EVANGELICAL THEOLOGICAL SEMINARY

OSIJEK, CROATIA

ANALYSIS AND TREATMENT OF SOCIAL ANXIETY DISORDER

COURSE: Counsellor Assessment Skills

PROFESSOR: dr. Daniel Verrengia
STUDENT: Damir Pil
YEAR OF STUDY: 1st Mth
DATE: 29th November 2012

CONTENT

Introduction............................................................................................................................................ 3
IAnalysis of Social Anxiety Disorder....................................................................................................4
Background and Significance of Social Anxiety Disorder..4
a. Definition and Triggers of Social Anxiety Disorder...........................................4
b. Differentiating Social Anxiety Disorder.6
c. Signs and Symptoms of Social Anxiety Disorder...7
II Treatment of Social Anxiety Disorder.....................................9
Cognitive Behavioural Therapy.11
a. Challenge Negative Thoughts........12
b. Helping to Overcome Social Anxiety Disorder.................................................13

Conclusion..............................................................................................................................................15
Bibliography..........................................................................................................................................16

APPENDIX A
APPENDIX B
APPENDIX C

INTRODUCTION
Social Anxiety Disorder or SAD, (also known as social phobia1) is third largest mental
health care problem in the world, immediately after alcoholism and depression.2 Statistics shows
that about 3 to 5% of children and adolescents have social phobia, as do 12 to 13% of adults.3
Of all other disorders, I decided to present social anxiety disorder in this research because
this disorder is so common that everyone has experienced it at least once in lifetime. What
motivated me to research SAD is awareness that there are many good and talented people which
are chained with chains of falsehood of their own incapability. Great number of people lack in
progress in school, job, or lose contact with people they care about just because of their irrational
fear that something will go wrong during certain social situation.
There is a great challenge to recognize SAD among many similar disorders so purpose of
this research is to present significance of SAD and way on which counsellor is cooperating with
counselee who has SAD through treatment.
First chapter will present main features of social anxiety disorder and it will also show
boundaries between some other similar disorders. Second chapter will present some steps in
cognitive behavioural treatment of SAD, which will also demonstrate role of the counsellor
during the treatment. Finally, there is conclusion of research and some helping material in the
Appendix on the end of research.
1

The official view on social phobia is introduced in DSM III, but with the release of DSM IV this term is
replaced with social anxiety disorder. Although these terms are often used interchangeably today, in this research I
will use term social anxiety disorder or its abbreviated form SAD.
2
The Social Anxiety Network, Social Anxiety Disorder: The Third Largest Mental Health Care Problem in
the World, [Online] Available at <http://www.social-anxiety-network.com/third.html>[8 November 2012]
3
Deborah C. Beidel et al., Abnormal Psychology (Boston: Pearson Education, 2011; 2nd edn), 126.

I ANALYSIS OF SOCIAL ANXIETY DISORDER

Background and Significance of Social Anxiety Disorder

a. Definition and Triggers of Social Anxiety Disorder

Diagnostic and Statistical Manual of Mental Disorders defines Social Anxiety Disorder as:
A marked and persistent fear of one or more social or performance situations in which the
person is exposed to unfamiliar people or to possible scrutiny by others. The individual
fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating
or embarrassing.4
Crucial fear among people who have SAD is that they are going to be rejected by others.
Because of that fear and a fear that their performance will not be successful, this self focused
individual get anxious and he/she has none positive thoughts on possibility of positive outcome
in that given situation.5 We are not dealing here only with fear of certain social situations; it is
rather intense fear of unfamiliar situations in which you can be evaluated by others. It is
important to understand difference between fear and anxiety. Fear can help us avoid getting hurt
and it is realistic feeling, which is necessary if we find ourselves in dangerous situation, while
anxiety is unrealistic fear about something which actually doesnt present any threat.
Often individuals with SAD get anxious even when they are reminded on certain social
situation. Because of intensity of anxiety which person is feeling, he/she is capable to go in such
an extreme like neglecting school or job. Problems occur when people worry too much, feel
anxious very often, and are afraid at improper occasions. Examples of social situation which are
4

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (Washington
D.C.: American Psychiatric Association, 4th edn., 1994), 416.
5
Adrian Wells, Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide
(Chichester: John Wiley and Sons, 1997), 16.

often stressful for people with SAD are many. Holt, Heimberg, Hope, and Liebowitz suggested
classification of SAD triggers in four categories: 6
-

Formal speaking and interaction (participating in small groups, acting)

Informal speaking and interaction (giving a party, calling someone you dont know very well)
Assertive interaction (talking to authority figures, expressing disapproval of someone)
Observation of behaviour (eating while others are watching)

Furthermore, Vladan Starcevic introduced two main kinds of social situations more
briefly:7
-

Performance type situations (speaking in public and eating, drinking, writing, working, and using
public toilets in the presence of others (or while others are watching)).
Interactional situations informal and formal interactions with other people.

So we see that person with SAD has pessimistic fears and thoughts connected with
certain social situation to which is exposed. It is interesting that children and adolescents have
same fears as adults. It seems that for all age groups most often the biggest fear is giving oral
presentations.8 On the first sight someone can suppose that these situations can be stressful for
most people and this is why it is important to notice that we are not dealing on this place with
normal fear but with intensive anxiety which interferes in individuals life in such way that he/she
cannot function normally in home, school or work (or in any social occasion).
If social fear of person with SAD is limited just on public speaking or just few other
social situations then it is specific subtype of SAD, while generalized subtype is when person
experience distress across a broad range of social situations.9 Research has shown that patients
with generalized subtype, when compared to those with specific subtypes, are more often single,
the disorder can be seen earlier, the patients are characterized by a fear of interpersonal
6

Mark R. Leary and Robin M. Kowalski, Social Anxiety (New York: The Guilford Press, 1995), 5.
Vladan Starcevic, Anxiety Disorders in Adults: A Clinical Guide (New York: Oxford, 2010), 152.
8
Deborah C. Beidel et al., Abnormal Psychology, 127.
9
Deborah C. Beidel et al., Abnormal Psychology, 125.
7

interactions, they have a higher rate of alcohol-related disorders, typical depression, and is
accompanied by avoidant, obsessive compulsive, and dependent personality disorders. 10
Because of wide range of these comorbid disorders which often occurs together with
generalized subtype of SAD, it is more complicate to help these counselees with cognitive
behavioural therapy (CBT) so often in these cases there is need for combining CBT with
pharmacotherapy.11

b. Differentiating Social Anxiety Disorder

Research has shown that more than 50% of people with social phobia have additional
anxiety disorders, such as GAD, agoraphobia, panic disorder, specific phobia, or posttraumatic
stress as well as depression.12 We need to be careful not to put in the same box shy people,
people with agoraphobia, people with avoidant personality disorder and people with SAD. Main
difference between agoraphobia and SAD is in nature of the fear, i.e., agoraphobia is most
known as fear of public places13 with or without people in these places.
Just because someone is shy or get nervous on occasion doesnt mean that he/she has
social anxiety disorder. One of noticeable differences between SAD and shyness is that shy
persons feel anxious about performance and other social interactions before entering these
10

Pavo Filakovi et al., Social Phobia, Coll. Antropol. 27 Suppl. 1 (2003) 147157, 149.
In social anxiety disorder, there is evidence of acute treatment efficacy for SSRIs, venlafaxine, the
monoamine oxidase inhibitors (MAOI) phenelzine and moclobemide, the benzodiazepines bromazepam and
clonazepam, the anticonvulsants gabapentin and pregabalin and the antipsychotic olanzapine. Neither imipramine
nor buspirone is efficacious in acute treatment, but placebo-controlled studies demonstrate that clonazepam and
some SSRIs can prevent relapse. (Robert J. Blanchard et al., series editor J. P. Huston, Handbook of Anxiety and
Fear: Handbook of Behavioral Neuroscience, Vol 17[Amsterdam: Academic Press, 2008], 396.)
12
Deborah C. Beidel et al., 125.
13
Salih Selek, Different Views of Anxiety Disorders (Rijeka: InTech, 2011), 15. I also gave in Appendix B
a copy of table with essential differences between SAD and agoraphobia taken from Vladan Starcevic, Anxiety
Disorders in Adults: A Clinical Guide, 169.
11

situations, but once they have been engaged socially, their anxiety levels drop considerably 14
and then they feel relieved, while in case with SAD there is not such phenomena. Besides being
shy and behave in embarrassing ways, people with social phobia avoid social situations to the
level when they limit their activities or disrupt their life. In order to get a whole picture in
differentiating shyness from SAD it is important to understand intensity of avoiding social
situations and of experiencing symptoms. It needs to be understood that reasonable anxiety and
shyness are completely normal and omnipresent feelings, but when their intensity becomes too
high, then it obviously hinder social functioning.
At least a third of people who have SAD also meet the DSM-IV-TR criteria for diagnosis
of avoidant personality disorder.15 It is hard to differentiate generalized subtype of SAD and
avoidant personality disorder. But maybe what can be helpful in differentiating these two is in
fact that avoidant individuals have more extreme form of SAD. They are unwilling to get
involved with people unless certain of being liked, and also it seems that they are much more
preoccupied what others think of them than in SAD.16
To better understand this difference it is useful to see how Millon differentiate these two:
Avoidant personality disorder is essentially a problem of relating to persons; social phobia has been
formulated largely as a problem of performance situations. More specifically, persons with social phobia
may have a multitude of satisfying social/personal relationships with others; the individual with avoidant
personality disorder is socially withdrawn, has few close relationships, and desires close relationships but
does not trust others sufficiently to relate closely without assurances of acceptance. 17

c. Signs and Symptoms of Social Anxiety Disorder

Unlike other anxiety disorders, it is interesting that social fears in SAD are more
reasonable than fear from heights, or water etc. It is true that individuals with SAD overestimate
14

Vladan Starcevic, Anxiety Disorders in Adults: A Clinical Guide, 160.

Ann M. Kring et al., Abnormal Psychology, (John Wiley and Sons, 11th edn, 2010), 120.
16
Len Sperry, Handbook of Diagnosis and Treatment of DSM IV TR Personality Disorders (New York:
Brunner Routledge, 2003; 2nd edn), 62.
15

frequency and severity of experiencing problems, but compared to the other phobias their
worries are much more realistic. Symptoms of SAD are separated in three groups emotional
symptoms, physical symptoms, and behavioural symptoms.
Emotional Symptoms of SAD:18
-

Excessive self consciousness and anxiety in everyday social situations

Intense worry for days, weeks, or even months before un upcoming social situation
Extreme fear of being watched or judged by others
Fear that you'll act in ways that will embarrass or humiliate yourself
Fear that others will notice that you're nervous

Often anxious counselee reports that she is feeling nervous or tense. Feelings of
subjective anxiety or nervousness are accompanied by other negative emotions, such as anger,
hopelessness, or depression.19
Physical Symptoms of SAD:20
-

Red face (blushing)

Shortness of breath
Upset stomach, nausea
Trembling or shaking
Racing heart or tightness in chest
Sweating or hot flashes
Feeling dizzy or faint

Behavioural symptoms of SAD:21

-

Avoiding social situations to a degree that limits your activities or disrupts your life
Staying quiet or hiding in the background in order to escape notice and embarrassment
A need to always bring a buddy along with you wherever you go
Drinking before social situations in order to soothe your nerves

17

Ray W. Crozier and Lynn E. Alden, The Essential Handbook of Social Anxiety for Clinicians
(Chichester: John Wiley & Sons, 2005), 229.
18
Dianna Gordon, Social Anxiety Disorder, [online] Available at: <http://diannagordoncounselling.com/ican-help-with/social-anxiety-disorder-socoal-phobia/> [29 November 2012]
19
Mark R. Leary and Robin M. Kowalski, Social Anxiety (New York: The Guilford Press, 1995), 8.
20
Dianna Gordon, Social Anxiety Disorder, [online] Available at: <http://diannagordoncounselling.com/ican-help-with/social-anxiety-disorder-socoal-phobia/> [29 November 2012] see alsoThomas A Richards,
Overcoming Social Anxiety: Step by Step (The Social Anxiety Institute, 2000), 35.
21
Dianna Gordon, Social Anxiety Disorder, [online] Available at: <http://diannagordoncounselling.com/ican-help-with/social-anxiety-disorder-socoal-phobia/> [29 November 2012]

II TREATMENT OF SOCIAL ANXIETY DISORDER

Already the first step in treatment of social anxiety disorder is to make valid diagnose.
This is why we need to know DSM diagnostic criteria for SAD.22
Counsellor needs to ask counselee how she feels, i.e., ask her to describe signs and
symptoms (it may also be helpful if he/she describes dreams because it can show negative
thoughts and fears). Signs of SAD may be seen in the first interactions with the counselee.
Counselee with SAD may avoid eye contact, introduce themselves awkwardly or selfconsciously, and offer weak handshakes. 23 Counsellor must be aware that acknowledging
symptoms may be difficult or embarrassing for counselee so it is crucial for him to be empathic
and aware of all his gestures and words in order not to embarrass counselee and to help her feel
relaxed as much is possible. Relaxation techniques, such as abdominal breathing, visualization,
and cue controlled relaxation, can also be helpful in reducing the anxiety associated with social
phobia.24
Next step is to ask counselee how often these symptoms occur and in what situations.
This information can help counsellor to see intensity of SAD and to see is it general or specific
type. In order to give diagnose of SAD, avoidance and distress must disturb person's everyday
routines, occupational functioning or social relationships.
In order to consider a diagnosis of social phobia in adults, the social fears and anxiety
must be present at least six months.25 As social anxiety disorder usually occurs among first
22

In the Appendix C on the end of this research you can find DSM IV diagnostic criteria for SAD.
Borwin Bandelow and Dan J. Stein, Social Anxiety Disorder (New York: Marcel Dekker, 2004), 6.
24
If it is necessary there are some relaxation techniques, such as abdominal breathing, visualization, and
cue controlled relaxation, which can be helpful in reducing the anxiety, associated with social phobia. (Linda
Seligman and Lourie W. Reichenberg, Selecting Effective Treatments: A Comprehensive, Systematic Guide to
Treating Mental Disorders [San Francisco: John Wiley & Sons, 2007], 264.)
25
Nancy A. Heiser, Differentiating Social Phobia from Shyness (Dissertation submitted to the Faculty of
the Graduate School of the University of Maryland, College Park, in partial fulfilment of the requirements for the
degree of Doctor of Philosophy, 2004), 3.
23

degree biological relatives of those with the disorder, counsellor needs to have it also on his
mind when he approaches his client.26
There are several very useful assessment tools which can help us in diagnose and
measuring severity of social anxiety disorder. These are Liebowitz Social Anxiety scale, 27 the
Social Phobia and Anxiety Inventory, Behavioural Assessment Tests and the Fear
Questionnaire.28 Besides these tools there are also some self rated scales which are limited or
maybe complex to fill out and score. These are Social Phobia Scale, Social Interaction Anxiety
Scale, and Social Phobia and Anxiety Inventory.29
There is possibility that SAD has same symptoms as some other psychological or anxiety
disorder, or maybe it occurs along with depression or substance abuse problems. This is why is
important to know similar personality disorders and phobias in order to be diagnostic aware
and also be aware of the presence of comorbid disorders.
Once when we are sure that we are dealing with social anxiety disorder, we have two
current recommended treatment options pharmacotherapy and cognitive behavioural therapy30
(or for many the best option combined). Some pharmacotherapy drugs have already been
mentioned in this research, and it is most often used in general type of SAD, so further in this
research I am going to concentrate only on cognitive behavioural therapy.
26

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (Washington
D.C.: American Psychiatric Association, 4thedn., 1994), 414.
27
I gave a copy of this scale from Social Anxiety Support web site, and it can be found in an Appendix at
the end of this research paper.
28
Vladan Starcevic, Anxiety Disorders in Adults: A Clinical Guide, 168.
29
Borwin Bandelow and Dan J. Stein, Social Anxiety Disorder (New York: Marcel Dekker, 2004), 83.
30
Salih Selek, Different Views of Anxiety Disorders (Rijeka: InTech, 2011), 27.

10

Cognitive Behavioural Therapy

Many researches had shown that of all professional treatments which are available today,
cognitive behavioural therapy shows the best results in treating social anxiety disorder.
In cognitive behavioural therapy it is important to lead counselee through several
nonpharmacological treatments exposure, cognitive re structuring, relaxation techniques and
social skills training, and these are often combined.31 Group therapy can be also helpful but
counsellor must be aware that for counselee who has SAD it can be very intimidating.
As it is mentioned in beginning of this research, main fear of person with SAD is the fear
of negative evaluation by others. This fear is a consequence of certain assumptions and beliefs
which person with SAD has about herself, others, and social situations. Because of these
negative assumptions, person sees some inoffensive situations as threatening. So, there are only
few possible getaways from these situations such as avoiding them, acting on a different way to
feel safe, or maybe if they don't get away, they are enduring social situations with a lot of anxiety
and distress.
This is reason why it is necessary to recognize and treat SAD, and as it is mentioned
before, cognitive behavioural research is most successful solution.
Thomas A. Richards in his book Overcoming Social Anxiety gives comprehensive steps
in treatment of social anxiety disorder. Among first things which he has mentioned in his book,
and which are also important for client to know, is that there are automatic negative thoughts
(ANTs) which needs to be recognized and challenged.32
31
32

Salih Selek, Different Views of Anxiety Disorders, 27.

Thomas A Richards, Overcoming Social Anxiety: Step by Step (The Social Anxiety Institute, 2000), 7.

11

a. Challenge negative thoughts

Through interview with client, counsellor will most probably recognize negative thoughts
and beliefs that contribute to their anxiety. For example, by asking questions as Why are you
afraid of speaking up in a meeting, anxious counselee will probably answer that she is afraid
because she know that she is going to look like a fool, or that people will think that she is stupid.
There are many possible irrational reasons why person is feeling anxious in different social
situations. These fears can be result of emotionally negative events in our lives.
Counsellor needs to help counselee to recognize her fears, to name them, and to challenge
them. Counselee needs to ask herself Do I know for sure that they will laugh at me? or Do I
know for sure that I will not make a great progress? This is how counselees irrational fear
becomes challenged. By doing this symptoms of SAD are getting reduced and now there are
open doors for replacing irrational fears with realistic and positive ways of looking at social
situation which trigger counselees anxiety. When counselee start to think something as:33

If I worry too much about how I look to others, I may not get things done
Looking clumsy or inexperienced is not the same as looking stupid
I can live with the thought that I may look stupid to some, because I know I am not stupid,

then she is replacing dysfunctional appraisals and beliefs with realistic alternatives.
Furthermore, counselee needs to be aware that her negative beliefs, her negative
expectations put her in negative cycle and make her believe that something is wrong with her,
that something wrong is going to happen.34
33
34

Vladan Starcevic, Anxiety Disorders in Adults: A Clinical Guide, 195.

Thomas A Richards, Overcoming Social Anxiety: Step by Step, 26.

12

b. Helping to Overcome Social Anxiety Disorder

As it is mentioned before, most often the biggest fear among individuals with SAD is
giving public speeches. But it is not their only communication problem. When person has SAD,
she is experiencing unpleasant feelings also in any group communication or when teacher is
asking questions in the class and so on. That is why counsellor needs to extend communication
skills of this person. When doing so, counsellor need to use confidence building gestures like
eye contact, firm handshakes and not folding his arms when communicating.35
Counsellor needs to advice counselees to put themselves out there, i.e., in public places,
to confront her fears. It is important for counselee to exposure gradually. She needs primarily to
confront least anxiety provoking situations, and then to move up further.36 On this place
Behavioural Assessment Tests (BAT)37 can be very useful.
For example, if a patient fears confrontations with authority figures, the BAT could
involve asking the patient to role-play speaking with his or her boss, with the goal being to ask
for a raise in pay.38
Counselee needs to be advised to find a way how to be every day in some social
situations which they can handle. They need to be exposed to their fears in order to confront
them. This is the way for them to find out that their fears are irrational. In order to help counselee
to decrease a level of physical anxiety symptoms, counsellor should advice counselee to exercise
her mind and body. Reason for this is that exercise in general can make counselee feel better
35

Maria Oh, Building Social Confidence, [online] Available at:

<http://www.counseling.caltech.edu/InfoandResources/social_confidence> [27 November 2012]
36
Vladan Starcevic, Anxiety Disorders in Adults: A Clinical Guide, 192.
37
BATs are brief role-plays in which the patient encounters a mock-up of a fear-eliciting social situation.
Common BATs include giving a speech to a small audience and conversations with same- or opposite-gender
strangers.(Dan J. Stein, Clinical Manual of Anxiety Disorders [Wasshington: American Psychiatric Publishing,
2004], 70.)
38
Dan J. Stein, Clinical Manual of Anxiety Disorders, 70.

13

about her with raising her confidence. And also with organizing her thoughts, counselee might
succeed in getting out of some of her social problems.
Counsellor needs to help counselee to understand that if we are too quiet, others may feel
uncomfortable around us. 39 He needs to tell counselee that she mustn't allow her old beliefs and
feelings to control her future. She needs to know that no one who is adult, i.e., mature, will react
negatively to us as individuals, but they will react to the way we act or behave. So, if she realizes
that if she avoids too many things makes others to see her as unfriendly, weird or strange, it can
motivate her to act more social, to try to gradually expose herself.
Healing counselees with SAD takes some time but if there is empathic counsellor and
counselee who is willing to tear of these chains which are holding her back, during few months
she can be free. Counsellor needs to give hope to counselees, and give them self-confidence.
Once when counselee overcomes SAD there is possibility that she will feel on the similar
way later during some situations in her life, and counsellor needs to prepare it not to worry too
much about it because it is completely normal to feel anxious for a while, but if it last longer to
be free to come again.
Also, if it happens that counsellor isnt completely trained to help the client with SAD
(for example, if it is type of SAD which requires some medicines), counsellor need to tell this to
counselee and recommend some clinician or other professional person on this field.
39

Thomas A Richards, Overcoming Social Anxiety: Step by Step (The Social Anxiety Institute, 2000), 26.

14

CONCLUSION
Social anxiety disorder is very common and complex disorder. For this reason I gave in
the first part of this research some basic information how to recognize it in order to give valid
diagnose. Already in childhood there comes to problems which accumulate during time, and
depending on life circumstances symptoms mostly become worse. It is sad to know that people
several years live with SAD before they decide to search for help. They dont get help
immediately because they feel guilty and ashamed for some reason, or maybe they live in hope
that one day will be better. When these people come to counsellor he must be kind, sincere, and
full with empathy in order to help them. There are many assessment tools, great number of scales
which can determine real counselees condition and assign necessary steps toward recovery.
Counsellor needs to recognize if some other disorder is comorbid with SAD, and to determine
level of SAD to which counselee is exposed.
There are many ways to treat SAD, but in this research I decided to define treatment with
cognitive behavioural therapy because it seemed to me practical and most useful treatment for
SAD.

15

BIBLIOGRAPHY
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.
Washington D.C.: American Psychiatric Association, 4th edition, 1994.
Bandelow, Borwin and Dan J. Stein. Social Anxiety Disorder. New York: Marcel Dekker, 2004.
Beidel, Deborah C. et al. Abnormal Psychology. Boston: Pearson Education, 2nd edition,
2011.
Blanchard, Robert J.et al. Series editor J. P. Huston. Handbook of Anxiety and Fear: Handbook
of Behavioral Neuroscience. Vol 17. Amsterdam: Academic Press, 2008.
Crozier, Ray W. and Lynn E. Alden. The Essential Handbook of Social Anxiety for Clinicians.
Chichester: John Wiley & Sons, 2005.
Filakovi, Pavo et al. Social Phobia. Coll. Antropol. 27 Suppl. 1 (2003) 147157, 149.
Gordon, Dianna. Social Anxiety Disorder.[online] Available at:
<http://diannagordoncounselling.com/i-can-help-with/social-anxiety-disorder-socoalphobia/> [29 November 2012]
Heiser, Nancy A. Differentiating Social Phobia from Shyness. Dissertation submitted to the
Faculty of the Graduate School of the University of Maryland, College Park, in partial
fulfilment of the requirements for the degree of Doctor of Philosophy, 2004.
Kring, Ann M et al. Abnormal Psychology. John Wiley and Sons, 11th edition, 2010.
Leary Mark R. and Robin M. Kowalski. Social Anxiety. New York: The Guilford Press, 1995.
Oh, Maria. Building Social Confidence. [online] Available at:
<http://www.counseling.caltech.edu/InfoandResources/social_confidence> [27
November 2012]
Richards, Thomas A. Overcoming Social Anxiety: Step by Step. The Social Anxiety Institute,
2000.
Selek, Salih. Different Views of Anxiety Disorders. Rijeka: InTech, 2011.
Seligman, Linda and Lourie W. Reichenberg. Selecting Effective Treatments: A Comprehensive,
Systematic Guide to Treating Mental Disorders. San Francisco: John Wiley & Sons,
2007.
Sperry, Len. Handbook of Diagnosis and Treatment of DSM IV TR Personality Disorders.
New York: Brunner Routledge,; 2nd edition, 2003.
Starcevic, Vladan. Anxiety Disorders in Adults: A Clinical Guide. New York: Oxford, 2010.
16

Stein, Dan J. Clinical Manual of Anxiety Disorders. Wasshington: American Psychiatric

Publishing, 2004.
Social Anxiety Support. Managing Social Anxiety Workbook: A Cognitive Behavioral Therapy
Approach, Liebowitz Social Anxiety Scale Test. [online] Available at:
<http://www.socialanxietysupport.com/disorder/liebowitz/> [25 November 2012]
The Social Anxiety Network. Social Anxiety Disorder: The Third Largest Mental Health Care
Problem in the World. [Online] Available at <http://www.social-anxietynetwork.com/third.html> [8 November 2012]
Wells, Adrian. Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual
Guide. Chichester: John Wiley and Sons, 1997.

17

APPENDIX A
Liebowitz Social Anxiety Scale Test40
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

0 - None

0 - Never

6. Acting, performing, or speaking in front of an 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

0 - None

0 - Never

0 - None

0 - Never

0 - None

0 - Never

11. Talking face to face with someone you don't know very
well
12. Meeting strangers
Situation

Fear

Avoidance

13. Urinating in a public bathroom

0 - None

0 - Never

14. Entering a room when others are already seated

0 - None

0 - Never

15. Being the center of attention

0 - None

0 - Never

16. Speaking up at a meeting

0 - None

0 - Never

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

0 - None

0 - Never

0 - None

0 - Never

0 - None

0 - Never

0 - None

0 - Never

0 - None

0 - Never

22. Returning goods to a store for a refund

0 - None

0 - Never

23. Giving a party

0 - None

0 - Never

24. Resisting a high pressure sales person

0 - None

0 - Never

18. Expressing disagreement or disapproval to someone

you don't know very well
19. Looking someone who you don't know very well straight
in the eyes
20. Giving a prepared oral talk to a group
21. Trying to make someone's acquaintance for the
purpose of a romantic/sexual relationship

Result:

40

Social Anxiety Support, Managing Social Anxiety Workbook: A Cognitive Behavioral Therapy
Approach, Liebowitz Social Anxiety Scale Test [online] Available at:
<http://www.socialanxietysupport.com/disorder/liebowitz/> [25 November 2012]

18

Your score:

The scoring scale:

55-65 Moderate social phobia
65-80 Marked social phobia
80-95 Severe social phobia
Greater than 95 - Very severe social
phobia

APPENDIX B
Distinguishing Between Social Anxiety Disorder and Agoraphobia41
Characteristics
Main underlying concerns

Social Anxiety Disorder

Scrutiny and harsh judgment
by others

Agoraphobia
Having a panic attack in
specific situations

Fear of being alone

Generally rare

Generally frequent

Fear of large crowds

Generally rare

Very common

Anonymity seeking

Present

Usually absent

Type of symptoms in
phobic situations

Blushing, sweating
trembling, muscle spasms

Dizziness,
lightheadedness, choking
feelings

41

Vladan Starcevic, Anxiety Disorders in Adults: A Clinical Guide (New York: Oxford, 2010), 169.

19

APPENDIX C
Table 4 1. DSM-IV diagnostic criteria for social phobia (SAD)42
A.

A marked and persistent fear of one or more social or performance situations in which the person
is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or
she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing.
Note: In children, there must be evidence of the capacity for age-appropriate social relationships
with familiar people and the anxiety must occur in peer settings, not just in interactions with
adults.

B.

Exposure to the feared social situation almost invariably provokes anxiety, which may take the
form of a situational bound or situational predisposed panic attack.
Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from
social situations with unfamiliar people.

C.

The person recognizes that the fear is excessive or unreasonable.

Note: In children, this feature may be absent.

D.

The feared social or performance situations are avoided or else are endured with intense anxiety
or distress.

E.

The avoidance, anxious anticipation, or distress in the feared social or performance situation(s)
interferes significantly with the persons normal routine, occupational (academic) functioning, or
social activities or relationships, or there is marked distress about having the phobia.

F.

In individuals under age 18 years, the duration is at least 6 months.

G.

The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition and is not better accounted for by another
mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder,
body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder).

H.

If a general medical condition or another mental disorder is present, the fear in Criterion A is
unrelated to it, e.g., the fear is not of stuttering, trembling in Parkinsons disease, or exhibiting
abnormal eating behaviour in anorexia nervosa or bulimia nervosa.

Specify if:
Generalized: If the fears include most social situations (also consider the additional diagnosis of
avoidant personality disorder).
42

American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (Washington
D.C.: American Psychiatric Association, 4thedn., 1994), 416 417.

20