Social Anxiety Disorder
social anxiety disorder
Social anxiety disorder (formerly called social phobia) is characterized by extreme and persistent fear or anxiety and avoidance of social situations in which the person could potentially be evaluated negatively by others (APA, 2013). As with specific phobias, social anxiety disorder is common in the United States; a little over 12% of all Americans experience social anxiety disorder during their lifetime (Kessler et al., 2005).
The heart of the fear and anxiety in social anxiety disorder is the person’s concern that he may act in a humiliating or embarrassing way, such as appearing foolish, showing symptoms of anxiety (blushing), or doing or saying something that might lead to rejection (such as offending others). The kinds of social situations in which individuals with social anxiety disorder usually have problems include public speaking, having a conversation, meeting strangers, eating in restaurants, and, in some cases, using public restrooms. Although many people become anxious in social situations like public speaking, the fear, anxiety, and avoidance experienced in social anxiety disorder are highly distressing and lead to serious impairments in life. Adults with this disorder are more likely to experience lower educational attainment and lower earnings (Katzelnick et al., 2001), perform more poorly at work and are more likely to be unemployed (Moitra, Beard, Weisberg, & Keller, 2011), and report greater dissatisfaction with their family lives, friends, leisure activities, and income (Stein & Kean, 2000).
safety behaviors
When people with social anxiety disorder are unable to avoid situations that provoke anxiety, they typically perform safety behaviors: mental or behavioral acts that reduce anxiety in social situations by reducing the chance of negative social outcomes. Safety behaviors include avoiding eye contact, rehearsing sentences before speaking, talking only briefly, and not talking about oneself (Alden & Bieling, 1998). Other examples of safety behaviors include the following (Marker, 2013):
- assuming roles in social situations that minimize interaction with others (e.g., taking pictures, setting up equipment, or helping prepare food)
- asking people many questions to keep the focus off of oneself
- selecting a position to avoid scrutiny or contact with others (sitting in the back of the room)
- wearing bland, neutral clothes to avoid drawing attention to oneself
- avoiding substances or activities that might cause anxiety symptoms (such as caffeine, warm clothing, and physical exercise)
Although these behaviors are intended to prevent the person with social anxiety disorder from doing something awkward that might draw criticism, these actions usually exacerbate the problem because they do not allow the individual to disconfirm his negative beliefs, often eliciting rejection and other negative reactions from others (Alden & Bieling, 1998).
Explaining Social Anxiety Disorder
People with social anxiety disorder may resort to self-medication, such as drinking alcohol, as a means to avert the anxiety symptoms they experience in social situations (Battista & Kocovski, 2010). The use of alcohol when faced with such situations may become negatively reinforcing: encouraging individuals with social anxiety disorder to turn to the substance whenever they experience anxiety symptoms. The tendency to use alcohol as a coping mechanism for social anxiety, however, can come with a hefty price tag: a number of large-scale studies have reported a high rate of comorbidity between social anxiety disorder and alcohol use disorder (Morris, Stewart, & Ham, 2005).
As with specific phobias, it is highly probable that the fears inherent to social anxiety disorder can develop through conditioned experiences. For example, a child who is subjected to early unpleasant social experiences (e.g., bullying at school) may develop negative social images of herself that become activated later in anxiety-provoking situations (Hackmann, Clark, & McManus, 2000). Indeed, one study reported that 92% of a sample of adults with social anxiety disorder reported a history of severe teasing in childhood, compared to only 35% of a sample of adults with panic disorder (McCabe, Antony, Summerfeldt, Liss, & Swinson, 2003).
Behavioral Inhibition
One of the most well-established risk factors for developing social anxiety disorder is behavioral inhibition (Clauss & Blackford, 2012). Behavioral inhibition is thought to be an inherited trait, and it is characterized by a consistent tendency to show fear and restraint when presented with unfamiliar people or situations (Kagan, Reznick, & Snidman, 1988). Behavioral inhibition is displayed very early in life; behaviorally inhibited toddlers and children respond with great caution and restraint in unfamiliar situations, and they are often timid, fearful, and shy around unfamiliar people (Fox, Henderson, Marshall, Nichols, & Ghera, 2005). A recent statistical review of studies demonstrated that behavioral inhibition was associated with more than a sevenfold increase in the risk of development of social anxiety disorder, demonstrating that behavioral inhibition is a major risk factor for the disorder (Clauss & Blackford, 2012).
Generalized Anxiety Disorder
Alex was always worried about many things. He worried that his children would drown when they played at the beach. Each time he left the house, he worried that an electrical short circuit would start a fire in his home. He worried that his wife would lose her job at the prestigious law firm. He worried that his daughter’s minor staph infection could turn into a massive life-threatening condition. These and other worries constantly weighed heavily on Alex’s mind, so much so that they made it difficult for him to make decisions and often left him feeling tense, irritable, and worn out. One night, Alex’s wife was to drive their son home from a soccer game. However, his wife stayed after the game and talked with some of the other parents, resulting in her arriving home 45 minutes late. Alex had tried to call her cell phone three or four times, but he could not get through because the soccer field did not have a signal. Extremely worried, Alex eventually called the police, convinced that his wife and son had not arrived home because they had been in a terrible car accident.
generalized anxiety disorder
Alex suffers from generalized anxiety disorder: a relatively continuous state of excessive, uncontrollable, and pointless worry and apprehension. People with generalized anxiety disorder often worry about routine, everyday things, even though their concerns are unjustified (Figure 2). For example, an individual may worry about her health and finances, the health of family members, the safety of her children, or minor matters (e.g., being late for an appointment) without having any legitimate reason for doing so (APA, 2013). A diagnosis of generalized anxiety disorder requires that the diffuse worrying and apprehension characteristic of this disorder—what Sigmund Freud referred to as free-floating anxiety—is not part of another disorder, occurs more days than not for at least six months, and is accompanied by any three of the following symptoms: restlessness, difficulty concentrating, being easily fatigued, muscle tension, irritability, and sleep difficulties.
About 5.7% of the U.S. population will develop symptoms of generalized anxiety disorder during their lifetime (Kessler et al., 2005), and females are 2 times as likely as males to experience the disorder (APA, 2013). Generalized anxiety disorder is highly comorbid with mood disorders and other anxiety disorders (Noyes, 2001), and it tends to be chronic. Also, generalized anxiety disorder appears to increase the risk for heart attacks and strokes, especially in people with preexisting heart conditions (Martens et al., 2010).
Although there have been few investigations aimed at determining the heritability of generalized anxiety disorder, a summary of available family and twin studies suggests that genetic factors play a modest role in the disorder (Hettema et al., 2001). Cognitive theories of generalized anxiety disorder suggest that worry represents a mental strategy to avoid more powerful negative emotions (Aikins & Craske, 2001), perhaps stemming from earlier unpleasant or traumatic experiences. Indeed, one longitudinal study found that childhood maltreatment was strongly related to the development of this disorder during adulthood (Moffitt et al., 2007); worrying might distract people from remembering painful childhood experiences.