This literature review is based on social anxiety disorder (also called social phobia) and covers its definition and definitive statements about the disorder. Various examples and explanations are included about this condition, and how it affects those who suffer from it. Research shows that, in the U.S. alone, more than 15 million adults suffer from social anxiety and report they noticed symptoms in childhood or early adolescence. More than 36% of these people report having the condition for more than 10 years. Research also shows that many children are prone to or pre-disposed to social anxiety early on and are influenced by parents and peers, which can affect their behavior. Social anxiety is a common condition and can go from mild to debilitating for sufferers. This literature review examines symptoms, prevalence, treatments, causes and issues related to cultural/social differences regarding the disorder. As well, the review examines how people react in various situations regarding social anxiety online and offline. Specific treatments that include psychotherapy and medication are presented, along with other considerations, such as morbidity and comorbidity regarding the disorder. The purpose of this literature review is to give an understanding of this disorder in society and how it affects those who suffer from it.
Defining Social Anxiety Disorder
According to the article, “What is Social Anxiety?” by Social Anxiety Institute Psychologist, Thomas A. Richards, PhD, social anxiety is also known as ‘social phobia’ and is defined as “the fear of interaction with other people that brings on self-consciousness, feelings of being negatively judged and evaluated, and, as a result, leads to avoidance” (Richards, 2013, para. 1). He states that people who suffer from this disorder have an extreme fear of interacting with other people, because they are afraid of negative judgments from other people. Additionally, Dr. Richards reports that social anxiety disorder is the third largest mental health condition worldwide and highlights the symptoms of the disorder. Additionally, he describes treatment and therapy options for those suffering from this health issue. He states that social anxiety that is only specific may be a person afraid to speak in front of groups. Others who have generalized social anxiety are just anxious all the time, in general. According to the article, the definition of this condition includes hallmark symptoms that are constant, such as a fear of meeting people, being criticized, being the center of attention, social encounters, etc.
Another hallmark defining aspect of social anxiety disorder, according to the Anxiety and depression Association of America, is the fact that the disorder can ruin the lives of sufferers. It is beyond mere shyness and symptoms of the disorder can disrupt someone’s daily life. “People with this disorder, also called social phobia, may have few or no social or romantic relationships, making them feel powerless, alone, or even ashamed” (ADAA). The ADAA website shows that approximately 15 million adults in the U.S. have the disorder and they typically begin seeing symptoms as early as 13 years old. Additionally, 36% of these people report they have suffered from the disorder for at least 10 years. According to the ADAA, people with social anxiety disorder have phobias and fears that keep them from functioning with daily routines and having friendships or jobs. It is noted that the disorder begins early in life and “and children are prone to clinging behavior, tantrums, and even mutism” (ADAA), with this disorder.
As mentioned, social anxiety is also called social phobia, and according to the National Institute of Mental Health, social phobia is described as having a strong fear of being judged and embarrassed in public situations (NIH). The NIH explains similar symptoms of this disorder as the ADAA such as people being afraid to meet others; however, the NIH also points out that people with social phobia worry excessively, unnecessarily over their fears. They worry about performing common tasks in front of people such as signing a check at the store, eating in front of people in public, or using a public restroom facility. They are afraid of being embarrassed and sometimes this causes them to stay out of public places (NIH). The article also reports that social anxiety disorder can run in families but other causes are unknown. As the ADAA points out, the NIH lists symptoms to include fear of being judged by people and having difficulty making friends or keeping friends. Other symptoms are listed as feeling sick to the stomach when interacting with other people and sweating or trembling around other people. The same as noted with the ADAA, the NIH reports that 15 million American adults have social anxiety or phobia. Prevalence includes men and women equally, onset in childhood or early adolescence, genetic factors, and possibly substance abuse. Additionally, it is noted that people can live with the condition through proper diagnosis and treatment that includes psychotherapy and medication.
Social Anxiety and Children
Another definitive look at social anxiety in this literature review is from Drs. Bettina E. Bernstein, DO and Eduardo Dunayevich, MD. Their Medscape article states social phobia is a mental health disorder that is even more common than depression and substance abuse. The disorder affects more than 10 million American people. As with the latter review entries, Bernstein & Dunayevich (2013) state that “Social phobia is an anxiety disorder involving intense distress in response to public situations” (para. 1). As well, they state that social anxiety makes people afraid of socializing or speaking in public, using public restrooms, or eating in public. What the other articles do not state, that this one does, is that the disorder causing physical symptoms in people who become upset or stressed from feeling embarrassed or humiliated in public. These physical symptoms include rapid heartbeat, excessive sweating, and other signs of nervousness. Case studies examined in the research of this review piece include examining the effects of social anxiety disorder on a 9-year-old boy who insists that nobody likes him or wants to play with him. He rarely raises his hand to answer teacher questions and has difficulties functioning at school. According to the research, the pathophysiology of social phobia and anxiety involves brain connectivity and function research. Epidemiology facts about the disorder is reported as 9% of American youth suffer with social anxiety and this factor is 12.1% for adults. As Richards (2013) states, Bernstein & Dunayevich (2013) point out that social anxiety disorder is related to other conditions such as generalized or specific anxiety disorder and mutism, but also other disorders such as attention deficit/hyperactivity disorder and separation anxiety disorder. Prevalence is noted in relation to race, gender and age. It is stated that people of Asian descent that suffer from the disorder are less likely to seek treatment because of cultural norm concerns. Additionally, more females generally suffer from the disorder than males and the disorder usually manifests in middle childhood between the ages of 11 to 12.
In a Contemporary Pediatrics journal article by Marcy Burstein, PhD titled, “When to Get Anxious About Social Anxiety Disorder,” it is stated that social anxiety disorder usually begins in childhood and points out that excessive shyness in children could lead to the disorder, because children are in a state of mental and physical growth. The author points out four distinctions of shyness vs. social anxiety disorder such as (1) with shyness, concepts are perceived with normal temperament, and with social anxiety disorder it is a psychiatric issue. (2) When it comes to prevalence, shyness is common and social anxiety disorder is not so common. (3) With shyness, there is no impairment, but with social anxiety there is significant impairment. (4) As it relates to associated psychiatric disorders, shyness has little risk, but social anxiety has a great risk for being associated with other disorders (Burnstein, 2012).
Parental and Peer Influences on Children
The authors, Candice C. Fest and Golda S. Ginsburg, of “Parental and Peer Predictors of Social Anxiety in Youth” in Child Psychiatry & Human Development examine the effects of negative parental influences and peer influences on social anxiety among the youth. Negative parental influences include being exposed to parents who have anxiety issues, over control their children, or reject their children. Peer influences include being accepted and supported by peers and friends. It is noted that these factors affect social anxiety in children who suffer from the condition. As with the previous review entries above, this research also explains that this disorder presents in childhood and adolescence. The results show that parental anxiety and validation from friends were the strongest influences (Festa & Ginsburg, 2011).
Social Anxiety and Physical Symptoms in Children
A group of psychologists, Schmitz et al (2012), studied how anxiety symptoms in children with social anxiety cause them to panic in certain situations. They examined how biased perception and interpretation of stressful situations causes physical symptoms in these children. This study examines how children perceive how they come across to other people when in perceived stressful situations. It is noted that they overreact to stress cues like and bodily anxiety symptoms such as the heart beating faster when anxious. The authors focus on understanding any correlation between children overreacting to stress cues and being predisposed to developing to social phobia and social anxiety disorder. Similar to the study by Burnstein (2012), this study analyzes differences between shy and nonshy children regarding social anxiety.
Cognitive Behavior Therapy and Social Anxiety
Additionally, just like Schmitz et al (2012), another study focuses on bodily sensations and fear regarding social anxiety. This study by Ashbaugh & Radomsky (2011), examines memory and social anxiety disorder, and also whether there is a correlation between fear of bodily sensations and social anxiety in some people. The study was based on cognitive models to prove that people with social anxiety disorder are prone to having enhanced memories related to social threat information. The study comprised 74 participants completing a performance task study while being electronically monitored.
Another research study, by Sportel et al (2013), based on cognitive indicators focuses on
cognitive bias modification (CBM) versus cognitive behavioral therapy (CBT) in reducing adolescent social anxiety. The methodology used for this research was a randomized controlled trial. Researchers compared the effect of cognitive behavioral therapy treatment on adolescents with social anxiety disorder. Participants in the study were either in a control group (CBM) or in the CBT group. Results showed that participants in the CBT group showed better results with the cognitive behavioral therapy intervention than did the CBM.
Cognitive behavior therapy can also affect depression symptoms in people with social anxiety, as it relates to them having shame and guilt with their condition (Hedman et al, 2013).
The research shows that some people feel shame and guilt associated with their social anxiety. They feel they are always scrutinized by others, according to the research. The study assessed how cognitive behavior therapy may reduce these feelings with social anxiety disorder. The purpose of the study was investigating how shame, guilt, depressive symptoms, and social anxiety are interrelated, as well as the effect of CBT on treating the emotions of shame and guilt in people with the disorder.
Emotion-related Social Anxiety
As with Hedman et al (2013), a study by Moore et al (2009) deals with emotions and social anxiety. The study examines how anxiety sensitivity and what people perceive in threat situations determines their level of social anxiety. This research examines the relationship between people’s tendencies toward anxiety (their sensitivity) and what they expect will happen in perceived stressful situations (their expectations). The author points out study findings of how the expectancy theory and integration theory relate to this issue. It is stated that, “According to expectancy theory, each fundamental fear is a multiple of an individual’s perceived likelihood (i.e., expectancy) of a fear-producing event and their sensitivity to that type of fear” (p. 43).
People with emotion-related social anxiety may have difficulty calming themselves down when becoming upset from perceived threat. A study by Schofield (2012) examines this and focuses on difficulty those who suffer with social anxiety may have with disengaging themselves from the thought of threat. The study method used was via an eye-tracking device for study participants. The purpose of the research was assessing how people with this disorder are able to handle their hyper vigilance to threat cues. The study examines this by evaluated social anxiety disorder study participants through eye-movement data.
Other Technology-based Social Anxiety Research
Yen et al (2012) reported on their research study called, Social Anxiety in Online and Real-Life Interaction and Their Associated Factors. This study examines how people deal with social anxiety online and offline. The purpose of the study was assessing whether social anxiety disorder was worse with online interactions or in real-life situations. The methods used for the research were with a Behavioral Inhibition System (BIS) and a Behavioral Activation System (BAS). It is interesting to note that the study result shows online interventions for social anxiety could be promising, as the research showed that social anxiety decreased in online interaction from results of the BIS.
Similarly, virtual encounters were studied regarding social anxiety with Rinck et al (2010). This study focuses on whether avoidance behaviors in those with social anxiety are more prevalent in the real world on online. The method used for the study was electronic technology to assess instances of social avoidance with social anxiety disorder. The study results found that people unintentionally use avoidance behaviors in social interactions in the virtual environment, if they are prone to anxiousness in social situations.
Culture and Social Anxiety
The previous section focuses on behavior in social situations whether online or offline, but it does not have any information about how this differs in people from different cultures who have social anxiety disorder. Hofmann, Asnaai & Hinton (2010) focus on the cultural aspects of social anxiety disorder. It is noted that there is a relationship between culture and social anxiety. Cultural differences effect how people view social anxiety and it also affects help-seeking behaviors of those who have it. Cultural influences include social norms, individualism, and gender roles in a society. The study examines the effects of cultural differences on social anxiety prevalence rates and cultural-specific presentations of the disorder.
Similarly, Schreier et al (2010) researched social anxiety and social norms in individualistic and collectivistic countries. The researched examines social anxiety and culture in different countries. This has to do with cultural norms in both individualistic and collectivistic countries. For example, the study results show that Latin American cultures promote being social, friendly and engaging in conversation, and this decreases social anxiety. However, East Asian cultures promote submissiveness and being quiet and these behaviors have been shown to increase social anxiety. This research shows that social anxiety in various countries is strongly related to cultural and social norms in different countries.
ADAA. (n.d.). Social Anxiety Disorder. Retrieved from https://www.adaa.org/understanding-anxiety/social-anxiety-disorder
Ashbaugh, A. & Radomsky, A. (2011). Memory for Physiological Feedback in Social Anxiety Disorder: The Role of Fear of Bodily Sensations. Cognitive Therapy & Research, 35(4), p. 304-316.
Bernstein, B. E. & Dunayevich, E. (2013). Social Phobia. Retrieved from http://emedicine.medscape.com/article/290854-overview
Burstein, M. (2012). When to Get Anxious About Social Anxiety Disorder. Contemporary Pediatrics, 29(12), p. 32-42.
Festa, C. C., Ginsburg, G. S. (2011). Parental and Peer Predictors of Social Anxiety in Youth. Child Psychiatry & Human Development, 42(3), p. 291-306.
Hedman, E., Strom, P., Stunkel, A., & Mortberg, E. (2013). Shame and Guilt in Social Anxiety Disorder: Effects of Cognitive Behavior Therapy and Association with Social Anxiety and Depressive Symptoms. PLoS ONE, 8(4), p. 1-8.
Hofmann, S. G., Asnaai, A., & Hinton, D. E. (2010). Cultural aspects in social anxiety and social anxiety disorder. Depression & Anxiety, 27(12), p. 1117-1127.
Moore, P. J., Chung, E., Peterson, R. A., Katzman, M. A., & Vermani, M. (2009). Information integration and emotion: How do anxiety sensitivity and expectancy combine to determine social anxiety? Cognition and Emotions, 23(1), p. 42-68
NIH. (n.d.). What is Social Phobia (Social Anxiety Disorder). Retrieved from http://www.nimh.nih.gov/health/topics/social-phobia-social-anxiety-disorder/index.shtml
Richards, T. A. (2013). What is Social Anxiety? Social Anxiety Institute. Retrieved from https://socialanxietyinstitute.org/what-is-social-anxiety
Rinck, M., Rortgen, T., Lange, W., Dotsch, R., Wigboldus, D. H., & Becker, E. S. (2010). Social anxiety predicts avoidance behavior in virtual encounters. Cognition & Emotion, 24(7) p. 126-1276.
Schmitz, J., Blechert, J. Kramer, M., Asbrand, J., & Tuschen-Caffier, B. (2012). Biased Perception and Interpretation of Bodily Anxiety Symptoms in Childhood Social Anxiety. Journal of Clinical Child & Adolescent Psychology, 41(1), p. 92-102.
Schofield, C. A. (2012). Social anxiety and difficulty disengaging threat: Evidence from eye-tracking. Cognition & Emotion, 26(2), p. 300-311.
Schreier, S., Heinrichs, N., Alden, L. Rappe, R. M., Hofmann, S. G., Ghen J., Oh, K. J., & Bogels, S. (2010). Social anxiety and social norms in individualistic and collectivistic countries. Depression & Anxiety, 27(12), p. 1128-1134.
Sportel, B. E., de Hullu, E., de Jong, P. J., & Nauta, M. H. (2013). Cognitive Bias Modification versus CBT in Reducing Adolescent Social Anxiety: A Randomized Controlled Trial. PLoS Clinical Trials, 10(5), p. 1-11.
Yen, J., Yen, C., Chen, C., Wang, P., Chang, Y., & Ko, C. (2012). Social Anxiety in Online and Real-Life Interaction and Their Associated Factors. CyberPsychology, Behavior & Social Networking, 15(1), p. 7-12.