Canadian University of Dubai

Dr. Nazli Balkir

 December 9th, 2022

PSY 240 - Introduction to Learning

SOCIAL ANXIETY DISORDER

Loloa Essam Mahmoud Ahmed 20210001749

Yolanda Vedanayagam 20200001051

Amrita Unnikrishnan 20210001154

Anum Patel 20210001450

                                
Introduction

It is common to experience slight discomfort and fear in social situations such as meeting

new people and while presenting a speech in front of an audience. However, social anxiety

disorder is characterised with a strong and persistent fear of social situations which is

different from the typical fear that challenging social situations can provoke. The symptoms

associated with SAD interferes with an individual’s social and professional life and causes

them to fear and avoid all social situations. Epidemiological studies have recognized that

Social Anxiety disorder is a common disorder with a present prevalence of 5 to 10%, and

lifetime prevalence of 8.4 to 15% (Koyuncu et al., 2019). The onset of SAD disorder

symptoms starts during early adolescence, and it mostly persistent to adulthood unless the

individuals seek effective treatment. Help-seeking behaviour for SAD is usually occasional,

late, and often complemented with other psychiatric disorder (Koyuncu et al., 2019).

RQ 1: Definition and symptomatology of social anxiety disorder

Social anxiety disorder (SAD) is a highly prevalent and chronic disorder that is defined by

the intense fear of behaving or projecting anxiety symptoms that would be perceived

negatively by others, generating high distress, psychosocial issues and functioning

impairment (Svenaeus, 2013).  SAD is one of the most prevailing mental disorders, with a

lifelong prevalence of 12.1% as well as a 12-month prevalence of 7.1% (Ruscio et al., 2007).

There have been some notable modifications in the description of the disorder in the new

updated DSM-5 when compared to DSM-4 social phobia (Heimberg et al., 2014). First, the

list of feared outcomes has extended from humiliation and embarrassment to also include the

fear of rejection or offending others. Second, across all age groups, severe anxiety and

avoidance of situations of socialization and performance must last at least 6 months. Third,

the patient's evaluation of the fear as unreasonable or extreme has passed to the therapist.
Fourth, a "performance-only" specifier has replaced the declaration of a generic subtype.

Fifth, people with a medical illness may now be diagnosed if their social anxiety symptoms

are "obviously unrelated or extreme." (Heimberg et al., 2014).

Patients with social anxiety disorder typically expect the worst possible scenario during a

social situation, so they overthink every action before it actually happens, limiting their

ability to do certain activities. After a social situation, they overthink and analyze their

performance and identify flaws in the interactions they engaged in, this causes them to regret

their actions resulting in more avoidance of social interactions in the future. Another

emotional symptom is the fear of others noticing their anxiety and then negatively judging

based on that.

Individuals suffering from social anxiety disorder tend to be shy when meeting new people,

quiet in gatherings, and distant in unfamiliar social experiences. When they engage with

people, they may or may not display visible signs of discomfort or distress (e.g., blushing,

avoiding eye contact), but they usually face constant intense emotional, physical, or both

symptoms (eg, fear, heart racing, sweating, shaking, easily distracted). People with social

anxiety disorder may talk quietly or provide only brief responses to questions in medical

settings. Eye contact is usually avoided. However, patients of SAD will frequently divulge

their social anxiety issues only when directly questioned, rarely revealing their symptoms to

their caregiver without prompting. This resistance might be cause due to the patients feeling

ashamed or embarrassed about their symptoms, a feeling that the healthcare professional

would not take their condition seriously (Roy-Byrne & Stein, 2005).

RQ 2: Epidemiology of Social Anxiety Disorder

The current literature places the prevalence of social anxiety disorder (SAD) in categories,

primarily focusing on lower, middle, and high-income countries with SAD (Stein et al.,
2017). A report which analyzed over 28 community samples from various other countries,

not focusing on the west, found differences in prevalence rates in low, middle, and high-

income nations. High-income countries such as Australia and Belgium had the highest rates

of prevalence putting them at a 5.5%, 3.1%, and 1.7% rates. Upper-middle-income countries

such as Brazil and Bulgaria had a prevalence rate of around 2.9%, 2.1%, and 1.3% while

lower/lower-middle-income countries had a prevalence rate of around 1.6%, 1.0%, and 0.5%.

Looking at these statistics, it is possible to infer that higher-income countries had higher

prevalence rates of SAD however, the paper concludes its results stating that western pacific

regions and the Americas have the highest rates of SAD while Africa and Easter

Mediterranean countries have lower prevalence rates of SAD (Stein et al., 2017). In terms of

the prevalence rates in the UAE, taken from samples across the UAE, placed the rate between

12.5%-28.6% (Razzak et al., 2018)

The age of onset is said to be placed between mid to late adolescence up until the early 40’s

found in all countries. For high-income countries, the most common onset age was around

age eleven, over 50% attain this by the age of eleven and the latest by seventeen. In upper-

middle countries, some found onset to be around thirteen and the latest at around 26 for 50%

of the sample. In lower/lower-middle-income countries, the onset was around eleven years

old and the latest at sixteen years of age for 50% of the sample (Stein et al., 2017). In terms

of gendered differences, it is found that women face higher chances of acquiring SAD in

comparison to men (Stein et al., 2017; Schneier & Goldmark, 2015).

RQ3 – Aetiology of social anxiety disorder

Fear is activated when an individual perceives danger or threat. This process prepares the

body to respond to a threatening situation. However, abnormal fear processing can cause

anxiety disorders in which the individual experiences fear exceeding the actual possibility of
danger (Garcia, 2017). Grace is a 24-year-old female who quit her job because it became

difficult to perform well as a sales assistant. For example, she avoided taking phone calls in

the presence of others and avoided having lunch with her colleagues because she feared doing

something wrong and making a fool of herself. Grace is highly self-conscious and aware of

specific physical symptoms such as sweating and shaking while talking with her superiors

and colleagues at work. She is always worried that others will recognize these symptoms, and

she often tries to avoid situations that can trigger her anxiety symptoms. Grace has always

been shy and quiet, but her social anxiety worsened at university after she gave a wrong

answer to a question during class. Her professor commented that she was not adept at being

at university if she could not answer a simple question. Grace was very embarrassed, and she

hurriedly left the classroom. She recollects her classmates giggling when she left the

classroom. However, she is unsure whether her memory of being mocked is true. After this

incident, Grace started to bunk classes and avoided contact with her classmates due to

embarrassment.

Learning theory suggests that social anxiety is acquired through classical conditioning, and

anxiety symptoms are maintained due to operant fear conditioning. This reinforces the

avoidant behaviour shown by Grace. Fear conditioning is an associative learning process

wherein a neutral stimulus gains the ability to produce a fear response because it was

repeatedly paired with an aversive US. In the case of Grace, the (US) is an embarrassing

experience in university, and (CS) are people, places and things associated with the

unconditioned stimulus. An individual with social anxiety, such as Grace, has learnt that

saying something wrong in front of others is associated with ridicule and rejection, which in

turn causes her current symptoms of social anxiety and avoidance of similar situations

(Lissek et al., 2008).

Watson's simple acquisition procedure of anxiety disorder was insufficient to explain why

many anxiety patients cannot recollect or accurately determine a CS-US event association

that explains the anxiety symptoms they are currently going through. Adaptive processes like

Stimulus Generalization allow an individual to respond to novel stimuli related to a

previously learned stimulus. However, fear generalization can be maladaptive when non-

threatening stimuli are inappropriately treated as harmful based on similarity to a known

threat. Differential inhibition is a process wherein one stimulus (CS+) is paired with an

aversive outcome/result and another stimulus (CS-) without the aversive outcome

(Scheveneels et al., 2018). This procedure states that individuals with anxiety display high

fear response to safe stimuli (CS-) and cannot discriminate between danger and safety signals

(Dunsmoor et al., 2009). Perceptual stimulus generalization is a process in which the fear

response is elicited by a stimulus with perceptual commonalities with the original (CS+).

When Grace sits to attend the same professor's class, she experiences physical symptoms of

anxiety. She avoids attending his class and answering questions to prevent a similar negative

experience (Scheveneels et al., 2018). Fear responses can be generalized with stimuli that

significantly differ in perceptual features, such as categories and conceptual knowledge,

which are non-perceptual. After the incident, we observe that Grace not only avoided going

to the class of that specific professor but also bunked other classes and avoided social

situations, including attending activities and events she enjoyed before the incident. Although

the situations mentioned above differ from the original learning experience, they can fall

under a category of situations in which Grace fears putting herself at risk of saying something

wrong/stupid and being ridiculed and rejected by people around her. This generalization type

is called non-perceptual-based generalization (Dunsmoor & Murphy, 2015).

SAD can also be acquired through vicarious conditioning. Simply observing another person

experiencing trauma or behaving with fear can be sufficient to develop a phobia.

Observational learning of children from parents regarding social concerns and avoidance

contributes to social anxiety disorder development. Parents model social concerns, express

fears of negative evaluation and catastrophize potential adverse social outcomes. Such

modelling may build a perception of social threat and an assumption that others may judge

them negatively. Individuals such as Grace reported that her parents highlighted the

importance of others' opinions and emphasized the importance of appearance and academic

success. Studies indicate that families provide an environment in which children learn to

interpret and respond to situations as safe or threatening. Parents may modulate and reinforce

children's anxious cognition and behaviour (Mineka & Zinbarg, 2006).

Another important observation of the learning theory indicates that not all individuals who

went through a traumatic event will develop an anxiety disorder in the future. Only 10-30%

develop anxiety disorders, even though 95% of the population go through at least one

traumatic event in their lifetime. This indicates the presence of other important variables that

moderate the learning process. These variables include genetic predispositions and individual

differences in contextual factors before, during and after the conditioning experience

(Scheveneels et al., 2018). The hypothalamic-pituitary-adrenal axis is a hormonal system that

regulates the sympathetic and parasympathetic nervous systems. Studies suggest that one of

the significant causes of anxiety is the unregulated activity of the sympathetic nervous system

(prepares the body to encounter stressful situations) without necessary mediation with the

parasympathetic nervous system (provides the energy and resource of fight/flight). The

variations in the genes regulating these systems could indicate the likelihood of developing

anxiety disorders under stressful circumstances (Herman et al., 2016).

The contextual factors before, during, and after the conditioning process of an event can

mediate the resulting behaviour by either protecting the individual against developing an

anxiety disorder or by making the individual more at risk of exhibiting anxiety symptoms. If
an individual has non-traumatic experiences with CS before conditioning, this can reduce the

chances of developing CR. Previously exciting trauma can put the individual at higher risk of

developing an anxiety disorder after the conditioning has taken place. Studies indicate that

non-traumatic experience with an event or stimulus before an aversive social situation can

protect the individual from developing psychopathology. In the example of Grace, she has

already been through traumatic experiences in social situations, such as being bullied in

school. Her previous negative experience in a social situation could have made her more

susceptible to developing social anxiety disorder after the incident with her professor

(Scheveneels et al., 2018).

The contextual variables after conditioning are definitive of whether a specific learning

experience results in the development of anxiety. Learning theory describes Unconditioned

stimulus inflation as a process wherein a strong US is presented after being conditioned with

a mild US, thus causing an increase in the conditioned fear response. The inflation effect can

be brought out by verbally describing the US to the individual. However, verbal information

can threaten people by reminding them of the negative consequences of the US after

conditioning, increasing their fear response and avoidance. Similarly, Grace's parents were

over-stressed about their daughter's professional career. They responded to the incident by

saying that she would be unable to pursue a successful career if her professor thought she was

not competent for the course (Scheveneels et al., 2018).

In addition, constantly thinking or ruminating about the traumatic event can make an

individual more vulnerable to developing an anxiety disorder. Repeated rumination about the

conditioning experience can reactivate the CS-US contingency, strengthening and retaining

the fear memory. The rehearsal of the Conditioned stimuli, the Unconditioned stimulus, and

the contingency between them cause the fear memory and avoidant behavior to remain.
Rumination of the socially traumatic event mediates the outcome of the learning process

resulting in an increased risk of developing a SAD.

Considering the entire fear conditioning history is essential while attempting to explain why

some people do not develop social anxiety disorder despite going through the same/similar

traumatic experience (Scheveneels et al., 2018).

Therefore, the development of SAD is caused by Genetic factors and Aversive social

conditioning that threaten the basic human need for acceptance.

RQ4 – Treatment of Social anxiety disorder

Exposure therapy (based on learning theories) is considered one of the most effective

treatments for social anxiety (Hofmann, 2008). Research further suggests that the intensity of

the pairing of CS and US is due to the repetitive presentations of the two stimuli, where CS is

the neutral stimulus, and the unconditioned stimulus is the fear-eliciting stimulus. The now-

conditioned stimulus is sustained by the negative reinforcement people derive from their

measures to dodge or evade it (McGinn & Newman, 2013).

Essentially, exposure therapy is when an individual is repeatedly exposed to CS in the

absence of the US (the aversive consequence) in a clinical setting, this will cause a decrease

in the conditioned response and eventually lead to the extinction of the association of CS with

the US (Hofmann, 2008). This process of extinction is called extinction training. Exposure

therapy is obtained from early models of extinction. Extinction learning does not really focus

on unlearning the CS-US contingency. Instead, there is a new form of learning where when

the CS is presented. There is no longer a connection to the fear-eliciting stimuli being the US,

creating a new type of learning (Craske et al., 2014).

This new type of learning is derived from inhibitory learning models, where the CS no longer

expects the US, thus, forming a new secondary inhibitory learning. This fact means both

associations are present, and the original is not eliminated, which promotes that the original
excitatory association can return. Many factors determine if an individual will recover the

original association (Craske et al., 2014). According to research,  19–62% of clients

experience at least some retrieval of fear after exposure-based therapy (Scheveeneels et al.,

2018).

 First, the CR (Conditioned Response ) can increase depending on how long it has been since

the individual last sought exposure therapy. For instance, an individual who fears public

speaking and participates in exposure therapy is most likely to recover that fear without long-

term public speaking situations. Second, if the context in which the individual had sought

exposure therapy changes. For instance, if the individual only sought exposure therapy in the

presence of a therapist or other limited situations, the individual is most likely to go through

the original association, following the previous example, once alone. Third, reinstatement is

an adverse situation following exposure therapy. It may result in the reinstatement of fear of

previously feared stimuli if confronted in an anxiety-generating environment. For instance, an

individual has recently sought exposure therapy to overcome their fear of asking questions in

the classroom. This individual is most likely to retain that fear if they experience rejection in

a social situation, even though both (being able to ask questions and rejection of the social

situation) may be completely unrelated. Lastly, immediate retrieval of CR (Conditioned

Response) can be seen if CS-US pairings are repeated after extinction. The clinical

application is that a decreased fear can be easily and quickly retraumatized, as might happen

in combat or other dangerous situations (Craske et al., 2014).

Although exposure therapy can be implemented independently, research shows that

pharmacological drugs and exposure therapy can create an even more significant effect on the

individual. According to research, an experiment was conducted where 27 participants were

to receive five sessions of exposure therapy with d-cycloserine (DCS) or five sessions of

exposure therapy with placebo pills. Post-experiment results revealed that the anxiety levels
of those who had DCS before the experiment decreased greater than those who had placebo

pills before the experiment. Furthermore, the results were evident at the follow-up after one

month of the experiment (Hofmann, 2008).

When relating this, Grace, the individual in our case study, was negatively reinforcing her

fear by avoiding the aversive stimuli being the professor's class, other classes, and social

situations. In review with treatment, Exposure therapy would help Grace greatly by

weakening the connection of the CS with the US, the classroom being the  CS, and the

embarrassment that she faced in the US. Furthermore, repeated exposure to social situations

would promote secondary inhibitory learning that will help the original association of the CS

no longer signal the US.

Discussion

SAD is a chronic and debilitating illness that has a life-long prevalence of 12.1% (Svenaeus,

2013). Categorized by the anxiety of feeling judged by people, it causes several impairments

in daily function, for example, one would not be able to perform well at school settings,

work, or any social event in general. Socialization is a vital part of human nature; therefore,

one could interpret that the presence of this disorder would impair development quite greatly.

In terms of its epidemiology, SAD has a higher prevalence in higher-income countries while

having a less cumulation in lower-income countries. One could draw conclusions that these

results could be explained by the collectivistic nature of less westernized nations which

conveniently happen to be lower-income countries. Similarly, as higher-income countries are

more individualistic, it could be presumed that this leads to more isolation and less cohesive

social nets and ultimately the formation of SAD. Through the process of operant fear

conditioning, and reinforcing factors, it quite simplistically explains the process of acquiring

SAD or any anxiety disorder in general. One could acquire SAD from watching someone
experience a socially negative situation as well. In terms of its treatment, like the way it is

acquired, this can be unlearned. Exposure therapy and CBT are pioneers in treatment

processes and usually end up benefiting its user vastly.

Conclusion

Learning theory suggests that social anxiety is acquired through classical conditioning, and

anxiety symptoms are maintained due to operant fear conditioning. This reinforces the

avoidant behaviour shown by Grace. Fear conditioning is an associative learning process

wherein a neutral stimulus gains the ability to produce a fear response because it was

repeatedly paired with an aversive US. In the case of Grace, the (US) is an embarrassing

experience in university, and (CS) are people, places and things associated with the

unconditioned stimulus. Therefore, the development of SAD disorder is caused by Genetic

factors and Aversive social conditioning experiences that may be humiliating and repetitive

events of chronic social trauma that threaten the basic human need for acceptance, which

becomes experiences that confirm developing social fears and beliefs (Baumeister & Leary,

2012).When relating this, Grace, the individual in our case study, negatively reinforced her

fear by avoiding the aversive stimuli of the professor's class, other classes, and social

situations. In review with treatment, Exposure therapy would help Grace greatly by

weakening the connection of the CS with the US, the classroom being the  CS, and the

embarrassment that she faced in the US. Furthermore, repeated exposure to social situations

would promote secondary inhibitory learning that will help the original association of the CS

no longer signal the US

Implications

When confronted with challenging social situations, people with SAD tend to focus on their

anxiety, perceive themselves negatively as social objects, exaggerate the negative effects of

social interactions, think they have little control over their emotional reactions, and think

their social skills are insufficient to deal with the situation. People with SAD revert to

unhealthy coping mechanisms, such as avoidance and safety behaviors, in order to avoid

social mishaps. This is followed by post-event obsessing, which increases future social

anxiety. We outline potential disorder-specific effective treatments. SAD can be effectively

treated with both pharmacological and psychological therapy. Nonetheless, a significant

percentage of SAD patients do not respond to sufficient pharmacotherapy with CBT,

emphasizing the need for new treatments.  And even though exposure therapy can be used on

its own, research reveals that pairing it with prescription medications has a greater influence

on the individual.
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