Apart from depression, social anxiety (a.k.a. social phobia) is probably the most common clearly “diagnosable” mental health condition I see in the clinic. Although there is much information on the web about social anxiety, I rarely see it explained at the level of psychological depth necessary for folks to understand all the various elements that go into it. Instead, it usually is just described as a list of symptoms that are fairly obvious, such as the individual “often feels nervous in social situations," and the message is to take it seriously and seek treatment in the form of CBT or meds or both.
Social anxiety is indeed a serious psychological health condition, but I think we can do better than just describing the symptoms. In this blog, I use the unified approach as a backdrop to map out the key components that go into social anxiety. This involves understanding the following seven elements: 1) The nature of emotions and moods, and fear and anxiety in particular; 2) The personality traits of Neuroticism and (low) Extraversion; 3) Motives toward Relational Value and Social Influence; 4) Attachment security versus insecurity; 5) Core anxieties about (a) strangers and uncertainty; (b) performance and comparisons; and (c) conflicts and rejections; 6) The nature of the private-to-public filter in human consciousness; and 7) The role of the internal narrator, which, in social anxiety, often becomes a “critical, self-conscious introject” that is especially likely to be activated in novel social situations. Once we have these components laid out, we can add the lens of developmental history and learning via avoidance to paint a clear picture about the sequences that give rise to the condition.
Before I get into these seven elements, let me offer a fairly typical exchange in the clinic room to give you a flavor of what social anxiety looks like (this is accelerated, but should give you the basic gist of what such interactions look like). This is a (generic) clip from the first session with a 20 year old male college student who presented with feelings of “depression and anxiety”.
Me: So I hear you have been kind of down and discouraged lately, can you tell me how you have been spending your time?
Client: I haven’t been doing much. Just hanging out in my apartment, trying to study.
Me: Have you been hanging out with your friends much?
Client: I have been spending some time with my housemate, when he is around. I am not going out that much.
Me: From what I have heard of your story, it seems like you have been kind of isolated for the past several years, at least since coming to college.
Client: I guess. I am kind of shy.
Me: Tell me about that.
Client: I don’t know, I guess I just don’t feel very comfortable meeting new people, especially women.
Me: When you meet new folks, do you feel like you are anxious, kind of “on stage”, meaning that you have the feeling like everyone is watching your every move?
Client: Definitely. Then I get nervous and I have no idea what to say. Everyone else seems so relaxed. I just kind of freeze up.
Me: And then what?
Client: I don’t know. Usually I try to get out of there as fast as possible.
Me: So you retreat to your apartment. (Client nods). Then how do you feel?
Client: Some relief at first. But then I am just sitting there, feeling like a loser.
Me: Do you feel like you are somehow less than others, that you don’t measure up?
Client: I definitely feel that some times. Everyone else has done stuff, accomplished stuff, can speak their mind. I just can’t help but think there is something wrong with me.
Me: Sounds like a part of you is pretty pissed with yourself for being shy or socially anxious.
Client: Definitely. I mean, it is a pretty clear sign of weakness.
Me: And now you are kind of isolated and feeling lonely and depressed, huh?
Client: Yep. That is pretty much my life.
With this clinical backdrop in mind, let me explain each of the seven elements mentioned before and then piece them together so folks can get a picture of what social anxiety looks like.
1. Emotions and moods. I find it helpful to start with the basics, so let’s be clear about what emotions are. Emotions are “perceptual response sets”, meaning that they are patterned ways of responding to certain triggers, situations and events that are relevant to our needs and goals. Emotions can be divided into two broad groups of “positive and approach” versus "negative and avoid”. There is also a useful distinction between emotions that are active and those that are passive.Fear and anxiety are examples of “negative-avoid/active” emotions, because when triggered they activate the person to scan for threats and dangers to be avoided. Moods are related to emotions, but they are more diffuse, generally last longer, are more broadly positive or negative in nature, and operate more to prime certain clusters of emotion (i.e., when you are in a negative mood, you are more likely to have specific negative emotions like shame, anger or frustration be triggered). Folks who suffer from depression and/or anxiety disorders are in chronically negative mood states (see here for how to think about depression as a state of psychological shutdown).
2. Neuroticism and (Low) Extraversion. Personality traits refer to broad dispositional differences in ways individuals tend to feel, think and act. They emerge in childhood and then solidify in adulthood. There are two traits that are centrally related to social anxiety: 1) Neuroticism and 2) (low) Extraversion. Neuroticism refers to the “set point” of one’s negative emotion system. This means that one who is high on neuroticism will have more frequent and intense negative emotional reactions to stressors, will take longer to calm down, and will have more negative or pessimistic thoughts about their environment. Extraversion, in contrast, refers to both one’s general set point for the positive emotion system and is also tied (secondarily) into one’s sociality, meaning one’s tendency to seek novel social contact and exchange. If an individual is high in neuroticism and low in extraversion, they will be far more vulnerable to developing social anxiety than someone who has the reverse trait profile.
3. Relational Value and Social Influence. We are inherently social creatures with relational needs and goals. We have fundamental motives for social influence (having people act in accordance with our interests) and relational value (being known and valued by important others). Our emotional system guides us to approach gains and avoid losses in relational value and social influence. The unified approach uses the Influence Matrix to map the human relationship system. Folks with social anxiety, as a function of their basic emotional system tendencies and learning history, generally are much more oriented to avoiding losses in relational value and social influence than approach gains. Unfortunately, though, this focus on avoiding immediate losses often ends up trapping them over time.
4. Attachment security versus insecurity. The base of our relationship system is formed in early attachments and attachment security is the basic sense that one is cared for and known and valued by one’s inner relational circle. It starts as the dance between infant and caretakers and develops throughout the lifestyle. In social anxiety, I have seen attachment security generally operate in one of two ways. First, there are some folks who have a basic attachment insecurity, meaning that they always felt off key or out of step with their caregivers and tend to feel unsafe in all of their relationships. Second, I have seen other folks who have deep attachment to their “home base”, which functions to keep them from wanting to explore and reach out. Thus, their anxiety about strangers becomes tied to their need to stay close to home. That said, for many, social anxiety can develop when they have normal, healthy relationships with the family of origin.
5. The Core Social Anxieties: A) Strangers and Uncertainty; B) Performances and Comparisons; C) Conflicts and Rejections. There are some really basic, core anxieties that human come “prepared” to feel, and for social anxiety, the three broad classes of anxiety listed here are key. Stranger anxiety is one of the most basic humans have. It is so basic that it serves as one of the most famous tests of attachment, called the strange situation, where toddlers and young children and unexpectedly placed in the presence of a stranger. Some kids just naturally flip out in such circumstances. Strangers are related potentially to both threat and uncertainty--not knowing what is coming next or what to do next can be enough to trigger fear and anxiety.
One of the most basic ways we achieve social influence and relational value is via effective performance of skilled tasks. Related to the idea of achievement is the idea that we are primed to compare ourselves with others in our degree of skill and attraction. The flip side of this fact is that a poor performance or poor social comparison is tied to the loss of relational value and social influence. As such that loss is often feared and for many individuals with social anxiety the idea of offering a social performance (e.g., public speaking) that opens them up to criticism or poor social comparisons with others is nothing short of terrifying.
Third, conflict and rejection are the most direct threats to social influence and relational value. Indeed, the idea of being criticized or rejected from a group, which is understandably scary to many people, is simply intolerable for folks with social anxiety. So they work enormously hard to avoid all possible forms of criticism or rejection.
6. The “Private-to-Public” or Rogerian Filter. The unified approach offers a “tripartite model of human consciousness” (depicted below), in which there is the experiential self, a private narrator, and a public self. The filter between private to public is crucial for understanding social anxiety. Reflect for a minute on your private thoughts and feelings and then think about what you share with others. Although there are likely some people in some contexts in which you can be your full, true, authentic self, it nevertheless is likely the case that it is easy to recognize that there is a general filter between one’s private thoughts and feelings and one’s public presentation. The reason is straightforward, as our public behavior is regulated by social norms, expectations, reactions and judgments from others. As such, we need a way to filter problematic impulses, thoughts and feelings from public view to prevent those unfortunate consequences. Of course, if someone is terrified by social changes, uncertainty and threats, then there will be much greater levels of private to public filtering. (Note, it is called the Rogerian filter because Rogers was central in noting how judgments and criticisms from others shaped the expression of our true, authentic self). That, however, sets the stage for folks with social anxiety to be isolated and alienated and have many fewer people "know their true selves".
7. The Internal Narrator—turned Critical Introject. Your private self is the internal narrator that is making sense of your experiences and the world around you, houses your explicit self-concept, and regulates your behavior in relationship to the social field (i.e., it plays a central role in managing your public self). Feeling “self-conscious” describes the process by which the internal narrator becomes particularly active in trying to filter out problematic displays, utterances and performances. The inner narrator becomes critical when one’s performance is not living up to expectations. The function here is to try to (a) motivate the individual to work harder and (b) to avoid doing “stupid things” that others will judge and punish. Unfortunately, however, as described in this blog, this sets the stage for one to “turn against the self”, which in turn creates a vicious intrapsychic cycle. Indeed, the clip above is suggestive of someone who has started to turn against the self.
The above seven elements are necessary to capture the full picture of social anxiety. These are the components that go into the condition, but they do not tell the whole story. To do that, one needs to place them in the context of one’s learning and developmental history. That is, we need to understand the following: 1) what were the developmental origins of the social anxiety, with a particular focus on the attachment history and any history of trauma; 2) what is the current relational context and how skilled is the individual in navigating relationships in general; and 3) how did the “negatively reinforcing” avoidance pattern emerge and how do we understand the vicious psychological cycle that followed.
So, returning to the college student and continuing with his story to get the full picture, further assessment revealed a fairly comfortable family history, one in which he was “valued”, but was not known, meaning that he was never really given the chance to talk about who he was and what he felt inside. Then, as an adolescent, some opportunities emerged for him to interact with girls; for example, to ask them out on a date. This, however, evoked a tremendous anxiety, and he found himself repeatedly freezing whenever he encountered such an opportunity. He would then avoid the situation, which would relieve his immediate sense of fear, but over time he began to see himself as weak and ineffective. He wanted to date in part because he was lonely but even more so because his father communicated to him that prowess with women was a sign of being a real man. So he started feeling less and less like a real man. Then he had a very awkward encounter at a party, where a girl hit on him and he froze and left. She was a bit taken aback and then told some of his friends that he was “weird”. His friends then teased him and asked him if he was gay. This caused him to then become increasingly isolated and fearful of social exchanges. He was hoping to start new in college, but was overwhelmed with all the new relationships that were present and found himself isolating more and more. And the more he isolated the more his life deviated from what he hoped, the more self-critical he became, and ultimately started to slide into a clinical depressive episode.
Social anxiety is a relatively common psychological condition impacting approximately 7% of the population. It is associated with a number of impairments, and dramatically impacts psychological well-being overall. And it is not uncommon for folks to take 10 years or more of struggling with the condition prior to getting help. Hopefully, this blog helps folks understand this condition in greater depth, which then in turn sets the stage for earlier identification and more clear pathways for enhancing adaptive living for those struggling with it.