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• Social Phobia/Anxiety Case Study: Jim

Jim was a nice looking man in his mid-30’s.  He could trace his shyness to boyhood and his social anxiety to his teenage years.  He had married a girl he knew well from high school and had almost no other dating history.  He and his wife, Lesley, had three children, two girls and a boy.

At our first meeting, Jim was very shy and averted his eyes from me, but he did shake hands, respond, and smile a genuine smile.  A few minutes into our session and Jim was noticeably more relaxed.  "I’ve suffered with this anxiety for as long as I can remember", he said.  "Even in school, I was backward and didn’t know what to say.  After I got married, my wife started taking over all of the daily, family responsibilities and I was more than glad to let her."

If there was an appointment to be made, Lesley made it.  If there was a parent-teacher conference to go to, Lesley went to it.  If Jim had something coming up, Lesley would make all the social arrangements.  Even when the family ordered takeout food, it was Lesley who made the call.  Jim was simply too afraid and shy.

Indeed, because of his wife, Jim was able to avoid almost all social responsibility -- except at his job.  It was his job and its responsibilities that brought Jim into treatment.

Years earlier, Jim had worked at a small, locally-owned record and tape store, where he knew the owner and felt a part of the family.  The business was slow and manageable and he never found himself on display in front of lines of people.  Several years previously, however, the owner had sold his business to a national record chain, and Jim found himself a lower mid-range manager in a national corporation, a position he did not enjoy.

"When I have to call people up to tell them that their order is in," he said, "I know my voice is going to be weak and break, and I will be unable to get my words out.  I’ll stumble around and choke up....then I’ll blurt out the rest of my message so fast I’m afraid they won’t understand me.  Sometimes I have to repeat myself and that is excruciatingly embarrassing........"

Jim felt great humiliation and embarrassment about this afterwards: he couldn’t even make a telephone call to a stranger without getting extremely anxious and giving himself away.  That was pretty bad!  Then he would beat himself up.  What was wrong with him?  Why was he so timid and scared?  No one else seemed to be like he was.  He simply must be crazy!  After a day full of this pressure, anxiety and negative thinking, Jim would leave work feeling fatigued, tired, and defeated.

Meanwhile, his wife, being naturally sociable and vocal, continually enabled Jim not to have to deal with any social situations.  In restaurants, his wife always ordered.  At home, she answered the telephone and made all the calls out.  He would tell her things that needed to be done and she would do them.

He had no friends of his own, except for the couples his wife knew from her work.  At times when he felt he simply had to go to these social events, Jim was very ill-at-ease, never knew what to say, and felt the silences that occurred in conversation were his fault for being so backward.  He knew he made everyone else uncomfortable and ill-at-ease.

Of course, the worst part of all was the anticipatory anxiety Jim felt ahead of time – when he knew he had to perform, do something in public, or even make phone calls from work.  The more time he had to worry and stew about these situations, the more anxious, fearful and uncomfortable he felt.

REMARKS: Jim presented a very typical case of generalized social phobia/social anxiety.  His strong anticipation and belief that he wouldn’t do well at social interactions and in social events became a self-fulfilling prophecy, and his belief came true: he didn’t do well.  The more nervous and anxious he got over a situation, and the more attention he paid to it, the more he could not perform well.  This was a very negative paradox or "vicious cycle" that all people with social anxiety get stuck in.  If your beliefs are strong that you will NOT do well, then it is likely you will not do well.  Therefore, thoughts, beliefs, and emotions need to be changed.

The depression (technically "dysthymia") that comes about after the anxious event continued to fuel the fire.  "I’ll never be able to deal with this," Jim would tell himself, thus constantly reinforcing the fact that he saw himself as a failure and a loser.

Unusual in this situation is that Jim’s wife remained loyal to him, understood his problem to some extent, and even seemed to enjoy her role as the family’s "social director".  The more and more she did for Jim, the more and more he could avoid.  It got so bad that Jim, who loved to listen to new albums and read new books -- could not even go to stores or to the library.  He would tell his wife what to buy and she would buy it.  She even kept track of when the library books were due and made sure she took them back on time.

This family situation is unusual because most people with social anxiety/social phobia have an extremely difficult time making and continuing personal relationships -- because of self-consciousness and the need for more privacy than most other people.  In fact, social phobia ranks among one of the highest psychological disorders when it comes to failed relationships, divorce, and living alone.

TREATMENT for Jim consisted of the normal course of cognitive strategies so that he would relearn and rethink what he was doing to himself.  He was cooperative from the beginning, and progressed nicely doing therapy.  He took each of the practice handouts and spent time each day practicing.  He made a "special time" for himself that his family respected and he used this place and time to practice the cognitive strategies his mind had to learn.

His biggest real-life fear, speaking to another person in public, was not really a speaking problem; it was an anxiety problem.  There was nothing wrong with Jim’s voice, his reading ability, or his speaking ability.  Jim was a bright man who had associated great anxiety around these social events in public situations.

The course of treatment here is NOT to practice!  In fact, practicing would just draw attention to what Jim perceived was the problem: his voice, his awkwardness, his perceived inability to speak to others.  Thus, it would reinforce the very behaviors we do not want to reinforce.

Instead, Jim worked on paradoxes.  We deliberately goofed-up.  We tried to make as many mistakes as possible.  We injected humor into the situation and found that when he exaggerated his fears, he thought this was funny.  Although more is involved than just this, the concept here is to de-stress the situation and enable the person to see it for what it is: NO BIG DEAL!  If you make a mistake, SO WHAT?  Everyone else does too!

Over the weeks, before group therapy began, Jim did a number of interesting things in public that began proving to him that he was NOT the center of attention, and it just didn’t matter if he made a mistake or two.  After all, he was human just like everyone else.  It’s this idea of perfectionism, of always having to "do your best" that must be broken down.  Jim was human; humans make mistakes; so what?  It was certainly nothing to get upset about.  In fact, as time went by, it become even more funny and humorous, rather than humiliating or embarrassing.

After completion of the behavioral group therapy, Jim had an opportunity for advancement in his company, which he now felt comfortable to take.  The promotion entailed holding weekly meetings in which he was in charge.  He would have to do some public speaking and respond to his employees’ questions.  By this time, Jim was feeling much more comfortable and much less anxious about the whole situation.  "I think I’ll deliberately goof up," he joked to me before the start of his new job.  "It would be interesting to see how everyone else responds."

To say that Jim did not have any anticipatory anxiety before taking this position or before making his weekly presentations would be inaccurate.  The difference was now they were manageable.  They were simply minor roadblocks that could be overcome.  Jim’s thinking about social events and activities had changed a great deal since the first day I saw him in therapy.

I talked to Jim a few months ago and everything was going well.  His responsibilities at work had increased slightly, but Jim now had the ability and beliefs to deal with them.  He was much more confident and had a feeling of being in control.  He was doing more around the house and his wife was a little surprised at his metamorphosis.  Luckily, this did not change the marriage dynamics adversely, and the last time I talked with him, Jim had become a father again: another little boy.

"He’s the last," Jim said, laughing over the phone, "I can’t get too distracted.  I’ve got too many speeches to give now."

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“I Don’t Want to Bother You” – A Case Study in Social Anxiety Disorder

• First Online: 29 March 2023

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• Katharine E. Daniel 3 &
• Bethany A. Teachman 3  

Part of the book series: CBT: Science Into Practice ((CBT))

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Gi, a 34-year-old second-generation Korean American man, presented to treatment with pronounced and longstanding anxiety in many social situations, which significantly impaired his functioning (e.g., his perceived ability to run errands in crowded stores and care for his ill father). Gi engaged in cognitive behavior therapy (CBT) via telehealth during the COVID-19 pandemic. Key cognitions and biased cognitive processes that were maintaining his anxiety included a judgment that others frequently reject him, an assumption that if he expressed his own needs, then he would be unreasonably burdening others, and a core belief that he was incompetent, along with a pervasive tendency to make negative interpretations about his abilities in most social situations. He experienced marked functional improvements and reduced anxiety throughout his 17-session course of treatment. Gi’s case and treatment are detailed throughout this chapter to illustrate how individual CBT for social anxiety disorder can be implemented. Special discussion of how the clinician continuously and collaboratively modified her case conceptualization and intervention approaches with reference to aspects of Gi’s identities and in response to her own missteps are offered throughout.

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Daniel, K.E., Teachman, B.A. (2023). “I Don’t Want to Bother You” – A Case Study in Social Anxiety Disorder. In: Woud, M.L. (eds) Interpretational Processing Biases in Emotional Psychopathology . CBT: Science Into Practice. Springer, Cham. https://doi.org/10.1007/978-3-031-23650-1_16

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Counselling Case Study: Social Anxiety

Sasha is a 60 year old woman who has recently retired from a career in teaching. Working for many years in a secondary school environment, Sasha was confident, motivated and dedicated to her work, but at the same time looking forward to retirement so she and her husband could travel and spend more time with their adult children who lived nearby.

However upon finishing work, Sasha found herself experiencing severe anxiety, particularly when around other people, and began not wanting to leave the house or invite people into the house. She also experienced bouts of crying when attempting to complete tasks such as housework and using the sewing machine. Sasha found her symptoms eased when she and her husband went on camping trips in national parks where they often did not see other people for days.

While working with Sasha, the Professional Counsellor adopts strategies from Cognitive Behavioural Therapy and Gestalt frameworks in order to address any irrational thoughts and behaviours which may be maintaining Sasha’s anxiety, and to complete any unfinished business which may have led to the development of her anxieties in the first place. For ease of writing, the Professional Counsellor is abbreviated to “C”.

Sasha was an unplanned baby, born after her older brother. Her parents did not want a second child but when they realised another was on the way, they hoped for another boy. As a child Sasha remembers always being in the background and her brother and father being the ‘important’ ones.

Sasha reported a vivid memory of coming home from school one day and finding no-one home. Sasha sat on the front porch and cried until her mother eventually came home and told her to stop being so silly. She described her mother as being more concerned with the state of the house than with her young daughter.

Sasha’s father died when she was very young, and she remembers her mother not coping well for a long time. During this time she (but not her brother) was often sent to her grandparents’ farm to give her mother a break. Here Sasha spent most days on her own. However she remembers these visits fondly, like ‘a lull in the storm’.

When her mother died, she left everything to Sasha’s brother, who was by then a well- paid solicitor with a young family. Sasha also had a young family but did not question her mother’s decision as she had been conditioned from childhood to believe males were more important.

Issues identified

Sasha’s symptoms appeared to be those of social anxiety disorder. They included:

• An extreme fear of situations where she may have to meet new people or be scrutinized by others.
• Social situations were either experienced with intense anxiety or avoided altogether.

When she did face these situations, she experienced physical symptoms such as sweating, shaking, tension, shaky voice, dry mouth and a pounding heart. The main symptom of this disorder involves feeling extreme anxiety in the presence of others. Sufferers often believe other people are very confident in public and that they are the only ones who aren’t.

Almost everyone experiences some social anxiety now and then; however social anxiety disorder severely limits the lifestyle of the sufferer, causing them to avoid making friends or miss important opportunities at work.

Formulation

In the first session, Sasha described her current physical symptoms and her feelings of hopelessness that she would never have the lifestyle she had dreamed of having in retirement. She was very tearful and her voice was quite high and shaky. She stuttered occasionally and her hands moved constantly, tearing the tissue she was holding to pieces.

She described trying to sew curtains and being overtaken by an uncontrollable fit of crying. She could not explain why this had made her so upset. She had also avoided inviting former work colleagues to her house for fear it would not be ‘good enough’. Her main concern was her daughter’s wedding, coming up in three months. She became more tearful talking about this, saying she did not know how the bride’s mother was supposed to look or act.

C then took a history of Sasha’s family background and noted that she had always been relegated to the background, leading to the core belief that she was unimportant. Sasha then described her work history which seemed to be in sharp contrast to her family experiences. C took some time to explore this with Sasha.

Sasha described being in the classroom as ‘being in control’. She felt that she had a good rapport with students and was good at her job. She often took on more than she could handle at work but somehow managed to get through it and was praised by her colleagues when she did this. It appeared that the only time Sasha had ever felt important was in the workplace.

However while she got along with other staff, she had made no real friends and had never had any friends throughout her life. C asked her why this was. Sasha became tearful again and said that she just wanted to go and live somewhere she wouldn’t have to see anyone except her husband and her children. She described her camping trips with her husband as being relaxed because she didn’t have to talk to other people. She experienced particular anxiety when her husband’s family visited as she felt pressure to be a perfect wife and housekeeper in their eyes.

Sasha mentioned that while she was working in the Education Department, she had been given a personality test to complete which had told her she was an extrovert. She was puzzled by this because she did not like people and clearly stated that it was not her goal in counselling to change this.

At this stage, C shared with Sasha her impression that Sasha appeared to have developed the belief that her authentic self was unacceptable and had created a false self to present to the world. This created intense anxiety because she was never quite sure who people wanted her to be from one situation to the next, requiring her to constantly scan her environment for clues as to how to feel and behave. Consequently it was easier to think about going away to a place where she would not have to see anyone, as she had done as a child at her grandparents’ farm. Only when she was away from people was she able to relax and feel in control.

Also, because she had married an introverted man who indulged her need to avoid social situations, she had learned to suppress her extroverted nature still further. It was no surprise that retirement was causing her such distress, since the only time she had ever felt important and comfortable around people had been in the work environment.

Session Content

Empty chair.

C decided to explore the unexpressed extroverted side of Sasha’s personality first. She asked Sasha what she did that was fun. Sasha could only list one item, the morning walk she took with her husband in the hills. Even this caused her concern however, because she felt she should be walking faster and further than she was.

Using the Gestalt technique known as Empty Chair, C placed a chair opposite Sasha and asked her if she would speak to the extroverted side of herself. Sasha found it difficult to stay in the first person and avoided this by talking directly to C. C guided her attention back to the empty chair and suggested she ask this part of herself what it would do if it could take over for a day.

When Sasha had done this, C asked her to move to the empty chair and reply as her extroverted self. Once seated in the other chair, Sasha began to relax and freely spoke about wanting to go to Dreamworld and wanting to make a quilt. When she returned to her original seat, C asked Sasha how she felt about allowing this side of her to have some fun. Sasha appeared reluctant but agreed to ask her husband if he would go to Dreamworld with her.

In the following session, Sasha reported she had not only gone to Dreamworld, but that they had purchased season tickets. Throughout the course of the counselling sessions, Sasha and her husband began visiting the theme park for half a day every week. She also started several creative projects, including hand quilting and scrap booking. She found these activities extremely difficult at first, but utilising cognitive-behavioural strategies to challenge her core beliefs, she was able to continue to the point where she was able to enjoy herself for the first time in years.

Cognitive Restructuring

Challenging and modifying a client’s faulty thought processes is the basis of Cognitive Behavioural Therapy (CBT). After Sasha had outlined several situations that were causing her anxiety, C helped her identify her beliefs about these situations. Sasha was shown that it was her beliefs about these situations which led to her bad feelings, and was encouraged to find more realistic alternative beliefs. Some of these processes included:

Activating event (A) = sewing

Belief (B) = I can’t do it well enough, I might as well give up

Consequence (C) = crying, giving up, bored and depressed

Dispute (D) = I’ll do my best and focus on enjoying myself rather than focusing on the outcome

A = husband’s family staying

B = they’ll see the state of my house and be horrified

D = I’ve got better things to do than clean the house and if they don’t like it, it doesn’t mean I’m a bad wife

A = attending daughter’s wedding

B = I’ll let her down and embarrass the whole family by saying or doing something wrong

D = people will be focusing on the bride, not me, so I’ll focus on her too

In this manner, Sasha was asked to practice disputing her thoughts for homework.

C then asked Sasha to use the Empty Chair technique to complete unfinished business with her mother, addressing her feelings about coming home to an empty house and then being told she was ‘silly’ for crying. Sasha had always believed her mother had treated her as insignificant because she had been such an inadequate child. Playing both roles, Sasha was able to see that her mother had her own agenda which made it difficult for her to have time for her daughter. After Sasha told her mother via the Empty Chair technique how she had felt in this situation, she realised the beliefs she had developed about herself were not necessarily accurate or helpful and could therefore be challenged.

Again reverting to CBT techniques, C asked Sasha to look for disconfirming evidence for the belief that she was inadequate. She was able to find many examples of this, chiefly in her work and as a mother to her own children. Sasha was asked to continue noticing examples like this on a daily basis. She was also asked to be aware of herself in the present moment as much as possible, rather than focusing on the past or the future. This allowed her to enjoy what she was doing, rather than focusing on previous failures and criticisms, or future ‘what ifs’.

Session Summary

Sasha’s counselling sessions focused on a number of issues:

• Integrating repressed parts of herself that were ‘unacceptable’
• Allowing her extroverted side to be expressed so she could take part in and enjoy pleasurable activities which lifted her depression
• Completing unfinished business with her mother
• Challenging her thoughts and behaviours – the belief that she was unimportant and the need to compensate by being perfect
• Learning to be present in the here and now, allowing her to focus on the activity at hand and enjoy it, rather than worrying about the outcome Experimenting with relaxing her perfectionist standards, which showed her that nobody else even noticed.
• Her daughter’s wedding – Sasha discovered that by distracting her thoughts about being around so many other people in such an important role at her daughter’s wedding, and instead focusing on the needs of her daughter and guests, her anxiety was no longer present.

Sasha’s experiments reinforced the fact that her thoughts were producing her anxiety, not other people. She realised that when she wasn’t focused on herself, her anxiety was no longer there. When she couldn’t distract her thoughts, she learned to modify them to something more realistic. By challenging her irrational belief that if she wasn’t perfect she was inadequate, she began to enjoy everyday activities and became much more relaxed. This was noticeable even in her voice, which lowered in tone, and in her generally more relaxed nonverbal behaviour.

As a result of implementing these strategies, Sasha found it a lot easier to be around other people. By learning to accept herself as she was, she no longer felt the need to guess what other people wanted from her, and began to feel comfortable presenting her authentic self to the world.

Author: Leanne Chapman is a Psychologist who has worked in community clinics and hospital settings with both children and adults. She has also conducted group therapy for patients with anxiety, depression and eating disorders at New Farm Clinic. In addition to her work with AIPC, Leanne operates a successful private practice.

• February 11, 2008
• Anxiety , Case Study , CBT , Gestalt , Stress
• Case Studies , Clinical Mental Health , Stress Management

Comments: 1

I found this article useful especially as it illustrates how effective forms of CBT can be in regard to treating anxiety. I thought the model used (ABC of Emotional Disturbance) was Albert Ellis’ Rational Emotive Behaviour Therapy. I think CBT and the ABC of Emotional Disturbance is sometimes attributed to the work of Beck and others. I have always understood that this was Ellis’ creation.

Thanks again for a very helpful article.

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8 Treatment of Social Anxiety Disorder: A Case Complicated by Panic Disorder

• Published: February 2013
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Chapter 8 covers the treatment of Social Anxiety Disorder (SAD), and includes information about the condition, epidemiological considerations, the case study, assessment strategy and case formulation, intervention model and course of treatment, strategies for handling homework non-compliance, handling poor attendance and relapse, relapse prevention, post-treatment assessment, basic science for this case/condition, alternative strategies to consider, ethical consideration, cultural factors, clinical implications, and avoiding common mistakes during treatment.

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A Study Of Social Anxiety And Perceived Social Support

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

Learn about our Editorial Process

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Social anxiety , a common mental health concern, can be greatly influenced by an individual’s perceived social support. Those with strong, supportive relationships often report lower levels of social anxiety, as they feel more secure and accepted in social situations. Conversely, individuals who lack a robust support system may experience heightened anxiety due to feelings of isolation and fear of negative evaluation. Developing social skills and building a reliable support network can be crucial for managing social anxiety . Improving communication abilities, assertiveness, and emotional expression can help individuals navigate social interactions more confidently and effectively. Moreover, having trusted friends, family members, or a therapist to provide encouragement, validation, and a safe space to practice social skills can be invaluable in reducing anxiety and fostering a sense of belonging.

• Social anxiety is associated with lower perceived social support among both men and women.
• Communication styles mediate the relationship between social anxiety and perceived social support, but the specific communication styles involved differ by gender.
• For both men and women, lower expressiveness explains some of the link between social anxiety and lower perceived social support.
• For men, lower preciseness also mediates the relationship between social anxiety and perceived social support. For women, lower verbal aggressiveness and higher emotionality play mediating roles.
• The study has limitations like using self-report measures and a predominantly female college student sample, but provides insights into how socially anxious individuals may be able to increase perceived social support through modifying communication styles.

Social anxiety is one of the most common anxiety disorders (Kessler et al., 2012) and has been linked to lower perceived social support (Calsyn et al., 2005; Davidson et al., 1994; Torgrud et al., 2004).

While the size of one’s social network influences perceived social support, other factors like satisfaction with available support matter more (Sarason et al., 1983).

Among women in relationships, self-disclosure helps explain the social anxiety-perceived support link (Cuming & Rapee, 2010), suggesting interpersonal communication plays a role.

However, more research is needed on how communication styles impact the relationship between social anxiety and perceived support, and potential gender differences.

Previous studies found socially anxious individuals are less emotionally expressive and assertive (Davila & Beck, 2002; Turk et al., 2005).

Gender differences also exist in social anxiety, communication, and social support. Women have higher rates of social anxiety (Asher et al., 2017) and are more expressive and polite, while men are more assertive and verbally aggressive (Basow & Rubenfeld, 2003).

Women tend to provide, receive (Neff & Karney, 2005), and perceive more social support than men (Kendler et al., 2005).

Building on this research, the current study examined six communication styles as mediators between social anxiety and perceived social support among men and women.

Understanding these relationships could inform interventions to help socially anxious individuals harness communication skills to increase perceived support.

This study explored relationships between social anxiety, perceived social support, and six communication styles (expressiveness, preciseness, verbal aggressiveness, questioningness, emotionality, and impression manipulativeness) among college students.

It also examined gender differences in these variables and whether communication styles mediated the link between social anxiety and perceived social support differently for men and women.

Participants completed an online survey with measures of social anxiety, communication styles, and perceived social support. The order of the measures was randomized.

813 psychology students (233 men, 580 women) at a large southern U.S. university participated. They ranged in age from 18-30 (M=20.56 years).

The sample was 52.8% White, 16.5% Black, 19.7% Hispanic, 8% Asian, and 3.1% other ethnicities.

• Social Interaction Anxiety Scale-6 (SIAS-6) & Social Phobia Scale-6 (SPS-6): 12 items total measuring social anxiety on a 5-point scale. The SIAS-6 assesses anxiety related to social interactions, while the SPS-6 measures fear of being scrutinized during routine activities.
• Communication Styles Inventory (CSI): 96 items assessing 6 communication domains (expressiveness, preciseness, verbal aggressiveness, questioningness, emotionality, and impression manipulativeness) on a 5-point scale. Each domain consists of 4 facets measuring specific aspects of that communication style.
• Multidimensional Scale of Perceived Social Support (MSPSS): 12 items measuring perceived support from family, friends, and significant others on a 7-point scale. The scale provides a subjective assessment of the adequacy of social support from these three sources.

Statistical Analysis

Descriptive statistics, bivariate correlations, and independent t-tests compared men and women.

Multiple mediation models using PROCESS tested communication styles as mediators between social anxiety and perceived support, separately for men and women.

As hypothesized, social anxiety was associated with lower perceived social support (H1).

For both genders, social anxiety was related to lower perceived support through lower expressiveness (H2).

Social anxiety was linked to lower support through higher emotionality for women only (H3).

The mediating communication styles differed by gender:

• For men, social anxiety was associated with lower support through lower preciseness.
• For women, social anxiety was linked to lower support through lower verbal aggressiveness and higher emotionality.

This study highlights that the way socially anxious individuals communicate influences their perceptions of available support.

While prior research found self-disclosure impacted the social anxiety-perceived support link just for women (Cuming & Rapee, 2010), the current study showed that for both genders, being less expressive and contributing less to conversations explained some of the relationship.

The gender-specific mediators align with research on gender norms in communication. For men, conveying ideas precisely and substantively seems important for feeling supported and fitting masculine norms around clear, outcome-focused communication (Mulac et al., 2001).

For women, lower verbal aggressiveness or a lack of assertiveness to marshal support when needed mediated the link, perhaps reflecting expectations for women to be less direct (Palomares, 2009).

Higher emotionality also played a role for women, suggesting that socially anxious women feel their sensitivity and emotional expressiveness could burden others and reduce support.

This study extends prior work by revealing communication styles as a mechanism linking social anxiety and perceived support. It suggests socially anxious individuals could benefit from interventions targeting communication skills to bolster confidence in their ability to garner support.

Future research could incorporate third-party observations of communication and longitudinal designs to clarify causal relationships.

This study had several strengths, including:

• Explored an understudied mechanism (communication styles) in the link between social anxiety and perceived social support
• Examined gender differences
• Used well-validated measures
• Tested multiple mediators simultaneously
• Large sample size (N=813)

Limitations

This study also had several limitations, including:

• Cross-sectional design prevents conclusions about directionality and causality
• Predominantly female sample limits generalizability
• Self-report measures introduce potential for bias; no behavioral observations of communication
• College student sample may not generalize to broader population

Implications

The findings suggest that psychotherapy for social anxiety could incorporate communication skills training to help individuals develop tools to increase their perception of social support.

Increasing expressiveness may benefit both men and women. However, clinicians may need to tailor interventions by gender, for example helping men communicate ideas clearly and succinctly, assisting women with healthy assertiveness, and normalizing emotionality.

With social anxiety one of the most prevalent disorders, better understanding its interpersonal effects and the role of communication could substantially improve sufferers’ relational experiences and mental health.

However, more research in representative samples using observational methods is needed to establish causal links and inform interventions.

Primary reference

Barnett, M. D., Maciel, I. V., Johnson, D. M., & Ciepluch, I. (2021). Social anxiety and perceived social support: Gender differences and the mediating role of communication styles.  Psychological Reports ,  124 (1), 70-87. https://doi.org/10.1177/0033294119900975

Other references

Asher, M., Asnaani, A., & Aderka, I. M. (2017). Gender differences in social anxiety disorder: A review.  Clinical psychology review ,  56 , 1-12. https://doi.org/10.1016/j.cpr.2017.05.004

Calsyn, R. J., Winter, J. P., & Burger, G. K. (2005). The relationship between social anxiety and social support in adolescents: A test of competing causal models.  Adolescence ,  40 (157), 103.

Cuming, S., & Rapee, R. M. (2010). Social anxiety and self-protective communication style in close relationships.  Behaviour Research and Therapy ,  48 (2), 87-96. https://doi.org/10.1016/j.brat.2009.09.010

Davila, J., & Beck, J. G. (2002). Is social anxiety associated with impairment in close relationships? A preliminary investigation.  Behavior Therapy ,  33 (3), 427-446. https://doi.org/10.1016/S0005-7894(02)80037-5

Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve‐month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States.  International journal of methods in psychiatric research ,  21 (3), 169-184. https://doi.org/10.1002/mpr.1359

Sarason, I. G., Levine, H. M., Basham, R. B., & Sarason, B. R. (1983). Assessing social support: the social support questionnaire.  Journal of personality and social psychology ,  44 (1), 127. https://doi.org/10.1037/0022-3514.44.1.127

Keep Learning

Here are some potential discussion questions for a college class on this paper:

• How might cultural norms and values impact the relationships between social anxiety, communication styles, and perceived social support? What cultural factors would be important to consider in future research?
• What are some specific ways psychotherapy could help socially anxious individuals modify their communication to increase perceived social support? What role could assertiveness training, expressive writing, or role-playing conversations play?
• If you were designing a longitudinal study to clarify the causal links between social anxiety, communication, and perceived support, what variables would you measure at each timepoint? What would be the ideal time lag between assessments?
• The current study found that emotionality was linked to lower perceived support for socially anxious women. However, could there be contexts where emotional expressiveness helps elicit support? What factors might moderate this relationship?
• How might the increasing prevalence of digital communication impact the relationships explored in this study? Would you expect communication styles to play a smaller or larger role in linking social anxiety to perceived support in online interactions compared to face-to-face?

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Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

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Jack manages his social anxiety

A case study about social anxiety disorder in an ex-serving member of the Australian Defence Force.

Time to read: 4 minutes

Jack, 28 years old, 10 years in the RAAF as an electronics technician

I reckon I was OK until high school. It was there that I started to get really anxious if I had to do a presentation to the class. I’d worry about it for days and the night before I couldn't sleep. When it came to the presentation, I’d be sweating, blushing, my mouth would go dry…it was like torture. It felt like everyone in the class was laughing at me. Other social situations were really difficult too. Going to parties, chatting up girls… I just　couldn't　do it. I’d stick close to one or two mates, let them do the talking, and just tag along. I've been pretty much the same ever since. When I was doing my tech training in the air force, I’d sit at the back of the class hoping no-one would notice me. If there was any chance I’d have to talk in front of the class, I’d call in sick or make some lame excuse. If it was a party, I’d get blind drunk first (and usually end up making a real dick of myself). I was OK if it was only a couple of mates, but with people I didn't know or large groups, I was cactus. I knew it was stupid and irrational, but that just made it worse. Why couldn't I just pull myself together and be confident like my mates?

Taking action

I was missing out on so much. My career was being affected – I should be a flight sergeant by now, but I never pushed myself forward. My social life was crap, and as for girlfriends… well, that seemed impossible. In the end I decided to bite the bullet. I couldn't face seeing anyone in uniform, so I found a GP in town and made an appointment. I was dead scared when the time came, but I forced myself to go in. The doctor was a woman about the same age as my Mum – I think that made it easier. She asked lots of questions like, did I avoid doing things because of being embarrassed, and did I worry a lot about what people thought of me? Of course, I said yes to all those and she told me I had "social anxiety" or "social phobia". It was a relief to know that it had a name and I wasn't the only person who had these problems. In fact, the doc said it was quite common, which made me feel a bit better. She also said there was a clinic at the university where they treated that kind of thing.

Well, long story short I rolled up to this clinic and they told me that I would go into a treatment group… a group for God’s sake. Didn't they understand that was my worst fear? But when I got there it was nowhere near as bad as I’d expected. Of course, I was terrified before I walked in, but all the others in the group had exactly the same problems as me and I knew they were finding it as hard as me to be there. We had to introduce ourselves and once I’d said something (and the world didn't end!) I felt like maybe I could do this group thing after all. We met every week for 12 weeks. We learnt about social anxiety and what causes it. We learnt ways to calm down physically, like relaxation and breathing. We discovered what a big impact our "self-talk" has on how we feel (I was telling myself how horrible this would be and how I’d look like a complete idiot, so I don’t know why I was surprised when I got anxious). The hardest – but I reckon the most important – part of treatment was the practical stuff. We had pretend meetings and parties, we went out to shopping centres and had to talk to strangers, we had to give talks… all those things I hated. But the more I did – combined with the other stuff we learnt – the easier it got.

Now? Well, I’m not exactly Mr Confident, but I’m a hell of a lot better and I don’t avoid things anymore. Sure, I still get anxious if I have to give a talk, but everyone does. I don’t put myself down. And I’ve met a girl… it’s early days, but we get on really well. I feel like my life is beginning to turn around.

Social Anxiety Disorder: Female 15-Year-Old Student Case Study

Background of the client, presenting the problem, assessment or diagnosis of the problem and justification of the assessment, treatment recommendations, client goals.

The client is a fifteen year old student called Joann. She has had trouble in school since her second grade. Joann reported class work problems and difficulties in test taking, as well. In earlier grades, she complained about difficulties in reading words and concentrating. However, as she grew older, the problems got worse; Joann experienced frequent headaches and reported occasional fainting spells.

These symptoms started when Joann was just about to complete her fifth grade, and they have persisted to date. Her teachers also noticed that excessive panic during tests also characterizes her school days. This panic often manifested as a physical illness, and came about when Joan needed to do group assignments or quizzes. She also had a fear of classroom questions throughout her childhood.

Joann’s academic performance seemed unaltered by these situations because her report cards were always above average, with A’s and B’s as her mean grades. Once in a while, Joann would get a C; furthermore, Joann attended school regularly, but she never enjoyed her experiences. Previously administered standardized tests also indicated that she had above average academic skills. Some of the tests that she did include: TerraNova and Metropolitan Achievement Tests.

This adolescent is a highly anxious one. The trait stems from Joann’s fear of tests, quizzes, and group assignments. She also has certain physical problems that include frequent headaches and occasional fainting episodes; they often manifest prior to these high-stress situations.

Joan tends to react negatively to compliments on her performance. She tries to neutralize any of these compliments by cutting down her efforts. Joann has the same reaction when adults try to give her reinforcement or compliment her for her exceptional work. This individual enters into a state denial when another person comments about her high-quality performance in an activity.

This adolescent feels isolated; she dislikes school and claims not have a favorite subject. However, she does relatively well in other non academic activities such as volleyball or basketball. Teachers and other instructors have not noticed any emotional distress in these areas. Joan continues to experience the same social and emotional problems that she had in the past; these include falling physically ill prior to: exams, group assignments and quizzes. Furthermore, she still suffers from frequent headaches and fainting spells. She also faces significant challenges with question-answering in class.

The adolescent under analysis suffers from performance anxiety that manifests as test anxiety and fear of classroom participation. This individual, therefore, possesses a social phobia, which the American Psychological Association (APA) recognizes in its DSM IV criteria (American Psychological Association, 2000). A person with performance anxiety, such as Joann, differs from others who experience universal fear because she experiences immense distress and disabling impairment in unrealistic dangers.

Common manifestations of performance anxiety include the fear of theatrical performance, the fear of eating in public, or the fear of writing in front of a large group of people. In this case, Joann has a fear of talking in public when asked to respond to classroom questions or participate in group assignments. Additionally, she has a problem with test taking. This is also another performance situation because she has to prove herself before the concerned assessors.

In order to classify an individual as one who suffers from performance anxiety, one must look for specific behavioral and cognitive signs. First, the person must object to performance situations or social situations that would expose him or her to scrutiny. He or she also fears performance situations because they might lead to embarrassment or humiliation. Furthermore, such a person usually thinks that he or she will not meet the required standard and will fail. In this case, Joann has all these signs; she dreads tests, classroom participation, and group assignments because she fears exposure to scrutiny. Since she often downplays her achievements, then it may also be true that Joann expects to fail in the tests or classroom activities.

Secondly, a person with performance anxiety manifests intense level of anxiety when placed in that performance situations (American Psychological Association, 2000). Examples of such anxious behavior include freezing, crying, tantrums and many more. Joann’s teachers continually report that this adolescent is extremely anxious prior to classroom tests and other academic milestones. Her headaches, fainting spells and physical illness indicate this level of stress.

Thirdly, a person with performance anxiety needs to recognize that his or her fear is excessive. However, analysts say that children do not have the ability to do so. Joann is an adolescent, so she has adult-like characteristics and child-like traits. The case study notes do not mention whether Joann recognizes that her fear is excessive. Nonetheless, one may assume that this is true owing to the differences in behavior that exist between Joann and her classmates before tests or classroom tasks.

Fourthly, an individual with this problem may try to avoid the performance situation, or may go through it with intense distress. Joann falls in the latter category. She explicitly stated that she dislikes school and has no favorite subject. Because Joann has no choice but to attend school, she does it with immense distress. Her headaches and fainting spells also prove this.

Lastly, people with this condition tend to function abnormally in social or occupation activities because of the avoidance, anxiety and anticipation inherent in their disorder. Joann is distressed about her phobia because she keeps struggling in her academic work. This problem is so severe that her educational administrators decided to study her situation.

One should not consider test anxieties and other performance anxieties as recognizable DSM IV disorders, i.e. social phobias, unless they are long lasting and cause marked psychological effects. Joann’s case has been quite prolonged, and it has clear effects on her behavioral and cognitive functioning. Furthermore, the condition should have lasted for longer than six months; Joann has had her condition from the second grade. This individual is quite sensitive to negative evaluation or rejection.

Joann manifests this symptom because tests and assessments are her main problem, yet people design tests to evaluate individuals. They may either result in positive or negative feedback; it is likely that Joann has a problem with negative comments from her instructors. If this problem persists, Joann’s academic performance may decrease substantially. In the long run, she may avoid other situations in her career that require her to take tests. This may hinder pursuance of jobs or promotions. She may settle for unsatisfying work because of the fear of evaluation of test taking in lucrative jobs.

This situation requires a multifaceted approach to the treatment of the problem, but all these components fall under cognitive behavior treatment. Psychologists assert that the most effective treatment for this psychological condition is cognitive-behavioral therapy (CBT). This method is not one-sided; it involves collaborative efforts between the therapist and the client. Joann and a therapist should each come up with ways of conquering her anxiety. The general goal in this choice of behavior is to transform the client into her own therapist; therefore, therapeutic sessions should last for a short time (Antony & Rowa, 2008). In this case, Joann should do 16 sessions only. This method of treatment also requires a focus on the present.

Although certain childhood experiences may have contributed to the problem, it is imperative to focus on behavioural patterns that exist presently, and perpetuate the client’s symptoms. The therapist should structure all the sessions in CBT. This means that the therapist will identify gaols for every single session. Joann will have to do ‘homework’, or unsupervised activities. The intention is to ascertain that she can experience real-life scenarios that necessitate a renewed manner of thinking. Lastly, research is the foundation for this proposed therapeutic method. Analysts have worked on clients with similar conditions and have found that CBT works (Hoffman & Otto, 2008).

The first step should involve psycho-education. One should learn about one’s problem in order to deal with test anxiety and performance anxiety. If a person recognizes that he or she has a psychological problem, then he or she can start working towards a solution. Joann needs to be educated about performance anxiety and social phobia in general. She should be told about its possible origins as well as its persistence in her since childhood. The individual should also learn that her performance anxiety – like all performance anxieties – is unique, so she should work hand in hand with the therapist in order to understand her conditions well (Hoffman & Otto, 2008).

Cognitive restructuring is another step that they should consider in treatment. The main cause of performance anxiety is holding negative beliefs about oneself and others. These beliefs often manifest as unhelpful thoughts in those performance situations. Cognitive restructuring will involve a joint effort between Joann, and her therapist to establish the negative thought patterns that cause her to have performance anxiety. The main point is to practice these thought patterns until Joann becomes skilled in detecting them.

That will allow her to come-up with strategies for looking at her experiences in different or harmless ways. Joann should keep saying positive things to herself whenever a stressful situation arises. For instance, when her teacher asks her to respond to a certain question, Joann might think “Oh my! I will give a silly answer, and everyone is going to think that I am stupid”. The therapist should teach her to say things such as “Everyone can give a wrong answer in class; it does not mean they are stupid” or “I am here to learn; no one expects me to have all the right answers”.

The therapist will need to write down these phrases and require Joann to memorize them. With time, the irrational thoughts that lead to her physical illnesses may start to subside. The same self-talk should go on when she receives compliments or reinforcements from her parents or peers. In the cognitive restructuring processes, the therapist should focus on teaching Joann how to believe in her own abilities as a student. Since she has above average grades, then she needs to realize that she can accomplish academic goals independently.

Treatment should also entail in vivo exposure. Joann will discuss with her therapist the situations that cause her to manifest the performance anxiety. Some of these situations are question-answering and group discussions. Joan will gradually enter those scenarios without fighting the anxiety; she will allow it to dissipate naturally. It is likely that Joann will find this as one of the most difficult components of therapy. Therefore, the therapist should pay a lot of attention. Exposure must be done gradually, and both parties should plan for it. The difference between Joann’s exposure in the present and Joan’s exposure in the past is that this time the therapist will be beside her when confronting that situation. He will give her support and ascertain that she learns valuable lessons from her experiences (Hoffman & Otto, 2008).

In this case study, no details are available regarding the existence of interoceptive situations. However, there is a serious possibility that this might be a problem for Joann. Some clients tend to fear anxiety-related physical symptoms that accompany the actual performance situation such as shivering, sweating and many others. Interoceptive exposure should be another method of dealing with Joann’s problems. Since she has physical symptoms such as headaches, she may have anxiety about dealing with that symptom when in pressure-filled situations; that may intensify her condition. The therapist should expose this adolescent to situations that can cause some mild physical symptoms. Familiarizing Joann with the performance-related ailments is likely to minimize anxiety.

Lastly, the treatment process should also involve social skills training and academic training. When in the middle of an academic-related performance situation, Joann feels like she does not have the necessary academic or social skills needed to meet expectations. Extreme self consciousness and negative self talk have created this scenario.

However, Joann would probably find it helpful to learn new skills like how to: have conversations, do effective listening, be assertive, and many more. She will probably appreciate some tips on classroom etiquette as well as improvement of her academic performance. Since her problem also revolves around tests, Joann could benefit from study tips on early test preparation and the like. She needs to prepare for the tests and read ahead. The latter step will assist her in dealing with the tensions that relate to poor performance (Antony & Rowa, 2008).

The session should also involve prevention of the physical illnesses in the performance situation; this specifically centers on the tests as well as the classroom discussions. Joann should learn about relaxation techniques in order to achieve this. Research shows that relaxation techniques play a tremendous role in coping with performance situations. One way of achieving this is through controlled breathing. The technique involves carrying out slow, regulated breathing. Joann should concentrate on the process of exhaling and inhaling.

To do this effectively, she will need to close her eyes so as to seal off other interfering factors. She can then take-in one breath, hold it for a while and exhale. Joann must then start counting the periods between her breaths. She can take in a deep breath and hold it for 5 seconds then exhale and hold it for five seconds. When she feels confident about the process, she can then count to ten when exhaling and inhaling. She may do this in class when the performance situation arises. Another method of relaxation is positive self talk.

This therapy session will involve self efficacy as the major goal. Self efficacy is a person’s ability to believe in his or her performance capability. The actions under consideration ought to relate to a desired outcome. Joan believes that one requires certain actions to sit for tests or to participate in group assignments. She also possesses those skills, but lacks the belief in her ability to execute them when in that situation. The client’s classmates may think that she has the right skills, but her subjective appraisal differs from this belief.

Therefore, working on this subjective belief can improve her outcomes. Other smaller goals (that will facilitate achievement of self efficacy) include verbal persuasion, performance accomplishment, and emotional or physiological arousal. When used out of context, verbal persuasion is the least successful method for handling performance anxiety. The therapist will only use this in relation to anxiety management. However, Joann will use verbal persuasion as explained in cognitive restructuring (Hoffman & Otto, 2008). Another treatment goal is performance accomplishment. The therapist will assist Joann to approach her fears rather than run away from them. Role playing and grading of tasks should help her.

It is likely that Joann will achieve self efficacy when she has mastered this situation. The therapist should avoid interruptions during role plays so as to allow Joann to commit to the condition. She must give feedback about her performance too. Lastly, the treatment will entail the mastery of physiological or emotional arousal. When excessive physiological arousal takes place, it tends to hinder performance. Joann’s headaches and fainting spells are a manifestation of this. Reducing this arousal is one of the goals of treatment. Joann will achieve this through relaxation techniques such as breathing and internal verbalizations like “I am packing my body with peaceful energy”.

Questions to the supervisor regarding assessment, treatment or goal issues of the client.

“Does Joann’s stress increase when she thinks about the accompanying symptoms?”: In one of the treatment approaches, the therapist should induce situations that mirror the performance situation so as to physiologically arouse Joann. If the physical illnesses do not bother Joann, then this may not be an effective intervention strategy.

“Do Joann’s parents have the financial resources for therapy?”: The methods suggested in this paper require regular sessions for at least four months; Joann will meet the therapist four times in a week for sixteen sessions. If her parents cannot afford these sessions, then this may undermine the method’s effectiveness.

“Is Joann motivated enough to solve this problem?”: Cognitive behavior therapy does not solve a client’s problems overnight. It takes a lot of patience and perseverance from the parties involved. Joann should have a deep desire to deal with her psychological challenges; otherwise, the method may not work.

“Is it ethical to induce some of the physiological symptoms of stress?”: Joann may be afraid of these symptoms, and these may add to her anxiety. It may be necessary to expose her to those situations to allay these fears. However, it may be unethical to cause the client too much discomfort.

“What happens when CBT fails?” It is necessary to know whether Joann be put on drugs.

American Psychological Association (2000). Diagnostic and Statistical manual of mental disorders . Washington DC: APA.

Antony, M. & Rowa, K. (2008). Social anxiety disorder: physiological approaches to assessment and treatment . Gottingen, Germany: Hogrefe Press.

Hoffman, S. & Otto, M. (2008). Cognitive behavior therapy for social anxiety disorder. Evidence based and disorder specific treatment techniques . NY: Routledge.

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Greater Good Science Center • Magazine • In Action • In Education

Four Habits to Help Kids With Social Anxiety

Anjali sat at the kitchen table in front of a blank piece of paper. She sat, and sat, and sat. Then she got up from the table and walked away. The unfinished task? A Valentine’s card for her grandmother.

What was the problem? Eleven-year-old Anjali was the one who had decided to make a card, so the problem was not a lack of care. What was holding her back was a fear that her card would not be good enough for her grandma. Although she was seated alone at the table, she was experiencing social anxiety.

Social anxiety involves fear of negative evaluation, and this fear can stem from social interactions or performing in front of others. As Anjali pondered the creation of her card, she was imagining that her grandma would negatively judge her card and reject her.

Performance and social anxiety can be a natural part of growing up, but they can become problematic if children begin to avoid situations that trigger their fears or their fears become overwhelming. For youth, social anxiety disorder is often identified during the teenage years, and it includes anxiety related to interacting with peers . Often we hear about cases of teens who avoid going to school and interacting socially.

Other forms of social anxiety in children can include fears of being awkward in front of peers, fears of displeasing authority figures, fears of negative evaluation from others, preoccupation with siblings’ judgments, or an unwillingness to try tasks that don’t bring immediate success. Of course, experiencing anxiety about how others perceive you is a normal part of being human; it doesn’t necessarily mean that a child has an anxiety problem. What can make a difference in their life trajectory is not so much the presence or absence of these patterns, but rather how a caregiver helps a child respond to their fears.

Here are four habits that can help kids and parents effectively respond to anxiety-related symptoms before they reach the debilitating level of a disorder.

1. Notice and name your feelings, thoughts, and sensations

The journey to coping effectively with any mental or emotional challenge always begins with awareness. Kids who are experiencing social anxiety need to become aware of the emotions, thought patterns, and body sensations that accompany their anxiety.

To help kids identify feelings patterns, I like to use the Feelings Habit Animal Quiz that I developed. There are four feelings-related animal habits that many kids have: Bear explodes with feelings, beaver obsesses about feelings, chameleon hides feelings, and deer is ashamed of feelings. Most kids quickly relate to one or more of these feelings habits.

Playfully identifying with a feelings animal can help kids observe their habits with less judgment. It is common for kids with social anxiety symptoms to have the beaver habit of obsessing and the deer habit of feeling ashamed, but it’s important to remember that kids with anxiety are not always quiet and timid. Kids with anxiety can also hide feelings or be explosive with feelings. The key is to help kids non-judgmentally recognize and name their feelings habits. Naming our feelings can help to deactivate the alarm center of the brain , which can allow kids to think more clearly.

In addition to identifying feelings, it can also be helpful for kids to notice their thought patterns. It is common for kids with social anxiety problems to have a number of distorted thinking patterns that contribute to their anxiety. For this reason, one common treatment is cognitive behavioral therapy (CBT), which can help kids identify these “cognitive distortions.”

When I teach kids about cognitive distortions, I call them “mind muddles.” Caregivers who would like to help kids informally learn about problematic thinking patterns could play a game of “pretend” with a child, imagining that a child’s favorite stuffed animal or toy is having big feelings and distorted thoughts. After listening to the stuffed toy’s thoughts, you could help the child to identify the mind muddles.

Just as I use a set of animals to talk about feelings, I use another set of animals to help kids learn resilience habits in both the Parent-Child Self-Compassion program that I’ve developed as well as the Quest for Self-Compassion workbook series. Spots the giraffe is the resilience animal that can help us to “spot” our feelings, thoughts, five-senses and sensations. In this excerpt from the first Quest for Self-Compassion workbook , Spots invites us to “spot” Bear’s mind muddles:

Once children are adept at noticing and labeling the mind muddles of their stuffed animals, you can begin labeling your own mind muddles out loud, and then eventually help kids identify their own.

2. Understand that you are not alone

In a recent study (not yet published) of the Self-Compassion for Children and Caregivers program, the number-one resilience habit that kids reported using was the “Buddy habit.” Buddy the dog is the resilience habit animal that helps us to remember that we are not alone when we experience hard things. Children reported that the “Buddy habit” helped them with all kinds of difficult feelings:

“I find the Buddy habit really helpful, whereas before . . . I was like ‘I’m the only person going through this.’” “The Buddy habit . . . taught me that everyone has feelings like this sometimes.”

Remembering that we are not alone can be especially helpful for kids dealing with social anxiety-related thoughts and feelings. Children with social anxiety are typically shame-prone and fearful of being negatively perceived by others. These children are often aware that their anxiety is not socially appropriate. Sometimes well-meaning adults tell kids that they “shouldn’t” feel anxious, but this just tends to compound kids’ anxiety and shame. What a child needs to hear instead is that other kids and grownups sometimes feel anxious, too. When an adult says, “Did I ever tell you about the time that I….” and shares about when they felt social anxiety, it creates a bridge to their child’s experience and helps the child internalize that they are not alone.

Caregivers can also expose their children to books in which the protagonists struggle with anxiety. Are You Mad at Me? is a delightful children’s book that tackles the topic of social anxiety in a playful way. When I left the book on a table in my living room, both of my daughters carefully read and reread the book. My younger daughter said, “What I love about it the most is that I can relate to it so much.”

3. Soothe and encourage yourself with kindness

Self-compassion is an antidote to shame, and studies of adults and youth who have taken self-compassion training have found significant decreases in their anxiety symptoms . In a nutshell, self-compassion invites us to learn to treat ourselves with the same kindness that we would offer to a good friend.

When I teach children about self-compassion, I introduce Snuggles the bunny. Snuggles can soothe us with kind words when we are struggling. Reassuring words include, “You are not alone, I’m here for you, and I care about you.”

When Snuggles dons a cape, it’s Super Snuggles. Super Snuggles can help kids to do hard things, including facing their anxiety fears. Super Snuggles likes to say, “I believe in you. You can do hard things. You’ve got this.”

One parent-based treatment program, Supportive Parenting for Anxious Childhood Emotions (SPACE), teaches parents to provide their children with both validating and encouraging words. Children need to know that adults understand their struggles with anxiety-related feelings and thoughts. They also need to know that we believe that they can handle their anxious feelings and do hard things.

4. Take action and celebrate progress

Let’s return now to Anjali’s fear of creating a card for her grandmother. I know a little bit more about this story, because I happen to be Anjali’s mom. And because I’m a self-compassion-for-children teacher, I was able to help her identify and name her fear, and understand that she was not alone; and I offered her both gentle validation and strong encouragement. We talked about the pictures and words she wanted to create, and with some effort she created the cover of the card. But when it came time to write the interior, she again froze. Aren’t you glad that I chose an example that did not have an easy ending!?

In Anjali’s case, she needed extra support to complete the interior of the card. Her anxiety was preventing her from putting words on paper, but she was able to engage in conversation about what she might want to say to her grandma. I recorded her words on my phone, and then I replayed the words and sat with her as she wrote the words in the card.

After her grandma’s card was complete, we called Grandma, who squealed with delight as Anjali shared it with her. I encouraged Anjali to soak in the goodness of her grandmother’s joy. We then together retold the story of her anxiety and connected it to the joy that she brought her grandma by creating the card despite her fear.

Often kids with anxiety want to avoid events that trigger their fear, but avoidance only compounds their anxiety over time. This is why recommendations for social anxiety emphasize helping children move forward in the face of fear.

Supporting children when they have anxiety is critical, and it’s also important to progressively help children learn to face fears independently. In the parent-based treatment program, SPACE, parents are taught to gradually reduce their accommodations to help children learn that they can cope and move forward in anxiety-provoking situations on their own.

Coincidentally, as I was writing this article, Anjali decided to make a birthday card for a friend’s birthday. Within 10 minutes, she had independently gotten the paper, written a note, and decorated and colored the card. When I asked her how she had whipped through it so quickly, she mentioned that she had seen kids give a friend very imperfect birthday cards the previous week, which had reduced her fear and increased her trust in her friends’ acceptance.

Does this mean that Anjali will no longer suffer from shame-prone social anxiety? Absolutely not. This is a process that we will walk through together again and again. It’s important to remember that there are myriad factors that will influence whether a child experiences anxiety on any given day, including their health, their relationship with others, and how much sleep they’ve gotten. Our job as caregivers is to equip kids with the ability to name their fears, understand that they are not alone, and help themselves through tender nurturing and strong action. Each time we bring resilience resources to a fear, we are placing another stone on the path that leads to freedom.

About the Author

Jamie lynn tatera.

Jamie Lynn Tatera is a certified Mindful Self-Compassion teacher with a passion for sharing self-compassion with children and their grownups. She is an educator, author, mom, and creator of the Self-Compassion for Children and Caregivers program.

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• Indian J Psychol Med
• v.41(3); May-Jun 2019

A Case Report of Psychotic Symptoms in Social Anxiety Disorder

Gitanjali natarajan.

Department of Clinical Psychology, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Sangeetha P. Louis

Praveen arathil.

1 Department of Psychiatry, Amrita Institute of Medical Sciences, Kochi, Kerala, India

Social phobias come under the category of phobic anxiety disorders and are centered around a fear of scrutiny by other people, usually leading to avoidance of social situations.[ 1 ] Although social anxiety has been found to be the most common comorbidity in people with psychosis,[ 2 ] social phobia or anxiety per se is a neurotic disorder in which the patient usually maintains an adequate touch with reality and is rarely associated with psychotic symptoms, beyond the self-referential feelings often observed in social anxiety disorder (SAD). Although there are a few contradictory pieces of evidence of the presence of psychotic symptoms in anxiety disorders,[ 3 , 4 ] it is usually accepted that there are clear lines of demarcation between anxiety disorders and psychosis. The exact prevalence of psychotic symptoms in SAD is not known. Although the presence of psychotic symptoms in SAD would have an immense impact on the severity, management, and prognosis of the disorder, there are only case reports available and the matter is not yet studied in a systematic manner. This case report details how a person with SAD gradually developed disorder-congruent delusions.

CASE REPORT

A 34-year-old married male, graduate in business administration, working as a clerical staff in the Middle East, premorbidly having anxious avoidant personality, presented to the clinical psychology department with a 3 years history of gradual onset of fear of blushing when meeting people and avoiding social interactions with familiar people, especially those in authority, after he started working in a new office. He had less anxiety when meeting unfamiliar people. His social phobia and avoidance increased in the last 2 years, with social interactions getting restricted to only his wife and child as well as colleagues during office work. He started avoiding phone conversations with friends and extended family members, as he believed that they would notice the change in his voice and come to know about his discomfort.

For the last 6 months, he started believing that his blushing during social interactions is offensive to others in the office. Moreover, he was convinced that his “fear of blushing” was contagious and was being transmitted to other people. He reported that he had transmitted his blushing to his supervisor who also started blushing during social encounters. He also believed that his supervisor was offended by the patient's presence, as he would blush more. Hence, the patient has been avoiding meeting his supervisor. Off late, he felt that more people in the office were finding him offensive, and he was transmitting the blushing to all of them. He wanted to stop going to the office, as he felt responsible for others’ discomfort. He returned to Kerala to get his problem treated.

There is no history suggestive of severe depression, as the patient did not have marked anhedonia, fatigue, or diminished activity. He had past history of low mood, feeling tired, and increase in sleep and appetite that persisted for a few months after he failed in his pre-degree examination 18 years back and it resolved without treatment. Family history of depression in paternal uncle, personal history of restrictive upbringing by parents, and premorbid anxious-avoidant traits were reported. Mental status examination showed low mood, worries about his social anxiety, and firm belief about others finding him offensive as he was transmitting “fear of blushing” to them. He admitted to the possibility that there could be something wrong in his mind, and hence, wanted treatment.

A detailed psycho-diagnostic assessment indicated average intellectual functioning, social anxiety, depressive symptoms, and a high tendency for fantasy. On Beck Depression Inventory scale, he got a score of 26 indicating moderate depressive symptoms; on Beck Anxiety Inventory scale, a score of 16 indicating mild anxiety symptoms; and on Social Interaction Anxiety scale, a score of 43 indicating presence of social anxiety disorder. The diagnosis of SAD was retained as the client did not fit the criteria for severe depression with psychotic symptoms or persistent delusional disorder.

Management involved a combination of paroxetine controlled release tablets and cognitive behavior therapy (CBT) involving cue-controlled relaxation, graded exposure, and cognitive restructuring. At 1 year follow-up, the patient still continued having the delusion that his boss had developed social anxiety and blushing through him, but it appeared to have become encapsulated and to be not interfering in his daily functioning in the office. He continued interacting with his boss through phone whenever possible. He no longer believed that he was transmitting social anxiety to all his colleagues. His interaction with colleagues was normal, and he was no longer reluctant to go to his office.

This case is different from a typical case of social phobia in two aspects: first by the presence of a firm belief that his symptoms of social anxiety, especially his fear of blushing, were contagious and his concern over spreading this fear to more and more people, and second, by his conviction that others found his social discomfort offensive.

The false belief in this patient is similar to the offensive subtype of Taijin-Kyofusho (TKS), a condition mentioned under SAD in Diagnostic and Statistical Manual of Mental Disorders 5.[ 5 ] The offensive subtype of TKS includes patients with a delusional conviction of offensiveness-persistent and excessive fear of causing offence to others in social circumstances by physical characteristics such as blushing, facial expressions, body odors, or intestinal noises. Cultural and societal norms engendering guilt, shame, and embarrassment are also likely etiological factors.[ 6 ] Belonging to a collective society with restricted upbringing, the patient would be more attentive and sensitive to the thoughts, feelings, and behaviors of significant others.

Three explanations have been suggested for the psychotic manifestations in SAD: (1) the individual's inability to challenge his social fears; (2) stressor and perpetuating role of SAD; and (3) the possibility of a primary thought abnormality leading to psychotic self-reference.[ 3 ] Greater paranoid ideation, in a non-clinical sample, was found to be associated with higher levels of social anxiety, avoidance, apprehension about evaluation, self-observation, and low self-esteem.[ 7 ]

The transformation of social apprehensions to a delusional level could also be explained using the changes in “social brain” and perception because of the increasingly worsening social isolation.[ 8 , 9 ] This could explain how the patient's initial fears of blushing and discomfort progressed into a delusional level with increasing isolation.

The patient improved with treatment focused on SAD - using Selective Serotonin Reuptake Inhibitor and CBT. Antipsychotics have been found to have a lower efficacy in SAD even when delusions are present. This may be because of the hypoactivity of dopaminergic circuits and D2 receptor found in SAD. Antipsychotics could further reduce dopamine action in a system that is already in deficit.[ 3 ]

The above case highlights that the commonly assumed demarcation between anxiety disorders and psychosis is questionable and points to the fragility of current diagnostic constructs. Affective and psychotic phenomena often co-occur, and such a co-occurrence predicts a poorer course and outcome, with greater persistence of schizotypal and negative symptoms, more illness behavior, greater likelihood of service use, and more evidence of familial liability for mental illness.[ 4 ] New diagnostic subcategories or expanding the social anxiety diagnosis to include psychotic symptoms, as in mood disorders, would have to be considered. This case also suggests that SAD with psychosis could be an entity midway in the dimensional spectrum between SAD and delusional disorder. In addition, the role of social isolation, secondary to social phobia, in the development of psychotic symptoms among patients with social phobia also needs to be further explored.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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• About Adverse Childhood Experiences
• Risk and Protective Factors
• Program: Essentials for Childhood: Preventing Adverse Childhood Experiences through Data to Action
• Adverse childhood experiences can have long-term impacts on health, opportunity and well-being.
• Adverse childhood experiences are common and some groups experience them more than others.

What are adverse childhood experiences?

Adverse childhood experiences, or ACEs, are potentially traumatic events that occur in childhood (0-17 years). Examples include: 1

• Experiencing violence, abuse, or neglect.
• Witnessing violence in the home or community.
• Having a family member attempt or die by suicide.

Also included are aspects of the child’s environment that can undermine their sense of safety, stability, and bonding. Examples can include growing up in a household with: 1

• Substance use problems.
• Mental health problems.
• Instability due to parental separation.
• Instability due to household members being in jail or prison.

The examples above are not a complete list of adverse experiences. Many other traumatic experiences could impact health and well-being. This can include not having enough food to eat, experiencing homelessness or unstable housing, or experiencing discrimination. 2 3 4 5 6

Quick facts and stats

ACEs are common. About 64% of adults in the United States reported they had experienced at least one type of ACE before age 18. Nearly one in six (17.3%) adults reported they had experienced four or more types of ACEs. 7

Preventing ACEs could potentially reduce many health conditions. Estimates show up to 1.9 million heart disease cases and 21 million depression cases potentially could have been avoided by preventing ACEs. 1

Some people are at greater risk of experiencing one or more ACEs than others. While all children are at risk of ACEs, numerous studies show inequities in such experiences. These inequalities are linked to the historical, social, and economic environments in which some families live. 5 6 ACEs were highest among females, non-Hispanic American Indian or Alaska Native adults, and adults who are unemployed or unable to work. 7

ACEs are costly. ACEs-related health consequences cost an estimated economic burden of $748 billion annually in Bermuda, Canada, and the United States. 8

ACEs can have lasting effects on health and well-being in childhood and life opportunities well into adulthood. 9 Life opportunities include things like education and job potential. These experiences can increase the risks of injury, sexually transmitted infections, and involvement in sex trafficking. They can also increase risks for maternal and child health problems including teen pregnancy, pregnancy complications, and fetal death. Also included are a range of chronic diseases and leading causes of death, such as cancer, diabetes, heart disease, and suicide. 1 10 11 12 13 14 15 16 17

ACEs and associated social determinants of health, such as living in under-resourced or racially segregated neighborhoods, can cause toxic stress. Toxic stress, or extended or prolonged stress, from ACEs can negatively affect children’s brain development, immune systems, and stress-response systems. These changes can affect children’s attention, decision-making, and learning. 18

Children growing up with toxic stress may have difficulty forming healthy and stable relationships. They may also have unstable work histories as adults and struggle with finances, jobs, and depression throughout life. 18 These effects can also be passed on to their own children. 19 20 21 Some children may face further exposure to toxic stress from historical and ongoing traumas. These historical and ongoing traumas refer to experiences of racial discrimination or the impacts of poverty resulting from limited educational and economic opportunities. 1 6

Adverse childhood experiences can be prevented. Certain factors may increase or decrease the risk of experiencing adverse childhood experiences.

Preventing adverse childhood experiences requires understanding and addressing the factors that put people at risk for or protect them from violence.

Creating safe, stable, nurturing relationships and environments for all children can prevent ACEs and help all children reach their full potential. We all have a role to play.

• Merrick MT, Ford DC, Ports KA, et al. Vital Signs: Estimated Proportion of Adult Health Problems Attributable to Adverse Childhood Experiences and Implications for Prevention — 25 States, 2015–2017. MMWR Morb Mortal Wkly Rep 2019;68:999-1005. DOI: http://dx.doi.org/10.15585/mmwr.mm6844e1 .
• Cain KS, Meyer SC, Cummer E, Patel KK, Casacchia NJ, Montez K, Palakshappa D, Brown CL. Association of Food Insecurity with Mental Health Outcomes in Parents and Children. Science Direct. 2022; 22:7; 1105-1114. DOI: https://doi.org/10.1016/j.acap.2022.04.010 .
• Smith-Grant J, Kilmer G, Brener N, Robin L, Underwood M. Risk Behaviors and Experiences Among Youth Experiencing Homelessness—Youth Risk Behavior Survey, 23 U.S. States and 11 Local School Districts. Journal of Community Health. 2022; 47: 324-333.
• Experiencing discrimination: Early Childhood Adversity, Toxic Stress, and the Impacts of Racism on the Foundations of Health | Annual Review of Public Health https://doi.org/10.1146/annurev-publhealth-090419-101940 .
• Sedlak A, Mettenburg J, Basena M, et al. Fourth national incidence study of child abuse and neglect (NIS-4): Report to Congress. Executive Summary. Washington, DC: U.S. Department of Health an Human Services, Administration for Children and Families.; 2010.
• Font S, Maguire-Jack K. Pathways from childhood abuse and other adversities to adult health risks: The role of adult socioeconomic conditions. Child Abuse Negl. 2016;51:390-399.
• Swedo EA, Aslam MV, Dahlberg LL, et al. Prevalence of Adverse Childhood Experiences Among U.S. Adults — Behavioral Risk Factor Surveillance System, 2011–2020. MMWR Morb Mortal Wkly Rep 2023;72:707–715. DOI: http://dx.doi.org/10.15585/mmwr.mm7226a2 .
• Bellis, MA, et al. Life Course Health Consequences and Associated Annual Costs of Adverse Childhood Experiences Across Europe and North America: A Systematic Review and Meta-Analysis. Lancet Public Health 2019.
• Adverse Childhood Experiences During the COVID-19 Pandemic and Associations with Poor Mental Health and Suicidal Behaviors Among High School Students — Adolescent Behaviors and Experiences Survey, United States, January–June 2021 | MMWR
• Hillis SD, Anda RF, Dube SR, Felitti VJ, Marchbanks PA, Marks JS. The association between adverse childhood experiences and adolescent pregnancy, long-term psychosocial consequences, and fetal death. Pediatrics. 2004 Feb;113(2):320-7.
• Miller ES, Fleming O, Ekpe EE, Grobman WA, Heard-Garris N. Association Between Adverse Childhood Experiences and Adverse Pregnancy Outcomes. Obstetrics & Gynecology . 2021;138(5):770-776. https://doi.org/10.1097/AOG.0000000000004570 .
• Sulaiman S, Premji SS, Tavangar F, et al. Total Adverse Childhood Experiences and Preterm Birth: A Systematic Review. Matern Child Health J . 2021;25(10):1581-1594. https://doi.org/10.1007/s10995-021-03176-6 .
• Ciciolla L, Shreffler KM, Tiemeyer S. Maternal Childhood Adversity as a Risk for Perinatal Complications and NICU Hospitalization. Journal of Pediatric Psychology . 2021;46(7):801-813. https://doi.org/10.1093/jpepsy/jsab027 .
• Mersky JP, Lee CP. Adverse childhood experiences and poor birth outcomes in a diverse, low-income sample. BMC pregnancy and childbirth. 2019;19(1). https://doi.org/10.1186/s12884-019-2560-8 .
• Reid JA, Baglivio MT, Piquero AR, Greenwald MA, Epps N. No youth left behind to human trafficking: Exploring profiles of risk. American journal of orthopsychiatry. 2019;89(6):704.
• Diamond-Welch B, Kosloski AE. Adverse childhood experiences and propensity to participate in the commercialized sex market. Child Abuse & Neglect. 2020 Jun 1;104:104468.
• Shonkoff, J. P., Garner, A. S., Committee on Psychosocial Aspects of Child and Family Health, Committee on Early Childhood, Adoption, and Dependent Care, & Section on Developmental and Behavioral Pediatrics (2012). The lifelong effects of early childhood adversity and toxic stress. Pediatrics, 129(1), e232–e246. https://doi.org/10.1542/peds.2011-2663
• Narayan AJ, Kalstabakken AW, Labella MH, Nerenberg LS, Monn AR, Masten AS. Intergenerational continuity of adverse childhood experiences in homeless families: unpacking exposure to maltreatment versus family dysfunction. Am J Orthopsych. 2017;87(1):3. https://doi.org/10.1037/ort0000133 .
• Schofield TJ, Donnellan MB, Merrick MT, Ports KA, Klevens J, Leeb R. Intergenerational continuity in adverse childhood experiences and rural community environments. Am J Public Health. 2018;108(9):1148-1152. https://doi.org/10.2105/AJPH.2018.304598 .
• Schofield TJ, Lee RD, Merrick MT. Safe, stable, nurturing relationships as a moderator of intergenerational continuity of child maltreatment: a meta-analysis. J Adolesc Health. 2013;53(4 Suppl):S32-38. https://doi.org/10.1016/j.jadohealth.2013.05.004 .

Adverse Childhood Experiences (ACEs)

ACEs can have a tremendous impact on lifelong health and opportunity. CDC works to understand ACEs and prevent them.