research paper on social anxiety

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Research Article

Social anxiety in young people: A prevalence study in seven countries

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Resilience Research Centre, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada

Roles Conceptualization, Methodology, Writing – review & editing

• Philip Jefferies, 
• Michael Ungar

• Published: September 17, 2020
• https://doi.org/10.1371/journal.pone.0239133
• Peer Review
• Reader Comments

Social anxiety is a fast-growing phenomenon which is thought to disproportionately affect young people. In this study, we explore the prevalence of social anxiety around the world using a self-report survey of 6,825 individuals (male = 3,342, female = 3,428, other = 55), aged 16–29 years (M = 22.84, SD = 3.97), from seven countries selected for their cultural and economic diversity: Brazil, China, Indonesia, Russia, Thailand, US, and Vietnam. The respondents completed the Social Interaction Anxiety Scale (SIAS). The global prevalence of social anxiety was found to be significantly higher than previously reported, with more than 1 in 3 (36%) respondents meeting the threshold criteria for having Social Anxiety Disorder (SAD). Prevalence and severity of social anxiety symptoms did not differ between sexes but varied as a function of age, country, work status, level of education, and whether an individual lived in an urban or rural location. Additionally, 1 in 6 (18%) perceived themselves as not having social anxiety, yet still met or exceeded the threshold for SAD. The data indicate that social anxiety is a concern for young adults around the world, many of whom do not recognise the difficulties they may experience. A large number of young people may be experiencing substantial disruptions in functioning and well-being which may be ameliorable with appropriate education and intervention.

Citation: Jefferies P, Ungar M (2020) Social anxiety in young people: A prevalence study in seven countries. PLoS ONE 15(9): e0239133. https://doi.org/10.1371/journal.pone.0239133

Editor: Sarah Hope Lincoln, Harvard University, UNITED STATES

Received: March 11, 2020; Accepted: August 31, 2020; Published: September 17, 2020

Copyright: © 2020 Jefferies, Ungar. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All data files are available from the Open Science Framework repository (DOI: 10.17605/OSF.IO/VCNF7 ).

Funding: The author(s) received no specific funding for this work.

Competing interests: I have read the journal's policy and the authors of this manuscript have the following competing interests: Unilever funds the lead author's research fellowship at Dalhousie University's Resilience Research Centre, though in no way have they directed this research, its analysis or the reporting or results.

Introduction

Social anxiety occurs when individuals fear social situations in which they anticipate negative evaluations by others or perceive that their presence will make others feel uncomfortable [ 1 ]. From an evolutionary perspective, at appropriate levels social anxiety is adaptive, prompting greater attention to our presentation and reflection on our behaviours. This sensitivity ensures we adjust to those around us to maintain or improve social desirability and avoid ostracism [ 2 ]. However, when out of proportion to threats posed by a normative social situation (e.g., interactions with a peer group at school or in the workplace) and when impairing functioning to a significant degree, it may be classified as a disorder (SAD; formerly ‘social phobia’; [ 3 ]). The hallmark of social anxiety in western contexts is an extreme and persistent fear of embarrassment and humiliation [ 1 , 4 , 5 ]. Elsewhere, notably in Asian cultures, social anxiety may also manifest as embarrassment of others, such as Taijin kyofusho in Japan and Korea [ 6 ]. Common concerns involved in social anxiety include fears of shaking, blushing, sweating, appearing anxious, boring, or incompetent [ 7 ]. Individuals experiencing social anxiety visibly struggle with social situations. They show fewer facial expressions, avert their gaze more often, and express greater difficulty initiating and maintaining conversations, compared to individuals without social anxiety [ 8 ]. Recognising difficulties can lead to dread of everyday activities such as meeting new people or speaking on the phone. In turn, this can lead to individuals reducing their interactions or shying away from engaging with others altogether.

The impact of social anxiety is widespread, affecting functioning in various domains of life and lowering general mood and wellbeing [ 9 ]. For instance, individuals experiencing social anxiety are more likely to be victims of bullying [ 10 , 11 ] and are at greater risk of leaving school early and with poorer qualifications [ 11 , 12 ]. They also tend to have fewer friends [ 13 ], are less likely to marry, more likely to divorce, and less likely to have children [ 14 ]. In the workplace, they report more days absent from work and poorer performance [ 15 ].

A lifetime prevalence of SAD of up to 12% has been reported in the US [ 16 ], and 12-month prevalence rates of .8% have been reported across Europe [ 17 ] and .2% in China [ 18 ]. However, there is an increasing trend to consider a spectrum of social anxiety which takes account of those experiencing subthreshold or subclinical social anxiety, as those experiencing more moderate levels of social anxiety also experience significant impairment across different domains of functioning [ 19 – 21 ]. Therefore, the proportion of individuals significantly affected by social anxiety, which include a substantial proportion of individuals with undiagnosed SAD [ 8 ], may be higher than current estimates suggest.

Studies also indicate younger individuals are disproportionately affected by social anxiety, with prevalence rates at around 10% by the end of adolescence [ 22 – 24 ], with 90% of cases occurring by age 23 [ 16 ]. Higher rates of social anxiety have also been observed in females and are associated with being unemployed [ 25 , 26 ], having lower educational status [ 27 ], and living in rural areas [ 28 , 29 ]. Leigh and Clark [ 30 ] have explored the higher incidence of social anxiety in younger individuals, suggesting that moving from a reliance on the family unit to peer interactions and the development of neurocognitive abilities including public self-consciousness may present a period of greater vulnerability to social anxiety. While most going through this developmentally sensitive period are expected to experience a brief increase in social fears [ 31 ], Leigh and Clark suggest that some who may be more behaviourally inhibited by temperament are at greater risk of developing and maintaining social anxiety.

Recent accounts suggest that levels of social anxiety may be rising. Studies have indicated that greater social media usage, increased digital connectivity and visibility, and more options for non-face-to-face communication are associated with higher levels of social anxiety [ 32 – 35 ]. The mechanism underpinning these associations remains unclear, though studies have suggested individuals with social anxiety favour the relative ‘safety’ of online interactions [ 32 , 36 ]. However, some have suggested that such distanced interactions such as via social media may displace some face to face relationships, as individuals experience greater control and enjoyment online, in turn disrupting social cohesion and leading to social isolation [ 37 , 38 ]. For young people, at a time when the development of social relations is critical, the perceived safety of social interactions that take place at a distance may lead some to a spiral of withdrawal, where the prospect of normal social interactions becomes ever more challenging.

Therefore, in this study, we sought to determine the current prevalence of social anxiety in young people from different countries around the world, in order to clarify whether rates of social anxiety are increasing. Specifically, we used self-report measures (rather than medical records) to discover both the frequency of the disorder, severity of symptoms, and to examine whether differences exist between sexes and other demographic factors associated with differences in social anxiety.

Materials and methods

This study is a secondary analysis of a dataset that was created by Edelman Intelligence for a market research campaign exploring lifestyles and the use of hair care products that was commissioned by Clear and Unilever. The original project to collect the data took place in November 2019, where participants were invited to complete a 20-minute online questionnaire containing measures of social anxiety, resilience, social media usage, and questions related to functioning across various life domains. Participants were randomly recruited through the market research companies Dynata, Online Market Intelligence (OMI), and GMO Research, who hold nationally representative research panels. All three companies are affiliated with market research bodies that set standards for ethical practice. Dynata adheres to the Market Research Society code of conduct; OMI and GMO adhere to the ESOMAR market research code of conduct. The secondary analyses of the dataset were approved by Dalhousie University’s Research Ethics Board.

Participants

There were 6,825 participants involved in the study (male = 3,342, female = 3,428, other = 55), aged 16–29 years (M = 22.84, SD = 3.97), from seven countries selected for their social and economic diversity (Brazil, China, Indonesia, Russia, Thailand, US, and Vietnam) (see Table 1 for full sample characteristics). Participant ages were collected in years, but some individuals aged 16–17 were recruited through their parents and their exact age was not given. They were assigned an age of 16.5 years in order to derive the mean age and standard deviation for the full sample.

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https://doi.org/10.1371/journal.pone.0239133.t001

Email invitations to participate were sent to 23,346 young people aged 16–29, of whom 76% (n = 17,817) were recruited to take the survey. These were panel members who had previously registered and given their consent to participate in surveys. Sixty-five percent of respondents were ineligible, with 10,816 excluded because they or their close friends worked in advertising, market research, public relations, journalism or the media, or for a manufacturer or retailer of haircare products. A further 176 respondents were excluded for straight-lining (selecting the same response to every item of the social anxiety measure, indicating they were not properly engaged with the survey; [ 39 ]). The final sample comprised 6,825 participants and matched quotas for sex, region, and age, to achieve a sample with demographics representative of each country.

Participants were compensated for their time using a points-based incentive system, where points earned at the end of the survey could be redeemed for gift cards, vouchers, donations to charities, and other products or services.

The survey included the 20-item self-report Social Interaction Anxiety Scale (SIAS; [ 40 ]). Based on the DSM, the SIAS was originally developed in conjunction with the Social Phobia Scale to determine individuals’ levels of social anxiety and how those with SAD respond to treatment. Both the SIAS and Social Phobia Scale correlate strongly with each other [ 40 – 43 ], but while the latter was developed to assess fears of being observed or scrutinised by others, the SIAS was developed more specifically to assess fears and anxiety related to social interactions with others (e.g., meeting with others, initiating and maintaining conversations). The SIAS discriminates between clinical and non-clinical populations [ 40 , 44 , 45 ] and has also been found to differentiate between those with social anxiety and those with general anxiety [ 46 ], making it a useful clinical screening tool. Although originally developed in Australia, it has been tested and found to work well in diverse cultures worldwide [ 47 – 50 ], and has strong psychometric properties in clinical and non-clinical samples [ 40 , 42 , 43 , 45 – 47 ].

For the current study, all 20 items of the SIAS were included in the survey, though we omitted the three positively-worded items from analyses, as studies have demonstrated that including them results in weaker than expected relationships between the SIAS and other measures, that they hamper the psychometric properties of the measure, and that the SIAS performs better without them [e.g., 51 – 53 ] (the omitted items were ‘I find it easy to make friends my own age’ , ‘I am at ease meeting people at parties , etc’ , and ‘I find it easy to think of things to talk about’ .). One item of the SIAS was also modified prior to use: ‘ I have difficulty talking to attractive persons of the opposite sex’ was altered to ‘ I have difficulty talking to people I am attracted to’ , to make it more applicable to individuals who do not identify as heterosexual, given that the original item was meant to measure difficulty talking to an attractive potential partner [ 54 ].

The questionnaire also included measures of resilience, in addition to other questions concerning functioning in daily life. These were included as part of a corporate social responsibility strategy to investigate the rates of social anxiety and resilience in each target market. A translation agency (Language Connect) translated the full survey into the national languages of the participants.

We analysed social anxiety scores for the overall sample, as well as by country, sex, and age (for sex, given the limited number and heterogeneity of individuals grouped into the ‘other’ category, we only compared males and females). As social anxiety is linked to work status [ 25 ], we also examined differences in SIAS scores between those working and those who were unemployed. Urban/rural differences were also investigated as previous research has suggested anxiety disorders may differ depending on where an individual lives [ 28 ]. Education level [ 27 ], too, was included using completion of secondary education (ISCED level 3) in a subgroup of participants aged 20 years and above to ensure all were above mandatory ages for completing high school. Descriptive statistics are reported for each group with significant differences explored using ANOVA (with Tukey post-hoc tests) or t-tests.

The SIAS is said to be unidimensional when using just the 17 straightforwardly-worded items [ 52 ], with item scores summed to give general social anxiety scores. Higher scores indicate greater levels of social anxiety. Heimberg and colleagues [ 42 ] have suggested a cut-off of 34 on the 20-item SIAS to denote a clinical level of social anxiety (SAD). This level has been adopted in other studies [e.g., 45 ] and found to accurately discriminate between clinical and non-clinical participants [ 53 ]. This threshold for SAD scales to 28.9 when just the 17 items are used, and this is slightly more conservative than others who have used 28 as an adjusted 17-item threshold [ 53 , 55 ]. Therefore, in addition to analyses of raw scores to gauge the severity of social anxiety (and reflect consideration of social anxiety as a spectrum), we also report the proportion of individuals meeting or exceeding this threshold for SAD (≥29) and analyse differences between groups using chi-square tests.

Additionally, despite the unidimensionality of the SIAS, the individual items can be interpreted as examples of contexts where social anxiety may be more or less acutely experienced (e.g., social situations with authority: ‘ I get nervous if I have to speak with someone in authority ’, social situations with strangers: ‘ I am nervous mixing with people I don’t know well ’). Therefore, as social anxiety may be experienced differently depending on culture [ 6 ], we also sorted the items in the measure to understand the top and least concerning contexts for each country.

Finally, we also sought to understand whether individuals perceived themselves as having social anxiety. After completing the SIAS, participants were presented with a definition of social anxiety and asked to reflect on whether they thought this was what they experienced. We contrasted responses with a SIAS threshold analysis to determine discrepancies, including assessment of the proportion of false positives (those who thought they had social anxiety but did not exceed the threshold) and false negatives (those who thought they did not have social anxiety but exceeded the threshold).

All analyses were conducted using SPSS v25 [ 56 ].

As the survey required a response for each item, there were no missing data. The internal reliability of the SIAS was found to be strong (α = .94), with the removal of any item resulting in a reduction in consistency.

Social anxiety by sex, age, and country

In the overall sample, the distribution of social anxiety scores formed an approximately normal distribution with a slightly positive skew, indicating that most respondents scored lower than the midpoint on the measure ( Fig 1 ). However, more than one in three (36%) were found to score above the threshold for SAD. There were no significant differences in social anxiety scores between male and female participants ( t (6768) = -1.37, n.s.) and the proportion of males and females scoring above the SAD threshold did not significantly differ either ( χ 2 (1,6770) = .54, n.s.).

https://doi.org/10.1371/journal.pone.0239133.g001

Social anxiety scores significantly differed between countries ( F (6,6818) = 74.85, p < .001, η p 2 = .062). Indonesia had the lowest average scores ( M = 18.94, SD = 13.21) and the US had the highest ( M = 30.35, SD = 15.44). Post-hoc tests revealed significant differences ( p s≤.001) between each of the countries, except between Brazil and Thailand, between China and Vietnam, between Russia and China, and between Russia and Indonesia (see Table 2 ). The proportion of individuals exceeding the threshold for SAD was also found to significantly differ between the seven countries (χ 2 (6,6825) = 347.57, p < .001). Like symptom severity, the US had the highest prevalence with more than half of participants surveyed exceeding the threshold (57.6%), while Indonesia had the lowest, with fewer than one in four (22.9%).

https://doi.org/10.1371/journal.pone.0239133.t002

A significant age difference was also observed ( F (2,6822) = 39.74, p < .001, η p 2 = .012), where 18-24-year-olds scored significantly higher ( M = 25.33, SD = 13.98) than both 16-17-year-olds ( M = 21.92, SD = 14.24) and 25-29-year-olds ( M = 22.44, SD = 14.22). Also, 25-29-year-olds scored significantly higher than 18-24-year-olds ( p s < .001). The proportion of individuals scoring above the threshold for SAD also significantly differed between age groups (χ 2 (2,6825) = 48.62, p < .001) ( Fig 2 ).

https://doi.org/10.1371/journal.pone.0239133.g002

A three-way ANOVA confirmed significant main effect differences in social anxiety scores between age groups ( F (2,6728) = 38.93, p < .001, η p 2 = .011) and countries ( F (6,6728) = 45.37, p < .001, η p 2 = .039), as well as the non-significant difference between males and females ( F (1,6728) = .493, n.s.). However, of the interactions between sex, age, and country, the two-way country*age interaction was significant ( F (12,6728) = 1.89, p = .031, η p 2 = .003), where 16-17-year-olds in Indonesia were found to have the lowest scores ( M = 15.70, SD = 13.46) and 25-29-year-olds in the US had the highest ( M = 30.47, SD = 16.17) ( Fig 3 ). There was also a significant country*sex interaction ( F (6,6728) = 2.25, p = .036, η p 2 = .002), where female participants in Indonesia had the lowest scores ( M = 18.07, SD = 13.18) and female participants in the US had the highest ( M = 30.37, SD = 15.11) ( Fig 4 ).

https://doi.org/10.1371/journal.pone.0239133.g003

https://doi.org/10.1371/journal.pone.0239133.g004

Work status

Social anxiety scores were also found to significantly differ in terms of work status (employed/studying/unemployed; F (2,6030) = 9.48, p < .001, η p 2 = .003), with those in employment having the lowest scores ( M = 23.28, SD = 14.32), followed by individuals who were studying ( M = 23.96, SD = 13.50). Those who were unemployed had the highest scores ( M = 26.27, SD = 14.54). Post-hoc tests indicated there were significant differences between those who were employed and unemployed ( p < .001), between those studying and unemployed ( p = .006), but not between those employed and those who were studying. The difference between those exceeding the SAD threshold between groups was also significant (χ 2 (2,6033) = 7.55, p = .023).

Urban/Rural

Social anxiety scores also significantly varied depending on an individual’s place of residence ( F (4,6820) = 9.95, p < .001, η p 2 = .006). However, this was not a linear relationship from urban to rural extremes ( Fig 5 ); instead, those living in suburban areas had the highest scores ( M = 25.64, SD = 14.08) and those in central urban areas had the lowest ( M = 22.70, SD = 14.67). This pattern was reflected in the proportions of individuals exceeding the SAD threshold (χ 2 (4,6825) = 35.84, p < .001).

https://doi.org/10.1371/journal.pone.0239133.g005

Education level

In the subsample of individuals aged 20 or above, level of education also resulted in a significant differences in social anxiety scores ( t (5071) = 5.51, p < .001), with individuals who completed secondary education presenting lower scores ( M = 23.40, SD = 14.15) than those who had not completed secondary education ( M = 27.94, SD = 15.07). Those exceeding the threshold for SAD also significantly differed (χ 2 (1,5073) = 38.75, p < .001), with half of those who had not finished secondary education exceeding the cut-off (52%), compared to just over a third of those who had (35%).

Concerns by context

Table 3 illustrates the items of the SIAS sorted by severity for each country. For East-Asian countries, speaking with someone in authority was a top concern, but less so for Brazil, Russia, and the US. Patterns became less discernible between countries beyond this top concern, indicating heterogeneity in the specific situations related to social anxiety, although individuals in most countries appeared to be least challenged by mixing with co-workers and chance encounters with acquaintances.

https://doi.org/10.1371/journal.pone.0239133.t003

Self-perceptions of social anxiety

Just over a third of the sample perceived themselves to experience social anxiety (34%). Although this was similar to the proportion of individuals who exceeded the threshold for SAD (36%), perceptions significantly differed from threshold results (χ 2 (1,6825) = 468.80, p < .001). Just fewer than half of the sample (48%) perceived themselves as not being socially anxious and were also below the threshold, and a fifth (18%) perceived themselves as being socially anxious and exceeded the threshold ( Fig 6 ). However, 16% perceived themselves to be socially anxious yet did not exceed the threshold (false positives) and 18% perceived themselves not to be socially anxious yet exceeded the threshold (false negatives). This suggests a large proportion of individuals do not properly recognise their level of social anxiety (over a third of the sample), and perhaps most importantly, that more than 1 in 6 may experience SAD yet not recognise it ( Table 4 ).

https://doi.org/10.1371/journal.pone.0239133.g006

https://doi.org/10.1371/journal.pone.0239133.t004

This study provides an estimate of the prevalence of social anxiety among young people from seven countries around the world. We found that levels of social anxiety were significantly higher than those previously reported, including studies using the 17-item version of the SIAS [e.g., 55 , 57 , 58 ]. Furthermore, our findings show that over a third of participants met the threshold for SAD (23–58% across the different countries). This far exceeds the highest of figures previously reported, such as Kessler and colleague’s [ 16 ] lifetime prevalence rate of 12% in the US.

As this study specifically focuses on social anxiety in young people, it may be that the inclusion of older participants in other studies leads to lower average levels of social anxiety [ 27 , 59 ]. In contrast, our findings show significantly higher rates of SAD than anticipated, and particularly so for individuals aged 18–24. It also extends the argument of authors such as Lecrubier and colleagues [ 60 ] and Leigh and Clark [ 30 ] that developmental challenges during adolescence may provoke social anxiety, especially the crucial later period when leaving school and becoming more independent.

We also found strong variations in levels of social anxiety between countries. Previous explorations of national prevalence rates have been less equivocal, with some reporting differences [ 6 ] while others have not [ 61 ]. Our findings concur with those of Hofmann and colleagues’ [ 6 ] who note that the US has typically high rates of social anxiety, which we also found (in contrast to other countries). However, the authors suggest Russia also has a high prevalence and that Asian cultures typically show lower rates. In contrast, we found samples from Asian countries such as Thailand and Vietnam had higher rates than in the sample from Russia, and that there were significant differences between Asian countries themselves ( Table 2 ). As our study used the SIAS, which determines how socially anxious an individual is based on their ratings of difficulty in specific social situation, one way of accounting for differences may be to consider the kinds of feared social situations that are covered in the measure. For instance, our breakdown of concerns by country ( Table 3 ) indicates that in Asian countries, speaking with individuals in authority is a strongly feared situation, but this is less challenging in other cultures. For non-Asian countries, one of the strongest concerns was talking about oneself or one’s feelings. In Asian countries, where there is typically less of an emphasis on individualism, talking about oneself may be less stressful if there is less perceived pressure to demonstrate one’s uniqueness or importance. Future investigations could further explore cultural differences in social anxiety across different types of social situations or could confirm cross-cultural social anxiety heterogeneity by using approaches that are less heavily tied to determining social anxiety within given contexts (e.g., a diagnostic interview), as many of the commonly used measures appear to be [ 62 , 63 ].

Our findings also provide mixed support for investigations of other demographic differences in social anxiety. First, previous studies have tended to indicate that female participants score higher than males on measures of social anxiety [ 27 , 64 ]. Although the samples from Brazil and China reflected this, we found no difference between males and females in the overall sample, nor in samples from Indonesia, Russia, Thailand, US, or Vietnam. Sex-related differences in social anxiety have been attributed to gender differences, such as suggestions that girls ruminate more, particularly about relationships with others [ 65 , 66 ]. It is possible that as gender roles and norms vary between countries, and in some instances start to decline, so may differences in social anxiety, which younger generations are likely to reflect first. However, given the unexpected finding that males in Vietnam scored significantly higher than their female counterparts, further investigation is needed to account for the potentially culturally nuanced relationship between sex and social anxiety.

We also confirmed previous findings that higher levels of social anxiety are associated with lower levels of education and being unemployed. Although these findings are in-line with previous research [ 27 , 64 ], our study cannot shed light on causal mechanisms; longitudinal research is required to establish whether social anxiety leads individuals to struggle with school and work, whether struggling in these areas provokes social anxiety, or whether there is a more dynamic relationship.

Finally, we found that 18% of the sample could be classified as “false negatives”. This sizeable group felt they did not have social anxiety, yet their scores on the SIAS considerably exceeded the threshold for SAD. It has been said that SAD often remains undiagnosed [ 67 ], that individuals who seek treatment only do so after 15–20 years of symptoms [ 68 ], and that SAD is often identified when a related condition warrants attention (e.g., depression or alcohol abuse; Schneier [ 5 ]). It has also been reported that many individuals do not recognise social anxiety as a disorder and believe it is just part of their personality and cannot be changed [ 3 ]. Living with an undiagnosed or untreated condition can result in substantial economic consequences for both individuals and society, including a reduced ability to work and a loss of productivity [ 69 ], which may have a greater impact over time compared to those who receive successful treatment. Furthermore, the variety of avoidant (or “safety”) behaviours commonly associated with social anxiety [ 70 , 71 ] mean that affected individuals may struggle or be less able to function socially, and for young people at a time in their lives when relationships with others are particularly crucial [ 72 , 73 ], the consequences may be significant and lasting. Greater awareness of social anxiety and its impact across different domains of functioning may help more young people to recognise the difficulties they experience. This should be accompanied by developing and raising awareness of appropriate services and supports that young people feel comfortable using during these important developmental stages [see 30 , 74 ].

Study limitations

Our ability to infer reasons for the prevalence of SAD is hindered by the present data being cross-sectional, and therefore only allowing for associations to be drawn. We are also unable to confirm the number of clinical cases in the sample, as we did not screen for those who may have received a professional diagnosis of SAD, nor those who are receiving treatment for SAD. Additionally, the use of an online survey incorporating self-report measures incurs the risk of inaccurate responses. Further research could build on this investigation by surveying those in middle and older age to discover whether rates of social anxiety have also risen across other ages, or whether this increase is a youth-related phenomenon. Future investigations could also use diagnostic interviews and track individuals over time to determine the onset and progression of symptoms, including whether those who are subclinical later reach clinical levels, or vice versa, and what might account for such change.

On a global level, we report higher rates of social anxiety symptoms and the prevalence of those meeting the threshold for SAD than have been reported previously. Our findings suggest that levels of social anxiety may be rising among young people, and that those aged 18–24 may be most at risk. Public health initiatives are needed to raise awareness of social anxiety, the challenges associated with it, and the means to combat it.

Acknowledgments

The authors would like to acknowledge the role of Edelman Intelligence for collecting the original data on behalf of Unilever and CLEAR as part of their mission to support the resilience of young people.

• View Article
• PubMed/NCBI
• Google Scholar
• 3. National Collaborating Centre for Mental Health (UK). Social Anxiety Disorder: Recognition, assessment and treatment. Leicester, UK: British Psychological Society; 2013. Report No.: NICE Clinical Guidelines, No. 159. https://www.ncbi.nlm.nih.gov/books/NBK327674/
• 4. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: Author; 2013.
• 29. McNeil DW. Evolution of terminology and constructs in social anxiety and its disorders. Social anxiety: Clinical, developmental, and social perspectives, 2nd ed. San Diego, CA, US: Elsevier Academic Press; 2010. pp. 3–21. https://doi.org/10.1016/B978-0-12-375096-9.00001-8
• 33. Dobrean A, Păsărelu C-R. Impact of social media on social anxiety: a systematic review. New Developments in Anxiety Disorders. London, UK: IntechOpen; 2016. https://www.intechopen.com/books/new-developments-in-anxiety-disorders/impact-of-social-media-on-social-anxiety-a-systematic-review
• 44. Blanc ALL, Bruce LC, Heimberg RG, Hope DA, Blanco C, Schneier FR, et al. Evaluation of the psychometric properties of two short forms of the Social Interaction Anxiety Scale and the Social Phobia Scale. Assessment. 2014 [cited 31 Jan 2020].
• 56. IBM Corp. IBM SPSS Statistics. Armonk, NY: IBM Corp; 2017.
• 63. Liebowitz MR, Pharmacopsychiatry MP. Social phobia. 1987.
• 72. Brown BB, Larson J. Peer relationships in adolescence. Handbook of adolescent psychology: Contextual influences on adolescent development, Vol 2, 3rd ed. Hoboken, NJ, US: John Wiley & Sons Inc; 2009. pp. 74–103.
• 73. Collins WA, Steinberg L. Adolescent development in interpersonal context. 6th ed. Handbook of child psychology. 6th ed. New York, NY: John Wiley & Sons, Inc; 2007. pp. 1003–1067. https://doi.org/10.1002/9780470147658.chpsy0316

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Social anxiety and social anxiety disorder

Affiliation.

• 1 Department of Psychology, Temple University, Philadelphia, Pennsylvania 19122, USA. [email protected]
• PMID: 23537485
• DOI: 10.1146/annurev-clinpsy-050212-185631

Research on social anxiety and social anxiety disorder has proliferated over the years since the explication of the disorder through cognitive-behavioral models. This review highlights a recently updated model from our group and details recent research stemming from the (a) information processing perspective, including attention bias, interpretation bias, implicit associations, imagery and visual memories, and (b) emotion regulation perspective, including positive emotionality and anger. In addition, we review recent studies exploring the roles of self-focused attention, safety behaviors, and post-event processing in the maintenance of social anxiety. Within each area, we detail the ways in which these topics have implications for the treatment of social anxiety and for future research. Finally, we conclude with a discussion of how several of the areas reviewed contribute to our model of social anxiety disorder.

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• Safety behaviors, self-focused attention and negative thinking in children with social anxiety disorder, socially anxious and non-anxious children. Kley H, Tuschen-Caffier B, Heinrichs N. Kley H, et al. J Behav Ther Exp Psychiatry. 2012 Mar;43(1):548-55. doi: 10.1016/j.jbtep.2011.07.008. Epub 2011 Jul 22. J Behav Ther Exp Psychiatry. 2012. PMID: 21831344
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• Cognitive-behavioral approaches to the treatment of social anxiety disorder. Singh JS, Hope DA. Singh JS, et al. Isr J Psychiatry Relat Sci. 2009;46(1):62-9. Isr J Psychiatry Relat Sci. 2009. PMID: 19728574 Review.
• Does how individuals handle social situations exacerbate the relationship between physique anxiety and food addiction? The role of emotional expressive suppression and social avoidance and distress. Li Y, Fan Y, Lin J, Shi S. Li Y, et al. PeerJ. 2024 Aug 16;12:e17910. doi: 10.7717/peerj.17910. eCollection 2024. PeerJ. 2024. PMID: 39161967 Free PMC article.
• Sport anxiety and subjective happiness of college athletes: a self-determination theory perspective. Zhang Z, Chen X, Xu L, Qin X, Veloo A. Zhang Z, et al. Front Psychol. 2024 Jul 24;15:1400094. doi: 10.3389/fpsyg.2024.1400094. eCollection 2024. Front Psychol. 2024. PMID: 39114588 Free PMC article.
• Abnormal large-scale brain functional network dynamics in social anxiety disorder. Zhang X, Wu B, Yang X, Kemp GJ, Wang S, Gong Q. Zhang X, et al. CNS Neurosci Ther. 2024 Aug;30(8):e14904. doi: 10.1111/cns.14904. CNS Neurosci Ther. 2024. PMID: 39107947 Free PMC article.
• Mindfulness, social evaluation anxiety, and self-regulation: exploring their association on impulsive behavior among athletes. Zhong Z, Jiang H, Wang H, Liu Y. Zhong Z, et al. Front Psychiatry. 2024 May 14;15:1404680. doi: 10.3389/fpsyt.2024.1404680. eCollection 2024. Front Psychiatry. 2024. PMID: 38807692 Free PMC article.
• Adolescent Social Anxiety, School Satisfaction, Family Emotional Support, and School Absenteeism: Findings from Young-HUNT3 and Norwegian National Education Data. Halidu MD, Kotera Y. Halidu MD, et al. J Clin Med. 2024 Apr 26;13(9):2547. doi: 10.3390/jcm13092547. J Clin Med. 2024. PMID: 38731079 Free PMC article.

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• Research article
• Open access
• Published: 23 April 2019

Social anxiety increases visible anxiety signs during social encounters but does not impair performance

• Trevor Thompson   ORCID: orcid.org/0000-0001-9880-782X 1 ,
• Nejra Van Zalk 2 ,
• Christopher Marshall 3 ,
• Melanie Sargeant 4 &
• Brendon Stubbs 5  

BMC Psychology volume  7 , Article number:  24 ( 2019 ) Cite this article

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Preliminary evidence suggests that impairment of social performance in socially anxious individuals may be specific to selective aspects of performance and be more pronounced in females. This evidence is based primarily on contrasting results from studies using all-male or all-female samples or that differ in type of social behaviour assessed. However, methodological differences (e.g. statistical power, participant population) across these studies means it is difficult to determine whether behavioural or gender-specific effects are genuine or artefactual. The current study examined whether the link between social anxiety and social behaviour was dependent upon gender and the behavioural dimension assessed within the same study under methodologically homogenous conditions.

Ninety-three university students (45 males, 48 females) with a mean age of 25.6 years and varying in their level of social anxiety underwent an interaction and a speech task. The speech task involved giving a brief impromptu presentation in front of a small group of three people, while the interaction task involved “getting to know” an opposite-sex confederate. Independent raters assessed social performance on 5 key dimensions from Fydrich’s Social Performance Rating Scale.

Regression analysis revealed a significant moderate association of social anxiety with behavioral discomfort (e.g., fidgeting, trembling) for interaction and speech tasks, but no association with other performance dimensions (e.g., verbal fluency, quality of verbal expression). No sex differences were found.

Conclusions

These results suggest that the impairing effects of social anxiety within the non-clinical range may exacerbate overt behavioral agitation during high demand social challenges but have little impact on other observable aspects of performance quality.

Peer Review reports

Social anxiety disorder (SAD) is a common psychiatric disorder, with up to 1 in 8 people suffering from SAD at some point in their life [ 1 ]. SAD is linked to reduced quality of life, occupational underachievement and poor psychological well-being, and is highly comorbid with other disorders [ 2 ]. Mounting evidence suggests that social anxiety exists on a severity continuum [ 3 ], and that social anxiety that is not severe enough to warrant a diagnosis of SAD may still produce significant individual burden [ 4 ].

There is little evidence to suggest that social anxiety may negatively affect others’ perceptions of agreeableness or warmth [ 5 ]. However, if social anxiety impairs an individual’s ability to function effectively in common performance situations such as job interviews, presentations and other social challenges [ 6 ], this could cause or maintain feelings of failure and inadequacy and even affect career success [ 7 ]. Cognitive models [ 8 ] predict that social anxiety could impair social competence by increasing self-focused attention and consuming attentional resources necessary for effective communication. On the other hand, social anxiety can also lead to a willingness to engage in socially-facilitative behavior such as polite smiling, head nodding and avoiding interruption, which can facilitate interaction and lead to more favorable impression of another’s social behavior [ 9 ].

While socially anxious individuals reliably believe their social behavior is deficient, the existence of actual impairment has been the subject of a fair amount of debate [ 10 ]. Empirical studies that have examined the association between social anxiety and behavior in response to social challenge tasks in both clinical and non-clinical samples have produced inconsistent findings. Strahan and Conger [ 11 ], for example, compared the responses of 26 men with low social anxiety with 27 men reporting clinical levels of social anxiety on the Social Phobia and Anxiety Inventory in their response to a simulated job interview. Observer ratings of videotaped interviews indicated no group differences in overall social competence ratings. Rapee and Lim [ 12 ] found that, when asked to give a brief impromptu speech, a group of 28 individuals with SAD did not differ in observer ratings of overall performance relative to a group of 33 non-clinical controls. Similar null results have been reported in a non-clinical sample of males on overall impressions of social skill on an opposite-sex “getting to know you” task [ 13 ], and in a sample of 110 schoolchildren participating in a two-minute impromptu speech where observers rated video recordings for global impressions and “micro-behaviors” (e.g., clarity of speech, ‘looking at the camera’) [ 14 ].

However, a number of other studies have identified a link between social anxiety and impaired social behavior. Levitan et al. [ 15 ] found that patients with SAD were rated significantly more poorly on observer ratings of voice intonation and fluency during a three-minute speech compared to controls. Other studies have also found patients with SAD to be rated more poorly by observers on adequacy of eye contact and speech clarity [ 16 ] and as exhibiting more “negative social behaviors” (e.g. awkwardness) during conversations [ 17 , 18 ]. In a non-clinical study of 48 women, Thompson and Rapee [ 18 ] found individuals with high social anxiety to be rated more poorly during an opposite-sex “getting to know you” task on summed measures of molecular (e.g. voice quality, conversational skill) behaviors and on overall impression.

A recent review by Schneider and Turk [ 10 ] suggests that the apparently variable link between social anxiety and behavior is likely to be influenced by differences across studies in factors such as statistical power, sample characteristics and the type of behavioral assessments used. Assessment measures, for example, have ranged from global impression ratings to composite scores of molecular behaviors (e.g., smiling frequency, eye contact), and it may be that social anxiety impairs certain social behaviors but not others. There is some evidence that social anxiety may selectively exacerbate observable anxiety signs but have little impact on performance ‘quality’ (e.g. factors central to effective communication) [ 14 , 19 ]. Schneider and Turk [ 10 ] note, however, that it is difficult to identify a coherent pattern that identifies which aspects of performance may be impaired by social anxiety and which may not and this is additionally complicated by differences in study designs. Furthermore, where associations of social anxiety across multiple behavioral dimensions have been examined within the same study, where they are evaluated under the same conditions, these differences have rarely been compared statistically which limits the reliability of the current evidence for selective deficits in social behavior [ 20 ].

Norton [ 21 ] also notes that studies using exclusively female samples have often found stronger associations of social anxiety with behavioral deficits than studies with male samples, consistent with the argument that gender-role expectations may lead to more deleterious effects of social anxiety in women [ 22 ]. Again, however, it is impossible to determine with any certainty whether more pronounced effects of social anxiety in studies with females is attributable to moderating effects of gender or some other difference in study characteristics. Unfortunately, few studies have directly compared males and females, or different performance dimensions, within the same study where there is greater methodological homogeneity.

This study aimed to assess social behavior during social challenges in a non-clinical sample of individuals varying in their levels of social anxiety. We used speech and interaction tasks, as these represent different types of commonly-encountered social challenges. Performance was assessed by independent raters using Fydrich’s Social Performance Rating Scale, which consists of five separate dimensions of social competence. The aim of the study was to examine whether social anxiety is associated with impaired social behavior, and in particular: (1) whether impairment occurs only for specific dimensions of behavior, and (2) whether impairing effects are greater in females.

Participants

The sample consisted of 93 participants (45 males and 48 females) with a mean age of 25.6 years ( SD  = 7.7, Range = 18–53). Males ( M  = 26.5 years) and females ( M  = 24.7 years) did not differ significantly with respect to age, t (86)  = 1.12, p  = .26. Scores on the Social Phobia Scale were lower for males (M = 17.1, SD = 9.68) compared to females (M = 22.7, SD = 12.7), and this difference reached statistical significance, t (91) = 2.36, p  = .02.

The mean SPS score of the current sample was 20.0 ( SD  = 11.6, range = 2–48). Compared to McNeil et al.’s (1995) reference data, this is significantly lower than the mean SPS score of individuals with SAD, M  = 32.8, SD  = 14.8, t (57) = 5.86, p  < .001, but significantly higher than undergraduates, M  = 13.4, SD  = 9.6, t (144) = 3.69, p  < .001, and community volunteers, M  = 12.5, SD  = 11.5, t (141) = 3.70, p  < .001. The mean age of these comparison groups was higher (SAD sample M  = 36.5 years, community sample M  = 33.2 years, with age data not reported for undergraduates) than the current sample.

An exclusion criterion of previous acquaintance with the experimenters was implemented, as familiarity may have reduced the effectiveness of the social challenge tasks as anxiety inductions. A recruitment request was e-mailed to all students at Greenwich University which stated that “volunteers are sought to take part in a paid (£10) study which will involve filling in some questionnaires, engaging in a conversation task and talking to others about a set topic, giving your views”.

Anxiety and social behavior scales

Mattick and Clarke’s Social Phobia Scale (SPS) Footnote 1 was used to assess level of trait social anxiety. The SPS consists of 20 items rated on a five-point (0–4) scale, with higher scores indicating greater social anxiety. The scale has been shown to reliably assess social anxiety in both non-clinical and clinical populations [ 23 ]. The SPS has previously demonstrated good test-retest reliability, internal consistency and convergent validity [ 24 , 25 ] and exhibited high internal consistency (Cronbach’s α = .89) for the current data.

State anxiety was assessed in order to verify that the speech and interaction tasks resulted in increased anxiety relative to participants’ baseline anxiety. Baseline anxiety was assessed with a single self-report item that asked respondents to indicate their current anxiety on a scale of 1–10. State anxiety was also assessed immediately prior to the commencement of each task (participants had been provided with task details a few minutes earlier), and immediately after each task where participants were asked to rate the anxiety they had felt during the task itself. Single-item assessments of state anxiety have shown good reliability and convergent validity [ 26 ].

The Social Performance Rating Scale (SPRS) [ 27 ] was used to rate the participant on the following five dimensions: Gaze - adequacy of eye contact, Vocal Quality – warmth, clarity and enthusiasm demonstrated in verbal expression, Length – low level of monosyllabic speech/excessive talking, Discomfort – low levels of behavioral anxiety (e.g., fidgeting, trembling, postural tension), and Flow - verbal fluency (including the ability to incorporate information provided by the conversation partner smoothly into the interaction). The flow item was not used in the assessment of the speech task, as the rating descriptors for this component are specific to conversation. All SPRS items were rated on a 5-point scale and scored so that higher scores represented more effective social performance. Detailed descriptive anchors accompany each rating point to facilitate scoring; for example, Vocal Quality, “5 (Very Good) = Participant is warm and enthusiastic in verbal expression without sounding condescending or gushy”. The SPRS has shown excellent inter-rater reliability, internal consistency, convergent, discriminant and criterion validity [ 27 , 28 ]. Agreement across the three raters assessing the speech task was examined with an intraclass correlation (ICC). An absolute-agreement model was used [ 29 ], which is a stringent test requiring both high inter-rater correlations and minimal discrepancy in actual rating values to produce a high ICC. Analysis revealed ICC’s = .64–.86 for individual SPRS dimensions (all p’s < .001), suggesting good rater agreement [ 30 ]. Scores were therefore averaged across raters for each individual SPRS dimension for the speech task. Similar means (range: 3.4–3.8) and standard deviations (range: 0.7–1.1) were observed across SPRS components for both interaction and speech tasks.

Speech task

Participants were given 3 min to prepare a speech presenting a persuasive argument on their choice of one of the following topics: “sometimes it is ok to lie, discuss” or “can any crime be justified?”. Participants were told they would be presenting in front of a small audience and that they should try to keep going for 3 min although they could terminate the task at any point. Three confederates (one male and two female) comprised the “audience” for the speech task, with the same three-confederate audience used for each participant. The confederate audience had previously undertaken a number of trial sessions with several undergraduate volunteers acting as participants where they had practiced maintaining neutral facial expressions.

Interaction task

Participants were told that they would shortly be introduced to someone and that they would have 3 min to find out as much as they could about this person, although they could terminate the task at any time. The conversation partner was an experimental confederate, who was of the opposite-sex in order to maximize socially-evaluative challenge [ 6 ]. The same male confederate was used for each female participant, and the same female confederate was used for each male participant, with the one male and one female confederate taken from the pool of three confederates used in the speech task. Confederates had previously undertaken a number of trial sessions amongst each other and with undergraduate volunteers, where they practiced giving minimal responses, avoiding asking questions and maintaining neutral facial expressions [ 6 ]. Nobody other than the participant and the confederate was present during the interaction task when the experiment began.

To put participants in a relaxed state for a reliable assessment of baseline state anxiety, and to provide time for the experimenter to prepare the social challenge tasks, participants watched a 5-min relaxation video showing images of various seascapes accompanied by relaxing sounds. They then immediately completed the baseline state anxiety item along with the Social Phobia Scale and were randomized to undergo either the speech or interaction task first.

Participants were given details of the first social challenge task and reminded that they had the right to withdraw from the study at any point (no withdrawals occurred). Immediately prior to the social challenge task, participants completed the state anxiety item to assess anticipatory anxiety. Immediately following the task, participants again completed the state anxiety item, retrospectively indicating the anxiety they had experienced during the task. Participants were independently rated on their social performance by the audience of confederates (speech task) or the conversation partner (interaction task) using the SPRS, with ratings not disclosed to participants. This procedure was then repeated with the second social challenge task.

Statistical analysis plan

The association of social anxiety and sex with observer ratings was examined by conducting separate regression analyses on each SPRS dimension, with predictors of social anxiety, sex (− 1 = males, + 1 = females) and a Social Anxiety X Sex interaction term. Social anxiety was standardized but SPRS ratings were left unstandardized, so that the raw regression coefficient is interpreted as the mean change in rating points (on the 1–5 scale) following a one standard deviation increase in social anxiety. The interaction term was computed by cross-multiplication of sex and standardized social anxiety scores [ 31 ].

To determine whether regression coefficients of social anxiety and behavioral ratings differed significantly across the different SPRS dimensions, we tested the equality of these coefficients within a structural equation model. Predictors were the same as for the multiple regression analysis described above, and outcome variables were two SPRS dimensions (specified with correlated errors) whose coefficients were to be compared. We then imposed an equality constraint on the coefficient of social anxiety with each of two performance dimension coefficients. If a likelihood ratio test indicates a significant decrease in fit when an equality constraint is used, this indicates that the two coefficients are not equal [ 32 ]. Analyses were conducted in R using the lavaan [ 33 ] package .

Data screening

Regression residual plots for SPRS ratings revealed normality and homoscedasticity assumptions were met with no obvious outliers present. A negative skew of speech and interaction task times (due to a ceiling effect from the 3-min time limit) was observed, so p -values for analysis of task time data were computed from 10,000 bootstrapped samples.

Social challenge tasks: anxiety manipulation check

Consistent with the successful induction of anxiety, paired t-tests found significant increases from baseline anxiety for the speech task at pre-task ( t (92) =5.58, p  < .001) and during-task ( t (92) =9.92, p  < .001) periods, and for the interaction task at pre-task ( t (92) =5.84, p  < .001) and during-task periods ( t (92) =5.69, p  < .001) (see Table  1 for mean task anxiety scores at each assessment period). To check that anxiety was induced in both male and female participants, t-tests were repeated for each gender separately. For males, significant increases from baseline anxiety were uniformly found at pre-task ( t (44) =3.61, p  < .001) and during-task ( t (44) =5.63, p  < .001) in the speech task, and pre-task ( t (44) =2.52, p  = .015) and during-task ( t (44) =4.15, p  < .001) in the interaction task. This pattern of results was replicated for females, with significant increases from baseline anxiety observed at pre-task ( t (47) =4.49, p  < .001) and during-task ( t (47) =8.58, p  < .001) for the speech task, and pre-task ( t (47) =5.89, p  = .015) and during-task ( t (47) =4.03, p  < .001) for the interaction task.

Table 1 also reports correlations of social anxiety and gender with self-reported anxiety and shows social anxiety to be consistently moderately associated with increased anxiety response, and additionally that females generally reported greater anxiety compared to males.

Some participants terminated the social challenge tasks before the 3-min limit (speech M  = 127  s , interaction M  = 177  s ). As such, we computed the association between social anxiety and task time, as observers’ ratings might conceivably be affected by early task termination. No significant association was observed for either speech ( r  = −.02, p  = .88) or interaction ( r  = −.19, p  = .13) tasks.

Primary analysis

Separate regression analyses were performed on each SPRS dimension for the speech and interaction tasks resulting in 9 regression tests (4 SPRS speech dimensions, 5 SPRS interaction dimensions). To control type I error rate, we used an adjusted alpha criterion of α = .021 based on the Dubey-Armitage Parmar correction [ 34 ], which adjusts the conventional level of .05 based on the number of tests conducted (9) and the mean correlation between outcomes ( r  = .59 for SPRS ratings).

Speech task: social anxiety, sex and SPRS ratings

Table  2 shows the unstandardized ( B ) and standardized ( ß ) coefficients of social anxiety with observer ratings on each SPRS item resulting from the regression analysis of the speech task. These results show that social anxiety was a significant predictor of increased discomfort 2 ( B  = -0.28, ß  = -0.42 , p  < .001), but not of gaze, vocal quality or length. There were no significant sex (Table 3 ) or Social Anxiety X Sex interaction effects ( p  = .10–.96).

With respect to the magnitude of the association between social anxiety and SPRS discomfort, as SPRS ratings were left unstandardized, B represents the mean change in SPRS discomfort ratings on the 5-point scale for a one SD increase in social anxiety. As such, this indicates that a change from − 1 SD (low) to + 1 SD (high) social anxiety is associated with a 0.56-point increase in discomfort. Footnote 2

Interaction task: social anxiety, sex and SPRS ratings

For the interaction task, social anxiety was significantly associated with ratings on the discomfort dimension ( B  = -0.36, ß  = -.45, p  < .001), but not with other SPRS dimensions (Table 2 ). No significant sex (Table 3 ) or interaction effects ( p  = .09–.98) were observed. The unstandardized regression coefficient of B  = -0.36 for discomfort indicates that a change from − 1 SD (low) to + 1 SD (high) social anxiety is associated with a 0.72-point increase 2 in discomfort.

Comparison of regression coefficients of social anxiety across SPRS dimensions

A likelihood ratio test was used to compare the regression coefficient of social anxiety for SPRS discomfort with regression coefficients for the other SPRS dimensions. For the speech task, the coefficient for SPRS discomfort was significantly greater than all other SPRS dimensions (χ 2  = 6.56–17.65, all p ’s < .01). For the interaction task, the coefficient was significantly greater for SPRS discomfort compared to all other SPRS dimensions (χ 2  = 4.37–5.36, all p ’s < .05) except SPRS gaze (χ 2  = 1.31, p  = .25). Footnote 3

One of the primary findings from this study was that social anxiety was associated with higher observer ratings of behavioral discomfort (e.g., fidgeting, trembling, swallowing) during interaction and speech tasks, but not with other dimensions such as verbal fluency or quality of verbal expression.

Previous research investigating the link between social anxiety and social behavior has produced inconsistent results. It has been suggested that this inconsistency could be partially attributable to differences across studies in the dimension of social behavior assessed, with social anxiety potentially impairing only some behavioral dimensions; although no coherent pattern of which elements of social behavior may be affected has emerged [ 10 ]. The current results suggest that, at the non-clinical level at least, social anxiety may magnify the visible signs of anxiety but have little impact on other social behavior dimensions that were assessed here. These results are broadly consistent with Bögels et al. [ 19 ] who compared performance ratings for undergraduates low and high in social anxiety. They found that socially anxious participants received significantly more negative ratings on a “showing anxiety symptoms” factor, but not on a “skilled behavior” factor. Similarly, Cartwright-Hatton et al. [ 14 ] found that social anxiety scores were significantly associated with observer ratings of nervousness in schoolchildren based on a videotaped two-minute presentation, but not with “overall” impressions of performance (based on three items of ‘cleverness of speech’, friendliness and performance quality). It is difficult to determine from these previous studies if this is indicative of genuine selective effects on visible anxiety signs or simply chance variation, as no statistical comparison across dimensions was made. To our knowledge, the current study is the first to provide a statistical evaluation of these differences. The fact that social anxiety was significantly more strongly associated with behavioral discomfort than the vast majority of all other dimensions suggests that social anxiety in the non-clinical range is reliably associated with selective behavioral impairment and that this is confined to manifest and observable signs of discomfort.

It is important to note that not all previous studies are consistent with an effect of social anxiety confined only to overt signs of anxiety. Some studies have found poorer observer ratings of fluency and voice intonation during a speech [ 15 ] and vocal clarity and eye contact during a conversation task [ 16 ] for patients with SAD compared to controls. However, a tabulated summary of past research findings [ 10 ] seems to suggest that where the ‘performance’ aspects of social behavior are also affected, this generally appears to be in clinical samples. The most logical conclusion to draw from this is that high levels of social anxiety within the non-clinical range may primarily exacerbate visible anxiety signs with less impact on other performance aspects, but exhibit broader impairing effects at the clinical level; although it is important to point out this does not appear to have been systematically examined.

The link between social anxiety and discomfort ratings suggests that behavioral signs of anxiety are visible to others during social challenges. If those high in social anxiety engage in safety behaviors to mask their anxiety (e.g., attempting to disguise shaking) as evidence suggests [ 8 ], our findings indicate these may have limited effectiveness – at least within the range of social anxiety typically encountered in a non-clinical population. In terms of the magnitude of increased visible anxiety symptoms, those high in social anxiety (one standard deviation above the mean) were rated by observers as approximately half (speech task) to three-quarters (interaction task) of a point higher than those low in social anxiety (one standard deviation below the mean) on the five-point scale used. Determining whether this constitutes a “meaningful” difference is difficult, although the fact that this difference at least approaches a whole-point difference in the scale’s anchor-points (e.g., from “good” to “fair”) is suggestive of a meaningful discrepancy and one that can be demonstrably perceived by others. Overall, these findings clearly show that social anxiety is associated with observable effect on social behavior even in the non-clinical range. Given that a non-clinical sample represents the largest segment of the population, this indicates that social anxiety may have negative effects for a large number of individuals.

The fact that social anxiety failed to be associated with behavioral ratings other than for overt anxiety symptoms is perhaps surprising. Social anxiety scores were strongly correlated with increased anxiety response during social challenges, and the disruptive effect of state anxiety on working memory and the processing of external information including social cues is well supported both theoretically (e.g., via occupation of attentional resources) and empirically [ 8 , 35 ]. As such, aspects of social behavior expected to involve significant cognitive demands, such as the production of coherent and fluent verbal responses, would seem likely to be impaired. While the lack of association is perhaps unexpected, several possible explanations can be considered. First, the sheer frequency of anxious thoughts in the socially anxious during social challenges could lead to their automatization, so that they fail to consume significant attentional resources to cause cognitive interference [ 11 ]. Second, socially anxious individuals are more likely to employ socially facilitative coping strategies, such as overt expressions of enthusiasm or listening to others [ 9 ], and this may help compensate for any disruptive effects of anxiety and encourage more favourable impressions of overall social competence. Third, although social anxiety was associated with increased task anxiety for our non-clinical sample, the magnitude of anxiety response needed to produce significant impairment may only be apparent at the clinical level. It should be noted that these explanations for the pattern of effects observed are necessarily speculative and require empirical corroboration.

With respect to sex, while women reported greater anxiety during social challenges, no evidence was found that the link between social anxiety and behavior was more pronounced in females. One recent non-experimental study did report a negative association between social anxiety and self-assessment of social skill in females but not males [ 36 ]. The current results suggest that, if such a sex-specific effect on self-assessed social competence is reliable, this does not appear to translate to actual behaviour as rated by others. It is important to treat the lack of any sex-specific influence found here with caution, however, given that interaction effects typically require large sample sizes to detect small or even medium effects. Nevertheless, our findings do suggest that if any such sex-specific effect does exist, this effect is unlikely to be large.

Several limitations of the current study should be noted. First, we used a non-clinical sample, and even if social anxiety does operate on a continuum as is commonly believed [ 3 ], results may not generalize to clinical levels of social anxiety. Second, conclusions drawn on the link between social anxiety and social behavior are necessarily limited to the circumscribed set of parameters examined, i.e., molecular indicators of performance during brief social challenges. Findings cannot be automatically assumed to apply to other, perhaps less easily defined or quantifiable facets of performance [ 6 ] in more prolonged or situationally different social challenges. Similarly, we used relatively structured tasks with participants given clear instructions on what to do, with evidence suggesting that unstructured situations may cause greater difficulties for socially anxious people [ 18 ]. Third, we restricted our study to presentational and interactive scenarios and did not examine situations involving fears of being observed (e.g. eating or drinking) and our results may not generalize to these types of situations. Nevertheless, the tasks employed here are fairly indicative of those commonly encountered outside of the laboratory, with the behavioral indicators believed to represent important features of social competence [ 27 ].

Despite these limitations, the current findings have several implications. The fact that social anxiety appears to be most strongly linked to an increase in observable signs of anxiety suggests that techniques directed towards the management of overt anxiety symptoms for those high in social anxiety may be particularly effective for improving impressions of social competence in specific domains where this is likely to be important. Techniques that help the individual recognize their use of anxious behaviors (e.g., throat clearing, fidgeting) and practicing elimination of these in a safe environment [ 37 ] may be especially beneficial. Progressive muscle relaxation may also prove useful to reduce muscle rigidity and promote the appearance of a relaxed posture. If successful, these techniques may produce more successful outcomes in situations where reduced signs of anxiety might be considered favorable, such as job interviews or presentations. Such interventions might even contribute to a potential reduction in social anxiety. Specifically, one feature of cognitive models is that socially anxious people tend to excessively focus on and overestimate the occurrence of behavioural, cognitive and somatic responses (e.g. shaking and sweating), and this contributes to a negative mental image of how one appears to others during social encounters [ 38 ]. Controlling somatic symptoms which are one source of this attentional focus may promote more positive imagery of one’s projected social self, which has been shown to increase explicit self-esteem [ 39 ] and may act as a positive reinforcer of social encounters reducing safety behaviours such as avoidance. It is important to emphasise that we did not investigate such interventions within this study, so these interpretations are entirely speculative. Nevertheless, these processes do represent logical pathways for how techniques directed towards managing visible anxiety signs, that we found to be amplified in those with high social anxiety here, could be potentially beneficial. In addition, the fact that social anxiety was associated with increased observable discomfort in a non-clinical sample also suggests that such management techniques may have potentially widespread benefits to a large sector of the population vulnerable to anxiety in a range of commonly encountered and important social challenges. The apparent selective effect of social anxiety also underlines the need for future studies to include multidimensional assessments of social behavior to fully explicate the nature of the relationship between social anxiety and social behavior.

In conclusion, the current findings suggest that, the detrimental effects of social anxiety on social behavior within the non-clinical range may be confined to the exacerbation of observable, physical anxiety symptoms with little discernible impact on performance quality. These results underline the necessity of including multiple behavioral dimensions in additional studies and suggest that techniques directed towards the management of outwardly observable anxiety symptoms may be particularly beneficial for socially anxious individuals. Given the importance of everyday “performing” to successful social functioning, research should continue to examine how social anxiety impacts upon social behavior at both the clinical and non-clinical level.

We also administered Mattick and Clarke’s companion SIAS scale to provide psychometric data for a separate study. When we substituted the SPS with the SIAS in the current study, there was no impact on the pattern of results.

SPRS discomfort is scored such that lower ratings indicate poorer performance (i.e. greater discomfort).

We also reran these tests using only one SPRS outcome at a time. This was done as a consistency check to ensure that the results of the hypothesis testing in sections 3.4 and 3.5, which used a regression approach, were the same as those using an SEM approach. As expected, both techniques produced the same results (least squares and maximum likelihood estimators used in regression and SEM respectively produce identical estimates under the usual assumptions of regression).

Abbreviations

Intraclass Correlation

Social anxiety disorder

Standard Deviation

Social Interaction Anxiety Scale

Social Performance Rating Scale

Social Phobia Scale

Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602. https://doi.org/10.1001/archpsyc.62.6.593 .

Article   PubMed   Google Scholar  

Acarturk C, de Graaf R, van Straten A, Have MT, Cuijpers P. Social phobia and number of social fears, and their association with comorbidity, health-related quality of life and help seeking: a population-based study. Soc Psychiatry Psychiatr Epidemiol. 2008;43(4):273–9. https://doi.org/10.1007/s00127-008-0309-1 .

McNeil DR. Evolution of terminology and constructs in social anxiety and its disorders. In: Hofmann SG, DiBartolo PM, editors. Social anxiety: clinical, developmental, and social perspectives. London: Academic Press; 2014. p. 3–21.

Chapter   Google Scholar  

Fehm L, Beesdo K, Jacobi F, Fiedler A. Social anxiety disorder above and below the diagnostic threshold: prevalence, comorbidity and impairment in the general population. Soc Psychiatry Psychiatr Epidemiol. 2008;43(4):257–65. https://doi.org/10.1007/s00127-007-0299-4 .

Dijk C, van Emmerik AAP, Grasman RPPP. Social anxiety is related to dominance but not to affiliation as perceived by self and others: a real-life investigation into the psychobiological perspective on social anxiety. Personal Individ Differ. 2018;124:66–70. https://doi.org/10.1016/j.paid.2017.11.050 .

Article   Google Scholar  

Stravynski, A., Kyparissis, A., & Amado, D. (2010). Social phobia as a deficit in social skills. In S. G. Hofmann & P. M. DiBartolo (pp. 147-181). San Diego: Elsevier academic press. doi: https://doi.org/10.1037/t03750-000 .

Leary MR, Kowalski RM. Social anxiety. New York: Guilford Press; 1995.

Google Scholar  

Clark DM, Wells A. A cognitive model of social phobia. In: Heimberg RG, Liebowitz MR, Hope DA, editors. Social phobia: diagnosis, assessment and treatment. New York: Guilford Press; 1995. p. 69–93.

Leary MR. Social anxiousness: the construct and its measurement. J Pers Assess. 1983;47(1):66–75. https://doi.org/10.1207/s15327752jpa4701_8 .

Schneider BW, Turk CL. Examining the controversy surrounding social skills in social anxiety disorder: the state of the literature. In: Weeks JW, editor. The Wiley Blackwell handbook of social anxiety disorder; 2014. p. 366–87. https://doi.org/10.1002/9781118653920.ch17/summary .

Strahan E, Conger AJ. Social anxiety and its effects on performance and perception. J Anxiety Disord. 1998;12(4):293–305. https://doi.org/10.1016/S0887-6185(98)00016-4 .

Rapee RM, Lim L. Discrepancy between self- and observer ratings of performance in social phobics. J Abnorm Psychol. 1992;101(4):728–31. https://doi.org/10.1037/0021-843X.101.4.728 .

Clark JV, Arkowitz H. Social anxiety and self-evaluation of interpersonal performance. Psychol Rep. 1975;36(1):211–21. https://doi.org/10.2466/pr0.1975.36.1.211 .

Cartwright-Hatton S, Hodges L, Porter J. Social anxiety in childhood: the relationship with self and observer rated social skills. J Child Psychol Psychiatry. 2003;44(5):737–42. https://doi.org/10.1111/1469-7610.00159 .

Levitan MN, Falcone EM, Placido M, Krieger S, Pinheiro L, Crippa JA, et al. Public speaking in social phobia: a pilot study of self-ratings and observers’ ratings of social skills. J Clin Psychol. 2012;68(4):397–402. https://doi.org/10.1002/jclp.20868 .

Baker SR, Edelmann RJ. Is social phobia related to lack of social skills? Duration of skill-related behaviours and ratings of behavioural adequacy. Br J Clin Psychol. 2002;41:243–57. https://doi.org/10.1348/014466502760379118 .

Stopa L, Clark DM. Cognitive processes in social phobia. Behav Res Ther. 1993;31(3):255–67. https://doi.org/10.1016/0005-7967(93)90024-O .

Thompson S, Rapee RM. The effect of situational structure on the social performance of socially anxious and non-anxious participants. J Behav Ther Exp Psychiatry. 2002;33(2):91–102. https://doi.org/10.1016/S0005-7916(02)00021-6 .

Bögels SM, Rijsemus W, De Jong PJ. Self-focused attention and social anxiety: the effects of experimentally heightened self-awareness on fear, blushing, cognitions, and social skills. Cogn Ther Res. 2002;26(4):461–72. https://doi.org/10.1023/A:1016275700203 .

Gelman A, Stern H. The difference between “significant” and “not significant” is not itself statistically significant. Am Stat. 2006;60(4):328–31. https://doi.org/10.1198/000313006X152649 .

Norton PJ. Social anxiety and withdrawal. In: Nangle DW, Hansen DJ, Erdley CA, Norton PJ, editors. Practitioner’s guide to empirically based measures of social skills. NY: Springer; 2010. p. 167–78. https://doi.org/10.1007/978-1-4419-0609-0 .

McLean CP, Anderson ER. Brave men and timid women? A review of the gender differences in fear and anxiety. Clin Psychol Rev. 2009;29:496–505. https://doi.org/10.1016/j.cpr.2009.05.003 .

McNeil DW, Ries BJ, Turk CL. Behavioral assessment: self-report, physiology, and overt behavior. In: Heimberg RG, Liebowitz MR, Hope DA, Schneier FR, editors. Social phobia: diagnosis, assessment, and treatment. New York: Guilford Press; 1995. p. 202–31.

Osman A, Gutierrez PM, Barrios FX, Kopper BA, Chiros CE. The social phobia and social interaction anxiety scales: evaluation of psychometric properties. J Psychopathol Behav Assess. 1998;20:249–64. https://doi.org/10.1023/A:1023067302227 .

Mattick RP, Clarke JC. Development and validation of measures of social phobia scrutiny fear and social interaction anxiety. Behav Res Ther. 1998;36:455–70. https://doi.org/10.1016/S0005-7967(97)10031-6 .

Davey HM, Barratt AL, Butow PN, Deeks JJ. A one-item question with a Likert or visual analog scale adequately measured current anxiety. J Clin Epidemiol. 2007;60(4):356–60. https://doi.org/10.1016/j.jclinepi.2006.07.015 .

Fydrich T, Chambless DL, Perry KJ, Buergener F, Beazley MB. Behavioral assessment of social performance: a rating system for social phobia. Behav Res Ther. 1998;36:995–1010. https://doi.org/10.1016/S0005-7967(98)00069-2 .

Harb GC, Eng W, Zaider T, Heimberg RG. Behavioral assessment of public-speaking anxiety using a modified version of the social performance rating scale. Behav Res Ther. 2003;41(11):1373–80. https://doi.org/10.1016/S0005-7967(03)00158-X .

McGraw KO, Wong SP. Forming inferences about some intraclass correlation coefficients. Psychol Methods. 1996;1(1):30–46. https://doi.org/10.1037/1082-989X.1.1.30 .

Cicchetti DV. Guidelines, criteria, and rules of thumb for evaluating normed and standardized assessment instruments in psychology. Psychol Assess. 1994;6(4):284–90. https://doi.org/10.1037/1040-3590.6.4.284 .

Aiken LS, West SG. Multiple regression: testing and interpreting interactions. London: Sage; 1991.

Kwan JL, Chan W. Comparing standardized coefficients in structural equation modeling: a model reparameterization approach. Behav Res Methods. 2011;43(3):730–45. https://doi.org/10.3758/s13428-011-0088-6 .

Rosseel Y. Lavaan: an R package for structural equation modeling. J Stat Softw. 2012;48(2):1–36. https://doi.org/10.18637/jss.v048.i02 .

Sankoh AJ, Huque MF, Dubey SD. Some comments on frequently used multiple endpoint adjustment methods in clinical trials. Stat Med. 1997;16(22):2529–42. https://doi.org/10.1002/(SICI)1097-0258(19971130)16:22<2529::AID-SIM692>3.0.CO;2-J .

Amir N, Bomyea J. Cognitive biases in social anxiety disorder. In: Hofmann SG, DiBartolo PM, editors. Social anxiety: clinical, developmental, and social perspectives. London: Academic Press; 2010.

Al-Ali MM, Singh AP, Smekal V. Social anxiety in relation to social skills, aggression, and stress among male and female commercial institute student. Education. 2011;132(2):351–61.

Wells A, Clark DM, Salkovskis P, Ludgate J, Hackmann A, Gelder M. Social phobia: the role of in-situation safety behaviors in maintaining anxiety and negative beliefs. Behav Ther. 1995;26(1):153–61. https://doi.org/10.1016/S0005-7894(05)80088-7 .

Rapee RM, Heimberg RG. A cognitive-behavioral model of anxiety in social phobia. Behav Res Ther. 1997;35(8):741–56.

Hulme N, Hirsch C, Stopa L. Images of the self and self-esteem: do positive self-images improve self-esteem in social anxiety. Cogn Behav Ther. 2012;41(2):163–73. https://doi.org/10.1080/16506073.2012.664557 .

Article   PubMed   PubMed Central   Google Scholar  

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Acknowledgements

Our grateful appreciation goes to Marta Kaminska for help with data collection and for acting as an experimental confederate.

This work was supported by an internal grant awarded to the first author by the University of Greenwich. The funders had no role in any aspect of the study design, data collection, analysis or data or writing of the manuscript.

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Trevor Thompson

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Melanie Sargeant

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Thompson, T., Van Zalk, N., Marshall, C. et al. Social anxiety increases visible anxiety signs during social encounters but does not impair performance. BMC Psychol 7 , 24 (2019). https://doi.org/10.1186/s40359-019-0300-5

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How Can Social Anxiety Be Caused By Parents?

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Social anxiety is a common issue many people face, which may often stem from early life experiences with parents.

If you have social anxiety, you might find yourself avoiding social interactions, feeling nervous about being judged, or experiencing physical symptoms like sweating and trembling.

These anxieties can often be traced back to how you were raised. Overprotective, critical, inconsistent, or emotionally abusive parenting can deeply influence how you feel in social settings, even well into adulthood. 

Understanding these connections and how they may also be caused by intertwining influences is key to finding peace and improving your social life.

It’s important to note that social anxiety may not solely be caused by parents. Other factors, such as early negative experiences with bullying, social rejection, and humiliation, can also contribute to social anxiety developing.

This article goes over some of the most common parenting styles and their relation to SAD, and offers practical tips for managing it, from recognizing patterns in your family’s behavior to seeking professional help and building your confidence step-by-step. 

What kind of parenting can cause social anxiety? 

Overprotective parents.

Overprotective parents shield their children from challenges and potential failures, leading to underdeveloped social skills and low confidence. 

For instance, an overprotective parent might immediately intervene when their child disagrees with a friend about which game to play at recess, suggesting a compromise instead of allowing the children to resolve the issue themselves.

This deprives the child of the opportunity to develop crucial social skills like negotiation and conflict resolution, potentially leading to anxiety in future social interactions.

By constantly intervening, these parents hinder their child’s ability to learn important social cues and problem-solving skills. 

Consequently, children may feel ill-equipped to handle social scenarios, resulting in anxiety when interacting with peers or entering new social environments.

Examples of Thoughts:

• “What if I say something wrong?”
• “I can not do this on my own; I need help.”
• “I am not ready to handle this by myself.”
• “I need someone with me to feel safe.”

Examples of Behaviors:

• Hesitating to join group activities without parental presence
• Frequently calling or texting parents for advice during social events
• Struggling to make simple decisions, like choosing a lunch option, without consulting others

Overly critical or demanding parents

Constant criticism and high expectations from overly critical or demanding parents can make children overly self-conscious and afraid of making mistakes. 

“She used to hit me and constantly criticize me and told me I wasn’t as good as my friends or whatever other kid my age was around. Didn’t take much for me to start being scared everyone else was judging me just as harshly.”

This fear extends to social interactions, where they may worry excessively about others’ opinions and potential negative evaluations. The pressure to meet high standards can lead to perfectionism and reluctance to engage socially, fostering anxiety.

• “Everyone will think I am not good enough.”
• “I can not make any mistakes, or I will be judged.”
• “People will notice all my flaws.”
• “I must be perfect, or I will be criticized.”
• Avoiding social interactions where there is the possibility of being judged 
• Trying to ‘perfect’ social interactions and beating themselves up over perceived ‘mistakes’ 
• Being overly self-conscious of how they present themselves

Inconsistent parents

Inconsistent parenting creates an unpredictable environment, leading to insecurity. When parents are sometimes supportive and other times neglectful or critical, children struggle to form a stable sense of trust. 

For example, an inconsistent parent may encourage their child to attend more social activities with friends, but then when the child actually plans to meet friends, their parent complains that they are ‘always going out’ and should stay home. This can cause the child to be conflicted about attending social events.  

This inconsistency makes it hard for children to predict others’ reactions, resulting in anxiety and uncertainty in social interactions. They may become overly cautious or avoidant in relationships, fearing rejection or unpredictability.

• “I do not know how they will react to me.”
• “What if they leave me or do not like me anymore?”
• “People are unpredictable, I can not trust them.”
• “I am always waiting for the other shoe to drop.”
• Constantly seeking reassurance from friends and partners
• Overanalyzing social interactions and reading too much into others’ actions
• Engaging in people-pleasing behaviors to maintain relationships

Authoritative parents

While authoritative parenting involves setting clear rules and expectations, it can suppress a child’s ability to voice their thoughts and feelings if it veers into authoritarianism. 

This suppression can lead to social anxiety, as children may fear expressing themselves, worry about disagreeing with others, or struggle with asserting their needs and boundaries.

Research has also uncovered such relationships between authoritative styles and increased social anxiety and social withdrawal. This further highlights the detrimental effects of poor parenting on children’s mental health.

• “It is better to stay quiet than to cause trouble.”
• “My opinions do not matter.”
• “I should not speak up; it will just make things worse.”
• “No one wants to hear what I have to say.”
• Hesitating or stumbling when asked for an opinion in group settings
• Agreeing with others’ suggestions even when internally disagreeing
• Struggling to say “no” to requests, even when they’re unreasonable
• Becoming overly stressed when faced with authority figures

Anxious parents

Parents who exhibit anxiety can unintentionally transmit these behaviors to their children. Children often learn by observing their parents, and anxious parents may model hypervigilance and avoidance. 

As a result, they may internalize these anxious behaviors, leading to social anxiety. For example, they may become overly cautious in social settings, fear potential negative outcomes, and instinctively mimic what they have observed in their parents.

• “Something bad will happen if I talk to them.”
• “People are always judging me.”
• “I need to be careful or I will embarrass myself.”
• “It is safer to stay quiet and unnoticed.”
• Exhibiting physical symptoms of anxiety (e.g., sweating, trembling) in situations the parent finds stressful
• Excessively checking for danger in new environments, mirroring a parent’s behavior
• Seeking constant reassurance about safety or performance, similar to an anxious parent

Emotionally abusive parents

Emotionally abusive parents undermine their child’s self-esteem and sense of worth, significantly contributing to social anxiety. Through verbal abuse, manipulation, or neglect, these parents instill a deep sense of inadequacy and fear. 

Constant exposure to emotional abuse makes children feel worthless and overly sensitive to criticism, leading them to avoid social situations where they fear further emotional harm. 

This long-lasting impact severely impairs their ability to form healthy social connections.

“I grew up in an abusive household and developed severe social anxiety. I have Autism Spectrum Disorder and PTSD which worsen my SA, but I firmly believe I wouldn’t have full blown SA if I lived with healthy, loving non-judgemental people growing up.”

• “If I open up to someone, they’ll use it against me like my parents did.”
• “I don’t deserve to be included or have friends.”
• “I don’t belong here. Everyone else seems so comfortable and I’m just faking it.”
• Becoming overly apologetic for minor perceived social missteps
• Difficulty accepting compliments or positive feedback
• Isolating oneself to avoid potential social rejection

Dealing with social anxiety that may be caused by parents 

Recognizing generational patterns.

Understanding the origins of your social anxiety involves recognizing generational patterns. Often, behaviors and attitudes are passed down unconsciously from parents to children. 

By identifying these patterns, you can better understand the context of your anxiety and begin to break the cycle. 

Reflect on your parents’ upbringing and how their experiences may have influenced their parenting style. Acknowledging that your parents may have also struggled with similar issues can foster empathy and provide a foundation for change.

Discuss family history with your parents or other relatives to gain insight into generational behaviors. This awareness can help you identify specific patterns and work towards breaking them, fostering a healthier environment for yourself and your children.

“I am aware that my social anxiety was probably influenced by my mother’s parenting. After reflecting, I recognized my grandmother had similar overly critical and anxious parenting. Then, after speaking to my grandmother, she shared that even HER mother was an incredibly anxious person. It is now down to me to break this anxious cycle.”

Practice Self-Parenting

Self-parenting involves nurturing yourself in ways your parents might not have. This means providing yourself with the support, encouragement, and love that you need. Develop a positive inner voice to counteract any negative messages received in childhood. 

Engage in self-care practices that promote mental and emotional well-being. Affirmations, journaling, and self-compassion exercises can be powerful tools in reparenting yourself, helping you build confidence and reduce social anxiety.

An activity for self-parenting: 

In your journal, imagine that you are writing a letter to your younger self. In this letter, you can take on the role of your younger self’s parent or older mentor. 

Consider what you will say to your younger self. What advice would you give them? What encouragement or reassurance can you offer? 

Think specifically about how you can counter some of the criticism you may have heard from your parent/s.

Practice Forgiveness

Forgiveness can be a critical step in healing from parental influences that have contributed to social anxiety.

While it may not be easy, forgiving your parents, whether they were overly critical, inconsistent, or anxious, can free you from lingering resentment and pain. 

This does not mean condoning their behavior but rather accepting that they were doing their best with the tools they had (obviously, if the parent was abusive, you may not want to forgive this). Forgiveness can provide emotional relief and allow you to focus on your growth and recovery.

Do this by engaging in reflective practices such as writing letters (not necessarily to be sent) to express your feelings.

Therapy can also help you process these emotions and move towards forgiveness, providing emotional relief and allowing you to focus on your growth.

Foster Your Own Independence

Cultivating independence is essential in overcoming social anxiety linked to parental influences.

Establishing some distance from your parents’ anxious beliefs helps you form your own identity and perspectives. 

Engage in activities that challenge you and build confidence, such as joining clubs, volunteering, or taking up new hobbies. Setting boundaries with your parents allows you to develop autonomy and self-assurance.

Push yourself to break the vicious cycle of avoiding social situations by signing up for clubs, volunteering, or taking up new hobbies that allow for social interaction.

While anxiety may feel heightened, to begin with, gradually exposing yourself to fearful social situations should help your confidence in the long run and ultimately increase your independence. 

Likewise, practice setting healthy boundaries with your parents, such as saying no to unreasonable requests or reducing visiting times if you feel more anxious in their presence. 

Seek Professional Help

Therapy is an effective way to address social anxiety, particularly when it stems from parental influences.

Cognitive-behavioral therapy (CBT) can help you identify and reframe negative thought patterns, while exposure therapy can gradually reduce fear of social situations. 

Family therapy might also be beneficial if your parents are willing to participate, providing a platform to address and resolve underlying issues.

A mental health professional can guide you through these processes, offering support and strategies tailored to your needs.

Lastly, parent-only CBT is available and has been shown to be an effective treatment for reducing anxiety symptoms and relieving anxiety in children when compared to control groups.

Build a Support Network

Creating a support network of friends, mentors, and support groups can significantly help in managing social anxiety. Surround yourself with positive influences who understand and respect your experiences. 

Engaging with others who share similar challenges can provide comfort and reduce feelings of isolation.

These connections can offer encouragement, practical advice, and opportunities for social interaction in a safe and supportive environment.

Challenge Negative Thoughts

A key aspect of managing social anxiety is learning to challenge and reframe negative thoughts. 

When you catch yourself thinking, “Everyone will judge me,” counter it with evidence-based thoughts like, “Most people are focused on themselves, not on judging me.” 

Try to identify where your socially anxious thoughts are coming from and verbalize this to help challenge them. 

For example, “I am probably feeling anxious about being judged because my father was very critical of me, but that does not mean everyone is also critical of me.”

Practicing mindfulness and staying present in the moment can also help prevent anxious thoughts from spiraling.

Techniques such as meditation and deep breathing exercises can reduce anxiety and improve emotional regulation.

Develop Social Skills Gradually

Practicing social skills incrementally helps build confidence and reduces the fear associated with social situations. Over time, these experiences can lessen social anxiety and improve your overall quality of life.

Therapist Emma McAdam shared the following advice:

“When you want to decrease your social anxiety, it is really essential to allow yourself to stretch your comfort zone. You can do this by practicing willingness. It is an Acceptance and Commitment Therapy (ACT) term that means choosing to let yourself feel your emotions even if they are uncomfortable ”

Implement the stepladder approach, a gradual exposure technique used to overcome social anxiety. This method involves:

• Creating a hierarchy of anxiety-provoking social situations, from least to most challenging.
• Starting with the least anxiety-inducing situation and gradually working your way up.
• Practicing each step until you feel comfortable before moving to the next.

For example:

• Start with simple actions like smiling at a stranger or saying hello to a cashier.
• Progress to brief conversations with acquaintances or joining a small group activity.
• Work your way up to more challenging interactions, such as initiating conversations with new people or speaking up in larger group settings.

As you gain confidence at each level, move on to more complex social situations.

Ilyas, U., & Khan, S. D. (2023). Role of Parenting and Psychosocial Correlates Contributing to Social Anxiety in Asian Adolescents: A Systematic Review. Innovations in Clinical Neuroscience , 20 (7-9), 30.

Therapy in a Nutshell. (2022, May 26,). 3 Skills to Overcome Social Anxiety Post-Pandemic . [Video File]. YouTube.

Yin, B., Teng, T., Tong, L., Li, X., Fan, L., Zhou, X., & Xie, P. (2021). Efficacy and acceptability of parent-only group cognitive behavioral intervention for treatment of anxiety disorder in children and adolescents: a meta-analysis of randomized controlled trials. Bmc Psychiatry , 21 , 1-12.

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The Experience Among College Students with Social Anxiety Disorder in Social Situations: A Qualitative Study

Ya-song luan.

1 Department of Nursing Science, Shandong Traditional Chinese Medicine College, YanTai, People’s Republic of China

Gao Zhan-ling

2 Department of Neurosurgery, YanTai Affiliated Hospital of Binzhou Medical College, YanTai, People’s Republic of China

Few individuals have focused on the experience of students during social events, especially among college students with social anxiety disorder. This study aimed to explore the anxiety experience among college students with social anxiety disorder in social situations.

This qualitative interpretive study was conducted on college students who were diagnosed with social anxiety disorder (SAD) and recruited from two colleges in Heilongjiang Province, China. A total of 7 participants were selected by purposive sampling with maximum variability. Data were collected through semistructured individual interviews, and data analysis was performed by using Colaizzi’s 7-step analysis method.

The findings from the analysis of the interviews were classified into 4 themes and several main categories, including distorted self-awareness (3 main categories), fear of negative reaction from others (2 main categories), adverse reaction of body and mind (4 main categories) and strong desire to seek treatment.

In our study, we sought to understand the anxiety experience among college students with social anxiety disorder in social situations. The study results provide a reference for psychologists and clinical medical staff and establish a scientific basis for the prevention and intervention of social anxiety disorder.

Introduction

The college period is important for the rapid maturation of the cognition, emotion and behavior of college students. Interpersonal communication is increasingly important to college students’ studies, lives and employment. However, interpersonal communication problems have become a common psychological problem faced by contemporary college students, and social anxiety is one of the most important psychological problems affecting college students’ studies and lives. 1 Studies have found that the proportion of moderate and severe social anxiety among college students was as high as 22.4% in China. 2 The social anxiety of college students should be given more attention by scholars in related fields and universities.

Social anxiety disorder (SAD) is a common psychological disorder that is regarded as introversion and shyness in personality and has been misdiagnosed as “shyness”. 3 It is essentially a symptom of dysfunctional anxiety (psychological and/or autonomic nervous system) that is confined to specific social situations and leads to fear or avoidance. 4

Epidemiological studies have found that SAD is a disease across the cultural spectrum, and there is a significant increase in social anxiety experience from childhood development to adolescence. 5 Studies have shown that there are different degrees of social anxiety among college students that affect their social functions. 6 The fear and avoidance of social occasions and crowds often lead to severe psychosocial impairment and other psychological disorders, such as depression and compulsion. 5 Moreover, SAD mostly occurs in adolescents, and many patients have other mental disorders, which further lead to intense personal pain and increase social burden. 7 If not treated in time, SAD will become chronic and progressive, seriously affecting the healthy development of personality. 8

Previous studies have found that there were certain differences in epidemiological and clinical characteristics in different countries. 9 At present, with the improvement and development of psychological counseling in China, an increasing number of SAD patients are seeking help in psychological clinics. 10 At present, a large number of relevant investigations and experimental studies have been performed; 11–14 however, there are few studies from the perspective of SAD patients, which leads to the lack of findings of their inner experiences.

Qualitative research methods can precisely understand patients’ social process experience on their own and add missing or potential factors to quantitative research. 15 In this study, the phenomenological research method was used to deeply explore the understanding and feelings of SAD students in social occasions, and to integrate and analyze them to provide a scientific basis for mental health and medical workers to implement prevention and intervention.

Participants

In this qualitative study, a purposive sampling method was used to select college students who were diagnosed with social anxiety disorder by SCID. A random sampling method was used to determine the diagnosis. A total of 1200 undergraduate students were screened using the Interaction Anxiety Scale (IAS) with the mean ± standard deviation (X ± SD) as the cutoff point. A total of 298 students with the highest score > (X + SD) were selected for the SCID interview. The interviewers were 2 schoolteachers and 2 clinical psychiatrists with many years of psychological counseling experience. A preinterview was conducted before the formal interview, and a consistency test was conducted. Ultimately, 93 college students were diagnosed with SAD, from which students were selected for qualitative interviews. Inclusion criteria: ① meeting the diagnostic criteria of DSM-4 social anxiety disorder and that being the primary diagnosis; ② age ≥16 years; ③ able to understand and communicate with others; and ④ willing to participate in this study with signed informed consent. Exclusion criteria: ① combined with other mental disorders, such as schizophrenia; ② personality disorder (including avoidant personality disorder); ③ severe brain and body diseases and psychoactive substance abuse. The sample size of this study was based on the saturation during data analysis, and a total of seven SAD college students whose codes were P1~P7 were selected. The mean age was 18.34±1.02 years, there were 3 males and 4 females, and 2 patients were hospitalized. The general situations of the patients are shown in Table 1 .

The General Information of Participants (n=7)

Data Collection

Using the phenomenological research method of qualitative research, in-depth interviews were conducted with the patients according to the semistructured interview outline. The interview outline was prepared according to the research content and was revised after 2 preinterviews. Finally, the interview outline was determined as follows: ① How do you feel in social occasions? ② What do you worry about in social situations? ③ How do you see yourself in this situation? ④ How do you think this will affect you? Since the subjects of this study are SAD patients who fear and avoid strangers, in view of this particularity, the researcher conducted a 30–40 min conversation with the interviewees before the formal interview to explain the purpose of the study and establish a sense of security and trust, which is conducive to the smooth progress of the interview. Two formal interviews were conducted for each person, with each time being 40–60 min. During the interview, the interviewees were encouraged to fully express their feelings and thoughts, and the interview contents were recorded to document the interviewees’ expressions, tone, movements and other nonverbal information at any time. The interview place was the psychological consulting room. The sample size was established on the basis that no new information appeared when the data reached saturation.

Data Analysis

At the end of each interview, all the contents of the interviewees’ statements and the researchers’ on-site records were translated into words, the materials were repeatedly read, word by word, sentence by sentence, and classified and inferred, and the recordings were repeatedly listened to and recalled. Colaizzi’s 7-step analysis method was adopted to summarize the common concepts as the theme of this study. The details were as follows: (1) thoroughly understand the interview data of this research; (2) extract meaningful viewpoints from the data; (3) encode ideas that repeatedly occur and conform to the phenomenon of this study; (4) cluster the views after coding; (5) provide a detailed description of the clustered views without omission; (6) identify similar viewpoints and form theme concepts; and (7) return the data to the interviewees for verification. During the analysis and induction, if there are new data, divide it or generate a new topic. The entire data analysis process was completed by two researchers and verified by consensus.

Ethical Considerations

This study was approved by the institutional review board of Shandong Traditional Chinese Medicine College, which complies with the Declaration of Helsinki. The study procedures were explained to the eligible patients; they were informed of their right to withdraw from the study at any time for any reason and of their right to treatment whether or not they decided to participate in this study. All participants signed an informed consent form. To maintain anonymity, all recognizable personal data of the patients were protected by replacing their names with code numbers.

The anxiety experience among college students with social anxiety disorder in social situations can be classified into four major themes: (1) distorted self-consciousness, (2) fear of negative reactions from others, (3) negative psychosomatic experience, and (4) a strong desire to seek treatment.

Theme 1: Distorted Self-Consciousness

Low self-evaluation.

In the study, the main problem of SAD students is that they lack objective self-knowledge and describe themselves with very poor evaluation, which is also an important factor causing their anxiety and fear in social occasions. Low self-evaluation makes them lose their willingness and courage to spend time with others.

P7: “Certainly not, even if I go up, also certainly not as good as others speak, finally still cannot choose.”

P4: “I just thought, is it okay? Is my speech reading all right? Or how do I sound? How was it?”

Interviewees are extremely unsure of themselves, always full of doubts and worries, and want to be recognized by others. For example,

P3: “When doing such things, I always want to be right or wrong and long to be accepted by others.”

Self-Experience Lacking Self-Confidence

People with SAD tend to have an “I cannot do it” mentality, which reflects their lack of self-worth. For example,

P3: “I will subconsciously feel that I am not good and will always deny myself, probably because I am not confident and inferior.”

This lack of self-experience not only causes anxiety and fear but also further affects one’s ability to expect to accomplish something, namely, self-efficacy. Therefore, it is difficult to avoid tension in social occasions, which then affects the normal level of self-play. For example,

P2: “When I’m nervous, I think of nothing but failure.”

Attitude and Avoidance Behavior

As an important part of self-consciousness, self-regulation can play a corresponding role in evaluation, feedback and control. SAD patients lack the ability of correct and objective self-regulation and cannot actively face social situations. They often avoid attitudes and engage in avoidance behavior. It is common for them to refuse to accept such assignments or arrangements.

P5: “If the teacher asks me to come to the platform, I will put it off as long as I can.”

P7: “Even if I prepared the best, I would run away if I could. I would only go if it was mandatory. I would never go if I could escape.”

In addition, this avoidance behavior is reflected not only in the refusal to participate in such occasions but also in the face of others. For example,

P1: “The people who dare not look at the people below want to finish and get down quickly.”

P6: “Every time I stood up to speak in class, I didn’t look at my classmates, nor did I dare to look at the teacher. I just looked at the wall or the window, and even then I couldn’t speak.”

Theme 2: Fear of Negative Reactions from Others

Excessive concern about other people’s evaluation.

In the interview, all 7 interviewees were afraid that others would not approve of them and worried about others’ opinions.

P5: “In front of people, I am mainly afraid that others will laugh at you (the patient himself). I am mainly afraid of this one.”

P4: “What do they think? The main problem is that reading what other people think makes me nervous.”

Because of their excessive worry about others’ feedback, SAD students cannot properly view others’ evaluation, which increases their anxiety level without good control of themselves. For example,

P2: “If the performance is not good, others will not be satisfied, so I want to show the good side as much as possible. But the more I think about it, the more nervous I get, the worse I get.”

Worry About Making a Bad Impression

The negative assessment of fear was echoed by the respondents’ concern about how they were perceived by others.

P7: “If I make mistakes, others will definitely criticize me, which gives a bad impression. I care about others’ impression and don’t want others to think I’m bad.”

P6: “At these times, I am mainly afraid of making a fool of myself. Making a fool of myself is easy to have a bad influence, so the first impression is very important.”

It can be seen from the interviews that SAD students pay too much attention to whether they are perfect or not and try their best to perform well in front of others and get acceptance and recognition from others. For example,

P5: “I feel more confident when others praise me.” This is a good example of SAD students’ need to be well evaluated by others.

Theme 3: Negative Psychosomatic Experience

Feelings of pain and helplessness.

When SAD students are stressed, they are filled with feelings of pain and helplessness.

P4: “When I’m nervous, I just can’t control it. The more I control it, the more nervous I become. Sometimes I just stand there and ignore it.”

P1: “Even if I can ask questions, I will stand up and speak nervously (shaking my head) and feel very uncomfortable (lowering my head). Even if I am nervous, I cannot speak continuously.”

Most interviewees suffer from anxiety and are at a loss in the face of such situations. As a result, helpless psychology is formed over time.

For example,

P4: “Most of the time, I don’t know what to do, so I can only laugh or stay, just like this, very uncomfortable (breathe deeply).”

Ambivalence

The experience of ambivalence is mainly reflected in the cognitive level of the interviewees. SAD students can realize that their thoughts are incorrect, but they cannot correct them in time. Therefore, incorrect psychological cognition leads to tension and anxiety, resulting in inner conflict.

P7: “In fact, you know that people will not always be looking at you, but at that moment you feel that people will always be looking at you, looking for you to make mistakes, laughing at you. I know it’s not true, but it’s just scary.”

P6: “When I sit here, I always feel that someone is watching me. When I do things, I feel that many people are paying attention to me. Maybe no one is watching me at all, but I still don’t feel very relaxed.”

P3: “(At parties) I also know that other people are playing their own games and don’t even notice me, but I still get nervous.”

Anticipatory and Persistent Anxiety Experience

SAD students experience anxiety not only during social situations but also over a broader time horizon, such as before or after the social situation begins.

P1: “When the teacher asks a question and says, ‘I want to find someone to answer’, I will be nervous, and then I will be more nervous, and when the teacher has finished ordering a student, my heart is still nervous.”

P2: “I get nervous when I prepare, and then I get more and more nervous when I get close to me. (Deep breath) … After the end, I still think about how well I did.”

Physiological Reaction

Some SAD scales describe common physical reactions, such as “flushing”, “sweating”, “shaking”, and “panic.” The study also found other physical symptoms, such as involuntary movements.

P4: “I will scratch my head when I am nervous. I feel very deliberate and stuffy.”

P5: “Hands will be constantly moving, hair will be pulled, feet will be constantly moving.”

In addition, some SAD students experience the speed of speech (P7) or unclear pronunciation (P3) phenomenon.

Theme 4: A Strong Desire to Seek Treatment

During the interview, we learned that the interviewees were deeply troubled by social anxiety, which seriously affected their work and studies. In retrospect, they felt more pain, so they had a strong desire to get rid of this situation.

P6: “I am nervous all the time. It must be wrong. I must change.”

P3: “I really don’t know what to do. I’m too old to go to work. If I want to get well soon, I can go back to work.”

Most SAD college students can face their own problems with a positive attitude, as shown in P4:I think I should attend more such occasions and do more exercise. I don’t want to go on like this.

Most current studies have focused on effective interventions to improve the SAD of college students; however, only a few studies have focused on the subjective experiences of the patients involved. To the best of our knowledge, this is the first qualitative study to explore the anxiety experience among college students with social anxiety disorder in social situations.

Improve Self-Esteem and Rebuild the Correct Self-Image

Studies have shown that one of the core psychological characteristics of SAD patients is low self-esteem. 16 Self-esteem is an overall experience and cognition of whether a person is good enough for himself or not. It is the core of self-awareness and reflects the difference perceived by an individual between the actual self and ideal self. 17 Low self-esteem makes SAD people develop negative self-evaluation and lack the ability to correctly recognize themselves. 18 From the perspective of etiology, improper parenting style and family environment are closely related to it. The early upbringing of SAD patients is mostly negative, that is, negative evaluation and negative feedback, and the parent–child relationship is mainly rejection, rigor and negation, 19–22 resulting in the overall low sense of self-worth and self-ability, that is, low self-esteem and low self-efficacy. Due to low self-esteem and early experience, the negative interpersonal cognitive schema triggered by automation is generalized to the interpersonal situation: it affects self-cognition and makes the individual’s cognitive evaluation lose objectivity; it affects self-experience, forming a sense of shame and a lack of confidence; and it affects self-regulation, the formation of avoidance and avoidance behavior and attitude. 29 Therefore, psychological workers should comprehensively popularize family mental health knowledge using media in the community, which can help parents understand their children’s mental health status, create a warm family atmosphere, give them more affirmation and emotional support, and cultivate their children to form a high level of self-esteem and correct self-recognition ability.

Avoid Negative Comments and Correct Sensitive External Perspective Patterns

The interviewees’ low self-esteem and distorted self-awareness make them sensitive in social interactions so they easily perceive negative feedback from others. During individual development, infants are naturally well-behaved and crave positive feedback from their caregivers. If the external feedback is negative, sluggish, indifferent or rejected, infants will form low self-esteem, namely, the core self-concept diagram of “I am not good”, thus forming a lower level of security and a more sensitive external perspective. 23 In adulthood, when such sensitivity becomes an obstacle to adaptation, resulting in subjective pain and even avoidance behaviors, individuals suffer from SAD, which is often presented by negative automatic thinking and attention bias. 24 The specific manifestations are as follows: overly concerned about others’ evaluation, worried about leaving a bad impression on others, and other psychological experiences. Thus, when a traumatic event (being punished in public, humiliated by a teacher, ridiculed by a classmate, conflict between parents, etc.) occurs, the automated thinking centered on low self-esteem is quickly triggered, and shame is generated. These repetitive and persistent shame experiences are closely related to emotional and behavioral problems, making individuals anxious about social situations or attention and often contributing to SAD. 25–27 Therefore, SAD students pay more attention to the evaluation given by the outside world and form an external perspective to identify their social perception tendency. Therefore, it is particularly important to pay attention to those with early social anxiety. Due to the early onset of the SAD, is in the stage to accept education in school, and school of psychological prevention and intervention can effectively prevent the occurrence of anxiety disorders; 28 , 29 therefore, education workers need to students’ psychological development process and health prevention, reduce negative evaluations, provide positive affirmations, a timely support psychology found that anxiety of the students.

Reduce Negative Experiences and Promote the Harmony of Mind and Body

SAD students are very sensitive to feedback from others, including nonverbal information such as faces and postures that reflect emotional cues. This sensitivity is an automated, knee-jerk reaction mechanism. 30 This is the patient’s defense and survival strategy. When this defense or survival strategy affects self-functioning and social functioning, it is a pathological reaction. Schachter’s emotion theory holds that emotion is generated by experiencing a high degree of physiological arousal and certain cognition of its state changes; that is, people’s cognition and evaluation of physiological responses determine their final emotional experience. The secondary emotion generated after self-reflective cognition is self-conscious emotion, which plays an important role in the regulation of individual social behaviors. 18 , 31 The physiological response of SAD patients forms the emotional experience of anxiety after self-cognitive awakening. Patients in a social situation in automation stimulate physical arousal (sweating, flushed, flustered, voice, etc.), produce certain cognitive evaluations, such as he might be “caught” and “wrong”, “they would laugh at me”, etc., to evaluate their own performance, and others form automation of the cognitive processing model through the integration of the cerebral cortex to this information, concentrating on negative emotional experiences such as anxiety and fear. In this way, medical staff should understand the causes and inner experiences of SAD patients and correct distorted perceptions, formulate effective and targeted intervention programs to relieve patients’ sense of pain and helplessness, and give them hope and confidence to overcome psychological barriers.

Pay Attention to Social Anxiety Disorder and Improve Their Mental Health Level

Epidemiological surveys show that the incidence of SAD ranks fourth among many psychological disorders. 32 Compared with foreign studies, China has not paid enough attention to this disease. This psychological disorder has a long course, accompanied by severe psychosocial impairment and a high social and economic burden. 33 Seven interviewees had a strong desire to seek treatment because the pain caused by symptoms had seriously affected their lives, studies and work, which was also a common feature of SAD patients in previous studies. 33 , 34 Therefore, the government and mental health departments should pay attention to adolescents and patients, actively improve the allocation of medical and health resources, provide economically convenient treatment and medical conditions for patients, and provide professional personnel and material support for the prevention and treatment of SAD.

Limitations

Our study has some limitations. First, this study enrolled only patients from one province in China. Patients from various regions were not enrolled in our study; thus, we may have failed to explore potentially different experiences by region. Moreover, this was a qualitative study with a relatively small sample size. For more generalized findings of a target population, further studies with larger sample sizes and studies using quantitative methodology may be necessary.

This study was designed to explore the SAD psychological experience of college students in social situations and found that respondents’ existence consciousness and cognitive deviation are sensitive to external evaluation and feedback, thus producing anxiety in social situations. The resulting fear and pain of patients prevent normal studies, work and lives, so they desperately want to change the status quo to seek treatment. Based on the results of this study, it is suggested that mental health workers should pay more attention to SAD adolescents, meet the psychological needs of SAD college students, and provide theoretical support for comprehensive and systematic psychological intervention management programs.

Acknowledgments

The authors were grateful for all the participants in this study for their corporation.

Data Sharing Statement

The datasets used during the current study are available from the corresponding author on reasonable request.

Ethics Approval and Consent to Participate

This study was approved by the ethics commitment of Shandong Traditional Chinese Medicine College and informed consent was obtained from every participant.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

The authors report no other conflicts of interest in this work.