The Management of Social Anxiety: More Than 25 Years Later,Where are we?

Abstract

Behavioral and cognitive therapies are today the most effective toolbox and the most evidenced-based therapy for social anxiety. The purpose of this article is to provide an overview of some of the most popular methods for treating social anxiety. A selective review of literature published between 1997 and 2022 on social anxiety management. We have found that the majority of behavioral and cognitive treatment protocols are based on the following pillars: exposure to avoided situations, cognitive restructuring, assertiveness, and social skills training, as well as decentration techniques such as getting out of self-observation and cognitive fusion. Several psychotherapists agree on some components of social anxiety management while others do not. Within these agreements and disagreements, the path to the sketch of a new model should open. We argue that some techniques may ultimately be useless, counterproductive, and time-consuming. Alter the existing models and improve them in a different way in light of the multiple information and clinical examples is much needed. We suggest reconfiguring the theoretical and clinical elements to derive a new therapeutic combination of old techniques. In this new theoretical model of social anxiety, we scrupulously suggest including the cognitive and emotional elements and opt for primacy to be given to behavioral inhibition and the role of the biological part such as amygdala.

Introduction

The management of social phobia, now called “social anxiety” has evolved well in a few decades. This pathology has come a long way!

Almost missing from publications at the turn of the 20th century, it was not considered until the work of Marks in 1970, and did not appear in the DSM-III until 1980. Since the early 1990s, authors such as Heimberg and Hope have developed a comprehensive behavioural and cognitive protocol for therapists. They laid the initial cornerstones (Hope et al., 2006). American Psychiatric Association (2013) defined the social anxiety as “A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others). The social situations almost always provoke fear or anxiety. The social situations are avoided or endured with intense fear or anxiety. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning” (American Psychiatric Association 2013).

In spite of the fact that there are methods that are supported by scientific research, social anxiety is frequently debilitating and difficult to treat. More than 25 years later, where are we? Are there important elements to highlight, complicated ways to simplify? Does the third wave, known as “emotional therapies” (ACT, Acceptance and Commitment Therapy), have a place to take in the management of social anxiety (Cousineau & Thanh-Lan, 2013)? Can we make a more ergonomic protocol for therapists and patients? Easier to implement in our hospital or liberal practices? Maybe faster?

To answer the previous questions, we have conducted a literature review to investigate, summarize, and evaluate the data on the management of social anxiety.

Methods

Study Design

This article is a selected literature evaluation of works published between 1997 and 2022 on the management of social anxiety. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria were followed.

Search Strategy

A complete search of the databases PubMed/MEDLINE, Cochrane Library, Cumulative, and PsycINFO was done. We utilized a search strategy based on the combination of the following terms: (social anxiety) and (management of social anxiety). The search was last updated on December 2021.

Selection Criteria

The included research explored social anxiety management. Therefore, only studies examining the treatment of social anxiety were considered. Non-relevant articles, such as conference proceedings, editorials, and letters, were eliminated from this review. There were no language or research design constraints in place.

Results

On the basis of a review of the literature published since 1997 and of over 15 years of clinical experience, we give a new viewpoint and perspective on the social anxiety condition. Clair's research on OCD patients (Clair et al., 2013) offers a comprehensive explanation of the mechanics behind anxiety and additional strategies. The studies documenting social anxiety are already rather old, but the underlying disease has not necessarily been discovered. In addition, Hippocrates articulated Social Anxiety using his own terminology and concepts:

“Because of his shyness, his suspicious and timid character, he will not be able to be stared at, he will like to live in the shade and will not be able to endure the light or sit in broad daylight; his hat still hiding his eyes, he could not be seen despite his good intentions. He will not dare to go in company for fear of being abused, ridiculed, overwhelmed by his actions or his words, of appearing ill, he thinks that everyone is watching him” (Francis, 1891; Britannica Concise Encyclopedia, 2006).

This description already includes almost everything we can spontaneously say about a patient with social anxiety. If some classical authors will here and there evoke social anxiety mainly under the term “shyness”, it was not until Casper in 1846 (reported by Pitres & Regis in 1878) for a first scientific description of “Ereutophobia”.

In 1903, Janet spoke of a “phobia of social situations” and insisted that the various phobias known at the time were well differentiated from one another (Janet, 1903). Schilder (1938) described extremely shy patients as having “social neurosis.” (Fahlén, 1995).

In 1960s Marks identified and separated agoraphobia, simple phobias, and social phobias (Marks, 1969; Marks & Gelder, 1966), and the DSM-III in 1980 recognized social phobia as an entity in its own right (APA, 1980). In 1985, Liebowitz and his colleagues published an article titled “Social phobia. Literature review of a neglected anxiety disorder “in which they stress the importance of studying this pathology more widely and of implementing new therapeutic methods (Liebowitz et al., 1985).

Explanatory Models of Social Anxiety

There have been different explanatory models of social anxiety for several decades, but the most widely shared hypothesis remains that of a model based on the interweaving of different biological, psychological and social variables (Rosa-Alcázar et al., 2022).

The behavioral inhibition of Kagan et al. in 1980s is based on longitudinal studies showing that children who are inhibited (withdrawal attitude) at a young age in the face of social (unfamiliar people) and non-social (unusual situations) stimuli appear to be more physiologically responsive and much more at risk. of social anxiety onset in adolescence than other children (Kagan, 1989; Kagan et al., 1989). This hypothesis has been validated many times, in particular by the work of Eisenberg and Fabes (1992), Bruch & Heimberg (1994), Hayward et al. (1998), and Biederman et al. (2001). Schwartz et al. (1999) shows that the inhibited child at 2 years old doubles the risk of having generalized anxiety disorder at 13 years old. This relationship appears to be specific to social anxiety since behavioral inhibition in children does not increase the risk of a specific phobia, separation anxiety, or performance anxiety. This hypothesis is taken up in France with the idea of "a more or less significant emotivity which is triggered in reaction to all kinds of new events” (Légeron, 1995, p. 196).

Rettew (2000) believes that behavioral inhibition and social anxiety should be viewed as the same developmental continuum. Also, the study by Kendler et al. (1992) carried out in twins supposes the existence of a hereditary component of social anxiety (with the presence of social anxiety of 24.4% in monozygotic twins, and of 15.3% in dizygotic twins).

Another possible cause for the social anxiety is the comparisons that are made by the significant people. So, person with social anxiety may feel it is too negative and abusive and hurtful to compare them with others (Gabbard, 2014).

Social learning experiences in childhood and adolescence are an important component of recent pathophysiological hypotheses for social anxiety (Clark & Wells, 1995; Rapee & Heimberg, 1997; Spence & Rapee, 2016). In social anxiety, childhood abuse is connected to a higher symptom severity. If people have repeatedly received emotionally abusive messages from significant others, they may develop Social Anxiety. If someone else criticizes a part of their experience, they are invalidated (Curran, 2016). They will stop paying attention to how they think or feel if someone continuously tells them that they shouldn't feel a certain way or that their way of thinking is worthless. Persons probably feel ashamed of themselves. It is not necessary for emotionally abusive messages to contain words. Nonverbal signals are, in fact, some of the most destructive. Abuse and neglect are two instances of emotionally abusive signals that plainly imply that person thoughts and feelings are unimportant (Simon et al., 2009).

The message in the emotional abuse is: “Nothing about the person counts.” It makes no difference what they think. Their feelings are unimportant. It makes no difference what they look like. They don't matter in terms of mental, emotional, physical, spiritual, or sexual well-being (Bernstein et al., 1994; Bruce et al., 2012). Individuals with social anxiety reported more childhood emotional abuse and emotional neglect as compared to controls. Childhood emotional abuse and neglect were linked to the degree of social anxiety, trait anxiety, depression, and self-esteem in the social anxiety group (Kuo et al., 2011). If people are continuously told that they don't matter, that they’re worthless, that they shouldn't have been created, they may develop symptoms similar to those of someone who has been raped. They may experience nightmares, flashbacks, or triggers as a result of the invalidation (Linehan, 2015).

They eventually come to believe their negative or misleading beliefs more than their positive ones. And the results are devastating once they’ve learnt to ignore their good messages. They have lost the ability to detect or control their thoughts and feelings. So, they’re basically at the control of whatever they’re thinking or feeling at the time (Reutter, 2019).

Persons learn to stop listening to their logical and positive thoughts when they had experienced chronic invalidation. They lose their security of emotion by either feeling shame and socially not good enough then isolating ourselves from others or being aggressive, stubborn, blaming and hurting others (Shahar et al., 2015; Nanda et al., 2016).

Management of the Social Anxiety

Behavioral and cognitive therapies are today the most effective toolbox and the most evidenced based therapy for social anxiety and validated by studies (Chrysanthou & Köllner, 2022; Gould et al., 1997; Fedoroff & Taylor, 2001).

In France, the study by Camart et al. (2006) shows the effectiveness of CBTs in 60 patients conducted in group therapy settings. Most behavioral and cognitive therapy protocols are built on the following pillars: exposure to avoided situations, cognitive restructuring, assertiveness, and social skills training, decentration including getting out of self-observation and out of cognitive fusion (Creswell et al., 2021).

Let us discuss these different elements, their functioning, their supposed role and what the studies say about them (adapted from André Féline, in Lempérière et al., 2006, p. 172 to 188). In vivo exposure: patients with social anxiety are led to avoid certain situations because of anxiety, and these avoidances reinforce the anxiety. The point is to expose Anxious patients to what they dread on a prolonged and repeated basis so that the anxious conditioning goes away. The concern is that certain situations are difficult to plan (rare or brief in everyday life), and that the exhibition does not work if there are subtle avoidances (speaking, but without touching on thorny subjects, speaking, but not drink for fear of shaking) or that it is too short (too short exposure would have an anxiety-inducing effect). Several psychotherapists agree on some components of social anxiety management. Yet, within this agreement on the components, we find disagreements on how to apply them. Is it within these agreements and disagreements that the path to the sketch of a new model opens?

One of the most relevant illustrations of these debates concerning the management of social anxiety comes from one of its greatest promoters: Christophe André. Along with Légeron, Macqueron and Roy, he was one of the first to import the Heimberg model, translate it and democratize it. Social anxious people and French therapists owe him a lot (André & Légeron, 2000; Macqueron et al., 2004).

When it comes to treating social phobia, patient exposure is crucial (Becker-Haimes et al., 2022). Even behaviorists therapists themselves do not practice it in a large enough, regular, and repeated manner, perhaps because it takes more time and is more difficult to manage in this disorder than in others. It's also known that exposure can affect the disease's cognitive components, including self-deprecating ruminations (Do Bú et al., 2022). However, patients are required also, to expose themselves in a specific cognitive environment, based on their acceptance of their thoughts, emptions, needs and values (National Collaborating Centre for Mental Health, 2013).

Yet, we argue that some techniques may ultimately be useless, counterproductive and time consuming (Jessup & Olatunji, 2022). Alter the existing models and improve them in a different way in light of the multiple information and clinical examples is much needed. Hence, we are going to explain how to reconfigure the theoretical and clinical elements and how to derive a new therapeutic combination of old techniques.

In this novel theoretical model of social anxiety, we carefully advise incorporating cognitive and affective components while giving importance to behavioral inhibition and the involvement of the amygdala (biological part). These biological variables would cause hyperreactivity and sensitivity to the feeling of shame. It is because of the refusal to feel this shame, increased or maintained by environmental variables (the family, among significant others) that the patient would enter into a perspective of control. Any controlling behavior (emotional avoidance) would lead to the production of anxiety. Anxiety would lead to observation of behaviors, feelings, self and interlocutors, censorship of thought, unrealistic expectations of fluidity and relevance, and thus inhibition of communication skills.

These different variables: production of anxiety, observation of behaviors, sensations, self and interlocutors, censorship of thought, unrealistic expectations of fluidity and relevance, inhibition of communication skills would then be secondary to the refusal to feel shame. The work on social skills (knowing how to communicate fluently) requires that preliminary work on shame vaccination has been done, with the various ramifications and Russian dolls that segmentation could attempt to do.

Indeed, every time a patient fails a session on learning to communicate, he remains allergic to shame in certain situations. He may also have digested the shame well but remains anxious at the persistent gaze. Indeed, the insistent gaze is not only related to shame: there is also something which is of the order of intrusion into the intimate. It is proposed to work the segmentation up and down and across, or to do a full session of confrontation with the gaze before tackling the techniques of fluid communication.

The confrontation with the gaze also remains an exercise of choice for patients finding the two-hour session in the street too difficult and wishing an intermediate exercise. Therapists should never be afraid to offer it since, once the habituation is in place, patients have an entirely different perception of the session. The most reluctant patients are generally happy with their progress between the start and the end of the session on the gaze and most often agree with the two hours in the street, as if their whole relationship to shame, the intrusion and anxiety had been altered by this simple, easy-to-implement exercise.

Conclusion

Emotional abuse and neglect have both been linked to a higher level of social anxiety symptom severity. Exposure, behavioral, and cognitive treatments are now the most effective toolboxes available, as well as the most evidenced-based and research-validated forms of treatment for social anxiety. Yet, we argue that certain strategies may be ultimately ineffective, harmful, and time-consuming. In view of the abundance of information and clinical cases, it is crucial to revise and enhance the existing models in a novel approach. It is critical to change existing models and improve them in new ways in light of new information and clinical experiences. However, we suggest a strategy of social anxiety management that may out to be effective in the long run. In this innovative approach to the study of social anxiety, we suggest paying careful consideration to the incorporation of cognitive and emotional components, while also placing an emphasis on the role that behavioral inhibition plays and the participation of the biological component. Additionally, treatment for social anxiety should aim to increase a person's ability to communicate effectively and compassionately with self and others.