336 TREATMENT OF SPECIFIC ANXIETY DISORDERS
Anxious Arousal and Panic
The second diagnostic criterion in DSM-IV-TR is that exposure to the feared social situ-
ation will invariably provoke anxiety, which may involve a situationally bound or situ-
ationally predisposed panic attack (American Psychiatric Association, 2000). Individu-
als with social phobia often experience panic attacks when in feared social situations or
even when anticipating a social event (Kendler, Neale, Kessler, Heath, & Eaves, 1992c).
Although the physical symptoms of these situationally triggered attacks are identical to
those in panic disorder (Beidel & Turner, 2007), physical symptoms of anxiety that can
be observed by others, such as twitching muscles or blushing, may be more prominent in
the anxiety experienced in social phobia (Amies, Gelder, & Shaw, 1983). Furthermore,
individuals with social phobia experience greater physiological arousal during exposure
to a distressing social situation than nonphobic individuals (e.g., Turner et al., 1986). It
is little wonder that fear of having a panic attack in a social situation is a major concern
of many people with social phobia (Hofmann, Ehlers, & Roth, 1995). In fact fear of
losing control over any emotional responses, especially anxiety symptoms, is a critical
aspect of the perceived social threat (Hofmann, 2005). Even though fear of anxiety
is common across the anxiety disorders, it is particularly germane to social phobia
because any display of anxiety in social settings is perceived to increase the likelihood
of negative evaluation by others.
Awareness, Avoidance, and Inhibition
To meet DSM-IV-TR diagnostic criteria for social phobia, the person must have some
awareness of the excessive or unreasonable nature of her social fears (i.e., Criterion C).
This criterion helps distinguish social phobia from other diagnoses such as paranoid
personality disorder in which the person actually believes others are trying to embarrass
or humiliate him (Beidel & Turner, 2007).
Given the experience of intense anxiety when anticipating or entering feared social
situations, the urge to avoid social situations can be intense in social phobia. Compared
to other anxiety disorders, individuals with social phobia are more likely to engage in
avoidance of social situations even though they may be convinced it is detrimental for
them (i.e., Rapee, Sanderson, & Barlow, 1988). Assessment of the frequency and extent
of avoidance associated with various social evaluative situations (see Table 9.2) is an
important part of the diagnostic assessment of social phobia (Hope, Laguna, Heimberg,
& Barlow, 1996–1997).
Individuals with social phobia are highly inhibited when encountering social inter-
actions. They often appear rigid and stiff, their face taut with forced expression. When
trying to speak they can appear inarticulate because of stumbling over their words,
being “tongue-tied,” or having difficulty thinking of the right word. All of these invol-
untary behaviors are detrimental to their performance and increase the probability of a
negative evaluation by others—the very essence of their social anxiety.
Individuals with social phobia also rely on subtle avoidance or safety behaviors in
an attempt to conceal their anxiety which they assume will cause others to evaluate them
negatively (Beck et al., 1985; Wells & Clark, 1997). Individuals with social phobia may
try to conceal their anxiety by avoiding eye contact or trying to keep physically cool so
that one’s face does not look red or flushed, wearing certain clothes or makeup to hide