Social Anxiety Disorder
Social Anxiety Disorder (SAD) is the most prevalent of all anxiety disorders. A 2011 study of 10, 000 American adolescents revealed that anxiety disorders were the most common disorder in youth, occurring in approximately one third of adolescents.
SAD is a marked and persistent fear in social situations characterized by pervasive social inhibition, timidity, lack of confidence and fear. It has an early age of onset, by age 11 years in about 50% and by age 20 years in about 80% of individuals, and it is a risk factor for subsequent depressive illness and substance abuse (Stein & Stein, 2008). SAD is associated with significant impairment in all areas of life (Ruscio, et. al, 2008).
Excessive anger has been found to be present (co-morbid) with social anxiety (Barrett, et al. 2013) and arises from a number of emotionally painful life experiences with peers, siblings or parents. The result is a loss of confidence, anxiety, sadness and anger.
Due to the strong relationship between anxiety and anger it is important to evaluate the degree of anger present in anxious children. We explain to parents and to youth that anger is present after life hurts and can, in a manner of speaking, encapsulate anxiety and interfere with its resolution. Please complete the anger checklist on your child and identify the number of active and passive aggressive angry behaviors.
Triggers for Social Anxiety
In children the anxiety must occur in peer settings and not just during interaction with adults (DSM-5, p.202). In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations. Intense fears often emerge in children when they are observed by others, such as in reading in front of a classroom. The average age of onset in early to middle adolescence but social phobia has been documented in children as young as eight.
The most common distressing events were an unstructured peer encounters (e.g., having to talk to another child), taking tests, performing in front of others and reading aloud. These fears can contribute to social avoidance. In socially distressful situations, children with social phobia report a number of physical symptoms including heart palpitations, shakiness, sweating, nausea and flushes or chills. (Beidel, et al., 2004). Among adolescents with social phobia, 41.2% were reported to have a somatoform disorder, 29.4% had a depressive disorder and 23.5% had a substance abuse disorder (Essau, 1999). Teenagers with SAD can come to rely upon alcohol to diminish their social anxiety.
Major life transitions also can trigger social anxiety such as the move to middle school, high school or college; a family relocation or parental separation or divorce.
Factors in the Development of Social Anxiety
Higher levels of social support, acceptance, and validation are associated in studies of adolescents to be associated with lower levels social anxiety. The strongest predictors of social anxiety symptoms were friendship quality (i.e., perceived social acceptance vs. rejection) and parental anxiety or control (Festa & Ginsburg, 2011). Peer rejection in the middle school years is a common source of SAD in our work with youth.
In addition, parenting practices that are characterized as disengaged, less warm and withdrawn have been linked to anxiety in children (McLeod, et al., 2007).
It has been estimated that the odds of children of anxious parents developing social phobia are 4.7 times greater than the odds for children of non affected parents (Lieb, et al., 2000).
In our clinical work the loss of self-esteem and trust in youth as the result of traumatic experiences with peers, siblings or parents result in the development of both significant anxiety and anger. Other causes are common causes of low self-esteem are poor body image, difficulty in males to bond with other males in athletic activities or physical disabilities.
In a 2014 study of social anxiety disorder in adults cognitive behavioral and psychoanalytic therapy were equally effective. Although behavioral and CBT therapies of childhood anxiety disorders are effective (Silverman, Pina & Viswesvaran, 2008), as many as half of anxious youth do not benefit from these interventions (Alfano, et al., 2009).
In our clinical experience, the recovery from SAD is improved by resolving the anger that is associated with the anxiety in those youth who have experienced significant rejection in relationships with peers, siblings or parents. Often, therapists often fail to uncover and treat the comorbid anger in these anxious youth which limits recovery.
As a result of emotional trauma, thinking disorders develop that need to be addressed in order to build confidence and trust and to reduce anxiety.
These distortions include:
- I will not be accepted by my peer group.
- I am inadequate socially.
- My peers will not accept me.
- I have to be perfect in all that I do.
- The peer rejection in my past will continue.
- My peers will reject me as did a sibling, parent or youth when I was younger.
- I have nothing to offer in relationships.
- I am unattractive as a person.
- I will not be able to find a friend whom I can trust.
These distortions result in withdrawn behavior and difficulty in self-giving in friendships. An important response to these distortions is that of gratitude for one's special gifts and a rejection of the belief that one is inadequate or has to be perfect. When cognitive distortions are effectively uncovered and addressed, confidence and trust regularly increase. However, fears, insecurities and cognitive distortions are deeply rooted and their resolution takes significant effort, time and patience.
These cognitive distortions need to be corrected by thinking of one's good qualities and of those people who have given acceptance, warmth and love, especially before engaging in peer relationships. Behaviorally, a greater commitment needs to be made to take risks and to try to trust more in relationships. Youth need to think that the past does not control the present and that new successes can occur in relationships.
Parents need to coach their children with SAD to try to become more vulnerable to peer friendships and to try to socialize more with them. It is important that parents not accommodate desire of youth with SAD to withdraw from friendships and to isolate. It is particularly important that parents insist on the pursuit of close friendships primarily with those of the same sex because of weaknesses in this area of personality development.
An effective parental intervention in Christian adolescents, who have experienced significant peer rejection when younger, is to encourage participation in a parish youth group. This behavior has often led to the development of new, accepting and healthy friendships. These friendships build confidence, increase trust and diminish anxiety.
The role of loneliness as an important mechanism of change during treatment for social anxiety has been identified. As loneliness diminishes, social anxiety symptoms decrease (Alfa no, et al., 2009).
Other parental interventions, when appropriate, can be to work to decrease parental anxiety and marital conflicts and to let go of any controlling tendency.
Some youth with SAD also give into anger attacks, which has been described as being somewhat similar to panic attacks, with the sudden emergence of excessive anger. Others engage in various types of angry behaviors which they try to mask. It is important to attempt to uncover any possible anger associated with the hurts that give rise to SAD.
Also, the identification of the origins of the fears in youth with SAD and the uncovering and resolution of the anger associated with them through forgiveness therapy can enhance the use of CBT. The failure to resolve the anger associated with traumatic experiences that cause insecurities and fears interferes with the recovery from anxiety, as it does with recovery from depression also.
Youth are encouraged to think of forgiving on one of three ways:
cognitively - thinking of forgiving others in order to resolve decrease the influence of the hurts of the past
emotionally - when one truly feels like forgiving as a result of deep understanding of an offender
spiritually - reflecting God forgive those who have hurt me or help me to forgive
In Catholic youth, the sacrament of reconciliation can be helpful in mastering and resolving anger
Case: Social Anxiety in a Boy
Chad was nine years old and had been shy as a child. His SAD symptoms of fears of socializing with peers and growing timidity become more apparent in the third grade. He then tried to avoid going to school and when his mother rejected his request to stay home from school, he would fly into a rage. He would tell her that he would not talk to her when he returned from school. In the evenings he became increasingly fearful and anxious. The history revealed that there had been no traumatic experiences with his peers at school that could explain such intense fears.
The family history revealed conflicts in each parent that contribute to his SAD symptoms. His mother, Renata, was a warm, loving mother, but she had struggled with chronic anxiety from her youth as a result of her parents’ divorce when she was ten. When anxious, she would often overreact in irritability. Also, his father, Bill, who was a hard working man, expressed his love for Chad through his financial support for the family but not through the affection or praise that Chad desired. Both his mother and Chad described Bill as being emotionally distant and not particularly warm or affirming of his son or of her. In the family sessions Bill recognized that he had modeled after an emotionally distant father and failed to recognize the importance of communicating affection and affirmation to his son in order to build his confidence. Chad’s mother’s anxiety was also influenced a degree of loneliness and stress in her martial relationship.
After several therapy sessions, Chad was able to recognize that he was angry with his mother for being so anxious and with his father for contributing to his insecurity and anxiety by being so emotionally distant and difficult to please. He stated, “I want my mother to be less upset about everything and my father to be more loving and closer to me. Also, I want them to get along better.”
In family sessions, Chad’s parents apologized to him for their behaviors and insisted that they were motivated to work on their own conflicts. His mother began a course of CBT for her anxiety and started on an SSRI also. His father uncovered anger with his father for being so distant and worked in forgiveness therapy to try to break the negative paternal legacy. These issues were also addressed in marital therapy. His father told Chad, “I am sorry that I was not a warmer, more positive father, but I am committed to change and to help you to feel better about yourself and less anxious.”
When it was explained to Chad that the resolution of his own anger would help his fears diminish, he decided to work on thinking of forgiving his parents for the hurts and disappointments of the past. His work on forgiving was aided by the fact that his parents regularly requested forgiveness from him for all the stress they had caused him.
As Chad worked at forgiving his parents, he became aware that he had much more anger than he realized with each of them. The therapist made the recommendation that he should not feel guilty because the anger was justified and if he worked regularly at forgiving, he would experience his anger diminishing in time. Over the course of several months, each of his parents became more sensitive to him and he experienced less anxiety and more confidence with his peers. He began to isolate himself less and to enjoy more his peer relationships.
At the same time, the marital therapy with Chad’s parents strengthened their marital friendships and decreased the stress in the home. Consequently, the improvement in the marital relationship helped to diminish Chad’s social anxiety in a significant way.
The Role of Faith
Many youth have serious problems with social anxiety because of a lack of confidence that leads to a tendency to isolation. In some youth their social anxiety is directly the result of a poor body image in a highly narcissistic culture that is obsessed with the body.
These conflicts can decrease by growth in gratitude for one’s God-given body and attractiveness, as well as by attempting to reject the rigid culture norms of masculinity and femininity that focus on a superficial and incorrect view of the human person.
Research studies demonstrate the beneficial role of faith in the treatment of anxiety disorders. Some youth with faith benefit from meditating upon asking the Lord to help them to feel safer, more trusting and more confident in relationships with their peers, particularly those of the same sex. Also, working on a friendship with the Lord has been reported by parents and youth to be beneficial.
Medication that decreases anxiety can be effective as a chemical crutch to assist youth with SAD while they work on growing in confidence and in giving themselves more in relationship with same sex peers. SSRIs are helpful in decreasing not only anxiety, but also the sadness and excessive anger also present in these youth. These drugs are used primarily to treat anxiety in these youth and we have never seen them increase symptoms of depression. In fact, as anxiety diminishes, so to do symptoms of depression also decrease.
Medication is particularly important to use if extreme social isolation or anger attacks are present.
There are reasons to be hopeful that social anxiety can decrease by uncovering its origins and by growth in trust and confidence. A major goal of treatment is that of helping the child establish same sex friendships in which they feel accepted.. CBT with forgiveness therapy can be an effective treatment protocol in helping these youth and their families.