1. Social Anxiety
Amanda Dahlquist

2. Introduction
n this interactive presentation, I hope to explore
Social Anxiety in depth. The term “Social Anxiety” may be
used synonymously with “Social Phobia”; however, for the
purpose of this presentation I will be using the term “Social
Anxiety”.
Because of the difference in the manifestation of the
disorder, I will be presenting the adult and child population
in a semi-separate fashion. I will also explore how the brain
of someone with Social Anxiety may function differently
then the normal population.
This presentation is built around a navigational system.
To get the most out of your experience use the buttons on
the following pages to navigate as you explore. All research
used in this presentation is cited under “References”.

3. Main Menu

4. What is Social Anxiety?
Because most everyone has experienced some
of the characteristics of Social Anxiety, it is
easier to relate to; however, this also makes it
more difficult for some individuals to
understand the disorder.
For example, everyone has felt nervous about
a social situation at some time in life. This helps
a person to relate, on a certain level, to how an
individual with Social Anxiety feels. However,
because everyone has felt this characteristic on
some level, it is more difficult to understand
why this disorder is different from what is felt
by a normal individual.

5. What does Social Anxiety look like?
An individual with Social Anxiety Disorder
experiences a persistent fear of social or performance
situations.[1][2] This fear is generated by the idea that
the individual will be scrutinized or evaluated in some
way and that they will do something to deserve a
negative opinion. Although this individual realizes
their anxiety is unfounded, most often they will
choose to avoid these social situations. Though, in
some cases the situation is endured with extreme
discomfort. The severity of anxious behaviors varies
in different individuals, from “minor discomfort”, to
“severely de-habilitating”.

6. Sever to Minor Anxiety Exhibited in Individuals:
Panic Attack[1][2]
Confusion
Diarrhea
Gastrointestinal Discomfort
Muscle tension
Tremors
Heart Palpitations
Sweating
Blushing

7. Specific Social Anxiety Disorder
Usually, an individual exhibits Social Anxiety in a
specific social situation or performance situation. [1]
This is called “Specific” or “Non-Generalized Social
Anxiety”.
To be diagnosed with Specific Social Anxiety, the
anxiety must significantly interfere with the
person’s daily routine, occupation or social life.

8. Example of a Specific Social Anxiety:
As a hypothetical example, suppose an individual exhibits a
Specific Social Phobia: riding their bicycle in public. This
person has no other phobias about riding the bike itself (they
are not afraid of the bicycle and they know how to ride a bike,
etc.).
This person may not be diagnosed with Specific Social
Phobia, because they do not need to ride their bike in public, or
even want to be able to. So they are able to live a full un-
prohibited life without dealing with the fear of riding a bicycle
in public.
However, what if all other means of transportation became
outlawed and the bicycle was the only means of getting
somewhere of a substantial distance? This would severely
impact the individual’s life. This is of course an extreme
example, but this individual would probably be diagnosed and
need to work though their Specific Social Anxiety of riding a
bicycle in public.

9. Generalized Anxiety Disorder
An individual with Generalized Social Anxiety Disorder
has fear concerning most all facets of social and
performance situations. [1] This individual often suffers
from hypersensitivity. They interpret neutral social signals
as negative. For example, they may interpret a yawn as
they are boring someone or someone squinting their eyes
against the sun as glaring at them. Because of this
hypersensitivity constructive criticism can be wrongfully
devastating to a person suffering from Social Anxiety, as it
is interpreted as a personal rejection or affront. General
Social Anxiety is usually associated with a feeling of
inferiority and low self-esteem, which is perpetuated by a
difficulty with being assertive.

10. Hypersensitivity:
How much emotion do these pictures invoke?
It maybe surprising that these images
actually provoke a response within the
amygdale of the brain, a part of the brain used
to process emotions. [2][13]

11. Hypersensitivity:
Perhaps this is not so surprising after all, because
as the pictures of the different faces were viewed, the
brain was able to process the emotions the faces
convey. [2]
Studies done with the Social Anxiety population
showed that when they were shown photographs of
people’s faces with emotion their amygdale had an
exaggerated response.[5] Dr. Evens along with his
fellow researches wondered if they could get the same
response from the Generalized Social Anxiety
population by just using line drawings of emotional
faces. So here’s the surprising part, it worked. Go
ahead and look at the pictures again, then think of
trying to function in everyday situations if these line
drawings provoke an exaggerated response in the
emotional centers of the brain.

12. In Summary
In summary, a person with Social Anxiety has
a persistent fear of social or performance
situations. [1][2] This fear is generated by the
anxiety of being watched or evaluated in a
negative way. This person usually recognizes
that their fear is unreasonable or unfounded;
however, exposure to the social situation
inevitably results in anxiety. Usually, this
person avoids these social situations but, if they
are unavoidable they are endured with a great
amount of discomfort. Social Anxiety, if
untreated, significantly interferes with a
person’s daily routine and social life.

13. Social Anxiety in Children
Children experience an incredible amount of change as they grow
older. As they change they build upon a basic understanding of their
world. Sometimes this understanding can lead to a temporary Social
Anxiety, such as not wanting to talk in front of the opposite gender. But as
they get older and their understanding of the world changes this behavior
also changes and their anxiety disappears as the begin realize that they
actually like the “cooties” of the opposite gender, so much so that they
don’t even mind their “cootie shots” anymore.
Because of this incredible amount of change, it is sometimes harder to
diagnose a child with Social Anxiety Disorder. To complicate things
further, there are many different other disorders that can either be the
cause of “Social Anxiety like” symptoms or can be caused by the Social
Anxiety, as demonstrated under the “Differential Diagnosis” section of
presentation.
In young children, there is less to draw on in their life experiences to
know or understand what their symptoms may be a result of. Because of
this fact a diagnosis is usually not made until the child has been displaying
symptoms for at least 6 months.

14. Characteristics in Children
Because a child’s life will be significantly
different from an adult’s life, some aspects of
Social Anxiety manifests itself a little
differently. For example, as a child, school is a
significant part of our lives. This is why the
first people to recognize the symptoms of
Social anxiety are usually the principle,
teachers and nurse of the school the child
attends. [14] It is important to understand the
difference between simple shyness and Social
Anxiety Disorder in children. As Dr. Setzer
and his associate points out, “School refusal
behavior” can be a main indicator of Social
Anxiety.[19]

15. School Refusal Behavior
Children will be children, and sometimes that means that
they want stay at home and play rather then go to school and
learn. When this desire becomes a concern is when children
want to stay home for the sake of not going to school. [19] This
avoidant behavior can be due to the anxiety cause by peer and
or authority interaction (when no apparent reason is present,
ie. Bullying), and performance based situations (ie. Test taking,
reading aloud).[18]
School refusal behavior can be taken to dangerous levels by
the child, such as the child making themselves sick (ie.
Purposefully overdosing on medications, self inflicted
vomiting). When school refusal becomes habitual, it is
important to investigate why it exists before it becomes an
immediate danger to the child. The avenues for investigation
will be more apparent within the “Causes” section of this
presentation and how to help the child will become clear in the
“Treatment” section of this presentation.

16. School Refusal Behavior
Drawing on personal experience (see “Life” for more
details) as well as the results of recent studies, it is
important for the caretakers in the child’s life to be able to
work together.
Regardless of the cause of school refusal behavior, it is
important for the parents to be involved with the teaches of
the child, not to create a crutch for the child’s anxiety, but to
provide support for overcoming their disorder. This will
provide tremendous insight for the parent into what the
child may be trying to avoid. It will also alert the teacher to
be mindful of the child’s behavior. And perhaps most
importantly it will eventually help make the rehabilitation of
the child easier, by bringing a consistency of goals and the
exposure to the feared situations to both the home and the
school environment. This will provide a safer atmosphere for
the child to learn vital social skills.[14][10]

17. Brain Characteristics of Social Anxiety
The field of Brain Research is a relatively new one. Because of
this fact there is so much exploration waiting to be done, especially
in relation to this presentation’s topic, Social Anxiety.
However, there have been some interesting developments on this
front. There have been many studies conducted comparing the
amygdala (a part of the brain used to process emotions) in
participants with Social Anxiety and participants without it. When
these participants are presented with an emotional cue (line
drawings of faces), their responses where recorded by an MRI scan.
These studies revealed that the participants with Social Anxiety
Disorder reacted with a hyperactive amygdala compared to those
with out the disorder. More will be discussed under the “Causes”
section of this presentation.
SAD = Social Anxiety Disorder
HC = Healthy Control, those without

18. How is Social Anxiety distinctive?
Because Social anxiety can sometimes precede
other disorders, or co-occur, it is sometimes
misdiagnosed. [3][6][8][16][20] Mood disorders such
as major depression, panic disorder and bipolar
disorder are just some of the disorders highly
associated with Social Anxiety. [10][14] This can
make Social Anxiety more difficult to recognize,
because the symptoms of these co-existent
disorders are usually more visible. For example,
some individuals suffering from Social Anxiety
Disorder may turn to a substance abuse method in
order to cope. So, they may be diagnosed with
alcoholism or other drug related issues instead of
with the root problem.

19. Differential Diagnostics
However, the converse is also possible. Because
many disorders may start out looking like Social
Anxiety disorder, an individual may be diagnosed
with Social Anxiety and actually suffer from a
different problem, or disorder. To explore some
differential diagnostics choose a button below.

20. Substance Abuse
Though substance abuse can be a coping method for individuals with
Social Anxiety, it can also cause symptoms that look a lot like the disorder.
When an individual has an addiction to a substance there is a set of
cognitive thought processes that allow the individual to tolerate their
behavior. [21]This thought process may include the idea that the individual
needs to fulfill their cravings because they need or deserve to escape
reality. They may experience anxiety, depression and even anger and
paranoia before and sometimes even after the administration of the
substance. This thought process may begin to look like Social Anxiety,
because the individual becomes withdrawn from reality, begins to become
anxious without the substance and may show some social withdraw, or
phobia, such as difficulty talking to authority figures.
Substance Abuse: Social Anxiety:
Social Anxiety like Anxiety is present
symptoms are usually caused because of a social situation.
by withdraw. Anxiety is not The individual may find the
brought on my the social situation more bearable when
situation itself, it is instead they use a certain substance,
brought on by a withdrawal but the cause of the anxiety is
from the substance.
the social situation itself.

21. Schizoid Personality Disorder
Individuals with schizoid personality
disorder become withdrawn socially and may
display inappropriate emotional responses in
social situations.[1]
Schizoid Personality Disorder: Social Anxiety:
The individual does not An individual with Social
desire or enjoy close Anxiety may seem emotionally
relationships, usually chooses to distant. This may be because of
be alone, even in situations their self-analyzing mindset,
meant to be socially stimulating. which may cause them to miss
They are emotionally detached important social cues. However,
and they may not be aware, or they are painfully aware of their
care about their antisocial antisocial behavior and tend to
behavior. They tend to be shy away from social situations
because they care too much about
indifferent to praise or criticism.
their social behavior. They are
hypersensitive to even neutral
verbal and physical social cues,
which may cause them to miss
realistic social cues.

22. Body Dysmorphic Disorder
Individuals with Body Dysmorphic Disorder can
tend to shy away from certain social situations.[1]
They also have low self-esteem and trouble with
confidence. They are socially anxious in certain
social situations.
Body Dysmorphic Disorder: Social Anxiety:
This disorder is different An individual with Social
from Social Anxiety because of Anxiety has low self esteem,
the root cause of the anxiety. An which may carry over into a
individual with Body
Dysmorphic disorder has a poor body image. However, it
preoccupation on an imagined or is not this poor body image
slight defect about their bodies. that makes the individual
They become socially anxious socially anxious. It is the
because of this preoccupation, phobia of the social situation
believing that people are judging itself. This phobia is what
their defect and based on this makes them shy away from
judgment will not be able to social situation, specifically or
accept them socially.
in general.

23. Pervasive Developmental Disorder
Examples: Autism and Schizophrenia
Pervasive Developmental Disorder:
Individuals with a
Social Anxiety:
developmental disorder may An individual with Social
exhibit social disturbances, such Anxiety both knows of and
as having trouble engaging in cares about their Social
social situations and building Anxiety and withdrawal from
relationships. But, this is social situations. It is their
because of either a lack of extreme, unrealistic fear of
understanding of social the social situations that
situation, or because a mental debilitates the individual.
disturbance that make it There is not a basic lack of
impossible to correctly operate understanding of the social
in a social situations. Individuals situation itself.
with one of these disorders may
not even know they have a social
problem, or if they know they
may not be able to care.

24. Separation Anxiety
Individuals with Separation Anxiety suffer in some
social situations. They may also experience symptoms
as extreme as panic attacks when triggered.
Separation Anxiety: Social Anxiety:
Separation Anxiety may look An individual with
like Social Anxiety, but it is the Social Anxiety Disorder
root of the anxiety that differs. will always feel a degree of
Anxiety caused by this disorder anxiety in social situations
is based on the separation of the
individual from a person or no matter who or what is
thing. However, when the present. Because it is the
individual is reunited with the social situation itself that
person of thing anxiety is usually is the root cause for the
extinguished. For example, an anxiety they exhibit.
individual suffering from
Separation Anxiety from their
parents would not feel anxious in
the same social situations if their
parents were present.

25. Panic Disorder
Individuals with Panic Disorder experience
redcurrant and unpredictable panic attacks. They
tend to shy away from certain social situations or
situations that could trigger an attack.
Panic Disorder Social Anxiety:
An individual with
Because this disorder
sometimes lacks specific Social Anxiety Disorder
triggers, a person may experience a panic
attack, but the attack is
experiencing Panic Disorder brought on by an extreme
may become socially phobia of the social
anxious with the situation at hand. It is an
anticipation of a panic extreme reaction or
attack. It is a panic attack symptom of Social
itself that makes the person Anxiety, not the reason for
feel socially anxious.
the Social Anxiety itself.

26. What are some causes of Social Anxiety?

27. The Nature Aspect of Social Anxiety
Ina Marteinsdottir and her colleges wondered what role genetics played
in Social Anxiety.[10] They found that there was a connection between
parents who have Social Anxiety Disorder and children who would
later develop the disorder. So a genetic link may be a possibility,
though most results of current studies are not significant enough to
say for sure. [10][9] This is because it is hard to tell is the child learned
this disorder from their parents or inherited it. Because studies show
the amygdala to be hyperactive within participants with Social
Anxiety disorder there is much speculation as to whether this is
because of a habitual way of processing information, or if this is due to
an inborn trait.
Another possibility Dr. Kristensen and Dr. Torstersen set out to test was:
What if individuals who suffer from Social anxiety disorder really
have a reason to be socially anxious? Such as a developmental deficit
or delay?[14] They found that Social Anxiety in children may indeed be
linked to subtle deficits in language and motor function. In fact, a long
term study that examined children with early language impairment
found that this was a large predictor for the development of anxiety
disorder later in their adolescence.[16]

28. The Nurture Aspect of Social Anxiety
Bifulia and her team of researchers decided to see how attachment
styles to childhood caregivers effected the development of Social Anxiety
in adults.[3] They found that certain attachment styles to caregivers was a
good predictor of weather an adult would have Social Anxiety. Most often
adults with Social Anxiety Disorder suffered from decreased social
networks, impaired relationships, and a skewed perception of themselves
by being devalued in previous or current social interactions. These adults
had exhibited a fearful attachment style, which means they had a
conflicting need for intimacy and independence. They wanted to be close
to their caregiver, but feared rejection so at the same time they pushed
their caregiver away. These Attachment styles usually develop in children
when they are traumatized by inconsistent and insensitive parenting
(extreme bi-polar parent), or in extreme cases of neglect or abuse.
Another aspect of nurture is that perhaps, to some extent, Social
Anxiety is self-perpetuating. [20][17][12][11] An individual feels socially
anxious and so they are acting under the influence of they anxiety.
Because of this they are impaired socially, which gives them more reason
to be anxious. The Cognitive Behavioral treatment method is built around
this idea.

29. What are some treatment methods?

30. Learning to Break the cycle: Cognitive Behavioral Therapy
High perceived social Click any box to explore the cycle of
standards & poorly
defined goals
Social Anxiety proposed by
Hofmann, citing Heimberg, Beck &
Clark. [11]
Social apprehension
Avoidance and safety
Post-event rumination
behaviors
Heightened self-focused Anticipation of social
attention
mishap
Negative self-perception
High estimated social cost
Low perceived emotional
control
Perceived poor social
skills

31. High perceived social standards & poorly defined goals

32. Social apprehension

33. Heightened self-focused attention

34. Negative self-perception

35. High estimated social cost

36. Low perceived emotional control

37. Perceived poor social skills

38. Anticipation of social mishap

39. Avoidance and safety behaviors

40. Post-event rumination

41. What is Cognitive Behavioral Group Therapy?

42. Medications

43. How prevalent is Social Anxiety?

44. Living with Social Anxiety

45. References:
[1] American Psychological Association: Siagnostic and Statistical Manual of Mental Disorders, Forth
Edition, Text Revition. Washingtion, DC, American Psychiatric Association, 2000.
[2] Ackerman,Sandra, Broll, Sharon, Lamberg, Lynne, MacDonald, Ann, Nadis, Steve, & Parson, Ann
(2006). The dana guide to brain health.New York: Dana Press.
[3] Bifulco,
Antonia, Kwon, Junghye, Jacobs, Catherine, Moran, Patricia, Bunn, Amanda, & Beer, Nils
(2006). Adult attachment style as mediator between childhood neglect/abuse and adult
depression and anxiety. 41, 796-805.
[4] Etkin,
Amit, & Wager, Tor (2007). Functional Neuroimaging of Anxiety: A Meta-Analysis of
Emotional Processing in PTSD, Social Anxiety Disorder, and Specific Phobia. American journal of
psychiatry. 164, 1476-1488.
[5] Evans,Karleyton, Wright, Christopher, Wedig, Michelle, Gold, Andrea, Pollack, Mark, & Rauch,
Scott (2008). A functional MRI study of amygdala responses to angry schematic faces in social
anxiety disorder. 25, 496-505.
[6] Fehm,Lydia, Beesdo, Katja, Jacobi, Frank, & Fiedler, Agnes (2008). Social anxiety disorder above
and below the diagnostic threshold: prevalence, comorbidity and impairment in the general
population. Social psychiatry & psychiatric epidemiology, 43, 257-265.
[7] Ferrari,
Maria, Busatto, Geraldo, McGuire, Philip, & Crippa, José Alexandre (2008). Structural
magnetic resonance imaging in anxiety disorders: an update of research findings. Revista
Brasileira de Psiquiatria, 30, 251-264.

46. References:
[8] Fontenelle,Leonardo, Domingues, Aline, Souza, Wanderson, Mendlowicz, Mauro, de Menezes,
Gabriela, & Figueira, Ivan (2007). History of Trauma and Dissociative Symptoms among
Patients with Obsessive-compulsive Disorder and Social Anxiety Disorder. Psychiatric
quarterly. 78, 241-250.
[9] Furmark, Tomas, Henningsson, Susanne, Appel, Lieuwe, Åhs, Fredrik, Linnman, Clas,
Pissiota, Anna, Faria, Vanda, Oreland, Lars, Bani, Massimo, Pich, Emilio Merlo, Eriksson,
Elias , & Fredrikson, Mats, et. al. (2009). Genotype over-diagnosis in amygdala
responsiveness: affective processing in social anxiety disorder. Journal of Psychiatry &
Neuroscience. 34, 30-40.
[10]Hayward, Chris, Wilson, Kimberly, Lagle, Kristy, Kraemer, Helena, Killen, Joel, & Taylor, C.
Barr (2008). The Developmental Psychopathology of social anxiety in adolescents.
Depression and anxiety. 25, 200-206.
[11]Hofmann, Stefan (2007).Cognitive factors that maintain social anxiety disorder: a
comprehensive model and its treatment implications . Cognitive behavioral therapy. 36,
193-209.
[12]Kocovski,Nancy, & Rector, Neil (2007). Post-Event Processing in Social Anxiety Disorder:
Idiosyncratic Priming in the Course of CBT . Cognitive therapy & research. 32, 23-36.
[13]Kolassa,Iris-Tatjana, Kolassa, Stephan, Musial, Frauke, & Miltner, Wolfgang (2007). Event-
related potentials to schematic faces in social phobia . Cognition and emotion, 21,
1721-1744.

47. References:
[14]Kristensen,Hanne, & Torgersen, Svenn (2008). Is social anxiety disorder in childhood associated
with developmental deficit/delay?. European child adolescent psychiatry. 17, 99-107.
[15]Kummer,Arthur, & Harsanyi, Estefania (2008). Flashbacks in social anxiety disorder:
Psychopathology of a case. Indian journal of psychiatry. 50, 200-201.
[16]Marteindottir, Ina, Svensson, Anna, Svedberg, Marcus, Anderberg, Ulla, & Knorring, Lars (2007).
The role of life events in social phobia. Nordic journal of psychiatry. 61, 207-212.
[17]Nortje,
Charl, Posthumus, Tanya, & Möller, André (2007). Comparison of integrated cognitive
restructuring plus exposure with exposure alone in group treatment of generalized social anxiety
disorder. Psychological society of South Africa. 38, 647-658.
[18]Rosenthal, Jessica, & Katzman, Martin (2007).Beyond shy: When to suspect social anxiety
disorder . The Journal of Family Practice, 5, 369-374.
[19]Setzer,
Nicole, & Salzhauer, Amanda (2001).Understanding why your kids refuse school;
prevalence and defining characteristics. Brown university child & adolescent behavior letter
[20]Voncken, Marisol, Alden, Lynn, Bögels, Susan, & Roelofs, Jeffrey (2008). Social rejection in social
anxiety disorder: The role of performance deficits, evoked negative emotions and dissimilarity .
The British Psychological Society, 47, 439-450.
[21]TheNational Institute on Drug Abuse, (2008, Jul 22). A Cognitive-Behavioral Approach: Treating
Cocaine Addiction. Retrieved Apr 24, 2009, from National Institute of Drug Abuse Web site: http://
www.nida.nih.gov/TXManuals/CBT/CBT4.html

48. Special Thanks to:
• Branch from letting me use your
incredible music to set the mood, thank
you Jim and Andy!
– http://www.jamesbailey.tv