent of people with SAD do not receive therapy for it. SAD was first included in the DSM in 1980; various studies suggest a prevalence rate from 2 to 15 percent of the population with many clinicians suggesting around 13 percent. The wide range indicates the difficulty clinicians have in setting a cut-off point at which one side is considered “disordered” and the other merely represents “normal” worrying (AI Therapy, 2014; Otto, n.d. – a).

Of course, nearly everyone experiences occasional anxiety in certain social settings or at some social events. Were we never to own moments of awkwardness, embarrassment, or a sense of being inhibited in public, we might have a disorder of a different type! The question for diagnosing SAD is: how extreme must the fear and stress in social situations be and how severely do such situations need to impact on a person’s life before the person is considered to suffer from SAD?

The core patterns of Social Anxiety Disorder

Also called “Social Phobia”, this form of anxiety disorder is characterised by self-focused attention, negative self-evaluation, anxious apprehension, avoidance and escape, behavioural disruption of normal functioning, and (social) skills deficits (Otto, n.d. – a).

The symptoms

SAD-diagnosed individuals may experience any of a lengthy list of symptoms. These can be divided into three components which comprise the disorder. While separate, they are interrelated, with the unfortunate result that they can strengthen one another, leading sufferers into ever-deeper maintaining cycles of anxiety. The three components are: anxious bodily sensations, anxious thoughts, and anxious behaviours.

Anxious bodily sensations may be: blushing; sweating; fast heartbeat; upset stomach; nausea; diarrhoea; shaking or tremor; muscle tension; dry mouth; cold, clammy hands; shortness of breath; and feeling faint.

Anxious thoughts (can be about self, others, or the situation) include:

• Everyone is staring at me”
• “They’ll think I’m a loser”
• “They will reject me”
• “They will think I’m weird”
• “I will be found out as incompetent”
• “I don’t belong here”
• “I won’t have anything to say”
• “I can’t even do the simplest things”
• “People will see how nervous I am – and think I’m crazy”
• “I will stumble over my words and be unable to continue”
• “They won’t want to talk to me again.”
• “I will keep looking more and more foolish”

Anxious behaviours (which can be triggered by anxiety, but can also make the anxiety worse over the long term) are:

• Avoiding entering social situations; intense fear of interacting with strangers or of meeting new people
• Leaving situations
• Avoiding eye contact
• Avoiding situations where one might be the centre of attention
• Experiencing difficulty talking
• Only entering “safe” places or with “safe” people
• Using mobile phones, MP3 players, or other devices to avoid being in conversations
• Apologising excessively
• Asking for reassurance from others
• Preparing excessively (memorising what to say, doing extreme grooming)
• Trying to direct people’s attention away from one’s performance (say, by making jokes or dressing in a certain way)
• Watching for signs that someone is judging (Jacobs & Antony, 2014; Mayo Clinic, 2011; Otto, n.d. – a).

The situations: Is your client interaction-anxious or performance-anxious?

Interestingly, as more is learned about SAD, experts have come to realise that not all potentially anxiogenic (anxiety-generating) situations affect everyone with SAD. Some researchers have suggested that people with this diagnosis can be grouped according to whether they get more strongly anxious at the idea of aspects of interpersonal relations, especially with new people or situations (the interactional group), or their fears centre around doing something with other people watching (the performance group). Here are situations that often generate severe anxiety for each type of SAD:

Interaction-anxious SAD means fear of:

• Asking for directions
• Starting a conversation or keeping it going
• Going on a date
• Attending a party
• Holding eye contact
• Being interviewed for a job
• Returning items to a store

Performance-anxious SAD sees anxiety triggered by:

• Spilling a drink
• Dropping something in a public place
• Voicing an opinion during a class or meeting
• Entering a room in which people are already seated
• Ordering food in a restaurant
• Eating alone at a restaurant
• Writing in front of others
• Using a public toilet or telephone
• Reading in front of others (Mayo Clinic, 2011; Jacobs & Antony, 2014)

Special cases of SAD: Medical or physical problems

In addition to the two main types of SAD, some clinicians have noted a manifestation of this anxiety disorder in individuals who have an ongoing medical or physical problem and fear being negatively judged for how they are or look. This group includes people with conditions such as: Parkinson’s disease, obesity, facial or bodily disfigurement (including amputees), some types of dwarfism, and any sort of condition which causes a person to look different from the norm. Individuals with this type of social anxiety fear attracting attention and disdain (Grohol, 2011).

What’s shared among anxiety disorders?

The common elements of anxiety conditions for which clinicians search are below. We show how each element may manifest with SAD:

Increased attention to threatening and dangerous stimuli

Anxious clients are more likely to be aware of what they perceive to be threatening or dangerous, and their attention is biased and distorted. In the case of SAD, the attentional bias/distortion is around other people’s reactions, which are perceived as threatening to the person’s job, reputation, relationships, or other facets of life.

Distorted perception and interpretation of internal and external events

Clients tend to overestimate how likely the threat and danger are, exaggerate the consequences should negative events occur, and underestimate their own ability to cope. SAD clients may, for example, be certain that they will forget their prepared speech, exaggerate the consequences – say, by assuming audience rejection and disdain, should forgetting happen – and believe that they wouldn’t be able to cope.

Irrational assumptions and beliefs (which form themes in the client’s life)

These revolve around danger schemas (viewing the world as a dangerous place, acceptance (feeling like one is nothing if not loved), competence (the pressure to do things perfectly), responsibility (incorrectly assuming sole blame for how things turn out), and control (needing to have it at all times).

Those diagnosed with SAD tend to hold assumptions/beliefs that they are being evaluated negatively most of the time, whether they believe the judgment is that they are socially inept as a conversationalist, incompetent because they have trouble speaking up, or merely clumsy because they dropped something while others were watching. The world is a dangerous place for sufferers of SAD because there is the ever-present danger of being rejected by others for lack of social or other skills.

Maladaptive coping responses

These can be irrational beliefs about worry (such as that one should worry or that it is uncontrollable) or obsessions (such as that thinking something increases the chances that a negative outcome will occur). Maladaptive coping responses involve avoidance of or escape from feared objects or situations, safety behaviours, and cognitive avoidance (that is, suppression of thoughts or distraction from them and thought rituals) (Gasper, n.d.).

An example of this behaviour with a SAD-diagnosed client might be avoiding parties – even work functions where other attendees are known – because of fears of entering a room where a party is in full swing and striking up a conversation with others. The SAD client may believe, for example, that to turn up at the work party and do something which is socially awkward (such as try to speak and have the throat be dry from stress) will have a dire consequence: perhaps even that it will cost him/her the job. Forced to attend the party, s/he may then always have a bottle of water to sip from (a safety behaviour) so that no one will notice the dry throat.

This article was adapted from the upcoming Mental Health Academy CPD course “Using CBT with Social Anxiety Disorder”.

References

• AI Therapy. (2014). About social anxiety. A1CBT Ltd. Retrieved on 14 July, 2104, from: hyperlink.
• Gasper, P. (n.d.) Assessment & formulation in CBT. The Marian Centre. Retrieved on 30 June, 2014, from: hyperlink.
• Grohol, J. (2011). Social Anxiety overview. Psych Central. Retrieved on 14 July, 2014, from: hyperlink.
• Jacobs, A.M. & Antony, M.M. (2014). Social Anxiety Disorder and Social Phobia. Social Anxiety Support. Retrieved on 14 July, 2014, from: hyperlink.
• Mayo Clinic. (2011). Social Anxiety Disorder (Social Phobia). Mayo Clinic. Retrieved on 23 July, 2014, from: hyperlink.
• Otto, M.W. (n.d. – a) Cognitive behavioral treatment of Social Anxiety Disorder. Boston University: Center for Anxiety and Related Disorders. Pollack APA Symposium. Retrieved on 22 July, 2014, from: hyperlink.