Question 1

Does SAD tend to make those with it less empathetic towards others?

Ellen Hendriksen · Accepted Answer

Not necessarily. Several studies have found equal or even increased facets of empathy in individuals with social anxiety.

For example, one study found individuals with social anxiety differed from controls only in positive affective empathy (meaning that they were less able to vicariously feel others' positive emotions, but otherwise did not differ). https://pubmed.ncbi.nlm.nih.gov/27816799/

Another found elevated abilities in regards to cognitive empathy.
https://pubmed.ncbi.nlm.nih.gov/22120444/

Yet another found that social anxiety was associated with increased empathy, but only under conditions of social threat (as opposed to social inclusion). 
https://open.library.ubc.ca/cIRcle/collections/ubctheses/24/items/1.0354466

That said, sometimes individuals with social anxiety can appear less empathetic or seem unfeeling in social situations (e.g., not comforting someone in pain or being hesitant to offer help) but this is usually driven by perfectionism, not a lack of empathy. The individual with social anxiety isn't sure of the "right way" to help or comfort, doesn't want to do it wrong, or thinks their assistance will be judged or rejected, and therefore may not help at all.

Question 2

Is it possible to grow out of social anxiety as we get older and care less what people think?

Ellen Hendriksen · Accepted Answer

Yes indeed. In fact, many people find themselves becoming less anxious as they age. This is largely because social anxiety is maintained by avoidance. As we age, we can't avoid everything we fear in life. Over the years, we are inevitably faced with new and different situations, many of which allow us to learn, grow, and gain confidence. We can hasten this process by deliberately facing our fears, whether formally through exposure therapy or informally through self-help.

By contrast, if we continually avoid situations that make us anxious, we never get the chance to learn we are capable of handling the situation or that our feared outcome isn't likely to occur. Indeed, if avoidance is maintained over years and decades, social anxiety can actually grow in scope and severity as we age.

Question 3

How can I not care what other people think of me?

Ellen Hendriksen · Accepted Answer

There are a couple of ways to answer your question. On the one hand, let's validate and normalize that it's impossible not to care at all what people think of us. We humans are social animals. Evolution has wired us to be aware of others' opinions in order to help us find and maintain relationships, belonging, and community. To act in an entirely self-centered way would lead to isolation.

That said, I imagine you are asking, "How can I feel less anxious about what other people think of me?" There are many ways to challenge perceived and anticipated judgment and rejection. A cognitive-behavioral therapist can customize treatment to your life and situation. That said, I'll list a sample of techniques here.

First, find some gray between the black and white--rather than caring or not caring what "people" think, specify which people. It's not worth dwelling on what an angry stranger yells at you from their car, but it is worth considering a loved one's gentle constructive feedback.

Next, people are likely judging you less than you think. As humans, we have a tendency to believe that others are focused on the same things we're focused on. This is called the spotlight effect (see attached classic paper from Dr. Thomas Gilovitch and colleagues). Therefore, when we focus on a gaffe we made or a perceived flaw in our social performance, we assume others are focused on it, too. It's not true that no one ever judges us, but it's to a much smaller degree than we anticipate.

Finally, when we feel anxious, we often turn our attention inward and focus on our self-critical running commentary, which frequently highlights perceived judgment ("She is probably bored stiff by our conversation.") Instead, turn your attention outward and focus on what is actually happening. Listening and engaging, rather than focusing inward, lessens the perception of judgment and makes the conversation more enjoyable for everyone.

Again, this merely scratches the surface. To go deeper, consider working with a cognitive-behavioral therapist.

Question 4

Is being shy or an introvert the same as having social anxiety?

Ellen Hendriksen · Accepted Answer

Shyness and social anxiety are essentially the same thing--"shy" is the colloquial way of saying socially anxious.

Introversion and social anxiety, on the other hand, are very different, for several reasons.

First, introversion is a personality trait. According to the APA, introversion is an "orientation toward the internal private world of one’s self and one’s inner thoughts and feelings, rather than toward the outer world of people and things. Introversion is a broad personality trait and, like extraversion, exists on a continuum of attitudes and behaviors. Introverts are relatively more withdrawn, retiring, reserved, quiet, and deliberate; they may tend to mute or guard expression of positive affect, adopt more skeptical views or positions, and prefer to work independently."

Culturally, introversion is defined as a lower threshold for social overstimulation. While both introverts and extroverts feel energized by social stimulation--lower levels for introverts and higher levels for extroverts--and both need to recharge at some point, extroverts have a higher threshold for social stimulation. Being alone for too long leaves an extrovert sluggish and bored while solitude may feel energizing to an introvert.

Second, the heart of social anxiety is fear. While introversion/extroversion are about energy and stimulation, social anxiety is about fear--it’s the worry that a perceived "fatal flaw" will be revealed and judgement and rejection will follow.

As such, there are many socially anxious extroverts out there. Think of someone who really wants to join his colleagues at the bar after work, but worries they don't want him there. Or, imagine an aspiring stand-up comic who is pulled to the microphone and the stage, but worries the entire audience will hate her.

For more detailed answer, see my article on the difference between introversion and anxiety from Quiet Revolution, a community by and for introverts. 
https://www.quietrev.com/the-4-differences-between-introversion-and-social-anxiety/

Question 5

What is social anxiety?

Ellen Hendriksen · Accepted Answer

Social anxiety is the perception that there is something wrong with us, and that unless we work hard to conceal that "fatal flaw," it will become obvious to others, and then we'll be judged or rejected for it.

While this perceived fatal flaw feels very real, in reality, it’s either not true or only true to a degree that is much smaller than we imagine.

This idea was originated by Dr. David Moscovitch at the University of Waterloo. Attached is his 2009 paper, What Is the Core Fear in Social Phobia? A New Model to Facilitate Individualized Case Conceptualization and Treatment.

Question 6

I have social anxiety for more than 15 years, however the use of a beta blocker (propranolol, 10mg) prior to situations like presentations, does help me a lot for more than 10 years now. Question: do you really disapprove use of beta blockers (i can imagine), but on other hand it does help me a lot.

Ellen Hendriksen · Accepted Answer

It depends. On the one hand, do what works. If beta blockers allow you to give presentations and they don't otherwise interfere with your life, there's nothing wrong with doing what you need to do.

On the other hand, if this is something you'd like to work on, there is indeed room to do that. I imagine that when your presentations go well, the beta blocker gets the credit. You may consider slowly letting go of the beta blocker in order to learn that you, not the beta blocker, are responsible for your successful presentations.

You can do this gradually, in situations of slowly increasing difficulty. For example, after consulting with your prescribing physician, perhaps you try lowering your dose to 5 mg and give a low-stakes presentation, like leading a small team meeting or introducing a guest speaker. Then up the ante of your presentation while keeping the dose at 5 mg--perhaps lead a large team meeting or give a talk with prepared slides. Then up the ante again, keeping the dose at 5 mg and giving a longer talk, speaking before a larger audience, or speaking without notes. Then repeat the whole process without the beta blocker at all.

This is just an example--a cognitive behavioral therapist can collaborate with you on a hierarchy that fits your life and goals. They can also help you identify safety behaviors you might be using and help you let go of them, and help you practice experiencing physical sensations of anxiety via interoceptive exposures so the sensations are less distressing when they occur before a presentation.

Ultimately, the choice to take or not take medication is yours. It's common and understandable to use beta blockers once in a while to deal with anxiety-provoking situations like public speaking, air travel, or high-stakes testing. At the same time, it can be empowering and freeing to go through the process of letting go of medication.

Question 7

What can I do when my mind goes completely blank due to social anxiety during public speaking?

Ellen Hendriksen · Accepted Answer

In the moment, you can do a couple of things. First, take your time. Take a deep breath. Take a sip of water. What seems like a zillion years is really only a few seconds. Often audiences don't even notice you've gone blank--they think you're pausing for effect or collecting your thoughts.

Second, counterintuitively, is to connect with your audience. Rather than turning your attention inward and frantically searching your brain for what you had planned to say, turn your attention outward, look at, and connect with the audience. They are just people.  Deliver your talk to them as you would to a friend. This shifts the dynamic from a performance to a conversation, which lowers the pressure and frees you up to remember what you intended to say.

However, it is easier to prevent your mind from going blank in the first place by trying three things. First is to let go of word-for-word memorized presentations. Rather than memorizing your entire talk, memorize the opening and closing lines and organize the rest into talking points you can tick through in your head as you give the presentation. Stop short of expecting yourself to remember full paragraphs. It's too much and sets you up for failure. Allow yourself wiggle room by having bullet points you want to cover, but otherwise allowing yourself to speak naturally.

Second, practice your talk out loud! I have discovered that many of my socially anxious clients will rehearse a talk in their head or will look over their presentation notes exhaustively, but they'll never open their mouth to practice. Instead, practice presenting out loud, to no one, to a trusted friend or partner, or to your phone camera. Go through your talk enough times that you know the material, but stop short of over-rehearsing or over-preparing just to reduce your anxiety.

Finally, if public speaking is a major part of your life (e.g., your new promotion requires you to lead trainings or you often speak at meetings or conferences), it's helpful to practice regularly. Public speaking groups like Toastmasters or public speaking meetups are perfect for practicing both prepared and spontaneous remarks. Best of all, you'll be with a group of like-minded, supportive people on the same journey as you.

Question 8

What are some techniques to quiet the inner critic when there is a lack of awareness of the specific self-critical thoughts?

Ellen Hendriksen · Accepted Answer

There are two main ways to quiet the inner critic when insight into thoughts is low: one is to get creative about helping the client articulate their thoughts; the other is to circumvent thoughts altogether and go the behavioral route.

First is to try to get at the specific thoughts through an alternate pathway. The most effective way, in my experience, is to ask the client what they are worried others will see. What imagined defect are they trying to conceal from others? For example, you might ask, "If your feared outcome occurred, what would become obvious to those around you? That you are ______?" (examples: stupid, incompetent, have no social skills, boring)

Other ways include the following:
--If the client can't articulate thoughts because they experience physical symptoms more acutely, ask what their symptoms are saying. For example, "In a socially anxious moment, if that pit in your stomach could talk, what would it say?" "If your shaking hands could talk, what would they be saying?"  You can also do this if clients simply respond with a noise: "What is 'aaaagh!' trying to say?"
--Clients with social anxiety are often also perfectionists and may feel the need either to articulate their thoughts perfectly or not at all. When we are deconstructing a socially anxious moment and the answer to, "What was going through your head?" or "What were you saying to yourself in that moment?" is "I don't know," I encourage them simply to take a guess, or I'll use a surprisingly productive question: "Well, if you *did* know, what would you say was going through your head?"

Second is to go a more behavioral route. Just like many clients believe mood has to precede action (e.g., "I have to feel like exercising before I can go to the gym," "I have to feel inspired before I sit down and play the piano."), many also believe that confidence has to precede facing social fears (e.g., "I have to feel confident before I can say 'hi' to colleagues I don't know well," "I have to feel confident before I talk to customer service without rehearsing first." The answer is to reverse this order. Put action first, and confidence (and thoughts) will catch up.

Therefore, regardless of the inner critic's thoughts, you can collaboratively set up a hierarchy of exposures with your client. Collaboratively create a list of 10-20 things they avoid or would like to practice doing, rating each item 0-100 on how anxiety-provoking it is. Tweak variables like gender or closeness to include more richness and variety. For example, it may be easier or harder to initiate a conversation with a male vs. female colleague, or it may be easier or harder to talk about a controversial topic with someone they don't know well vs. someone they do know well. Then start with the easiest (lowest-rated) items and work your way through, usually as between-session homework.

Question 9

Is social anxiety disorder the same as social phobia?

Ellen Hendriksen · Accepted Answer

Yes and no. The two terms refer to the same disorder, but are different in scope and reflect the changes in our understanding of the disorder over the years. The term Social Phobia was used in the third edition of the Diagnostic and Statistical Manual (DSM-III). It was replaced by the current term, Social Anxiety Disorder, in the DSM-IV, which continues to appear in DSM5.

Social phobia was a comparatively narrow term and referred only to performance situations, while Social Anxiety Disorder is broader and more generalized. For example, Social Phobia would not have recognized fear and avoidance of casual conversation, like chatting with the checkout clerk or meeting a friend's friend, while Social Anxiety Disorder does include those situations.

Question 10

What are some signs of social anxiety?

Ellen Hendriksen · Accepted Answer

At the heart of social anxiety lies a fear of being revealed as deficient, and then being judged or rejected for that perceived deficiency.

This can result in many different versions of social anxiety. For example, one person may fear that others will notice a perceived physical flaw, such as blushing or sweating. Another person may fear judgment of their social skills--perhaps they worry they will go blank while conversing or will appear awkward. Another individual may worry their personality is somehow lacking--that they are boring or incompetent--and therefore will be rejected. The specifics will vary from person to person, but the core fear of being revealed and judged/rejected remains consistent.

Behaviorally, individuals with social anxiety engage in some kind of avoidance. This avoidance may be overt, such as skipping social events or calling in sick on the day they are to give a presentation, or it may be covert, such as attending a social event but spending most of the time scrolling through their phone, or giving the presentation but reading off a word-for-word script rather than connecting with the audience.

In terms of outward, observable signs of social anxiety, often there are none. Social anxiety is largely an internal experience. But sometimes avoidance behaviors can be observed: wearing sunglasses during a conversation to avoid eye contact, walking the long way around to avoid bumping into an acquaintance, or avoiding assertive requests like asking a neighbor to turn down the music.

Question 11

Can social anxiety be acquired later in life?

Ellen Hendriksen · Accepted Answer

Yes indeed. While social anxiety typically begins between the ages of 8 and 15, it can develop or intensify at any time. Many factors feed into the development of social anxiety, including genetics,   personality, and life experience. Those who develop social anxiety later in life often report the trigger was a life change or transition, such as going away to college or being thrust in the spotlight at a new job, or a traumatic experience, like being bullied at school or work.

Question 12

Is social anxiety learned or natural?

Ellen Hendriksen · Accepted Answer

Both. There does appear to be a genetic component to social anxiety. If you have a first-degree relative with Social Anxiety Disorder, you have a four-to-sixfold increased risk of also having the disorder.

However, much of social anxiety is learned. It can come from the modeling of a socially anxious parent, from consistently avoiding social situations that are anxiety-provoking, from being socially rejected or neglected by peers, from bullying, or other situations that imply social rejection is imminent.

Question 13

Can you be charismatic and have social anxiety?

Ellen Hendriksen · Accepted Answer

Absolutely. In fact, the charisma might be a "safety behavior." That is, it might be a tool to cover a perceived personality or social skills defect.

Safety behaviors serve to protect an individual from perceived imminent judgment or rejection, but on another level, they backfire. In the case of charisma, the outgoing persona the individuals affects likely keeps others from truly knowing or getting close to them.

The solution would be for the charismatic individual to experiment with dropping the act and learn that true friends still like and accept them, even when they're not "on" or being entertaining.

Question 14

Does everyone experience social anxiety to a degree?

Ellen Hendriksen · Accepted Answer

Almost everyone. According to Dr. Philip Zimbardo and colleagues' classic 1974 paper, 40% of individuals call themselves shy, which is the colloquial way of saying socially anxious. Eighty percent (80%) call themselves formerly shy. A full 99% of individuals report experiencing socially anxious moments.
https://apps.dtic.mil/dtic/tr/fulltext/u2/a101822.pdf

In terms of Social Anxiety Disorder, 13% of Americans meet diagnostic criteria.
https://jamanetwork.com/journals/jamapsychiatry/article-abstract/496456

Question 15

Can social anxiety make a person appear unfriendly?

Ellen Hendriksen · Accepted Answer

Yes indeed. This is quite common and largely unintentional. Individuals with social anxiety use "safety behaviors" to conceal their perceived inadequacies and avoid anticipated judgment, but those same safety behaviors can make them appear unfriendly. I like to call safety behaviors "the life preserver that holds you underwater."

For example, visible safety behaviors might include wearing sunglasses and earbuds in public, scrolling through one's phone in order to appear absorbed, asking nothing but questions in conversation to avoid talking about oneself, or ending conversations prematurely ("Well, I don't want to take up any more of your time, so I'll let you go.") More subtle, internal safety behaviors might include rehearsing in one's head before speaking or not revealing anything about one's own life.

While safety behaviors serve to reduce one's anxiety, they can send an unintentionally unfriendly  message. Wearing sunglasses and earbuds sends the message, "Don't talk to me." Peppering a conversation partner with questions leaves them feeling interrogated. Not revealing anything about your life makes others have to work hard to get to know you. Safety behaviors make individuals with social anxiety appear snobby, aloof, or distant, when really they are just anxious.

See the attached paper from Drs. Lynn Alden and Charles Taylor regarding the effects of dropping safety behaviors.

Question 16

What's it like to have social anxiety disorder?

Ellen Hendriksen · Accepted Answer

By definition, Social Anxiety Disorder means one's social anxiety causes distress or impairment. Respectively, this means that social anxiety causes a lot of stress and worry, or it gets in the way of living the life you want to live.

Distress might look like worry or rumination: dreading social interactions or replaying them over in your head to check if you said anything stupid, offensive, or awkward. It might include physical symptoms: an upset stomach, tense muscles, or lost sleep leading up to social interactions or performance situations. It very likely includes a strong urge to hide, conceal, or avoid, like fantasies of calling in sick to avoid a presentation, a powerful urge to cancel social plans, or a period of dread before a feared social interaction.

Impairment is when fear or avoidance negatively impacts one's life. For example, it's when a student consciously forgoes the participation portion of their grade because they feel they can't raise their hand or break into discussion. It's when an employee turns down a promotion that would require them to give presentations or lead trainings. It's missing out on a romantic life because it's too anxiety-provoking to go on a date. But it can also be smaller impairments: walking the long way around so as not to run into anyone and make small talk wastes time. Never saying hello to the neighbors leaves you with no one to turn to when you need to borrow a ladder.

That said, as with most mental health diagnoses, social anxiety exists on a continuum. It's extremely common to experience occasional social anxiety without it crossing the line into diagnosable Social Anxiety Disorder.

Unpacking Social Anxiety