- Individuals with social anxiety disorder fear judgment or rejection, often avoiding common social situations as a result.
- Recent research suggests that faulty emotion regulation strategies play a key role in social anxiety.
- Socially anxious individuals tend to be less likely to reframe a feared situation in a more positive light, or may attempt to suppress negative emotions rather than accepting them.
- Psychotherapy approaches that impart healthier emotion regulation techniques can be an effective tool against social anxiety.
Most people have experienced social anxiety at some point—whether it’s before a work presentation or first date, or when meeting new people. While the experience of anxiety itself is not usually problematic, it’s often our response to the anxiety that creates a problem. So, when does social anxiety cross over into disorder territory?
According to the DSM-5, the frequency of anxiety and the impact of anxiety on someone’s life constitutes a disorder. Specifically, the DSM-5 defines Social Anxiety Disorder (SAD) as:
- the frequent experience of a marked fear about social situations where someone could potentially be exposed to judgment or rejection by others
- the social anxiety and associated avoidance of situations causes significant impairment in the person’s life
SAD is the fourth most common mental health disorder, after depression, alcohol use, and specific phobias, and approximately 12.1 percent of the general population will experience SAD in their lifetime (Kessler et al., 2012). There are many comorbidities (or co-occurring disorders) with SAD; two of the most common are depression and alcohol use disorders. People with eating disorders, psychosis, or autism spectrum disorders also have an elevated rate of SAD compared to the general population.
Recently, there has been a lot of interest in the role of emotion regulation in SAD. Emotion regulation has been defined as “efforts made to influence the particular emotions one has, when one has them, and how these emotions are (or, in some cases, are not) experienced and/or expressed” (Jazaieri et al., 2014, p. 2).
The process model of emotion regulation (Gross, 1998) identifies five distinct stages where strategies can be implemented to influence one’s emotional experience and expression. This process model is a useful conceptualization of the factors that maintain social anxiety, and also helps explain why social anxiety co-occurs with other disorders.
In an updated model of social anxiety, Heimberg, Brozovich, and Rapee (2010) expand on how maladaptive emotion regulation strategies and deficits in applying adaptive strategies are involved in SAD during each of the stages of emotion regulation:
- Situation selection: Choosing which situations we approach, and in the case of someone with SAD, choosing to avoid a social event to avoid the discomfort that may come with socializing.
- Situation modification: Altering certain aspects of the situation to change our experience, such as standing in the farthest corner to avoid interacting with others.
- Attentional deployment: Focusing on specific internal or external cues, such as focusing on uncomfortable bodily sensations (e.g., racing heart, flushed face) or how others are reacting to conversation.
- Cognitive change: How we interpret a situation, such as jumping to a conclusion that the person you are talking to is not interested, when they might just be distracted.
- Response modulation: All the above stages can elicit a range of emotional responses, such as anxiety. Instead of accepting the discomfort, many people try to change or hide that experience, either by getting rid of or suppressing the emotions.
Across the stages of emotion regulation, relying on a single strategy (e.g., avoidance) too often and not being able to flexibly employ a variety of strategies is problematic. SAD has been associated with the underutilization of cognitive reappraisal and the overuse of emotional suppression (see Jazaieri et al., 2014).
- Cognitive reappraisal: Included in the cognitive change stage of emotion regulation, cognitive reappraisal is an attempt to reframe thoughts or conclusions about a situation. For example, someone might reframe their initial reaction “That presentation was a total failure” to something more realistic and less catastrophic “I stumbled on my words in the beginning, but the rest of the presentation was OK.”
- Emotional suppression: Included in the response modulation stage of emotion regulation, emotional suppression is an attempt to control outwardly-expressed emotion. For example, someone might try to hide their anxiety during a work meeting, which can paradoxically make them appear stiff and disinterested.
In addition to increasing anxiety in the long-term, maladaptive emotion regulation strategies may also be related to the tendency for people with SAD to experience less positive affect and more negative affect. For example, one study found that participants with high social anxiety used emotional suppression more frequently and experienced fewer positive emotions and positive social events (Farmer & Kashdan, 2012). Low positive affect, cognitive reappraisal, and emotional suppression are also implicated in depression, which could explain the high rates of comorbidity between SAD and depression (Dryman & Heimberg, 2018).
Understanding the mechanisms underlying SAD is critical for creating effective treatments. Currently, Cognitive Behavioral Therapy (CBT) is considered the gold standard for social anxiety disorder (see resources: ADAA or NICE ). More recently, Mindfulness and Acceptance-Based Treatments for social anxiety have been shown to significantly reduce SAD symptoms.
These psychotherapies for SAD focus on both distorted cognitions (e.g., unrealistic social expectations, overestimating negative consequences, post-event processing, self-focused attention) and maladaptive behaviors (e.g., avoidance of social situations, safety behaviors like phone or substance use) that maintain social anxiety symptoms.
Behavioral therapies typically also include exposure therapy, where the individual purposely exposes themselves to situations that cause anxiety. Exposures done in a therapeutic context can help people learn that the terrible outcomes they feared don’t occur as often as they thought and that when they do occur, they are better able to cope with the situation and their emotional response than they believed. Most importantly, people learn that tolerating some discomfort is a price worth paying to live their lives fully and consistent with their values.
Emily Bowers contributed to this post. Emily is the Research Coordinator for the Behavioral Health Partial Hospital Program at McLean Hospital.
Dryman, M. T., & Heimberg, R. G. (2018). Emotion regulation in social anxiety and depression: a systematic review of expressive suppression and cognitive reappraisal. In Clinical Psychology Review (Vol. 65, pp. 17–42). Elsevier Inc. https://doi.org/10.1016/j.cpr.2018.07.004
Farmer, A. S., & Kashdan, T. B. (2012). Social anxiety and emotion regulation in daily life: Spillover effects on positive and negative social events. Cognitive Behaviour Therapy, 41(2), 152–162. https://doi.org/10.1080/16506073.2012.666561
Gross, J. J. (1998). Antecedent-and Response-Focused Emotion Regulation: Divergent Consequences for Experience, Expression, and Physiology (Vol. 74, Issue 1). Psychological Association, Inc.
Heimberg, R. G., Brozovich, F. A., & Rapee, R. M. (2010). A Cognitive Behavioral Model of Social Anxiety Disorder: Update and Extension. In Social Anxiety (pp. 395–422). Elsevier Inc. https://doi.org/10.1016/B978-0-12-375096-9.00015-8
Jazaieri, H., Morrison, A. S., Goldin, P. R., & Gross, J. J. (2014). The role of emotion and emotion regulation in social anxiety disorder. Current Psychiatry Reports, 17(1), 1–9. https://doi.org/10.1007/s11920-014-0531-3
Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H.-U. (2012). Twelve-month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21(3), 169–184. https://doi.org/10.1002/mpr.1359