Social Anxiety: The next big mental health issue?

Social Anxiety is something I come across very often in my practice, frequently at levels that are very disabling and distressing for clients.  The DSM 5 defines Social Anxiety Disorder as:
Marked fear of one or more social situations in which the person is exposed to possible scrutiny by others. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e. will be humiliating or embarrassing; will lead to rejection or offend others)". (American Psychiatric Association, 2013)

It also emphasises that “the social situations almost always provoke fear or anxiety” and that “the feared situations are avoided or are endured with intense fear or anxiety.” The anxiety and avoidance must interfere significantly with the person’s life functioning, otherwise we are not talking about a disorder, but about normal (though perhaps very uncomfortable) levels of social anxiety.

A simpler summary would be that Social Anxiety refers to symptoms such as:
•    acute self-consciousness, awkwardness and self-focus
•    over-focus on anxiety symptoms such as blushing, shaking and sweating
•    frequent embarrassment, feeling different, unwanted and negatively judged.

Social Anxiety is not the same as shyness (a shy person may not be very confident in social situations, but they don’t necessarily experience a high level of anxiety around them) or as introversion (a personality characteristic – some people just like a lot of time alone). Nor are the Socially Anxious person’s social skills necessarily poor, though they generally fear they are (and they may well be out of practice). While we all experience some social anxiety when we are in social situations outside of our comfort zones (e.g. attending a wedding where we know almost nobody), the extremeness of the above symptoms in some cases, and the huge extent to which they negatively affect some people's lives, are what leads us to diagnose Social Anxiety. For the Socially Anxious person there is a constant fear of being negatively judged – social life is like one long nightmare job interview. They can never fully relax when there are others around, and so often tend to avoid social situations. In some cases there are specific worries and self-consciousness about anxiety symptoms such as blushing, sweating, shaking etc. These symptoms may of course be real, but are rarely as bad as the sufferer imagines.

Many sufferers manage to mask and cope with the problem to a certain extent, but only at the cost of quite a lot of damage to their life and happiness: they experience constant high levels of anxiety, and/or impose serious limitations on their social life, relationships, work, education etc.

According to the Social Anxiety Ireland website, “Prevalence rates of social anxiety vary across the world. It is believed that approximately 13% of the population in Ireland; 10% in the UK, 15% in Sweden; and 13% (that’s roughly 15 million) in the US have Social Anxiety in any given year.” (See web link below).

Fortunately, Cognitive Behavioural Therapy can be very effective in helping people with Social Anxiety to explore their tendencies
•    To worry and mentally rehearse for hours before social events
•    To practice a range of “Safety Behaviours” in social settings (e.g. staying on your own, leaving early, drinking before going out, trying too hard to be “interesting”)
•    To carry out a thorough, self-critical, “post mortem” after social events.

Such habits of thinking and behaving are understandable, given the anxiety the sufferer feels, but unfortunately they all tend to further exacerbate and perpetuate the problem. The Cognitive Behavioural Therapist and client work together to change these ingrained habits by identifying habitual thoughts (e.g. 'what if somebody sees me blushing'), beliefs (e.g. “people will think I am weak”), and patterns of thinking (e.g. common cognitive distortions such as All or Nothing Thinking, Discounting Positive Feedback, Mind-reading, Emotional Reasoning, and Catastrophising), which can be questioned and tested. Even getting a clear picture of these can take some of their power away. The next step is to reality-test some of these in an experiential way, through planned behavioural experiments (e.g. going to a cafe and observing that not everyone is looking at you). People who believe that they blush “as red as a fire engine” may need to take the step of seeing themselves on video when they are blushing (e.g. when describing an embarrassing moment to the therapist), so that they can see that the reality does not match their fears.

One crucial step is that the socially anxious person must, at some point, begin to drop some of their safety behaviours, and see what happens. This may mean, for example, not preparing what to say in advance, not trying to agree with everyone, not bringing a huge present to a dinner party, etc. They gradually begin to see that not only are people not judging them all the time (only sometimes, and maybe they can survive this!), but that they are not even in other people’s minds most of the time.

In my work with socially anxious clients I sometimes think a better term to use might be “Interpersonal Anxiety”, as sufferers are usually affected in more than just the typically “social” part of their lives (i.e. with friends, at parties etc.) In fact their fear of being negatively judged can paralyse them in contexts as far apart as paying at a checkout, posting on social media, collecting a child from school, and being sexually intimate with a partner. Indeed, sexual intimacy is an area where a sense of being negatively judged can be particularly painful.

Social media such as Facebook are now becoming very relevant in this kind of work, both as a place where some socially anxious people may feel safer through avoiding more direct social interaction, and also as a place that isn’t really any socially safer than face-to-face contexts (judgment, rejection, hurt, etc. are at least as real on Facebook as they are in any other human social setting).

What stands out clearly in working with these clients is their underlying innate sensitivity, and very likely their high degree of empathy (Tibi-Elhanany & Shamay-Tsoory 2011). While these are obviously not negative qualities in themselves, they can combine with negative experiences to leave a sense of personal vulnerability, shame and low self-esteem. Some people may even be left genuinely vulnerable to being taken advantage of in relationships, as they typically assume that they are the one who is in the wrong. On the other hand, this can also make them defensive and hard to live with; unidentified anger may be one of the underestimated issues in social anxiety work.

Social Anxiety, and the CBT approach to it, is definitely an area I would recommend therapists to become more familiar with, as it may be the next big issue in mental health.

Eoin Stephens, MIACP, MACI

PCI College President


(this article first appeared in the Winter 2015 edition of Reflections, PCI College Alumni Journal)



APA (American Psychiatric Association) (2013) Diagnostic and Statistical Manual of Mental Disorders. 5th edn. APA, Washington, DC.

Tibi-Elhanany, Y. & Shamay-Tsoory, S.G. (2011) Social cognition in social anxiety: first evidence for increased empathic abilities. Isr J Psychiatry Relat Sci. 48(2):98-106.

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