The terms ``social anxiety'' and ``social phobia'' are used inter-changeably and, in the DSM IV classi®cation system, the term ``social phobia'' (300.23) is followed by the term ``social anxiety disorder'' in parentheses. In this classi®cation, the essential feature of the disorder is an intense and persistent fear of social or performance situations.
Entry into one of these situations ``almost invariably provokes an immediate anxiety response'' (DSM IV, p. 411) but a formal diagnosis is appropriate only if the anxiety interferes signi®cantly with the person's life or causes extreme distress.
Social anxiety can manifest in a variety of forms. It can appear as a reluctance or inability to speak in public, stage fright, an inability to write or eat in public, excessive blushing, sweating or trembling in public. As is implied in the DSM de®nition, social phobia, or for that matter social anxiety, is described as social because the anxiety is experienced in social situations or in anticipation of entering such situations. It is also implicit in the de®nition of social phobia that the
affected people are fearful of possible scrutiny and also anxious that they might behave in a manner that is embarrassing, inept, unaccept-able, or all of these. It is a source of distress, concern, and shame.
Some people report that they fear and avoid a range of different social situations but for others the fear is circumscribed and is evoked in a speci®c context (Rapee, 1995). The most commonly feared speci®c situations include, in descending order, fear of public speak-ing, attendance at parties, meetings, and speaking to ®gures in authority. In recognition of the difference between multiple and circumscribed fears, it is now common to distinguish between generalized social anxiety and speci®c social anxiety. Thus far, few important causal or treatment implications of this distinction have been teased out but there are indications that generalized social anxiety is associated with wider psychological problems and that the circumscribed social phobias are more often preceded by speci®c traumatic experiences (Sternberger, Turner, Beidel, & Calhoun, 1995).
Socially phobic people tend to engage in considerable avoidance behaviour but some social interactions are unavoidable and hence a cause of anticipatory anxiety as well as situational anxiety. Because of the variety of manifestations of social anxiety, and the possibility of confusing it with other overlapping disorders (see below), it is dif®cult to reach reliable estimates of the prevalence of social phobia, with ®gures ranging from as low as 1% of the population to as high as 22% (see Barlow, 1988, 2002; Edelmann, 1992). For speci®c mani-festations of social anxiety, such as a fear of public speaking, the prevalence can go as high as 70% (Pollard & Henderson, 1988).
Mannuzza, Schneier, Chapman, Liebowitz, Klein, and Fyer (1995) estimated that social phobia might affect more than 10% of the population and that more than 20% of the population experience signi®cant irrational fears of social situations, although these do not meet all of the criteria for social phobia. Social phobias tend to emerge in late adolescence and early adulthood: 15±25 years of age (Schneier
& Johnson, 1992). Survey data collected by Weiller, Bisserbe, Boyer, Lepine, and Lecrubier (1996) suggest that social phobia is common, under-recognized and costly, and that affected people could be at risk for later depression and/or alcoholism; one-quarter of social phobics had alcohol-related problems.
The connection can be illustrated by a lawyer who sought treatment for his social anxiety, which was making court appearances a torment.
He attempted to control his anxiety by drinking increasing amounts of alcohol before appearances, as a form of ``self-medication''. On some occasions he needed so much alcohol that his speech was slurred.
It is widely believed that alcohol reduces anxiety, and there is persuasive evidence that this can happen. However, there are excep-tions, when drinking alcohol is followed by an increase in anxiety, and several moderating factors have to be taken into account when assessing the relation between alcohol and anxiety. These include the social setting in which the drinking takes place, the person's previous history of drinking, the interpretation the drinker places on bodily and psychological changes that occur during drinking, and so forth. It is also possible that the same episode of drinking can have anxiety-reducing effects and, later, anxiety-elevating effects. This sequence is not uncommonly reported by patients with anxiety disorders who describe an initial period of reduced anxiety during the drinking episode itself, only to be followed the following day by uncomfor-table jittery feelings that resemble anxiety.
This pattern of early relief and later jitters is illustrated by a patient who had social anxiety and agoraphobia. In the early stages of a course of behavioural treatment he made slow, steady progress in overcoming his social anxiety and in regaining the ability to walk about freely. However, he continued to have troublesome weekends, when he frequently experienced a return of anxiety and an inability to venture through those parts of the city that he was able to manage on most days. It turned out that he celebrated the end of the working week, in tried and tested tradition, by drinking on Friday night, only to wake up on Saturday morning feeling agitated and fearful. He subsequently decided to curtail his drinking and this was followed by a decline in his weekend anxiety.
The distinction between the social phobics and the so-called avoidant personality disorder was teased out by Heimberg (1996).
When there is a viable distinction, it is that social phobics recognize that their anxiety constitutes a problem and ideally would like to overcome it. The person with an avoidant disorder expresses no wish to have a more active social life and adopts an isolated life by choice.
Perhaps even more than people with other types of anxiety disorders, those who suffer from persistent social anxiety frequently complain of the unpleasant intrusiveness of the bodily manifestations accom-panying these problems, especially blushing, twitching, palpitations, and sweating.
Social phobics tend to rate their social skills as de®cient. There is, however, some debate as to whether some or most people who suffer from intense social anxiety do indeed lack the appropriate social skills, whether they have the skills but have dif®culty in deploying them, or whether they deploy the skills appropriately but feel that
they have not done so. The present consensus appears to be that a signi®cant minority of people with intense social anxiety do indeed have de®cits in social skills but the extent of these de®cits and the exact role that they play in social anxiety remains to be determined.
Undoubtedly, the phobic person's appraisal of their social skills and conduct are of critical importance.
The general ®nding that people with anxiety disorders tend to have multiple problems (Barlow, 2002) is evident in social phobia (Rapee, 1995). According to Rapee's estimate, approximately 50% of those people with intense social anxiety also suffer from related disorders, two of the most common being depression and substance abuse. Among social phobics one commonly encounters agoraphobia, generalized anxiety disorder, and obsessional-compulsive problems.
Or, to put it the other way around, people who suffer from anxiety disorders such as obsessional problems, agoraphobia, etc. have a high chance of suffering from concomitant social anxiety. Similarly, a high proportion of people who have signi®cant depression also experience excessive social anxiety.
Because of the dif®culties involved in carrying out experimental analyses of social behaviour, most researchers have resorted to administering self-report questionnaires. These instruments provide useful information but inevitably assume that the respondents have greater self-knowledge than is justi®ed [see Nisbett & Ross (1980) for a description of how people tend to tell more than they can know].
Assessment of the personal beliefs that are given such an important place in the cognitive theory of social phobia rests on similar assumptions about self-knowledge, and also tends to assume that there is greater generality of these beliefs than is the case. Many of these beliefs are idiosyncratic and dif®cult to capture on standardized questionnaires.