research paper on social anxiety

Research article
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Published: 23 April 2019

Social anxiety increases visible anxiety signs during social encounters but does not impair performance

Trevor Thompson ORCID: orcid.org/0000-0001-9880-782X 1 ,
Nejra Van Zalk 2 ,
Christopher Marshall 3 ,
Melanie Sargeant 4 &
Brendon Stubbs 5

BMC Psychology volume 7 , Article number: 24 ( 2019 ) Cite this article

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Preliminary evidence suggests that impairment of social performance in socially anxious individuals may be specific to selective aspects of performance and be more pronounced in females. This evidence is based primarily on contrasting results from studies using all-male or all-female samples or that differ in type of social behaviour assessed. However, methodological differences (e.g. statistical power, participant population) across these studies means it is difficult to determine whether behavioural or gender-specific effects are genuine or artefactual. The current study examined whether the link between social anxiety and social behaviour was dependent upon gender and the behavioural dimension assessed within the same study under methodologically homogenous conditions.

Ninety-three university students (45 males, 48 females) with a mean age of 25.6 years and varying in their level of social anxiety underwent an interaction and a speech task. The speech task involved giving a brief impromptu presentation in front of a small group of three people, while the interaction task involved “getting to know” an opposite-sex confederate. Independent raters assessed social performance on 5 key dimensions from Fydrich’s Social Performance Rating Scale.

Regression analysis revealed a significant moderate association of social anxiety with behavioral discomfort (e.g., fidgeting, trembling) for interaction and speech tasks, but no association with other performance dimensions (e.g., verbal fluency, quality of verbal expression). No sex differences were found.

Conclusions

These results suggest that the impairing effects of social anxiety within the non-clinical range may exacerbate overt behavioral agitation during high demand social challenges but have little impact on other observable aspects of performance quality.

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Social anxiety disorder (SAD) is a common psychiatric disorder, with up to 1 in 8 people suffering from SAD at some point in their life [ 1 ]. SAD is linked to reduced quality of life, occupational underachievement and poor psychological well-being, and is highly comorbid with other disorders [ 2 ]. Mounting evidence suggests that social anxiety exists on a severity continuum [ 3 ], and that social anxiety that is not severe enough to warrant a diagnosis of SAD may still produce significant individual burden [ 4 ].

There is little evidence to suggest that social anxiety may negatively affect others’ perceptions of agreeableness or warmth [ 5 ]. However, if social anxiety impairs an individual’s ability to function effectively in common performance situations such as job interviews, presentations and other social challenges [ 6 ], this could cause or maintain feelings of failure and inadequacy and even affect career success [ 7 ]. Cognitive models [ 8 ] predict that social anxiety could impair social competence by increasing self-focused attention and consuming attentional resources necessary for effective communication. On the other hand, social anxiety can also lead to a willingness to engage in socially-facilitative behavior such as polite smiling, head nodding and avoiding interruption, which can facilitate interaction and lead to more favorable impression of another’s social behavior [ 9 ].

While socially anxious individuals reliably believe their social behavior is deficient, the existence of actual impairment has been the subject of a fair amount of debate [ 10 ]. Empirical studies that have examined the association between social anxiety and behavior in response to social challenge tasks in both clinical and non-clinical samples have produced inconsistent findings. Strahan and Conger [ 11 ], for example, compared the responses of 26 men with low social anxiety with 27 men reporting clinical levels of social anxiety on the Social Phobia and Anxiety Inventory in their response to a simulated job interview. Observer ratings of videotaped interviews indicated no group differences in overall social competence ratings. Rapee and Lim [ 12 ] found that, when asked to give a brief impromptu speech, a group of 28 individuals with SAD did not differ in observer ratings of overall performance relative to a group of 33 non-clinical controls. Similar null results have been reported in a non-clinical sample of males on overall impressions of social skill on an opposite-sex “getting to know you” task [ 13 ], and in a sample of 110 schoolchildren participating in a two-minute impromptu speech where observers rated video recordings for global impressions and “micro-behaviors” (e.g., clarity of speech, ‘looking at the camera’) [ 14 ].

However, a number of other studies have identified a link between social anxiety and impaired social behavior. Levitan et al. [ 15 ] found that patients with SAD were rated significantly more poorly on observer ratings of voice intonation and fluency during a three-minute speech compared to controls. Other studies have also found patients with SAD to be rated more poorly by observers on adequacy of eye contact and speech clarity [ 16 ] and as exhibiting more “negative social behaviors” (e.g. awkwardness) during conversations [ 17 , 18 ]. In a non-clinical study of 48 women, Thompson and Rapee [ 18 ] found individuals with high social anxiety to be rated more poorly during an opposite-sex “getting to know you” task on summed measures of molecular (e.g. voice quality, conversational skill) behaviors and on overall impression.

A recent review by Schneider and Turk [ 10 ] suggests that the apparently variable link between social anxiety and behavior is likely to be influenced by differences across studies in factors such as statistical power, sample characteristics and the type of behavioral assessments used. Assessment measures, for example, have ranged from global impression ratings to composite scores of molecular behaviors (e.g., smiling frequency, eye contact), and it may be that social anxiety impairs certain social behaviors but not others. There is some evidence that social anxiety may selectively exacerbate observable anxiety signs but have little impact on performance ‘quality’ (e.g. factors central to effective communication) [ 14 , 19 ]. Schneider and Turk [ 10 ] note, however, that it is difficult to identify a coherent pattern that identifies which aspects of performance may be impaired by social anxiety and which may not and this is additionally complicated by differences in study designs. Furthermore, where associations of social anxiety across multiple behavioral dimensions have been examined within the same study, where they are evaluated under the same conditions, these differences have rarely been compared statistically which limits the reliability of the current evidence for selective deficits in social behavior [ 20 ].

Norton [ 21 ] also notes that studies using exclusively female samples have often found stronger associations of social anxiety with behavioral deficits than studies with male samples, consistent with the argument that gender-role expectations may lead to more deleterious effects of social anxiety in women [ 22 ]. Again, however, it is impossible to determine with any certainty whether more pronounced effects of social anxiety in studies with females is attributable to moderating effects of gender or some other difference in study characteristics. Unfortunately, few studies have directly compared males and females, or different performance dimensions, within the same study where there is greater methodological homogeneity.

This study aimed to assess social behavior during social challenges in a non-clinical sample of individuals varying in their levels of social anxiety. We used speech and interaction tasks, as these represent different types of commonly-encountered social challenges. Performance was assessed by independent raters using Fydrich’s Social Performance Rating Scale, which consists of five separate dimensions of social competence. The aim of the study was to examine whether social anxiety is associated with impaired social behavior, and in particular: (1) whether impairment occurs only for specific dimensions of behavior, and (2) whether impairing effects are greater in females.

Participants

The sample consisted of 93 participants (45 males and 48 females) with a mean age of 25.6 years ( SD = 7.7, Range = 18–53). Males ( M = 26.5 years) and females ( M = 24.7 years) did not differ significantly with respect to age, t (86) = 1.12, p = .26. Scores on the Social Phobia Scale were lower for males (M = 17.1, SD = 9.68) compared to females (M = 22.7, SD = 12.7), and this difference reached statistical significance, t (91) = 2.36, p = .02.

The mean SPS score of the current sample was 20.0 ( SD = 11.6, range = 2–48). Compared to McNeil et al.’s (1995) reference data, this is significantly lower than the mean SPS score of individuals with SAD, M = 32.8, SD = 14.8, t (57) = 5.86, p < .001, but significantly higher than undergraduates, M = 13.4, SD = 9.6, t (144) = 3.69, p < .001, and community volunteers, M = 12.5, SD = 11.5, t (141) = 3.70, p < .001. The mean age of these comparison groups was higher (SAD sample M = 36.5 years, community sample M = 33.2 years, with age data not reported for undergraduates) than the current sample.

An exclusion criterion of previous acquaintance with the experimenters was implemented, as familiarity may have reduced the effectiveness of the social challenge tasks as anxiety inductions. A recruitment request was e-mailed to all students at Greenwich University which stated that “volunteers are sought to take part in a paid (£10) study which will involve filling in some questionnaires, engaging in a conversation task and talking to others about a set topic, giving your views”.

Anxiety and social behavior scales

Mattick and Clarke’s Social Phobia Scale (SPS) Footnote 1 was used to assess level of trait social anxiety. The SPS consists of 20 items rated on a five-point (0–4) scale, with higher scores indicating greater social anxiety. The scale has been shown to reliably assess social anxiety in both non-clinical and clinical populations [ 23 ]. The SPS has previously demonstrated good test-retest reliability, internal consistency and convergent validity [ 24 , 25 ] and exhibited high internal consistency (Cronbach’s α = .89) for the current data.

State anxiety was assessed in order to verify that the speech and interaction tasks resulted in increased anxiety relative to participants’ baseline anxiety. Baseline anxiety was assessed with a single self-report item that asked respondents to indicate their current anxiety on a scale of 1–10. State anxiety was also assessed immediately prior to the commencement of each task (participants had been provided with task details a few minutes earlier), and immediately after each task where participants were asked to rate the anxiety they had felt during the task itself. Single-item assessments of state anxiety have shown good reliability and convergent validity [ 26 ].

The Social Performance Rating Scale (SPRS) [ 27 ] was used to rate the participant on the following five dimensions: Gaze - adequacy of eye contact, Vocal Quality – warmth, clarity and enthusiasm demonstrated in verbal expression, Length – low level of monosyllabic speech/excessive talking, Discomfort – low levels of behavioral anxiety (e.g., fidgeting, trembling, postural tension), and Flow - verbal fluency (including the ability to incorporate information provided by the conversation partner smoothly into the interaction). The flow item was not used in the assessment of the speech task, as the rating descriptors for this component are specific to conversation. All SPRS items were rated on a 5-point scale and scored so that higher scores represented more effective social performance. Detailed descriptive anchors accompany each rating point to facilitate scoring; for example, Vocal Quality, “5 (Very Good) = Participant is warm and enthusiastic in verbal expression without sounding condescending or gushy”. The SPRS has shown excellent inter-rater reliability, internal consistency, convergent, discriminant and criterion validity [ 27 , 28 ]. Agreement across the three raters assessing the speech task was examined with an intraclass correlation (ICC). An absolute-agreement model was used [ 29 ], which is a stringent test requiring both high inter-rater correlations and minimal discrepancy in actual rating values to produce a high ICC. Analysis revealed ICC’s = .64–.86 for individual SPRS dimensions (all p’s < .001), suggesting good rater agreement [ 30 ]. Scores were therefore averaged across raters for each individual SPRS dimension for the speech task. Similar means (range: 3.4–3.8) and standard deviations (range: 0.7–1.1) were observed across SPRS components for both interaction and speech tasks.

Speech task

Participants were given 3 min to prepare a speech presenting a persuasive argument on their choice of one of the following topics: “sometimes it is ok to lie, discuss” or “can any crime be justified?”. Participants were told they would be presenting in front of a small audience and that they should try to keep going for 3 min although they could terminate the task at any point. Three confederates (one male and two female) comprised the “audience” for the speech task, with the same three-confederate audience used for each participant. The confederate audience had previously undertaken a number of trial sessions with several undergraduate volunteers acting as participants where they had practiced maintaining neutral facial expressions.

Interaction task

Participants were told that they would shortly be introduced to someone and that they would have 3 min to find out as much as they could about this person, although they could terminate the task at any time. The conversation partner was an experimental confederate, who was of the opposite-sex in order to maximize socially-evaluative challenge [ 6 ]. The same male confederate was used for each female participant, and the same female confederate was used for each male participant, with the one male and one female confederate taken from the pool of three confederates used in the speech task. Confederates had previously undertaken a number of trial sessions amongst each other and with undergraduate volunteers, where they practiced giving minimal responses, avoiding asking questions and maintaining neutral facial expressions [ 6 ]. Nobody other than the participant and the confederate was present during the interaction task when the experiment began.

To put participants in a relaxed state for a reliable assessment of baseline state anxiety, and to provide time for the experimenter to prepare the social challenge tasks, participants watched a 5-min relaxation video showing images of various seascapes accompanied by relaxing sounds. They then immediately completed the baseline state anxiety item along with the Social Phobia Scale and were randomized to undergo either the speech or interaction task first.

Participants were given details of the first social challenge task and reminded that they had the right to withdraw from the study at any point (no withdrawals occurred). Immediately prior to the social challenge task, participants completed the state anxiety item to assess anticipatory anxiety. Immediately following the task, participants again completed the state anxiety item, retrospectively indicating the anxiety they had experienced during the task. Participants were independently rated on their social performance by the audience of confederates (speech task) or the conversation partner (interaction task) using the SPRS, with ratings not disclosed to participants. This procedure was then repeated with the second social challenge task.

Statistical analysis plan

The association of social anxiety and sex with observer ratings was examined by conducting separate regression analyses on each SPRS dimension, with predictors of social anxiety, sex (− 1 = males, + 1 = females) and a Social Anxiety X Sex interaction term. Social anxiety was standardized but SPRS ratings were left unstandardized, so that the raw regression coefficient is interpreted as the mean change in rating points (on the 1–5 scale) following a one standard deviation increase in social anxiety. The interaction term was computed by cross-multiplication of sex and standardized social anxiety scores [ 31 ].

To determine whether regression coefficients of social anxiety and behavioral ratings differed significantly across the different SPRS dimensions, we tested the equality of these coefficients within a structural equation model. Predictors were the same as for the multiple regression analysis described above, and outcome variables were two SPRS dimensions (specified with correlated errors) whose coefficients were to be compared. We then imposed an equality constraint on the coefficient of social anxiety with each of two performance dimension coefficients. If a likelihood ratio test indicates a significant decrease in fit when an equality constraint is used, this indicates that the two coefficients are not equal [ 32 ]. Analyses were conducted in R using the lavaan [ 33 ] package .

Data screening

Regression residual plots for SPRS ratings revealed normality and homoscedasticity assumptions were met with no obvious outliers present. A negative skew of speech and interaction task times (due to a ceiling effect from the 3-min time limit) was observed, so p -values for analysis of task time data were computed from 10,000 bootstrapped samples.

Social challenge tasks: anxiety manipulation check

Consistent with the successful induction of anxiety, paired t-tests found significant increases from baseline anxiety for the speech task at pre-task ( t (92) =5.58, p < .001) and during-task ( t (92) =9.92, p < .001) periods, and for the interaction task at pre-task ( t (92) =5.84, p < .001) and during-task periods ( t (92) =5.69, p < .001) (see Table 1 for mean task anxiety scores at each assessment period). To check that anxiety was induced in both male and female participants, t-tests were repeated for each gender separately. For males, significant increases from baseline anxiety were uniformly found at pre-task ( t (44) =3.61, p < .001) and during-task ( t (44) =5.63, p < .001) in the speech task, and pre-task ( t (44) =2.52, p = .015) and during-task ( t (44) =4.15, p < .001) in the interaction task. This pattern of results was replicated for females, with significant increases from baseline anxiety observed at pre-task ( t (47) =4.49, p < .001) and during-task ( t (47) =8.58, p < .001) for the speech task, and pre-task ( t (47) =5.89, p = .015) and during-task ( t (47) =4.03, p < .001) for the interaction task.

Table 1 also reports correlations of social anxiety and gender with self-reported anxiety and shows social anxiety to be consistently moderately associated with increased anxiety response, and additionally that females generally reported greater anxiety compared to males.

Some participants terminated the social challenge tasks before the 3-min limit (speech M = 127 s , interaction M = 177 s ). As such, we computed the association between social anxiety and task time, as observers’ ratings might conceivably be affected by early task termination. No significant association was observed for either speech ( r = −.02, p = .88) or interaction ( r = −.19, p = .13) tasks.

Primary analysis

Separate regression analyses were performed on each SPRS dimension for the speech and interaction tasks resulting in 9 regression tests (4 SPRS speech dimensions, 5 SPRS interaction dimensions). To control type I error rate, we used an adjusted alpha criterion of α = .021 based on the Dubey-Armitage Parmar correction [ 34 ], which adjusts the conventional level of .05 based on the number of tests conducted (9) and the mean correlation between outcomes ( r = .59 for SPRS ratings).

Speech task: social anxiety, sex and SPRS ratings

Table 2 shows the unstandardized ( B ) and standardized ( ß ) coefficients of social anxiety with observer ratings on each SPRS item resulting from the regression analysis of the speech task. These results show that social anxiety was a significant predictor of increased discomfort 2 ( B = -0.28, ß = -0.42 , p < .001), but not of gaze, vocal quality or length. There were no significant sex (Table 3 ) or Social Anxiety X Sex interaction effects ( p = .10–.96).

With respect to the magnitude of the association between social anxiety and SPRS discomfort, as SPRS ratings were left unstandardized, B represents the mean change in SPRS discomfort ratings on the 5-point scale for a one SD increase in social anxiety. As such, this indicates that a change from − 1 SD (low) to + 1 SD (high) social anxiety is associated with a 0.56-point increase in discomfort. Footnote 2

Interaction task: social anxiety, sex and SPRS ratings

For the interaction task, social anxiety was significantly associated with ratings on the discomfort dimension ( B = -0.36, ß = -.45, p < .001), but not with other SPRS dimensions (Table 2 ). No significant sex (Table 3 ) or interaction effects ( p = .09–.98) were observed. The unstandardized regression coefficient of B = -0.36 for discomfort indicates that a change from − 1 SD (low) to + 1 SD (high) social anxiety is associated with a 0.72-point increase 2 in discomfort.

Comparison of regression coefficients of social anxiety across SPRS dimensions

A likelihood ratio test was used to compare the regression coefficient of social anxiety for SPRS discomfort with regression coefficients for the other SPRS dimensions. For the speech task, the coefficient for SPRS discomfort was significantly greater than all other SPRS dimensions (χ 2 = 6.56–17.65, all p ’s < .01). For the interaction task, the coefficient was significantly greater for SPRS discomfort compared to all other SPRS dimensions (χ 2 = 4.37–5.36, all p ’s < .05) except SPRS gaze (χ 2 = 1.31, p = .25). Footnote 3

One of the primary findings from this study was that social anxiety was associated with higher observer ratings of behavioral discomfort (e.g., fidgeting, trembling, swallowing) during interaction and speech tasks, but not with other dimensions such as verbal fluency or quality of verbal expression.

Previous research investigating the link between social anxiety and social behavior has produced inconsistent results. It has been suggested that this inconsistency could be partially attributable to differences across studies in the dimension of social behavior assessed, with social anxiety potentially impairing only some behavioral dimensions; although no coherent pattern of which elements of social behavior may be affected has emerged [ 10 ]. The current results suggest that, at the non-clinical level at least, social anxiety may magnify the visible signs of anxiety but have little impact on other social behavior dimensions that were assessed here. These results are broadly consistent with Bögels et al. [ 19 ] who compared performance ratings for undergraduates low and high in social anxiety. They found that socially anxious participants received significantly more negative ratings on a “showing anxiety symptoms” factor, but not on a “skilled behavior” factor. Similarly, Cartwright-Hatton et al. [ 14 ] found that social anxiety scores were significantly associated with observer ratings of nervousness in schoolchildren based on a videotaped two-minute presentation, but not with “overall” impressions of performance (based on three items of ‘cleverness of speech’, friendliness and performance quality). It is difficult to determine from these previous studies if this is indicative of genuine selective effects on visible anxiety signs or simply chance variation, as no statistical comparison across dimensions was made. To our knowledge, the current study is the first to provide a statistical evaluation of these differences. The fact that social anxiety was significantly more strongly associated with behavioral discomfort than the vast majority of all other dimensions suggests that social anxiety in the non-clinical range is reliably associated with selective behavioral impairment and that this is confined to manifest and observable signs of discomfort.

It is important to note that not all previous studies are consistent with an effect of social anxiety confined only to overt signs of anxiety. Some studies have found poorer observer ratings of fluency and voice intonation during a speech [ 15 ] and vocal clarity and eye contact during a conversation task [ 16 ] for patients with SAD compared to controls. However, a tabulated summary of past research findings [ 10 ] seems to suggest that where the ‘performance’ aspects of social behavior are also affected, this generally appears to be in clinical samples. The most logical conclusion to draw from this is that high levels of social anxiety within the non-clinical range may primarily exacerbate visible anxiety signs with less impact on other performance aspects, but exhibit broader impairing effects at the clinical level; although it is important to point out this does not appear to have been systematically examined.

The link between social anxiety and discomfort ratings suggests that behavioral signs of anxiety are visible to others during social challenges. If those high in social anxiety engage in safety behaviors to mask their anxiety (e.g., attempting to disguise shaking) as evidence suggests [ 8 ], our findings indicate these may have limited effectiveness – at least within the range of social anxiety typically encountered in a non-clinical population. In terms of the magnitude of increased visible anxiety symptoms, those high in social anxiety (one standard deviation above the mean) were rated by observers as approximately half (speech task) to three-quarters (interaction task) of a point higher than those low in social anxiety (one standard deviation below the mean) on the five-point scale used. Determining whether this constitutes a “meaningful” difference is difficult, although the fact that this difference at least approaches a whole-point difference in the scale’s anchor-points (e.g., from “good” to “fair”) is suggestive of a meaningful discrepancy and one that can be demonstrably perceived by others. Overall, these findings clearly show that social anxiety is associated with observable effect on social behavior even in the non-clinical range. Given that a non-clinical sample represents the largest segment of the population, this indicates that social anxiety may have negative effects for a large number of individuals.

The fact that social anxiety failed to be associated with behavioral ratings other than for overt anxiety symptoms is perhaps surprising. Social anxiety scores were strongly correlated with increased anxiety response during social challenges, and the disruptive effect of state anxiety on working memory and the processing of external information including social cues is well supported both theoretically (e.g., via occupation of attentional resources) and empirically [ 8 , 35 ]. As such, aspects of social behavior expected to involve significant cognitive demands, such as the production of coherent and fluent verbal responses, would seem likely to be impaired. While the lack of association is perhaps unexpected, several possible explanations can be considered. First, the sheer frequency of anxious thoughts in the socially anxious during social challenges could lead to their automatization, so that they fail to consume significant attentional resources to cause cognitive interference [ 11 ]. Second, socially anxious individuals are more likely to employ socially facilitative coping strategies, such as overt expressions of enthusiasm or listening to others [ 9 ], and this may help compensate for any disruptive effects of anxiety and encourage more favourable impressions of overall social competence. Third, although social anxiety was associated with increased task anxiety for our non-clinical sample, the magnitude of anxiety response needed to produce significant impairment may only be apparent at the clinical level. It should be noted that these explanations for the pattern of effects observed are necessarily speculative and require empirical corroboration.

With respect to sex, while women reported greater anxiety during social challenges, no evidence was found that the link between social anxiety and behavior was more pronounced in females. One recent non-experimental study did report a negative association between social anxiety and self-assessment of social skill in females but not males [ 36 ]. The current results suggest that, if such a sex-specific effect on self-assessed social competence is reliable, this does not appear to translate to actual behaviour as rated by others. It is important to treat the lack of any sex-specific influence found here with caution, however, given that interaction effects typically require large sample sizes to detect small or even medium effects. Nevertheless, our findings do suggest that if any such sex-specific effect does exist, this effect is unlikely to be large.

Several limitations of the current study should be noted. First, we used a non-clinical sample, and even if social anxiety does operate on a continuum as is commonly believed [ 3 ], results may not generalize to clinical levels of social anxiety. Second, conclusions drawn on the link between social anxiety and social behavior are necessarily limited to the circumscribed set of parameters examined, i.e., molecular indicators of performance during brief social challenges. Findings cannot be automatically assumed to apply to other, perhaps less easily defined or quantifiable facets of performance [ 6 ] in more prolonged or situationally different social challenges. Similarly, we used relatively structured tasks with participants given clear instructions on what to do, with evidence suggesting that unstructured situations may cause greater difficulties for socially anxious people [ 18 ]. Third, we restricted our study to presentational and interactive scenarios and did not examine situations involving fears of being observed (e.g. eating or drinking) and our results may not generalize to these types of situations. Nevertheless, the tasks employed here are fairly indicative of those commonly encountered outside of the laboratory, with the behavioral indicators believed to represent important features of social competence [ 27 ].

Despite these limitations, the current findings have several implications. The fact that social anxiety appears to be most strongly linked to an increase in observable signs of anxiety suggests that techniques directed towards the management of overt anxiety symptoms for those high in social anxiety may be particularly effective for improving impressions of social competence in specific domains where this is likely to be important. Techniques that help the individual recognize their use of anxious behaviors (e.g., throat clearing, fidgeting) and practicing elimination of these in a safe environment [ 37 ] may be especially beneficial. Progressive muscle relaxation may also prove useful to reduce muscle rigidity and promote the appearance of a relaxed posture. If successful, these techniques may produce more successful outcomes in situations where reduced signs of anxiety might be considered favorable, such as job interviews or presentations. Such interventions might even contribute to a potential reduction in social anxiety. Specifically, one feature of cognitive models is that socially anxious people tend to excessively focus on and overestimate the occurrence of behavioural, cognitive and somatic responses (e.g. shaking and sweating), and this contributes to a negative mental image of how one appears to others during social encounters [ 38 ]. Controlling somatic symptoms which are one source of this attentional focus may promote more positive imagery of one’s projected social self, which has been shown to increase explicit self-esteem [ 39 ] and may act as a positive reinforcer of social encounters reducing safety behaviours such as avoidance. It is important to emphasise that we did not investigate such interventions within this study, so these interpretations are entirely speculative. Nevertheless, these processes do represent logical pathways for how techniques directed towards managing visible anxiety signs, that we found to be amplified in those with high social anxiety here, could be potentially beneficial. In addition, the fact that social anxiety was associated with increased observable discomfort in a non-clinical sample also suggests that such management techniques may have potentially widespread benefits to a large sector of the population vulnerable to anxiety in a range of commonly encountered and important social challenges. The apparent selective effect of social anxiety also underlines the need for future studies to include multidimensional assessments of social behavior to fully explicate the nature of the relationship between social anxiety and social behavior.

In conclusion, the current findings suggest that, the detrimental effects of social anxiety on social behavior within the non-clinical range may be confined to the exacerbation of observable, physical anxiety symptoms with little discernible impact on performance quality. These results underline the necessity of including multiple behavioral dimensions in additional studies and suggest that techniques directed towards the management of outwardly observable anxiety symptoms may be particularly beneficial for socially anxious individuals. Given the importance of everyday “performing” to successful social functioning, research should continue to examine how social anxiety impacts upon social behavior at both the clinical and non-clinical level.

We also administered Mattick and Clarke’s companion SIAS scale to provide psychometric data for a separate study. When we substituted the SPS with the SIAS in the current study, there was no impact on the pattern of results.

SPRS discomfort is scored such that lower ratings indicate poorer performance (i.e. greater discomfort).

We also reran these tests using only one SPRS outcome at a time. This was done as a consistency check to ensure that the results of the hypothesis testing in sections 3.4 and 3.5, which used a regression approach, were the same as those using an SEM approach. As expected, both techniques produced the same results (least squares and maximum likelihood estimators used in regression and SEM respectively produce identical estimates under the usual assumptions of regression).

Abbreviations

Intraclass Correlation

Social anxiety disorder

Standard Deviation

Social Interaction Anxiety Scale

Social Performance Rating Scale

Social Phobia Scale

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Acknowledgements

Our grateful appreciation goes to Marta Kaminska for help with data collection and for acting as an experimental confederate.

This work was supported by an internal grant awarded to the first author by the University of Greenwich. The funders had no role in any aspect of the study design, data collection, analysis or data or writing of the manuscript.

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Thompson, T., Van Zalk, N., Marshall, C. et al. Social anxiety increases visible anxiety signs during social encounters but does not impair performance. BMC Psychol 7 , 24 (2019). https://doi.org/10.1186/s40359-019-0300-5

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Social anxiety and social anxiety disorder

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DOI: 10.1146/annurev-clinpsy-050212-185631

Research on social anxiety and social anxiety disorder has proliferated over the years since the explication of the disorder through cognitive-behavioral models. This review highlights a recently updated model from our group and details recent research stemming from the (a) information processing perspective, including attention bias, interpretation bias, implicit associations, imagery and visual memories, and (b) emotion regulation perspective, including positive emotionality and anger. In addition, we review recent studies exploring the roles of self-focused attention, safety behaviors, and post-event processing in the maintenance of social anxiety. Within each area, we detail the ways in which these topics have implications for the treatment of social anxiety and for future research. Finally, we conclude with a discussion of how several of the areas reviewed contribute to our model of social anxiety disorder.

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Published: 27 July 2022

Social anxiety disorder and its associated factors: a cross-sectional study among medical students, Saudi Arabia

Wejdan M. Al‑Johani ORCID: orcid.org/0000-0003-4851-0934 1 ,
Nouf A. AlShamlan ORCID: orcid.org/0000-0002-8049-237X 1 ,
Naheel A. AlAmer ORCID: orcid.org/0000-0003-2700-5197 1 ,
Rammas A. Shawkhan ORCID: orcid.org/0000-0002-2623-0838 2 ,
Ali H. Almayyad ORCID: orcid.org/0000-0001-8633-9432 3 ,
Layla M. Alghamdi ORCID: orcid.org/0000-0002-5624-8625 1 ,
Hatem A. Alqahtani ORCID: orcid.org/0000-0002-0832-1357 1 ,
Malak A. Al-Shammari ORCID: orcid.org/0000-0002-7434-7432 1 ,
Danya Mohammed Khalid Gari 1 &
Reem S. AlOmar ORCID: orcid.org/0000-0003-4899-7965 1

BMC Psychiatry volume 22 , Article number: 505 ( 2022 ) Cite this article

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Social Anxiety disorder (SAD) is common worldwide. However, data from Saudi Arabia is deficient. This study aims to determine the prevalence of SAD across Saudi medical students and its associations with sociodemographic factors and their academic performance.

The main outcome was presence/absence of SAD and the secondary outcome was its level of severity. These were assessed from the Social Phobia Inventory. Associated factors included sociodemographic variables, as well as educational characteristics of students. Descriptive statistics were reported as counts and percentages, and unadjusted and adjusted odds ratios (OR) and their 95% confidence intervals (CIs) were computed through bivariate and multivariate logistic regression.

Of 5896 Saudi medical students who participated in the study , the prevalence of SAD was almost 51%. While 8.21% and 4.21% had reported severe and very severe SAD, respectively. Older age students were at lower risk of developing SAD (OR = 0.92, 95% CI = 0.89 – 0.96). In contrast, females (OR = 1.13, 95% CI = 1.01 – 1.26), students enrolled in private colleges and colleges implementing non-problem-based learning (OR = 1.29, 95% CI = 1.09 – 1.52 and OR = 1.29. 95% CI = 1.15 – 1.46 respectively) were at higher risk. A significant elevated risk of SAD was found among students who had previously failed, and had a low GPA.

SAD is prevalent among the sampled population, and different associated factors were identified. Current results could raise the awareness of faculty members and healthcare providers towards early detection and management of these cases.

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Social Anxiety Disorder (SAD) which was initially named social phobia, is defined according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an extreme fear or anxiety about one or more social situations in which the individual is exposed to scrutiny by others, for instance, social interactions (e.g., meeting and talking to new people), being observed (e.g., eating or drinking), and performing in front of others (e.g., public speaking) [ 1 ]. The most common reported presentation of SAD was fear of speech-making [ 2 ]. SAD can occur in any public place where a person feels observed and judged by others [ 3 ]. Individuals will develop different cognitive and somatic anxiety symptoms characterized by autonomic stimulation, such as blushing, tremors, increased sweating, and tachycardia [ 4 ].

It is one of the most predominant anxiety disorders among adolescents and younger aged groups, impairing their functioning capabilities if left untreated [ 5 ]. In addition, its high prevalence would make it the third most common mental disorder after depression and alcohol abuse [ 6 ].

The lifetime prevalence of SAD has been reported in various studies, ranging between 3–13% [ 1 ]. The prevalence of SAD among university students has been assessed in multiple studies. In Jordan, Ghana, Nigeria, Brazil and Sweden Universities, the prevalence was around 9–16.1% [ 5 , 7 , 8 , 9 , 10 ]. A higher prevalence of SAD has been found among university students in Ethiopia and India (26%, 31.1%) respectively [ 11 , 12 ]. Moreover, it was associated with female gender, low educational attainment, positive personal or family history of mental disorders, psychiatric medication use, and lack of social support [ 2 , 13 ]. Studies have shown that SAD has led to low self-esteem and impaired body image, consequently negatively impacting on students' academic performance [ 14 , 15 ].

Furthermore, SAD is considered a significant risk factor for developing major depressive disorders and alcohol abuse disorder [ 16 ].

Although various studies worldwide have assessed the prevalence and impact of SAD among different populations, Saudi Arabia's data is scarce. After a thorough literature search, few data regarding SAD among medical students in small cities in Saudi Arabia have been obtained. Medical students are more exposed to academic challenges, including the lengthiest education and training period, the stress of multiple written and clinical examinations, oral presentations, interaction with patients and their families, and exposure to serious life and death issues. Consequently, medical students particularly require intact physical and mental well-being, strong personality structures, and a willingness to attain professional and communication skills to deal with academic challenges [ 17 ]. Therefore, this study aims to estimate the prevalence of SAD among medical students in the Kingdom of Saudi Arabia (KSA) and determine its association with students' sociodemographic factors and academic performance.

Study design and participants

This cross-sectional study included all medical students and medical interns both males and females attending any medical college in Saudi Arabia whether private or governmental. The number of medical colleges in Saudi Arabia is rising to 34 colleges, 27 of which are governmental. All Saudi medical colleges provide six-year undergraduate study, followed by one year of practical internship [ 18 , 19 ].

Sample size and sampling technique

The Saudi Commission for Health Specialties in its most recent published report stated that the total number of undergraduate students in medical colleges both private and governmental was 101,256 students [ 20 ]. The minimum required sample was calculated to be 2342 students using Epiinfo V.7.0. The 51.9% of presence of (SAD) was obtained from a Saudi study that examined social phobia among Saudi students in a single college, with an alpha level of 0.05 and a precision of 2% [ 21 ].

A non-probability sampling technique was used where students were invited to take part by answering an online-based questionnaire. The QuestionPro questionnaire software (Seattle, Washington, USA) was used.

Data collection tool and processes

Data were collected using a validated online self-administered questionnaire consisting of two parts. The first part included the socio-demographic information (age, gender, educational level, marital status, income, and Grade Point Average (GPA)). The second part included the validated Social Phobia Inventory (SPIN) questionnaire by K. M. Connor, a screening tool for SAD, consisting of 17 items. Each point is ranked with a five-degree Likert scale (0 = No, 1 = Low, 2 = Somewhat, 3 = High, 4 = Very Much). The total score ranges from 0 – 68; thus, an individual who scores more than 20 is considered to have SAD. The SPIN had good test–retest reliability, internal consistency, convergent and divergent validity, the Cronbach alpha is 0.85. Therefore, SPIN can be used as a measurement for the screening of SAD and monitoring the responses of treatment [ 22 , 23 ]

The online link of the survey was sent to the students' phone numbers through assigned data collectors from each college. The survey was customized to accept a single response from each number to avoid duplication of responses.

Statistical analysis

The primary outcome in this study was whether medical students had SAD or not according to the Social Phobia Inventory. A secondary outcome is the severity of SAD which may be computed from the inventory itself. After summing all 17 items of the inventory, participants who score less than or equal to 20 are assumed to not have SAD while those who score above 20 do have SAD. As for the severity as a secondary outcome, a participant scoring from 21 to 30 is considered to have mild SAD, 31 to 40 as moderate, 41 to 50 as severe and more than 51 as very severe. Descriptive statistics were obtained by counts and percentages, and potential associations were tested through the Pearson’s X 2 test and the T-test. Trends of proportions over GPA were tested for statistical significance. Unadjusted and adjusted Odds Ratios (ORs) and 95% Confidence Intervals (CIs) were drawn through binary logistic regression analyses where the outcome was for the presence/absence of SAD. Final variables in the regression model were decided based on a Directed Acyclic Graph of associations and were not entirely based on significance testing of bivariate associations. The model with the best fit was chosen based on model diagnostics. The Variance Inflation Factor measure was used to test for multicollinearity. All analyses were performed in Stata V.15.0.

Characteristics of the students

A total of 5896 students participated in this study (5.82% of the target population). It included 44.88% of males and 55.12% of females. The mean age of all students was 22.43 ± 1.68 years. Most students were single (85.72%). Overall, 24.87% had previously failed during their studies. However, the last known GPA was mostly A (43.49%) and only 35 students (0.59%) had a last known GPA of F. Most students belonged to a medical college that implemented a Problem-Based learning scheme (PBL) (65.84%), and only 16.50% of the total respondents were in private medical colleges. According to the Social Phobia Inventory severity score, 49.05% were not found to have SAD, while 20.22% were considered as mild, 18.32% as moderate, 8.21% severe and 4.21% as very severe (Table 1 ).

Figure 1 presents the five-level severity score of the Social Phobia Inventory across the different GPAs of the students. Among those with a GPA of A and B, a larger portion of the students are seen to not have (SAD). Whereas among those with a GPA of F, students were found to have a higher portion of (SAD) across all levels of severity, mild, moderate, severe, and very severe.

The five-level score of the Social Phobia Inventory and students’ GPA, Saudi Arabia, N = 5896

Factors relating to the presence/absence of social anxiety disorder (SAD)

The presence of SAD was found to be associated with several factors at the bivariate analyses level (Table 2 ). For example, it was found to be associated with age ( P < 0.01). It was also found to be statistically associated with sex ( P = 0.02) where females were found to have more SAD compared to males. Previous academic failure and the last known GPA were highly statistically associated with SAD ( P < 0.001). The data clearly shows that the lower the GPA the more the proportion of SAD (P for trend < 0.001). Neither family income nor the year of study were statistically associated with SAD in the study sample.

Factors associated with SAD according to multivariable analyses

Table 3 shows the results of the binary logistic regression both before and after adjustment. Age was a significant predictor whereby the risk of SAD decreased with increasing age both before and after adjustment (Unadjusted OR = 0.93, 95% CI = 0.90 – 0.96 and Adjusted OR = 0.92, 95% CI = 0.89 – 0.96 respectively). The model also showed that females were significantly more likely to have SAD when compared to males after adjustment (Adjusted OR = 1.46, 95% CI = 1.26 – 1.69). Having previously failed was also associated both before and after adjustment (Unadjusted OR = 1.64, 95% CI = 1.45 – 1.84 and Adjusted OR = 1.46, 95% CI = 1.26 – 1.69). An increase in risk was found with decreased GPA levels, for example the highest odds of 4.13 was found for students with a GPA of F (95% CI = 1.56 – 10.92) when compared to students with a GPA of A. Elevated risk was also observed for students who are enrolled in colleges that do not adopt a problem-based educational scheme and those who are in private colleges (Adjusted OR = 1.29, 95% CI = 1.15 – 1.46 and Adjusted OR = 1.29, 95% CI = 1.09 – 1.52).

The model was highly significant ( P < 0.001) with a Pseudo R 2 value of 0.16. The Hosmer–Lemeshow value for this model was 11.25, with a p -value of 0.19 indicating good model fit.

The present study demonstrated that about half of the examined medical students in Saudi Arabia screened positive for SAD. Moreover, 8.21% and 4.21% of students had severe and very severe SAD symptoms, respectively. Other studies worldwide have also investigated the prevalence of SAD in undergraduate universities and medical students. Nevertheless, comparing our findings with these studies is difficult because of variations in the methodologies, study tools used, participants' backgrounds, social factors, and cultures. In agreement with the findings from the current study, Al-Hazmi et al., conducted a study among 504 medical students from Taibah university, Saudi Arabia, using the SPIN questionnaire and reported that 13.5% of the participating medical students had severe to very severe SAD [ 21 ]. Findings from the present study were higher than Desalegn et al.'s study which demonstrated that 31.2% (95% CI 27.3 to 35.6%) of undergraduate health science students in Ethiopia had SAD symptoms [ 24 ]. A study among 525 medical students in Germany revealed that 12.2% reported SAD symptoms [ 25 ]. In Iran, Afshari surveyed 400 medical sciences students using the SPIN tool and demonstrated that 41.5% and 13.2% of students had moderate and high SAD, respectively [ 26 ].

Furthermore, the findings of this study showed that SAD is less common among older aged students, which is consistent with Al-Hazmi et al. findings [ 21 ]. The decreased prevalence in older students may be attributed to their exposure to the clinical settings, as senior students tend to interact more with patients and are more experienced in interviewing skills. For instance, Alotaibi et al., found that older aged groups and higher-level students showed a higher score on the positive attitude scale towards learning communication skills [ 27 ]. Moreover, Davis et al.'s study showed that the final-year students had better communication skills than first-year students, indicating that they have a better vision and understanding of the importance of communication skills [ 28 ].

An expected and true finding of the current study is that social anxiety rates are higher among females compared to males. This finding is relevant to the (DSM-5) statement, which revealed that the prevalence of SAD is higher in females, and this difference is more pronounced among adolescents [ 4 ]. A similar finding was obtained by Xu et al.'s data survey from the National Epidemiologic Sample on Alcohol and Related Conditions among the United States adult population where the lifetime prevalence of SAD was higher in females than in males (5.7% and 4.2% respectively) [ 29 ]. Additionally, studies among the Canadian and European populations have shown similar results [ 30 , 31 , 32 , 33 , 34 ]. This outcome is contrary to Elhadad et al.'s study on only 380 medical students in Abha, Saudi Arabia, which found that SAD rates were higher among males. However, the Elhadad study population was obtained from a single institution and a relatively small sample size, hence, their results are less generalizable [ 35 ]. A possible explanation of why females are at higher risk of developing SAD can be best understood from a “vulnerability-stress perspective”. Exposure to variable psychosocial stressors and an increased biological and psychological vulnerability towards anxiety in females may explain the sex differences in anxiety disorders [ 36 ]. Interestingly, the current study found higher SAD rates among divorced, widowed, and singles than married ones. This finding supports the result of the systematic review conducted by Toe et al., which found that SAD was consistently associated with social isolation, such as being unmarried or living alone. Whether social isolation causes social anxiety or vice versa is still unclear [ 37 ].

Moreover, this study demonstrates that students who were enrolled in institutions implementing traditional teaching methods had an increased risk of having phobia compared to the students in PBL institutions, which indicates the effect of different learning styles on students’ mental well-being [ 38 ]. Furthermore, it draws attention to the nature of PBL, which revolves around the idea that a problem is of crucial importance in learning. It focuses on community problems, scientific problems, and real-life scenarios, motivating trainees and boosting their confidence. PBL promotes a deep learning approach rather than a superficial one by making trainees interact with information in a multilevel fashion. The absence of a teacher role in PBL increases the sense of responsibility towards self-learning and promotes personal development [ 39 ]. In other words, PBL is student-centered and encourages communication and teamwork through multiple tools of assessments, including presentations, small group discussions, seminars, assignments, and Objective Structured Clinical Examinations. The repeated exposure to social interactions and public speaking through PBL may increase students' confidence in social and clinical settings [ 40 ].

Many studies have reported high levels of stress and psychological comorbidities among Saudi medical students [ 41 ]. However, studies examining the differences between governmental and private medical schools in Saudi Arabia are limited. Moreover, we propose that the differences in teaching and learning approaches could explain finding a lower risk of SAD among governmental college students than those in private colleges. AlOmar et al. conducted a survey among 3767 students using the Approaches and Study Skills Inventory for Students (ASSIST), which showed that the deep and strategic approaches were predominant among Saudi medical students. In addition, private medical school students were more likely to adopt a strategic rather than a deep learning approach [ 42 ], which suggests that the difference in SAD levels between governmental and private medical college students may be explained by the differences in learning methods.

SAD was found to be associated with impairment in education and work productivity [ 43 , 44 ]. A large cohort, population-based study in Sweden showed an inverse association between SAD and academic performance at different levels [ 43 ]. In line with this finding, the current study revealed that a lower GPA was linked to a higher risk of SAD; hence it was more frequently reported among students with a previous failure in medical school. Furthermore, previous Saudi studies have also reported a similar inverse relationship [ 21 , 35 ]. This may be explained by the fact that medical school environments are highly competitive; students are working hard to achieve higher grades and GPA to look for opportunities in the postgraduate residency programs and jobs. These stressors make medical students vulnerable to mental health problems [ 45 ]. Moreover, the presence of students with low GPA or previous failure with their high achieving colleagues could be another burden on them. It might lead to social isolation, low self-esteem, being inactive in the group work, and consequently having social anxiety symptoms more frequently than their peers.

To the best of our knowledge, the current study is the first Saudi study investigating SAD among a large sample of medical students from all regions in the kingdom. However, some limitations exist. Firstly, the sample only included medical students and did not represent the general Saudi population. Secondly, since the design of the study was cross-sectional, temporality and causality between factors could not be assured. Additionally, despite of the high response rate the possibility of response bias could not be eliminated. Finally, the SPIN tool utilized in the study is a screening tool, and the high-risk cases need a further diagnostic step by a clinical interview.

The current study found that SAD was highly prevalent among the investigated medical students in Saudi Arabia. Older students had lower odds of SAD. On the other hand, being female, studying in private colleges or with non-problem-based learning methods, and having a history of a previous failure in the medical school or a lower GPA were identified as factors that had higher odds of SAD. These findings emphasize the positive role of the university faculty members, counselors, and mentors in supporting these students and encouraging them to participate in curricular and extracurricular activities. In addition, evaluation of the educational environment and the types of the teaching curriculum in Saudi Medical schools is necessary to optimize students learning experience and maintain their psychological wellbeing. Along with enhancing the primary care providers and mental health care experts to accomplish their role of early detection and management of these cases.

Availability of data and materials

The datasets generated and analysed for the current study are not publicly available for data protection reasons. However, the data that support the findings of this study may be available from the corresponding author on reasonable request.

Abbreviations

Social Anxiety Disorder

Diagnostic and Statistical Manual of Mental Disorders

Kingdom of Saudi Arabia

Grade Point Average

Problem-Based Learning

Approaches and Study Skills Inventory for Students

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Acknowledgements

The authors would like to acknowledge the efforts of medical students who participated in the data collection. Also, we would like to thank all students who filled out the questionnaires.

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Wejdan M. Al‑Johani, Nouf A. AlShamlan, Naheel A. AlAmer, Layla M. Alghamdi, Hatem A. Alqahtani, Malak A. Al-Shammari, Danya Mohammed Khalid Gari & Reem S. AlOmar

College of Medicine, King Khalid University, Abha, Saudi Arabia

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WMAJ, RSAO, and NAAS conceived the idea and developed the study design. AHA and RAS recruited participants and helped in data collection. Data preparation, statistical analyses, results interpretation, and creation of tables and figures were carried out by RSAO. The initial draft of the introduction, methods, and discussion were written by WMAJ, HAA, LMA, NAAS, AHA, RAS, MAAS, NAAA, and DMKG. The final manuscript was written by WMAJ, RSAO, and NAAS. All authors read and approved the final manuscript.

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Al‑Johani, W.M., AlShamlan, N.A., AlAmer, N.A. et al. Social anxiety disorder and its associated factors: a cross-sectional study among medical students, Saudi Arabia. BMC Psychiatry 22 , 505 (2022). https://doi.org/10.1186/s12888-022-04147-z

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v.3(1); 2001 Feb

Social Anxiety Disorder: More Than Just a Little Shyness

Social anxiety is defined as a “marked and persistent fear of social or performance situations” and includes such symptoms as sweating, palpitations, shaking, and respiratory distress. Social anxiety is fairly common, occurring in as much as 13% of the population, and can be extremely disabling. It can be either specific (confined to 1 or 2 performance situations) or generalized, and can be diagnosed with a scale-based questionnaire. Social anxiety may coexist with other disorders, such as depression and dysthymia. The differential diagnosis for social anxiety includes panic disorder, agoraphobia, atypical depression, and body dysmorphic disorder. Treatment for social anxiety can be quite effective and consists of psychotherapy, pharmacotherapy (including such medications as β-blockers, anxiolytics, antidepressants, and anticonvulsants), or a combination. This article details the prevalence, onset, disease impact, and etiology of social anxiety. Specific treatments, including both psychotherapy and pharmacotherapy, are presented in detail, along with other treatment considerations, such as comorbidity.

There is nothing new about social anxiety. One of the earlier descriptions was by Robert Burton in The Anatomy of Melancholy (1621) in reference to a patient of Hippocrates: “He dare not come into company for fear he should be misused, disgraced, overshoot himself in gestures or speeches, or be sick; he thinks every man observeth him.” 1

More recently, it was revealed that William Wilson, the physician who accompanied Robert Falcon Scott on his ill-fated trek to the South Pole in 1912, was quite impaired socially: “Yet back at home he found normal social intercourse so difficult that he confided to his diary that he took sedatives before going to parties, and one of his biographers wrote that it required far more courage for him to face an audience than to cross a crevasse.” 2(p153)

For these individuals, social anxiety was far from trivial—it substantially compromised their lives. One could make a strong case that today each would meet diagnostic criteria for social anxiety disorder, also known as social phobia. The key feature of social anxiety disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), is “a marked and persistent fear of social or performance situations in which embarrassment may occur.” 3(p411) Exposure to such situations produces considerable anxiety, often as intense as a panic attack, with associated physical symptoms such as sweating, shaking, garbled speech, blushing, palpitations, and gastrointestinal and respiratory distress. Awareness that others may see visible signs of anxiety further compounds anxious feelings. People with social anxiety disorder generally avoid social and performance situations whenever possible or endure them with considerable distress. While it is often said that social anxiety is restricted to social settings, those with the disorder will attest to considerable anxiety in anticipation of social encounters, even when they are very much alone.

While the dividing line between social anxiety disorder and being “just a little shy” is not always clear, the former causes marked distress and interferes with relationships and functioning, while the latter is far less disruptive. Social anxiety disorder is either specific or generalized. Specific (also known as limited or discrete) social anxiety is usually confined to 1 or 2 performance situations, such as speaking, musical performance, or writing. Generalized social anxiety is triggered by nearly all social situations (performance and interpersonal interactions).

Clinicians often underestimate the magnitude and pervasiveness of social anxiety in patients unless a comprehensive interview is conducted or a rating scale is completed. For example, the Liebowitz Social Anxiety Scale 4 is a 24-item questionnaire that assesses most aspects of social anxiety by rating severity of both anxiety and avoidance. The Social Phobia Inventory (SPIN) 5 is a 17-item validated scale that rates fear and avoidance across a wide variety of social situations. An abbreviated form of the SPIN, known appropriately as the Mini-SPIN, 6 has proven effective as a screen for social anxiety disorder by asking only 3 questions and rating responses on a scale of 0 (not at all) to 4 (extremely). The questions are used to evaluate whether a person avoids situations or contact because of fear of embarrassment, avoids being the center of attention, or strongly fears being embarrassed or looking stupid.

At the far extreme of social anxiety severity is a condition referred to in the DSM-IV as avoidant personality disorder. It is characterized by “a pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation that begins by early adulthood and is present in a variety of contexts.” 3(p662) Avoidant personality disorder is currently viewed as a severe form of generalized social anxiety disorder for which conventional therapies are likely to be effective.

Differential Diagnosis

Differential diagnosis of social anxiety disorder involves distinguishing it from panic disorder, agoraphobia, atypical depression, and body dysmorphic disorder. Panic disorder is characterized by recurrent unexpected panic attacks, in contrast to the panic attacks of social anxiety disorder that are provoked by and confined to social encounters. Agoraphobia involves anxiety about being in situations or places where escape may be compromised; an agoraphobic individual would avoid a shopping mall because of the crowd, while someone with social anxiety disorder would avoid that setting because of fear of social interaction. Atypical depression, like social anxiety disorder, is characterized by rejection sensitivity, but unlike social anxiety disorder it is also associated with low mood, hypersomnia, increased appetite or weight gain, and a sense of leaden paralysis. Individuals with body dysmorphic disorder are excessively concerned about imagined defects in appearance, but this preoccupation transcends social settings.

COMORBIDITY

The differential diagnosis of social anxiety disorder would be relatively uncomplicated except for the confounding factor of comorbidity. Frequently, social anxiety disorder coexists with 1 or more mood, anxiety, or substance use disorders. Although studies cite varying percentages, they tend to confirm a disturbingly high lifetime prevalence of comorbid conditions such as major depression, dysthymia, panic disorder, generalized anxiety disorder, specific phobia, and alcohol and other substance abuse. Since a comorbid condition is frequently the driving force pushing a patient toward evaluation and treatment, social anxiety disorder often gets overlooked.

As expected, the coexistence of 2 or more disorders can greatly complicate treatment and adversely affect prognosis. For example, there is no question that alcohol played a destructive role in the life of baseball superstar Mickey Mantle. Whether he had social anxiety disorder is less clear, although this quote in an interview in Sports Illustrated is quite suggestive: “In the past five years I used alcohol as a crutch. To help me overcome my shyness and make me feel more comfortable before all those personal appearances, I'd warm up with three or four vodkas before leaving the hotel, go straight to the cocktail party and have three or four more drinks, and then I'd start feeling, Whew, all right. Let's go.” 7(p67)

Numerous studies have found increased rates of social phobia in alcoholic patients and increased rates of alcoholism in social phobia patients, with the onset of social phobia typically preceding that of alcoholism. 8 This temporal association may lead one to deduce that for some patients, early recognition and treatment of social anxiety disorder might prevent the subsequent development of alcoholism.

PREVALENCE, ONSET, AND IMPACT

Social anxiety disorder is a common condition. The National Comorbidity Survey of more than 8000 individuals in the contiguous 48 states found a lifetime prevalence of 13.3% and a 12-month prevalence of 7.9%. 9 More recently, a community survey from Germany of 3021 individuals aged 14 to 24 years found a lifetime prevalence of 9.5% in women and 4.9% in men. 10 Closer to home, Katzelnick et al. 11 screened more than 3000 members of a health maintenance organization (HMO) in Madison, Wisconsin, and found that 8.2% met criteria for social anxiety disorder. A particularly disturbing finding from this study was that only 0.5% had been diagnosed previously. In the primary care setting, Stein et al. 12 found that 7% of 511 patients were afflicted with social anxiety disorder.

Social anxiety disorder usually begins in childhood or adolescence. The mean age at onset is 10 to 13 years, although a substantial minority (21%) reported onset between ages 0 and 5 years. 13 Patients from the very early onset group describe the disorder as having been present for as long as they can remember. In community samples, women are overrepresented by a ratio of up to 2 to 1, while in clinical settings the gender distribution is often more even. 14 Once present, social anxiety disorder is likely to be persistent and debilitating.

The impact of social anxiety disorder on quality of life is enormous. A study from Germany found that the unemployment rate was 3 times higher, mean work hours missed were increased substantially, and performance was impaired significantly in patients with social phobia. 15 Similar findings were reported by Katzelnick et al., 11 who found that social phobia had a marked negative impact on earning ability, educational level, and vocational achievement. Individuals with social anxiety disorder commonly report remaining in “safe” lower level jobs rather than accepting more socially demanding promotions.

So what causes social anxiety disorder? A reasonable answer would encompass the interplay of genetic, developmental, and neurobiological factors. Family studies of individuals with social anxiety disorder show a higher incidence of the disorder than that found in the general population, and a twin study found a concordance rate of 15.3% in dizygotes and a 24.4% concordance in monozygotes. 16 Hirschfeld-Becker et al. 17 summarized work by Kagan and others describing a temperament referred to as behavioral inhibition. This temperament is present in 10% to 15% of children studied and first manifests in toddlers with “retreat, avoidance and quiet restraint or fear in the face of unfamiliar situations, objects or people.” 17(p52) Follow-up studies suggest that behavioral inhibition may be an important predisposition to developing social phobia and other anxiety disorders. Many other factors influence individuals during the course of development and are likely to interact in complex ways to promote or prevent the onset of social anxiety disorder. Some individuals with social anxiety disorder associate its onset with a specific social event or interaction that was particularly embarrassing or humiliating. Such a circumstance could be considered an adverse conditioning stimulus.

If one looks to neurobiology for an etiologic explanation, the findings thus far are meager. Other than the fact that selective serotonin reuptake inhibitors (SSRIs) are effective treatments for social anxiety disorder, there is little evidence to implicate dysfunction of the serotonergic system. Likewise, despite a well-established link between fear and adrenaline, noradrenergic dysfunction has yet to be established as an important etiologic factor. Dopaminergic dysfunction is also unlikely, especially since dopamine agonists and antagonists have no important role in treating social anxiety disorder.

On the other hand, a neuroimaging study did find lower D 2 receptor binding potential in the striatum of 10 subjects with generalized social phobia compared with 10 healthy controls. 18 Attempts to implicate abnormalities of neuroendocrine systems or immune function have been similarly unrewarding. 19 Stein 20 concludes his thoughtful review by stating, “It is clear that we have a long way to go before we can speak with authority about the ‘neurobiology of social phobia.’”( p1282 ) It seems inescapable that multiple risk factors are involved in the etiology of social anxiety disorder and that further research will be necessary to clarify these ambiguities.

While the exact etiology of social anxiety disorder remains enigmatic, treatment strategies have become reasonably well defined and gratifyingly successful. Treatment effectiveness is particularly striking in that patients have often been ill for decades. For example, the mean duration of illness was about 15 years in a study of paroxetine 21 and well over 20 years in a study of gabapentin. 22

Before addressing the specifics of psychological and pharmacologic interventions, establishing an educational foundation is important. Given the early onset and long duration of illness in most patients, many have accepted it as an immutable part of their personalities so that the possibility that substantial change could occur may be difficult to accept. In addition, when change does occur, it can have a temporarily disruptive effect on long-established relationships that may require interpersonal rebalancing. Written materials can be helpful in providing the necessary foundation. My colleagues and I wrote Social Anxiety Disorder: A Guide , 23 which has been effective in helping to educate patients, and there are several other useful nontechnical publications available. 24–26 The social anxiety disorders Web site at www.socialanxiety.factsforhealth.org is also a useful resource.

Some individuals, particularly those with public speaking anxiety, find nonprofessional programs such as Toastmasters to be beneficial. By repeatedly applying the principles of preparation, rehearsal, and exposure, they can often achieve a level of comfort in performance settings.

Psychotherapy

Formal psychotherapies for social anxiety disorder include social skills training, exposure in vivo, cognitive therapy, and cognitive-behavioral therapy (individual and in groups). 27 While these treatments can be quite effective, finding well-trained, experienced therapists may be difficult. (Both the Madison Institute of Medicine, Inc., 7617 Mineral Point Road, Suite 300, Madison, WI 53717, (608) 827-2470, and the Anxiety Disorders Association of America, 11900 Parklawn Drive, Suite 100, Rockville, MD 20852-2624, (301) 231-9350, are referral sources.) In addition, these programs require a substantial commitment of time and effort by the patient. Since repeated exposure to feared situations is an integral part of treatment, some find it difficult to structure an adequate exposure paradigm. For example, the timing and duration of weekly sales meetings may be immutable, opportunities for speaking before large audiences may be limited, and confronting the boss for a raise is usually not conducive to repeated, lengthy contacts.

Social skills training involves teaching patients the essential verbal and nonverbal skills necessary to effectively and comfortably interact with others. Rehearsal and role-playing with exposure are critical elements. Social skills training is a central component of an intervention known as social effectiveness training. 28

Exposure therapy (also referred to as behavior therapy) is based on the premise that continued exposure to feared situations leads to anxiety reduction by habituation. An example might be repeatedly asking strangers for directions to a location across town until the process becomes comfortable. In general, exposure needs to be repeated and lengthy to be effective.

Cognitive therapy focuses on correcting the irrational thoughts or beliefs that contribute to inappropriate social anxiety. Ultimately, an element of exposure is almost always introduced into a cognitive schemata.

Cognitive-behavioral therapy , or CBT, is the best-studied psychotherapeutic approach to social anxiety disorder. CBT blends the best of exposure therapy and cognitive therapy using cognitive restructuring, exposure simulation, and in vivo homework assignments. Heimberg and others 29 developed cognitive-behavioral group therapy (CBGT), which provides CBT in a group setting. It has been shown to be as effective as pharmacotherapy for social phobia and may provide a greater likelihood of maintaining response following termination of treatment. 30

Pharmacotherapy

While paroxetine is currently the only medication with a U.S. Food and Drug Administration (FDA) indication for social anxiety disorder, the range of effective medications is considerably more extensive. 31–33

β-Blockers.

As early as the 1970s, these drugs were shown to be effective in single-dose, double-blind, crossover studies for treating both public speaking and musical performance anxiety. 33 They are thought to work by reducing autonomic arousal (i.e., less tremor, palpitation, and sweating) and interrupting an otherwise vicious cycle of somatic symptoms and increased anxiety. A β-blocker is usually taken 1 to 1½ hours before a performance (after having tried a dose at home to be sure that there are no idiosyncratic reactions). Typical doses are 20 to 40 mg of propranolol or 25 to 100 mg of atenolol. Of interest is a survey of presenters at the 1983 American College of Cardiology Annual Meeting that found that 13% took a β-blocker to allay performance anxiety. 34 While β-blockers on an as-needed basis may benefit performance anxiety, they have not proven useful on a scheduled basis for treating generalized social anxiety.

Anxiolytic Pharmcotherapy

Benzodiazepines..

A benzodiazepine anxiolytic would seem like a logical choice to treat social anxiety. While results with alprazolam in a controlled study were not particularly impressive (perhaps because all patients also received self-directed exposure), clonazepam withstood the scrutiny of a 10-week, placebo-controlled trial. At a mean daily dose of 2.4 mg, 78% of patients responded, compared with 20% on placebo. 35 Clonazepam was also shown to be more effective than placebo in a 5-month maintenance study. 36 Since benzodiazepines have been off-patent for quite some time, it is unlikely that further definitive studies will be forthcoming. Positive aspects of benzodiazepines include rapid onset, good tolerability, overdose safety, and flexibility of dosing. Disadvantages include side effects such as sedation, incoordination, and sexual dysfunction, as well as abuse potential, discontinuation difficulties, adverse interactions with other drugs and alcohol, and lack of antidepressant activity (given the high comorbidity of social phobia with depression).

While buspirone showed promise in open studies of social anxiety disorder, 2 placebo-controlled trials were not particularly encouraging. 32 Some feel that further studies at higher doses (e.g., 60 mg/day) might be more productive; nonetheless, buspirone is not currently a leading drug for treating social anxiety disorder.

Antidepressant Pharmacotherapy

Monoamine oxidase inhibitors (maois)..

Phenelzine, an irreversible, nonselective MAOI, is an effective treatment for generalized social phobia, 37 but its adverse event profile, the need for dietary restrictions, and the risk of hypertensive and hyperthermic crises have relegated it and other members of its class to treatments of last choice. The reversible inhibitors of monoamine oxidase A (RIMAs) such as moclobemide and brofaromine promised a wide safety margin and freedom from dietary restrictions, but for various reasons their development was terminated in the United States several years ago.

Tricyclics.

While tricyclic antidepressants are effective treatments for depression, they do not appear particularly useful for treating social anxiety disorder.

Selective serotonin reuptake inhibitors.

The spectrum of SSRI effectiveness extends well beyond depression and now encompasses social anxiety disorder, for which these drugs have become the treatments of choice. 38 Large double-blind, placebo-controlled studies established the effectiveness of paroxetine (which is FDA approved for social anxiety disorder), sertraline, and fluvoxamine. Open studies suggest that citalopram and fluoxetine are also effective.

In general, SSRIs manifest their benefits gradually over several weeks at doses consistent with those used to treat depression. For example, Baldwin et al. 21 found paroxetine at a mean daily dose of 34.7 mg/day to be more effective than placebo beginning at 4 weeks of treatment. A fixed-dose study of paroxetine 39 found 20, 40, and 60 mg to be equally effective, suggesting that time rather than dose may be the critical factor in achieving response. In view of the chronicity of social anxiety disorder and the slow onset of action of SSRIs, it would seem reasonable to persist with the starting dose for at least a month before considering an increase. Starting doses include the following: citalopram, 20 mg; fluoxetine, 20 mg; fluvoxamine, 50 mg; paroxetine, 20 mg; and sertraline, 50 mg.

There are no studies comparing one SSRI with another for treating social anxiety disorder, and there is no evidence that one is more effective than another. Choice of drug therefore depends on whether an approved indication for social anxiety disorder is a comfort factor, as well as considerations based on personal preferences of both patient and physician, side effect profiles, and compatibility with other medications the patient may be taking.

Other antidepressants.

Mirtazapine, nefazodone, venlafaxine, and bupropion have all shown promise as treatments for social anxiety disorder, but results have been derived only from small, open-label case reports and case series. 32

Anticonvulsant Pharmacotherapy

Only 2 anticonvulsants have been studied in controlled trials as treatments for social anxiety disorder: gabapentin, which is currently marketed as a treatment for epilepsy, and pregabalin, an investigational drug. The rationale behind studying these drugs included observations of reduced anxiety, improved mood, and increased well-being in patients with epilepsy and favorable findings in animal models of anxiety. In a 14-week, placebo-controlled trial involving 69 adults with social anxiety disorder, gabapentin outperformed placebo as measured by reduction of scores on the Liebowitz Social Anxiety Scale (−27.3 points versus −11.9 points on placebo). 22 Early terminations due to adverse events occurred in 21% taking gabapentin and 11% taking placebo. Since the study design encouraged dosing as high as 3600 mg/day, the mean daily dose of 2868 mg is likely to be more than necessary to effectively treat many patients. Studies directly comparing gabapentin with SSRIs have not been conducted.

Pregabalin, like gabapentin, is an analog of γ-aminobutyric acid, an inhibitory neurotransmitter. It is currently under investigation as a treatment for social anxiety disorder, with one study thus far showing promising results. 40

TREATMENT CONSIDERATIONS

For individuals with specific social anxiety disorder, non-pharmacologic treatments range from self-help programs to a more formal cognitive-behavioral approach administered by a qualified therapist (who is often hard to find). Pharmacotherapy is generally used as needed, with β-blockers being the preferred medication. Benzodiazepines are sometimes successful but may impair cognition and coordination.

Generalized social anxiety disorder is amenable to both psychotherapy and pharmacotherapy, either alone or in combination. A cognitive-behavioral approach is preferable, either individually or in a group utilizing a therapist trained specifically to administer this type of treatment. Pharmacotherapy should be scheduled, rather than used as needed, with SSRIs being the drugs of first choice. Patients should be reminded that several weeks may be required to see progress and several months to maximize benefit.

Should an SSRI be ineffective or not tolerated, changing to a different SSRI may be beneficial. Alternatively, treatment could be switched to a benzodiazepine (clonazepam is the best studied) or gabapentin. In patients who are partial responders, adding one of these drugs to an SSRI may produce further improvement; remember that some SSRIs may interfere with benzodiazepine metabolism, while gabapentin is devoid of pharmacokinetic interactions. Although the newer antidepressants (bupropion, mirtazapine, nefazodone, venlafaxine) are not established treatments for social anxiety disorder, they can be considered if better-defined approaches prove ineffective.

Relatively little has been written about the optimal duration of effective and well-tolerated pharmacotherapy. Given the chronicity of social anxiety disorder, treatment should be continued for at least a year before an attempt is made to taper and discontinue the medication. Even then, the relapse rate is likely to be high, especially if cognitive-behavioral therapy has not been incorporated into the treatment regimen.

DEALING WITH COMORBIDITY

Primary care physicians may choose to refer patients with comorbid conditions to a psychiatrist for either consultation or ongoing treatment, although this is sometimes either impractical (limited resource availability) or unnecessary. For example, a primary care physician may feel comfortable treating a patient who has social anxiety disorder and major depression because a single drug (usually an SSRI) is likely to be effective for both conditions. However, comorbid social anxiety disorder and obsessive-compulsive disorder may not respond to treatment with SSRIs, as demonstrated by a small retrospective study in which improvement in both conditions was the exception rather than the rule. 41 In general, a multifactorial approach is usually necessary to deal with social anxiety disorder when it is associated with comorbidity. For example, social anxiety might be treated with an SSRI and comorbid alcohol dependence with naltrexone and 12-step facilitation therapy. The biggest obstacle to dealing with comorbidities is actually not the treatments required, but rather the failure to recognize them in the first place.

CONCLUSIONS

Social anxiety disorder is a common, chronic, often disabling yet greatly underrecognized condition. It is also a condition for which effective therapies (both pharmacologic and psychotherapeutic) are readily available. The impact of treatment can be strikingly beneficial, even in individuals who have been suffering with the condition for decades.

Drug names: alprazolam (Xanax and others), atenolol (Tenormin and others), bupropion (Wellbutrin), buspirone (BuSpar), citalopram (Celexa), clonazepam (Klonopin and others), fluoxetine (Prozac), fluvoxamine (Luvox), gabapentin (Neurontin), mirtazapine (Remeron), naltrexone (ReVia), nefazodone (Serzone), paroxetine (Paxil), phenelzine (Nardil), propranolol (Inderal and others), sertraline (Zoloft), venlafaxine (Effexor).

Financial disclosure: Dr. Jefferson has received grant/research support from Abbott, Bristol-Myers Squibb, Forest, GlaxoSmithKline, Lilly, Novartis, Organon, Janssen, Pfizer, Solvay, and Wyeth-Ayerst; has served as a consultant for GlaxoSmithKline, Novartis, Scios, and TAP; has received lecture honoraria from Bristol-Myers Squibb, Forest, GlaxoSmithKline, Janssen, Lilly, Novartis, Pfizer, Pharmacia & Upjohn, Solvay, and Wyeth-Ayerst; is a minor stock shareholder in GlaxoSmithKline and Scios and principal in Healthcare Technology Systems, Inc.; and has received various other financial or material support from time to time from the pharmaceutical companies listed above.

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Social anxiety in college students

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Social anxiety increases visible anxiety signs during social encounters but does not impair performance

Conclusions

Participants

Anxiety and social behavior scales

Speech task

Interaction task

Statistical analysis plan

Data screening

Social challenge tasks: anxiety manipulation check

Primary analysis

Speech task: social anxiety, sex and SPRS ratings

Interaction task: social anxiety, sex and SPRS ratings

Comparison of regression coefficients of social anxiety across SPRS dimensions

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Social anxiety disorder and its associated factors: a cross-sectional study among medical students, Saudi Arabia

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BMC Psychiatry

Social Anxiety Disorder: More Than Just a Little Shyness

Differential Diagnosis

COMORBIDITY

PREVALENCE, ONSET, AND IMPACT

Psychotherapy

Pharmacotherapy

β-Blockers.

Anxiolytic Pharmcotherapy

Antidepressant Pharmacotherapy

Tricyclics.

Selective serotonin reuptake inhibitors.

Other antidepressants.

Anticonvulsant Pharmacotherapy

TREATMENT CONSIDERATIONS

DEALING WITH COMORBIDITY