typical presentation of social anxiety

Social Anxiety Disorder (Social Phobia)

Reviewed by Psychology Today Staff

Social anxiety disorder, formerly referred to as social phobia, is an anxiety disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. People with social anxiety disorder have a persistent, intense, and chronic fear of being watched and judged by others and of being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work, school, or other activities. While many people with social anxiety disorder recognize that their fear of being around people may be excessive or unreasonable, they are unable to overcome it. They often worry for days or weeks in advance of a dreaded situation. In addition, they often experience low self-esteem and depression .

Social anxiety disorder can be limited to only one type of situation—such as a fear of public speaking —or a person can experience symptoms whenever they are around other people. If left untreated, social phobia can have severe consequences. For example, it may keep people from work or school or prevent them from making friends.

Physical symptoms, which often accompany the intense stress of social anxiety disorder, include blushing , sweating, trembling, nausea, and difficulty speaking. Because these visible symptoms heighten the fear of disapproval, they themselves can become an additional focus of fear, creating a vicious cycle: As people with social anxiety disorder worry about experiencing these symptoms, the greater their chances are of developing them.

Social anxiety disorder often runs in families and may be accompanied by depression or other anxiety disorders, such as panic disorder or obsessive-compulsive disorder. Some people with social anxiety disorder self-medicate with alcohol or other drugs, which can lead to addiction .

A diagnosis of social anxiety disorder is made only if this avoidance, fear, or anxious anticipation of a social or performance situation interferes with daily routine, occupational functioning, and social life or if there is marked distress as a result of the anxiety . The DSM-5 provides the following criteria for diagnosing social anxiety disorder:

• The individual fears one or more social or performance situations in which he or she is exposed to possible scrutiny by others. Examples include meeting unfamiliar people, being observed eating or drinking, or giving a speech or performance.
• The individual fears behaving in a manner that causes embarrassment or being negatively evaluated.
• Exposure to social situations almost always causes intense anxiety.
• The feared situation is avoided or endured with anxiety and distress.
• The fear or anxiety is out of proportion to the actual threat posed by the social situation.
• The fear or anxiety is persistent and typically lasts for six months or longer.
• The avoidance, anxious anticipation, or distress interferes significantly with the person's social, academic, or occupational functioning.

The physical symptoms of social anxiety disorder include the following:

• Blushing, sweating, trembling, experiencing a rapid heart rate, or feeling the “mind going blank”
• Nausea or upset stomach
• Displaying a rigid body posture, poor eye contact, or speaking too quietly

Additionally, the diagnosis can specify whether the anxiety or fear is present only when the person is speaking or performing in public.

According to the National Institute of Mental Health, about 7 percent of the U.S. population is estimated to have social anxiety disorder within a given 12-month period. Social anxiety disorder occurs about twice as often in women as in men, although a higher proportion of men seek help for the condition. The disorder typically begins in childhood or early adolescence and rarely develops after age 25.

For some people, just starting a simple conversation is anxiety-provoking. Other situations include:

• Picking up the phone

• Giving a speech or any form of public speaking

• Speaking up in a group

• Meeting new people

• Speaking to a teacher or other authority figure

While research to better understand the causes of social anxiety disorder is ongoing, some investigations implicate a small structure in the brain called the amygdala. The amygdala is believed to be a central site in the brain that controls fear responses.

Social anxiety disorder is heritable. In fact, first-degree relatives have a two to six times higher chance of developing social anxiety disorder. Research supported by the National Institute of Mental Health (NIMH) has also identified the site of a gene in mice that affects learned fearfulness. Scientists are exploring the idea that heightened sensitivity to disapproval may be physiologically or hormonally based. Other researchers are investigating the environment 's influence on the development of social phobia . Childhood maltreatment and adversity are risk factors for social anxiety disorder.

Children living in high-conflict homes can develop social anxiety disorder; trauma or abuse are also associated with SAD in children. In addition, a child who experiences bullying , rejection, humiliation, or teasing may also develop SAD.

Most anxiety disorders can be treated successfully by a trained mental healthcare professional. Social anxiety disorder is often treated effectively with two forms of treatment: psychotherapy and medications.

Cognitive-behavioral therapy (CBT) is a form of psychotherapy that is very effective in treating severe social anxiety. A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the anxiety disorder. For example, avoidance of a feared object or situation prevents a person from learning that it is harmless.

A key element of CBT for anxiety is exposure, in which people confront the things they fear. The exposure process generally involves three stages. First, a person is introduced to the feared situation. The second step is to increase the risk for disapproval in that situation so a person can build confidence that he or she can handle rejection or criticism. The third step involves teaching a person techniques for coping with disapproval. In this stage, people are asked to imagine their worst fear and are encouraged to develop constructive responses to this fear and perceived disapproval.

These stages are often accompanied by anxiety management training—for example, teaching people techniques such as deep breathing to control their anxiety. If this is done carefully and with support from a therapist, it may be possible to defuse the anxiety associated with feared situations. If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission. You will work with the therapist to determine how much you can handle and at what pace you can proceed.

CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well-trained in the techniques of the treatment for it to work as desired. During treatment, the therapist will likely assign homework—specific problems that the patient will need to work on between sessions. CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Supportive therapy, such as group, couples, or family therapy can be helpful to educate significant others about the disorder. Sometimes people with social anxiety also benefit from social skills training.

Medications

Proper and effective medications may also play a role in treatment, along with psychotherapy. Medications include antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as drugs known as high-potency benzodiazepines. Some people with a form of social anxiety that presents itself only when they have to perform in front of others have been helped by beta-blockers, which lower heart rate and reduce physical symptoms of anxiety.

Treatments for social anxiety disorder do not work instantly and that no one plan works well for all patients. Treatment must be tailored to the needs of each individual. A therapist and patient should work together to determine which treatment plan will be most effective and to assess whether the approach seems to be on track. Adjustments to the plan are sometimes necessary because patients respond differently to any one type of treatment.

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Social Phobia Clinical Presentation

• Author: Bettina E Bernstein, DO, DFAACAP, DFAPA; Chief Editor: Caroly Pataki, MD  more...
• Sections Social Phobia
• Practice Essentials
• Pathophysiology
• Epidemiology
• Patient Education
• Physical Examination
• Complications
• Approach Considerations
• Laboratory Studies
• Imaging Studies
• Other Tests
• Medical Care
• Surgical Care
• Long-Term Monitoring
• Medication Summary
• Selective Serotonin Reuptake Inhibitors
• Serotonin/norepinephrine reuptake inhibitors
• Benzodiazepines
• Antianxiety agents
• Anticonvulsants
• Antibiotic, Miscellaneous
• Monoamine Inhibitor

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision ( DSM-5-TR ) criteria for social phobia are as follows: [ 3 ]

Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. In children, the anxiety must occur in peer settings and not just during interactions with adults.

The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated.

The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent.

The social situations almost always provoke fear or anxiety. In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.

The social situations are avoided or endured with intense fear or anxiety.

The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

The fear, anxiety, or avoidance cause clinically significant distress or impairment in social, occupationals, or other important areas of functioning.

The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance or another medical condition.

The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder.

If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

The chief complaint of a 9-year-old boy is, "No one likes me or wants to play with me, and I hate it when the teacher asks me to read aloud." He has difficulties with functioning at school, his teacher reports that he rarely raises his hand to be called on, and his mother reports that he has frequent stomachaches, especially the night before he is supposed to take standardized tests. At home, he seems content to play his clarinet by himself, and he tells the clinician that he dreads concerts because he is expected to play in front of others.

A thorough Mental Status Examination should be conducted, with the following areas specifically assessed:

General appearance: The patient may be noticeably uncomfortable or anxious in the office. The patient may be hesitant or have difficulty speaking. However, in one-on-one situations, the patient may not demonstrate significant social anxiety. Individuals observed to be silent or mute should undergo screening for selective mutism with the selective mutism questionnaire or other appropriate checklists that gather information from the child and other sources of information (eg, from parents or teachers). [ 34 ]

Mood/affect: Because depression is commonly comorbid with social phobia, the patient may report depressed or anxious mood and may appear to have a depressed or anxious affect.

Speech: The patient may speak softly and with hesitancy.

Thought processes: Thought processes in individuals with social phobia are usually in the "normal" range. Their thought processes are usually appropriately goal-directed and syntonic without morbid preoccupation or impairment of reality.

Perception: Auditory or visual hallucinations are not elements of social phobia; however, schizophrenia or acute stress disorder may be comorbid with social phobia. [ 35 ]

Thought content: The patient may be preoccupied with what others are thinking about him or her. Delusions are not present, but preoccupation with the scrutiny of others may approach delusional levels. True fixed delusions are not consistent with social phobia and are more suggestive of schizophrenia. [ 35 ]

A 2015 study of adolescents found that individuals with social anxiety disorder (SAD) displayed more frequent and intense paranoid thoughts than a control group and that the level of paranoid thoughts was significantly predicted by the degree of social phobia, even after adjusting for sex and other anxiety disorders, although adjusting for depression slightly reduced the extent and significance of the prediction. [ 36 ]

Cognition: Cognition is normal.

Suicidal/homicidal ideation: This is not common with social phobia per se, but the social isolation associated with social phobia can lead to despair, depression, and suicidal ideation. Thus, it is important to screen for depression, especially in the presence of obsessive thinking accompanied by compulsive behaviors. [ 37 , 38 ]

Very low-weight (600–1250g) premature babies may be at higher risk for later development of social anxiety disorder, possibly owing to abnormalities in the uncinate fasciculus, the major white matter tract connecting the frontal cortex to the amygdala, and other limbic temporal regions. [ 14 ]

Genetic factors may contribute to social phobia. Pedigree analyses suggest that first-degree relatives of probands with social phobia are 3 times more likely to have social phobia than controls. However, specific genes have not been isolated. An inhibited temperament in childhood has been linked with the development of social phobia in adolescence. The brain dysfunction in social phobia may result from increased activation of neural circuitry to fearful faces, specifically in the amygdala. [ 37 , 38 ]

Paternal social anxiety is a specific risk factor for the development of childhood social anxiety. When fathers exhibit social anxiety, this can be interpreted by their children as a strong negative signal about the external social world and cause them to rationally adjust their beliefs and feel stressed instead of secure. This can hinder children developing feelings of security regarding individuation and autonomy. [ 39 ]

A cross-cultural perspective is essential, as individuals of some cultures (Japanese, Korean) may have a persistent and excessive fear of offending others in social situations, called taijin kyofusho . Specifically, the individual fears that his or her body odor, eye-to-eye contact, or blushing could be offensive to others. [ 40 ]

A severe form of social phobia and avoidant personality disorder, Hikikomori has been associated with adverse cardiovascular consequences including hypertension. [ 22 ]

The importance of culturally sensitive measures in diagnosis of social phobia and social anxiety is critical, although social phobia and social anxiety has been found in many cultures, not exclusively in Japan but also in Hong Kong, China, India, South Korea, Spain, and the United States. One study found differences in sensitivity of detection of the disorder finding that the Social Interaction Anxiety Scale and Social Phobia Scale were not as sensitive in detecting the disorder in test subjects from Japan compared with those from Australia. [ 41 ]

Preliminary findings of one study show possible blood biomarkers that may reflect increased risk for Hikikomori—lower serum HDL-C in females and lower serum uric acid in males—which may reflect an underlying mechanism of oxidative stress and inflammation increasing risk of social phobia. [ 42 ]

Because elevated cortisol levels may worsen symptoms of social phobia, the history and cursory observation of the patient's habitus should include ruling in or out conditions that cause elevated cortisol levels (intrinsic or extrinsic) via taking blood pressure, pulse, and observing for abnormal facies like "mood facies." [ 43 ]

Social phobia has a wide range of severity. It may be mild and associated with minimal distress or may be severe to the point of causing marked disability. Extreme avoidance behavior (ie, avoiding contact with others and being unable to maintain employment) sometimes complicates this condition.

Substance abuse, particularly the abuse of alcohol, sedatives, or narcotics, can also make treatment more difficult because benzodiazepines may not be appropriate or may need to be used with extreme caution in patients with substance dependency.

School refusal is a common complication of social anxiety disorder. A classic article highlights the importance of using cognitive behavioral therapy techniques for youth who are on an inpatient psychiatric unit to prevent school refusal. [ 44 ]

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Contributor Information and Disclosures

Bettina E Bernstein, DO, DFAACAP, DFAPA Distinguished Fellow, American Academy of Child and Adolescent Psychiatry; Distinguished Fellow, American Psychiatric Association; Clinical Assistant Professor of Neurosciences and Psychiatry, Department of Psychiatry/Psychiatric Medicine, Philadelphia College of Osteopathic Medicine; Clinical Affiliate Medical Staff, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Consultant to Gemma Services, Private Practice; Consultant PMHCC/CBH at Family Court, Philadelphia Bettina E Bernstein, DO, DFAACAP, DFAPA is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry , American Psychiatric Association Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Received salary from Medscape for employment. for: Medscape.

Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry , New York Academy of Sciences , Physicians for Social Responsibility Disclosure: Nothing to disclose.

Mohammed A Memon, MD Psychiatrist/Geriatric Psychiatrist, Carolina Center for Behavioral Health; Assistant Professor of Psychiatry, Virginia Commonwealth University School of Medicine Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry , American Medical Association , American Psychiatric Association Disclosure: Nothing to disclose.

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor, Kiki D Chang, MD, to the development and writing of this article.

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• Social anxiety disorder (social phobia)

Your health care provider will want to determine whether other conditions may be causing your anxiety or if you have social anxiety disorder along with another physical or mental health disorder.

Your health care provider may determine a diagnosis based on:

• Physical exam to help assess whether any medical condition or medication may trigger symptoms of anxiety
• Discussion of your symptoms, how often they occur and in what situations
• Review of a list of situations to see if they make you anxious
• Self-report questionnaires about symptoms of social anxiety
• Criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

DSM-5 criteria for social anxiety disorder include:

• Persistent, intense fear or anxiety about specific social situations because you believe you may be judged negatively, embarrassed or humiliated
• Avoidance of anxiety-producing social situations or enduring them with intense fear or anxiety
• Excessive anxiety that's out of proportion to the situation
• Anxiety or distress that interferes with your daily living
• Fear or anxiety that is not better explained by a medical condition, medication or substance abuse
• Care at Mayo Clinic

Our caring team of Mayo Clinic experts can help you with your social anxiety disorder (social phobia)-related health concerns Start Here

Treatment depends on how much social anxiety disorder affects your ability to function in daily life. The most common treatment for social anxiety disorder includes psychotherapy (also called psychological counseling or talk therapy) or medications or both.

• Psychotherapy

Psychotherapy improves symptoms in most people with social anxiety disorder. In therapy, you learn how to recognize and change negative thoughts about yourself and develop skills to help you gain confidence in social situations.

Cognitive behavioral therapy (CBT) is the most effective type of psychotherapy for anxiety, and it can be equally effective when conducted individually or in groups.

In exposure-based CBT, you gradually work up to facing the situations you fear most. This can improve your coping skills and help you develop the confidence to deal with anxiety-inducing situations. You may also participate in skills training or role-playing to practice your social skills and gain comfort and confidence relating to others. Practicing exposures to social situations is particularly helpful to challenge your worries.

First choices in medications

Though several types of medications are available, selective serotonin reuptake inhibitors (SSRIs) are often the first type of drug tried for persistent symptoms of social anxiety. Your health care provider may prescribe paroxetine (Paxil) or sertraline (Zoloft).

The serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor XR) also may be an option for social anxiety disorder.

To reduce the risk of side effects, your health care provider may start you at a low dose of medication and gradually increase your prescription to a full dose. It may take several weeks to several months of treatment for your symptoms to noticeably improve.

Other medications

Your health care provider may also prescribe other medications for symptoms of social anxiety, such as:

• Other antidepressants. You may have to try several different antidepressants to find the one that's most effective for you with the fewest side effects.
• Anti-anxiety medications. Benzodiazepines (ben-zoe-die-AZ-uh-peens) may reduce your level of anxiety. Although they often work quickly, they can be habit-forming and sedating, so they're typically prescribed for only short-term use.
• Beta blockers. These medications work by blocking the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs. Because of that, they may work best when used infrequently to control symptoms for a particular situation, such as giving a speech. They're not recommended for general treatment of social anxiety disorder.

Stick with it

Don't give up if treatment doesn't work quickly. You can continue to make strides in psychotherapy over several weeks or months. Learning new skills to help manage your anxiety takes time. And finding the right medication for your situation can take some trial and error.

For some people, the symptoms of social anxiety disorder may fade over time, and medication can be discontinued. Others may need to take medication for years to prevent a relapse.

To make the most of treatment, keep your medical or therapy appointments, challenge yourself by setting goals to approach social situations that cause you anxiety, take medications as directed, and talk to your health care provider about any changes in your condition.

Alternative medicine

Several herbal remedies have been studied as treatments for anxiety, but results are mixed. Before taking any herbal remedies or supplements, talk with your health care team to make sure they're safe and won't interact with any medications you take.

More Information

Social anxiety disorder (social phobia) care at Mayo Clinic

• Cognitive behavioral therapy

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Lifestyle and home remedies

Although social anxiety disorder generally requires help from a medical expert or qualified psychotherapist, you can try some of these techniques to handle situations that are likely to trigger symptoms:

• Learn stress-reduction skills.
• Get physical exercise or be physically active on a regular basis.
• Get enough sleep.
• Eat a healthy, well-balanced diet.
• Avoid alcohol.
• Limit or avoid caffeine.
• Participate in social situations by reaching out to people with whom you feel comfortable.

Practice in small steps

First, consider your fears to identify what situations cause the most anxiety. Then gradually practice these activities until they cause you less anxiety. Begin with small steps by setting daily or weekly goals in situations that aren't overwhelming. The more you practice, the less anxious you'll feel.

Consider practicing these situations:

• Eat with a close relative, friend or acquaintance in a public setting.
• Purposefully make eye contact and return greetings from others, or be the first to say hello.
• Give someone a compliment.
• Ask a retail clerk to help you find an item.
• Get directions from a stranger.
• Show an interest in others — ask about their homes, children, grandchildren, hobbies or travels, for instance.
• Call a friend to make plans.

Prepare for social situations

At first, being social when you're feeling anxious is challenging. As difficult or painful as it may seem initially, don't avoid situations that trigger your symptoms. By regularly facing these kinds of situations, you'll continue to build and reinforce your coping skills.

These strategies can help you begin to face situations that make you nervous:

• Prepare for conversation, for example, by reading about current events to identify interesting stories you can talk about.
• Focus on personal qualities you like about yourself.
• Practice relaxation exercises.
• Learn stress management techniques.
• Set realistic social goals.
• Pay attention to how often the embarrassing situations you're afraid of actually take place. You may notice that the scenarios you fear usually don't come to pass.
• When embarrassing situations do happen, remind yourself that your feelings will pass and you can handle them until they do. Most people around you either don't notice or don't care as much as you think, or they're more forgiving than you assume.

Avoid using alcohol to calm your nerves. It may seem like it helps temporarily, but in the long term it can make you feel even more anxious.

Coping and support

These coping methods may help ease your anxiety:

• Routinely reach out to friends and family members.
• Join a local or reputable internet-based support group.
• Join a group that offers opportunities to improve communication and public speaking skills, such as Toastmasters International.
• Do pleasurable or relaxing activities, such as hobbies, when you feel anxious.

Over time, these coping methods can help control your symptoms and prevent a relapse. Remind yourself that you can get through anxious moments, that your anxiety is short-lived and that the negative consequences you worry about so much rarely come to pass.

Preparing for your appointment

You may see your primary care provider, or your provider may refer you to a mental health professional. Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

• Situations you've been avoiding, especially those that are important to your functioning
• Any symptoms you've been experiencing, and for how long, including any symptoms that may seem unrelated to the reason for your appointment
• Key personal information, especially any significant events or changes in your life shortly before your symptoms appeared
• Medical information, including other physical or mental health conditions with which you've been diagnosed
• Any medications, vitamins, herbs or other supplements you're taking, including dosages
• Questions to ask your health care provider or a mental health professional

You may want to ask a trusted family member or friend to go with you to your appointment, if possible, to help you remember key information.

Some questions to ask your health care provider may include:

• What do you believe is causing my symptoms?
• Are there any other possible causes?
• How will you determine my diagnosis?
• Should I see a mental health specialist?
• Is my condition likely temporary or chronic?
• Are effective treatments available for this condition?
• With treatment, could I eventually be comfortable in the situations that make me so anxious now?
• Am I at increased risk of other mental health problems?
• Are there any brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask other questions during your appointment.

What to expect from your health care provider

Your health care provider or a mental health professional will likely ask you a number of questions. Be ready to answer them to reserve time to go over any points you want to focus on. Your health care provider may ask:

• Does fear of embarrassment cause you to avoid doing certain activities or speaking to people?
• Do you avoid activities in which you're the center of attention?
• Would you say that being embarrassed or looking stupid is among your worst fears?
• When did you first notice these symptoms?
• When are your symptoms most likely to occur?
• Does anything seem to make your symptoms better or worse?
• How are your symptoms affecting your life, including work and personal relationships?
• Do you ever have symptoms when you're not being observed by others?
• Have any of your close relatives had similar symptoms?
• Have you been diagnosed with any medical conditions?
• Have you been treated for mental health symptoms or mental illness in the past? If yes, what type of therapy was most beneficial?
• Have you ever thought about harming yourself or others?
• Do you drink alcohol or use recreational drugs? If so, how often?
• Social anxiety disorder (social phobia). In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. American Psychiatric Association; 2013. http://dsm.psychiatryonline.org. Accessed May 21, 2021.
• Gabbard GO, ed. Social anxiety disorder (social phobia). In: Gabbard's Treatments of Psychiatric Disorders. 5th ed. American Psychiatric Association; 2014. http://psychiatryonline.org/doi/book/10.1176/appi.books.9781585625048. Accessed May 21, 2021.
• Schneier FR. Social anxiety disorder in adults: Epidemiology, clinical manifestations, and diagnosis. https://www.uptodate.com/contents/search. Accessed April 8, 2021.
• Stein MB, et al. Approach to treating social anxiety disorder in adults. https://www.uptodate.com/contents/search. Accessed April 8, 2021.
• Hofmann SG. Psychotherapy for social anxiety disorder in adults. https://www.uptodate.com/contents/search. Accessed April 8, 2021.
• Stein MB. Pharmacotherapy for social anxiety disorder in adults. https://www.uptodate.com/contents/search. Accessed April 8, 2021.
• Bystritsky A. Complementary and alternative treatments for anxiety symptoms and disorders: Herbs and medications. https://www.uptodate.com/contents/search. Accessed April 8, 2021.
• Bystritsky A. Complementary and alternative treatments for anxiety symptoms and disorders: Physical, cognitive, and spiritual interventions. https://www.uptodate.com/contents/search. Accessed April 8, 2021.
• Social anxiety disorder: More than just shyness. National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/social-anxiety-disorder-more-than-just-shyness/index.shtml. Accessed April 8, 2021.
• Natural medicines in the clinical management of anxiety. Natural Medicines. https://naturalmedicines.therapeuticresearch.com. Accessed April 8, 2021.
• Sawchuk CN (expert opinion). Mayo Clinic. April 29, 2021.
• AskMayoExpert. Anxiety disorders. Mayo Clinic; 2020. Accessed April 8, 2021.
• Brown A. Allscripts EPSi. Mayo Clinic. Sept. 11, 2020.
• Valerian. Natural Medicines. https://naturalmedicines.therapeuticresearch.com. Accessed April 12, 2021.
• Sarris J, et al., eds. Anxiety. In: Clinical Naturopathy. 3rd ed. Elsevier; 2019. https://www.clinicalkey.com. Accessed April 12, 2021.

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How to Manage Public Speaking Anxiety

Luis Alvarez / Getty Images

Speech Anxiety and SAD

How to prepare for a speech.

Public speaking anxiety, also known as glossophobia , is one of the most commonly reported social fears.

While some people may feel nervous about giving a speech or presentation if you have social anxiety disorder (SAD) , public speaking anxiety may take over your life.

Public speaking anxiety may also be called speech anxiety or performance anxiety and is a type of social anxiety disorder (SAD). Social anxiety disorder, also sometimes referred to as social phobia, is one of the most common types of mental health conditions.

Public Speaking Anxiety Symptoms

Symptoms of public speaking anxiety are the same as those that occur for social anxiety disorder, but they only happen in the context of speaking in public.

If you live with public speaking anxiety, you may worry weeks or months in advance of a speech or presentation, and you probably have severe physical symptoms of anxiety during a speech, such as:

• Pounding heart
• Quivering voice
• Shortness of breath
• Upset stomach

Causes of Public Speaking Anxiety

These symptoms are a result of the fight or flight response —a rush of adrenaline that prepares you for danger. When there is no real physical threat, it can feel as though you have lost control of your body. This makes it very hard to do well during public speaking and may cause you to avoid situations in which you may have to speak in public.

How Is Public Speaking Anxiety Is Diagnosed

Public speaking anxiety may be diagnosed as SAD if it significantly interferes with your life. This fear of public speaking anxiety can cause problems such as:

• Changing courses at college to avoid a required oral presentation
• Changing jobs or careers
• Turning down promotions because of public speaking obligations
• Failing to give a speech when it would be appropriate (e.g., best man at a wedding)

If you have intense anxiety symptoms while speaking in public and your ability to live your life the way that you would like is affected by it, you may have SAD.

Public Speaking Anxiety Treatment

Fortunately, effective treatments for public speaking anxiety are avaible. Such treatment may involve medication, therapy, or a combination of the two.

Short-term therapy such as systematic desensitization and cognitive-behavioral therapy (CBT) can be helpful to learn how to manage anxiety symptoms and anxious thoughts that trigger them.

Ask your doctor for a referral to a therapist who can offer this type of therapy; in particular, it will be helpful if the therapist has experience in treating social anxiety and/or public speaking anxiety.

Research has also found that virtual reality (VR) therapy can also be an effective way to treat public speaking anxiety. One analysis found that students treated with VR therapy were able to experience positive benefits in as little as a week with between one and 12 sessions of VR therapy. The research also found that VR sessions were effective while being less invasive than in-person treatment sessions.

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If you live with public speaking anxiety that is causing you significant distress, ask your doctor about medication that can help. Short-term medications known as beta-blockers (e.g., propranolol) can be taken prior to a speech or presentation to block the symptoms of anxiety.

Other medications may also be prescribed for longer-term treatment of SAD, including selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). When used in conjunction with therapy, you may find the medication helps to reduce your phobia of public speaking.

In addition to traditional treatment, there are several strategies that you can use to cope with speech anxiety and become better at public speaking in general . Public speaking is like any activity—better preparation equals better performance. Being better prepared will boost your confidence and make it easier to concentrate on delivering your message.

Even if you have SAD, with proper treatment and time invested in preparation, you can deliver a successful speech or presentation.

Pre-Performance Planning

Taking some steps to plan before you give a speech can help you better control feelings of anxiety. Before you give a speech or public performance:

• Choose a topic that interests you . If you are able, choose a topic that you are excited about. If you are not able to choose the topic, try using an approach to the topic that you find interesting. For example, you could tell a personal story that relates to the topic as a way to introduce your speech. This will ensure that you are engaged in your topic and motivated to research and prepare. When you present, others will feel your enthusiasm and be interested in what you have to say.
• Become familiar with the venue . Ideally, visit the conference room, classroom, auditorium, or banquet hall where you will be presenting before you give your speech. If possible, try practicing at least once in the environment that you will be speaking in. Being familiar with the venue and knowing where needed audio-visual components are ahead of time will mean one less thing to worry about at the time of your speech.
• Ask for accommodations . Accommodations are changes to your work environment that help you to manage your anxiety. This might mean asking for a podium, having a pitcher of ice water handy, bringing in audiovisual equipment, or even choosing to stay seated if appropriate. If you have been diagnosed with an anxiety disorder such as social anxiety disorder (SAD), you may be eligible for these through the Americans with Disabilities Act (ADA).
• Don’t script it . Have you ever sat through a speech where someone read from a prepared script word for word? You probably don’t recall much of what was said. Instead, prepare a list of key points on paper or notecards that you can refer to.
• Develop a routine . Put together a routine for managing anxiety on the day of a speech or presentation. This routine should help to put you in the proper frame of mind and allow you to maintain a relaxed state. An example might be exercising or practicing meditation on the morning of a speech.

Practice and Visualization

Even people who are comfortable speaking in public rehearse their speeches many times to get them right. Practicing your speech 10, 20, or even 30 times will give you confidence in your ability to deliver.

If your talk has a time limit, time yourself during practice runs and adjust your content as needed to fit within the time that you have. Lots of practice will help boost your self-confidence .

• Prepare for difficult questions . Before your presentation, try to anticipate hard questions and critical comments that might arise, and prepare responses ahead of time. Deal with a difficult audience member by paying them a compliment or finding something that you can agree on. Say something like, “Thanks for that important question” or “I really appreciate your comment.” Convey that you are open-minded and relaxed. If you don’t know how to answer the question, say you will look into it.
• Get some perspective . During a practice run, speak in front of a mirror or record yourself on a smartphone. Make note of how you appear and identify any nervous habits to avoid. This step is best done after you have received therapy or medication to manage your anxiety.
• Imagine yourself succeeding . Did you know your brain can’t tell the difference between an imagined activity and a real one? That is why elite athletes use visualization to improve athletic performance. As you practice your speech (remember 10, 20, or even 30 times!), imagine yourself wowing the audience with your amazing oratorical skills. Over time, what you imagine will be translated into what you are capable of.
• Learn to accept some anxiety . Even professional performers experience a bit of nervous excitement before a performance—in fact, most believe that a little anxiety actually makes you a better speaker. Learn to accept that you will always be a little anxious about giving a speech, but that it is normal and common to feel this way.

Setting Goals

Instead of trying to just scrape by, make it a personal goal to become an excellent public speaker. With proper treatment and lots of practice, you can become good at speaking in public. You might even end up enjoying it!

Put things into perspective. If you find that public speaking isn’t one of your strengths, remember that it is only one aspect of your life. We all have strengths in different areas. Instead, make it a goal simply to be more comfortable in front of an audience, so that public speaking anxiety doesn’t prevent you from achieving other goals in life.

A Word From Verywell

In the end, preparing well for a speech or presentation gives you confidence that you have done everything possible to succeed. Give yourself the tools and the ability to succeed, and be sure to include strategies for managing anxiety. These public-speaking tips should be used to complement traditional treatment methods for SAD, such as therapy and medication.

Crome E, Baillie A. Mild to severe social fears: Ranking types of feared social situations using item response theory . J Anxiety Disord . 2014;28(5):471-479. doi:10.1016/j.janxdis.2014.05.002

Pull CB. Current status of knowledge on public-speaking anxiety . Curr Opin Psychiatry. 2012;25(1):32-8. doi:10.1097/YCO.0b013e32834e06dc

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Anderson PL, Zimand E, Hodges LF, Rothbaum BO. Cognitive behavioral therapy for public-speaking anxiety using virtual reality for exposure . Depress Anxiety. 2005;22(3):156-8. doi:10.1002/da.20090

Hinojo-Lucena FJ, Aznar-Díaz I, Cáceres-Reche MP, Trujillo-Torres JM, Romero-Rodríguez JM. Virtual reality treatment for public speaking anxiety in students. advancements and results in personalized medicine .  J Pers Med . 2020;10(1):14. doi:10.3390/jpm10010014

Steenen SA, van Wijk AJ, van der Heijden GJ, van Westrhenen R, de Lange J, de Jongh A. Propranolol for the treatment of anxiety disorders: Systematic review and meta-analysis . J Psychopharmacol (Oxford). 2016;30(2):128-39. doi:10.1177/0269881115612236

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

SOCIAL ANXIETY IN TEENAGERS: HOW TO RECOGNIZE IT AND FIND APPROPRIATE SUPPORT

As an adolescent psychologist, I hear many parents talk about how their teenagers struggle to meet new people, and to initiate and maintain friendships. These same parents often worry about their teens isolating in their rooms, where socializing only comes from virtual means. At times, parents report that their teen is afraid of speaking with authority figures, such as teachers or coaches, or they may avoid these interactions altogether. These behaviors can lead parents to assume their teenager is depressed or uninterested in engaging with others. However, much of the time, it’s actually just the opposite. Typically, teens want desperately to connect with others. But when they try to face social situations, they find themselves too fearful of the possibility of negative outcomes or embarrassment to fully engage. In this way, a teen’s avoidance of social interaction might actually be a symptom of a deeper underlying issue. Fortunately, fear and avoidance of social situations is a problem that can be resolved if both recognized and treated appropriately. This article should provide some insight if your teen appears to be struggling socially and will guide you in finding the right support.

Teenagers are working extremely hard to live up to the daily pressures they face in school, within their community, and at home. Some might even say, it is more challenging to be a teenager today because of the added pressures that come along with social media and the unrealistic expectations it creates. As adults, we can sometimes forget how excruciating the fear of being judged by others was during this challenging developmental stage where all you want to do is “fit in.” Furthermore, we can sometimes be guilty of minimizing how debilitating social anxiety can be, especially for adolescents who are just now learning to navigate the complex and sometimes cruel world around them. It should be noted that 1 out of 3 adolescents between 13 and 18 years old meet criteria for Social Anxiety Disorder (SAD), which is currently the third most common mental health disorder in the country.

What are the signs?

You might be asking yourself, how can I tell if my teenager is struggling with social anxiety? Here are some helpful signs to look out for:

• A general fear of being judged by others
• Concerns about being a burden to others
• Frequent self-inflicted judgment and/or criticism after social interactions
• Difficulty talking to peers or authority figures
• Feeling uncomfortable or self-conscious when meeting new people
• Worry for long periods of time before a public or social event
• Avoidance of public places and/or social situations
• Difficulty making friends and maintaining relationships
• Physical discomfort (i.e. sweating, shaking, stomach aches, or rapid heartbeat) when in social situations

Let me clarify that almost every person on this planet has experienced social anxiety in some form at one point in their lives. Rest assured this is not only normal but healthy. After all, anxiety can be an adaptive response to stress in order to help us survive and sometimes even thrive. However, some of us with social anxiety can begin to experience an excessive amount of these symptoms listed above which creates what therapists refer to as “functional impairment.” This means that your anxiety can become maladaptive, often taking over and causing a decrease in performance and fulfillment in your life.

How Teens Might Experience Social Anxiety

Below are some specific case examples of how social anxiety might manifest within teenagers. After all, social anxiety is much more than just a set of observable behaviors, like the ones listed above. It is an internal experience. Furthermore, it is common for social anxiety to be “in disguise” when first addressing the issue.

In working with many teenagers, it has been my experience that before they truly understand their social anxiety, they will initially endorse feelings of depression. Specifically, they might talk about feelings of hopelessness, worthlessness, and chronic fatigue which are all symptoms of clinical depression. They often say things like “I feel worthless because I can’t be around my friends” or “I’m exhausted by feeling stupid, ugly, or inferior all the time.” When I first began treating social anxiety, I was pleasantly surprised by how quickly their overall mood would improve once they were functioning more effectively and confidently with others. Of course, depression and suicidality are not things we ever want to minimize or overlook. However, it is not uncommon for social anxiety to be at the core of what’s fueling a teenager’s low mood. In this way, symptoms of depression may be a secondary factor, rather than the primary diagnosis.

Some parents have been worried about their teenagers having an eating disorder when they first come to treatment. Although it is extremely important to rule out the presence of an eating disorder, it is very common that teenagers with severe social anxiety, have difficulty eating in front of others and often avoid wearing revealing clothing (i.e. bathing suits, shorts) out of fear of social judgement and scrutiny.

What to Expect in Treatment

Research shows that a combination of the following treatment modalities hold the best outcomes for social anxiety disorder:

Cognitive Behavioral Therapy (CBT): Cognitive behavioral therapy is the most commonly used approach for treating social anxiety disorder, and anxiety disorders in general. CBT is an evidence based treatment and is typically short term in duration. Additionally, CBT is effective because of the solution focused approach, where clinicians set realistic and concrete goals with patients in order to achieve measurable results. For teens with social anxiety, CBT works with specific negative thoughts (i.e. “I’m stupid and everyone knows it”) and unhealthy behaviors (i.e. avoidance of people) that can negatively impact mood. It helps teens with social anxiety understand the deeper connection between their thoughts, feelings, and behaviors. It is a collaborative therapeutic approach rooted in scientific discovery which I find can be extremely empowering for teenagers.

Exposure Therapy: A more specific component of behavioral therapy is exposure to feared stimuli or triggering situations. Clinicians that work from an exposure based perspective help teens create a gradual exposure hierarchy in order to confront their social anxiety head on. Research shows the more we avoid anxiety provoking situations, the more our anxiety is reinforced. This is called the avoidance cycle. Therefore, teens with social anxiety are encouraged to “feel their fear” while understating that it is not life threatening and often times a false alarm going off in the emotional center of their brains. The goal with exposure is not to eliminate anxiety but to learn how to tolerate it. Over time, as teens become more confident with this concept, their anxiety tends to decrease.

Medications: While cognitive and behavioral therapy are both typically quite effective for social anxiety disorder, medication can aid in recovery when there is significant functional impairment. More directly, it can “take the edge off” for teens who struggle with more severe forms of anxiety in order to tolerate and engage in therapy more effectively. The most common medications prescribed for social anxiety include:

• Selective Serotonin Reuptake Inhibitors (SSRIs): This medication is typically prescribed for depression. Common SSRIs include escitalopram (Lexapro), sertraline (Zoloft), and fluoxetine (Prozac.) These medications prevent the brain from reabsorbing serotonin, a neurotransmitter that regulates anxiety and promotes positive mood.
• Benzodiazepines: Although these medications are typically not the first course of treatment due to addictive properties, they can be useful with short term relief of acute anxiety symptoms. Some common sedatives include alprazolam (Xanax), clonazepam (Klonopin), diazepam (Valium), and lorazepam (Ativan.) Benzodiazepines work by increasing the amount of GABA in the brain, which is a neurotransmitter responsible for an overall calming effect.

An Interpersonal Approach: On a personal note, I have numerous professional experiences with adolescents in treatment who initially don’t want to be there because they are stuck in that avoidance cycle discussed earlier in this article. Because they have a difficult time meeting new people and maintaining connection out of fear of scrutiny, it is important for the clinician to be warm, engaging, accepting, and transparent in the room with a vulnerable teenager. Therefore, when you are looking for a good therapist, keep in mind how that person makes you feel during the intake appointment. Does the clinician normalize anxiety? Are they able to make you and your teen feel at ease in the room? Are they able to laugh at themselves and/or connect with your teen in relatable ways? If the clinician feels stiff, unrelatable, or even anxious themselves; chances are the teen will have a difficult time trusting that person and taking social risks in therapy. This is very important because the therapeutic relationship is where the social anxiety exposures begin. Additionally, this relationship has been shown time and time again in research to directly impact the overall success of treatment.

How to Find a Qualified Therapist

The National Social Anxiety Center https://nationalsocialanxietycenter.com/

The American Board of Professional Psychology https://www.abpp.org/

Academy of Cognitive and Behavioral Therapies https://www.academyofct.org/

Beck Institute for Cognitive Behavior Therapy https://beckinstitute.org/

How to Get Help for Social Anxiety

The National Social Anxiety Center (NSAC) is an association of independent Regional Clinics and Associates throughout the United States with certified cognitive-behavioral therapists (CBT) specializing in social anxiety and other anxiety-related problems.

Find an NSAC Regional Clinic or Associate which is licensed to help people in the state where you are located.

Places where nsac regional clinics and associates are based.

Written by,

Jade Starleaf,PsyD

NSAC – Long Beach, CA

Might be useful for you:

• OVERCOME YOUR SOCIAL ANXIETY WITH AN EFFECTIVE EXPERIMENTAL APPROACH May 18, 2022
• SOCIAL ANXIETY: STOP FOCUSING ON WHAT YOU THINK IS TRUE May 25, 2019
• SCHEMA THERAPY: A DEPTH APPROACH FOR AVOIDANT PERSONALITY DISORDER February 2, 2016
• PARENTING IN PUBLIC WITH SOCIAL ANXIETY June 19, 2023

Stages Of Social Anxiety

The Stages Of Social Anxiety worksheet is a tool to record unhelpful socially anxious responses to social situations, and to map alternative ways of thinking and responding at each stage (before, during, and after a social situation). In addition to behavioral experiments, clients may find it helpful as a form of treatment plan or therapy blueprint for social anxiety.

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• Social anxiety

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Introduction & theoretical background.

People who suffer from social anxiety disorder (previously known as social phobia) experience persistent fear or anxiety about social or performance situations that is out of proportion to the actual threat posed by the situation or context. Anxiety provoking situations might include talking in groups, meeting people, going to school or work, eating or drinking in public, or public performances. 

It is common for socially anxious individuals to worry extensively ahead of a social event, and to engage in safety behaviors. While in the situation, they usually focus on how they feel. This can backfire, causing them to miss important social cues and negatively affecting their social performance. After a social event, they often ruminate on how badly they believe they ‘performed’, which often leads to self-criticism. 

The Stages Of Social Anxiety worksheet is a tool to record unhelpful socially anxious responses to social situations, and to map alternative ways

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Therapist Guidance

Would you be willing to work with me to map out how you respond to social situations? We’ll break it down into what you do before, during, and after a social event.

Step 1: The problem. Choose a recent or typical example of when the client felt anxious before a social encounter. 

Ask the client to describe a recent example of when they felt anxious. If the client struggles to describe a recent example, ask them to recall any strong memory of feeling socially anxious. This can be made more vivid by asking them to close their eyes and describe aloud what they can see in their mind. Note that anxiety is likely not the only emotion present: embarrassment and shame are equally relevant for socially anxious individuals.

• "Did you imagine the

References And Further Reading

Clark, D. M., Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment. New York: Guilford Press

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Understanding Social Anxiety Disorder in Adolescents and Improving Treatment Outcomes: Applying the Cognitive Model of Clark and Wells (1995)

Eleanor leigh.

1 Department of Experimental Psychology, University of Oxford, Oxford, UK

2 Oxford Centre for Anxiety Disorders and Trauma, The Old Rectory, Paradise Square, Oxford, OX1 1TW UK

David M. Clark

Social anxiety disorder is a condition characterised by a marked and persistent fear of being humiliated or scrutinised by others. Age-of-onset data point to adolescence as a developmentally sensitive period for the emergence of the condition, at a time when the peer group becomes increasingly important. Social anxiety in adolescence is associated with considerable impairment that persists through to adulthood. There are clear potential benefits to delivering effective interventions during adolescence. However, there is limited evidence on the specific efficacy of available therapies. This is in contrast to adults, for whom we have interventions with very specific treatment effects. One such treatment is individual cognitive therapy. Cognitive therapy is based on the cognitive model of social anxiety proposed by Clark and Wells (in: Heimberg, Leibowitz, Hope, Scheiber (eds) Social phobia: diagnosis, assessment and treatment, The Guilford Press, New York, 1995 ). The present review examines the potential application of this adult cognitive model to the understanding of adolescent social anxiety and considers additional adolescent-specific factors that need to be accommodated. It is suggested that a developmentally sensitive adoption of the cognitive model of social anxiety disorder (Clark and Wells 1995 ) for adolescents may lead to better treatment outcomes.

Introduction

Social anxiety disorder (SAD) is a debilitating condition characterised by a marked and persistent fear of being humiliated or scrutinised by others (World Health Organization 1992 ; American Psychiatric Association 2013 ). Individuals fear a range of social interactions, such as conversations with strangers, joining in groups or speaking on the telephone. Most things that involve being observed by others are difficult. These include walking into a room when other people are already seated, eating or drinking in public, and performing in front of an audience. Sufferers fear that they will say or do something that they believe will be humiliating or embarrassing. Common concerns include the fear of sweating, shaking, blushing, stumbling over words, looking anxious, or appearing boring, stupid, or incompetent (Stein and Stein 2008 ).

Social anxiety disorder is the third most common mental health disorder after depression and substance abuse, with lifetime prevalence rates of around 12% (Kessler et al. 2005 ). It is common in young people. Prevalence rates of around 10% have been reported by the end of adolescence in US and New Zealand samples (Burstein et al. 2011 ; Merikangas et al. 2010 ; Feehan et al. 1994 ). Social anxiety disorder persists in the absence of treatment (Bruce et al. 2005 ; Reich et al. 1994a , b ). For example, Bruce et al. ( 2005 ) reported findings of a US-based community study in which adults with various anxiety disorders were followed up for 12 years. At the start of the study, individuals had suffered with social anxiety disorder for 19 years on average, and over the next 12 years only 37% recovered. This is compared with recovery rates of 58% for generalised anxiety disorder and 82% for panic disorder without agoraphobia. Remarkably similar findings have been reported in adolescent samples. A 10-year prospective community study with over 3000 German adolescents and young adults (aged 14–24 years) (Beesdo-Baum et al. 2012 ) found that 57% of those with social anxiety disorder at the start of the study were still reporting at least symptomatic social anxiety at follow-up and higher persistence of social anxiety was significantly predicted by an earlier age of onset of the disorder. Only 15% were completely remitted.

Social anxiety disorder is associated with profound negative consequences and high levels of impairment even when compared to other psychiatric disorders (Alonso et al. 2004 ). Social anxiety disorder affects all areas of life. For adolescents, academic attainment is curtailed, with individuals at risk of leaving school early and obtaining poorer qualifications (Van Ameringen et al. 2003 ). Amongst a sample of 784 Finnish 13–17-year olds, those with clinical or subclinical social anxiety disorder had a lower grade point average compared to those with no diagnosis (Ranta et al. 2009 ). Social relationships are inevitably particularly challenging for socially anxious adolescents. They report having fewer friends, and the peer and romantic relationships they do have are of poorer quality (La Greca and Harrison 2005 ; Hebert et al. 2013 ). They are more likely to be victims of bullying (Acquah et al. 2016 ; Ranta et al. 2009 ). Social anxiety makes day-to-day life difficult, for example, shopping and using the telephone can be a challenge. Research with adults demonstrates that the impairments associated with social anxiety disorder persist into adulthood. Employment is affected: although the majority of adults with social anxiety disorder are employed, they take more days off and report lower productivity due to their symptoms (Stein and Kean 2000 ). In terms of close relationships, adults with social anxiety disorder are less likely to marry, more likely to divorce and less likely to have children (Wittchen et al. 1999a ). A study amongst adults seeking treatment for social anxiety disorder found that the functional impairment was not due to the presence of comorbid mood or anxiety disorders (Aderka et al. 2012 ).

Adolescence and the Development of Social Anxiety Disorder

Social anxiety is very much a disorder with its origins in adolescence, with the majority of cases occurring during this period (90% occur by the age of 23 years; Kessler et al. ( 2005 )). Prospective, longitudinal studies suggest that it is relatively unusual in early childhood (Wittchen et al. 1999b ), with incidence increasing through the adolescent years and a median age of onset of 13 years (Kessler et al. 2005 ). After this peak period of onset, new cases are fairly rare after about the age of 25 years (Heimberg et al. 2000 ). The increased incidence of social anxiety disorder during adolescence is perhaps unsurprising. Adolescence is a time when people are moving from a unique reliance on their family unit and are learning how to interact with peers in a way that will set them up for the rest of their life. They become increasingly autonomous from their parents and reliant instead upon their peer group (Larson and Richards 1991 ).

Underpinning this social reorientation is the development of particular neurocognitive abilities (Kilford et al. 2016 ). One of these is self-consciousness. Self-consciousness is the directing of attention inwards, with both a private and public dimension (Davis and Franzoi 1999 ). Private self-consciousness refers to an awareness of one’s inner thoughts and feelings, whilst public self-consciousness is an awareness of the self as a social object. Self-consciousness, and particularly the public aspect of it, is thought to peak in early adolescence (Cicchetti and Cohen 2006 ; Rankin et al. 2004 ; Vartanian 2000 ). The development of public self-consciousness will enhance adolescents’ sensitivity to how they are being perceived by others. This awareness will inform how adolescents behave towards other people and will help them to establish more mature and enduring relationships with their peers. However, it seems very plausible that an acute awareness of the self as a social object may also confer vulnerability for increased social anxiety and in line with this suggestion, public self-consciousness has been found to be related to social anxiety in adolescents (Mallet and Rodriguez-Tomé 1999 ) and in adults (Mor and Winquist 2002 ). Although all young people seem to experience a normative increase in public self-consciousness in early adolescence, only a small proportion will develop persistent social anxiety, and so it is not in itself enough to explain the increased incidence. Rather, self-consciousness may be a necessary precursor implicated in the development and maintenance of social anxiety (Tillfors and Van Zalk 2015 ). It seems plausible that the acute self-consciousness experienced during early adolescence renders this a developmentally sensitive period for the emergence of social anxiety (Haller et al. 2015 ).

As well as heightened self-consciousness, adolescence is also normally a period of strong sensitivity to peer influence and it is a crucial phase of social learning. Social relationships during adolescence are especially rewarding during this time, and it has been suggested that this increases the impact of both positive and negative aspects of social interactions (Kilford et al. 2016 ). In line with this, studies consistently demonstrate that peer rejection leads to increased distress, anxiety and lower mood in adolescents compared to children and adults (Platt et al. 2013 ). The heightened emotional salience of peer interactions means adolescents are primed to prioritise the development of social networks, but for some it will also bring about an increased vulnerability for the emergence and maintenance of social fears (Eldreth et al. 2013 ).

In adulthood we pay attention to what others think, but there is a certain resistance to peer influence. In contrast during adolescence, this resistance is far weaker, with young people showing a strong susceptibility to peer influence. This can present as conformism to trends. A study examining the effects of peer influence on risk taking in adolescents and peers bears this suggestion out (Gardner and Steinberg 2005 ). When playing a driving-based video game, youths took significantly more risks when with peers than when alone, whereas adult risk-taking behaviour was not affected by the presence of peers. Studies looking at resistance to peer influence are consistent with this finding. At the beginning of adolescence, this resistance is low and only gradually increases to adult levels (Steinberg and Monahan 2007 ). Susceptibility to peer influence in adolescence is likely to be adaptive, as it will provide the opportunity to form strong social bonds and learn vital lessons about relationships. However, it is also like to represent a developmental sensitivity for the emergence of social fears.

As this brief discussion highlights, adolescence ushers in a host of changes at various levels including in neural circuitry, information processing and the social environment (Blakemore 2008 ). For the majority of adolescents, one of the consequences of these changes is a short-lived increase in social fears (Weems and Costa 2005 ). But for a subset, perhaps those who are more behaviourally inhibited by temperament, it has been proposed that these cognitive, brain maturational and social changes confer vulnerability for the development and also the maintenance of social anxiety disorder (Caouette and Guyer 2014 ). With this in mind, any theoretical accounts that aim to explain the persistence of social anxiety in adolescence need to be positioned within a developmental context. In other words, it is necessary to take into account developmental influences on maintenance processes that are relevant across the lifespan, as well as considering processes that may be unique to the adolescent period.

When considering treatment, it is clear that understanding and intervening in social anxiety disorder in adolescence is vital in order to avert long-term consequences. But in addition to this, the plasticity associated with adolescence may also offer a ‘window of opportunity’ in which to provide particularly potent interventions (Haller et al. 2015 ).

Current Treatments for Social Anxiety Disorder in Adolescents

Traditionally, cognitive behavioural therapies (CBT) did not target specific anxiety disorders in young people. Instead, social, separation and generalised (or overanxious) anxiety disorder were all treated with the same set of techniques. Creswell et al. ( 2014 ) suggest this approach was motivated by two principal factors. Firstly, the high comorbidity amongst the anxiety disorders in children and young people and secondly, the lack of well-validated disorder-specific maintenance models. The most well-known examples of the ‘generic’ CBT approach are ‘Coping Cat’ for children (Kendall and Hedtke 2006 ) and the ‘CAT Project’ for adolescents (Kendall et al. 2002 ). The treatments usually comprise 16 sessions and involve a combination of psycho-education, anxiety management strategies and graded exposure. There have been many large randomized controlled trials undertaken examining the effectiveness of Coping Cat and its various relations in treating separation, social and generalised anxiety disorder (e.g. Ginsburg et al. ( 2011 ), Walkup et al. ( 2008 )). Meta-analyses have shown that these treatments are associated with substantial effect sizes (Bennett et al. 2013 ). However, a number of studies have shown that outcomes from generic CBT are less good for young people with SAD compared to those with other anxiety disorders. Young people (mixed child and adolescent samples) with SAD are significantly less likely to lose their diagnosis of SAD after treatment compared with young people with other anxiety diagnoses (Crawley et al. 2008 ; Ginsburg et al. 2011 ; Hudson et al. 2015a , b ; Lundkvist-Houndoumadi and Thastum 2017 ; Kodal et al. 2018 ).

As well as traditional generic CBT, psychological therapies designed specifically for social anxiety disorder have been developed. Cognitive behavioural group therapy (CBGT; Albano et al. ( 1995 )) was one of the first to be tested. This treatment, based on the Heimberg model (Rapee and Heimberg 1997 ), involves psycho-education and skills training (social skills and anxiety management strategies) followed by exposure tasks (Albano and DiBartolo 2007 ). In an early randomized controlled trial (RCT), CBGT was compared to no treatment amongst female adolescents (Hayward et al. 2000 ). The authors note that whilst those in the CBGT group showed significantly greater reductions in social anxiety symptoms compared to the no treatment group post-treatment, they continued to report considerable residual symptoms and at one-year follow-up the control group had also improved and there was no longer a significant group difference. Herbert et al. ( 2009 ) did not find evidence for specific treatment effects of CBGT in an RCT comparing the treatment to an educational supportive therapy amongst adolescents, with both treatments associated with an improvement in social anxiety symptoms, functioning and social skills.

Social Effectiveness Therapy (SET; Turner et al. ( 1994 )) and its parallel version for 8–12-year olds Social Effectiveness Therapy for Children (SET-C; Beidel et al. ( 2000 )) is another SAD specific treatment. It is a behavioural group treatment comprising psycho-education, social skills training and exposure. Baer and Garland ( 2005 ) adapted the treatment for adolescents and compared it to waitlist in a pilot RCT with 12 adolescents. SET-C outperformed waitlist based on clinician- and self-report of symptoms. Olivares et al. ( 2002 ) compared SET-C and CBGT to a waitlist control using a quasi-experimental design (participants were allocated to group according to their school timetables; random allocation was not used). Both active treatments yielded significantly better self- and clinician-rated improvements compared to waitlist with no differences between the two, and gains were maintained at 5-year follow-up (Garcia-Lopez et al. 2006 ).

Masia-Warner and colleagues ( 2001 ) adapted SET-C for an adolescent schools-based population, and they have tested the treatment, Skills for Academic Success (SASS) in two RCTs. Compared to waitlist control, SASS led to significantly greater improvements in social anxiety, functioning and social skills based on self-report, parent-report and clinician-report (Masia-Warner et al. 2005 ). Examining specific treatment effects, the authors compared SASS with an attention control which involved psycho-education and supportive therapy (Masia-Warner et al. 2007 ). Findings showed significantly greater improvement in clinician-report and self-report but not parent-report of social anxiety after SASS compared to the comparison, suggesting preliminary evidence for treatment specificity. Whilst results from these two studies are very encouraging, because SASS was designed to be a low-intensity school-based intervention, the findings may not be directly relevant to the treatment of clinically referred adolescents.

Overall, the literature on specific CBT-based interventions for social anxiety disorder in adolescents show that a number of interventions are effective compared to no treatment; however, only one study has provided evidence for treatment specificity, in the sense of being superior to other credible interventions.

Improving Treatment Outcomes

In contrast to the limited evidence for treatment specificity in adolescents, substantial evidence for specific treatment effects has been observed in adults (Mayo-Wilson et al. 2014 ), including CBT treatment based on the Heimberg model (Rapee and Heimberg 1997 ). The version of CBT for adults that has the most evidence for treatment specificity is a specialised form of individual cognitive therapy, developed to target the cognitive abnormalities and maintenance processes specified in the Clark and Wells ( 1995 ) model of social anxiety disorder. Whilst there is overlap between this model and other cognitive behavioural models of social anxiety (Wong and Rapee 2016 ) and the treatment has similarities to some other CBT approaches, many of the techniques are distinct. This can be seen in Table  1 which summarises what does and does not happen in cognitive therapy for social anxiety disorder.

Table 1

Summary of what does and does not happen in cognitive therapy for social anxiety disorder

Cognitive therapy based on the Clark and Wells ( 1995 ) has been compared to a number of other active treatments, and in the six randomized controlled trials that have been undertaken it has been shown to be superior to: Group CBT (Stangier et al. 2003 ; Mörtberg et al. 2007 ), exposure therapy (Clark et al. 2006 ), interpersonal psychotherapy (Stangier et al. 2011 ), psychodynamic psychotherapy (Leichsenring et al. 2013 ), fluoxetine (Clark et al. 2003 ), medication-based treatment as usual (Mörtberg et al. 2007 ) and pill placebo (Clark et al. 2003 ). Therapy based on the Clark and Wells ( 1995 ) model is one of the two first-line treatments recommended by the National Institute for Health and Care Excellence (NICE 2013 ), an independent body that synthesises available research evidence to develop treatment guidelines [the other recommended treatment being individual CBT based on the Heimberg model ( 1997 )].

Such consistent and broad evidence for treatment specificity is unusual and suggests that it might be profitable to investigate whether the Clark and Wells’ ( 1995 ) model applies to adolescent social anxiety disorder as well as the adult condition. If the model does apply to adolescents, then a treatment that rather single-mindedly focuses on the maintenance factors specified in the model may be helpful for this population. Certainly, this type of approach, in which interventions are very tightly tied to known maintenance factors, has proved successful as a strategy for developing effective forms of CBT for a range of anxiety-related conditions in adults (Clark 2004 ).

Clark and Wells’ Cognitive Model of Social Anxiety in Adults

Socially anxious individuals will face many social situations every day, and the vast majority of these are benign, so why does social anxiety persist? A number of cognitive accounts have been put forward to try to explain this (Clark and Wells 1995 ; Heimberg et al. 2010 ; Hofmann 2007 ; Rapee and Heimberg 1997 ). There is considerable overlap amongst these models, for example they all highlight the importance of fear of negative evaluation and of self-focused attention in maintaining social anxiety. A useful review of the prominent cognitive behavioural models including a description of their commonalities and differences is provided by Wong and Rapee ( 2016 ).

According to the cognitive model developed by Clark and Wells ( 1995 ), people with social anxiety hold firm beliefs about the importance of making a good impression to others, but they also believe they come across badly (Leary 2001 ). Broad unconditional beliefs such as ‘I am weird’ lead them to make assumptions about themselves and their social environment. These usually involve high self-expectations (“I must always look cool and calm”) and conditional beliefs about their social behaviour (“If I look at all anxious people will think I am a gibbering wreck”) (Wong and Moulds 2011 ). These negative beliefs are activated in social settings and understandably trigger alarm (Hofmann 2007 ). The sense of threat then motivates a chain of cognitive, affective and behavioural responses. This chain of responses is self-perpetuating and closed off to new information. Several inter-linked processes are emphasised in the model: a shift to an internal focus of attention and the use of internal information to infer how one appears to others (collectively described as ‘processing of the self as a social object’); safety behaviours; and worry and rumination that occur before and after the social event. These are described in more detail below, and the model is displayed in Fig.  1 .

Cognitive model of social anxiety disorder (Clark and Wells 1995 )

First, the model suggests that when individuals enter a social situation their attention will shift to a predominantly internal focus, in order to closely monitor how they are coming across. One of the reasons that this self-focused attention is problematic is because it reduces the opportunity for the individual to process the social situation and other peoples’ reactions. As a result, individuals often fail to observe that other people are responding to them in a broadly benign manner. Another consequence of the shift to an internal focus of attention is an increased awareness of feared sensations.

Second, the model proposes that individuals use internally generated information to create an impression of how they appear to other people. The information drawn upon includes feelings of anxiety and negative self-imagery. Individuals will often overestimate how anxious they look, because they are assuming that they look as anxious as they feel (for example, ‘I feel hot therefore I must be really red in the face’). Negative images are common. Images usually come to mind from an observer perspective rather than a personal (or field) viewpoint, and so it is natural that the images are assumed to be an accurate representation of how the individual looks to other people.

Third, the use of safety behaviours, which are motivated by the desire to prevent or minimise the consequences of feared outcomes (such as sounding stupid or blushing), further maintains social anxiety and negative social beliefs. Common safety behaviours in social anxiety include avoiding eye contact, preparing topics of conversation in advance, wearing lots of make-up, and agreeing with others. Safety behaviours are unhelpful for a number of reasons. They prevent the individual from discovering that the feared outcome was very unlikely to happen anyway. For example, ‘the only reason no-one spotted me blushing was because I was wearing thick foundation’ (rather than because it was not particularly obvious to others anyway). Safety behaviours can heighten self-focus and monitoring, as an individual checks that the safety behaviours are ‘working’. Safety behaviours can directly cause feared symptoms. For example, covering your cheeks to prevent blushing can make you hotter and cause flushing. Safety behaviours can make one appear withdrawn and unfriendly. Behaviours such as avoiding eye contact or keeping conversations short can contaminate the social interaction and give the impression that one is not interested. Finally, safety behaviours can draw attention to feared behaviours. For example, speaking very quietly may cause others to lean in and pay especially close attention in order to hear what is said.

Safety behaviours comprise a broad range of overt behaviours and mental operations. Some safety behaviours involve avoidance, such as speaking less and avoiding eye contact, whilst others are concerned with making a good impression, for example checking you are coming across well and preparing topics in advance. Whilst it is suggested that both groups of safety behaviours are unhelpful as they prevent disconfirmation of negative beliefs and increase anxiety, only avoidance behaviours contaminate the social situation by making the individual appear withdrawn and unfriendly. Three studies have provided support for the distinction between avoidance and impression management safety behaviours. Plasencia et al. ( 2011 ) conducted a factor analysis of data from the Social Behaviour Questionnaire which confirmed the existence of the two factors. In addition, correlational analyses indicated that both sets of safety behaviour appear to maintain social anxiety, but only the avoidance behaviours had a negative effect on other people. In an earlier study, Hirsch et al. ( 2004 ) examined correlations between subsets of items of the Social Behaviour Questionnaire and a questionnaire measuring the quality of a conversation as rated by the conversation partner. They found that items assessing avoidance behaviours were significantly correlated with negative ratings of the conversation, whilst items assessing impression management behaviours were not. Extending these correlational studies, a recent experimental study (Gray and Clark submitted) directly manipulated the use of safety behaviours during a conversation task. The pattern of results was as expected, with use of both safety behaviour types increasing anxiety, but only avoidance behaviours resulting in a negative response from the conversation partner.

Further unhelpful processes include anticipatory worry and post-event processing. Before a social event, individuals with social anxiety will review what they think is going to happen in detail. Negative predictions will prevail and are associated with anxiety and a host of memories of past failures and negative self-images. This worry is often enough to stop someone entering a social situation in the first place. If they do manage to go, they will be cued up to interpret social failings. Despite some brief relief on leaving a social situation, socially anxious individuals often describe a continued cycle of negative thoughts and distress. Due to the inherently ambiguous nature of most social situations, it is rare that people receive an unquestionable seal of social approval. This ambiguity will usually equate to doubt for the socially anxious individual and in turn initiates a ‘post-mortem’. Post-mortems involve detailed revisiting of the previous event. However, because attention is trained internally during social events, and the focus is on negative thoughts, feelings and images, it is this that is reviewed in detail (especially the most distressing moments), rather than the objective facts of the event. As a result, the event will most likely be labelled a failure. Intense humiliation and shame commonly run alongside these ruminative thoughts. The post-mortem process can continue for days and sometimes weeks after an event.

We suggest that the cognitive model of Clark and Wells ( 1995 ) has the potential to be a good fit for an adolescent population. For example, self-focused attention is emphasised in this model and it is a construct that has clear parallels with self-consciousness (Stein 2015 ) which is heightened during adolescence. Likewise, the concept of safety behaviours, which is emphasised in the model, may be pertinent to a teenage population. Avoidant safety behaviours may elicit particularly negative responses amongst adolescent peers, who as a group are especially sensitive to perceived peer rejection compared to children and adults (see Kilford et al. ( 2016 ) for a review). The rest of this review article is therefore concerned with two main questions. First, what evidence is there to support the application of the cognitive model of Clark and Wells ( 1995 ) to adolescents? And second, what are the developmentally specific processes that need to be considered for the successful application of the model? We note that quite a few of the maintenance processes that we discuss are highlighted in other prominent models, particularly the model of Rapee and Heimberg ( 1997 ), but those models also emphasise some other processes that are not included in this review.

A Review of Studies Examining the Applicability of the Cognitive Model to Adolescents

Methodology.

We describe a review undertaken to assess the available evidence in relation to the cognitive model of Clark and Wells ( 1995 ) in adolescents. The studies we are interested in focus on the maintenance of social anxiety rather than the development or aetiology of the disorder. That is not to say that it is not valuable and important to understand the genesis of social anxiety disorder in young people. Rather, we are concerned here in delineating the mechanisms by which social anxiety is maintained in adolescents as a route to developing targeted and effective therapeutic interventions. Studies including young people aged 11–18 years are included. This age range was selected for two reasons. First, we are interested in the adolescent period because this is a peak period of onset of SAD. Second, whilst a definition of adolescence as defined by years is arbitrary because the on- and off-set of puberty will vary from individual to individual, we selected the upper and lower limits of 11 and 18 years as these coincide with the start and end of secondary school in many countries. Studies with a lower age limit below 11 years were retained if the average age was at least 12 years. We included data on non-clinical as well as clinical populations. As noted by Stopa and Clark ( 2001 ), social anxiety is continuously distributed in the general population and so comparing (non-clinical) individuals at the relatively high and low ends of a measure of social anxiety seems a meaningful way of researching psychological processes implicated in social anxiety.

We searched the databases PsycINFO and WoK for peer-reviewed articles written in English published between 1995, and the date the search was conducted (28 November 2017). The following search terms were used: (social* AND (anxiet* OR anxious* OR phobi*)) AND ((cognitive AND model) OR (wells AND clark) OR (cognit* OR assumption* OR (interpretat* AND bias) OR belief*) OR image* OR (safety AND behav*) OR (self AND focus* AND attention*) OR ((event AND processing) OR worry OR worri* OR ruminat*)) AND (teen* OR adolescen* OR young OR youth*) . To be included studies had to include adolescent samples in which social anxiety symptoms had been assessed as well as at least one of the psychological variables specified in the cognitive model of Clark and Wells ( 1995 ). Review papers, studies evaluating measures and scales, and treatment studies were excluded. A PRISMA flowchart showing the selection of papers is presented in Fig.  2 . Twenty-five studies are included in the final review (please see Table  2 for a full list of included studies).

Flow diagram showing selection of papers

Table 2

Studies included in review

SPAI-C Social Phobia Anxiety Inventory for Children (Beidel et al. 1995 ), SAS-A Social Anxiety Scale for Adolescents (La Greca and Lopez 1998 ), SPIN Social Phobia Inventory (Connor et al. 2000 ), SAS-CR Social Anxiety Scale for Children Revised (La Greca and Stone 1993 ), SPAI Social Phobia Anxiety Inventory (Turner et al. 1989 ), MASC Multidimensional Anxiety Scale for Children (March et al. 1997 )

Effect sizes (ES) are provided. These are either reported directly from studies (where provided), or we have calculated these if they were not reported. For studies involving correlational analysis we have reported r and for group differences studies we have reported Cohen’s d. r is interpreted according to Cohen’s ( 1988 ) criterion whereby a small effect is at least 0.1, a medium effect is of a magnitude of at least 0.3, and an effect size greater than 0.5 is deemed large. Cohen’s d is interpreted as such: at least 0.2 is a small effect, at least 0.5 is a medium effect, and at least 0.8 is a large effect.

Negative Cognitions and Perceived Social Danger

Negative social attitudes and cognitions.

According to the cognitive model, individuals with social phobia hold dysfunctional assumptions about themselves that are activated in anticipation of a social situation (“I must always speak eloquently”). Negative social cognitions about oneself (e.g. “I will stutter”) and about other peoples’ reactions (“people will think I’m stupid”) predominate. Supportive evidence for this hypothesis in adolescents is provided by three questionnaire studies. Schreiber et al. ( 2012 ) and Hodson et al. ( 2008 ) reported on studies undertaken with German (aged 14–20 years) and UK (aged 11–14 years) school samples respectively. In their large non-clinical sample of 581 adolescents and young adults, Schreiber et al. ( 2012 ) found that those scoring in the upper quartile of the German version of a measure of social anxiety, the Social Phobia Anxiety Inventory (SPAI; Turner et al. ( 1989 )) endorsed more frequent negative social cognitions in social situations (e.g. ‘I am boring’, ‘I will blush’) on the Social Cognitions Questionnaire (Clark 2003 ). In the only study to look at negative social attitudes, the authors also found that those scoring in the top quartile on the SPAI rated themselves more highly on negative social attitudes (e.g. ‘I must be witty and intelligent at all times’) on the Social Attitudes Questionnaire (Clark 2003 ) compared to those in the lower quartile. Effect sizes were large for both findings; d  = 1.56 and 1.74, respectively. In regression analyses, both social cognitions and social attitudes were significant independent predictors of social anxiety across the whole sample, but they were also predictors of depression. Similarly, the smaller UK study with 171 non-clinical adolescents (Hodson et al. 2008 ) found that those scoring in the top quartile on the Social Phobia Anxiety Inventory for Children (SPAI-C; Beidel et al. ( 1995 )) reported more frequent negative social cognitions on the Social Cognitions Questionnaire compared to those in the middle quartiles ( d  = 1.20) and the lowest quartile ( d  = 1.40). The ‘middle’ and ‘low’ groups did not differ from each other ( d  = 0.39). Also in line with the findings of Schreiber and colleagues, regression analyses indicated that social cognitions were a significant independent predictor of both social anxiety and depression. In the third questionnaire study, Rudy et al. ( 2014 ) examined self-report questionnaire measures of negative social cognitions, self-efficacy and social anxiety in a US sample of 260 healthy adolescents aged 8–16 years. Negative social cognitions (e.g. ‘I sound stupid’) were associated with social anxiety both directly ( r  = 0.66) and indirectly via their effect on self-efficacy.

Using a semi-structured interview methodology, Ranta et al. ( 2014 ) asked adolescents to identify a time when they had felt very socially anxious and to then recall the thoughts that they had during the experience. Those scoring higher on the Social Phobia Inventory [SPIN; Connor et al. ( 2000 )] recalled more negative thoughts than those scoring lower ( d  = 0.48). Although the numbers of young people with clinical levels of SAD were small, the findings were similar when the authors compared those assigned a diagnosis of clinical or subclinical social anxiety disorder ( n  = 17) compared to those with no diagnosis of SAD ( n  = 116; d  = 0.58). Negative thoughts recalled by all participants were most commonly self-focused rather than focused on other people or the interaction. In another study comparing a sample of adolescents with social anxiety disorder with a group of healthy controls, Alfano et al. ( 2006 ) asked participants to engage in a role-play task. The authors found that not only did socially anxious youth make more negative predictions about their performance than controls ( d  = 1.61), but they also went on to believe they performed less well than they had expected, whereas control participants did not draw negative conclusions about their performance ( d  = 1.56). Negative self-talk was significantly more frequent in socially anxious adolescents compared to controls ( d  = 0.69) and compared to socially anxious children ( d  = 0.67).

The studies described all report consistent findings that are supportive of the cognitive model. Negative social cognitions and attitudes are elevated in adolescents endorsing more social anxiety. Two studies have suggested that this holds in clinical samples also. However, there are limitations to the data, most notably, all of the studies are correlational 1 and so the issue of whether cognitions are causally implicated in social anxiety cannot be resolved.

Negative Interpretation Bias

Social events are rarely conclusively negative, and yet socially anxious individuals will often draw very negative conclusions about their social performance and others’ reactions. Considerable evidence has amassed in support of the presence of a bias amongst socially anxious adults towards interpreting ambiguous events in a negative way and appraising mildly negative events catastrophically (Mobini et al. 2013 ). A study by Stopa and Clark ( 2000 ) provides particularly clear evidence for this. Adults with social anxiety disorder and healthy controls were presented with ambiguous scenarios depicting social and non-social events, and with unambiguous scenarios depicting mildly negative social events. Socially anxious adults not only made more negative interpretations of ambiguous social scenarios, but they were also more likely to catastrophize unambiguous, mildly negative social events. In pre-adolescent children there are fewer studies, but a review concluded that there is reasonable evidence for the association of a negative interpretation bias with social anxiety (Halldorsson and Creswell 2017 ).

Turning now to adolescents, in their review, Haller et al. ( 2015 ) note that the refinement of neurocognitive abilities such as perspective-taking coupled with exposure to increasingly large and complex social networks may make some adolescents especially susceptible to drawing negative social conclusions compared to children and adults. Studies examining interpretation bias in adolescent social anxiety have used a range of methods. Four studies, with Dutch (Miers et al. 2008 ), Italian (Giannini and Loscalzo 2016 ; Loscalzo et al. 2017 ) and US (Rheingold et al. 2003 ) samples, have employed a questionnaire measure of interpretation bias. In three of the studies (Miers et al. 2008 ; Giannini and Loscalzo 2016 ; Loscalzo et al. 2017 ), participants were given the Adolescent Interpretation and Belief Questionnaire (Miers et al. 2008 ). The questionnaire presents a series of ambiguous social and non-social scenarios followed by three possible interpretations (positive, negative and neutral). Respondents are asked to rate how likely the interpretations are to pop into mind and how much they believe them.

Miers et al. ( 2008 ) found that adolescents scoring high (in the top 10%) on a measure of social anxiety (the Social Anxiety Scale for Adolescents [SAS-A; La Greca and Lopez ( 1998 )]) made significantly more negative interpretations of social events than the average anxiety group (those scoring in the 45–55th centile on the SAS-A; d  = 1.18) and believed these more strongly ( d  = 0.54). There were no differences in positive interpretation of social events ( d  = 0.28). High social anxiety adolescents were also more likely to make negative interpretations ( d  = 0.62) of non-social situations and to believe these negative interpretations ( d  = 0.59) more than average anxiety adolescents. In line with these findings, Giannini and Loscalzo ( 2016 ) found non-clinical high scorers (on the SPIN) endorsed more frequent negative interpretations of social situations ( d  = 0.84) and believed these more than average scorers ( d  = 1.19). However, there were some differences between the two studies. First, in this study, high anxiety adolescents also made fewer positive interpretations ( d  = 0.70) than the average anxiety scorers (whereas no differences were found on this measure by Miers et al. ( 2008 )). Second, this study did not find any differences in interpretation of non-social situations, whereas a difference had been identified in the study by Miers et al. ( 2008 ).

The study by Loscalzo et al. ( 2017 ) compared 50 adolescents with a clinical diagnosis of social phobia with non-clinical adolescents scoring high or low on the SPIN. This study also used the Adolescent Interpretation and Belief Questionnaire. In line with the findings of Miers et al. ( 2008 ) there were no group differences in positive interpretations of social situations, but the social anxiety disorder group and the high social anxiety group made more frequent negative interpretations of social situations than those in the low social anxiety group ( d  = 1.82; 1.82, respectively). Those in the social anxiety disorder group believed the negative interpretations more than those in the high ( d  = 0.56) and low ( d  = 0.75) social anxiety groups, who did not differ from each other ( d  = 0.14). In terms of content-specificity, adolescents with social anxiety disorder also made more negative interpretations of non-social ambiguous scenarios and believed these more strongly than non-clinical adolescents with high or low social anxiety. Another correlational study was undertaken by Rheingold et al. ( 2003 ). Adolescents with a diagnosis of social anxiety disorder and healthy controls completed a questionnaire measure assessing judgments of the likelihood and cost of social and non-social events. Socially anxious youth overestimated the cost ( d  = 1.87) and probability ( d  = 1.50) of negative social events and the cost of negative non-social events ( d  = 0.84) compared to controls, even after controlling for depression symptoms. However, none of these four studies assessed interpretations ‘on-line’ and so we cannot determine whether they are measuring direct interpretations of events as they occur or rather some pre-existing negative beliefs.

Addressing the limitations associated with this method, a recent study by Haller et al. ( 2016 ) used a novel picture-based paradigm to measure interpretation bias amongst 95 school-based non-clinical 14–17-year olds. Participants were shown an ambiguous social scene with a photograph of themselves inserted as the protagonist. They were presented with neutral, negative and positive interpretations. Social anxiety was significantly negatively correlated with positive interpretation ratings ( r  = − 0.48) and significantly positively correlated with negative interpretation ratings ( r  = 0.45). Extending this finding, Haller et al. ( 2017 ) asked a community sample of adolescents to interpret ambiguous social situations presented with naturalistic photographs. Eye tracking data were gathered as a proxy measure of attentional allocation. Social anxiety levels predicted a tendency to make more negative and less positive interpretations. Furthermore, participants who spent more time on facial displays made more threatening interpretations. In a study measuring online interpretation biases in a sample of young adolescents with social anxiety disorder and a group of healthy controls (Pergamin-Hight et al. 2016 ) found that the clinical group made more negative interpretations compared to the control group ( d  = 0.47).

Seven studies have examined interpretation biases in social anxiety in adolescents. All point to an association between social anxiety and an increased tendency to draw negative interpretations of ambiguous social scenarios and to believe these more strongly. Findings are more mixed about the association between social anxiety and positive interpretations of social scenarios, and in relation to the interpretation of non-social events. In addition, as yet, no studies have examined whether socially anxious individuals tend to catastrophize in response to mildly negative social scenarios as would be predicted by the model.

Processing of the Self as a Social Object

Enhanced self-focused attention linked to reduced processing of external social cues.

The model would predict that when a social threat is perceived, socially anxious individuals shift their attention internally and reduce processing of external social cues. Indeed, socially anxious adolescents very often talk about being painfully self-conscious in social situations. To test this hypothesis, the questionnaire-based study of Hodson et al. ( 2008 ) included the Focus of Attention Questionnaire (FAQ; Woody ( 1996 ). High socially anxious adolescents reported higher levels of self-focus compared to middle ( d  = 0.49) and low socially anxious youth ( d  = 1.09). Self-focused attention was associated with social anxiety across the whole sample ( r  = 0.42), and it was also an additional independent predictor of social anxiety, with and without simultaneous adjustment for depression scores. Consistent with this finding, Schreiber et al. ( 2012 ) also found that high socially anxious adolescents reported higher levels of self-focused attention (measured by the FAQ) compared to low scorers ( d  = 1.15). Self-focused attention was not found to be a significant independent predictor of social anxiety across the whole sample. The authors also looked at external focus of attention, measured by certain items of the Focus of Attention Questionnaire. No differences between groups were found on this subscale. The authors suggested this null finding might have resulted from the lack of specificity regarding the type of external focus captured by the items.

A more ecologically valid study was undertaken by Blöte et al. ( 2014 ). One hundred and sixty-one non-clinical 14–18-year olds gave a speech to a pre-recorded neutral audience. Questionnaire measures of social anxiety and self-focus (using the FAQ), performance expectation and audience perception were completed. In relation to self-focused attention, it was found that as expected social anxiety was associated with higher self-focus ( r  = 0.43). The relationship between social anxiety and audience perception was found to be partially mediated by negative expectations of performance and self-focused attention. In line with the findings of Schreiber et al. ( 2012 ), external focused attention was not correlated with social anxiety ( r  = 0.12).

A longitudinal study was undertaken with a sample of unselected Dutch youth to examine pathways of social avoidance through adolescence and whether social anxiety and psychological processes, including self-focused attention (using the FAQ), discriminated between the pathways (Miers et al. 2014 ). A group of adolescents showed increasing social avoidance through adolescence, and another group showed consistently low avoidance. Self-focused attention was not found to discriminate between the two groups. However, the study was designed to identify vulnerability factors for the development of social avoidance rather than current maintenance factors.

A number of studies have been reported on that have examined the role of self-focused attention in social anxiety. In all but one study (Miers et al. 2014 ), self-focused attention was found to be related to social anxiety (or group differences were shown) with a medium effect. However, conclusions are limited by a number of issues. First, none of the studies were undertaken with clinical populations. Second, all of the studies used the FAQ to measure self-focused attention and often only used a small number of items taken from the questionnaire. Although the measure has been found to have moderate internal consistency, full psychometrics have not been reported with adolescents. Third, the studies cannot illuminate us on the causal role of self-focused attention in social anxiety; for this, experimental studies are needed.

Negative Observer-Perspective Social Images

The majority of adults with SAD report experiencing negative observer-perspective self-images in social situations (Hackmann et al. 2000 ). These are often related to events dating back to around the onset of the disorder. A number of studies have examined negative self-imagery and social anxiety in adolescents. Three of these used questionnaire or interview methods. Ranta et al. ( 2014 ) found that high socially anxious adolescents (compared to low scorers) and adolescents with SAD or subclinical SAD (compared to no diagnosis) report more negative observer-perspective self-images ( d  = 0.45 and r  = 0.47, respectively). Similarly, in their study with unselected adolescents, Schreiber et al. ( 2012 ) found that high social anxiety adolescents reported more frequent negative self-images than low scorers ( d  = 0.81). Frequency of negative self-images was also found to independently predict social anxiety in the group as a whole. The study used the Questionnaire of Recurrent Images in Social Phobia (QRI-SP; Schreiber et al. ( 2009 )) which is based on the semi-structured developed by Hackmann et al. ( 2000 ) for adults to assess negative self-imagery. However, the study only used a single item of the measure and this may not be reliable with a multi-faceted construct such as self-imagery. Addressing this limitation, Schreiber and Steil ( 2013 ) administered the full QRI-SP as a semi-structured interview to 31 adolescents with a clinical diagnosis of SAD and to a matched sample of 31 healthy adolescents. They found that whilst all adolescents had experienced negative self-imagery in social situations in the past, those with SAD experienced images more frequently ( d  = 0.84), and they were more distressing ( d  = 0.80) and more vivid ( d  = 0.54). These images were more likely to be experienced from the observer perspective by those with SAD compared to controls ( d  = 0.75). Almost half of controls (45.2%) and two-thirds of the SAD group (64.5%) identified a socially traumatic event linked to the negative self-image, but this proportion did not differ between the groups. A study by Hignett and Cartwright-Hatton ( 2008 ) further examined the hypothesis that the negative images experienced by socially anxious individuals tend to be from the observer perspective. One hundred and twenty-four unselected adolescents aged 12–18 years gave a brief talk to a camera. They were then asked to bring to mind how they thought they had appeared and rate the extent to which this image was from the field or observer perspective. A modest but significant association between social anxiety (SPAI-C) and tendency to take the observer perspective ( r  = 0.20) was found.

A convincing demonstration of the causal role of negative self-imagery in social anxiety in adults was provided by Hirsch et al. ( 2004 ) (see also Hirsch et al. ( 2003 )). In their study, socially anxious adults took part in two conversations, holding either a negative or a benign image in mind. Findings were in line with the cognitive model: compared to a benign image, holding a negative social image in mind increased anxiety, negative appraisals and use of safety behaviours and led to a poorer judgement by the conversation partner. Alfano et al. ( 2008 ) undertook a similar experimental study with 63 SAD and healthy control adolescents. Adolescents undertook videotaped role-play and read aloud tasks. Afterwards, they rated their anxiety and their social performance and an independent assessor made objective ratings of their performance. Half the control participants were instructed to engage in negative self-imagery during the tasks and the other half received no instructions. Contrary to the hypotheses and the findings of Hirsch et al. ( 2004 ) with adults, few differences were found in observer- or self-rated anxiety or performance between the two control groups. The SAD group was consistently rated as more anxious and less socially competent. The authors conclude that negative self-imagery may be a consequence of social anxiety rather than a causal factor as suggested by the cognitive model. However, it seems plausible that the null finding was due to design issues, in the sense that the manipulation of imagery was between-subjects which would give lower statistical power and also the control condition was not clearly defined. It is difficult to know what the imagery group was being compared to because participants in the comparison groups did not receive any instructions and were not subsequently asked about thought content during the experimental procedure. In comparison, the study of Hirsch et al. ( 2004 ) included a controlled within-subjects comparison (benign imagery). It therefore seems that there is scope for further causal experiments in adolescents including a tighter control over the experimental manipulation.

Video feedback with careful verbal preparation beforehand is a core cognitive therapy technique aimed at correcting negative and distorted self-imagery. Studies with adults have shown that the technique leads to more accurate appraisals of performance and reduced anxiety (Warnock-Parkes et al. 2017 ), providing corollary evidence for the role of self-images in social anxiety. Turning to studies with adolescents, Parr and Cartwright-Hatton ( 2009 ) examined the effect of video feedback with 36 highly socially anxious 14–17-year olds. Video feedback was provided with careful preparation to prepare an unbiased mode of processing (c.f. Warnock-Parkes et al. ( 2017 )). Compared to control participants (who sat quietly), young people who received video feedback after giving a speech felt less anxious about giving a subsequent speech ( d  = 1.43), predicted that they would perform better ( d  = 1.16) and went on to rate the later speech as better ( d  = 1.22). A somewhat similar study was undertaken with 11–13-year olds, scoring high and low on the SAS-A (Morgan and Banerjee 2006 ). Adolescents took part in a role-play task, with half receiving video feedback and half completing a distractor task prior to rating their performance. In contrast to the findings of Parr and Cartwright-Hatton ( 2009 ), the study did not find any improvements in participants’ performance ratings after video feedback for the high ( d  = 0.17) or low anxiety groups ( d  = 0.16). However, participants were not given any preparation for the video feedback. We know from adult research that whilst almost all studies have found the technique to be helpful, the two studies that have failed to find positive effects of video feedback (Rodebaugh 2004 ; Smits et al. 2006 ) did not include verbal preparation before watching the video. Careful verbal preparation is needed in order to overcome the processing biases that can undermine the effectiveness of the technique.

Reviewing the studies that have looked at self-imagery in adolescent social anxiety we find consistent results from the three questionnaire and interview studies (Ranta et al. 2014 ; Schreiber et al. 2012 ; Schreiber and Steil 2013 ), two of which reported on clinical samples. With a moderate effect, socially anxious youth reported more frequent negative observer-perspective social images compared to low scorers. The only experimental study to be undertaken (Alfano et al. 2008 ) did not find a detrimental effect of asking young people to engage in negative self-imagery, but this may be due to design issues. Looking at the relevant data on video feedback, we find that in line with adult reports, the study that undertook video feedback with careful verbal preparation yielded positive effects of the technique, whilst the study that did not include it failed to find a benefit. Experimental studies with clinical and non-clinical samples including valid manipulations are still needed to test the model’s hypothesis that negative self-imagery plays a causal role in adolescent social anxiety.

Use of Internal Information

The cognitive model would predict that socially anxious individuals use internal information made accessible by self-focused attention to make excessively negative inferences about how they look to others. This hypothesis has been supported in studies with adults. For example, Mansell and Clark ( 1999 ) asked adults with high and low levels of social anxiety to undertake a speech task. Participants rated their perceived body sensations and how they thought they appeared during the task. An independent assessor also rated how they came across. Amongst adults with high, but not with low social anxiety, a significant correlation was found between perceived body sensations and how anxious they thought they looked. The correlation between assessor ratings and perceived body sensations was non-significant for both groups. The findings are consistent with the suggestion that socially anxious individuals use perceived bodily sensations to make erroneous negative judgements about how they appear.

No studies have been undertaken examining this hypothesis with adolescents. Ancillary support comes from three studies that have compared subjective and objective measures of arousal in adolescents. In a study by Anderson et al. ( 2010 ), subjective physiological arousal and heart rate during a speech task were compared between 170, 13–17-year olds with SAD, high social anxiety adolescents and controls. SAD and high social anxiety adolescents both endorsed elevated self-reported arousal (measured on a subscale of items from the on Beck Anxiety Inventory (BAI) (Beck et al. 1988 ) compared to controls (SAD vs. low d  = 0.71; high social anxiety vs. low d  = 0.45), but did not differ from one another ( d  = 0.33). There were no differences in heart rate between the groups. Comparable findings were reported in an earlier study by Anderson and Hope ( 2009 ), comparing SAD ( n  = 85) with controls ( n  = 285) during a speech and a conversation task. There was no significant difference between groups in heart rate reactivity during the speech ( d  = 0.17) or the conversation ( d  = 0.15). However, adolescents with SAD rated themselves as more physiologically aroused on the BAI during both the speech ( d  = 0.81) and the conversation task ( d  = 0.65). In a non-clinical sample of 136, 9–17-year olds, high and low socially anxious youth were compared on self-reported and objective measures of heart rate and sweating during a speech task (Miers et al. 2011a ). High social anxiety participants reported a higher heart rate and sweatier palms ( d  = 0.52), but no differences in heart rate or skin conductance levels were found.

These three studies are consistent in their finding that whilst socially anxious adolescents and controls are comparable on indices of objective arousal, the socially anxious groups consistently overestimate their bodily symptoms of anxiety (Siess et al. 2014 ). It could be argued that these results are in line with the cognitive model because when socially anxious adolescents overestimate their physical sensations this may lead them to overestimate how anxious they look . However, studies in which adolescents are also asked how they think they appear are needed in order to directly test the hypothesis.

Use of Safety Behaviours

In adults, studies have found that socially anxious adults use safety behaviours in social situations more than those who are not socially anxious (e.g. Cuming et al. ( 2009 ), Pinto-Gouveia et al. ( 2003 )). We also have robust experimental data pointing to the causal role that these safety behaviours play in social anxiety in adults (e.g. McManus et al. 2009 , 2008 ). The data in relation to safety behaviours in children are scant (Halldorsson and Creswell 2017 ), but four studies have addressed the question in adolescents and they find similar results to in adults.

In the questionnaire study of Hodson et al. ( 2008 ), adolescents completed a self-report measure of safety behaviour use, the Safety Behaviour Questionnaire (Clark 2003 ). High social anxiety adolescents endorsed a greater use of safety behaviours compared to middle ( d  = 0.65) and low ( d  = 1.01) scorers, who did not differ from each other ( d  = 0.32). Safety behaviour use was significantly associated with social anxiety across the whole sample ( d  = 0.94), but it did not emerge as a unique predictor of social anxiety. In line with this study, Schreiber et al. ( 2012 ) using the same measure of safety behaviours (translated into German) found that high socially anxious 14–20-year olds used safety behaviours more than low socially anxious youth ( d  = 1.34). In contrast to the study of Hodson et al. ( 2008 ), they did find that across the whole sample safety behaviour use was a significant independent predictor of social anxiety but not of depression. Ranta et al. ( 2014 ) asked unselected adolescents about the safety behaviours they had used when they had felt socially anxious. 17% of the whole sample reported using at least one safety behaviour when they felt socially anxious. Safety behaviours were more frequent in the high social anxiety group compared to the low group ( d  = 0.68), and amongst those with a clinical or subclinical diagnosis of SAD compared to without ( r  = 0.63). The fourth study was undertaken by Thomas et al. ( 2012 ). The authors administered a measure of safety behaviours developed with adults, the SAFE (Cuming et al. 2009 ), and a measure of social anxiety to a group of adolescents referred to a clinic with possible social anxiety and to a group of community controls. In line with hypotheses, social anxiety was positively correlated with safety behaviour use across the whole sample ( r  = 0.49), and the socially anxious group endorsed significantly greater safety behaviour use than the community controls ( d  = 0.77).

In summary, four studies have looked at safety behaviours in adolescent social anxiety. A medium to large effect was found. Unfortunately, all of the studies were correlational. Studies modulating the use of safety behaviours and examining the effect (on, for example, anxiety, cognitions, self-focus and social performance) will be important in order to test the hypothesis that these behaviours are causally implicated in social anxiety. Due to the sensitised peer environment during adolescence we would expect avoidance safety behaviours to result in particularly negative reactions from their peers, and so socially anxious adolescents will be susceptible to becoming locked into a vicious cycle and subjected to peer victimisation, which we know is especially common in adolescents (Troop-Gordon 2017 ). Experimental studies will be valuable here. Furthermore, there are as yet no studies examining the putative sub-types of safety behaviours, their effects amongst adolescents or developmental influences on the use of safety behaviours. For example, it is conceivable that there may be a developmental progression in young people’s use of safety behaviours. As children move into and through adolescence they may become increasingly sophisticated in their use of safety behaviours, for example moving from a reliance on avoidance behaviours towards increasing adoption of impression management behaviours.

The notion of safety behaviours provides a different perspective on the understanding of the inhibited or withdrawn behaviours of people who are socially anxious. Traditionally, these behaviours have been interpreted as a sign that the individual lacks social skills (Wong and Rapee 2015 ). However, treated adults do not show ongoing social skills deficits (for a review see Hofmann ( 2007 )). When individuals are not anxious they do not show deficits in social skills. Any deficits in performance seem to be largely restricted to situations in which they are anxious, which suggests that they are an anxiety response rather than an indication of a lack of knowledge or ability (Alden and Taylor 2004 ). It seems likely that the apparent social skills deficits are in fact the observable safety behaviours (and the avoidance behaviours in particular).

Turning to studies with young people, in pre-adolescents a recent review concluded that there is evidence for an association between social anxiety disorder and a skills deficit (Halldorsson and Creswell 2017 ). In adolescents, a number of studies have found that peers rate socially anxious youth as less socially skilled than non-anxious peers (e.g. Miers et al. 2011b , 2010 ). However, as highlighted by Wong and Rapee ( 2015 ), it is not possible to determine the direction of causality from these studies. Further, none of these studies have considered the contaminating effect of safety behaviours on social skills. As such, it is difficult to draw conclusions from the available studies about whether there is a latent skills deficit. It will be important to test whether in adolescents, as in adults, the apparent performance deficits can in fact be explained by observable safety behaviours. Indeed, it seems plausible that if, as we suggest, socially anxious younger people do rely on avoidance safety behaviours more than impression management strategies, they may present as even more withdrawn and inhibited than socially anxious adults. As such, a performance deficit account could be drawn upon more readily with this population, despite the absence of an extant deficit. It will be important to test this hypothesis, as it has implications for our understanding of the maintenance of social anxiety and for treatment.

Pre- and Post-event Processing

Pre-event processing.

Worry is a feature of all anxiety disorders, and the cognitive model predicts that it is an important maintenance process in social anxiety as well. Examining this hypothesis, the questionnaire studies of Hodson et al. ( 2008 ) and Schreiber et al. ( 2012 ) both used a single item from the Social Phobia Weekly Summary Scale (Clark 2003 ) to measure pre-event processing (“over the past week, how often have you gone over in your mind things that you think might go wrong in a social situation before entering the situation”). In the study by Hodson et al. ( 2008 ), high socially anxious youth engaged in worry before social situations more than middle ( d  = 0.86) and low ( d  = 0.86) social anxiety groups, who did not differ from each other ( d  = 0.18). Across the whole sample, pre-event processing was significantly associated with social anxiety ( r  = 0.44) but also to depression ( r  = 0.42). It was a significant independent predictor of depression but not of social anxiety. This suggests that the process may not be specific to social anxiety, which is unsurprising given that repetitive thinking processes are implicated in a range of common mental health disorders (Watkins 2008 ). Schreiber et al. ( 2012 ) also found that high socially anxious youth reported more anticipatory worry than low scorers ( d  = 0.84). Again consistent with the findings of Hodson et al. ( 2008 ), pre-event processing was found to be an independent predictor of depression but not social anxiety in regression analyses. A correlational study of 60 adolescents with an anxiety disorder diagnosis (Rabner et al. 2017 ) found a significant correlation between self-reported social anxiety symptoms and worry ( r  = 0.432), as measured by the Penn State Worry Questionnaire (Chorpita et al. 1997 ).

Studies examining the related idea of anticipated performance criticism are relevant here. A recent study of anticipated audience criticism (Ranta et al. 2014 ) tested the hypothesis that socially anxious adolescents tend to expect more negative audience reactions in non-threatening situations compared to their peers. Amongst 333 adolescents scoring in the top and bottom quartile of the SAS-A, their hypothesis was confirmed: socially anxious youth demonstrated a tendency to expect negative classmate reactions (measured by self-report questionnaire) when they were the presenter ( r  = 0.60). There were no differences in expectations between anxiety groups when participants were asked to imagine an anxious peer rather than themselves, or in positive expectations of reactions. Similarly, in a study by Blöte et al. ( 2014 ), social anxiety was associated with more negative expectations of performance before a speech task ( r  = 0.32). Likewise, asked to rate expectations of their performance in a videotaped role-play task, high socially anxious young adolescents thought they would perform worse than low scorers ( d  = 0.51; Morgan and Banerjee ( 2006 )). Erath et al. ( 2007 ) asked 42 high socially anxious and 42 average anxiety adolescents to undertake a videotaped conversation task with a young adult. Higher social anxiety was significantly correlated with expectations of poorer social performance ( r  = 0.27). In addition, negative social performance expectations predicted skill deficits in the conversation task ( r  = 0.25).

These findings are all consistent with the cognitive model; pre-event processing involves a focus on potential negative outcomes of a social situation and an anticipation of social failure. These negative expectations will increase the likelihood that the situation is interpreted negatively, ones focus of attention shifts internally and safety behaviours are utilised, thereby maintaining anxiety. However, although using a variety of methods, all of these were correlational studies with analogue samples.

Post-event Processing

Rumination is in many respects a similar process to worry, and like worry it is implicated in a wide range of mental health difficulties (Watkins 2008 ) including social anxiety. Only two studies have examined this process in adolescent social anxiety. Using comparable methodologies, both Hodson et al. ( 2008 ) and Schreiber et al. ( 2012 ) examined whether group differences in post-event processing could be identified amongst a stratified non-clinical sample. Both used the Post-Event Processing Questionnaire (Rachman et al. 2000 ). It comprises 13 items related to how much the individual went over an event afterwards. Hodson et al. ( 2008 ) found that high socially anxious youth reported more post-event processing than middle ( d  = 0.62) or low ( d  = 0.95) groups (who did not differ from each other ( d  = 0.30). Post-event processing was significantly associated with social anxiety across the whole sample ( r  = 0.40) and with depression ( r  = 0.28). It was also a significant independent predictor of social anxiety. In the study of Schreiber et al. ( 2012 ), high socially anxious youth endorsed more post-event processing than low scorers ( d  = 0.94). In regression analysis, post-event processing was not a significant independent predictor of social anxiety, but it was of depression.

In summary, only two studies have looked at the role of post-event processing in adolescent social anxiety. Whilst both indicate that the process is elevated in adolescents with higher levels of social anxiety (with a medium effect), they were questionnaire studies with analogue samples, limiting the conclusions that we can draw.

Reviewing the studies undertaken with adolescent samples we see that there is encouraging support for the hypotheses derived from the cognitive model of Clark and Wells ( 1995 ). However, as yet the majority of studies have been undertaken with analogue samples, typically comparing extreme scorers on a measure of social anxiety. This is generally considered to be a valid research strategy given that social anxiety is thought to vary continuously across the population (Stopa and Clark 2001 ), but it will be important to replicate the findings with adolescent clinical samples. Another limitation of the studies is that the majority of them have been correlational. As such the resultant findings provide promising support for the hypotheses but cannot demonstrate the causal status of the processes in the model. To address this gap in the literature, further experimental studies are needed in which the psychological processes of interest are manipulated and their effect on social anxiety observed. As well as this, when considering the downward application of a static adult model to a dynamic adolescent period, there is a need to consider the developmental influences that have a bearing on these processes. Notwithstanding these caveats, the literature is sufficiently encouraging to suggest that adapting the treatment derived from the model for adolescents might be a promising approach. When considering this, attention must turn to the additional developmentally sensitive elements that may need to be included to explain the maintenance of social anxiety during the teenage years. There are features that are particular to adolescence that may well lock young people into the negative cycles that maintain social anxiety.

Developmentally Sensitive Factors Relevant to the Application of the Model to Adolescents

As outlined earlier, adolescence is a developmental period associated with particular cognitive, social and familial changes and these may well contribute to the persistence of social anxiety. We will focus here on the two factors that seem most salient and have been subject to the most scientific interest: parental factors and friendships and peer victimisation. Our ambition here is not to undertake a comprehensive review of these factors, but rather to consider whether these factors are associated with social anxiety, and if so, how they may maintain key processes in the cognitive model. We also briefly touch on the relationship between social anxiety and social media use. Although the research field is still relatively small it is an area of particular relevance in relation to adolescents and social anxiety.

Parenting Factors

Family processes, and parenting processes in particular, are commonly agreed to be a contributory factor in the development and maintenance of child anxiety (Rapee et al. 2009 ). The vast majority of the research in this area has been conducted with pre-adolescent children (Kendall and Ollendick 2004 ). However, given that the demands of parenting will shift and change considerably as children move into adolescence, it seems reasonable to think that parental influences on youth anxiety may also change during this time. For example, with increasing independence and autonomy the association between parental factors and child anxiety may be hypothesised to decrease over time. But it is equally conceivable that given the potential importance of parents in helping young people navigate their increasing autonomy, parental factors may be relevant in adolescent anxiety.

The most well-researched dimension of parenting in the aetiology and maintenance of youth anxiety is parental over-control or overprotection. This is defined as a pattern of behaviour involving overly protective, directive and controlling behaviours, even when the situation does not require it, and discouragement of independent problem solving. A recent review concluded that the majority of available studies (75%) point to a significant contribution of parental over-control to adolescent anxiety in general (Waite et al. 2014 ) and there is some evidence of its association with social anxiety symptoms specifically in pre-adolescents (Halldorsson and Creswell 2017 ).

In adolescents, three studies are particularly relevant when examining the relationship between parenting and adolescent social anxiety specifically (Loukas 2009 ; Fisak and Mann 2010 ; Caster et al. 1999 ). All were questionnaire studies undertaken with analogue adolescent samples in the USA. Adolescents completed measures assessing social anxiety (the SAS-A) and perceptions of parenting. The study by Loukas ( 2009 ) looked at the relationship between social anxiety and the perception of maternal psychological control amongst 479, 10–14-year olds. No significant association was found ( r  = 0.02 for females, and r  = 0.10 for males). The study by Fisak and Mann ( 2010 ) focused on 348 older adolescents (aged 15–18 years). Participants were split into ‘High’ (> 50 on the SAS-A) and ‘Low’ social anxiety groups. The high anxiety group rated their parents as more likely to model social fears, discomfort and avoidance ( d  = 0.39) and to communicate shame and criticism of adolescent’s social interactions and skills ( d  = 0.47). Adolescent perceived parental sociability and tendency to engage in social situations outside the family did not differ between groups ( d  = 0.08). Caster et al. ( 1999 ) undertook a large study comparing perceptions of parenting and the family environment made by adolescents categorised as high or low socially anxious. Adolescents were categorised in the high group if they scored at least one standard deviation above their gender and grade average on one or more of a number of measures of social anxiety (including the SAS-A). Those scoring at or below their gender and grade mean were classified as low social anxiety. High socially anxious youth rated all dimensions of the Family Environment Questionnaire (Caster et al. 1999 ) higher than low socially anxious youth. Specifically, they perceived their fathers and mothers as being more socially isolating, as being more concerned about others’ opinions, more ashamed of their shyness and poor performance, and less socially active (all d ’s between 0.37 and 0.69). A particularly interesting aspect of this study was the inclusion of parental reports of the family environment (using the same Family Environment Questionnaire). No significant differences in parent ratings of the family environment were found between parents of high and low socially anxious youths.

Overall, two of the three studies have found significant group differences between non-clinical groups scoring high and low on a measure of social anxiety. Interestingly, in one study this did not tally with findings on parent ratings of the family environment. All the studies used measures of perceptions of parenting. This makes sense in many ways, but if anxious adolescents are negatively biased in how they process information then higher scores on negative parenting dimensions may reflect a more general negative bias rather than a specific appraisal of parenting quality. Studies including measures of parenting completed by socially anxious youth and their parents as well as observational assessment of parenting would greatly add to the field. There has also been a notable lack of experimental studies examining the effect of manipulating parent–child interactions. One exception was an elegant study carried out by de Wilde and Rapee ( 2008 ) (although with pre-adolescents (mean age 10.19y), hence not reported in detail here). In brief, mothers were either required to be minimally or overly controlling with their children during preparation for a speech task. In a subsequent speech that the children prepared for alone, those whose mothers were overly controlling reported more anxiety than those whose mothers had been minimally controlling. Studies such as this would be especially informative about the relevance of parenting processes in adolescent social anxiety.

We can now consider the ways in which aspects of parenting may relate to the processes specified in the cognitive model. It seems likely that the relationship between parent and child anxiety, beliefs and behaviour is iterative and interactive (Rubin et al. 2009 ). Parents will bring their own attitudes and assumptions to their parenting practices. These parental beliefs are likely to motivate particular parenting behaviours (Rubin et al. 2009 ). Parenting beliefs characterised by a heightened perception of threat in the social environment and/or appraisals relating to their child’s vulnerability will most likely lead to anxiety about a child’s ability to thrive in a social environment. As such parents may engage in overprotective or over-controlling behaviours to mitigate their concerns (Rubin et al. 1999 ). Whilst well intentioned, we would suggest that these behaviours perpetuate the young person’s perception of social threat. The behaviours will be a source of evidence to the young person that they are less socially able than their peers and thereby maintain their negative attitudes (Ollendick and Hirshfeld-Becker 2002 ). Parental behaviours will become proxy safety behaviours for the young person. For example, a parent with these beliefs may step in and speak for their child, or give them permission to avoid social situations. These actions will preclude the young person’s opportunities to learn that their fears were unfounded or exaggerated. Some parents become constant companions to their teenage children. This could discourage the child’s peers from approaching or engaging with them, and so directly maintain social isolation.

Whilst some parents may hold overprotective beliefs, other parents may take quite a different view of the social environment and their child. Some parents’ beliefs may emphasise the importance of performing and being heard in a social situation. These may be driven by a parent’s temperamental extraversion or by a socially anxious parent who has coped by relying on impression management safety behaviours. Parents with these views may perceive their child to be missing out on opportunities and as such may express disappointment when their child feels unable to take part in a social commitment (Knappe et al. 2010 ; Bruch 1989 ). Likewise, they may push their child to engage in excessively demanding social activities in an attempt to help them overcome their fears. Again, we would suggest that whilst these behaviours are undoubtedly driven by good intentions they will maintain the young person’s anxiety. The young person will interpret expressed disappointment or frustration as evidence of their social failings. When faced with an excessively challenging social scenario, rather than learning new lessons the young person will most likely worry intensely beforehand, rely heavily on safety behaviours to get through the experience, and then ruminate over it afterwards, thereby preserving the negative thinking patterns.

These proposals provide a number of testable hypotheses that have not yet been examined. If supported, the account opens up the potential utility of including specific, focused work with parents in certain cases, where unhelpful parental beliefs and behaviours have been identified and where the young person is not progressing in treatment as one would expect and hope. Several well-established cognitive therapy techniques would be well suited to address parental beliefs and behaviours. For example, parents could be helped to identify unhelpful beliefs they hold and the impact of these on their child’s social anxiety. This could set the stage for behavioural experiments to test out specific predictions. The involvement of the adolescent in these experiments is likely to increase their effectiveness.

Friendships and Peer Victimisation

As children progress into adolescence, their social relationships become increasingly important (Furman and Buhrmester 1992 ). They will begin to see their peers as their primary source of social support (Nickerson and Nagle 2005 ), and so peer relationships take on even greater significance. Adolescents start to manage their own social arrangements, and their relationships will become more complex through this period, with different groups, cliques and subgroups forming, and with the start of romantic relationships. It is unsurprising that good peer relationships are associated with broad indices of well-being in adolescents (Chu et al. 2010 ). Alden and Taylor ( 2004 ) emphasised the importance of interpersonal processes in social anxiety and suggested that social anxiety is maintained by self-perpetuating relationship difficulties.

Numerous studies have examined the relationship between various dimensions of peer relationships and social anxiety cross sectionally. Consistently, less positive peer experiences have been found amongst socially anxious adolescents compared to their less anxious peers, in terms of fewer friends, less peer acceptance, more victimisation and less numerous and happy romantic relationship (see Rubin et al. ( 2009 ) for a review). A number of longitudinal studies have considered the impact of social anxiety on later peer relations (e.g. Siegel et al. ( 2009 ); Vernberg et al. ( 1992 )). For example, in a two month prospective study examining peer victimisation and social anxiety, Siegel et al. ( 2009 ) found that social anxiety predicted relational victimisation, a particular type of peer victimisation. Relational victimisation describes behaviours that use the relationship to in some way harm the intended victim, for example, not inviting a peer to a party, or not allowing another peer to join a group. Turning now to the reciprocal relationship, studies have also examined whether peer processes predict later social anxiety. In line with expectations, more negative peer relations have consistently emerged as a predictor of later social anxiety. For example, in a large sample of 12–19-year olds, lower levels of peer acceptance (as rated by peers) were associated with social anxiety levels one year later (Tillfors et al. 2012 ). A number of studies have found a relationship between peer victimisation and later social anxiety (Siegel et al. 2009 ; Storch et al. 2005 ; Vernberg et al. 1992 ). Interestingly, two studies (Siegel et al. 2009 ; Storch et al. 2005 ) again point to the significance of relational victimisation in social anxiety.

The convergent findings of a reciprocal relationship between social anxiety and peer difficulties are in line with the proposals of Alden and Taylor ( 2004 ) that social anxiety may lock individuals into a vicious cycle of interpersonal difficulties. It seems likely that these problems may be heightened during adolescence, when the socially anxious adolescent’s peers are themselves likely to be self-consciousness and particularly sensitive to potential rejection. This leads us to consider how peer problems may be related to the processes specified in the cognitive model. There are a number of ways this might operate, and the following mechanisms are suggested. When an individual experiences peer difficulties this may inform beliefs about their social acceptability directly and drive social anxiety. This suggestion is supported by findings from Grills and Ollendick ( 2002 ) in their study of 279 early adolescents. Amongst girls, perception of global self-worth was found to mediate the relationship between anxiety and peer victimisation. Social anxiety will inevitably cause some peer difficulties because gross avoidance of social interactions will limit individuals’ opportunities to forge friendships. It is also suggested that the socially anxious adolescent may be more vulnerable to unfriendly or victimising treatment due to their appraisals of others and the negative beliefs they hold. For example, the tendency for socially anxious adolescents to make negative interpretations of ambiguous social cues may lead them to respond to a fairly neutral situation in an excessively meek, unfriendly or avoidant manner. This may in turn lead to genuinely negative responses from peers. The use of avoidant safety behaviours will contaminate a social interaction; for example, avoiding eye contact and speaking less will convey disinterest. This will make an individual less attractive to their peers, reducing peer acceptance and thereby strengthening negative social beliefs. Furthermore, specific safety behaviours such as agreeing with other people and copying the dress sense of others in order to ‘blend in’ may lead to particular negative responses from peers in adolescence. This is because although adolescence is a time of low resistance to peer influence (Steinberg and Monahan 2007 ), it is also when individuals are concerned with determining their own identity and they are typically acutely sensitive to being copied.

Delineating these mechanisms provides a wealth of treatment opportunities. For example, the problematic negative thinking patterns and safety behaviours that may be implicated could be targeted well with existing cognitive therapy techniques. However, particular caution may be needed when planning behavioural experiments with teenagers in order to ensure positive outcomes. The ‘pack mentality’ of the social environment, increased frequency of peer victimisation, and heightened sensitivity to peer reactions in this period can all complicate behavioural experiments. Experiments should be set up in social contexts that are likely to lead to positive learning experiences for the adolescent patient. It may be necessary to undertake experiments in analogue social settings prior to testing out fears with known peers.

Social Media Use

Almost all young people now have access to a smartphone or to a tablet, laptop or desktop computer (Lenhart 2015 ). Over 90% go online daily, and almost a quarter use the Internet ‘almost constantly’ (Lenhart 2015 ). Whilst many adolescents spend time playing video games when online, almost all engage with social media. The number of social networking sites has grown in the last few years with the launch of influential sites such as Snapchat and Instagram. Social media is now one of the main ways that young people communicate with one another (Gross 2004 ), with modes of communication such as email, telephone and SMS falling in popularity. This is in contrast to adults. Although as a group the number of adults using social media has grown over the last few years, age remains negatively correlated with use (Duggan et al. 2015 ). For this reason, the relationship between social media use and social anxiety is of particularly relevance to adolescents. Because there are relatively few studies that have looked at social media use and social anxiety in adolescents, we have considered studies with both adolescents and young adult samples. Therefore, studies comprising adolescent samples are labelled as such and for those with adult samples we have included details of the age of the sample.

Online communication will hold great appeal for individuals with social anxiety (Pierce 2009 ). It provides the much-desired opportunity to interact with other people in a less anxiety-provoking setting than a face-to-face interaction (Bonetti et al. 2010 ; adolescent sample ). In line with this, a number of studies indicate a positive relationship between social anxiety and time spent on social networking sites (e.g. Lee-Won et al. ( 2015 ), mean age = 19.69 years, SD = 1.12 years; Shaw et al. ( 2015 ), mean age = 19.2 years, SD = 1.27 years; Orr et al. ( 2009 ), mean age = 21.5 years, SD = 5.29 years). One of the reasons online communication may be perceived as less threatening is because individuals feel they are more able to control the information they share and how they present themselves (Caplan 2007 ; mean age = 19.4 years, SD = 1.37 years). Indeed in a correlational study, adolescents with greater social anxiety reported valuing the controllability of online communication (Peter and Valkenburg 2006 ; adolescent sample ). It might be that this is because online, socially anxious individuals are able to engage in safety behaviours more intensively (Harman et al. ( 2005 ), adolescent sample ; Campbell et al. ( 2006 ), mean age = 28.7, SD = 10.16 years). For example, they can repeatedly edit posts and spend time preparing responses to messages.

Social anxiety will influence the ways in which people use social media. For example, social anxiety is associated with more passive use of social networking sites such as Facebook (Shaw et al. 2015 ). Rather than interacting with other users or posting material, people with social anxiety spend more time browsing other peoples’ profiles (Seabrook et al. 2016 , lifespan review, authors note that ‘the majority of studies examined young adults (late teens or early 20s)’ ). This type of use will lead individuals to generate unfavourable social comparisons (Vogel et al. 2015 ) thereby confirming negative social beliefs. Whilst we know that social comparison also occurs offline (Buunk and Gibbons 2007 ; review paper ), the online environment may be particular problematic because such a wealth of information is available (for example on profile pages, and through images and videos) and there are fewer limits on how long someone can spend browsing (Vogel et al. 2015 ; mean age = 18.93 years, SD = 3.94 years). We would also expect social anxiety to influence the ways that socially anxious individuals actively use these sites. For example, it is suggested that when socially anxious individuals do post material, this may tend to be self-denigratory in content; it may be that they would prefer to ‘get the criticism in first’ before they can be maligned by others.

Social media also provides another forum for peer victimisation. ‘Traditional’ bullying may continue after school and extend into online behaviours (Juvonen and Gross 2008 ; adolescent sample ). Due to the anonymity that the Internet affords, there may be fewer barriers to perpetrating bullying online and it may be harder to stop (Slonje et al. 2013 ; adolescent sample ). A survey of secondary school children found that the most common form of cyber bulling is name-calling via instant messaging (Smith et al. 2008 ; adolescent sample ). Cyber bullying is associated with negative outcomes including social anxiety. Cross-sectional studies have found a significant association between social anxiety and cyber bullying (Dempsey et al. 2009 , adolescent sample ; Kowalski and Limber 2013 , adolescent sample ). Two longitudinal studies indicate that social anxiety may confer vulnerability to online victimisation (Juvonen and Gross 2008 ; van den Eijnden et al. 2014 , adolescent sample ).

When thinking about treatment, we suggest that online social interactions need to be understood and addressed alongside those that occur face-to-face. This would start with a careful assessment of online behaviour at the beginning of treatment. Online safety behaviours could be targeted well with existing cognitive therapy techniques.

Treatment Implications and Emerging Evidence

Cognitive therapy for social anxiety disorder in adults is comprised of a series of techniques designed to reverse the processes specified in the Clark and Wells cognitive model ( 1995 ). The techniques are listed in Table  1 . Broadly, the treatment adopts an approach which encourages the patient to discover for him or herself how their social anxiety is maintained. This is achieved through a focus on experiential exercises; for example, a behavioural experiment is undertaken early on in therapy to demonstrate the unhelpful effects of self-focused attention and safety behaviours. Similarly, patients learn to focus their attention externally through a series of practical exercises. We would suggest that this method, of fostering cognitive change through action, is particularly well suited to adolescents, and we expect that many of the core elements of treatment could be employed successfully with adolescents with modest adaptations.

Only two randomised controlled trials have been undertaken examining the effectiveness of therapeutic interventions based on the cognitive model of Clark and Wells ( 1995 ) with children and young people. One of these involved children (Melfsen et al. 2011 ), but we describe it briefly here for interest. Forty-four socially anxious young people aged between 8 and 14 years of age were randomly allocated to individual therapy based on the cognitive model or to a waitlist control group. The authors reported medium to large effects of individual therapy compared to waitlist control on clinician reported (German version of the Anxiety Disorders Interview Schedule; d  = 0.96) and self-reported outcomes (German version of the SPAI; d  = 0.91). The results are certainly encouraging. However, the treatment did not represent a full implementation of cognitive therapy. For example, five to six sessions were dedicated to psycho-education. In cognitive therapy we would usually spend no longer than 15 min on this in session one. Critical components, such as the safety behaviour and self-focused attention behavioural experiment that is undertaken in session two of cognitive therapy, were not included. In addition, the trial was with children not adolescents.

Ingul et al. ( 2014 ) undertook a randomised controlled trial with socially anxious adolescents in which individual therapy based on the cognitive model was compared to the adolescent group version of Coping Cat (The CAT Project) and an attention placebo. The attention placebo involved group meetings in which socially anxious young people interacted with peers and adults to a similar degree to the treatment arms, but did not receive any of the hypothesised active components of the two treatments. A large effect of individual therapy was found on the SPAI post-treatment ( d  = 2.96). Surprisingly, there was no effect of Group CAT on self-reported SPAI ( d  = − 0.10) and a small effect of attention placebo ( d  = 0.50). The benefits of individual therapy were maintained at follow-up. The results are promising with regards individual therapy; however, treatment was not wholly consistent with cognitive therapy. For example, the first three sessions comprised psycho-education about anxiety, drawing up a broad model of anxiety maintenance, developing an anxiety thermometer and hierarchy, and learning about negative thoughts and thinking errors. An individualised version of the cognitive model was not introduced until session four (compared to session one in cognitive therapy).

In response to these promising findings, we undertook a treatment development case series to test preliminary feasibility of cognitive therapy with adolescents (Leigh and Clark 2016 ). Cognitive therapy was delivered to five adolescents, all of whom had severe and chronic social anxiety disorder as well as comorbid difficulties at the start of treatment. Four of the five had already received a standard course of CBT without apparent response. By the end of treatment, symptoms of social anxiety, as well as associated anxiety and depression, had reduced to subclinical levels and these gains were maintained at three to six month follow-up. All the young people also showed improved functioning, as evidenced by increased social participation and 100% school attendance at follow-up. Excitingly, we had the first indication that social anxiety treatment may also have a positive impact on classroom concentration, as evidenced by the self-reported improvement across all five patients. The average change (79%) on the primary outcome measure (the Liebowitz Social Anxiety Scale; Liebowitz ( 1987 )) was greater than observed in our trials of cognitive therapy for social anxiety disorder in adults (57 and 63% in Clark et al. 2003 , 2006 ).

Whilst the evidence base is extremely small, the results converge to suggest cognitive therapy may have important promise for adolescents with social anxiety disorder. Notably, although the trial of Ingul et al. ( 2014 ) did not test the full treatment, it demonstrated specific treatment effects.

Conclusions and Future Directions

The present review was motivated by an awareness of the divide in our understanding of the maintenance of social anxiety in adults compared to in adolescents. For example, in adults the development of empirically supported theoretical models to explain the persistence of social anxiety has paved the way for the generation of highly effective NICE recommended cognitive behavioural therapies (see Clark ( 2013 ) for a review). In contrast, a detailed mechanistic approach to understanding the maintenance (as opposed to the aetiology) of adolescent social anxiety has largely been lacking. This lack of maintenance models has limited the development of specific treatment techniques for adolescents. In response to this, the present review has focused on one particular model of social anxiety, the cognitive model of Clark and Wells ( 1995 ) and its application to social anxiety in adolescents. The review highlights the need for a programme of experimental studies with adolescents in order to test the causal role of the processes specified in the model. Notwithstanding this gap in the literature, the studies reviewed provide very promising support for the application of the model to this age group.

When adopting an adult model such as this for a youth population, it is of course essential to take a developmental perspective. It is suggested that there will be developmental influences on the psychological processes specified in the adult model. For example, as individuals progress through adolescence we would expect that they may use different safety behaviours (younger adolescents may rely on parents to speak for them but this may become developmentally inappropriate for older adolescents) and that the safety behaviours they tend to rely on may change over time (such as an increasing use of more sophisticated impression management safety behaviours with age). Turning to mental imagery, given that the ability to generate, inspect, maintain and manipulate mental images develops in an extended fashion through childhood and adolescence (Burnett Heyes et al. 2013 ), socially anxious adolescents may be particularly vulnerable to distressing social imagery, finding it difficult to inhibit images or shift attention away from them when they occur. But given this susceptibility, adolescents may also be particularly responsive to interventions targeting negative imagery. Likewise, given that adolescence is associated with heightened self-consciousness, socially anxious adolescents may show especially intense self-focus in social interactions, but they may also be especially responsive to an attention training intervention. No studies have yet examined these questions. As well as considering the developmental influences of the processes specified in the adult model, the explanatory power of the model will be enhanced with the addition of processes that are particular to adolescents, such as parental and peer processes. When considering these factors, it will be important to specify the mechanisms by which they maintain social anxiety in order to develop specific interventions.

The present review underscores the great potential for adapting and refining the cognitive model of social anxiety disorder (Clark and Wells 1995 ) for adolescents in order to improve treatment outcomes for this population.

Eleanor Leigh is funded by a Wellcome Trust clinical research training fellowship (102176/Z/13/Z). David M. Clark is a Wellcome Trust (WT069777) and NIHR (NF-SI-0512-10132) senior investigator.

Compliance with Ethical Standards

Conflict of interest.

David M. Clark is a co-author of the Clark and Wells ( 1995 ) Cognitive Model of Social Anxiety Disorder.

1 The term ‘correlational’ is used to refer to observational studies that measure co-variation either within or between groups but do not experimentally manipulate the variable.

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How to Overcome Social Anxiety: 8 Techniques & Exercises

I’ve tried going before, but at the door I blushed and started sweating. I just knew everyone would stare at me, judge me, and laugh at me.

I’ll just sit this one out too, pretend to be sick or something.

If this sounds like your typical diary entry, then you might struggle with some form of social anxiety.

In this article, we outline ways to cope with mild social anxiety and provide helpful tips, tricks, and exercises to help you prepare for upcoming social occasions. Before we begin, it’s important to note that social anxiety differs from social anxiety disorder, which is a clinical disorder. These two can be confused with each other because they are closely related, but this post focuses on mild social anxiety only.

Before you continue, we thought you might like to download our three Stress & Burnout Prevention Exercises (PDF) for free . These science-based exercises will equip you and your clients with tools to better manage stress and find a healthier balance in your life.

This Article Contains

• The Difference Between Social Anxiety & Social Anxiety Disorder

Symptoms of Social Anxiety

Social anxiety in the workplace, social anxiety and public speaking, can you overcome social anxiety 3 techniques, self-help exercises for managing social anxiety, 3 books about social anxiety, helpful resources from positivepsychology.com, a take-home message, frequently asked questions, the difference between social anxiety & social anxiety disorder.

Most of us experience moments of shyness, tension, nervousness, or anxiety around social events. Sometimes it can be as simple as butterflies in the stomach when expecting to meet new people at a party.

Physical reactions such as these signal that the situation is important enough to want to make a good impression. When our bodies are activated in this way, we are often galvanized into action (Weissman & Mendes, 2021).

However, the mild nervousness and shyness of social anxiety every now and again must not be confused with social anxiety disorder .

Social anxiety disorder , sometimes referred to as social phobia, is a type of clinical anxiety disorder whereby an individual’s persistent fear of being watched or judged by others impedes everyday functioning.

Individuals with this disorder may ruminate on planned social events weeks in advance and may actively avoid social situations completely. The disorder can be so intrusive and cause such distress to individuals that even simple tasks, such as buying groceries or visiting family, are impossible to do (Stein & Stein, 2008).

To be diagnosed with social anxiety disorder by a qualified mental health professional, individuals may experience several criteria as outlined by the Diagnostic Statistical Manual of Mental Disorders (American Psychiatric Association, 2013).

Criteria include:

• A persistent fear of social situations in which the individual fears being exposed to the scrutiny of others, or the fear of acting in a way that will be embarrassing or humiliating
• Avoiding social situations or enduring them with intense fear or anxiety
• The fear or anxiety is not proportional to the actual threat posed by the social situation.
• The fear or anxiety is so intense that it affects normal functioning.
• Lasting for six months or more
• The fear, anxiety, or avoidance is not because of a medical condition, substance use, or other mental disorder.

In these instances, the help of a therapist is needed. Let’s look at the symptoms of social anxiety to clarify where the line should be drawn.

These are fairly generic symptoms that occur when the autonomic nervous system (ANS; our fight-or-flight system ) becomes activated (Cannon, 1932), and the body is flooded with epinephrine (adrenaline).

Couple this with a decrease in gamma-aminobutyric acid (a main inhibitory neurotransmitter), which for most individuals is turned down during social situations, and you may feel tense and anxious. This activation happens when an event or situation is seen as stressful, whether the perception is accurate or not.

While chronic stress is extremely detrimental to the body — because of the continuous activation of the ANS (McEwen & Stellar, 1993) — mild stress can actually be helpful in enhancing performance (Kofman et al., 2006) and spurring action.

Usually when this happens, the parasympathetic nervous system (PNS) activates in order to counter the activation of the ANS, by releasing hormones that downregulate the mind and body and help us relax (Sapolsky, 2004).

So when tackling mild social anxiety, the key is to activate the PNS. Below, we will outline useful techniques to activate the parasympathetic nervous system.

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Given that we can all feel the effects of social anxiety at one time or another, how can we actively tackle such feelings? And how do we cope in stressful environments, such as work?

Coping with social anxiety at work

When those familiar feelings of anxiety emerge at work, individuals face a tough decision: to struggle ahead in silence or take a timeout. Ideally, this is the ability to step away and take a few minutes to apply grounding techniques, as an example. More on that below.

It is strongly recommended that all organizations and employers build supportive cultures where individuals feel able to take such a break. While discussions of mental health in the workplace are fortunately now more commonplace, there is still some way to go to normalize the pervasiveness of anxiety in the human experience.

Strategies for reducing workplace anxiety

To calm anxious feelings at work, individuals can tap into several key techniques that should help to turn things around quickly.

The primary aim here is to activate the PNS. When feeling anxious, it is hard to feel grounded. The mind is spiraling with unhelpful thoughts.

Grounding techniques work by helping the mind focus on the body and the present moment. This can help you feel calmer and more centered.

Below are three highly effective types of grounding techniques.

Breathing techniques

The breath is miraculous! By simply concentrating on breathing, the nervous system can be actively downregulated, and within no time at all, anxious moments may dissipate.

One example is to breathe in for four seconds, hold the breath for four seconds, and breathe out slowly over a count of eight seconds. There are many variations of this breathing technique, but essentially, breathing out for longer than breathing in helps slow a racing heart.

Touching the body can be an excellent way to soothe and calm the nervous system, particularly areas that are not associated with anxiety. This includes rubbing your earlobes or elbows, which cannot themselves hold tension or anxiety in them.

Touch is powerful; it is often used in therapeutic settings for the very purpose of relieving anxiety and has also been effective in reducing pain.

When feeling anxious, individuals should try to distract the mind from worrying. An alternative and equally effective technique to breathing exercises  is to focus on counting.

Counting can be particularly powerful when paired with observation of the surroundings. A popular example is to find five things that can be seen, four things that can be felt, three things that can be heard, two things that can be smelled, and one thing that can be tasted.

When doing this exercise, try to be as specific as possible and provide lots of detail with what is sensed.

It’s so intimidating in fact, that researchers often use the notion of having to speak in public to induce individuals into stressful states during experiments (see Kirschbaum et al., 1993).

Indeed, public speaking is the ultimate trigger for social anxiety because it involves purposefully exposing oneself to the opinions and judgments of others.

Overcoming public speaking anxiety

To prepare for an upcoming speech, public-speaking anxiety can be overcome similarly as other stressful events: by focusing on strategies to calm the nervous system.

Tips and strategies for delivering a confident speech

1. prepare well.

Practice, practice, practice! This might be an obvious tip, but by rehearsing the speech more confidence is built about delivering the speech.

This confidence can help offset some of the nervousness experienced.

2. Manage breathing

Engage in breathing exercises before delivering the speech. As mentioned earlier, slowing down breathing is a simple yet powerful way to downregulate the body.

When feeling those familiar anxiety symptoms before giving a speech, practice slow, deep breaths. Pair this with any of the aforementioned grounding or relaxation techniques to amplify the benefits and bring you back into the present moment.

3. Burn energy

Harness some of that nervous energy and take action. Do star jumps or jumping jacks before the speech to blow off steam. During the speech, individuals can move around and gesture to consume even more nervous energy.

4. Visualize success

Before the event, spend a few minutes visualizing the delivery of a successful speech or presentation. Imagine the audience responding positively and see yourself feeling calm and collected.

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If you recognize yourself as someone who often experiences social anxiety and are wondering what other steps you can take to reduce the frequency and/or intensity of these experiences, the key resides in being proactive .

If we simply do nothing and then try desperately to reduce anxiety when it rears its head in a stressful moment, we may very well be ill prepared to manage it effectively.

Given that it is not possible to avoid stressful events, the focus should be to learn how to better cope with them. By building internal resources , a stressful event can be navigated with ease.

Below are three preventive practices that will help build all-important psychological resources, such as resilience, positive coping, positive emotions, and self-esteem.

Physical exercise

The benefits of regular exercise to both physical and mental health are well documented (Penedo & Dahn, 2005).

By acting as a protective buffer against disease and psychological distress, exercise is one surefire way to bolster internal resources. Exercise boosts the experience of positive emotions, which in turn helps accrue psychological resources (see the broaden-and-build theory of positive emotions ; Fredrickson, 2001).

Mindfulness practice

Mindfulness is another superpower that can help stock up internal resources. If engaging in a regular practice, users can expect a cascade of positive outcomes, including reduced depressive and anxious symptoms and increased positive mood, compassion, and resilience (Gu et al., 2015).

Even 10 minutes a day of mindfulness practice can drastically improve both physical and psychological functioning.

The beauty of mindfulness is that it does not have to be practiced as a formal meditation. Rather, it can take many forms, including mindfulness walking or listening to music.

Experiment with different mindfulness activities to find the best-suited format for you or your clients.

Cognitive-Behavioral Therapy

Sometimes, in order to counteract anxiety, you might want to look more closely at patterns of thinking. Given that activation of the autonomic nervous system and symptoms of anxiety occur because we interpret  an event as stressful, it stands to reason that interpretations may not always be on point.

When this happens, engaging with Cognitive-Behavioral Therapy (CBT) can be a real game changer. CBT is often employed as a treatment for anxiety and works by challenging thinking patterns and helping individuals shift their mindsets.

Useful CBT techniques include writing down thoughts and then gently challenging the veracity of them, and learning positive coping mechanisms such as cognitive reframing.

Observing Anxiety Mindfully

This worksheet helps clients identify and observe how anxiety feels in the body.

Clients are encouraged to explore the different sensations that arise in the body when thinking about a stressful social situation.

Once the sensations have been observed, clients are encouraged to accept and sit with the feelings and sensations of anxiety from a place of nonjudgment, as with any mindfulness practice.

Lastly, clients are invited to use visualization to further tap into self-compassion and recognize the transient nature of anxiety.

Anxiety Record

The Anxiety Record is an effective worksheet that allows a client to capture step by step what happens when they experience anxiety.

The first step is to identify the stressor, before noting down anxious feelings and whether thoughts are helpful or realistic.

The client is then invited to identify more helpful thoughts when facing anxious moments and ways to regain a sense of control when feeling carried away with anxious thoughts.

Creating a Mindfulness Anxiety Plan

One excellent way to prepare for upcoming social situations is to create a mindfulness anxiety plan .

Mindfulness has a powerful impact on building coping skills, and it also enhances the ability to sit with discomfort without getting swept away by feelings.

If you are interested in learning more about social anxiety, the following three books provide excellent reading. These three were chosen because of their practical nature and the fact that they are grounded in science.

1. How to Be Yourself: Quiet Your Inner Critic and Rise Above Social Anxiet y – Ellen Hendriksen

Dr. Hendriksen is a clinical psychologist specializing in overcoming anxiety so that individuals may lead a more authentic life.

How to Be Yourself  takes real-life stories of situations where individuals have experienced social anxiety and weaves in a compelling narrative that outlines why social anxiety persists and the science behind it.

The book offers tangible, practical ways to rewire our brain so we can break free of the shackles of social anxiety.

Find the book on Amazon .

2. Overcoming Social Anxiety and Shyness: A Self-Help Guide Using Cognitive Behavioural Techniques – Gillian Butler

If you are looking for a self-help guide that takes individuals through the techniques of CBT as a pathway to reduce social anxiety, this book by Dr. Gillian Butler, a cognitive therapist and clinical psychologist, is for you.

Chock-full of practical strategies, the reader can work through the book at their own pace and by the end should feel armed to the teeth with solutions for fending off social anxiety.

3. Find Your Voice: The Secret to Talking With Confidence in Any Situation – Caroline Goyder

Caroline Goyder is a renowned voice coach and author of another highly popular book, Gravitas .

The central thesis of Find Your Voice  is learning to speak with confidence by implementing different strategies that help individuals relax, stand tall, and speak with clarity.

This is a must-read for anyone who wants to speak confidently in any type of social situation.

For more information on Goyder’s work, check out this popular TEDx Talk.

PositivePsychology.com has a plethora of useful resources for anyone interested in learning more about coping with social anxiety.

Below, you will find several worksheets for learning to cope with anxiety. Completing these exercises proactively can help ensure better navigation of anxiety, inducing in social situations.

Stressors and Resources

The aim of this worksheet is to help clients identify key sources of stress and anxiety, and outline strategies or resources that can deal with them.

This worksheet is extremely helpful because it also identifies past, present, and anticipated sources of stress and anxiety. After completing this worksheet, clients should have a greater awareness of their triggers and the strategies that work best for them in social situations.

Coping Skills Inventory

The Coping Skills Inventory worksheet introduces six common and widely used coping skills that can be used when facing social anxiety.

The client is guided in selecting the most appropriate coping skill that will work for them in a given social situation. Identifying coping strategies before a stressful event is an excellent way to build self-awareness and those all-important internal resources.

Recommended reading

For more informative and practical articles on anxiety and coping, you may enjoy this selection of articles:

• How to Deal With Anxiety: 5 Coping Skills and Worksheets
• 18 Anxiety Worksheets for Adults, Teens, and More
• Anxiety Therapy: Types, Techniques, and Worksheets

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17 Exercises To Reduce Stress & Burnout

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Social anxiety is a pervasive human experience and one we can all expect to encounter every now and again.

Whether we are at work, out with friends, or with family, some social events can and will trigger our fight-or-flight response.

Because life is fraught with stressful life events, trying to avoid them at all costs is not realistic or sustainable. Rather, it is better to be proactive in engaging in practices and techniques that will help us better cope with stress and anxiety as and when we need to.

We hope you enjoyed reading this article. Don’t forget to download our three Stress & Burnout Prevention Exercises (PDF) for free .

Physical symptoms can include an elevated heart rate, shortness of breath, sweaty palms, and feeling dizzy. Psychological symptoms can include feelings of panic or dread, rumination on negative thoughts, and a difficulty focusing on the here and now.

Social anxiety is not a mental illness. It is healthy and normal to experience mild physiological activation from time to time when faced with situations or tasks outside of our comfort zone. Often, low levels of anxiety are adaptive and can help us perform better. Only when social anxiety becomes intrusive to daily functioning, can social anxiety disorder be considered, as identified by the DSM -5.

Anxiety is highly prevalent worldwide, with about 309 million individuals experiencing an anxiety disorder in 2019 (World Health Organization, 2022). Since many individuals experience activated nervous systems in the face of social stressors, it is fair to say that social anxiety is extremely commonplace.

The activation of our autonomic nervous system causes social anxiety, which kicks into gear when a situation is perceived as stressful. The brain floods the body with adrenaline to prepare for action, and it is this adrenaline that causes many of the physical symptoms of social anxiety.

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• Cannon, W. B. (1932). The wisdom of the body . Norton.
• Fredrickson, B. L. (2001). The role of positive emotions in positive psychology: The broaden-and-build theory of positive emotions. American Psychologist , 56 (3), 218–226.
• Gu, J., Strauss, C., Bond, R., & Cavanagh, K. (2015). How do mindfulness-based cognitive therapy and mindfulness-based stress reduction improve mental health and wellbeing? A systematic review and meta-analysis of mediation studies. Clinical Psychology Review , 37 , 1–12.
• Kirschbaum, C., Pirke, K. M., & Hellhammer, D. H. (1993). The ‘Trier Social Stress Test’—A tool for investigating psychobiological stress responses in a laboratory setting. Neuropsychobiology , 28 (1–2), 76–81.
• Kofman, O., Meiran, N., Greenberg, E., Balas, M., & Cohen, H. (2006). Enhanced performance on executive functions associated with examination stress: Evidence from task-switching and Stroop paradigms. Cognition & Emotion , 20 (5), 577–595.
• McEwen, B. S., & Stellar, E. (1993). Stress and the individual: Mechanisms leading to disease. Archives of Internal Medicine , 153 (18), 2093–2101.
• Penedo, F. J., & Dahn, J. R. (2005). Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Current Opinion in Psychiatry , 18 (2), 189–193.
• Sapolsky, R. M. (2004). Why zebras don’t get ulcers: The acclaimed guide to stress, stress-related diseases, and coping (3rd ed.). Henry Holt and Company.
• Stein, M. B., & Stein, D. J. (2008). Social anxiety disorder. The Lancet , 371 (9618), 1115–1125.
• Weissman, D. G., & Mendes, W. B. (2021). Correlation of sympathetic and parasympathetic nervous system activity during rest and acute stress tasks. International Journal of Psychophysiology , 162 , 60–68.
• World Health Organization. (2022). Mental disorders . Retrieved June 15, 2023, from https://www.who.int/news-room/fact-sheets/detail/mental-disorders.

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Home / Parenting, Kids & Teens / Could my child’s social challenges actually be signs of social anxiety disorder?

Could my child’s social challenges actually be signs of social anxiety disorder?

An excerpt from Anxiety Coach

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Anxiety Coach by Mayo Clinic child psychologist Stephen P. Whiteside, Ph.D, L.P, takes Mayo Clinic’s safe, rapid, effective Exposure Therapy program for children and teens suffering from anxiety disorders, OCD and phobias, and adapts it from a supervised clinical setting to the family home in an easy to follow self help guide for parents and kids. In the following excerpt from Anxiety Coach , Stephen Whiteside helps parents figure out if their child’s social challenges are actually signs of social anxiety disorder, what sets off social anxiety, why a child avoids triggering situations and finally presents a simple case study of a 16 year old girl with social anxiety disorder, who went on to be successfully treated with Exposure therapy.

What is social anxiety disorder ?

The term social anxiety disorder fits when children are overly nervous about interacting with other people, particularly peers. Kids with social anxiety are afraid they will make mistakes when talking or will say or do something that could lead other people to think of them negatively. Feeling nervous leads kids to avoid situations that involve talking with or hanging out with or even being around other kids. When children with social anxiety disorder consistently avoid social situations, it means they miss out on fun activities, like sports, or don’t do things they need to do, like give a class presentation. Over time, missing out on these important activities can cause other problems. Social anxiety disorder is one of the most common reasons families come to our clinic.

How do we know it’s social anxiety disorder?

Social anxiety disorder is different from typical shyness in the degree of anxiety that kids experience and how much their fears cause problems. There is nothing wrong with being shy or introverted; I myself was pretty shy as a child. Being nervous giving presentations at school or starting a new activity is also a very normal, common experience. As I mentioned earlier, it’s important not to unnecessarily label your child’s behavior as a problem. If they are content with the way they are living their life and they are doing the school and social activities they need to, that’s a solid sign that all is well. However, when fears of embarrassment are so upsetting that  they get in the way of living everyday life, that’s when we call it social anxiety disorder and recommend treatment. There are times in our clinic when kids and parents disagree on whether social anxiety is a problem. This usually happens in two scenarios. Since many social interactions for kids occur in school, without parents there to witness their child’s difficulties, parents have only the impression they get from seeing their child function in the family setting, whether that’s at home or in public. In these cases, parents may not realize how much their teens or kids are struggling socially. Other times, it’s the reverse, and kids are so upset by their social difficulties that they deny they are nervous and instead say they are simply not interested in spending time with other kids, and what is wrong with that conscious choice, if they are making it? In that and similar kinds of cases, we need to focus on the three jobs we expect from kids and teens—being successful in school, with friends, and at home—and if there are problems in those areas, we can explore how social anxiety might be getting in the way. In addition to situations and activities, for some kids social anxiety is set off by memories of awkward social situations or physical feelings of anxiety or embarrassment, like blushing or sweating, which lead to the same withdrawal and avoidance as social anxiety that relates to real-time, everyday scenarios.

What sets off my child’s social anxiety?

Social anxiety is typically set off by things in the world around us, most often situations in which kids need to talk to their peers or other people or when they may be observed by others. There are many different types of social situations and not all will give your child feelings of anxiety. Some children get more nervous in performance situations— reading aloud in class, acting in a school play, singing in a school musical, answering a question in class, competing in a basketball game, playing in a school concert, or giving a presentation in class. Others might get more nervous in unstructured social situations, like initiating conversations, meeting other kids at the start of a new school year, joining a club, finding people to sit with during lunch, or making small talk in the hallways between classes. And then there are kids whose anxiety is set off by talking to adults, especially in public situations such as the school principal, a teacher, or a sports coach. These children may also be nervous to order food at restaurants, ask questions of store clerks, or check out with you at the grocery store. Sometimes children feel nervous simply being in public where people may be watching and observing them. For many kids with social anxiety, all of the above may set off their anxiety.

Expectations that make social situations scary                                      

Once you’ve identified the situations that set off your child’s anxiety, the next thing to do is pinpoint the expectations that cause your child to feel nervous in these situations when most of their peers enjoy them or feel only somewhat uncomfortable. As we have learned, there are two main expectations that drive fear and worry— something bad will happen and I won’t be able to handle this —both apply to kids with social anxiety. A core component of social anxiety is the fear of being judged negatively. However, the type of feared judgment often differs based on the situation in which kids feel anxious. Kids who get nervous speaking in performance situations may have expectations that they will make mistakes, perform poorly, and be judged as not good enough, smart enough, or talented enough. Kids who are more nervous about talking to peers may be more afraid that they will do something embarrassing and everyone will think they’re uncool or unlikable. And when kids are nervous around authority figures they are typically concerned about getting in trouble, being a burden, or irritating others. For many children with social anxiety, expectations can occur in any combination of the above. Despite the importance of expecting negative judgment in social anxiety, it’s important to note that some kids don’t describe these specific worries. Younger kids especially are more likely to simply say that talking to others is scary and they don’t know why. Teens may add that they know it’s unlikely that people will laugh at them or be mean but that they still feel nervous. If this is the case, you might describe the child’s expectation as believing they can’t handle talking to people or they have to avoid being around people to feel okay.

Avoidance of social situations

Next, we need to identify what avoidance strategies your child uses to stay away from the situations they fear and in doing so, miss out on the opportunity to learn that these situations are not as bad as they expect them to be. The most common form of avoidance for kids with social anxiety disorder is partial physical avoidance, which is when kids can’t completely avoid a situation but try to avoid as much of it as possible when they are in the midst of it. For example, these kids can’t avoid going to class, but when in class, they are careful never to raise their hand to answer a question asked by a teacher. Or because of anxiety around playing on the school football team, a teen might arrive at practice at the last minute and rush home quickly afterward to avoid the banter and socializing among teammates in the locker room. Partial avoidance due to social anxiety can also include a child keeping their head down while walking in the hallways between classes at school, avoiding eye contact to make sure no one talks to them, or purposefully reading a book before class to put up a wall against being greeted by fellow classmates. As many parents of socially anxious children know, full avoidance of anxiety-provoking activities can also occur. Complete avoidance involves not signing up for sports, clubs, and other extracurricular activities. Or not attending school dances or sporting events. Or eating lunch in the library. It may grow to include staying home from school on days there is a presentation due or even transitioning to online school or homeschooling. Kids with social anxiety may also often rely on others to help avoid feared social interactions. As we saw earlier, parents may be asked to order food in restaurants or communicate with teachers.

Social anxiety disorder, a case study

Meet 16-year-old Maria, a smart, likable teenager and a successful figure skater. She and her parents agreed that she had always been shy, but it hadn’t been a problem because she’d maintained a core group of friends since kindergarten. In restaurants, she’d appear nervous, and her parents would order for her, but they weren’t overly concerned about it. None of this was a problem until she entered middle school. With that transition, she began to struggle. Her core friends connected with new faces and added new friends, while Maria stayed on the sidelines, feeling shy. She felt even more nervous in class when she didn’t yet know many of the other students and, with seven different classes a day, there wasn’t much of a chance to get to know her teachers. In this new environment, she came to dread presentations, yet was too nervous to ask for help. Under pressure across the board, some of her grades began to slip. When Maria began to complain that she felt too sick to go to school on days she had a class where there was always a lot of student participation, her parents brought her in to Mayo Clinic for help. During the initial assessment, Maria readily acknowledged that in social situations she was afraid she would say the wrong thing and look ridiculous in front of other kids who all seemed to be calm, outgoing, and happy to make new friends and expand their social circle. She had always felt comfortable with figure skating because so much of it involved working on her own without having to make conversation with the other skaters. However, now that they were getting older and spending more time chit chatting before and after practice, she was struggling with these interactions and feeling awkward. What she feared most was doing something foolish that would lead her peers to laugh at her and, as a result, see no value in being friends with her. Although she outright avoided some school activities and relied on her parents to order for her at restaurants, most of her avoidance strategies involved finding ways to dodge direct conversation when at school or during activities by looking busy, avoiding eye contact, or leaving early. It had reached a point where she felt left out and was considering quitting. After our clinical assessment, a diagnosis of social anxiety disorder was agreed upon and she went on to be rapidly and successfully treated with Exposure therapy.

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Don’t Let Anxiety Sabotage Your Next Presentation

• Riaz Meghji

Stop focusing on yourself and start focusing on your audience.

If you want to beat speaking anxiety, you need to stop focusing on yourself and point your focus outward. This shift isn’t something that can happen instantaneously. It takes time, patience, and practice. Here’s how to get started.

• Be a giver, not a taker. Takers tend to have more anxiety. They want and need validation from their listeners.
• Givers, on the other hand, are all about service. They do work beforehand to connect with stakeholders and use the information they receive to address the needs of their audience. As a result, their presentation becomes less about them and more about helping the other people in the room.
• If you want to turn your presentation into an act of service, you need to talk to the people in the room — well before your presentation begins.
• Choose about three to five influential leaders, and meet with them before to learn their concerns and goals surrounding the topic you’re presenting on.
• Then, incorporate your findings into you presentation. This will help you shift your focus outwards, from yourself to the audience, and as a result, ease some of your nerves.

How many times have you had an important message to share, only to be sabotaged by anxiety right before you speak?

• RM Riaz Meghji is a human connection keynote speaker, author of Every Conversation Counts: The 5 Habits of Human Connection That Build Extraordinary Relationships and creator of The Magnetic Presenter speaker coaching program. He is also an accomplished broadcaster with 17 years of television hosting experience. Riaz has hosted for Citytv’s Breakfast Television, MTV Canada, TEDxVancouver, CTV News, and the Toronto International Film Festival.  

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Risk factor patterns define social anxiety subtypes in adolescents with brain and clinical feature differences

• Original Contribution
• Published: 28 August 2024

Cite this article

• Yinzhi Kang 1 ,
• Qingfeng Li 1 ,
• Wenjing Liu 2 ,
• Yang Hu 1 ,
• Zhen Liu 2 ,
• Shuqi Xie 1 ,
• Changminghao Ma 2 ,
• Lei Zhang 1 ,
• Xiaochen Zhang 1 ,
• Zhishan Hu 1 ,
• Yue Ding 1 ,
• Wenhong Cheng 2 &
• Zhi Yang 1 , 3 , 4  

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Social anxiety disorder (SAD) is one of the most common psychiatric disorders in adolescents. The heterogeneity of both symptoms and etiology is an essential source of difficulties in the treatment and prevention of SAD. The study aimed to identify subtypes of adolescent SAD based on etiology-related phenotype dimensions and examine symptom and brain associations of the subtypes. We used a deeply phenotyped sample (47 phenotype subscales from 13 measures) of adolescents with SAD ( n  = 196) and healthy controls ( n  = 109) to extract etiology-relevant risk factors, based on which we identified subtypes of SAD. We compared the subtypes on clinical characteristics and brain morphometrics and functional connectivity, and examined subtype-specific links between risk factors, brain aberrance, and clinical characteristics. We identified six etiology-relevant risk factors and two subtypes of adolescent SAD. One subtype showed mainly elevated negative emotionality trait and coping style and diminished positive emotionality trait and coping style, while the other additionally had significantly high environmental risk factors, more severe impairments in social functioning, and significant abnormalities in brain structure and function. There were subtype-specific links between the risk factor profiles, brain aberrance, and clinical characteristics. The finding suggests two etiology-based subtypes of adolescent SAD, providing novel insights to the diversity of pathological pathways and precise intervention strategies.

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Acknowledgements

The authors would like to thank the mental health professionals and subjects who were involved in the project.

This work was supported by the Science and Technology Innovation 2030-Major project (2022ZD0209100); National Natural Science Foundation of China (81971682, 81571756); Shanghai Science and Technology Commission (20Y11906700, 18JC1420305); Clinical Research Project of Shanghai Mental Health Center (CRC2018DSJ01-5; CRC2019ZD04); Natural Science Foundation of Shanghai (20ZR1472800); Shanghai Municipal Commission of Education (Gao-feng Clinical Medicine-20171929); Shanghai Municipal Health Commission (2019ZB0201; 2018BR17); Shanghai Xuhui District Health and Wellness Committee Joint Research Project on Important Diseases (XHLHGG202106);Shanghai Public Health System Enhancement Three-Year Action Plan( 2023— 2025) Project on Key Discipline Construction(GWVI-11. 1-33).

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Yinzhi Kang, Qingfeng Li, Yang Hu, Shuqi Xie, Lei Zhang, Xiaochen Zhang, Zhishan Hu, Yue Ding & Zhi Yang

Department of Child and Adolescent Psychiatry, Shanghai Mental Health Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China

Wenjing Liu, Zhen Liu, Changminghao Ma & Wenhong Cheng

Beijing Key Laboratory of Mental Disorders, Beijing Anding Hospital, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Capital Medical University, Beijing, China

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Y.K. conducted statistical analyses and drafted the manuscript. Q.L., W.L., Y.H., Z.L., S.X., C.M., L.Z., X.Z., Z.H., and Y.D. contributed to the acquisition of the data and verified. Z.Y. and W.C. designed the study and revised the manuscript. All authors reviewed and approved the final manuscript.

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Kang, Y., Li, Q., Liu, W. et al. Risk factor patterns define social anxiety subtypes in adolescents with brain and clinical feature differences. Eur Child Adolesc Psychiatry (2024). https://doi.org/10.1007/s00787-024-02548-x

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Received : 13 November 2023

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DOI : https://doi.org/10.1007/s00787-024-02548-x

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