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Managing Social Anxiety

Social anxiety disorder can present as generalized (across many situations--see below) or specific. The specific form involves only a particular performance situation (e.g., public speaking, music/dance/athletic performance).


Typical Features of Generalized Social Anxiety Disorder (SAD)


Common Fear of:


  • being looked at

  • someone noticing anxiety

  • bungling social performance

  • feeling forever humiliated

  • freezing--being unable to perform

  • voice/hands shaking; blushing

  • seeming foolish or awkward

  • being disapproved of

  • being bland, boring or dumb

  • being seen as weak or weird

  • having to escape--being forever disrespected or humiliated



Common Avoidance of:


  • being the center of attention

  • public speaking; reading aloud

  • writing while watched by others

  • telephone use

  • using public restrooms

  • entering crowded rooms

  • introductions/social events

  • speaking to authority

  • initiating social conversations

  • dating

  • assertiveness

  • eating or drinking in public

  • any potential embarrassments




Prevalence: 1 year = 2.8%; lifetime =5.0%


Average age of onset = 15; Average age of first treatment =27.2


But, 80% received no treatment (Grant, et al., 2005)




Screening: 3 questions identify SAD with 89% sensitivity & 90% specificity (Kobak, 1998)

  • Is being embarrassed or looking stupid among your worst fears?

  • Does fear of embarrassment cause you to avoid doing things or speaking to people?

  • Do you avoid activities in which you are the center of attention?


Are embarrassing/humiliating experiences contributory?


Except in extreme cases, probably only if one is "wired" for anxious apprehension or behavioral inhibition. However, a history of severe teasing experiences has been noted: social phobia (92%) vs. OCD (50%) and panic disorder (35%).(McCabe, et al., 2003)


Both SAD and shyness are moderately heritable. But most "shy" people do not truly have social anxiety disorder.

"Behavioral inhibition" = temperament risk factor for social anxiety disorder? Then panic attacks and conditioning may contribute to initial onset.


Avoidance only perpetuates social anxiety disorder:


  • diminished opportunities to disprove irrational predictions and beliefs

  • catastrophic assumptions can never be proven wrong

  • the momentary relief that follows avoidance reinforces avoidance and makes future avoidance more likely

  • with every avoidance, self-confidence is further eroded

  • ruminative repetition of worries escalates avoidance in a vicious cycle


Evaluating performance while performing:


  • self-absorption and self-observation raise anxiety and lower performance

  • can make mistakes; can look nervous; can receive disapproval

  • accepting anxiety as "being up for the game" is very different than fearing it and trying to control it


Alcohol may lead to alcohol dependence and more isolation, especially in young men with social anxiety.


Five meta-analyses support efficacy of Cognitive-Behavioral Treatment, usually including:

  • Teach relaxation training and breathing skills for general coping.

  • Focus on perfectionism, inevitable mistakes & accepting disapproval.

  • Focus on distortions of both probability and severity of consequences.

  • Assess and remediate actual skill deficits.

  • Exposure treatment, including self-conducted practice, is more important than cognitive intervention.

  • Start slow with collaboration/humor/role-playing/modeling.

  • Shows that actions don't predictably lead to disapproval.

  • When disapproval or embarrassment occasionally occur, it's not a catastrophe.

  • Allows habituation of bodily responses and gradual self-confidence.

  • Minimize use of distraction; stay until anxiety lessens.

  • Later, focus on making intentional mistakes, seeking actual disapproval and willingly seeking embarrassed feelings.

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