Social Anxiety Details

DSM-5 (SOCIAL ANXIETY DISORDER)

(Although we are not making items on disorder)
Diagnostic Features
1. Criterion A: Social anxiety disorder involves intense fear or anxiety in social situations
where scrutiny by others is expected.
2. Criterion B: Individuals fear negative evaluations and anticipate being judged in many
ways, such as appearing anxious, weak, or unlikable.
3. Cultural Factors: Fear of offending others might be predominant in cultures with strong
collectivistic orientations.
4. Specific Fears: Different fears, like trembling, sweating, or blushing, lead to avoidance
behaviors in specific situations.
5. Paruresis: Some individuals fear urinating in public restrooms when others are present.
6. Criterion C: Fear or anxiety is almost always provoked in social situations, not
occasional.
7. Variability of Anxiety: The level and type of anxiety may vary across different
occasions and may include anticipatory anxiety.
8. Criterion D: Avoidance behaviors are evident, ranging from extensive to subtle.
9. Criterion E: Fear or anxiety is judged to be disproportionate to the actual risk or
consequences of negative evaluation.
10. Consideration of Socio-Cultural Context: The individual's cultural context is
considered in assessing the appropriateness of social behaviors.
11. Criterion F: Duration of disturbance is typically at least 6 months, distinguishing it from
transient social fears.
12. Criterion G: Social anxiety must significantly interfere with daily functioning or cause
distress or impairment in various life areas.
Associated Features Supporting Diagnosis
1. Communication Style: Individuals with social anxiety disorder may display inadequate
assertiveness, excessive submissiveness, or an inclination towards controlling
conversations.
2. Nonverbal Behavior: They might exhibit rigid body posture, insufficient eye contact, or
speak softly.
 3. Social Behavior: Those affected might appear shy, withdrawn, disclose little about
themselves, and be less open in conversations.
4. Occupational Choices: They may seek jobs with minimal social interaction, excluding
individuals with performance-only social anxiety disorder.
5. Living Arrangements: Some individuals may live at home longer or delay marriage and
family-building (more common in men).
6. Gender Differences: Women may opt for a homemaking role instead of pursuing work
outside the home.
7. Substance Use: Self-medication through substances, such as alcohol before social
events, is common.
8. Symptoms in Older Adults: Social anxiety among older adults might exacerbate
medical symptoms like increased tremors or rapid heart rate.
9. Physical Response: Blushing is a common physical response observed in social anxiety
disorder.
Prevalence
Prevalence in Pakistan stats
In Pakistan, the mean overall prevalence of anxiety and depression based on community
samples is 33.62%, with a point prevalence of 45.5 % in women and 21.7% in men (Khan
et al., 2007). (FROM PREVALENCE OF ANXIETY DISORDERS IN PAKSITAN)
Khan, H., Kalia, S., Itrat, A., Khan, A., Kamal, M., Khan, M. A., Khalid, R., Khalid, S., Javed,

S., Javed, S., Umer, A., & Naqvi, H. (2007b). Prevalence and demographics of anxiety

disorders: a snapshot from a community health centre in Pakistan. Annals of General

Psychiatry, 6(1). https://doi.org/10.1186/1744-859x-6-30

1. Prevalence in the United States: The estimated 12-month prevalence of social anxiety
disorder in the U.S. is around 7%.
2. Global Prevalence: Outside the U.S., prevalence rates using the same diagnostic tool
range from 0.5% to 2.0%, with a median of 2.3% in Europe.
3. Age and Prevalence: Rates of social anxiety disorder decrease with age, with
comparable rates in children, adolescents, and adults.
4. Prevalence in Older Adults: Prevalence rates among older adults range from 2% to 5%.
 5. Gender Differences: Generally, higher prevalence is observed in females in the general
population, with odds ratios between 1.5 and 2.2. This difference is more pronounced in
adolescents and young adults.
6. Clinical Samples: In clinical samples, gender rates are equal or slightly higher for males,
likely influenced by gender roles and social expectations impacting help-seeking
behavior.
7. Ethnicity and Prevalence: Higher prevalence is observed in American Indians, whereas
lower rates are seen in individuals of Asian, Latino, African American, and Afro-
Caribbean descent compared to non-Hispanic whites in the United States.
Risk and Prognostic factors
1. Temperamental Factors: Traits such as behavioral inhibition and fear of negative
evaluation predispose individuals to social anxiety disorder.
2. Environmental Factors: While increased rates of childhood maltreatment or early-onset
psychosocial adversity don’t directly cause social anxiety disorder, they are considered
risk factors for its development.
3. Genetic and Physiological Factors:
 Behavioral inhibition and traits related to social anxiety disorder have a strong genetic
influence.
 Gene-environment interaction is significant, where children with high behavioral
inhibition are more susceptible to environmental influences, like socially anxious
modeling by parents.
 Social anxiety disorder has a heritable component, particularly fear of negative
evaluation, while performance-only anxiety shows lesser heritability.
 First-degree relatives have a significantly higher likelihood (two to six times) of
having social anxiety disorder.
 The disorder's liability involves the interaction of specific genetic factors (e.g., fear of
negative evaluation) and nonspecific factors (e.g., neuroticism).
 THEORY
Cognitive-Behavioral Model of Social Anxiety Disorder (SAD). This model emphasizes the
interplay between cognitive, behavioral, and physiological factors contributing to social anxiety:
1. Cognitive Factors: Individuals with social anxiety tend to have negative beliefs and
expectations about themselves in social situations. These thoughts often involve fear of
negative evaluation, feeling incompetent, or anticipating embarrassment. These negative
thoughts can trigger physical responses like increased heart rate, sweating, or trembling.
2. Behavioral Factors: Avoidance behaviors in social situations are prevalent among those
with social anxiety. They might avoid gatherings, public speaking, or situations where
scrutiny by others is expected. Avoidance behaviors reinforce the belief that these
situations are threatening, perpetuating the cycle of anxiety.
3. Physiological Factors: Physiological arousal, including increased heart rate, sweating,
blushing, and trembling, is a core aspect of social anxiety. These bodily responses are
triggered by the perception of threat in social situations and often reinforce the
individual's negative beliefs about themselves in these settings.
SCALE
One widely used scale to measure social anxiety is the "Liebowitz Social Anxiety Scale"
(LSAS). The LSAS assesses the fear and avoidance experienced in various social situations.
LSAS consists of two subscales:
1. Fear subscale: It evaluates the fear or anxiety experienced in different social situations,
such as speaking in public, initiating conversations, or eating in front of others.
2. Avoidance subscale: It measures the degree to which an individual avoids these social
situations due to anxiety or fear.

0 - None 0 - Never
1. Using a telephone in public

0 - None 0 - Never
2. Participating in a small group activity

0 - None 0 - Never
3. Eating in public

0 - None 0 - Never
4. Drinking with others

0 - None 0 - Never
5. Talking to someone in authority
6. Acting, performing, or speaking in front of an
0 - None 0 - Never
audience

0 - None 0 - Never
7. Going to a party

0 - None 0 - Never
8. Working while being observed

0 - None 0 - Never
9. Writing while being observed

0 - None 0 - Never
10. Calling someone you don't know very well

11. Talking face to face with someone you don't

0 - None 0 - Never
know very well

0 - None 0 - Never
12. Meeting strangers

Situation Fear Avoidance

0 - None 0 - Never
13. Urinating in a public bathroom

14. Entering a room when others are already

0 - None 0 - Never
seated

0 - None 0 - Never
15. Being the center of attention

0 - None 0 - Never
16. Speaking up at a meeting

17. Taking a test of your ability, skill, or

0 - None 0 - Never
knowledge

18. Expressing disagreement or disapproval to

0 - None 0 - Never
someone you don't know very well

19. Looking someone who you don't know very

0 - None 0 - Never
well straight in the eyes

0 - None 0 - Never
20. Giving a prepared oral talk to a group
 21. Trying to make someone's acquaintance for the
0 - None 0 - Never
purpose of a romantic/sexual relationship

0 - None 0 - Never
22. Returning goods to a store for a refund

0 - None 0 - Never
23. Giving a party

24. Resisting a high-pressure salesperson

Social Anxiety Cognitive Scale (for College Students)

(SACS-CS) based on Hofmann’s model of social anxiety disorder.
(Yuxin Zha, Qin Tang, Xiaoru Jin, Xinfei Cai, Wen Gong, Yongcong Shao and Xiechuan Weng)
1. When socializing, I always assume that others will comment negatively on my image.
2. I always think that my image is annoying or uncomfortable for others.
3. I always think that others will not recognize my ability.
4. When socializing, I always believe that others will dislike my disposition.
5. I always believe that I am going to speak or behave improperly.
6. When socializing, I always think I will do something that cannot be explained afterward.
7. Whenever something bad happens in social situations, I think it will have unacceptable
consequences.
8. I always believe that, if I do or say something wrong, it will lead to serious consequences.
9. I always think that, once I fail in a social interaction, I will leave a bad impression to others.
10. If I receive an unfavorable evaluation, I think that everyone present will always remember
it.
11. When socializing, I do not think I can control my nervousness.
12. When socializing, I think it’s hard to relieve my tension no matter how I try.
13. When socializing, I always think I cannot control my physiological responses (such as
blushing, shaking).
14. When socializing, I think I may have uncontrollable behaviors due to nervousness or fear
(such as picking fingers).
15. When socializing, I think people can easily tell that I ‘m uncontrollably nervous by my
facial expressions.
16. I always think that I have no control over the direction of social interaction (such as topics,
atmosphere).
17. I always think I’m unable to communicate with others.
18. I think my social skills are very poor.
19. I think I often fall into awkward situations when communicating with others.
20. I do not think I can handle social situations alone.
21. I think there is no situation where I can adequately use my social skills.

Hoffman’s Model of Social Anxiety Disorder

Severity Measure for Social Anxiety Disorder (Social Phobia)—Adult

(Craske M, Wittchen U, Bogels S, Stein M, Andrews G, Lebeu R. Copyright © 2013 American Psychiatric
Association.)
Instructions: The following questions ask about thoughts, feelings, and behaviors that you may
have had about social situations. Usual social situations include, public speaking, speaking in
meetings, attending social events or parties, introducing yourself to others, having conversations,
giving, and receiving compliments, making requests of others, and eating and writing in public.
1. felt moments of sudden terror, fear, or fright in social situations.
2. felt anxious, worried, or nervous about social situations.
3. had thoughts of being rejected, humiliated, embarrassed, ridiculed, or offending others.
4. felt a racing heart, sweaty, trouble breathing, faint, or shaky in social situations.
5. felt tense muscles, felt on edge or restless, or had trouble relaxing in social situations.
6. avoided, or did not approach or enter, social situations.
7. left social situations early or participated only minimally (e.g., said little, avoided eye
contact).
8. spent a lot of time preparing what to say or how to act in social situations.
9. distracted myself to avoid thinking about social situations.
10. needed help to cope with social situations (e.g., alcohol or medications, superstitious
objects).
Measuring the Scale and Scope of Social Anxiety among Students in Pakistani Higher Education
Institutions: An Alternative Social Anxiety Scale
(Bisma Ejaz, Amina Muazzam, Ambreen Anjum, Gary Pollock and Raheel Nawaz)

1- I feel afraid while talking to strangers.

2- I feel afraid while travelling with strangers.
3- I feel reluctant to talk to a stranger on phone.
4- I feel reluctant to ask a stranger for help.
5- I feel reluctant while bargaining with the shopkeeper.
6- I feel afraid to talk to a person of the opposite gender.
7- I feel uneasy when someone stares at me.
8- I feel uneasy going to a party or function.
9- I feel uneasy talking to influential persons.
10- I feel reluctant to talk to people while making eye contact.
11- I feel hesitant to make new friends.
12- I feel upset when unexpected guests come over.
13- I feel uneasy sitting with people.
14- I am scared of being judged by people at religious gatherings (Quranic / Milad / Majlis).
15- I feel uneasy talking in a crowd.
16- I feel reluctant to express my feelings in the presence of people.
17- I feel reluctant to address a gathering of people.
18- I feel uneasy performing any task in front of people.
19- I feel afraid of giving a job interview
20- I feel uneasy being the center of attention.
21- I fear rejection from people.
22- I fear being disliked by people.