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*What Causes Social Anxiety Disorder?*
The leading explanation for social anxiety disorder has been proposed by cognitive-behavioral theorists (Thurston et al., 2017; Heimberg et al, 2010). The explanation features an interplay of both cognitive and behavioral factors. As you read in Chapter 3, cognitive-behavioral theorists start with the contention that people with this disorder hold a group of dysfunctional beliefs and expectations regarding the social realm. These can include:
- Holding unrealistically high social standards and so believing that they must perform perfectly in social situations
- Believing they are unattractive social beings.
- Believing they are socially unskilled and inadequate.
- Believing they are always in danger of behaving incompetently in social situations.
- Believing that inept behaviors in social situations will inevitably lead to terrible consequences.
- Believing they have no control over feelings of anxiety that emerge in social situations.
Cognitive-behavioral theorists hold that, because of these beliefs, people with social anxiety disorder keep anticipating that social disasters will occur, overestimate how poorly things go in their social interactions, and dread most
social situations (Gavric et al., 2017). Moreover, they learn to perform “avoidance” and “safety” behaviors to help prevent or reduce such disasters.

*Treatments for Social Anxiety Disorder*
Only in recent decades have clinicians been able to treat social anxiety disorder successfully. Their success is due in part to the growing recognition that the disorder has two distinct features that may feed upon each other: (1) sufferers have overwhelming social fears, and (2) they often lack skill at starting conversations, communicating their needs, or meeting the needs of others. Armed with this insight, clinicians now treat social anxiety disorder by trying to reduce social fears, by providing training in social skills, or both.

*How Can Social Fears Be Reduced?*
Medication often helps alleviate social fears (Curtiss et al., 2017). Such fears are reduced to some degree in 55 percent of patients who take either benzodiazepines or antidepressant drugs, compared to 24 percent of similar patients who take placebo drugs (Stein, 2016). It appears that these medications bring about relief by improving functioning in the brain’s fear circuit, which tends to be
hyperactive for people with social anxiety disorder, just as it is in cases of generalized anxiety disorder (Brühl et al., 2014).
At the same time, cognitive-behavioral therapy has proved to be at least as effective as medication at reducing social fears, and people helped by this approach seem less likely to relapse than those treated with medications alone (Gregory & Peters, 2017; Thurston et al., 2017; Heimberg & Magee, 2014). This finding suggests to some clinicians that this form of therapy should always be featured in the treatment of social fears, either alone or in combination with medication.
To undo the cycle of problematic social beliefs and behaviors described earlier, cognitive-behavioral therapists combine both behavioral and cognitive techniques. On the behavioral side, they conduct exposure therapy, the intervention so effective with phobias. The therapists encourage clients to expose themselves to their dreaded social situations and to remain in these situations as their fears subside. Usually the exposure is gradual, and it often includes homework assignments. On the cognitive side, the clinicians and clients have systematic therapy discussions in which the clients are guided to re-examine and challenge their maladaptive beliefs and expectations, given the less-than-dire outcomes of their social exposures.