LIEBOWITZ SOCIAL PHOBIA SCALE :
Social anxiety, or social phobia, is a fear of certain social or performance activities. These are situations in which the person feels a strong anxiety about the possible negative judgment of others. He or she may feel observed, rejected, embarrassed, humiliated, thus triggering avoidance and isolation behavior. This phobia can cause a lot of suffering and should not be taken lightly.
Table of contents
- What is social phobia
- How is social anxiety characterized?
- What are the long-term consequences?
- What are the symptoms that may indicate social phobia in children?
- COVID-19 and social anxiety, an alliance to be feared?
- What is the Liebowitz test?
- What are the prevalences of social phobia?
- What solutions for social phobia?
1. What is social phobia?
Neglected for too long, social anxiety is increasingly attracting the attention of therapists who realize the pain it can cause sufferers (Liebowitz, 1987). Social phobias were originally defined by Marks and Gelder in 1966 as fears of eating, drinking, shaking, blushing, talking, writing or vomiting in the presence of others. However, it was not until 1980 that the disorder was really addressed (Heimberg & al., 1999), and its definition was generalized to a persistent anxiety about being ridiculed in public (Liebowitz, 1987). We can imagine that this person is particularly shy at first glance, but in reality, it is a disorder from which real suffering emanates.
This fear is fed by the fear of humiliating oneself in front of others. The person with a social phobia has an uncontrolled anxiety about the negative judgment of others (APA, 2013). The very idea of feeling watched or having to come into contact with an authority figure is distressing (Stein & Stein, 2008). In order to avoid performing any embarrassing behavior, she tends to isolate herself as much as possible. This leads to a vicious circle, where it is more difficult for them, in the long term, to integrate into a group (Fresco, 2000). A socially phobic person really needs to know that they are liked in order to feel comfortable with a person or group. If situations are easily avoided at first and the person does not feel any real impact, the situation may escalate, gradually expanding the situations avoided. At this point, daily life becomes a constant anxiety. However, this situation is very contradictory, since social relationships allow for a decrease in anxiety (Faytout & al., 2009). This is why it is important to take care of oneself, to re-establish a stronger self-esteem and to consolidate one’s self-assertion. This will allow us to regain serenity with others, which is calming and reassuring.
2. How is social anxiety characterized?
It is normal to feel anxious in certain social situations such as a job interview. In contrast, it is considered pathological to consider high danger in an everyday social situation (Liebowitz, 1987).
According to the DSM-5 (APA, 2013), social phobia is marked by disproportionate, sudden, and intense anxiety when the person is in a social situation, especially when he or she is the center of attention of others, whether in social relationships (meeting someone, asking for information, etc.), in observational situations (eating, vomiting, etc.), or in performance contexts (making a presentation, public speaking, etc.). Social phobia can be specific to one of these situations or generalized to all of them. An anxiety attack will ensue and will be described by tachycardias, excessive sweating, a feeling of loss of self-control, a feeling of dizziness or uneasiness, physiological pain, redness, hot flashes, etc.
This situation has generally been present for at least 6 months. There is thus an avoidance of social situations leading to an isolation, in order to no longer feel the feelings of anxiety. Moreover, social phobia tends to worsen over time when left untreated (Stein, & al., 1990). Several symptoms are recognizable to identify this phobia.
3. What are the long-term consequences?
The consequences can be multiple. Initially, the person with social anxiety, decreasing their social activities, experiences changes and difficulties in their social, professional environment and in other areas such as meeting administrative obligations for example (APA, 2015).
In addition, comorbidities set in as time goes on. Indeed, it is not uncommon to find a link between alcohol addiction and social phobia (Cognat-Brageot & al., 2013). Social phobia tends to facilitate craving (irresistible urge to consume alcohol), in order to inhibit anxious symptoms and silence suffering (Mueser & al., 2003).
More than half of patients with social phobia also suffer from severe depression, often leading to a risk of suicide (Aimes & al., 1983). It is true that human beings are not made to live alone; others contribute to their well-being (Mellor & al., 2008) and allow them to survive (Baumeister & al., 2000). We have seen that COVID-19 has been a real scourge on the morale of all confined and isolated people, due to this deprivation of social relationships (Glowacz, 2020). Indeed, isolation and anxiety in the face of social situations create demoralization that only accentuates depressive symptoms (Stein, & al., 1990).
Finally, a social phobia can lead to other anxiety disorders, such as generalized anxiety disorder for example (Ohayon & al., 2010). But, also other disorders whose association is less obvious such as the development of an eating disorder through anorexia nervosa (Coulon & al., 2009).
4. What are the symptoms that may indicate social phobia in children?
Social anxiety is not exclusive to adults. In fact, children can suffer from it too. There are certain signs that can give you an idea that your child may have a social phobia. In this case, it is important to consult a health professional to be sure.
A child with social phobia cries a lot, gets angry easily or becomes aggressive quickly. They may also freeze up completely, withdraw, stop communicating, or cling to a trusted adult (parent, teacher, etc.). Except with his parents, on whom he is particularly dependent. Finally, he is afraid to go to school, does not get involved in school activities and does not participate or very little in class. There is therefore a significant risk of dropping out of school (Liebowitz, 1987).
If you have any doubts about your child’s behavior at school, don’t hesitate to contact his or her teacher, who will be able to give you clues about his or her attitude in class. Treating social phobia in childhood will limit the risk of avoidant behavior in adulthood and allow the child to develop fully. Moreover, some studies show that social phobia can be transmitted through education, but also by imitation of parental reactions. Bandura (1969) speaks of vicarious experience, that is, by imitating or interpreting the behaviors of one’s parental figures.
5. COVID-19 and social anxiety, an alliance to be feared?
The combination of anxiety about the disease, the decrease in social relationships and the increase in any teleactivities made people fear social stimuli (Khan & al., 2021). The social isolation due to the COVID-19 pandemic crisis was very complicated to live with for many, generating anxieties and depressions, generally, higher (Gindt & al., 2021). As a result, Duan and colleagues (2020) demonstrated that the risk of social phobia was increased, particularly in children and adolescents. Indeed, social exchanges are limited, and the lifestyle changed (Witt & al., 2020). A psychological distance was therefore established (Zheng & al., 2020). A sense of diminished social supports has emerged, making individuals more avoidant (Bu & al, 2020).
Furthermore, this anxiety is further multiplied when isolation lasts longer than 10 days (Loades & al, 2020). The negative effect of distance learning on children and adolescents has been strongly noted, with a very clear increase in social phobias in this population (Morrissette, 2021). Furthermore, for all those who already suffered from social phobia before the health crisis, anxiety in social situations only increased. It is true that the population has been forced to reduce its exposure to social situations (Arad & al., 2021). Therefore, in a pandemic context, as social anxiety increased, life satisfaction decreased (Blasco-Belled & al., 2020). It is clear, therefore, that avoidance (even if constrained) is more likely to lead to phobia.
6. What is the Liebowitz test?
The Liebowitz Social Anxiety Scale was developed by Liebowitz in 1987. It is the most widely used scale by clinicians to assess social phobia, and has been for many years (Heimberg & al., 1999). Indeed, several scales have been developed, but none has yet considered both fear and avoidance (Yao & al., 1999). Through this questionnaire, you will be able to get an idea of your level of anxiety when you are involved in a social relationship. This test will mainly focus on your fear and avoidance in social and performance situations (Liebowitz, 1987). Respond in a completely honest and natural manner. Your answers are not recorded or viewed. The sole purpose of this test is to help you understand the anxiety you may be feeling and to give you a sense of your possibilities.
7. What are the prevalences of social phobia?
Social phobia is a disorder that affects approximately 16% of the population (Furmark & al., 1999) without distinction in age (Stein & al., 2017). Women also tend to be at greater risk than men (Wittchen & al., 1999). As a result, individuals with social phobia have been found to have a lower perceived quality of life than those without the disorder (Lipsitz & Schneier, 2000). Indeed, both professional and personal life are impacted. This is why this disorder becomes mostly chronic, since the person finds himself in a vicious circle of anxiety and malaise. As a result, co-morbidities are often associated with it: generalized anxiety disorder, specific phobias, depression, substance abuse, etc. It is even possible that a severe form of depression may arise even before the social anxiety is taken into consideration (Stein, & al., 1990). These different associated disorders lead to a continuous increase in suffering which increases the risk of suicidal thoughts and attempts (Safren & al., 1997), which increases even more when social anxiety is generalized (Stein & al., 1990).
8. What solutions for social phobia?
It is particularly important not to let the situation escalate. Two solutions are effective: the drug option with antidepressants or the gentle, non-drug option, cognitive-behavioural therapies (Klinger & al., 2005).
Antidepressants will reduce the symptoms, but the risk of recurrence at the end of the treatment is significant. In addition, beyond the risk of addiction, they have numerous side effects: sleep or sexual problems, loss of inhibition, delusions, digestive problems, cardiovascular problems, etc. (Lôo & Olié, 2004).
This is why exposure to these anxiety-provoking situations is encouraged. This is one of the most effective methods of reducing anxiety (Dimsdale & Moss, 1980). Indeed, avoidance situations only reinforce anxiety in social situations (Arad, 2021). For this reason, virtual reality exposures have been shown to be effective in social phobias (Anderson & al, 2013). During virtual reality exposures, the therapist, who has control over the software, will teach methods, directly applicable in virtual environments, to alleviate anxiety (Brinkman & al, 2012). The feeling of the situations is the same as in-vivo, with the difference that the environment is safe, controlled, and is done in a gradual way (Klinger & al., 2005). Therefore, it has been shown that the treatment of social phobias by virtual reality allows for visible and lasting changes in patients (Gebera & al., 2016). The patient progresses according to his or her time frame and is followed in his or her progress while being exposed to situations that he or she might not have thought were surmountable.
- Aimes, P., Gelder, M.,& Shaw, P. (1983). Social phobia : A comparative clinical study. British Journal of Psychiatry, 142, 174-179. 10.1192/bjp.142.2.174
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
- Anderson, P.L., Price, M., Edwards, S.M., Obasaju, M.A., Schmertz, S.K., Zimand, Z., & Calamaras, M.R. (2013). Virtual Reality Exposure Therapy for Social Anxiety Disorder : A Randomized Controlled Trial. Journal of Consulting & Clinical Psychology, 81(5), 751-760. 10.1037/a0033559
- Arad, G., Shamai-Leshem, D., & Bar-Haim, Y. (2021). Social distancing during a COVID-19 lockdown contributes to the maintenance of Social anxiety : A natural experiment. Cognitive Therapy and Research, 45, 708-714. 10.1007/s10608-021-10231-7
- Bandura, A. (1969). Social-Learning Theory of Identificatory Processes. Dans D.A. Gosling (Dir). Handbook of Socialization Theory and Research, 213-262.
- Baumeister, R.F., Dale, K.L., & Muraven, M. () Volition and Belongingness : Social Movements, Volition, Self-Esteem and the Need to Belong. Dans S. Stryker, J.O. Timothy, & R.W. Robert (Dir). Self, identity and social movements, 13, 239-246.
- Blasco-Belled, A., Tejada-Gallardo, C., Torrelles-Nadal, C., & Alsinet, C. (2020). The Cost of Covid-19 on Subjective Well-Being : An Analysis of the Outbreak in Spain. Sustainability, 12, 6243-6256. 10.3390/su12156243
- Brinkman, W.P., Hartanto, D., Kang, N., De Vliegher, D., Kampmann, I.L., Morina, N., Emmelkamp, P.G.M., & Neerincx, M. (2012). A virtual dialogue system for the treatment of social phobia. Extended Abstract on Human Factors in computing systems, 12, 1099-1102. 10.1145/2212776.2212395
- Bu, F., Steptoe, A., & Fancourt, D. (2020). Who is lonely in lockdown? Cross-cohort analyses of predictors of loneliness before and during the COVID-19 pandemic. Public Health, 186, 31–34. 10.1016/j.puhe.2020.06.036
- Cognat-Brageot, M., Louville, P., & Limosin, F. (2013). Comorbidités psychiatriques dans l’alcoolodépendance. La lettre du psychiatre, 9(2), 56-60.
- Coulon, N., Jeammet, P., & Godart, N. (2009) Phobie sociale dans l’anorexie mentale : Évolution au cours des soins. L’Encéphale, 35(6), 531-537. 10.1016/j.encep.2008.09.005
- Dimsdale, J.E., & Moss, J. (1980). Short-term catecholamine response to psychological stress. Psychosomatic Medecine, 42(5), 493-497. 10.1097/00006842-198009000-00003.
- Duan L., Shao X., Wang Y., Huang Y., Miao J., Yang X., & Zhu, G. (2020). An investigation of mental health status of children and adolescents in China during the outbreak of COVID-19. Journal Affective Disorders, 275, 112–118. 10.1016/j.jad.2020.06.029
- Faytout, M., & Swendsen, J. (2009) Phobie sociale et vie quotidienne. Journal de Thérapie Comportementale et Cognitive, 19(3), 88-92. 10.1016/j.jtcc.2009.08.004
- Furmark, T., Tillfors, M., Everz, P.O., Marteinsdottir, I., Gefvert, O., Fredrikson, M. (1999). Social phobia in the general population : prevalence and sociodemographic profile. Social Psychiatry and Psychiatric Epidemiology, 34, 416-424, 10.1007/s001270050163
- Gebara, C.M, De Barros-Neto, T.P., Gertsenchtein, L., & Lotufo-Neto, F. (2016). Virtual reality exposure using three-dimensional images for the treatment of social phobia. Brazilian Journal of Psychiatry, 38(1). 10.1590/1516-4446-2014-1560
- Gindt, M., Fernandez, A., Battista, M., & Askenazy, F. (2021). Psychiatric consequences of Covid 19 pandemic in the pediatric population. Neurpsychiatrie de l’enfance et de l’adolescence, 69(3), 115-120. 10.1016/j.neurenf.2021.01.001
- Glowacz, F. (2020). Lien social, besoin d’appartenance et engagement : Impliquer les jeunes dans les différentes étapes de la crise. Sciences sociales et comportementales. http://hdl.handle.net/2268/256926
- Heimberg, R.G., Horner, K.J., Juster, H.R., Safren, S.A., Brown, E.J., Schneier, F.R., Liebowitz, M.R. (1999). Psychometric properties of the Liebowitz Social Anxiety Scale. Psychological Medecine, 29(1), 199-212. 10.1017/S0033291798007879
- Khan, A.N., Bilek, E., Tomlinson, R.C. & Becker-Haimes, E.M. (2021). Treating Social Anxiety in an Era of Social Distancing : Adapting Exposure Therapy for Youth During COVID-19. Cognitive and Behavioral Practice.10.1016/j.cbpra.2020.12.002
- Klinger, E., Bouchard, S., Légeron, P., Roy, S., Lauer, F., Chemin, I., & Nugues, P. (2005). Virtual Reality Therapy Versus Cognitive Behavior Therapy for Social Phobia : A preliminary controlled study. CyberPsychology and Behavior, 8(1), 76-88. 10.1089/cpb.2005.8.76
- Liebowitz, M.R. (1987). Social phobia. Modern Problems Pharmacopsychiatry, 22, 141-173. 10.1159/000414022
- Lipsitz, J.D., & Schneier, F.R. (2000). Social Phobia : Epidemiology and Cost of Illness. PharmacoEconomics, 18. 23-32. 10.2165/00019053-200018010-00003
- Loades M., Chatburn E., Higson-Sweeney N., Reynolds S., Shafran R., Brigden A., Linney, C., McManus, M.N., Borwick, C., & Crawley, E. (2020). Rapid Systematic Review: The Impact of Social Isolation and Loneliness on the Mental Health of Children and Adolescents in the Context of COVID-19. Journal of the American Academy of Child and Adolescent Psychiatry, 59(11), 1218-1239. 10.1016/j.jaac.2020.05.009
- Lôo, H., & Olié, J.P (2004). Effets secondaires des antidépresseurs. EMC Psychiatrie, 1(4), 294-305. 10.1016/j.emcps.2004.05.003
- Marks, I. & Gelder, M. (1966). Different ages of onset in varieties of phobia. American Journal Psychiatry, 123(2), 218-221. 10.1176/ajp.123.2.218
- McManus, F., Clark, D. M., & Hackmann, A. (2000). Specificity of cognitive biases in social phobia and their role in recovery. Behavioural and Cognitive Psychotherapy, 28(3), 201–209.10.1017/S1352465800003015
- Mellor, D., Strokes, M., Firth, L., Hayashi, Y. & Cummins, R. (2008). Need for belonging, relationship satisfaction, loneliness and life satisfaction. Personality and Individual Differences, 45(3), 213-218.10.1016/j.paid.2008.03.020
- Morrissette, M. (2021). School Closures and Social Anxiety During the COVID-19 Pandemic. Journal of the American Academy of Child and Adolescent Psychiatry, 60(1), 6-7. 10.1016/j.jaac.2020.08.436
- Mueser, K.T., Noordsy, D.L., Fox,L., & Wolfe, R. (2003). Disulfiram Treatment for Alcoholism in Severe Mental Illness. American Journal of Addictions, 12(3), 242-252.
- Ohayon, M.M., & Schatzberg, A.F. (2010). Social phobia and depression : Prevalence and comorbidity. Journal of Psychosomatic Research, 68(3), 235-243. 10.1016/j.jpsychores.2009.07.018
- Safren, S.A., Heimberg, R.G., Brown, E.J., & Holle, C. (1997). Quality of life in social phobia. Depression and Anxiety 4, 126–133.10.1002/(SICI)1520-6394(1996)4:3<126:: AID-DA5>3.0.CO;2-E
- Stein, M.B., Tancer, M.E., Gelernter, C.S., Vittone, B.J., Uhde, T.W. (1990). Major depression in patients with social phobia. Major Journal of Psychiatry, 147(5), 637-639.10.1176/ajp.147.5.637
- Stein, M.B., & Stein, D.J. (2008). Social Anxiety Disorder. Lancet, 371(9618), 1115-1125. 10.1016/S0140-6736(08)60488-2.
- Stein, D.J., Lim., C.C.W., Roest, A.M., De Jonge, P., Aguilar-Gaxiola, S., Al-Hamzawi, A., Alonso, J., Benjet, C., Bromet, E.J., Bruffaerts, R., De Girolamo, G., Florescu, S., Gureje, O., Haro, J.M., Harris, M.G., He, Y., Hinkov, H., Horiguchi, I., Hu, C., Karam, E.G., Lee, S., Lepine, J.P., Navarro-Mateu, F., Pennell, B.E., Piazza, M., Posada-Villa, J., Ten Have, M., Torres, Y., Viana, M.C., Wojtyniak, B., Xavier, M., Kessler, R.C., & Scott, K.M. (2017). The cross-national epidemiology of social anxiety disorder : Data from the World Mental Health Survey Initiative. BMC Medecine, 15(1). 10.1186/s12916-017-0889-2
- Witt A., Ordóñez A., Martin A., Vitiello B., & Fegert J. (2020). Child and adolescent mental health service provision and research during the Covid-19 pandemic: challenges, opportunities, and a call for submissions. Child and Adolescent Psychiatry and Mental Health, 14(1), 14-19. 10.1186/s13034-020-00324-8
- Wittchen, H.U., Stein, M.B., Kessler, R.C. (1999). Social fears and social phobia in a community sample of adolescents and young adults : prevalence, risk factors and co-morbidity. Psychological Medecine, 29(2). 309-323. 10.1017/S0033291798008174
- Yao, S.N., Note, I., Fanget, F., Albuisson, E., Bouvard, M., Jalenques., & Cottraux, J. (1999). L’anxiété sociale chez les phobiques sociaux : validation de l’échelle d’anxiété sociale de Liebowitz (version française). L’encéphale : Revue de psychiatrie clinique biologique et thérapeutique , 25(5), 429-435.
- Zheng, L., Miao, M., Lim, J., Li, M., Nie, S., & Zhang, X. (2020). Is Lockdown bad for Social Anxiety in Covid-19 Regions ? : A national Study in the SOR Perspective. International Journal of Environmental Research and Public Health, 17(12), 4561. 10.3390/ijerph17124561