Cognitive Behaviour Therapy for Social Anxiety

Social Anxiety (SA) is considered one of the most common anxiety disorders that impacts all aspects of one’s life. Despite its prevalence, SA is often overlooked or undiagnosed and many only seeking treatments after 15-20 years of symptoms. SA is defined as a fear of social or performance situations where one is exposed to unfamiliar people or scrutiny by others.

The individual fears that they will act in an embarrassing and humiliating manner. Exposure to feared situations can cause anxiety and significant distress and the threat is recognised as out of proportion.

SA can be specific to situations but can also be generalized. Situations such as meetings, group activities or presentations around authority figures can be triggering for individuals with SA and be accompanied by various physical symptoms such as sweating, trembling or blushing.

The individual becomes preoccupied with the thought that others will see their anxiety and judge or ridicule them for being weak, stupid or incompetent. They fear they will say or do something embarrassing or humiliating so they often avoid any situation where possible or endure them with distress.
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CBT is the treatment of choice for SA. It is suggested that beliefs or cognitions play a crucial role in the development and maintenance of SA. Individuals with SA are usually known to hold rules that can be summarised in three categories:

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Excessively high standards for social performance
Conditional beliefs about the consequences of their performance which are usually catastrophic
Negative beliefs about the self

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Based on these beliefs, the individual is led to fear a negative evaluation from others, which is perceived as a social danger, and results in their attention shifting inwards. Individuals use self-focus to draw conclusions about how others perceive them, increasing their anxiety levels and exacerbating symptoms.

That is why exposure alone to social situations does not reduce anxiety by habituation.
Individuals with SA employ various safety behaviours to minimize any chance for negative evaluations from others and reduce anxiety. Individuals might avoid eye contact, cover their face or wear too much foundation to prevent others from seeing them blush.

The individual fears that others will notice them blush and perceive them as incompetent. Safety behaviours might be effective in reducing anxiety short-term which lead the individual to believe that the social danger was avoided because of them. Safety behaviours, however, prevent the individual from disconfirming their beliefs, resulting in the maintenance of the anxiety. Sometimes safety behaviours might even have the opposite desired effect.

For example, someone trying to conceal the fact they are shaking might hold on tightly onto something which can lead to more shaking. Individuals with SA are also reported to engage in post event processing and negative self-criticism
SA emphasizes self-focused attention, negative self-processing, and safety behaviours.

Treatment focuses on helping clients develop strategies which will provide opportunities for disconfirming negative beliefs by direct observation of the social situation and behavioural experiments (BE), rather than using self-focus and one’s emotions to evaluate their performance or how they are perceived.