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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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Social Anxiety and Its Maintaining Factors: Accounting for the Role of Neuroticism

• Open access
• Published: 12 April 2023
• Volume 45 , pages 469–479, ( 2023 )

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• Caitlin A. Clague 1 &
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Models of social anxiety disorder (SAD) and research indicate several cognitive and behavioural maintaining factors that perpetuate social anxiety (i.e., maladaptive social-evaluative beliefs, self-focus, attention towards threat in environment, anticipatory processing, post-event processing, safety behaviours). It is unknown whether these maintaining factors are exclusive to social anxiety or if they are also related to neuroticism – a tendency to experience negative emotions. A community sample of adults ( N  = 263) completed measures of relevant constructs (social anxiety, neuroticism, depression, aforementioned maintaining factors). Structural equation modelling was used to analyse the cross-sectional data. In a good fitting model which included depression, social anxiety had unique positive associations with all maintaining factors. Neuroticism had unique positive associations with social-evaluative beliefs, self-focus, and post-event processing, but not with any of the other maintaining factors. This model also had superior fit compared to a plausible competing model which did not include neuroticism. Certain maintaining factors may not be exclusive to social anxiety, in contrast to how they are conceptualised in models of SAD. Furthermore, neuroticism may play a role in social anxiety, highlighting the potential of interventions for social anxiety to be advanced through greater incorporation of emotion regulation strategies for negative affect.

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Social anxiety disorder (SAD) is a chronic and debilitating mental disorder characterised by significant anxiety in relation to social situations involving the potential for evaluation from other people (American Psychiatric Association, 2013 ; Wittchen & Fehm, 2003 ). Psychological models of SAD have highlighted a number of cognitive and behavioural maintaining factors which function to perpetuate social anxiety (e.g., Clark & Wells, 1995 ; Rapee & Heimberg, 1997 ; Wong & Rapee, 2016 ). However, within these psychological models, there is limited discussion of the role of personality dimensions. One personality trait that may be relevant to social anxiety is neuroticism, defined as a tendency to experience negative emotions and considered to be one of the five higher-order factors of personality (Goldberg, 1993 ). Given the potential of personality traits to influence psychopathology and its treatment (Bucher et al., 2019 ; Costache et al., 2020 ), further examination of neuroticism in the context of social anxiety and its maintaining factors is warranted.

In a recent psychological model of SAD (Wong & Rapee, 2016 ), maintaining factors for social anxiety are conceptualised as cognitive and behavioural processes that detect and eliminate social-evaluative threat, but which ultimately result in the maintenance of the threat value of social-evaluative stimuli. This in turn maintains maladaptive social-evaluative beliefs and the experience of anxiety in social situations. Within the model, the cognitive and behavioural processes specified can occur before, during or after social situations. First, the cognitive processes developed to detect social-evaluative threat include those that occur during social situations, which involves the directing of attention towards oneself and to one’s surrounds to scan for threat, referred to as self-focus and attention towards threat in the environment, respectively. Self-focused attention is maladaptive as it increases consciousness of internal threat cues (e.g., physiological responses; negative social-evaluative beliefs), whereas attention towards threat in the environment is maladaptive because one’s social context is scanned for evidence that confirms negative evaluation (i.e., threat). In addition, these processes are problematic because they reduce attentional resources available for adaptive task focus (e.g., focusing on what the other person is saying in a conversation). Second, the cognitive processes developed to detect social-evaluative threat also include those that occur before and after social situations, which involves a mental review of upcoming social situations or situations just experienced to scan for threat, referred to as anticipatory processing and post-event processing, respectively. Such mental reviews can involve negative mental imagery, recall of past social failures, and negative views of the self which exaggerate the perceived threat of upcoming social situations or situations just experienced. Third, behavioural processes developed to eliminate social-evaluative threat include those that are performed before or during social situations, referred to as safety behaviours. Safety behaviours aim to reduce the likelihood of the threat of negative evaluation from occurring (e.g., not talking during a conversation to prevent others judging what you say) but can ultimately result in increasing the likelihood of negative evaluation (e.g., not talking results in others thinking you are aloof and unfriendly).

A large body of research has shown positive associations between the aforementioned maintaining factors and social anxiety (maladaptive social-evaluative beliefs: e.g., Wong et al., 2021 ; self-focus and attention towards threat in the environment: e.g., Schultz & Heimberg, 2008 ; anticipatory processing: e.g., Mills et al., 2013 ; post-event processing: e.g., Brozovich & Heimberg, 2008 ; safety behaviours: e.g., Cuming et al., 2009 ). Although theory and empirical research have underscored the importance of the maintaining factors in social anxiety, it is not clear if these maintaining factors are uniquely related to social anxiety. This is particularly the case given evidence that social anxiety is associated with other negative emotional states.

At the disorder level, SAD typically co-occurs with other mental disorders, most commonly other anxiety disorders and depressive disorders (Crome et al., 2015 ; Ruscio et al., 2008 ; Stein et al., 2017 ). Notably, 30–50% of individuals with SAD also have a depressive disorder (e.g., Andrews et al., 2018 ). The co-occurrence of SAD and depression is significant, reflected in models developed to account for the symptom overlap and diagnostic comorbidity between anxiety and depression (e.g., tripartite model; Clark & Watson, 1991 ). Interestingly, there is also research showing that SAD is associated with other negative emotional states such as anger (e.g., Erwin et al., 2003 ) and shame (e.g., Swee et al., 2021 ).

One way to conceptualise these various negative emotional states and capture them in a unified fashion is with the personality trait of neuroticism. Research has shown that neuroticism is elevated in internalising disorders (Kotov et al., 2007 ) and is associated with greater risk of mental disorders (e.g., Kendler & Myers, 2010 ). A number of studies have demonstrated that neuroticism has positive cross-sectional associations with SAD as a diagnostic entity and with social anxiety as a continuous variable (e.g., Allan et al., 2017 ; Bienvenu et al., 2004 ; Costache et al., 2020 ; Levinson et al., 2011 ; Newby et al., 2017 ; Park & Naragon-Gainey, 2020 ). This raises the possibility that neuroticism may also have a link with the maintaining factors of social anxiety. However, no study to date has examined this possibility.

Further supporting the potential for associations between neuroticism and the maintaining factors of social anxiety, neuroticism while mainly characterised as elevated negative emotionality has also been described as involving heightened self-consciousness (e.g., McCrae & Costa, 2010 ). This aspect of neuroticism may prompt those maintaining factors of social anxiety which involve attention directed to the self, such as maladaptive social-evaluative beliefs, self-focus, anticipatory processing, and post-event processing (see Wong & Rapee, 2016 ). In addition, studies have shown that neuroticism has positive cross-sectional associations with cognitive and behavioural processes similar to the maintaining factors of social anxiety. For example, neuroticism is positively associated with rumination (e.g., Hervas & Vazquez, 2011 ), a repetitive thinking process similar to anticipatory processing and post-event processing. Neuroticism is also positively associated with behavioural and experiential avoidance (Lommen et al., 2010 ; Naragon-Gainey & Watson, 2018 ), which have overlaps with safety behaviours in the context of social anxiety.

Considering the aforementioned theory and research on the maintaining factors of social anxiety, the link between social anxiety and depression, and the link between social anxiety and neuroticism, this study used a community sample and a structural equation modelling framework to examine a model of social anxiety, depression, and neuroticism, and whether in this context social anxiety and neuroticism would each have unique associations with the maintaining factors of social anxiety. A community sample was used to allow analysis of individuals with a range of social anxiety levels. Based on previous literature (e.g., McCrae & Costa, 2010 ; Naragon-Gainey & Watson, 2018 ; Wong & Rapee, 2016 ), we hypothesised that while taking into account depression, both social anxiety and neuroticism would have unique positive associations with each of the maintaining factors (i.e., maladaptive social-evaluative beliefs, self-focus, attention towards threat in the environment, anticipatory processing, post-event processing, safety behaviours; see Fig.  1 ).

Proposed relationships between social anxiety, neuroticism, depression, and the maintaining factors of social anxiety. Double headed arrows reflect expected correlations and single headed arrows reflect expected directional paths. Correlations between the maintaining factors of social anxiety are also expected but are not shown for clarity

Participants

There were 263 adult participants recruited from the Sydney community using social media platforms (e.g., Facebook and Instagram), word-of-mouth, and a university-based research participant recruitment platform. Table 1 shows the demographic and symptom levels of the sample. Participants were entered into a draw to win one of three AU$50 vouchers or, if they were eligible, course credit for their participation. There were no exclusion criteria.

Sample size was determined based on a series of Monte Carlo simulations using the R package simsem (Pornprasertmanit et al., 2021 ). This method involves drawing many samples (i.e., replications) from a hypothesized population model and power for a given parameter is the proportion of the samples for which the null hypothesis (i.e., parameter = 0) is rejected at the .05 level (Muthén & Muthén, 2002 ). As no similar previous study exists, based on our hypothesised model shown in Fig.  1 , we decided for the hypothesised paths from social anxiety and neuroticism to the maintaining factors that medium effect sizes (0.3) would be meaningful to detect. We also set plausible values for the other parameters of the population model (e.g., factor loadings set at 0.75, correlation between social anxiety and neuroticism set at 0.5; see Newby et al., 2017 ; Park & Naragon-Gainey, 2020 ). A final simulation with 1000 replications and alpha = .05 indicated a minimum sample size of 255 would have power > 0.8 to detect medium paths from social anxiety and neuroticism to the maintaining factors. Our actual sample size of 263 exceeded this minimum.

Social Interaction Anxiety Scale – Straightforward Items (SIAS-S) and Social Phobia Scale (SPS)

The 17-item SIAS-S and 20-item SPS are companion measures that assess fears in relation to social interactions and while being observed in daily activities or social performance, respectively (Mattick & Clarke, 1998 ; Rodebaugh et al., 2006 ). Participants rate SIAS and SPS items on a 5-point Likert scale from 0 (Not at all characteristic or true of me) to 4 (Extremely true or characteristic of me), with higher total scores indicating greater social fears. The SIAS-S and SPS have good reliability (see Table 1 ) and validity (Mattick & Clarke, 1998 ; Rodebaugh et al., 2006 ).

Eysenck Personality Questionnaire Revised–short Form – Neuroticism subscale (EPQR–S–N)

The 12-item EPQR–S–N assesses one’s disposition to neuroticism (Eysenck et al., 1985 ; Sato, 2005 ). Following Sato’s ( 2005 ) recommendations, participants rate EPQR–S–N items on a 5-point Likert scale from 1 (Not at all) to 5 (Extremely), with higher total scores indicating greater neuroticism. The EPQR–S–N has good reliability (see Table 1 ) and validity (Sato, 2005 ).

Depression Anxiety Stress Scales 21-item Short Version – Depression Subscale (DASS-D)

The 7-item DASS-D assesses levels of depression over the preceding week (Lovibond & Lovibond, 1995 ). Participants rate DASS-D items on a 4-point Likert scale from 0 (Did not apply to me at all) to 3 (Applied to me very much, or most of the time), with higher total scores indicating greater depression levels. Following Lovibond and Lovibond ( 1995 ), the DASS-D score was doubled to obtain the full DASS score equivalent. The DASS depression subscale has good internal consistency (see Table 1 ) and validity (Antony et al., 1998 ).

Self-Belief Related to Social Anxiety (SBSA) Scale – Trait Version

The 15-item SBSA assesses maladaptive social-evaluative beliefs and has three subscales: a 4-item high standard beliefs subscale, a 7-item conditional beliefs subscale, and a 4-item unconditional beliefs subscale (Wong et al., 2014 ). Instructions were modified for the current study to assess an individual’s agreement with the beliefs typically in relation to social situations. Participants rate SBSA items on an 11-point Likert scale from 0 (Do not agree to all) to 10 (Strongly agree), with higher total scores indicating stronger maladaptive social-evaluative beliefs. The SBSA has good reliability (see Table 1 ) and validity (Wong et al., 2014 , 2021 ).

Attentional Focus Questionnaire–trait Version (AFQ-T)

The original 24-item AFQ (Rapee & Abbott, 2007 ) assesses attentional focus during a speech task and has two subscales that collectively measure self-focus (4-item attention to past experiences subscale, 5-item attention to physical symptoms subscale) as well as a subscale that measures attention towards threat in the environment (5-item attention to negative evaluation subscale). Instructions and items were modified for the current study to assess an individual’s general tendency to engage in these two forms of attentional focus (i.e., participants asked to rate AFQ-T items based on what they typically focus on during a social situation; example item modification: “I was focusing on my heartbeat” was modified to “I typically focus on my heartbeat.”). Participants rated AFQ-T items on a 5-point Likert scale from 0 (Not at all) to 4 (Extremely), with higher total scores indicating greater self-focus or attention towards threat in the environment. The original AFQ has good psychometric properties (Rapee & Abbott, 2007 ) and preliminary evidence suggests that the AFQ-T has good reliability (see Table 1 ).

Anticipatory Processing Questionnaire–trait Version (APQ-T)

The original 15-item APQ (Vassilopoulos, 2004 ) assesses anticipatory processing in relation to a specific social situation. Instructions and items were modified for the current study to assess an individual’s general tendency to engage in anticipatory processing (i.e., participants asked to rate APQ-T items based on how they typically are before a social situation; example item modification: “Did you try to stop thinking about the event?” was modified to “Before a social situation, do you typically try to stop thinking about the situation?”). Participants rated APQ-T items on an 11-point Likert scale from 0 (Not at all) to 10 (Very much so), with higher scores (average of items) indicating greater anticipatory processing. The original APQ has good psychometric properties (Vassilopoulos, 2004 ) and preliminary evidence suggests that the APQ-T has good reliability (see Table 1 ).

Extended Post-event Processing Questionnaire – 15 Item Trait Version (EPEPQ15-T)

The original EPEPQ15 (Wong, 2015 ) assesses post-event processing in relation to a specific social situation and has three subscales: a 7-item cognitive interference subscale, a 4-item negative self subscale, and a 4-item thoughts about the past subscale. Instructions and items were modified for the current study to assess an individual’s general tendency to engage in post-event processing (i.e., participants asked to rate EPEPQ15-T items based on how they typically are after a social situation; example item modification: “After the event was over, did you think about it a lot?” was modified to “After a social situation is over, do you typically think about the situation a lot?”). Participants rated EPEPQ15-T items on an 11-point Likert scale from 0 (Not at all) to 10 (Very much so), with higher scores (average of items) indicating greater post-event processing. The original EPEPQ15 has good psychometric properties (Wong, 2015 ) and preliminary evidence suggests that the EPEPQ15-T has good reliability (see Table 1 ).

Subtle Avoidance Frequency Examination (SAFE)

The 32-item SAFE assesses an individual’s utilisation of safety behaviours in relation to social situations and has three subscales: a 11-item inhibiting/restricting behaviours subscale, a 15-item active behaviours subscale, and a 6-item management of physical symptoms subscale (Cuming et al., 2009 ). Participants rate SAFE items on a 5-point Likert scale from 1 (Never) to 5 (Always), with higher total scores indicating higher levels of engagement in safety behaviours. The SAFE has good reliability (see Table 1 ) and validity (Cuming et al., 2009 ).

This study was approved by the Western Sydney University Human Research Ethics Committee (H13683). After providing informed consent, participants completed an online demographics questionnaire and then online versions of all study measures (along with other online questionnaires for other studies) presented in a randomised order. This was done while in the presence of a researcher who was on Zoom to maximise data quality.

Statistical Analyses

The R package “lavaan” (Rosseel, 2012 ) was used for the main analyses, which proceeded in two steps: (a) confirmatory factor analysis (CFA) was used to examine the fit of a measurement model for the latent variables of interest, and (b) this measurement model was entered into a structural equation model (SEM) to examine the relationships between the latent variables. In the first step, where possible we used the subscales of a measure (e.g., subscales of SAFE) or measures assessing an aspect of a construct (e.g., SIAS-S and SPS measuring facets of social anxiety) as indicators of latent variables (cf. Bagozzi & Heatherton, 1994 ). This was done because we were interested in the constructs broadly defined (as opposed to the specific underlying dimensions), and this also reduced overall model complexity of the SEM in the second step. Where this was not possible (e.g., scale has no subscales), items were used as indicators of latent variables. The latent constructs with indicator variables in parentheses were as follows: social anxiety (SIAS-S and SPS), neuroticism (EPQR-S–N items), depression (DASS-D items), social-evaluative beliefs (SBSA subscales), self-focus (attention to past experiences subscale and attention to physical symptoms subscale of the AFQ-T), attention towards threat in the environment (items of the attention to negative evaluation subscale of the AFQ-T), anticipatory processing (APQ-T items), post-event processing (EPEPQ15-T subscales), and safety behaviour (SAFE subscales). For the second step, relationships between latent variables were specified according to previous theory and research (e.g., McCrae & Costa, 2010 ; Naragon-Gainey & Watson, 2018 ; Wong & Rapee, 2016 ). Thus, social anxiety, neuroticism, and depression were expected to be correlated, and both social anxiety and neuroticism were expected to have regression paths to the maintaining factors. Correlations between social anxiety maintaining factors were also allowed (see also Fig.  1 ).

All CFAs were conducted using maximum likelihood estimation with robust (Huber-White) standard errors (MLR estimator). This estimator was chosen: (a) to guard against indicator non-normality, and (b) because of the need to treat all indicators as continuous given that subscales were used as indicators for certain latent variables. Notably, there was a small proportion of missing data (see Results) and the MLR estimator can use available data to estimate model parameters if missing values are missing at random (MAR) or missing completely at random (MCAR).

To evaluate model fit, the following fit indices were used (Brown, 2006 ): the χ 2 statistic (smaller values indicate better fit), the comparative fit index (CFI; ≥ .90 suggest acceptable fit; ≥ .95 suggest good fit), the Tucker-Lewis Index (TLI; ≥ .90 suggest acceptable fit; ≥ .95 suggest good fit), the root mean square error of approximation (RMSEA; ≤ .08 suggest acceptable fit; ≤ .05 suggest good fit), and the standardised root mean square residual (SRMR; ≤ .08 suggest acceptable fit; ≤ .05 suggest good fit).

Preliminary Analyses

Scale means and correlations are shown in Table 1 . All indicators had acceptable levels of skew (all absolute skewness < 3) and kurtosis (all absolute kurtosis < 8; Kline, 2011 ). A range of scores on all the measures was observed, covering the full scale or close to the full scale (see Table 1 ), as was expected given the community sample. At the item level, there were 238 missing data-points out of 38,661 possible (99.38%). At the indicator level, there were 72 missing data-points out of 12,624 possible (99.43% completion rate). Little’s Missing Completely at Random (MCAR) test was not significant at the indicator level, χ 2 (120) = 99.31, p  = .916, indicating the missing data were MCAR. Analyses proceeded with the full sample ( N  = 263).

Measurement Model

The CFI and TLI indicated the measurement model did not have an acceptable fit with the data, whereas the RMSEA and SRMR indicated acceptable fit, χ 2 (1238) = 2732.89, CFI = .889, TLI = .881, RMSEA = .071, SRMR = .055. Thus, modification indices were examined. A number of modification indices suggested correlated errors between certain APQ-T items, certain EPQR-S–N items, and certain AFQ-T items. We decided that it would be justifiable to have correlated errors for item pairs within the same scale which had similar wording (see Brown, 2006 ). Based on modification indices, correlated errors were added for 8 APQ-T item pairs (e.g., items of one item pair both referenced avoidance), 3 EPQR-S–N item pairs (e.g., items of one item pair both referenced worry), and 1 AFQ-T item pair (items of item pair both referenced other person). This modified measurement model had acceptable fit on all indices, χ 2 (1226) = 2476.11, CFI = .908, TLI = .900, RMSEA = .065, SRMR = .054. Across all factors, standardised factor loadings ranged from .67 to .98 (all p s < .001), suggesting all indicators were satisfactory markers of their hypothesised construct.

Structural Model

All fit indices suggested that the structural model had acceptable fit with the data, χ 2 (1232) = 2495.14, CFI = .907, TLI = .900, RMSEA = .065, SRMR = .055. Figure  2 shows the standardised estimates of the model. The correlations between social anxiety, depression, and neuroticism were large and significant, ranging from .71 to .89 (all p s < .001). Social anxiety had medium to large significant paths to each of the maintaining factors, ranging from .56 to .97 (all p s < .001). Neuroticism had small significant paths to social-evaluative beliefs, self-focus, and post-event processing, ranging from .24 to .34 (all p s < .043). Neuroticism had non-significant paths to attention towards threat in the environment, anticipatory processing, and safety behaviours ranging from –.02 to .21 (all p s > .057).

Relationships between latent variables representing social anxiety, neuroticism, depression, and the maintaining factors of social anxiety. Standardised estimates, 95% confidence intervals in brackets, and p -values are shown. Significant relationships are bolded. Double headed arrows reflect correlations and single headed arrows reflect directional paths. Error terms of certain indicator variables were allowed to correlate (see main text) and correlations between social anxiety maintaining factors were allowed. However, for clarity, only estimates for paths of interest are reported. Full model estimates may be requested from the authors

Exploratory Analysis: Competing Model

A plausible competing structural model was examined. The previous structural model was modified such that neuroticism was removed. Social anxiety and depression were still expected to be correlated, and social anxiety was expected to have regression paths to the maintaining factors. Correlations between social anxiety maintaining factors were again allowed. This model reflected the typical variables examined in relation to social anxiety (i.e., neuroticism is not typically taken into account). This model without neuroticism only had the RMSEA indicating acceptable model fit, χ 2 (1240) = 2841.94, CFI = .882, TLI = .873, RMSEA = .073, SRMR = .300. Hence, the original structural model with neuroticism had superior fit indices. A scaled χ 2 difference test based on Satorra and Bentler ( 2010 ) was also used to compare the difference in fit between the original structural model with neuroticism and the plausible competing structural model without neuroticism (see also Rosseel et al., 2020 , for the lavTestLRT function). Relative to the plausible competing structural model without neuroticism, the original structural model with neuroticism had significantly better fit based on the scaled χ 2 difference test, χ 2 (8) = 214.43, p  < .001.

The current study examined whether social anxiety and neuroticism each had unique positive associations with the maintaining factors of social anxiety while taking depression into account. Consistent with predictions, a model reflecting these associations had acceptable fit with the data and indicated that social anxiety had large significant unique positive associations with all maintaining factors. In addition, partially consistent with predictions, this model showed neuroticism had small significant positive unique associations with social-evaluative beliefs, self-focus, and post-event processing, but non-significant associations with attention towards threat in the environment, anticipatory processing, and safety behaviours. An exploratory analysis also showed that a plausible competing model which was the original tested model but with neuroticism removed had worse fit indices and significantly worse fit based on a scaled χ 2 difference test relative to the original model.

The finding of large significant unique positive associations between social anxiety and its maintaining factors is consistent with theory (e.g., Clark & Wells, 1995 ) and the large body of existing literature showing the same pattern of results (Brozovich & Heimberg, 2008 ; Cuming et al., 2009 ; Mills et al., 2013 ; Schultz & Heimberg, 2008 ; Wong et al., 2021 ). The findings of small significant positive unique associations between neuroticism and social-evaluative beliefs, self-focus, and post-event processing, but not attention towards threat in the environment, anticipatory processing, and safety behaviours, are novel. These results extend previous research (e.g., McCrae & Costa, 2010 ; Naragon-Gainey & Watson, 2018 ) which has suggested but never explicitly tested neuroticism’s potential unique associations with the maintaining factors of social anxiety.

The obtained unique relationships between neuroticism and certain maintaining factors but not others deserve explanation. One possibility is that relative to the other maintaining factors, social-evaluative beliefs, self-focus, and post-event processing may involve a greater degree of self-consciousness. Given the conceptualisation of neuroticism as involving heightened self-consciousness (McCrae & Costa, 2010 ), it may thus be the case that individuals with higher levels of neuroticism have a greater tendency to specifically experience social-evaluative beliefs, self-focus, and post-event processing. Another potential explanation is that social-evaluative beliefs, self-focus, and post-event processing involve a higher level of negative affect compared to the other maintaining factors. Individuals with higher levels of neuroticism may therefore have a predisposition to experience these specific maintaining factors involving greater negative affect. Future research will need to further investigate these potential explanations.

The results of this study have several important implications. First, the results suggest certain maintaining factors of social anxiety may not be exclusively related to social anxiety. This contrasts with prominent theoretical models of SAD (e.g., Clark & Wells, 1995 ) which describe the maintaining factors specifically in relation to social anxiety. However, if this study’s results are replicated, in particular with a clinical sample of individuals with SAD, then further research will be needed to determine the exact nature of the relationship between neuroticism and the maintaining factors related to it. Indeed, models of SAD may need to be expanded to include the role that neuroticism plays in relation to social anxiety and its maintaining factors. Second, the results of this study raise the possibility that neuroticism may impact on the treatment of social anxiety. If further research supports the causal role of neuroticism in this context, then neuroticism will need to be considered as part of the assessment of individuals seeking treatment for social anxiety, and existing gold-standard cognitive behavioural therapies for social anxiety (e.g., Clark et al., 2006 ; Rapee et al., 2009 ) may be advanced by incorporating further strategies targeting neuroticism where it is indicated. For example, a greater focus on the practice of cognitive restructuring to encourage cognitive reappraisal for emotion regulation purposes with application to anxiety and other negative affective states may be helpful in this regard (e.g., Dryman & Heimberg, 2018 ). Elements of emotion regulation therapy (e.g., Mennin et al., 2015 ) may also be relevant.

The current study has some limitations. First, this study was cross-sectional and causality cannot be inferred. Future research could evaluate the potential causal or temporal relationships between neuroticism and the maintaining factors by conducting studies with experimental or prospective longitudinal designs. As examples, experimental studies could induce negative emotionality and examine the effects on the maintaining factors as dependent variables, and prospective longitudinal studies could examine whether neuroticism can predict future maintaining factor levels. Second, this study examined a community sample. Although this sample allowed inclusion of individuals with a range of values on variables of interest which allowed this initial study to avoid restriction of range issues, future research should nonetheless replicate this study utilising a clinical sample with SAD as a next step. Third, the majority of participants in our sample were female and were highly educated, limiting generalisability. Future research should replicate the current study in more diverse samples and examine whether certain sample characteristics affect results. Fourth, the current study used modified trait versions of existing measures in the literature. Although these modified trait versions showed promising psychometrics in the current study (e.g., good reliability), further psychometric evaluation of these trait measures is warranted. Fifth, the current study used a specific measure of neuroticism, despite other measures of this construct in the literature (e.g., NEO Personality Inventory-Revised Neuroticism Subscale; Costa & McCrae, 1992 ). Although the EPQR-S–N is a reliable and valid measure of neuroticism, future research may consider replicating the current study with other measures of neuroticism. Finally, the initial measurement model in this study was modified based on modification indices which could have capitalised on chance characteristics in the sample analysed. However, the modifications enabled a sound measurement model before examination of the main structural model.

Overall, this study showed that when social anxiety, neuroticism, and depression are modelled together, social anxiety has unique positive associations with its maintaining factors, and neuroticism additionally has unique positive associations with social-evaluative beliefs, self-focus, and post-event processing. These results suggest that neuroticism may play a role in the context of social anxiety, and raise the interesting potential of existing interventions for social anxiety to be advanced through greater incorporation of emotion regulation strategies.

Data Availability

Data available on request from the authors.

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Clague, C.A., Wong, Q.J.J. Social Anxiety and Its Maintaining Factors: Accounting for the Role of Neuroticism. J Psychopathol Behav Assess 45 , 469–479 (2023). https://doi.org/10.1007/s10862-023-10030-2

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Peer attachment and self-control: implication on social anxiety in young adults.

1. Introduction

2. materials and methods, 2.1. participants, 2.2. instruments, 2.3. procedure and data analyses, 3.1. variance in peer attachment, social anxiety and self-control according to sex, sleep time and physical exercise in young adults, 3.2. role of peer attachment and self-control in social anxiety, 4. discussion, 5. practical implications, limitations and future studies, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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• Published: 27 July 2022

Social anxiety disorder and its associated factors: a cross-sectional study among medical students, Saudi Arabia

• Wejdan M. Al‑Johani   ORCID: orcid.org/0000-0003-4851-0934 1 ,
• Nouf A. AlShamlan   ORCID: orcid.org/0000-0002-8049-237X 1 ,
• Naheel A. AlAmer   ORCID: orcid.org/0000-0003-2700-5197 1 ,
• Rammas A. Shawkhan   ORCID: orcid.org/0000-0002-2623-0838 2 ,
• Ali H. Almayyad   ORCID: orcid.org/0000-0001-8633-9432 3 ,
• Layla M. Alghamdi   ORCID: orcid.org/0000-0002-5624-8625 1 ,
• Hatem A. Alqahtani   ORCID: orcid.org/0000-0002-0832-1357 1 ,
• Malak A. Al-Shammari   ORCID: orcid.org/0000-0002-7434-7432 1 ,
• Danya Mohammed Khalid Gari 1 &
• Reem S. AlOmar   ORCID: orcid.org/0000-0003-4899-7965 1  

BMC Psychiatry volume  22 , Article number:  505 ( 2022 ) Cite this article

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Social Anxiety disorder (SAD) is common worldwide. However, data from Saudi Arabia is deficient. This study aims to determine the prevalence of SAD across Saudi medical students and its associations with sociodemographic factors and their academic performance.

The main outcome was presence/absence of SAD and the secondary outcome was its level of severity. These were assessed from the Social Phobia Inventory. Associated factors included sociodemographic variables, as well as educational characteristics of students. Descriptive statistics were reported as counts and percentages, and unadjusted and adjusted odds ratios (OR) and their 95% confidence intervals (CIs) were computed through bivariate and multivariate logistic regression.

Of 5896 Saudi medical students who participated in the study ,  the prevalence of SAD was almost 51%. While 8.21% and 4.21% had reported severe and very severe SAD, respectively. Older age students were at lower risk of developing SAD (OR = 0.92, 95% CI = 0.89 – 0.96). In contrast, females (OR = 1.13, 95% CI = 1.01 – 1.26), students enrolled in private colleges and colleges implementing non-problem-based learning (OR = 1.29, 95% CI = 1.09 – 1.52 and OR = 1.29. 95% CI = 1.15 – 1.46 respectively) were at higher risk. A significant elevated risk of SAD was found among students who had previously failed, and had a low GPA.

SAD is prevalent among the sampled population, and different associated factors were identified. Current results could raise the awareness of faculty members and healthcare providers towards early detection and management of these cases.

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Social Anxiety Disorder (SAD) which was initially named social phobia, is defined according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as an extreme fear or anxiety about one or more social situations in which the individual is exposed to scrutiny by others, for instance, social interactions (e.g., meeting and talking to new people), being observed (e.g., eating or drinking), and performing in front of others (e.g., public speaking) [ 1 ]. The most common reported presentation of SAD was fear of speech-making [ 2 ]. SAD can occur in any public place where a person feels observed and judged by others [ 3 ]. Individuals will develop different cognitive and somatic anxiety symptoms characterized by autonomic stimulation, such as blushing, tremors, increased sweating, and tachycardia [ 4 ].

It is one of the most predominant anxiety disorders among adolescents and younger aged groups, impairing their functioning capabilities if left untreated [ 5 ]. In addition, its high prevalence would make it the third most common mental disorder after depression and alcohol abuse [ 6 ].

The lifetime prevalence of SAD has been reported in various studies, ranging between 3–13% [ 1 ]. The prevalence of SAD among university students has been assessed in multiple studies. In Jordan, Ghana, Nigeria, Brazil and Sweden Universities, the prevalence was around 9–16.1% [ 5 , 7 , 8 , 9 , 10 ]. A higher prevalence of SAD has been found among university students in Ethiopia and India (26%, 31.1%) respectively [ 11 , 12 ]. Moreover, it was associated with female gender, low educational attainment, positive personal or family history of mental disorders, psychiatric medication use, and lack of social support [ 2 , 13 ]. Studies have shown that SAD has led to low self-esteem and impaired body image, consequently negatively impacting on students' academic performance [ 14 , 15 ].

Furthermore, SAD is considered a significant risk factor for developing major depressive disorders and alcohol abuse disorder [ 16 ].

Although various studies worldwide have assessed the prevalence and impact of SAD among different populations, Saudi Arabia's data is scarce. After a thorough literature search, few data regarding SAD among medical students in small cities in Saudi Arabia have been obtained. Medical students are more exposed to academic challenges, including the lengthiest education and training period, the stress of multiple written and clinical examinations, oral presentations, interaction with patients and their families, and exposure to serious life and death issues. Consequently, medical students particularly require intact physical and mental well-being, strong personality structures, and a willingness to attain professional and communication skills to deal with academic challenges [ 17 ]. Therefore, this study aims to estimate the prevalence of SAD among medical students in the Kingdom of Saudi Arabia (KSA) and determine its association with students' sociodemographic factors and academic performance.

Study design and participants

This cross-sectional study included all medical students and medical interns both males and females attending any medical college in Saudi Arabia whether private or governmental. The number of medical colleges in Saudi Arabia is rising to 34 colleges, 27 of which are governmental. All Saudi medical colleges provide six-year undergraduate study, followed by one year of practical internship [ 18 , 19 ].

Sample size and sampling technique

The Saudi Commission for Health Specialties in its most recent published report stated that the total number of undergraduate students in medical colleges both private and governmental was 101,256 students [ 20 ]. The minimum required sample was calculated to be 2342 students using Epiinfo V.7.0. The 51.9% of presence of (SAD) was obtained from a Saudi study that examined social phobia among Saudi students in a single college, with an alpha level of 0.05 and a precision of 2% [ 21 ].

A non-probability sampling technique was used where students were invited to take part by answering an online-based questionnaire. The QuestionPro questionnaire software (Seattle, Washington, USA) was used.

Data collection tool and processes

Data were collected using a validated online self-administered questionnaire consisting of two parts. The first part included the socio-demographic information (age, gender, educational level, marital status, income, and Grade Point Average (GPA)). The second part included the validated Social Phobia Inventory (SPIN) questionnaire by K. M. Connor, a screening tool for SAD, consisting of 17 items. Each point is ranked with a five-degree Likert scale (0 = No, 1 = Low, 2 = Somewhat, 3 = High, 4 = Very Much). The total score ranges from 0 – 68; thus, an individual who scores more than 20 is considered to have SAD. The SPIN had good test–retest reliability, internal consistency, convergent and divergent validity, the Cronbach alpha is 0.85. Therefore, SPIN can be used as a measurement for the screening of SAD and monitoring the responses of treatment [ 22 , 23 ]

The online link of the survey was sent to the students' phone numbers through assigned data collectors from each college. The survey was customized to accept a single response from each number to avoid duplication of responses.

Statistical analysis

The primary outcome in this study was whether medical students had SAD or not according to the Social Phobia Inventory. A secondary outcome is the severity of SAD which may be computed from the inventory itself. After summing all 17 items of the inventory, participants who score less than or equal to 20 are assumed to not have SAD while those who score above 20 do have SAD. As for the severity as a secondary outcome, a participant scoring from 21 to 30 is considered to have mild SAD, 31 to 40 as moderate, 41 to 50 as severe and more than 51 as very severe. Descriptive statistics were obtained by counts and percentages, and potential associations were tested through the Pearson’s X 2 test and the T-test. Trends of proportions over GPA were tested for statistical significance. Unadjusted and adjusted Odds Ratios (ORs) and 95% Confidence Intervals (CIs) were drawn through binary logistic regression analyses where the outcome was for the presence/absence of SAD. Final variables in the regression model were decided based on a Directed Acyclic Graph of associations and were not entirely based on significance testing of bivariate associations. The model with the best fit was chosen based on model diagnostics. The Variance Inflation Factor measure was used to test for multicollinearity. All analyses were performed in Stata V.15.0.

Characteristics of the students

A total of 5896 students participated in this study (5.82% of the target population). It included 44.88% of males and 55.12% of females. The mean age of all students was 22.43 ± 1.68 years. Most students were single (85.72%). Overall, 24.87% had previously failed during their studies. However, the last known GPA was mostly A (43.49%) and only 35 students (0.59%) had a last known GPA of F. Most students belonged to a medical college that implemented a Problem-Based learning scheme (PBL) (65.84%), and only 16.50% of the total respondents were in private medical colleges. According to the Social Phobia Inventory severity score, 49.05% were not found to have SAD, while 20.22% were considered as mild, 18.32% as moderate, 8.21% severe and 4.21% as very severe (Table 1 ).

Figure  1 presents the five-level severity score of the Social Phobia Inventory across the different GPAs of the students. Among those with a GPA of A and B, a larger portion of the students are seen to not have (SAD). Whereas among those with a GPA of F, students were found to have a higher portion of (SAD) across all levels of severity, mild, moderate, severe, and very severe.

The five-level score of the Social Phobia Inventory and students’ GPA, Saudi Arabia, N  = 5896

Factors relating to the presence/absence of social anxiety disorder (SAD)

The presence of SAD was found to be associated with several factors at the bivariate analyses level (Table 2 ). For example, it was found to be associated with age ( P  < 0.01). It was also found to be statistically associated with sex ( P  = 0.02) where females were found to have more SAD compared to males. Previous academic failure and the last known GPA were highly statistically associated with SAD ( P  < 0.001). The data clearly shows that the lower the GPA the more the proportion of SAD (P for trend < 0.001). Neither family income nor the year of study were statistically associated with SAD in the study sample.

Factors associated with SAD according to multivariable analyses

Table 3 shows the results of the binary logistic regression both before and after adjustment. Age was a significant predictor whereby the risk of SAD decreased with increasing age both before and after adjustment (Unadjusted OR = 0.93, 95% CI = 0.90 – 0.96 and Adjusted OR = 0.92, 95% CI = 0.89 – 0.96 respectively). The model also showed that females were significantly more likely to have SAD when compared to males after adjustment (Adjusted OR = 1.46, 95% CI = 1.26 – 1.69). Having previously failed was also associated both before and after adjustment (Unadjusted OR = 1.64, 95% CI = 1.45 – 1.84 and Adjusted OR = 1.46, 95% CI = 1.26 – 1.69). An increase in risk was found with decreased GPA levels, for example the highest odds of 4.13 was found for students with a GPA of F (95% CI = 1.56 – 10.92) when compared to students with a GPA of A. Elevated risk was also observed for students who are enrolled in colleges that do not adopt a problem-based educational scheme and those who are in private colleges (Adjusted OR = 1.29, 95% CI = 1.15 – 1.46 and Adjusted OR = 1.29, 95% CI = 1.09 – 1.52).

The model was highly significant ( P  < 0.001) with a Pseudo R 2 value of 0.16. The Hosmer–Lemeshow value for this model was 11.25, with a p -value of 0.19 indicating good model fit.

The present study demonstrated that about half of the examined medical students in Saudi Arabia screened positive for SAD. Moreover, 8.21% and 4.21% of students had severe and very severe SAD symptoms, respectively. Other studies worldwide have also investigated the prevalence of SAD in undergraduate universities and medical students. Nevertheless, comparing our findings with these studies is difficult because of variations in the methodologies, study tools used, participants' backgrounds, social factors, and cultures. In agreement with the findings from the current study, Al-Hazmi et al., conducted a study among 504 medical students from Taibah university, Saudi Arabia, using the SPIN questionnaire and reported that 13.5% of the participating medical students had severe to very severe SAD [ 21 ]. Findings from the present study were higher than Desalegn et al.'s study which demonstrated that 31.2% (95% CI 27.3 to 35.6%) of undergraduate health science students in Ethiopia had SAD symptoms [ 24 ]. A study among 525 medical students in Germany revealed that 12.2% reported SAD symptoms [ 25 ]. In Iran, Afshari surveyed 400 medical sciences students using the SPIN tool and demonstrated that 41.5% and 13.2% of students had moderate and high SAD, respectively [ 26 ].

Furthermore, the findings of this study showed that SAD is less common among older aged students, which is consistent with Al-Hazmi et al. findings [ 21 ]. The decreased prevalence in older students may be attributed to their exposure to the clinical settings, as senior students tend to interact more with patients and are more experienced in interviewing skills. For instance, Alotaibi et al., found that older aged groups and higher-level students showed a higher score on the positive attitude scale towards learning communication skills [ 27 ]. Moreover, Davis et al.'s study showed that the final-year students had better communication skills than first-year students, indicating that they have a better vision and understanding of the importance of communication skills [ 28 ].

An expected and true finding of the current study is that social anxiety rates are higher among females compared to males. This finding is relevant to the (DSM-5) statement, which revealed that the prevalence of SAD is higher in females, and this difference is more pronounced among adolescents [ 4 ]. A similar finding was obtained by Xu et al.'s data survey from the National Epidemiologic Sample on Alcohol and Related Conditions among the United States adult population where the lifetime prevalence of SAD was higher in females than in males (5.7% and 4.2% respectively) [ 29 ]. Additionally, studies among the Canadian and European populations have shown similar results [ 30 , 31 , 32 , 33 , 34 ]. This outcome is contrary to Elhadad et al.'s study on only 380 medical students in Abha, Saudi Arabia, which found that SAD rates were higher among males. However, the Elhadad study population was obtained from a single institution and a relatively small sample size, hence, their results are less generalizable [ 35 ]. A possible explanation of why females are at higher risk of developing SAD can be best understood from a “vulnerability-stress perspective”. Exposure to variable psychosocial stressors and an increased biological and psychological vulnerability towards anxiety in females may explain the sex differences in anxiety disorders [ 36 ]. Interestingly, the current study found higher SAD rates among divorced, widowed, and singles than married ones. This finding supports the result of the systematic review conducted by Toe et al., which found that SAD was consistently associated with social isolation, such as being unmarried or living alone. Whether social isolation causes social anxiety or vice versa is still unclear [ 37 ].

Moreover, this study demonstrates that students who were enrolled in institutions implementing traditional teaching methods had an increased risk of having phobia compared to the students in PBL institutions, which indicates the effect of different learning styles on students’ mental well-being [ 38 ]. Furthermore, it draws attention to the nature of PBL, which revolves around the idea that a problem is of crucial importance in learning. It focuses on community problems, scientific problems, and real-life scenarios, motivating trainees and boosting their confidence. PBL promotes a deep learning approach rather than a superficial one by making trainees interact with information in a multilevel fashion. The absence of a teacher role in PBL increases the sense of responsibility towards self-learning and promotes personal development [ 39 ]. In other words, PBL is student-centered and encourages communication and teamwork through multiple tools of assessments, including presentations, small group discussions, seminars, assignments, and Objective Structured Clinical Examinations. The repeated exposure to social interactions and public speaking through PBL may increase students' confidence in social and clinical settings [ 40 ].

Many studies have reported high levels of stress and psychological comorbidities among Saudi medical students [ 41 ]. However, studies examining the differences between governmental and private medical schools in Saudi Arabia are limited. Moreover, we propose that the differences in teaching and learning approaches could explain finding a lower risk of SAD among governmental college students than those in private colleges. AlOmar et al. conducted a survey among 3767 students using the Approaches and Study Skills Inventory for Students (ASSIST), which showed that the deep and strategic approaches were predominant among Saudi medical students. In addition, private medical school students were more likely to adopt a strategic rather than a deep learning approach [ 42 ], which suggests that the difference in SAD levels between governmental and private medical college students may be explained by the differences in learning methods.

SAD was found to be associated with impairment in education and work productivity [ 43 , 44 ]. A large cohort, population-based study in Sweden showed an inverse association between SAD and academic performance at different levels [ 43 ]. In line with this finding, the current study revealed that a lower GPA was linked to a higher risk of SAD; hence it was more frequently reported among students with a previous failure in medical school. Furthermore, previous Saudi studies have also reported a similar inverse relationship [ 21 , 35 ]. This may be explained by the fact that medical school environments are highly competitive; students are working hard to achieve higher grades and GPA to look for opportunities in the postgraduate residency programs and jobs. These stressors make medical students vulnerable to mental health problems [ 45 ]. Moreover, the presence of students with low GPA or previous failure with their high achieving colleagues could be another burden on them. It might lead to social isolation, low self-esteem, being inactive in the group work, and consequently having social anxiety symptoms more frequently than their peers.

To the best of our knowledge, the current study is the first Saudi study investigating SAD among a large sample of medical students from all regions in the kingdom. However, some limitations exist. Firstly, the sample only included medical students and did not represent the general Saudi population. Secondly, since the design of the study was cross-sectional, temporality and causality between factors could not be assured. Additionally, despite of the high response rate the possibility of response bias could not be eliminated. Finally, the SPIN tool utilized in the study is a screening tool, and the high-risk cases need a further diagnostic step by a clinical interview.

The current study found that SAD was highly prevalent among the investigated medical students in Saudi Arabia. Older students had lower odds of SAD. On the other hand, being female, studying in private colleges or with non-problem-based learning methods, and having a history of a previous failure in the medical school or a lower GPA were identified as factors that had higher odds of SAD. These findings emphasize the positive role of the university faculty members, counselors, and mentors in supporting these students and encouraging them to participate in curricular and extracurricular activities. In addition, evaluation of the educational environment and the types of the teaching curriculum in Saudi Medical schools is necessary to optimize students learning experience and maintain their psychological wellbeing. Along with enhancing the primary care providers and mental health care experts to accomplish their role of early detection and management of these cases.

Availability of data and materials

The datasets generated and analysed for the current study are not publicly available for data protection reasons. However, the data that support the findings of this study may be available from the corresponding author on reasonable request.

Abbreviations

Social Anxiety Disorder

Diagnostic and Statistical Manual of Mental Disorders

• Kingdom of Saudi Arabia

Grade Point Average

Problem-Based Learning

Approaches and Study Skills Inventory for Students

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Acknowledgements

The authors would like to acknowledge the efforts of medical students who participated in the data collection. Also, we would like to thank all students who filled out the questionnaires.

No funding was received for conducting this study.

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Department of Family and Community Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, P.O. Box 1982, Dammam 34224, Saudi Arabia

Wejdan M. Al‑Johani, Nouf A. AlShamlan, Naheel A. AlAmer, Layla M. Alghamdi, Hatem A. Alqahtani, Malak A. Al-Shammari, Danya Mohammed Khalid Gari & Reem S. AlOmar

College of Medicine, King Khalid University, Abha, Saudi Arabia

Rammas A. Shawkhan

College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

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Contributions

WMAJ, RSAO, and NAAS conceived the idea and developed the study design. AHA and RAS recruited participants and helped in data collection. Data preparation, statistical analyses, results interpretation, and creation of tables and figures were carried out by RSAO. The initial draft of the introduction, methods, and discussion were written by WMAJ, HAA, LMA, NAAS, AHA, RAS, MAAS, NAAA, and DMKG. The final manuscript was written by WMAJ, RSAO, and NAAS. All authors read and approved the final manuscript.

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Correspondence to Wejdan M. Al‑Johani .

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Al‑Johani, W.M., AlShamlan, N.A., AlAmer, N.A. et al. Social anxiety disorder and its associated factors: a cross-sectional study among medical students, Saudi Arabia. BMC Psychiatry 22 , 505 (2022). https://doi.org/10.1186/s12888-022-04147-z

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National Collaborating Centre for Mental Health (UK). Social Anxiety Disorder: Recognition, Assessment and Treatment. Leicester (UK): British Psychological Society (UK); 2013. (NICE Clinical Guidelines, No. 159.)

Social Anxiety Disorder: Recognition, Assessment and Treatment.

2 social anxiety disorder, 2.1. the disorder, 2.1.1. what is social anxiety disorder.

Social anxiety disorder (previously termed ‘social phobia’) was formally recognised as a separate phobic disorder in the mid-1960s ( Marks & Gelder, 1965 ). The term ‘social anxiety disorder’ reflects current understanding, including in diagnostic manuals, and is used throughout the guideline. As set out in the International Classification of Diseases , 10th Revision (ICD-10) ( World Health Organization, 1992 ) and in the Diagnostic and Statistical Manual of Mental Disorders , 4th Edition Text Revision (DSM-IV-TR) ( American Psychiatric Association, 2000 ) social anxiety disorder is a persistent fear of one or more social situations where embarrassment may occur and the fear or anxiety is out of proportion to the actual threat posed by the social situation as determined by the person's cultural norms. Typical social situations can be grouped into those that involve interaction, observation and performance. These include meeting people including strangers, talking in meetings or in groups, starting conversations, talking to authority figures, working, eating or drinking while being observed, going to school, shopping, being seen in public, using public toilets and public performance including speaking. While anxiety about some of the above is common in the general population, people with social anxiety disorder can worry excessively about them and can do so for weeks in advance of an anticipated social situation. People with social anxiety disorder fear that they will say or do (involuntarily or otherwise) something that they think will be humiliating or embarrassing (such as blushing, sweating, shaking, looking anxious, or appearing boring, stupid or incompetent). Whenever possible, people with social anxiety disorder will attempt to avoid their most feared situations. However, this is not always feasible, and they will then endure the situation, often with feelings of intense distress. Usually the condition will cause significant impairment in social, occupational or other areas of functioning.

Children may manifest their anxiety somewhat differently from adults. As well as shrinking from interactions, they may be more likely to cry or ‘freeze’ or have behavioural outbursts such as tantrums. They may also be less likely to acknowledge that their fears are irrational when they are away from a social situation. Particular situations that can cause difficulty for socially anxious children and young people include participating in classroom activities, asking for help in class, activities with peers (such as team sports or attending parties and clubs), participating in school performances and negotiating social challenges.

2.1.2. How common is social anxiety disorder?

There are no UK epidemiological surveys that specifically report data on social anxiety disorder in adults; however, the prevalence of social anxiety disorder has been included in large general population surveys in other western European countries, the US and Australia. Prevalence estimates vary, with much of the variability probably being due to differences in the instruments used to ascertain diagnosis. However, it is clear that social anxiety disorder is one of the most common of all the anxiety disorders. Lifetime prevalence rates of up to 12% have been reported ( Kessler et al., 2005a ) compared with lifetime prevalence estimates for other anxiety disorders of 6% for generalised anxiety disorder, 5% for panic disorder, 7% for post-traumatic stress disorder (PTSD) and 2% for obsessive-compulsive disorder (OCD). Twelve-month prevalence rates as high as 7% have been reported for social anxiety disorder ( Kessler et al., 2005b ). Using strict criteria and face-to-face interviews in the US, the lifetime and yearly prevalence figures are halved to 5% and 3%, respectively ( Grant et al., 2005b ), but it is still more common than the major autoimmune conditions (rheumatoid arthritis, ulcerative colitis, Crohn's disease, systemic lupus erythematosus, diabetes mellitus type I, multiple sclerosis, uveitis, hypothyroidism and hyperthyroidism) put together ( American Autoimmune Related Diseases Association, 2011 ). Data from the National Comorbidity Survey reveals that social anxiety disorder is the third most common psychiatric condition after major depression and alcohol dependence ( Kessler et al., 2005a ).

Women and men are equally likely to seek treatment for social anxiety disorder, but community surveys indicate that women are somewhat more likely to have the condition ( Kessler et al., 2005a ). Turk and colleagues ( Turk et al., 1998 ) reported that in a clinical sample women feared more social situations and scored higher on a range of social anxiety measures. It therefore seems that although women are more likely to experience social anxiety, men may be more likely to seek treatment and to do so with less severe symptoms.

Population rates of social anxiety disorder in children and young people have been investigated in several countries. As in adult studies, a range of methods have been used for diagnosis, which probably explains the wide variability in prevalence estimates. A large New Zealand study reported that 11.1% of 18-year-olds met criteria for social anxiety disorder ( Feehan et al., 1994 ). However, a large, British epidemiological survey ( Ford et al., 2003 ) reported that just 0.32% of 5- to 15-year-olds had the disorder, a rate that was higher than that for PTSD, OCD and panic disorder, but lower than separation anxiety disorder, specific phobia and generalised anxiety disorder. Rates of diagnosis in this British study were higher in males than females, and increased slightly with age. A large US-based study reported very similar rates in 9- to 11-year-olds ( Costello et al., 2003 ), while a German study estimated rates of 4% for 14- to 17-year-olds ( Wittchen et al., 1999b ).

2.1.3. When does social anxiety disorder start and how long does it last?

Social anxiety disorder typically starts in childhood or adolescence. Among individuals who seek treatment as adults the median age of onset is in the early to mid-teens with most people having developed the condition before they reach their 20s. However, there is a small subgroup of people who develop the condition in later life. Some people can identify a particular time when their social anxiety disorder started and may associate it with a particular event (for example, moving to a new school or being bullied or teased). Others may describe themselves as having always been shy and seeing their social anxiety disorder as a gradual, but marked, exacerbation of their apprehension when approaching or being approached by other people. Others may never be able to recall a time when they were free from social anxiety.

Several studies ( Bruce et al., 2005 ; Reich et al., 1994a ; Reich et al., 1994b ) have followed-up adults with social anxiety disorder for extended periods of time. These studies have generally found that it is a naturally unremitting condition in the absence of treatment. For example, Bruce and colleagues (2005) reported a community study in which adults with various anxiety disorders were followed up for 12 years. At the start of the study, individuals had had social anxiety disorder for an average of 19 years. During the next 12 years 37% recovered, compared with 58% for GAD and 82% for panic disorder without agoraphobia.

Prospective longitudinal studies with children, although more sparse than those with adults, have confirmed that anxiety disorders are very likely to start by adolescence, and that this is particularly the case for social anxiety disorder. However, there is also evidence that some socially anxious young people will outgrow the condition (albeit still maintaining a high risk for other anxiety disorders) ( Pine et al., 1998 ). Putting the adult and child prospective studies together, it appears that a significant number of people who develop social anxiety disorder in adolescence may recover before reaching adulthood. However, if social anxiety disorder has persisted into adulthood, the chance of recovery in the absence of treatment is modest when compared with other common mental disorders.

2.1.4. What other mental disorders tend to be associated with social anxiety disorder?

Four-fifths of adults with a primary diagnosis of social anxiety disorder will experience at least one other psychiatric disorder at sometime during their life ( Magee et al., 1996 ). Among adults, social anxiety disorder is particularly likely to occur alongside other anxiety disorders (up to 70%), followed by any affective disorder (up to 65%), nicotine dependence (27%) and substance-use disorder (about 20%) ( Fehm et al., 2008 ; Grant et al., 2005b ). As social anxiety disorder has a particularly early age of onset, many of these comorbid conditions develop subsequently. It is of interest that comorbid anxiety predicts poorer treatment outcomes for people with bipolar affective disorder and major depressive disorder ( Fava et al., 2008 ; Simon et al., 2004 ) and also that 25% of people presenting with first episode psychosis have social anxiety disorder ( Michail & Birchwood, 2009 ), yet the relevance of this to clinical practice has been somewhat neglected. When people meet criteria for social anxiety disorder and another anxiety disorder, social anxiety comes first in 32% of people; in people with social anxiety and affective disorders or substance misuse, social anxiety precedes these comorbid conditions in 71% and 80%, respectively ( Chartier et al., 2003 ); and in individuals who present with major depressive and social anxiety disorder, the depressive episode may be secondary. This may reflect a common aetiology or a despondency about the way in which social anxiety disorder prevents the person from realising their full potential, or it may be an indication of different peak incidence. One study of adult outpatients presenting for treatment for social anxiety disorder found that 53% had had a previous episode of a depressive disorder, with the average number of episodes being 2.2 in a cohort that had a mean age of 33 years. Similarly, substance misuse problems can develop out of individuals' initial attempts to manage their social anxiety with alcohol and drugs. Of course, the relationship between social anxiety disorder and other clinical conditions can also work the other way. For example, some individuals with scars and/or other physical problems in the context of PTSD may subsequently develop social anxiety disorder when they become concerned about how they will appear to other people. Some individuals who are usually socially confident may develop social anxiety during a depressive episode and recover once the depression lifts. The picture is similar in adolescence: comorbidity is 40% for anxiety disorders, 40% for affective disorders and 16% for substance misuse ( Ranta et al., 2009 ); in one large German study of young people (aged up to 24 years) social anxiety preceded the additional anxiety diagnosis in 64.4% of people, the mood disorder diagnosis in 81.6% and the substance misuse diagnosis in 85.2% ( Wittchen et al., 1999b ).

There is also a significant degree of comorbidity between social anxiety disorder and some personality disorders. The most common is avoidant personality disorder (APD), with as much as 61% of adults who seek treatment for social anxiety also meeting criteria for a personality disorder ( Sanderson et al., 1994 ). However, there is some controversy about the significance of this finding. There is a marked overlap between the criteria for social anxiety disorder and APD, and some experts consider APD a severe variant of social anxiety disorder. As many people develop their social anxiety disorder in childhood, some researchers have argued that much of the association with APD is simply due to the chronicity of the anxiety disorder. However, research studies have succeeded in identifying a few characteristics that tend to distinguish people with social anxiety disorder alone from those with social anxiety disorder plus APD. These include interpersonal problems, in particular problems with intimacy, increased functional impairment and lower levels of social support ( Marques et al., 2012 ), although the differences have not always been replicated. Whatever the relationship between social anxiety disorder and APD, there is some evidence that successful psychological treatment of social anxiety also reduces the incidence of APD ( Clark et al., 2006 ; McManus et al., 2009a ). Similarly, Fahlen (1995) reported that abnormal personality traits wane with successful pharmacological treatment. Besides APD, comorbidity rates with other personality disorders are low and not higher than with other anxiety disorders or depression.

Among children and young people, comorbidity of anxiety disorders is also very high, as is comorbidity between anxiety and mood and behavioural disorders ( Ford et al., 2003 ). The specific comorbidities of social anxiety in this age group are less well explored, but in a large sample of young people (aged 14 to 24 years) Wittchen and colleagues (1999b) found that 41.3% of those with a diagnosis of social anxiety disorder also had a diagnosis of substance misuse (including nicotine), 31.1% a mood disorder and 49.9% another anxiety disorder (compared with 27.9%, 12.1% and 20.8% of participants without a diagnosis of social anxiety disorder, respectively). Social anxiety is a substantial predictor of nicotine use in adolescence ( Sonntag et al., 2000 ). In some people, social anxiety may be expressed as selective mutism ( Viana et al., 2009 ).

2.1.5. How does social anxiety disorder interfere with people's lives?

Social anxiety disorder should not be confused with normal shyness, which is not associated with disability and interference with most areas of life. Educational achievement can be undermined, with individuals having a heightened risk of leaving school early and obtaining poorer qualifications ( Van Ameringen et al., 2003 ). One study ( Katzelnick et al., 2001 ) found that people with generalised social anxiety disorder had wages that were 10% lower than the non-clinical population. Naturally, social life is impaired. On average, individuals with social anxiety disorder have fewer friends and have more difficulty getting on with friends ( Whisman et al., 2000 ). They are less likely to marry, are more likely to divorce and are less likely to have children ( Wittchen et al., 1999a ). Social fears can also interfere with a broad range of everyday activities, such as visiting shops, buying clothes, having a haircut and using the telephone. The majority of people with social anxiety disorder are employed; however, they report taking more days off work and being less productive because of their symptoms ( Stein et al., 1999b ). People may avoid or leave jobs that involve giving presentations or performances. The proportion of people who are in receipt of state benefits is 2.5 times higher than the rate for the general adult population. Katzelnick and colleagues (2001) also report that social anxiety disorder is associated with outpatient medical visits.

2.1.6. Are there different types of social anxiety disorder?

Individuals with social anxiety disorder vary considerably in the number and type of social situations that they fear and in the number and range of their feared outcomes. These two features (feared situations and feared outcomes) can vary independently. For example, some people fear just one or two situations but have multiple feared outcomes (such as, ‘I'll sound boring’, ‘I'll sweat’, ‘I'll appear incompetent’, ‘I'll blush’, ‘I'll sound stupid’ or ‘I'll look anxious’). Others can fear many situations but have only one feared outcome (such as ‘I'll blush’). Because of this variability, researchers have considered whether it might be useful to divide social anxiety disorder into subtypes. Several subtypes have been suggested, some of which are defined by specific feared outcomes (fear of blushing, fear of sweating and so on). The most common distinction is between generalised social anxiety disorder, where individuals fear most social situations, and non-generalised social anxiety disorder, where individuals fear a more limited range of situations (which often, but not always, involve performance tasks such a public speaking); however, some authors have suggested that the difference between these subtypes is a difference in degree. The generalised subtype is associated with greater impairment and higher rates of comorbidity with other mental disorders ( Kessler et al., 1998 ). The generalised subtype also has a stronger familial aggregation, an earlier age of onset and a more chronic course. While most psychological therapies are applied to both subtypes, evaluations of drug treatments have mainly focused on generalised social anxiety disorder.

2.2. AETIOLOGY

2.2.1. what do we know about the causes of social anxiety disorder.

As with many disorders of mental health, the development of social anxiety disorder is probably best understood as an interaction between several different biopsychosocial factors ( Tillfors, 2004 ).

Genetic factors seem to play a part, but genes may influence the probability of developing any anxiety or depressive disorder rather than developing social anxiety in particular. Higher rates of social anxiety disorder are reported in relatives of people with the condition than in relatives of people without the condition, and this effect is stronger for the generalised subtype ( Stein et al., 1998a ). Further evidence for a genetic component comes from twin studies. Kendler and colleagues (1992 ; 1999) found that if one twin is affected, the chance of the other twin being affected is higher if the twins are genetically identical (monozygotic) than if they only share 50% of their genes (dizygotic). However, heritability estimates are only 25 to 50%, indicating that environmental factors also have an important role in the development of the condition for many people.

Stressful social events in early life (for example, being bullied, familial abuse, public embarrassment or one's mind going blank during a public performance) are commonly reported by people with social anxiety disorder ( Erwin et al., 2006 ). Parental modelling of fear and avoidance in social situations plus an overprotective parenting style have both been linked to the development of the condition in some studies ( Lieb et al., 2000 ).

The success of selective serotonin reuptake inhibitors (SSRIs), serotonin and noradrenaline reuptake inhibitors (SNRI) and monoamine oxidase inhibitors (MAOIs) in treating social anxiety disorder suggests that dysregulation of the serotonin and dopamine neurotransmitter system may also play a role, but studies that establish a causal relationship for such dysregulation in the development of the condition have not yet been reported.

Neuroimaging studies so far suggest different activation of specific parts of the brain (the amygdalae, the insulae and the dorsal anterior cingulate – all structures that are involved in the regulation of anxiety) when threatening stimuli are presented compared with healthy volunteers.

2.3. TREATMENT AND MANAGEMENT IN THE NHS

2.3.1. how well is social anxiety disorder recognised.

Recognition of social anxiety disorder in adults, children and young people by general practitioners (GPs) is often poor. The problem of under-recognition for anxiety disorders in general has recently been highlighted by evidence that the prevalence of PTSD is significantly under-recognised in primary care ( Ehlers et al., 2009 ). In part this may stem from GPs not identifying the disorder, a general lack of understanding about its severity and complexity, and a lack of clearly defined care pathways. But it may also stem from service users' lack of knowledge of its existence, their avoidance of talking about the problem and stigma.

The early age of onset and effects on educational achievement mean that recognition of social anxiety disorders in educational settings is also an issue. As well as underachieving, children with social anxiety disorder may be particularly likely to be the targets of bullying and teasing. Teachers and other educational professionals may have limited knowledge of how to recognise and oversee the management of the condition.

In primary care many service users report being misdiagnosed as having ‘pure’ major depression. Missing the diagnosis may also occur in secondary care if an adequate history has not been taken. This is a serious omission because having a comorbidity has treatment and outcome implications.

2.3.2. How many people seek treatment?

Despite the extent of suffering and impairment, only about half of adults with the disorder ever seek treatment, and those who do generally only seek treatment after 15 to 20 years of symptoms ( Grant et al., 2005a ). Likely explanations for low rates and delays include individuals thinking that social anxiety is part of their personality and cannot be changed (or in the case of children, that they will grow out of it), lack of recognition of the condition by healthcare professionals, stigmatisation of mental health services, fear of being negatively evaluated by a healthcare professional, general lack of information about the availability of effective treatments and limited availability of services in many areas.

2.3.3. How can we know whether a treatment is effective?

Randomised controlled trials (RCTs) are the main way of determining whether a treatment is effective. Individuals who are diagnosed with social anxiety disorder are randomly allocated to the treatments under investigation or a control condition. Assessments are conducted at pre-treatment/control and post-treatment/control. The treatment is considered to be effective if significantly greater improvement is observed in the treatment condition than the control condition. In order to determine whether the improvements obtained by treatment are sustained, ideally participants should be systematically followed up for an extended period after the end of treatment.

RCTs are the best way of dealing with threats to internal validity (for example, ‘are the improvements that are observed due to the treatment or would they have happened in any case?’). However, they do not necessarily deal well with threats to external validity (for example, ‘would the results that are obtained with the rather selective group of participants that were studied in the RCT generalise to most people with social anxiety disorder?’). For this reason, it is helpful if data from RCTs are supplemented by data from large cohorts of relatively unselected people who receive the same treatment.

Researchers have traditionally distinguished between specific and non-specific treatment effects. The specific treatment effect refers to the amount of improvement that is attributable to the unique features of a particular treatment. The non-specific treatment effect refers to the amount of improvement that is attributable to features that are common to all (or most) well-conducted therapies.

In RCTs of pharmacological interventions the main contrast is always between the active drug and a placebo. The placebo controls for the non-specific effects of seeing a competent clinician, having one's symptoms consistently monitored, receiving a plausible treatment rationale and taking a tablet. The comparison between active drug and placebo is therefore only an index of the specific treatment effect attributable to a particular chemical. As most chemicals have side effects, some of which are severe, it is generally accepted that a drug must show a specific effect in order to warrant its use. However, it is important to note that service users are likely to show substantially greater improvements than implied by the active drug versus placebo effect size because giving a placebo also produces a further non-specific benefit.

In RCTs of psychological interventions the focus is less exclusively on establishing specific treatment effects. Commonly the control condition is a waitlist. In this case, the observed difference between the treatment and the control condition will be the sum of the relevant non-specific and specific effects. As psychological interventions are generally thought to have few side effects, it seems reasonable for researchers to have a primary interest in determining whether the treatment has any beneficial effects compared with no treatment. However, it is also important that evaluations of psychological interventions attempt to determine whether the treatment has specific effects as this gives us greater confidence in knowing exactly which procedures therapists should be taught in order to replicate the results that the treatment has obtained in RCTs. If a psychological intervention is known to have a specific effect, it is clear that therapists need to be trained to deliver the procedures that characterise that treatment. If a treatment has only been shown to have a non-specific effect people should be informed and it should not usually be offered in a publicly funded system.

In social anxiety disorder it seems highly plausible that part of the improvement that is observed in treatment is simply due to the non-specific effect of meeting someone who is (initially) a stranger while talking about one's emotions and numerous embarrassing topics. In other words, almost all interventions for social anxiety disorder involve a substantial amount of potentially beneficial exposure to feared social situations.

How does one determine whether a psychological intervention has a specific effect? Essentially one needs to demonstrate that the treatment is superior to an alternative treatment that includes most of the features that are common to various psychological interventions (such as seeing a warm and empathic therapist on a regular basis, having an opportunity to talk about one's problems, receiving encouragement to overcome the problems, receiving a treatment that seems to be based on a sensible rationale and having one's symptoms measured regularly). RCTs approach this requirement in one of three ways, each of which has strengths and weaknesses. In the first approach the alternative/control condition is a treatment that was specifically designed for the study and is intended to include non-specific features only, a good example of which is the education-support condition used by Heimberg and colleagues (1990 ; 1998 ). In the second approach, the alternative treatment might be something that is used routinely in clinical practice and is considered by some to be an active intervention but it turns out to be less effective than the psychological intervention under investigation, despite involving a similar amount of therapist contact. In the third approach, the psychological intervention is compared with pill placebo, which controls the many non-specific factors but often fails to fully control for therapist contact time because this is usually less in a medication-based treatment.

The fact that RCTs of medications almost always only focus on assessing specific treatment effects, whereas RCTs of psychological intervention may focus on assessing specific, non-specific or both types of effect, means that caution needs to be exercised when comparing the findings of such evaluations. In an ideal world, it should be possible to obtain an estimate of the effectiveness of each type of treatment against controls for specific effects as well as the overall benefit of treatment (compared with no treatment). The network meta-analysis (NMA) that underpins this guideline attempts to provide such information by inferring how medications would fair against no treatment even though most RCTs of medication use placebo controls and do not include a waitlist (no treatment) control (see Chapter 3 for further information about the NMA).

The next section outlines the different psychological and pharmacological interventions that have been tested for efficacy in social anxiety disorder.

2.3.4. Psychological interventions

In the mid 1960s, when social anxiety disorder was formally recognised as a separate phobic disorder ( Marks & Gelder, 1965 ), the dominant evidence-based psychological interventions for anxiety disorders involved repeated exposure to the phobic stimulus in imagination. The first RCTs of psychological interventions for social anxiety disorder used two variants of this approach (systematic desensitisation and flooding) and obtained modest improvements. However, in anxiety disorders in general imaginal exposure treatment soon became superseded by treatments that involved confronting the feared stimulus in real life. Marks (1975) published a seminal review arguing that real life (‘ in vivo ’) exposure was more efficacious than imaginal exposure. This review had a substantial effect on treatment development work in all anxiety disorders. Subsequent behavioural and cognitive behavioural interventions for social anxiety disorder have therefore focused on techniques that involve real life confrontation with social situations, to a greater or lesser extent.

Exposure in vivo is based on the assumption that avoidance of feared situations is one of the primary maintaining factors for social anxiety. The treatment involves constructing a hierarchy of feared situations (from least to most feared) and encouraging the person to repeatedly expose themselves to the situations, starting with less fear-provoking situations and moving up to more difficult situations as confidence develops. Exposure exercises involve confrontation with real-life social situations through role plays and out of office exercises within therapy sessions and through systematic homework assignments. Many people with social anxiety disorder find that they cannot completely avoid feared social situations and they tend to try to cope by holding back (for example, by not talking about themselves, staying quiet or being on the edge of a group) or otherwise avoiding within the situation. For this reason, exposure therapists devote a considerable amount of time to identifying subtle, within-situation patterns of avoidance (safety-seeking behaviours) and encouraging the person to do the opposite during therapy.

Applied relaxation is a specialised form of relaxation training that aims to teach people how to be able to relax in common social situations. Starting with training in traditional progressive muscle relaxation, the treatment takes individuals through a series of steps that enables them to relax on cue in everyday situations. The final stage of the treatment involves intensive practice in using the relaxation techniques in real life social situations.

Social skills training is based on the assumption that people are anxious in social situations partly because they are deficient in their social behavioural repertoires and need to enhance these repertoires in order to behave successfully and realise positive outcomes in their interactions with others. The treatment involves systematic training in non-verbal social skills (for example, increased eye contact, friendly attentive posture, and so on) and verbal social skills (for example, how to start a conversation, how to give others positive feedback, how to ask questions that promote conversation, and so on). The skills that are identified with the therapist are usually repeatedly practiced through role plays in therapy sessions as well as in homework assignments. Research has generally failed to support the assumption that people with social anxiety disorder do not know how to behave in social situations. In particular, there is very little evidence that they show social skills deficits when they are not anxious. Any deficits in performance seem to be largely restricted to situations in which they are anxious, which suggests that they are an anxiety response rather than an indication of a lack of knowledge. Nevertheless, social skills therapists argue that practising relevant skills when anxious is a useful technique for promoting confidence in social situations.

Cognitive restructuring is a technique that is included in a variety of multicomponent therapies and has also occasionally been used on its own, although this has usually been as part of a research evaluation assessing the value of different components of a more complex intervention. The therapist works with the person to identify the key fearful thoughts that they experience in anxiety-provoking social situations, as well as some of the general beliefs about social interactions that might trigger those thoughts. The person is then taught largely verbal techniques for generating alternative, less anxiety-provoking thoughts (‘rational responses’), which they are encouraged to rehearse in anticipation of, and during, social interactions. To facilitate this process, they regularly complete thought records, which are discussed with therapists in the treatment sessions. Some practitioners argue that it is not essential that they fully believe a rational response before they start rehearsing it in fear-provoking situations ( Marks, 1981 ).

Cognitive behavioural interventions encompass various well-recognised and manualised approaches including cognitive behavioural therapy (CBT) . However, most cognitive behavioural interventions involve exposure in vivo and cognitive restructuring. Some programmes also include some training in relaxation techniques and/or social and conversational skills training. In recent years, research studies have identified several processes that appear to maintain social anxiety in addition to avoidance behaviour. These include self-focused attention, distorted self-imagery and the adverse effects of safety-seeking behaviours, including the way they change other people's behaviour. Some cognitive behavioural interventions have included techniques that aim to address these additional maintaining factors, for example, training in externally focused and/or task-focused attention, the use of video feedback to correct distorted self-imagery and demonstrations of the unhelpful consequences of safety-seeking behaviours. CBT can be delivered in either an individual or group format. When it is delivered in a group format, other members of the group are often recruited for role plays and exposure exercises. Sessions tend to last 2 to 2.5 hours with six to eight people in a group and two therapists. When CBT is delivered in an individual format, therapists may need to identify other individuals who can sometimes join therapy sessions for role plays.

Cognitive therapy (CT) developed by Clark and Wells (1995) is based on a model of the maintenance of social anxiety disorder that places particular emphasis on: (a) the negative beliefs that individuals with social anxiety hold about themselves and social interactions; (b) negative self-imagery; and (c) the problematic cognitive and behavioural processes that occur in social situations (self-focused attention, safety-seeking behaviours). A distinctive form of CT that specifically targets the maintenance factors specified in the model has developed. The procedures used in the treatment overlap with some of the procedures used in more recent CBT programmes, therefore CT can validly be considered to be a variant of CBT. However, it is distinguished from many CBT programmes for social anxiety disorder by the fact that it takes a somewhat different approach to exposure (with less emphasis on repetition and more on maximising disconfirmatory evidence) and it does not use thought records. Instead, the key components of treatment are: developing an individual version of Clark and Wells' (1995) model using the service user's own thoughts, images and behaviours; an experiential exercise in which self-focused attention and safety behaviours are manipulated in order to demonstrate their adverse effects; video and still photography feedback to correct distorted negative self-images; training in externally focused non-evaluative attention; behavioural experiments in which the person tests specific predictions about what will happen in social situations when they drop their safety behaviours; discrimination training and memory rescripting for dealing with memories of past social trauma.

The treatment is usually delivered on an individual basis. However, there is a need for the therapist to be able to call on other people to participate in within-session role plays. It is common for the therapist and the person with social anxiety disorder to also leave the office to conduct behavioural experiments in the real world during therapy sessions. This is easier to do if sessions are for 90 minutes, rather than the usual 50 minutes.

Interpersonal psychotherapy (IPT) was originally developed as a treatment for depression but was modified by Lipsitz and colleagues (1997) for use in social anxiety disorder. Treatment is framed within a broad biopsychosocial perspective in which temperamental predisposition interacts with early and later life experiences to initiate and maintain social anxiety disorder. There are three phases to the treatment. In the first phase, the person is encouraged to see social anxiety disorder as an illness that has to be coped with, rather than as a sign of weakness or deficiency. In the second phase, the therapist works with the person to address specific interpersonal problems particularly in the areas of role transition and role disputes, but sometimes also grief. Role plays encouraging the expression of feelings and accurate communication are emphasised. People are also encouraged to build a social network comprising close and trusting relationships. In the last phase, the therapist and the person review progress, address ending of the therapeutic relationship, and prepare for challenging situations and experiences in the future. Sessions are typically 50 to 60 minutes of individual treatment.

Psychodynamic psychotherapy sees the symptoms of social anxiety disorder as the result of core relationship conflicts predominately based on early experience. Therapy aims to help the person become aware of the link between conflicts and symptoms. The therapeutic relationship is a central vehicle for insight and change. Expressive interventions relate the symptoms of social anxiety disorder to the person's underlying core conflictual relationship theme. Leichsenring and colleagues (2009a) consider that in social anxiety disorder the core conflictual relationship theme consists of three components: (1) a wish (for example, ‘I wish to be affirmed by others’); (2) an anticipated response from others (for example, ‘others will humiliate me’); and (3) a response from the self (for example, ‘I am afraid of exposing myself’). Supportive interventions include suggestion, reassurance and encouragement. Clients are encouraged to expose themselves to feared social situations outside therapy sessions. Self-affirming inner dialogues are also encouraged.

Mindfulness training is a psychological intervention that has developed out of the Buddhist tradition and encourages individuals to gain psychological distance from their worries and negative emotions, seeing them as an observer, rather than being engrossed with them. Treatment starts with general education about stress and social anxiety. Participants then attend weekly groups in which they are taught meditation techniques. Formal meditation practice for at least 30 minutes per day using audiotapes for guidance is also encouraged.

2.3.5. Pharmacological interventions

Several different pharmacological interventions have been used in the treatment of social anxiety, many of which were originally developed as antidepressants. Antidepressants used in the treatment of social anxiety disorder come from four different classes: SSRIs, SNRIs, noradrenaline and selective serotonin antagonists and MAOIs. A fifth class, tricyclic antidepressants (TCAs), have also been used in the past but this is no longer the case.

SSRIs were initially marketed in the 1980s, having been developed as more selective agents following work on the TCAs and MAOIs. They are thought to act by increasing serotonin concentration in the brain and, after obtaining licences for major depression, many pharmaceutical companies carried out additional studies that indicated their efficacy in social anxiety disorder as well as in other anxiety disorders. The only SNRI that has been studied extensively is venlafaxine and it is possible that its effects in social anxiety disorder are mediated solely through changes in serotonin at usually prescribed doses.

MAOIs inhibit the breakdown of noradrenaline, dopamine, serotonin, melatonin, tyramine and phenylethylamine. This effect is not limited to the brain and affects other parts of the body rich in monoamine oxidase (MAO), for example, the gut. Therapeutic effects in social anxiety disorder are again thought to be related to increased levels of serotonin and dopamine in the brain. However, inhibition of MAO may result in a potentially dangerous interaction with foods containing tyramine which may lead to episodes of dangerously high blood pressure. This risk is much reduced with moclobemide as it is ‘reversible’ – this means that in the presence of other relevant substances, moclobemide ‘comes off the enzyme’. Because of this, moclobemide prescription comes with far fewer dietary restrictions than the older MAOIs, such as phenelzine. MAOIs are now rarely prescribed because of their perceived risks.

Benzodiazepines are restricted by the fact that it is preferable not to administer them for prolonged periods of time because of potential tolerance and dependence. In addition they may complicate some of the more prevalent comorbidities such as PTSD and depression.

Finally, alpha2delta calcium gated channel blockers, such as pregabalin, reduce neuronal excitability but it is not at all clear why these should work when other anticonvulsants have no known therapeutic effects in social anxiety disorder.

2.4. THE ECONOMIC COST OF SOCIAL ANXIETY DISORDER

Social anxiety disorder imposes substantial economic costs on individuals, their families and carers and society, as a result of functional disability, poor educational achievement, loss of work productivity, social impairment, greater financial dependency and impairment in quality of life. These costs are substantially higher in those with comorbid conditions, which are very common in people with social anxiety: 50 to 80% of people with social anxiety disorder presenting to health services have at least one other psychiatric condition, typically another anxiety disorder, depression or a substance-use disorder ( Wittchen & Fehm, 2003 ).

A UK study by Patel and colleagues (2002) assessed the economic consequences of social anxiety disorder for individuals, health services and the wider society using information from the Adult Psychiatric Morbidity Survey conducted in England in 2000 ( Singleton et al., 2001 ). People with social anxiety disorder were less likely to be in the highest socioeconomic group and had lower employment rates and household income compared with those with no psychiatric morbidity. In terms of health service resource use and associated costs, people with social anxiety were estimated to incur a mean annual health service cost per person of £609, attributed to GP visits, inpatient and outpatient care, home visits and counselling. Annual productivity losses due to ill health reached £441 per employed person with social anxiety, while the annual social security benefit per person with social anxiety reached £1,479. Health service costs and social benefits were higher in people with social anxiety when a comorbidity condition was present compared with those with pure social anxiety disorder.

For comparison, people without a mental disorder incurred a mean annual cost per person of £379 for health services, £595 associated with productivity losses, and £794 relating to social security benefits (1997/98 prices).

By extrapolating the data to a population of 100,000 people attending primary care services, Patel and colleagues (2002) estimated that the total healthcare cost of social anxiety disorder would amount to over £195,000 per annum, with primary care costs alone approximating £49,000. Wider costs, such as social security benefit claims, were expected to reach £474,000.

Another study from the Netherlands ( Acarturk et al., 2009 ) estimated the resource use and costs incurred by people with both clinical and subthreshold social anxiety disorder using data from a national mental health survey. Costs assessed included direct medical costs related to mental healthcare services (for example, GP visits, sessions with psychiatrists, hospital days), direct non-medical costs (for example, service users' transportation, parking, and waiting and treatment time) and productivity losses. The annual mean cost per person with social anxiety disorder was €11,952 (2003 prices), significantly higher than the respective cost per person with no mental disorder of €2,957. However, when the cost was adjusted for comorbid conditions, the mean annual cost of social anxiety disorder was reduced to €6,100. For those with subthreshold social anxiety disorder, the annual mean cost was estimated at €4,687. Other costs falling on other sectors like education and social services were not considered in the study.

Despite the debilitating nature of the condition, social anxiety disorder is often unrecognised and under-treated with little information existing on the resource implications of the disorder on the individual, healthcare sector or society ( den Boer, 1997 ; Jackson, 1992 ; Ross, 1991 ). Also, given its early onset and chronic nature, the lifetime cost of an untreated individual is quite significant because of the negative impact on productivity ( Lipsitz & Schneier, 2000 ).

A more detailed review of the cost of social anxiety disorder indicated that the economic cost relating to poor educational attainment, social impairment, functional disability and poor quality of life may be greater than the direct healthcare costs. For every 10-point increase on the Liebowitz Social Anxiety Scale (LSAS), wages were found to decrease by 1.5 to 2.9% and college graduation to decrease by 1.8%. However, most of these economic costs have not yet been quantified in monetary values ( Lipsitz & Schneier, 2000 ).

In contrast to the studies summarised above, some evidence indicates that social anxiety disorder alone is not associated with greater use of mental and other health services, with only 5.4% of those with non-comorbid social anxiety disorder seeking treatment from a mental health provider ( Davidson et al., 1993a ; Lecrubier, 1998 ; Magee et al., 1996 ). In a retrospective study assessing the mean annual healthcare costs of anxiety disorders using a US reimbursement claims database of approximately 600,000 people, social anxiety disorder was noted to have the lowest cost of $3,772 per person, compared with that of GAD ($6,472) and major depressive disorder ($7,170) ( François et al., 2010 ). Similarly, an Australian study ( Issakidis et al., 2004 ), reported that individuals with social anxiety disorder utilised fewer healthcare resources (including GP, psychiatrist and medical specialist visits, and psychological and pharmacological interventions) compared with people with other anxiety disorders. A review of cost-of-illness studies confirmed that social anxiety disorder has been consistently found to cost less than other anxiety disorders. The overall mean annual cost of social anxiety disorder was estimated to range from $1,124 to $3,366 (2005 US$) ( Konnopka et al., 2009 ).

In summary, social anxiety disorder is associated with a range of indirect and intangible costs relating to reduced productivity, social impairment and reduction in quality of life. On the other hand, the often lower healthcare cost incurred by people with social anxiety disorder compared with those with other anxiety disorders reflects the under-utilisation of healthcare services by these individuals. Relatively high costs in some groups are often due to comorbidity with conditions like depression and alcohol dependence. Although the costs due to social anxiety disorder vary significantly across studies, countries and groups, they are nevertheless consistently lower than the costs associated with other anxiety disorders. This is understandable given the underlying primary problem, which is chiefly social avoidance.

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Enquiries in this regard should be directed to the British Psychological Society.

• Cite this Page National Collaborating Centre for Mental Health (UK). Social Anxiety Disorder: Recognition, Assessment and Treatment. Leicester (UK): British Psychological Society (UK); 2013. (NICE Clinical Guidelines, No. 159.) 2, SOCIAL ANXIETY DISORDER.
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• THE DISORDER
• TREATMENT AND MANAGEMENT IN THE NHS
• THE ECONOMIC COST OF SOCIAL ANXIETY DISORDER

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