Stefan G. Hofmann and Patricia M. DiBartolo

Delineation of Social Anxiety

Chapter 1 by McNeil reviews the evolution of the terms social anxiety, SAD, and related constructs. Constructs such as shyness, introversion, BI, social anxiety, and SAD all share very similar meanings and are often used interchangeably, which can complicate things enormously. Choosing the right terminology is not a trivial thing. It reflects, and possibly determines, our understanding and conceptualization of the issue under investigation. McNeil proposes a number of specific ways in which these terms may inter-relate. He concludes that different forms of “social anxieties” exist along a continuum, and that related constructs, such as shyness, span from “normal” and “high normal” to pathological levels of social anxiety.

A similar dimensional approach towards psychopathology is the implicit model of many psychological assessment procedures for social anxiety and social SAD. Consistent with this notion, Herbert and colleagues (Chapter 2) start from the basic premise that social anxiety and SAD do not differ qualitatively but rather quantitatively. Therefore, the various assessment methods (which should include a multimodal approach) can be used for assessing social anxiety as well as SAD. However, as we note below, other theorists believe that such a dimensional perspective toward SAD and shyness is problematic (e.g., see Chapter 12).

The aforementioned terminology problem becomes even more complex when we consider the construct of shyness, which is covered by Henderson and Zimbardo (Chapter 3). As their chapter shows, it seems almost impossible to discuss the psychopathology of shyness without referring to social anxiety or related constructs. Their chapter notes the overlap between shyness and SAD while recognizing that individuals who label themselves as shy often express heterogeneous behavioral and symptom profiles. A little clearer seems to be the distinction between social anxiety/SAD and embarrassment, which is discussed by Miller (Chapter 4). Unlike SAD, the experience of embarrassment is something ordinary, normal, and adaptive because it provides an effective way to overcome minor and inevitable mishaps that occur in interactions with other people. Miller points to one important commonality between social anxiety/SAD and embarrassment: both constructs include the fear of negative evaluation by others. Neither SAD nor embarrassment would exist if people did not care what others thought of them.

Does this mean that socially anxious individuals are overly perfectionistic when it comes to social interactions? This hypothesis is investigated in the chapter by Frost, Glossner, and Maxner (Chapter 5). They conclude that certain characteristics of perfectionism, and in particular the maladaptive evaluative concern dimensions, are in fact associated with social anxiety and related constructs. A review of the literature suggests that, compared to nonanxious controls, individuals with clinical levels of social anxiety are more perfectionistic. The central features of perfectionism related to SAD are an excessive concern over mistakes, doubts about the quality of one’s actions, and the perception that other people have excessively high expectations. Although similar differences in perfectionism dimensions can also be found when comparing nonclinical participants with other anxiety-disordered groups, certain of these dimensions are elevated in samples with SAD relative to other anxiety patients.

The next chapter, by Stravynski, Kyparissis, and Amado (Chapter 6), deals in detail with the relationship between social anxiety/SAD and social skills, and more specifically with the (once) popular assumption that SAD is caused by a deficit in social skills. Based on a critical review of the literature, Stravynski et al. conclude that there is very little empirical evidence to suggest that SAD is caused by, or even consistently linked with, deficits in social skills. They argue that the main problem lies in the conceptualization and operational definition of the construct of social skills. The authors encourage researchers to take a fresh look at the “social” aspect of SAD by investigating the pattern of social behaviors characterizing SAD in real-life situations.

Two of the remaining chapters of the first part of the volume deal with contemporary diagnostic controversies, namely with the relationship between SAD and other DSM (Diagnostic and statistical manual of mental disorders) Axis I disorders in adulthood (Chapter 7 by Wenzel), and Axis II disorders (Chapter 8 by Reich). Comorbidity, which refers to the co-occurrence of two or more mental disorders in one person, is an inevitable “side effect” of our existing categorical diagnostic classification system (the DSM). Based on the existing literature, Wenzel concludes that comorbidity is common, even typical, for individuals with SAD. Rates of comorbidity between SAD and other anxiety and mood disorder are high and there is growing evidence of heightened risk for substance use disorders as well. Wenzel also notes emerging evidence indicating increased risk of comorbidity for SAD and a variety of other conditions (e.g., eating disorders, bipolar disorder). She urges the field to begin to identify the pathogenesis of these comorbidities, rather than merely document their co-occurrence.

Among the Axis II disorders, the most highly comorbid (and most controversial) diagnostic category is avoidant personality disorder (APD). The empirical evidence, as reviewed by Reich, suggests that SAD and APD probably relate to the same disorder with different subtypes. SAD and APD cannot be distinguished on the basis of symptomatology or treatment response. Although individuals with both SAD and APD seem to report a greater degree of distress in social situations, they respond equally well to treatment to those without this additional Axis II diagnosis. Reich points out that this raises the question of whether APD is in fact a viable Axis II diagnosis because our diagnostic system defines a personality disorder as an enduring, inflexible, and pervasive problem. Reich offers a creative solution to this problem by creating a subcategory in Axis II for chronic Axis I disorders “with significant personality features.”

The final chapter of Part I, by Detweiler, Comer, and Albano (Chapter 9), examines the risks, phenomenology, etiology, and empirically supported treatments for socially anxious children and adolescents. Their review reveals the considerable social, occupational, and emotional tolls associated with SAD in developing youth. Furthermore, Detweiler et al. present the latest research on the biological, social, and developmental risks associated...