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Thisbook weaves together research findings gathered by renowned minds acrossvarious disciplines, and chapters deal with both theory and research. Thorough exploration is given as to how to define what constitutes social anxiety, assessment of the condition and its relationship to other psychological disorders, the biological basis, and treatment approaches are all explored in full. Coverage includes key issues not discussed fully by other existing books, including related disorders of adult and childhood, relationship to social competence and assertiveness, relationship to perfectionism, social skills deficit hypothesis, comparison between pharmacological and psychosocial treatments, and potential mediators of change in the treatment of social anxiety disorder.
Daniel W. McNeil Anxiety, Psychophysiology, and Pain Research Laboratory, Department of Psychology, West Virginia University, Morgantown, WV 26506
Unpleasant emotional states and nonadaptive behaviors associated with social situations have historically been known as significant, life-affecting problems for many people. Given the social nature of human beings, and the functional nature of social relationships (e.g., social support), discomfort associated with interacting with others is particularly difficult, as socialization cannot be easily avoided, unlike other anxiety problems such as some phobias. Social anxieties and fears were described by Hippocrates and began to be systematically delineated with other phobias in the 1870s (Marks, 1970, 1985). In the recent past, the social psychological focus on shyness (e.g., Zimbardo, 1977), the work of Marks and others in the 1960s and 1970s, and the identification of social phobia (SP) as a distinct disorder in the Diagnostic and statistical manual of mental disorders (DSM)–III (e.g., American Psychiatric Association, 1980) and subsequent revisions, heralded a massive growth in the related scientific and self-help literatures.
This general arena of problems likely includes several somewhat overlapping constructs; the scientific language has many different terms that apply or relate, including shyness, social anxiety, social withdrawal, SP, social anxiety disorder (SAD), behavioral inhibition (BI), communication apprehension, and introversion. In both everyday and scientific language, these states have been described in a myriad of ways. Leitenberg (1990, p.2), in introducing his book on the area, states:
Social anxiety has been studied in various guises. Shyness, performance anxiety, social phobia, avoidant personality disorder, social withdrawal, social isolation, public speaking anxiety, speech anxiety, communication apprehension, fear of interpersonal rejection, dating anxiety, separation anxiety, stage fright, fear of strangers, shame, embarrassment, social inhibition, social timidity — all of these and more fall under the umbrella of social anxiety.
Other anxiety-related syndromes, such as test anxiety and selective mutism, also likely have a strong social component, and may be instantiations of SAD (Bögels et al., 2010). Body dysmorphic disorder (BDD), highly comorbid with SAD, similarly is socially determined, at least in part, in that the perception of others regarding (imagined) defects may be an underlying feature.
There also are a variety of terms that suggest, at least in part, deficient social skills, such as "nerd," "geek," and "wallflower." Masia and Morris (1998) identify terms related to social distress in children across areas of psychology: developmental (i.e., peer neglect, social withdrawal), personality (i.e., shyness),and clinical (i.e., SP, avoidant personality disorder (APD)). Stranger anxiety and separation anxiety likely are related constructs as well (Thompson & Limber, 1990). Masia and Morris note that this varying "psychological language" (p. 212) creates problems in investigating phenomena (e.g., parental behavior and its relation to child social anxiety) that spans across subdisciplines in psychology, and presumably across related disciplines (e.g., psychiatry).
It should be noted that comparative psychology has contributions to this area as well. Social anxieties are not solely human phenomena; such social/ emotional problems are shared by other primates (Mineka & Zinbarg, 1995; Suomi, 1997) and lower animals. Social dominance and submissiveness hierarchies have been suggested as important as determinants of socially anxious behavior across species of primates, including humans (Schneier & Welkowitz, 1996; Trower & Gilbert, 1989). Facial expressions, for example, provide important social interactional cues in both humans and other primates, including both aggression and appeasement related to anxiety (Öhman, 1986).
One of the issues that is an albatross for the field concerns the everyday language basis of the most frequently used terms: shyness, stage fright, and social anxiety. Some years ago, Harris (1984) detailed a number of problems inherent in using the lay language of "shyness" in scientific discourse, problems that still exist today. Clinically oriented scientists may try to "distance" SAD from shyness, perhaps to emphasize that individuals who meet criteria for the disorder suffer with impairment in social and occupational functioning that can be quite terrible, leading to chronic misery. Adding further complexity, some degree of social anxiety can be adaptive (Schneier & Welkowitz, 1996). Moreover, the social consequences of some socially anxious behaviors are quite positive. One example is a "bashful" child who hides his face by planting it directly in some part of one of his parents' bodies, resulting in adult laughter and encouragement to socialize. A further example is a distant, detached person who is regarded as "coy," "interesting," or even "mysterious" (or conversely, as "stuck up") as a result of their lack of social initiation or response.
This chapter provides a perspective on conceptual, definitional, and diagnostic nosology issues for the field. It is proposed that social anxieties and fears, like other phobic disorders, exist along a continuum across the general population, as explicated later in this chapter and as shown in Figure 1.1. The range of social anxieties/fears along this continuum is from no anxiety/fear to "normal" levels to psychopathological extremes. The debate (e.g., Campbell-Sills & Stein, 2005; Wakefield, Horowitz, & Schmitz, 2005a; Wakefield, Horowitz, & Schmitz, 2005b) on "overpathologizing" socially anxious people then may be somewhat addressed by a conceptualization that acknowledges both "normal" social anxieties that are mildly to moderately intense, or transient, and also their potential connectedness to SAD, depending on potentially contributing environmental and individual factors.
This chapter also reviews the evolution of constructs important to the area. Finally, it re-emphasizes the need for a multidisciplinary approach to studying and understanding distress and dysfunction related to social situations. This chapter, similarly to other work (Masia & Morris, 1998), uses the term "social anxiety" in an attempt to broadly encompass the various constructs emanating from the various disciplines and subdisciplines. Given the recognized differences between anxiety and fear states generally (Bouton, Mineka, & Barlow, 2001; McNeil, Turk, & Ries, 1994), the term "social fear" is incorporated into this lexicon and will be further elaborated in this chapter. Consistently with the evolving literature (Bögels et al., 2010), the term "social anxiety disorder" (SAD) (and, more properly, in the plural to emphasize the heterogeneity of problems in this area) is used to describe psychopathological levels of such anxieties or fears, although "SP" is used when describing historical designations.
OVERLAPPING AND CONTRASTING EMOTIONAL STATES
Anxiety and fear are not "lumps" (Lang, 1968) and are not, in and of themselves, disease states. Rather, they exist along continua across the population. At the extreme, high levels of social fears and anxiety are psychopathological, and can be classified as clinical syndromes such as SAD. Depending on the type of anxiety or fear, as well as other factors such as gender (Craske, 2003), the distributions vary.
Figure 1.2 illustrates the distributions of general social anxiety based on Social Avoidance and Distress Scale (SADS; Watson & Friend, 1969) scores of 477 male (n = 214) and female (n = 263) university undergraduates. The mean age of the sample was 19.9 (SD 3.1). Score distributions also are provided for specific public speaking fear using the Personal Report of Confidence as a Speaker scale (PRCS; Paul, 1966) for these same individuals. The SADS distribution is positively skewed toward lower scores, which are associated with less anxiety, but kurtosis was unremarkable (skewness and kurtosis coefficients are 0.79 and -0.39, respectively). In contrast, the PRCS is more normally distributed, but has a rectangular distribution in which each score has the same frequency of occurrence (skewness and kurtosis coefficients are -0.04 and -1.1, respectively).
Self-reported social fears and anxieties are unique in that females and males typically differ less (or not at all), unlike many other types of anxiety and fear, in which females report higher scores and males report lower ones (Craske, 2003). In fact, it has been suggested that there may be a higher incidence of a social skill deficit type of SP in males, while other types of the syndrome may be displayed equally between the sexes (Marks, 1985), although the literature is equivocal in this regard. Given the size of the present sample, substantively small differences (i.e., less than 2 points on 28- and 30-item scales) were statistically significant. The varying directionality of the sex differences, however, is interesting. For general social anxiety measured by the SADS, males (M = 9.9, SD = 7.3) had higher scores, indicating more anxiety, than females (M = 8.4, SD = 6.3), t(475) = 2.40, > p 0.05. Conversely, for specific public speaking fear on the PRCS, females (M = 16.2, SD = 7.7) indicated more anxiety than males (M = 14.8, SD = 7.6), t(475) = 1.97, p < 0.05. These differences provide suggestive evidence of the differences between general social anxieties and specific public speaking fears. While there may be differences in SADS and PRCS total scores between the sexes, the shape of the distributions were relatively consistent, except for kurtosis on the SADS, as evidenced by coefficients for skewness (SADS: males = 0.60 and females = 0.95; PRCS: males = -0.02 and females = -0.06) and kurtosis (SADS: males = -0.79 and females = 0.06; PRCS: males = -1.1 and females = -1.0).
These unique features of public speaking fear as measured by the PRCS, relative to general social anxieties, are consistent with prior research (Klorman, Weerts, Hastings, Melamed, & Lang, 1974) that compared the PRCs to other specific-fear questionnaires, although not a general social anxiety instrument. The different distribution shapes for the SADS and PRCS are interesting, particularly since general social anxiety and public speaking fear seem intrinsically related. Regardless of the distribution shapes, these data clearly demonstrate that both general social anxiety and public speaking fear exist along continua, albeit different ones, in a general population. The more normal distribution of public speaking fear scores, with a greater number of individuals at the right tail of the distribution (associated with higher scores and greater anxiety), is consistent with reports of their high prevalence in the general population, relative to general social anxiety (Kessler, Stein, & Berglund, 1998; Pollard & Henderson, 1988; Stein, Torgrud, & Walker, 2000).
Not only do social anxieties and fears exist across the general population, but significant features of social anxiety are present across various psychological disorders, including but not limited to anxiety disorders in addition to SAD. The comorbidity of anxiety disorders with one another is well documented (Barlow, 2002) and argues for a more dimensional classification scheme. High levels of social anxiety, and perhaps other anxieties, also exist across clinical syndromes such as schizophrenic disorders, affective disorders, and substance use disorders (Hall & Goldberg, 1977).
In 1966, Marks and Gelder described patients with "social anxieties" as having "phobias of social situations, expressed variably as shyness, fears of blushing in public, of eating meals in restaurants, of meeting men or women, of going to dances or parties, or of shaking when the center of attention" (p. 218). A few years later, Marks (1970) further elucidated the classification of "SPs," distinguishing them from animal phobias and agoraphobia. He noted that the SP group of patients had "fears of eating, drinking, shaking, blushing, speaking, writing or vomiting in the presence of other people" (p. 383). Even at that point, however, Marks noted that "We need to know more about social phobics before definitely classifying them on their own" (p. 383). From these early scientific descriptions has grown a myriad of definitions; the evolution of our understanding of SAD continues with the recommended changes for the forthcoming DSM–V (Bögels et al., 2010; Lewis-Fernandez et al., 2010).
Most researchers in Western nations adopt the most current DSM definition (e.g., DSM-IV-TR, American Psychiatric Association, 2000). Presently, that definition includes, as an essential feature, "clinically significant anxiety provoked by exposure to certain types of social or performance situations, often leading to avoidance behavior" (American Psychiatric Association, 2000, p.429); it is further described in the next section. Aside from this definition, there is little consensus in the field, either about the definitions themselves or the underlying constructs. In each of the other areas, a different label (describing a slightly different construct) is used, with a correspondingly different definition. In fact, even within subdisciplines, there are different definitions depending on the model from which the researcher is working.
DIAGNOSTIC NOSOLOGY CLASSIFICATIONS
SP first was recognized as a separate diagnostic entity in the DSM system with the advent of DSM-III (American Psychiatric Association, 1980). DSM-II (American Psychiatric Association, 1968), for example, did not even specifically mention SPs under the phobic neurosis category. Nor was APD specifically detailed in that DSM version. In DSM-III, however, there were two fairly simple sets of criteria for SP, and an exclusionary category. Both fear and a desire to avoid were required in the first set of criteria. Significant distress and a recognition of the excess or unreasonableness of the fear were both necessary for the second criteria set. DSM-III descriptions implied that SP had discrete manifestations in one of four areas: public speaking/performing, using public bathrooms, eating in public, and writing in front of others. APD was one of the exclusionary criteria for SP, so patients might meet criteria for both disorders but only could be diagnosed with APD, thus making it the more predominant categorization. Children and adolescents with psychopathological social anxiety typically would be diagnosed with avoidant disorder of childhood or adolescence (AVD), which was in the DSM categorization of disorders usually first evident in infancy, childhood, or adolescence. There were, however, no stated criteria that would specifically prohibit diagnosis of a child or adolescent with SP. Conversely to adult classification, if the patient was under 18 years old, AVD was an exclusionary criterion for APD, and so took precedence over it.
The publication of DSM-III-R (American Psychiatric Association, 1987) represented a significant shift in the conceptualization of SP as a syndrome. In addition to a greater number of separate diagnostic criteria, and more specificity in these criteria, a generalized type of SP was allowed as a specifier "if the phobic situation includes most social situations" (p. 243), although it was noted that the disorder could be circumscribed. Also, APD was allowed as a comorbid diagnosis with SP. AVD was a formal exclusionary diagnosis for SP in individuals under age 18.
In DSM-IV (American Psychiatric Association, 1994), the SP diagnosis was slightly changed once again. For the first time, the term "SAD" was parenthetically listed along with "SP," apparently representing a conceptual shift to differentiate it from other phobic disorders. Perhaps this evolving change could also help in discriminating the extreme of psychopathological behaviors from "normal" social anxieties that affect most people in certain situations. In DSM-IV, AVD was subsumed into the SP diagnosis.
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1. Terminology and Evolution of Constructs 2. Assessment of Social Anxiety and Its Clinical Expressions 3. Shyness, Social Anxiety, and Social Anxiety Disorder 4. Embarrassment and Social Anxiety: Distant Cousins or Close Kin? 5. Social Anxiety Disorder and its Relationship to Perfectionism 6. Social Anxiety Disorder as a Deficit in Social Skills . Social Anxiety Disorder and Its Relationship to Clinical Syndromes in Adulthood 8. The Relationship of Social Anxiety Disorder to Avoidant Personality Disorder 9. The Development and Clinical Impact of Social Anxiety Disorder in Children and Adolescents 10. Neuroendocrinology and Neuroimaging Studies in Social Anxiety Disorder
11. Genetic Basis of Social Anxiety Disorder 12. Temperamental Contributions to Affective and Behavioral Profiles in Childhood 13. Behavioral Theories of Social Anxiety Disorder: Contributions of Basic Behavioral Principles 14. Cognitive biases in Social Anxiety Disorder 15. Social Anxiety Disorder: An Information-Processing Perspective 16. An Integrated Cognitive-Behavioral Model of Social Anxiety 17. Social Anxiety Disorder and the Self
18. Social Anxiety as an Early Warning System: A Refinement and Extension of the Self-Presentation Theory of Social Anxiety 19. Psychopharmacology 20. Treatment of Social Anxiety Disorder: A Treatments-by-Dimensions Review 21. Comparison between pharmacological and psychosocial treatments 22. Mechanisms of Action in the Treatment of Social Anxiety Disorder 23. Summary and Future Directions