# Social anxiety

Social anxiety is the anxiety and fear specifically linked to being in social settings (i.e., interacting with others). Some categories of disorders associated with social anxiety include anxiety disorders, mood disorders, autism spectrum disorders, eating disorders, and substance use disorders. Individuals with higher levels of social anxiety often avert their gazes, show fewer facial expressions, and show difficulty with initiating and maintaining a conversation. Social anxiety commonly manifests itself in the teenage years and can be persistent throughout life; however, people who experience problems in their daily functioning for an extended period of time can develop social anxiety disorder. Trait social anxiety, the stable tendency to experience this anxiety, can be distinguished from state anxiety, the momentary response to a particular social stimulus. Half of the individuals with any social fears meet the criteria for social anxiety disorder. Age, culture, and gender impact the severity of this disorder. The function of social anxiety is to increase arousal and attention to social interactions, inhibit unwanted social behavior, and motivate preparation for future social situations.

## Disorder

Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by a significant amount of fear in one or more social situations causing considerable distress and impaired ability to function in at least some parts of daily life.$^{:15}$ These fears can be triggered by perceived or actual scrutiny from others. Social anxiety disorder affects 8% of women and 6.1% of men. In the United States, anxiety disorders are the most common mental illness. They affect 40 million adults, ages 18 and older. Anxiety can come in different forms and panic attacks can lead to panic disorders which is the recurrence of unexpected panic attacks. Other related anxiety disorders include social anxiety disorder, generalized anxiety disorder, obsessive compulsive disorder (OCD), various types of phobias, and post traumatic stress disorder (PTSD). Fortunately, it is highly treatable and not everyone needs the treatment.
Physical symptoms often include excessive blushing, excess sweating, trembling, palpitations, and nausea. Stammering may be present, along with rapid speech. Panic attacks can also occur under intense fear and discomfort. Some sufferers may use alcohol or other drugs to reduce fears and inhibitions at social events. It is common for sufferers of social phobia to self-medicate in this fashion, especially if they are undiagnosed, untreated, or both; this can lead to alcoholism, eating disorders or other kinds of substance abuse. SAD is sometimes referred to as an "illness of lost opportunities" where "individuals make major life choices to accommodate their illness". According to ICD-10 guidelines, the main diagnostic criteria of social anxiety disorder are fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating, often coupled with avoidance and anxiety symptoms. Standardized rating scales can be used to screen for social anxiety disorder and measure the severity of anxiety.

## Stages
### Child development

Some feelings of anxiety in social situations are normal and necessary for effective social functioning and developmental growth. The difficulty with identifying social anxiety disorder in children lies in determining the difference between social anxiety and basic shyness. Typically, children may be diagnosed when their social fears are extreme or cannot be outgrown. Cognitive advances and increased pressures in late childhood and early adolescence result in repeated social anxiety. More and more children are being diagnosed with social anxiety, and this can lead to problems with education if not closely monitored. Part of social anxiety is fear of being criticized by others, and in children, social anxiety causes extreme distress over everyday activities such as playing with other kids, reading in class, or speaking to adults. Some children with social anxiety may act out because of their fear, or they may exhibit nervousness or crying in an event where they feel anxious. Adolescents have identified their most common anxieties as focused on relationships with peers to whom they are attracted, peer rejection, public speaking, blushing, self-consciousness, panic, and past behavior. Most adolescents progress through their fears and meet the developmental demands placed on them.

### Adults

It can be easier to identify social anxiety within adults because they tend to shy away from any social situation and keep to themselves. Common adult forms of social anxiety include performance anxiety, public speaking anxiety, stage fright, and timidness. All of these may also assume clinical forms, i.e., become anxiety disorders (see below).
Criteria that distinguish between clinical and nonclinical forms of social anxiety include the intensity and level of behavioral and psychosomatic disruption (discomfort) in addition to the anticipatory nature of the fear. Social anxieties may also be classified according to the broadness of triggering social situations. For example, fear of eating in public has a very narrow situational scope (eating in public), while shyness may have a wide scope (a person may be shy of doing many things in various circumstances). The clinical (disorder) forms are also divided into general social phobia (i.e., social anxiety disorder) and specific social phobia.

## Signs and symptoms

Blushing is a physiological response unique to humans and is a hallmark physiological response associated with social anxiety. Blushing is the involuntary reddening of the face, neck, and chest in reaction to evaluation or social attention. Blushing occurs not only in response to feelings of embarrassment but also other socially-oriented emotions such as shame, guilt, shyness, and pride. Individuals high in social anxiety perceive themselves as blushing more than those who are low in social anxiety. Three types of blushing can be measured: self-perceived blushing (how much the individual believes they are blushing), physiological blushing (blushing as measured by physiological indices), and observed blushing (blushing observed by others). Social anxiety is strongly associated with self-perceived blushing, weakly associated with blushing as measured by physiological indices such as temperature and blood flow to the cheeks and forehead, and moderately associated with observed blushing. The relationship between physiological blushing and self-perceived blushing is small among those high in social anxiety, indicating that individuals with high social anxiety may overestimate their blushing. That social anxiety is associated most strongly with self-perceived blushing is also important for cognitive models of blushing and social anxiety, indicating that socially anxious individuals use both internal cues and other types of information to draw conclusions about how they are coming across. Individuals with social anxiety might also refrain from making eye contact, or constantly fiddling with things during conversations or public speaking. Other indicators are physical symptoms which may include rapid heartbeat, muscle tension, dizziness and lightheadedness, stomach trouble and diarrhea, unable to catch a breath, and “out of body” sensation.

## Attention bias

Individuals who tend to experience more social anxiety turn their attention away from threatening social information and toward themselves, prohibiting themselves from challenging negative expectations about others and maintaining high levels of social anxiety. For example, a socially anxious individual may perceive rejection from a conversational partner, turn their attention away, and never learn that the individual is actually welcoming. Individuals who are high in social anxiety tend to show increased initial attention toward negative social cues, such as threatening faces, followed by attention away from these social cues, indicating a pattern of hypervigilance followed by avoidance. Attention in social anxiety has been measured using the dot-probe paradigm, which presents two faces next to one another. One face has an emotional expression and the other has a neutral expression, and when the faces disappear, a probe appears in the location of one of the faces. This creates a congruent condition in which the probe appears in the same location as the emotional face and an incongruent condition. Participants respond to the probe by pressing a button and differences in reaction times reveal attentional biases. This task has produced mixed results, with some studies finding no differences between socially-anxious individuals and controls, some studies finding avoidance of all faces by socially-anxious individuals, and other studies finding vigilance by socially-anxious individuals only toward threat faces. The Face-in-the-crowd task shows that individuals with social anxiety are faster at detecting an angry face in a predominantly neutral or positive crowd or slower at detecting happy faces than a non-anxious person.
Focus on the self has been associated with increased social anxiety and negative affect. However, there are two types of self-focus: public and private. In public self-focus, one shows concern for the impact of one's own actions on others and their impressions. This type of self-focus predicts greater social anxiety. Other more private forms of self-consciousness (e.g., egocentric goals) are associated with other types of negative affect.
Basic science research suggests that cognitive biases can be modified. Attention bias modification training has been shown to temporarily impact social anxiety.

## Triggers and behaviors

Triggers are sets of events or actions that can remind someone of a previous trauma or feared consequence. Exposure to a trigger could lead a person to have an emotional or physical reaction. Individuals could also have behavioral changes, such as avoiding public places or situations that might direct excessive focus and attention toward them, such as public speaking or talking to new people. They also may not participate in certain activities for fear of embarrassment, which can lead to isolation. For someone who has social anxiety, this could lead them to have a panic attack. There are many negative side effects that can come from social anxiety if untreated, such as low self-esteem, trouble being assertive, hypersensitivity to criticism, poor social skills, becoming isolated, having difficulties with social relationships, low academic and employment achievements, substance abuse, and suicidal thoughts or attempts. Safety behaviors often involve avoidance of the trigger itself or of perceived threats when exposed to the trigger. For example, once in a feared social situation, a socially-anxious individual may avoid eye contact, speaking to strangers, or eating in front of others. Safety behaviors meant to make an individual feel safer have been found to most often enforce or validate anxious feelings, thus leading to a cycle in which the safety behavior is thought to be needed and the trigger's perceived threat is never challenged.

## Measures and treatment

Trait social anxiety is most commonly measured by self-report. This method possesses limitations, but subjective responses are the most reliable indicator of a subjective state. Other measures of social anxiety include diagnostic interviews, clinician-administered instruments, and behavioral assessments. No single trait social anxiety self-report measure shows all psychometric properties, including different kinds of validity (content validity, criterion validity, construct validity), reliability, and internal consistency. The SIAS along with the SIAS-6A and -6B are rated as the best. These measures include:
* Fear of Negative Evaluation (FNE) and Brief form (BFNE)
* Fear Questionnaire Social Phobic Subscale (FQSP)
* Interaction Anxiousness Scale (IAS)
* Liebowitz Social Anxiety Scale--Self Report (LSAS-SR)
* Older Adult Social-Evaluative Situations (OASES)
* Social Avoidance and Distress (SAD)
* Self-Consciousness Scale (SCS)
* Social Interaction Anxiety Scale (SIAS) and brief form (SIAS-6A and -6B)
* Social Interaction Phobia Scale (SIPS)
* Social Phobia and Anxiety Inventory (SPAI) and brief form (SPAI-23)
* Situational Social Avoidance (SSA)
Many types of treatments are available for Social Anxiety Disorder (SAD). The disorder can more effectively be treated if identified early, such as in the early teenage years when SAD onset usually occurs. Treatment is made more effective by considering individual patients’ backgrounds and needs and often by combining behavioral and pharmacological interventions. The first-line treatment for social anxiety disorder is cognitive behavioral therapy (CBT), with medications recommended only in those who are not interested in therapy. CBT is effective in treating social phobia, whether delivered individually or in a group setting. The cognitive and behavioral components seek to change thought patterns and physical reactions to anxiety-inducing situations. The cognitive part of CBT helps individuals with social anxiety challenge unhelpful thoughts and allow new patterns of positive or realistic thinking. The behavioral component involves taking action to challenge the identified negative thoughts, such as participating in an anxiety-inducing activity that isn't dangerous in reality. Challenging behaviors in this way is part of exposure therapy. The attention given to social anxiety disorder has significantly increased since 1999 with the approval and marketing of drugs for its treatment. Prescribed medications include several classes of antidepressants: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and monoamine oxidase inhibitors (MAOIs). Other commonly used medications include beta blockers and benzodiazepines. SAD is the most common anxiety disorder, with up to 10% of people being affected at some point in their life. Other treatments that individuals with social anxiety may find helpful include massages, meditation, mindfulness, hypnotherapy, and acupuncture.

## Development and evolutionary theories
### Social development in childhood

Fearful temperament and either underdeveloped social skills or excessive socialization of a child can cause the child to become hyper-aware of inappropriate social situations. Additional factors in upbringing which can increase the likelihood of a child to develop social anxiety include overprotection by parents, lack of an emotionally expressive home environment, and observation of other people's social fears or mistakes.

### Sensory processing sensitivity

Sensory processing sensitivity (SPS) is a temperamental or personality trait involving "an increased sensitivity of the central nervous system and a deeper cognitive processing of physical, social and emotional stimuli". The trait is characterized by "a tendency to 'pause to check' in novel situations, greater sensitivity to subtle stimuli, and the engagement of deeper cognitive processing strategies for employing coping actions, all of which is driven by heightened emotional reactivity, both positive and negative". Genetic inheritance of a high level of sensory processing sensitivity may increase an individual's awareness of social situations and their potential consequences.

### Biological adaptation to living in small groups

There is a suggestion that people have adapted to live with others in small groups. Living in a group is attractive to humans as there are more people to provide labor and protection, and there is a concentration of potential mates. Any perceived threat to group resources should leave an individual on guard, as should any potential position of status that might bring conflict with others. In effect, anxiety is adaptive because it helps people understand what is socially acceptable and what is not. The threat of exclusion from resources could lead to death.
Much of evolutionary theory is concerned with reproduction, so exposure to potential mates within a group is an evolutionary benefit. Finally, at a basic level, being confined to a particular group of people limits exposure to certain diseases. Studies have suggested that social affiliation has an impact on health, and, the more integrated and accepted we are, the healthier we are. All of these factors are evolutionary primers for humans to be sensitive to social situations and their potential consequences.

### Exclusion theory

At its simplest, social anxiety might come from as a basic human need to 'fit into' a given social group. Someone might be excluded due to their inability to contribute to a group, deviance from group standards, or even unattractiveness. Due to the benefits of living in a group, an individual would want to avoid social isolation at any cost. Knowing what is and is not seen as attractive to others allows individuals to anticipate and prevent rejection, criticisms, or exclusion by others. Humans are physiologically sensitive to social cues and therefore detect changes in interactions which may indicate dissatisfaction or unpleasant reactions. Overall, social anxiety may serve as a way for people to avoid certain actions that might bring anticipated social exclusion.