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Research Article

Social anxiety in young people: A prevalence study in seven countries

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Resilience Research Centre, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada

Roles Conceptualization, Methodology, Writing – review & editing

• Philip Jefferies, 
• Michael Ungar

• Published: September 17, 2020
• https://doi.org/10.1371/journal.pone.0239133
• Peer Review
• Reader Comments

Social anxiety is a fast-growing phenomenon which is thought to disproportionately affect young people. In this study, we explore the prevalence of social anxiety around the world using a self-report survey of 6,825 individuals (male = 3,342, female = 3,428, other = 55), aged 16–29 years (M = 22.84, SD = 3.97), from seven countries selected for their cultural and economic diversity: Brazil, China, Indonesia, Russia, Thailand, US, and Vietnam. The respondents completed the Social Interaction Anxiety Scale (SIAS). The global prevalence of social anxiety was found to be significantly higher than previously reported, with more than 1 in 3 (36%) respondents meeting the threshold criteria for having Social Anxiety Disorder (SAD). Prevalence and severity of social anxiety symptoms did not differ between sexes but varied as a function of age, country, work status, level of education, and whether an individual lived in an urban or rural location. Additionally, 1 in 6 (18%) perceived themselves as not having social anxiety, yet still met or exceeded the threshold for SAD. The data indicate that social anxiety is a concern for young adults around the world, many of whom do not recognise the difficulties they may experience. A large number of young people may be experiencing substantial disruptions in functioning and well-being which may be ameliorable with appropriate education and intervention.

Citation: Jefferies P, Ungar M (2020) Social anxiety in young people: A prevalence study in seven countries. PLoS ONE 15(9): e0239133. https://doi.org/10.1371/journal.pone.0239133

Editor: Sarah Hope Lincoln, Harvard University, UNITED STATES

Received: March 11, 2020; Accepted: August 31, 2020; Published: September 17, 2020

Copyright: © 2020 Jefferies, Ungar. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data files are available from the Open Science Framework repository (DOI: 10.17605/OSF.IO/VCNF7 ).

Funding: The author(s) received no specific funding for this work.

Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: Unilever funds the lead author's research fellowship at Dalhousie University's Resilience Research Centre, though in no way have they directed this research, its analysis or the reporting or results.

Introduction

Social anxiety occurs when individuals fear social situations in which they anticipate negative evaluations by others or perceive that their presence will make others feel uncomfortable [ 1 ]. From an evolutionary perspective, at appropriate levels social anxiety is adaptive, prompting greater attention to our presentation and reflection on our behaviours. This sensitivity ensures we adjust to those around us to maintain or improve social desirability and avoid ostracism [ 2 ]. However, when out of proportion to threats posed by a normative social situation (e.g., interactions with a peer group at school or in the workplace) and when impairing functioning to a significant degree, it may be classified as a disorder (SAD; formerly ‘social phobia’; [ 3 ]). The hallmark of social anxiety in western contexts is an extreme and persistent fear of embarrassment and humiliation [ 1 , 4 , 5 ]. Elsewhere, notably in Asian cultures, social anxiety may also manifest as embarrassment of others, such as Taijin kyofusho in Japan and Korea [ 6 ]. Common concerns involved in social anxiety include fears of shaking, blushing, sweating, appearing anxious, boring, or incompetent [ 7 ]. Individuals experiencing social anxiety visibly struggle with social situations. They show fewer facial expressions, avert their gaze more often, and express greater difficulty initiating and maintaining conversations, compared to individuals without social anxiety [ 8 ]. Recognising difficulties can lead to dread of everyday activities such as meeting new people or speaking on the phone. In turn, this can lead to individuals reducing their interactions or shying away from engaging with others altogether.

The impact of social anxiety is widespread, affecting functioning in various domains of life and lowering general mood and wellbeing [ 9 ]. For instance, individuals experiencing social anxiety are more likely to be victims of bullying [ 10 , 11 ] and are at greater risk of leaving school early and with poorer qualifications [ 11 , 12 ]. They also tend to have fewer friends [ 13 ], are less likely to marry, more likely to divorce, and less likely to have children [ 14 ]. In the workplace, they report more days absent from work and poorer performance [ 15 ].

A lifetime prevalence of SAD of up to 12% has been reported in the US [ 16 ], and 12-month prevalence rates of .8% have been reported across Europe [ 17 ] and .2% in China [ 18 ]. However, there is an increasing trend to consider a spectrum of social anxiety which takes account of those experiencing subthreshold or subclinical social anxiety, as those experiencing more moderate levels of social anxiety also experience significant impairment across different domains of functioning [ 19 – 21 ]. Therefore, the proportion of individuals significantly affected by social anxiety, which include a substantial proportion of individuals with undiagnosed SAD [ 8 ], may be higher than current estimates suggest.

Studies also indicate younger individuals are disproportionately affected by social anxiety, with prevalence rates at around 10% by the end of adolescence [ 22 – 24 ], with 90% of cases occurring by age 23 [ 16 ]. Higher rates of social anxiety have also been observed in females and are associated with being unemployed [ 25 , 26 ], having lower educational status [ 27 ], and living in rural areas [ 28 , 29 ]. Leigh and Clark [ 30 ] have explored the higher incidence of social anxiety in younger individuals, suggesting that moving from a reliance on the family unit to peer interactions and the development of neurocognitive abilities including public self-consciousness may present a period of greater vulnerability to social anxiety. While most going through this developmentally sensitive period are expected to experience a brief increase in social fears [ 31 ], Leigh and Clark suggest that some who may be more behaviourally inhibited by temperament are at greater risk of developing and maintaining social anxiety.

Recent accounts suggest that levels of social anxiety may be rising. Studies have indicated that greater social media usage, increased digital connectivity and visibility, and more options for non-face-to-face communication are associated with higher levels of social anxiety [ 32 – 35 ]. The mechanism underpinning these associations remains unclear, though studies have suggested individuals with social anxiety favour the relative ‘safety’ of online interactions [ 32 , 36 ]. However, some have suggested that such distanced interactions such as via social media may displace some face to face relationships, as individuals experience greater control and enjoyment online, in turn disrupting social cohesion and leading to social isolation [ 37 , 38 ]. For young people, at a time when the development of social relations is critical, the perceived safety of social interactions that take place at a distance may lead some to a spiral of withdrawal, where the prospect of normal social interactions becomes ever more challenging.

Therefore, in this study, we sought to determine the current prevalence of social anxiety in young people from different countries around the world, in order to clarify whether rates of social anxiety are increasing. Specifically, we used self-report measures (rather than medical records) to discover both the frequency of the disorder, severity of symptoms, and to examine whether differences exist between sexes and other demographic factors associated with differences in social anxiety.

Materials and methods

This study is a secondary analysis of a dataset that was created by Edelman Intelligence for a market research campaign exploring lifestyles and the use of hair care products that was commissioned by Clear and Unilever. The original project to collect the data took place in November 2019, where participants were invited to complete a 20-minute online questionnaire containing measures of social anxiety, resilience, social media usage, and questions related to functioning across various life domains. Participants were randomly recruited through the market research companies Dynata, Online Market Intelligence (OMI), and GMO Research, who hold nationally representative research panels. All three companies are affiliated with market research bodies that set standards for ethical practice. Dynata adheres to the Market Research Society code of conduct; OMI and GMO adhere to the ESOMAR market research code of conduct. The secondary analyses of the dataset were approved by Dalhousie University’s Research Ethics Board.

Participants

There were 6,825 participants involved in the study (male = 3,342, female = 3,428, other = 55), aged 16–29 years (M = 22.84, SD = 3.97), from seven countries selected for their social and economic diversity (Brazil, China, Indonesia, Russia, Thailand, US, and Vietnam) (see Table 1 for full sample characteristics). Participant ages were collected in years, but some individuals aged 16–17 were recruited through their parents and their exact age was not given. They were assigned an age of 16.5 years in order to derive the mean age and standard deviation for the full sample.

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https://doi.org/10.1371/journal.pone.0239133.t001

Email invitations to participate were sent to 23,346 young people aged 16–29, of whom 76% (n = 17,817) were recruited to take the survey. These were panel members who had previously registered and given their consent to participate in surveys. Sixty-five percent of respondents were ineligible, with 10,816 excluded because they or their close friends worked in advertising, market research, public relations, journalism or the media, or for a manufacturer or retailer of haircare products. A further 176 respondents were excluded for straight-lining (selecting the same response to every item of the social anxiety measure, indicating they were not properly engaged with the survey; [ 39 ]). The final sample comprised 6,825 participants and matched quotas for sex, region, and age, to achieve a sample with demographics representative of each country.

Participants were compensated for their time using a points-based incentive system, where points earned at the end of the survey could be redeemed for gift cards, vouchers, donations to charities, and other products or services.

The survey included the 20-item self-report Social Interaction Anxiety Scale (SIAS; [ 40 ]). Based on the DSM, the SIAS was originally developed in conjunction with the Social Phobia Scale to determine individuals’ levels of social anxiety and how those with SAD respond to treatment. Both the SIAS and Social Phobia Scale correlate strongly with each other [ 40 – 43 ], but while the latter was developed to assess fears of being observed or scrutinised by others, the SIAS was developed more specifically to assess fears and anxiety related to social interactions with others (e.g., meeting with others, initiating and maintaining conversations). The SIAS discriminates between clinical and non-clinical populations [ 40 , 44 , 45 ] and has also been found to differentiate between those with social anxiety and those with general anxiety [ 46 ], making it a useful clinical screening tool. Although originally developed in Australia, it has been tested and found to work well in diverse cultures worldwide [ 47 – 50 ], and has strong psychometric properties in clinical and non-clinical samples [ 40 , 42 , 43 , 45 – 47 ].

For the current study, all 20 items of the SIAS were included in the survey, though we omitted the three positively-worded items from analyses, as studies have demonstrated that including them results in weaker than expected relationships between the SIAS and other measures, that they hamper the psychometric properties of the measure, and that the SIAS performs better without them [e.g., 51 – 53 ] (the omitted items were ‘I find it easy to make friends my own age’ , ‘I am at ease meeting people at parties , etc’ , and ‘I find it easy to think of things to talk about’ .). One item of the SIAS was also modified prior to use: ‘ I have difficulty talking to attractive persons of the opposite sex’ was altered to ‘ I have difficulty talking to people I am attracted to’ , to make it more applicable to individuals who do not identify as heterosexual, given that the original item was meant to measure difficulty talking to an attractive potential partner [ 54 ].

The questionnaire also included measures of resilience, in addition to other questions concerning functioning in daily life. These were included as part of a corporate social responsibility strategy to investigate the rates of social anxiety and resilience in each target market. A translation agency (Language Connect) translated the full survey into the national languages of the participants.

We analysed social anxiety scores for the overall sample, as well as by country, sex, and age (for sex, given the limited number and heterogeneity of individuals grouped into the ‘other’ category, we only compared males and females). As social anxiety is linked to work status [ 25 ], we also examined differences in SIAS scores between those working and those who were unemployed. Urban/rural differences were also investigated as previous research has suggested anxiety disorders may differ depending on where an individual lives [ 28 ]. Education level [ 27 ], too, was included using completion of secondary education (ISCED level 3) in a subgroup of participants aged 20 years and above to ensure all were above mandatory ages for completing high school. Descriptive statistics are reported for each group with significant differences explored using ANOVA (with Tukey post-hoc tests) or t-tests.

The SIAS is said to be unidimensional when using just the 17 straightforwardly-worded items [ 52 ], with item scores summed to give general social anxiety scores. Higher scores indicate greater levels of social anxiety. Heimberg and colleagues [ 42 ] have suggested a cut-off of 34 on the 20-item SIAS to denote a clinical level of social anxiety (SAD). This level has been adopted in other studies [e.g., 45 ] and found to accurately discriminate between clinical and non-clinical participants [ 53 ]. This threshold for SAD scales to 28.9 when just the 17 items are used, and this is slightly more conservative than others who have used 28 as an adjusted 17-item threshold [ 53 , 55 ]. Therefore, in addition to analyses of raw scores to gauge the severity of social anxiety (and reflect consideration of social anxiety as a spectrum), we also report the proportion of individuals meeting or exceeding this threshold for SAD (≥29) and analyse differences between groups using chi-square tests.

Additionally, despite the unidimensionality of the SIAS, the individual items can be interpreted as examples of contexts where social anxiety may be more or less acutely experienced (e.g., social situations with authority: ‘ I get nervous if I have to speak with someone in authority ’, social situations with strangers: ‘ I am nervous mixing with people I don’t know well ’). Therefore, as social anxiety may be experienced differently depending on culture [ 6 ], we also sorted the items in the measure to understand the top and least concerning contexts for each country.

Finally, we also sought to understand whether individuals perceived themselves as having social anxiety. After completing the SIAS, participants were presented with a definition of social anxiety and asked to reflect on whether they thought this was what they experienced. We contrasted responses with a SIAS threshold analysis to determine discrepancies, including assessment of the proportion of false positives (those who thought they had social anxiety but did not exceed the threshold) and false negatives (those who thought they did not have social anxiety but exceeded the threshold).

All analyses were conducted using SPSS v25 [ 56 ].

As the survey required a response for each item, there were no missing data. The internal reliability of the SIAS was found to be strong (α = .94), with the removal of any item resulting in a reduction in consistency.

Social anxiety by sex, age, and country

In the overall sample, the distribution of social anxiety scores formed an approximately normal distribution with a slightly positive skew, indicating that most respondents scored lower than the midpoint on the measure ( Fig 1 ). However, more than one in three (36%) were found to score above the threshold for SAD. There were no significant differences in social anxiety scores between male and female participants ( t (6768) = -1.37, n.s.) and the proportion of males and females scoring above the SAD threshold did not significantly differ either ( χ 2 (1,6770) = .54, n.s.).

https://doi.org/10.1371/journal.pone.0239133.g001

Social anxiety scores significantly differed between countries ( F (6,6818) = 74.85, p < .001, η p 2 = .062). Indonesia had the lowest average scores ( M = 18.94, SD = 13.21) and the US had the highest ( M = 30.35, SD = 15.44). Post-hoc tests revealed significant differences ( p s≤.001) between each of the countries, except between Brazil and Thailand, between China and Vietnam, between Russia and China, and between Russia and Indonesia (see Table 2 ). The proportion of individuals exceeding the threshold for SAD was also found to significantly differ between the seven countries (χ 2 (6,6825) = 347.57, p < .001). Like symptom severity, the US had the highest prevalence with more than half of participants surveyed exceeding the threshold (57.6%), while Indonesia had the lowest, with fewer than one in four (22.9%).

https://doi.org/10.1371/journal.pone.0239133.t002

A significant age difference was also observed ( F (2,6822) = 39.74, p < .001, η p 2 = .012), where 18-24-year-olds scored significantly higher ( M = 25.33, SD = 13.98) than both 16-17-year-olds ( M = 21.92, SD = 14.24) and 25-29-year-olds ( M = 22.44, SD = 14.22). Also, 25-29-year-olds scored significantly higher than 18-24-year-olds ( p s < .001). The proportion of individuals scoring above the threshold for SAD also significantly differed between age groups (χ 2 (2,6825) = 48.62, p < .001) ( Fig 2 ).

https://doi.org/10.1371/journal.pone.0239133.g002

A three-way ANOVA confirmed significant main effect differences in social anxiety scores between age groups ( F (2,6728) = 38.93, p < .001, η p 2 = .011) and countries ( F (6,6728) = 45.37, p < .001, η p 2 = .039), as well as the non-significant difference between males and females ( F (1,6728) = .493, n.s.). However, of the interactions between sex, age, and country, the two-way country*age interaction was significant ( F (12,6728) = 1.89, p = .031, η p 2 = .003), where 16-17-year-olds in Indonesia were found to have the lowest scores ( M = 15.70, SD = 13.46) and 25-29-year-olds in the US had the highest ( M = 30.47, SD = 16.17) ( Fig 3 ). There was also a significant country*sex interaction ( F (6,6728) = 2.25, p = .036, η p 2 = .002), where female participants in Indonesia had the lowest scores ( M = 18.07, SD = 13.18) and female participants in the US had the highest ( M = 30.37, SD = 15.11) ( Fig 4 ).

https://doi.org/10.1371/journal.pone.0239133.g003

https://doi.org/10.1371/journal.pone.0239133.g004

Work status

Social anxiety scores were also found to significantly differ in terms of work status (employed/studying/unemployed; F (2,6030) = 9.48, p < .001, η p 2 = .003), with those in employment having the lowest scores ( M = 23.28, SD = 14.32), followed by individuals who were studying ( M = 23.96, SD = 13.50). Those who were unemployed had the highest scores ( M = 26.27, SD = 14.54). Post-hoc tests indicated there were significant differences between those who were employed and unemployed ( p < .001), between those studying and unemployed ( p = .006), but not between those employed and those who were studying. The difference between those exceeding the SAD threshold between groups was also significant (χ 2 (2,6033) = 7.55, p = .023).

Urban/Rural

Social anxiety scores also significantly varied depending on an individual’s place of residence ( F (4,6820) = 9.95, p < .001, η p 2 = .006). However, this was not a linear relationship from urban to rural extremes ( Fig 5 ); instead, those living in suburban areas had the highest scores ( M = 25.64, SD = 14.08) and those in central urban areas had the lowest ( M = 22.70, SD = 14.67). This pattern was reflected in the proportions of individuals exceeding the SAD threshold (χ 2 (4,6825) = 35.84, p < .001).

https://doi.org/10.1371/journal.pone.0239133.g005

Education level

In the subsample of individuals aged 20 or above, level of education also resulted in a significant differences in social anxiety scores ( t (5071) = 5.51, p < .001), with individuals who completed secondary education presenting lower scores ( M = 23.40, SD = 14.15) than those who had not completed secondary education ( M = 27.94, SD = 15.07). Those exceeding the threshold for SAD also significantly differed (χ 2 (1,5073) = 38.75, p < .001), with half of those who had not finished secondary education exceeding the cut-off (52%), compared to just over a third of those who had (35%).

Concerns by context

Table 3 illustrates the items of the SIAS sorted by severity for each country. For East-Asian countries, speaking with someone in authority was a top concern, but less so for Brazil, Russia, and the US. Patterns became less discernible between countries beyond this top concern, indicating heterogeneity in the specific situations related to social anxiety, although individuals in most countries appeared to be least challenged by mixing with co-workers and chance encounters with acquaintances.

https://doi.org/10.1371/journal.pone.0239133.t003

Self-perceptions of social anxiety

Just over a third of the sample perceived themselves to experience social anxiety (34%). Although this was similar to the proportion of individuals who exceeded the threshold for SAD (36%), perceptions significantly differed from threshold results (χ 2 (1,6825) = 468.80, p < .001). Just fewer than half of the sample (48%) perceived themselves as not being socially anxious and were also below the threshold, and a fifth (18%) perceived themselves as being socially anxious and exceeded the threshold ( Fig 6 ). However, 16% perceived themselves to be socially anxious yet did not exceed the threshold (false positives) and 18% perceived themselves not to be socially anxious yet exceeded the threshold (false negatives). This suggests a large proportion of individuals do not properly recognise their level of social anxiety (over a third of the sample), and perhaps most importantly, that more than 1 in 6 may experience SAD yet not recognise it ( Table 4 ).

https://doi.org/10.1371/journal.pone.0239133.g006

https://doi.org/10.1371/journal.pone.0239133.t004

This study provides an estimate of the prevalence of social anxiety among young people from seven countries around the world. We found that levels of social anxiety were significantly higher than those previously reported, including studies using the 17-item version of the SIAS [e.g., 55 , 57 , 58 ]. Furthermore, our findings show that over a third of participants met the threshold for SAD (23–58% across the different countries). This far exceeds the highest of figures previously reported, such as Kessler and colleague’s [ 16 ] lifetime prevalence rate of 12% in the US.

As this study specifically focuses on social anxiety in young people, it may be that the inclusion of older participants in other studies leads to lower average levels of social anxiety [ 27 , 59 ]. In contrast, our findings show significantly higher rates of SAD than anticipated, and particularly so for individuals aged 18–24. It also extends the argument of authors such as Lecrubier and colleagues [ 60 ] and Leigh and Clark [ 30 ] that developmental challenges during adolescence may provoke social anxiety, especially the crucial later period when leaving school and becoming more independent.

We also found strong variations in levels of social anxiety between countries. Previous explorations of national prevalence rates have been less equivocal, with some reporting differences [ 6 ] while others have not [ 61 ]. Our findings concur with those of Hofmann and colleagues’ [ 6 ] who note that the US has typically high rates of social anxiety, which we also found (in contrast to other countries). However, the authors suggest Russia also has a high prevalence and that Asian cultures typically show lower rates. In contrast, we found samples from Asian countries such as Thailand and Vietnam had higher rates than in the sample from Russia, and that there were significant differences between Asian countries themselves ( Table 2 ). As our study used the SIAS, which determines how socially anxious an individual is based on their ratings of difficulty in specific social situation, one way of accounting for differences may be to consider the kinds of feared social situations that are covered in the measure. For instance, our breakdown of concerns by country ( Table 3 ) indicates that in Asian countries, speaking with individuals in authority is a strongly feared situation, but this is less challenging in other cultures. For non-Asian countries, one of the strongest concerns was talking about oneself or one’s feelings. In Asian countries, where there is typically less of an emphasis on individualism, talking about oneself may be less stressful if there is less perceived pressure to demonstrate one’s uniqueness or importance. Future investigations could further explore cultural differences in social anxiety across different types of social situations or could confirm cross-cultural social anxiety heterogeneity by using approaches that are less heavily tied to determining social anxiety within given contexts (e.g., a diagnostic interview), as many of the commonly used measures appear to be [ 62 , 63 ].

Our findings also provide mixed support for investigations of other demographic differences in social anxiety. First, previous studies have tended to indicate that female participants score higher than males on measures of social anxiety [ 27 , 64 ]. Although the samples from Brazil and China reflected this, we found no difference between males and females in the overall sample, nor in samples from Indonesia, Russia, Thailand, US, or Vietnam. Sex-related differences in social anxiety have been attributed to gender differences, such as suggestions that girls ruminate more, particularly about relationships with others [ 65 , 66 ]. It is possible that as gender roles and norms vary between countries, and in some instances start to decline, so may differences in social anxiety, which younger generations are likely to reflect first. However, given the unexpected finding that males in Vietnam scored significantly higher than their female counterparts, further investigation is needed to account for the potentially culturally nuanced relationship between sex and social anxiety.

We also confirmed previous findings that higher levels of social anxiety are associated with lower levels of education and being unemployed. Although these findings are in-line with previous research [ 27 , 64 ], our study cannot shed light on causal mechanisms; longitudinal research is required to establish whether social anxiety leads individuals to struggle with school and work, whether struggling in these areas provokes social anxiety, or whether there is a more dynamic relationship.

Finally, we found that 18% of the sample could be classified as “false negatives”. This sizeable group felt they did not have social anxiety, yet their scores on the SIAS considerably exceeded the threshold for SAD. It has been said that SAD often remains undiagnosed [ 67 ], that individuals who seek treatment only do so after 15–20 years of symptoms [ 68 ], and that SAD is often identified when a related condition warrants attention (e.g., depression or alcohol abuse; Schneier [ 5 ]). It has also been reported that many individuals do not recognise social anxiety as a disorder and believe it is just part of their personality and cannot be changed [ 3 ]. Living with an undiagnosed or untreated condition can result in substantial economic consequences for both individuals and society, including a reduced ability to work and a loss of productivity [ 69 ], which may have a greater impact over time compared to those who receive successful treatment. Furthermore, the variety of avoidant (or “safety”) behaviours commonly associated with social anxiety [ 70 , 71 ] mean that affected individuals may struggle or be less able to function socially, and for young people at a time in their lives when relationships with others are particularly crucial [ 72 , 73 ], the consequences may be significant and lasting. Greater awareness of social anxiety and its impact across different domains of functioning may help more young people to recognise the difficulties they experience. This should be accompanied by developing and raising awareness of appropriate services and supports that young people feel comfortable using during these important developmental stages [see 30 , 74 ].

Study limitations

Our ability to infer reasons for the prevalence of SAD is hindered by the present data being cross-sectional, and therefore only allowing for associations to be drawn. We are also unable to confirm the number of clinical cases in the sample, as we did not screen for those who may have received a professional diagnosis of SAD, nor those who are receiving treatment for SAD. Additionally, the use of an online survey incorporating self-report measures incurs the risk of inaccurate responses. Further research could build on this investigation by surveying those in middle and older age to discover whether rates of social anxiety have also risen across other ages, or whether this increase is a youth-related phenomenon. Future investigations could also use diagnostic interviews and track individuals over time to determine the onset and progression of symptoms, including whether those who are subclinical later reach clinical levels, or vice versa, and what might account for such change.

On a global level, we report higher rates of social anxiety symptoms and the prevalence of those meeting the threshold for SAD than have been reported previously. Our findings suggest that levels of social anxiety may be rising among young people, and that those aged 18–24 may be most at risk. Public health initiatives are needed to raise awareness of social anxiety, the challenges associated with it, and the means to combat it.

Acknowledgments

The authors would like to acknowledge the role of Edelman Intelligence for collecting the original data on behalf of Unilever and CLEAR as part of their mission to support the resilience of young people.

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• Research article
• Open access
• 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.

Peer Review reports

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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Trevor Thompson

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Start2Stop Addictions Treatment Centre, London, SW7 3HG, UK

Christopher Marshall

University of Greenwich, London, SE9 2UG, UK

Melanie Sargeant

Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AF, UK

Brendon Stubbs

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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
• Social performance
• Social discomfort
• Sex differences

BMC Psychology

ISSN: 2050-7283

• General enquiries: [email protected]

RECENT ADVANCES IN SOCIAL ANXIETY RESEARCH

November 14, 2023

Dear Colleagues,

The National Social Anxiety Center (NSAC) provides information about relevant and current research in service of disseminating and promoting evidence-based treatment. This month’s summary is written by Annika Okamoto, PhD, A-CBT, representing NSAC Santa Barbara , and examines the 2023 article by Wolitzky-Taylor & LeBeau: Recent advances in the understanding and psychological treatment of social anxiety disorder.

The Wolitzky-Taylor and LeBeau’s article provides an overview of the current understanding and psychological treatment of social anxiety disorder (SAD). Key takeaways for clinicians include:

How is SAD best treated?

• The gold standard psychotherapy continues to be CBT in individual or group settings, but comparison studies of ACT and CBT show that they have comparable effects.
• Pharmacological interventions, particularly SSRIs, may also be helpful.

What other factors that coincide with SAD could be addressed in therapy to improve outcomes?

• Prior social trauma that involves humiliation and rejection,
• Envy (individuals with social anxiety experience higher levels of envy that predicts anxiety),
• Uncontrollable thoughts, rumination and perseverative cognition,
• Inattention and being more likely to feel distracted,
• Difficulties with inferring others’ emotional states and feelings, but not beliefs and intentions,
• Deriving less pleasure from social interactions (but still more than from nonsocial situations),
• Poor recall of positive social outcomes,
• Behavioral avoidance and safety behaviors,
• Intolerance of uncertainty and
• Delays in shifting attention away from social threats.

What do we know about SAD and other disorders?

• SAD contributes to worse educational performance across one’s life span.
• Later onset is associated with higher comorbidity and diminished quality of life.
• SAD symptom severity is correlated to depression and cannabis use disorder as adults.
• There is a direct relationship between the severity of negative psychotic symptoms and ideas of reference, and social anxiety. Meanwhile, the SAD in psychosis may be overlooked as less salient.
• Non-assertiveness seems to be a shared core for SAD and some other disorders, such as avoidant personality disorder.
• SAD research supports the interpersonal theory of suicide that posits that perceived burdensomeness and thwarted belongingness predict acute suicidal ideation (SI). In individuals with SAD, these factors predict acute SI better than effects of depression, and clinicians should evaluate them as risk factors.

What’s new in the assessment of SAD?

• There are two new measures that address the gaps left by other measures: 1) The Socially Anxious Rumination Questionnaire (SARQ) assessing rumination, and 2) the Ryerson Social Anxiety Scale (RSAS) measuring distress and impairment level.
• Machine-learning algorithms have shown promise in differential diagnosis of social difficulties such as SAD, autism spectrum disorder, and prodromal psychosis.

What does research evidence show about the treatment of SAD?

• “Does changing cognitions change behavior (traditional model), or does changing behavior change cognitions?” Research evidence points to behavior changing cognition. For example, exposure therapy works even without a focus on cognitive strategies.
• Mindfulness interventions and attention bias modification do not improve treatment outcomes.
• Decreases in social cost estimates during exposure are associated with better social anxiety outcomes. Targeting shame may contribute to progress.
• Self-guided digital therapies for SAD work but roughly 2/3rds drop out. People with SAD need individualized engagement strategies.
• Telehealth-based exposures can be as effective as in vivo exposures for public speaking.
• For people with SAD who use substances, clinicians should consider integrated treatments (i.e., exposure therapy + motivational interviewing); just targeting SAD alone is less effective.
• Changes in social anxiety symptoms may lead to improvement in depression if the depression symptoms are not too severe.
• People who have significant depression and SAD improve from SAD treatment more than non-depressed individuals. Thus, comorbidity does not equal treatment resistance.

Question for clinicians: Behavior impacts cognition and mood. What would your patient do differently if they were not anxious? Could you get their buy-in for a few weeks to do these things on a trial basis, to see how it affects their thoughts about themselves and the way they feel?

Wolitzky-Taylor, Kate, and LeBeau, Richard. Recent advances in the understanding and psychological treatment of social anxiety disorder . Faculty reviews , vol. 12, issue 8, April 2023. __

Annika Okamoto, PhD, A-CBT Representing NSAC Santa Barbara ( California Counseling Clinics )

Social anxiety and social anxiety disorder

Affiliation.

• 1 Department of Psychology, Temple University, Philadelphia, Pennsylvania 19122, USA. [email protected]
• PMID: 23537485
• 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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• Attention / physiology*
• Emotions / physiology*
• Models, Psychological*
• Phobic Disorders / physiopathology
• Phobic Disorders / psychology
• Phobic Disorders / therapy
• Self Concept*

• Frontiers in Psychology
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• Research Topics

Highlights in Psychology: Social Anxiety

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We are pleased to introduce the collection Highlights in Psychology: Social Anxiety. Social anxiety is a long-term and overwhelming fear of social situations. In particular, the fear stems from being judged and evaluated negatively by other people, leading to feelings of inadequacy, inferiority, ...

Keywords : Social anxiety, Cognition, Relationships, Mental health, Depression, Cultural differences, Emotions, Neurobiology

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• Review Article
• Published: 25 May 2021

Resting-state neuroimaging in social anxiety disorder: a systematic review

• Simone Mizzi   ORCID: orcid.org/0000-0002-3346-566X 1 ,
• Mangor Pedersen 2 ,
• Valentina Lorenzetti 3 ,
• Markus Heinrichs 4 , 5 &
• Izelle Labuschagne   ORCID: orcid.org/0000-0002-1590-0947 1  

Molecular Psychiatry volume  27 ,  pages 164–179 ( 2022 ) Cite this article

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• Neuroscience
• Psychiatric disorders

There has been a growing interest in resting-state brain alterations in people with social anxiety disorder. However, the evidence has been mixed and contested and further understanding of the neurobiology of this disorder may aid in informing methods to increase diagnostic accuracy and treatment targets. With this systematic review, we aimed to synthesize the findings of the neuroimaging literature on resting-state functional activity and connectivity in social anxiety disorder, and to summarize associations between brain and social anxiety symptoms to further characterize the neurobiology of the disorder. We systematically searched seven databases for empirical research studies. Thirty-five studies met the inclusion criteria, with a total of 1611 participants (795 people with social anxiety disorder and 816 controls). Studies involving resting-state seed-based functional connectivity analyses were the most common. Individuals with social anxiety disorder (vs. controls) displayed both higher and lower connectivity between frontal–amygdala and frontal–parietal regions. Frontal regions were the most consistently implicated across other analysis methods, and most associated with social anxiety symptoms. Small sample sizes and variation in the types of analyses used across studies may have contributed to the inconsistencies in the findings of this review. This review provides novel insights into established neurobiological models of social anxiety disorder and provides an update on what is known about the neurobiology of this disorder in the absence of any overt tasks (i.e., resting state). The knowledge gained from this body of research enabled us to also provide recommendations for a more standardized imaging pre-processing approach to examine resting-state brain activity and connectivity that could help advance knowledge in this field. We believe this is warranted to take the next step toward clinical translation in social anxiety disorder that may lead to better treatment outcomes by informing the identification of neurobiological targets for treatment.

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This work was supported by the Australian Government Research Training Program Scholarship (SM).

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Mizzi, S., Pedersen, M., Lorenzetti, V. et al. Resting-state neuroimaging in social anxiety disorder: a systematic review. Mol Psychiatry 27 , 164–179 (2022). https://doi.org/10.1038/s41380-021-01154-6

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Social anxiety disorder.

Gregory M. Rose ; Prasanna Tadi .

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• Continuing Education Activity

Social anxiety disorder (SAD) includes the essential feature of marked fear or anxiety of one or more social situations during which the individual may or may not be under scrutiny by others. Exposure to such a social situation almost always provokes fear or anxiety in the affected individual, and the individual experiences concern that they will be judged negatively. These individuals often avoid the social situations that they fear or endure with intense anxiety, which results in impairment in social, occupational, or other realms important to function in society. This activity describes the evaluation and treatment of social anxiety disorder and reviews the role of the interprofessional team in managing patients with this condition.

• Examine the etiology of social anxiety disorder.
• Assess the evaluation of social anxiety disorder.
• Differentiate the management options available for social anxiety disorder.
• Communicate interprofessional team strategies for improving care coordination and communication to educate patients and professionals about social anxiety disorder and improve outcomes.
• Introduction

Social anxiety disorder (SAD) is characterized by excessive fear of embarrassment, humiliation, or rejection when exposed to possible negative evaluation by others when engaged in a public performance or social interaction. It is also known as social phobia. Over fifty years ago, in 1966, social phobia was first differentiated from agoraphobia and specific phobias. Since then, the concept has transformed from a relatively rare and neglected condition to 1 recognized as prevalent worldwide. [1] The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 described social phobia in a way that limited the diagnosis due to exclusionary criteria, including those with an avoidant personality disorder, a new category at the time. 1985, that view was challenged, and by 1987, the  DSM-III-R removed the exclusion. In 1994, DSM-IV added the alternative name of SAD due to a recognition that social phobia could be differentiated from specific phobias due to important pathophysiological and clinical factors. With the publication of DSM-5 in 2013, SAD became the primary name. [2]  With the publication of DSM-5, the diagnostic criteria for SAD have been broadened from previous editions to include fear of acting in a way or showing anxiety symptoms that offend others or lead to rejection in addition to fear of humiliation or embarrassment. [3]  The latest edition of DSM also removed the generalized subtype and added the "performance only" specifier. [4]

Family and twin studies suggest that genetic factors' role as an etiological factor in SAD is believed to be largely dependent on environmental factors. [5]  Genetic markers have been difficult to identify. Parenting that is overly controlling or intrusive may result in inhibited temperament in children, increasing the risk for SAD. Adverse and stressful life events may also increase risk. A search for neurobiological factors associated with SAD has been largely non-specific. Advances in neuroimaging technology may increase insight into the disorder in the future. Recent evidence suggests an extended amygdala is an essential region in anxiety disorders. [1]

• Epidemiology

Epidemiological studies have shown that SAD has a worldwide prevalence of 5 to 10% and a lifetime prevalence of 8.4 to 15%. [6]  Prevalence rates are comparable within the United States. The prevalence rates in children and adolescents are similar to those of adults. SAD more commonly affects women than men. SAD is the third most common mental disorder behind substance use disorder and depression and is the most common anxiety disorder. [7]

• Pathophysiology

Studies in the past have found that persons with performance-type SAD may have a greater response to the autonomic nervous system, including elevated heart rate. [8] Additionally, multiple neurotransmitter systems, including serotonin, dopamine, and glutamate, may be implicated in the pathogenesis of SAD. [9] [10] Brain imaging of those with SAD reveals increased paralimbic and limbic circuitry activity. [11] Certain temperaments of toddlers and maternal stress have also been shown to be associated with persons who develop SAD. [12]

• History and Physical

The majority of individuals with SAD report the onset of symptoms before 20 years old when obtaining a history. Many report symptoms beginning in early childhood. Social anxiety is a chronic disorder, typically lasting for 6 months or more. Individuals with SAD are more likely to be less educated, unmarried, and have lower socioeconomic status. Additionally, many patients with SAD may not seek treatment because they believe the social anxiety to be part of their personality structure and, therefore, does not require treatment. [7]  Patients with SAD frequently present to physicians because of other disorders, including major depression or substance use and related disorders. [5]

Evaluation of SAD must include its diagnostic criteria as classified in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5). Criteria include pronounced fear or anxiety around 1 or multiple social situations where a person is possibly exposed to the possible scrutiny of others. The person fears they may act in a way that may be evaluated negatively. The social situation, for the most part, provokes anxiety or fear. The situations are either endured with anxiety or fear or avoided entirely. This fear or anxiety is disproportionate to the threat posed by the situation. The avoidance, fear, or anxiety typically lasts for at least 6 months and causes significant impairment or distress in an important area of functioning. The fear must not be attributable to the effects of a substance or medical condition or the symptoms of a different mental disorder. Additionally, the anxiety, avoidance, or fear is excessive or unrelated if a separate medical condition is present. There is a performance-only specifier if fear is restricted exclusively to performing or speaking in public.

A core feature of SAD is the fear of negative evaluation. Instruments that assess for SAD include but are not limited to the Social Phobia Inventory (SPIN), Mini-SPIN, Liebowitz Social Anxiety Scale (LSAS), Liebowitz Self-Rated Disability Scale, Disability Profile, Brief Social Phobia Scale (BSPS), and Social Phobia Safety Behaviors Scale and Self Statements During Public Speaking Scale. [13]  There is evidence that the items on SPIN capture multiple symptoms of SAD, including fear of negative evaluation, distress as a result of physical symptoms of anxiety, and the fear of uncertainty when in social situations. [14]  Patients with SAD may speak quietly or offer cursory answers to questions. In addition, eye contact is often less than normal. Often, individuals with SAD reveal their symptoms with direct questioning. [15]

• Treatment / Management

There is a large amount of evidence supporting the efficacy of medications and cognitive behavioral therapy (CBT) in SAD. [15]  According to meta-analysis, SAD responds well to treatment with individual CBT and selective serotonin reuptake inhibitors (SSRI). Additionally, serotonin-norepinephrine reuptake inhibitors (SNRIs) have a greater effect on outcomes than placebo. The SSRIs sertraline and paroxetine, as well as the SNRI venlafaxine, have been approved by the FDA. Comparing different psychotherapies, SAD responded better to CBT than psychodynamic therapy and other psychological therapies. The beta-blocker propranolol, as well as benzodiazepines, are also used in the treatment of SAD. Propranolol has the advantage of being used on an as-needed basis without the risk of developing dependence and tolerance, as exists with benzodiazepines. There is no evidence that combining pharmacological and psychological interventions is more efficacious than monotherapy. [16] A comparison of pharmacotherapy and psychotherapy trials suggests medication has faster effects, but CBT has longer-lasting effects. [15]

• Differential Diagnosis

SAD must be differentiated from other disorders, including neurodevelopment disorders such as autism spectrum disorder, panic disorder and agoraphobia, depressive disorders, substance-related and addictive disorders, body dysmorphic disorder, and personality disorders such as schizoid personality disorder and avoidant personality disorder. As indicated in the DSM-5 criteria, to make a diagnosis of SAD, the individual's symptoms must not be better explained by symptoms of another mental disorder. Other diagnoses to rule out include hikikomori, an extreme form of social withdrawal lasting more than 6 months, occurring among 1.2% of adults in Japan, and schizophrenia. [5]

Left untreated, SAD is recognized as a debilitating and highly prevalent disorder that may result in lower educational attainment, worse occupational performance, hampered social interaction, lower-quality relationships, and decreased quality of life. SAD is associated with suicidal ideation, low self-esteem, lower socioeconomic status, unemployment, financial issues, and being unmarried. Many individuals with SAD are not aware of their mental health problems and, therefore, do not seek treatment. [17] [18]

• Complications

Comorbid psychiatric disorders occur in up to 90% of patients with SAD. SAD's presence is a predictor for the development of major depression and alcohol use disorder. Patients who have comorbid psychiatric disorders have an increased likelihood of greater severity of symptoms, treatment resistance, decreased functioning, and increased rates of suicide. [6]  

• Deterrence and Patient Education

Many patients with SAD do not realize they have a treatable illness and, therefore, do not seek treatment. Patient education, including public education, is essential to treating and preventing this disorder. [7]

• Enhancing Healthcare Team Outcomes

As discussed, educating patients and the public is vital to managing and preventing SAD. Recognition of SAD is poor and requires more effort from healthcare professionals to recognize it, as individuals with the disorder are unlikely to self-report it due to their symptoms. SAD is the third most common mental illness, affecting a significant proportion of the general population in their lifetimes. An important role of a primary care physician is to recognize the illness and either treat the disorder themselves or refer to a mental health specialist who has experience with the condition. [19]  Evidence shows that SAD is highly treatable with either cognitive behavioral therapy (CBT) or pharmacotherapy in the form of SSRIs and SNRIs or beta-blockers. [16]

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Social Anxiety Disorder: More Than Just Shyness

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Are you afraid of being judged by others? Are you self-conscious in everyday social situations? Do you avoid meeting new people due to fear or anxiety? If you have been feeling this way for at least 6 months and these feelings make it hard for you to do everyday tasks—such as talking to people at work or school—you may have social anxiety disorder.

Social anxiety disorder is an intense, persistent fear of being watched and judged by others. This fear can affect work, school, and other daily activities. It can even make it hard to make and keep friends. The good news is social anxiety disorder is treatable. Learn more about the symptoms of social anxiety disorder and how to find help.

What is social anxiety disorder?

Social anxiety disorder is a common type of anxiety disorder. A person with social anxiety disorder feels symptoms of anxiety or fear in situations where they may be scrutinized, evaluated, or judged by others, such as speaking in public, meeting new people, dating, being on a job interview, answering a question in class, or having to talk to a cashier in a store. Doing everyday things, such as eating or drinking in front of others or using a public restroom, also may cause anxiety or fear due to concerns about being humiliated, judged, and rejected.

The fear that people with social anxiety disorder have in social situations is so intense that they feel it is beyond their control. For some people, this fear may get in the way of going to work, attending school, or doing everyday things. Other people may be able to accomplish these activities but experience a great deal of fear or anxiety when they do. People with social anxiety disorder may worry about engaging in social situations for weeks before they happen. Sometimes, they end up avoiding places or events that cause distress or generate feelings of embarrassment.

Some people with the disorder do not have anxiety related to social interactions but have it during performances instead. They feel symptoms of anxiety in situations such as giving a speech, competing in a sports game, or playing a musical instrument on stage.

Social anxiety disorder usually starts during late childhood and may resemble extreme shyness or avoidance of situations or social interactions. It occurs more frequently in females than in males, and this gender difference is more pronounced in adolescents and young adults. Without treatment, social anxiety disorder can last for many years, or even a lifetime.

What are the signs and symptoms of social anxiety disorder?

When having to perform in front of or be around others, people with social anxiety disorder may:

• Blush, sweat, or tremble.
• Have a rapid heart rate.
• Feel their “mind going blank,” or feel sick to their stomach.
• Have a rigid body posture, or speak with an overly soft voice.
• Find it difficult to make eye contact, be around people they don’t know, or talk to people in social situations, even when they want to.
• Feel self-consciousness or fear that people will judge them negatively.
• Avoid places where there are other people.

What causes social anxiety disorder?

Risk for social anxiety disorder may run in families, but no one knows for sure why some family members have it while others don’t. Researchers have found that several parts of the brain are involved in fear and anxiety and that genetics influences how these areas function. By studying how the brain and body interact in people with social anxiety disorder, researchers may be able to create more targeted treatments. In addition, researchers are looking at the ways stress and environmental factors play a role in the disorder.

How is social anxiety disorder treated?

If you’re concerned you may have symptoms of social anxiety disorder, talk to a health care provider. After discussing your history, a health care provider may conduct a physical exam to ensure that an unrelated physical problem is not causing your symptoms. A health care provider may refer you to a mental health professional, such as a psychiatrist, psychologist, or clinical social worker. The first step to effective treatment is to get a diagnosis, usually from a mental health professional.

Social anxiety disorder is generally treated with psychotherapy (sometimes called “talk therapy”), medication, or both. Speak with a health care provider about the best treatment for you.

Psychotherapy

Cognitive behavioral therapy (CBT), a research-supported type of psychotherapy, is commonly used to treat social anxiety disorder. CBT teaches you different ways of thinking, behaving, and reacting to situations to help you feel less anxious and fearful. CBT also can help you learn and practice social skills, which is very important for treating social anxiety disorder. CBT has been well studied and is the gold standard for psychotherapy.

Exposure therapy is a CBT method that focuses on progressively confronting the fears underlying an anxiety disorder to help you engage in activities you have been avoiding. Exposure therapy is sometimes used along with relaxation exercises. CBT delivered in a group therapy format also can offer unique benefits for social anxiety disorder.

Another treatment option for social anxiety disorder is acceptance and commitment therapy (ACT). ACT takes a different approach than CBT to negative thoughts and uses strategies such as mindfulness and goal setting to reduce your discomfort and anxiety. Compared to CBT, ACT is a newer form of psychotherapy treatment, so less data are available on its effectiveness. However, different therapies work for different types of people, so it can be helpful to discuss what form of therapy may be right for you with a mental health professional.

For more information on psychotherapy, visit the National Institute of Mental Health (NIMH) psychotherapies webpage .

Health care providers may prescribe medication to treat social anxiety disorder. Different types of medication can be effective in treating this disorder, including:

• Antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs)
• Beta-blockers
• Anti-anxiety medications, such as benzodiazepines

SSRI and SNRI antidepressants are commonly used to treat depression, but they also can help treat the symptoms of social anxiety disorder. They may take several weeks to start working. Antidepressants may also cause side effects, such as headaches, nausea, or difficulty sleeping. These side effects are usually not severe, especially if the dose starts off low and is increased slowly over time. Talk to your health care provider about any side effects that you may experience.

Beta-blockers can help control some of the physical symptoms of social anxiety disorder, such as rapid heart rate, sweating, and tremors. Beta-blockers are commonly the medication of choice for the “performance anxiety” type of social anxiety disorder.

Benzodiazepines, which are anti-anxiety sedative medications, are powerful and begin working right away to reduce anxious feelings. These medications can be very effective in rapidly decreasing anxiety, but some people build up a tolerance to them and need higher and higher doses to get the same effect. Some people even become dependent on them. Therefore, a health care provider may prescribe them only for brief periods of time if you need them.

Both psychotherapy and medication can take some time to work. Many people try more than one medication before finding the best one for them. A health care provider can work with you to find the best medication, dose, and duration of treatment for you. People with social anxiety disorder usually obtain the best results with a combination of medication and CBT or other psychotherapies.

For basic information about these and other mental health medications, visit NIMH’s Mental Health Medications webpage . Visit the U.S. Food and Drug Administration (FDA) website  for the latest warnings, patient medication guides, and information on newly approved medications. 

Support Groups

Many people with social anxiety find support groups helpful. In a group of people who all have social anxiety disorder, you can receive unbiased, honest feedback about how others in the group see you. This way, you can learn that your thoughts about judgment and rejection are not true or are distorted. You also can learn how others with social anxiety disorder approach and overcome the fear of social situations.

Support groups are available both in person and online. However, any advice you receive from a support group member should be used cautiously and does not replace treatment recommendations from a health care provider.

Both psychotherapy and medication can take some time to work. A healthy lifestyle also can help combat anxiety. Make sure to get enough sleep and exercise, eat a healthy diet, and turn to family and friends who you trust for support. To learn more ways to take care of your mental health, visit NIMH’s Caring for Your Mental Health webpage .

How can I support myself and others with social anxiety disorder?

Educate yourself.

A good way to help yourself or a loved one who may be struggling with social anxiety disorder is to seek information. Research the warning signs, learn about treatment options, and keep up to date with current research.

Communicate

If you are experiencing social anxiety disorder symptoms, have an honest conversation about how you’re feeling with someone you trust. If you think that a friend or family member may be struggling with social anxiety disorder, set aside a time to talk with them to express your concern and reassure them of your support.

Know When to Seek Help

If your anxiety, or the anxiety of a loved one, starts to cause problems in everyday life—such as avoiding social situations at school, at work, or with friends and family—it’s time to seek professional help. Talk to a health care provider about your mental health.

Are there clinical trials studying social anxiety disorder?

NIMH supports a wide range of research, including clinical trials that look at new ways to prevent, detect, or treat diseases and conditions—including social anxiety disorder. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct clinical trials with patients and healthy volunteers. Talk to a health care provider about clinical trials, their benefits and risks, and whether one is right for you. For more information, visit NIMH's clinical trials webpage .

Finding Help

Behavioral health treatment services locator.

This online resource, provided by the Substance Abuse and Mental Health Services Administration (SAMHSA), helps you locate mental health treatment facilities and programs. Find a facility in your state by searching SAMHSA’s online Behavioral Health Treatment Services Locator  . For additional resources, visit NIMH's Help for Mental Illnesses webpage .

Talking to a Health Care Provider About Your Mental Health

Communicating well with a health care provider can improve your care and help you both make good choices about your health. Find tips to help prepare for and get the most out of your visit at Taking Control of Your Mental Health: Tips for Talking With Your Health Care Provider . For additional resources, including questions to ask a provider, visit the Agency for Healthcare Research and Quality website  .

If you or someone you know is in immediate distress or is thinking about hurting themselves, call the National Suicide Prevention Lifeline toll-free at 1-800-273-TALK (8255). You also can text the Crisis Text Line (HELLO to 741741) or use the Lifeline Chat on the National Suicide Prevention Lifeline website  .

The information in this publication is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

For More Information

MedlinePlus  (National Library of Medicine) ( en español  )

ClinicalTrials.gov  ( en español  )

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES  National Institutes of Health NIH Publication No. 22-MH-8083 Revised 2022

Social anxiety: topics and emotions shared on Reddit before and during the coronavirus pandemic

• Published: 11 April 2024
• Volume 43 , pages 26608–26617, ( 2024 )

Cite this article

• Viktoriya Manova   ORCID: orcid.org/0000-0002-6264-1853 1 ,
• Francesca Grosso 2 , 3 ,
• Bassam Khoury 1 &
• Francesco Pagnini 2  

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Social media platforms such as Reddit allow users to share information and find support about different topics. The present research investigated the topics, sentiments, and emotions discussed in a subreddit about social anxiety prior to and during the COVID-19 pandemic. Latent Dirichlet Allocation (LDA) was used to discover latent topics from the data. Sentiment and emotion analyses were performed on the posts and comments associated with each topic. Two-proportions z-tests were computed to investigate whether the percentage of positive, negative, and neutral sentiments expressed in posts and comments for each topic differed between the period prior to and during COVID-19. Thirteen topics about social interactions, coping mechanisms, and physiological and cognitive aspects of social anxiety emerged: (1) Miscellaneous, (2) Interacting with others, (3) Family and time, (4) Medication and receiving help, (5) Physical features and appearance, (6) At work, (7) Physical sensations and cognitive aspects, (8) School activities, (9) Dating, (10) Communicating and asking questions, (11) Social media, (12) Stressful behaviors, and (13) Substances. There was no difference in the sentiment of posts and comments between the two time periods, with the exception of a few topics for which there were more neutral comments and fewer positive comments prior to the pandemic. The three most prominent emotions expressed were anticipation, trust, and fear. These findings inform on the topics discussed in an online community about social anxiety, and on differences in the sentiment expressed about those topics prior to and during the pandemic. Future research can investigate causal associations between the COVID-19 pandemic and online discussions about social anxiety, as well as the clinical implications of interacting in such online communities for individuals struggling with social anxiety.

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Manova, V., Grosso, F., Khoury, B. et al. Social anxiety: topics and emotions shared on Reddit before and during the coronavirus pandemic. Curr Psychol 43 , 26608–26617 (2024). https://doi.org/10.1007/s12144-024-05891-z

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Fear of missing out may be based on concerns about future relationships, especially for those with social anxiety

by Sarah Magnus-Sharpe, Cornell University

Worrying about the consequences of missing group activities, especially when they involve social bonding, heightens the "fear of missing out," or FOMO, according to new research from the Cornell SC Johnson College of Business.

FOMO is the perception that others are living more fulfilling lives or having more fun, and it has gained attention with the rise of activity on social media platforms . As many as 69% of Americans have experienced a fear of missing out at some point in their lives, according to a study by OnePoll.

The paper is published in the Journal of Personality and Social Psychology .

The study found that a fear of missing out is driven by worries about possible negative impacts on future relationships, such that one's friends will withdraw or even purposely exclude them. They also found that those who already possess social anxiety were particularly vulnerable.

The researchers also find that FOMO stems from missing opportunities to bond with valued social groups, not with strangers or irrelevant social groups .

"FOMO is not about the missed event per se: If we miss a group dinner at a restaurant, we're not really upset about the missed food and drink. What we're upset about is the fact that we missed the chance to bond, connect and make memories. FOMO," said Jacqueline Rifkin, assistant professor at the Samuel Curtis Johnson Graduate School of Management and co-author of the paper titled "Anxiety About the Social Consequences of Missed Group Experiences Intensifies FOMO (the Fear of Missing Out)."

Rifkin's co-authors include Cindy Chan, assistant professor at the Rotman School of Management, University of Toronto; and Barbara Kahn, professor at the Wharton School. In a series of seven experiments involving more than 5,000 people, they observed real, recalled and imagined FOMO when people miss such events as concerts, retreats or general social gatherings.

One experiment found that if you miss a big event such as a concert by your favorite performer, but your social group isn't there, that triggers some FOMO, but not very much. The FOMO is amplified by the prospect of your social group being there.

Similarly, another experiment found that if you missed a special event with friends, but they didn't do much social bonding , such as if the event was very individualized or focused on solo meditation, this also wouldn't trigger much FOMO.

At the same time, it meant that missed events that are unpleasant but involve a lot of social bonding—completing a stressful initiation challenge or consoling a sad friend—can trigger quite a bit of FOMO.

The study revealed that being unable to partake in social bonding with people who matter to us creates anxieties about negative ramifications for relationships. One study found that witnessing friends connecting, making memories, or getting closer to one another on social media plants seeds of worry. The person who missed out may fear they are viewed as not involved enough or not able to keep up, and that they may someday be excluded from the group altogether.

Based on the knowledge from the studies, the researchers believe there are ways to combat FOMO.

One experiment found that after seeing social missed posts of missed social events , those who spent a moment reflecting on prior bonding experiences did not experience nearly as much FOMO.

"This suggests that reminding oneself of the meaningful relationships we already have can help mitigate the anxiety surrounding missing out," Rifkin said.

The researchers also found that people with higher levels of social anxiety or a greater need for social connection are more prone to experiencing FOMO. These individuals are more likely to worry excessively about the social costs of missing events, which can lead to compulsive behaviors such as constantly checking social media for updates. Continuously checking on what others are doing on social media can create a perception that one's peers are constantly engaging in socially bonding activities, further intensifying feelings of anxiety.

"FOMO has significant implications for mental health. It has been linked to reduced well-being, compulsive smartphone use, and even distracted driving," Rifkin said. Addressing FOMO is crucial in the context of the ongoing mental health crisis and the so-called "loneliness epidemic," she explained.

The research suggests that FOMO is not just a phenomenon affecting young social media users; it can impact anyone in a valued social group. This insight broadens a common understanding of FOMO and highlights the importance of social bonding. By identifying what specifically triggers and amplifies FOMO, this research paves the way for future research to design and test coping techniques and strategies.

"Developing strategies that help us challenge our beliefs about the negative consequences of missing out could potentially help," Rifkin said. "For instance, based on our results, encouraging individuals to engage in mindfulness practices and focus on the strong relationships we currently have could be one way to stave off FOMO. Ultimately, reminding ourselves that we belong, and not getting carried away with what could happen to us, can help."

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Cross-Cultural Psychology

How "urgency culture" contributes to anxiety and stress, a culture that extolls the virtues of busyness can lead us to feel stressed..

Posted October 21, 2024 | Reviewed by Devon Frye

• A culture of urgency leaves little room for joy in the moment, healthy balance, or time to rest.
• If we are always in a state of urgency, our minds and bodies respond by functioning on overdrive.
• Challenging rigid cultural definitions of productivity can help us to find a healthier balance.

The idea that we live in a culture of urgency can help us to frame why so many people report struggling with anxiety and worry. If we are always in a state of movement, our minds respond by overthinking and our bodies by overproducing cortisol, the naturally-occurring stress hormone . This recipe leads to persistent anxiety, stress, overwhelm, and worry.

Urgency culture can mean anything from unhealthy relationships with our jobs to pushing ourselves despite feeling exhausted to overscheduling our lives and not allowing ourselves to say “no.” The following are some of the ways that our culture stresses urgency and how these imaginary rules contribute to feelings of anxiety.

Misdefining “Productivity”

There are many myths surrounding the concept of “ productivity .” Who can truly define what it means to be productive? Does it mean we are unproductive unless there is a tangible result to our actions? Or that if we are not busy, we are not productive? The answer is open to interpretation.

Through this lens, we can redefine what productivity means for us uniquely. Many of the cultural “rules” about productivity are ripe for reassessment—for instance, the idea that anything less than a 40-hour work week is unproductive or the belief that we should be available to our jobs 24/7. When we fixate on being productive, we unwittingly push ourselves beyond our limits and throw our nervous systems into a state of overdrive. Accepting that it is OK to engage in activities that do not necessarily produce a tangible “result” is a radical shift from the narrative of urgency, but one that can result in a healthier life balance and a more realistic definition of productivity.

Stigmatizing Rest

In a culture of urgency, rest and relaxation are often misguidedly viewed as idleness or laziness. We have, however, tons of scientific research to back up the idea that rest, leisure, and self-care are actually vital to our health.

Without them, we simply run ourselves, our minds, and our bodies into the ground and the results can be catastrophic. Burnout is real and if we are not mindful of our daily functioning, we can quickly become burned out , which can have severe consequences for our minds and bodies. Destigmatizing rest and self-care is an important way to challenge some of the unhelpful and unrealistic messages of urgency culture.

Fixating on Perfectionism

Perhaps you have heard the saying, “Perfect is the enemy of good.” Nowhere is this more accurate than within a culture that extolls the virtues of busyness and repeats the message that anything short of “exactly right” is not good enough.

When we strive for perfection, we become stuck—like an artist who never completes a painting because he is unable to allow the work to be finished or “good enough”; he fixates and agonizes over each line, shade, and brushstroke. Letting go of perfectionism allows us to be “good,” to do well, and to balance our lives in a healthy way.

Misprioritizing Our Lives

Urgency culture often causes us to unknowingly prioritize our lives in ways that are not actually aligned with what we value.

Imagine a person who loves her family but places her job at the top of her priority list. Authentically, her family is her priority, but cultural rules cause her to mis-prioritize what is truly important to her. This leads her to focus more on her job than she wishes to, to miss out on important family experiences, and to feel stressed and anxious about making the various components of her life fit.

We cannot argue that our culture is one in which urgency is often seen as not only a virtue but also a requirement. Unfortunately, this way of looking at our lives leaves little room for joy in the moment, healthy balance, or time to rest. Challenging the imaginary rules of urgency culture can help us to live healthier, less stressful lives.

Phil Lane, MSW, LCSW, is a psychotherapist in private practice and the author of the book Understanding and Coping with Illness Anxiety.

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