Social Anxiety Disorder and Relationships

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The distinction between social anxiety disorder and social anxiety is a matter of severity; reference to one includes the other. The recovery tools and techniques provided are applicable to most emotional malfunctions including depression, substance abuse, ADHD, PTSD, generalized anxiety, and issues of self-esteem and motivation. These malfunctions originate homogeneously, their trajectories differentiated by environment, experience, and the diversity of human thought and behavior. 

“Dr. Mullen is doing impressive work helping the world. He is the pioneer of proactive neuroplasticity utilizing DRNI – deliberate, repetitive, neural information.” – WeVoice (Madrid, Málaga)

Enlisting Positive Psychologies to Challenge Love Within SAD’s Culture of Maladaptive Self-Beliefs

in C.-E. Mayer and E. Vanderheiden (eds.) International Handbook of Love. Transcultural and Transdisciplinary Perspectives, Springer Publications, 2021.

Robert F. Mullen, Ph.D.

Social anxiety disorder (SAD) is one of the most common psychophysiological malfunctions, affecting the emotional and mental well-being of over 15 million U.S. adults who find themselves caught up in a densely interconnected network of fear and avoidance of social situations. These observations provide insight into the relationship deficits experienced by people with SAD. Their innate need-for-intimacy is no less dynamic than that of any individual, but their impairment disrupts the ability (means-of-acquisition) to establish affectional bonds in almost any capacity. The spirit is willing, but competence is insubstantial. It is the means of acquisition and how they are symptomatically challenged by SAD that is the context of this research.

Notwithstanding overwhelming evidence of social incompatibility, there is hope for the startlingly few SAD persons who commit to recovery. A psychobiographical approach integrating positive psychology’s optimum human functioning with CBT’s behavior modification, neuroscience’s network restructuring, and other supported and non-traditional approaches can establish a working platform for discovery, opening the bridge to the procurement of forms of intimacy previously inaccessible. It is an arduous and measured crossing that only 5% of the afflicted will even attempt in the first year of onset.

Keywords: Love. Social anxiety disorder. Intimacy. Philautia. Means-of-acquisition.

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59.0 Social Anxiety Disorder

Social anxiety disorder (SAD) is the second most commonly diagnosed form of anxiety in the United States (MHA, 2019). The Anxiety and Depression Association of America (ADAA, 2019a) estimates that nearly 15 million (7%) American adults experience its symptoms. Ritchie and Roser (2018) report 284 million SAD persons, worldwide, and the National Institute of Mental Health (NIMH, 2017) reports 31.1% of U.S. adults experience some anxiety disorder at some time in their lives, Global statistics are subject to “differences in the classification criteria, culture, and gender” (Tsitsas & Paschali, 2014), and “in the instruments used to ascertain diagnosis”(NCCMH, 2013).

Studies in other western nations (e.g., Australia, Canada, Sweden) note similar prevalence rates as in the USA, as do those in culturally westernized nations such as Israel. Even countries with strikingly different cultures (e.g., Iran) note evidence of social anxiety disorder (albeit at lower rates) among their populace. (Stein & Stein, 2008)

SAD is the most common psychiatric disorder in the U.S. after major depression and alcohol abuse (Heshmat, 2014). It is also arguably the most underrated and misunderstood. A “debilitating and chronic” psychophysiological affliction (Castella et al., 2014), SAD “wreaks havoc on the lives of those who suffer from it” (ADAA, 2019a). SAD attacks all fronts, negatively affecting the entire body complex, delivering mental confusion (Mayoclinic, 2017b), emotional instability (Castella et al., 2014; Yeilding, 2017), physical dysfunction (NIMH, 2017; Richards, 2019), and spiritual malaise (Mullen, 2018). Emotionally, persons experiencing SAD feel depressed and lonely (Jazaieri, Morrison, & Gross, 2015). Physically, they are subject to unwarranted sweating and trembling, hyperventilation, nausea, cramps, dizziness, and muscle spasms (ADAA, 2019a; NIMH, 2017). Mentally, thoughts are discordant and irrational (Felman, 2018; Richards, 2014). Spiritually, they define themselves as inadequate and insignificant (Mullen, 2018).

SAD is randomly misdiagnosed (Richards, 2019), and the low commitment to recovery (Shelton, 2018) suggests a reticence by those infected to recognize and or challenge their malfunction. Approximately 5% of SAD persons commit to early recovery, reflective of symptoms that manifest maladaptive self-beliefs of insignificance and futility. Grant et al. (2005) state, “about half of adults with the disorder seek treatment,” but that is after 15–20 years of suffering from the malfunction (Ades & Dias, 2013). Resistance to new ideas and concepts transcends those of other mental complications and is justified by, among other attributions:

  • 1. general public cynicism
  • 2. self-contempt of the afflicted, generated by maladaptive self-beliefs
  • ignorance or ineptitude of mental health professionals
  • real or perceived social and mental health stigma
  • the natural physiological aversion to change

Many motivated towards recovery are unable to afford treatment due to SAD-induced “impairments in financial and employment stability” (Gregory, Wong, Craig, Marker, & Peters, 2018). The high percentage of jobless people experiencing social anxiety disorder in the U.S. is related to “job inefficiency and instability” (Felman, 2018), greater absenteeism, job dissatisfaction, and frequent job changes. “More than 70% of social anxiety disorder patients are in the lowest economic group” (Nardi, 2003).

According to leading experts, the high percentage of SAD misdiagnoses are due to “substantial discrepancies and variation in definition, epidemiology, assessment, and treatment” (Nagata, Suzuki, & Teo, 2015). The Social Anxiety Institute (Richards, 2019) reports that, among patients with generalized anxiety, an estimated 8.2% had the condition, but just 0.5% were correctly diagnosed. A recent Canadian study by Chapdelaine, Carrier, Fournier, Duhoux, and Roberge (2018) reported, of 289 participants in 67 clinics meeting the criteria for social anxiety disorder outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), 76.4% were improperly diagnosed.

Social anxiety disorder is a pathological form of everyday anxiety. The clinical term “disorder” identifies extreme or excessive impairment that negatively affects functionality. Feeling anxious or apprehensive in certain situations is normal; most individuals are nervous speaking in front of a group and anxious when pulled over on the freeway. The typical individual recognizes the ordinariness of a situation and accords it appropriate attention. The SAD person anticipates it, takes it personally, dramatizes it, and obsesses on its negative implications (Richards, 2014).

SAD’s culture of maladaptive self-beliefs (Ritter, Ertel, Beil, Steffens, & Stangier, 2013) and negative self-evaluations (Castella et al., 2014) aggravate anxiety and impede social performance (Hulme, Hirsch, & Stopa, 2012). “Patients with SAD often believe they lack the necessary social skills to interact normally with others” (Gaudiano & Herbert, 2003). Maladaptive self-beliefs are distorted reflections of a situation, often accepted as accurate. The co-founder of CBT, Aaron Beck provides three types of maladaptive self-beliefs responsible for persistent social anxiety. Core beliefs are enduring fundamental understandings, often formed in childhood and solidified over time. Because SAD persons “tend to store information consistent with negative beliefs but ignore evidence that contradicts them, [their] core beliefs tend to be rigid and pervasive” (Beck, 2011). Core beliefs influence the development of intermediate beliefs―attitudes, rules, and assumptions that influence one’s overall perspective, which, in turn, influences thought and behavior. Automatic thoughts and behaviors (ANTs) are real-time manifestations of maladaptive self-beliefs, dysfunctional in their irrationality (Richards, 2014; Wong, Moulds, & Rapee, 2013).

Negative self-images reported by patients with social anxiety disorder reflect a working self that is retrieved in response to social threat and which is characterized by low self-esteem, uncertainty about the self, and fear of negative evaluation by others. (Hulme et al., 2012)

Halloran and Kashima (2006) define culture as “an interrelated set of values, tools, and practices that is shared among a group of people who possess a common social identity.” As the third-largest mental health care problem in the world (Richards, 2019), social anxiety disorder is culturally identifiable by the victims’ “marked and persistent fear of social and performance situations in which embarrassment may occur,” and the anticipation “others will judge [them] to be anxious, weak, crazy, or stupid” (APA, 2017). Although studies evidence “culture-specific expression of social anxiety” (Hoffman, Asnaani, & Hinton, 2010), SAD “is a pervasive disorder and causes anxiety and fear in almost all areas of a person’s life” (Richards, 2019). SAD affects the “perceptual, cognitive, personality, and social processes” of the afflicted who find themselves caught up in “a densely interconnected network of fear and avoidance of social situations” (Heeren & McNally, 2018).

The superficial overview of SAD is intense apprehension—the fear of being judged, negatively evaluated, and ridiculed (Bosche, 2019). There is persistent anxiety or fear of social situations such as dating, interviewing for a position, answering a question in class, or dealing with authority (ADAA, 2019a; Castella et al., 2014). Often, mere functionality in perfunctory situations―eating in front of others, riding a bus, using a public restroom—can be unduly stressful (ADAA, 2019a; Mayoclinic, 2017b). This overriding fear of being found wanting manifests in perspectives of incompetence and worthlessness (Richards, 2019).

SAD persons are unduly concerned they will say something that will reveal their ignorance, real or otherwise (Ades & Dias, 2013). They walk on eggshells, supremely conscious of their awkwardness, surrendering to the GAZE―the anxious state of mind that comes with the maladaptive self-belief they are the center of attention (Felman, 2018; Lacan, 1978). Their movements can appear hesitant and awkward, small talk clumsy, attempts at humor embarrassing, and every situation reactive to negative self-evaluation (ADAA, 2019a; Bosche, 2019). They are apprehensive of potential “negative evaluation by others” (Hulme et al., 2012), and concerned about “the visibility of anxiety, and preoccupation with performance or arousal” (Tsitsas & Paschali, 2014). SAD persons frequently generate images of themselves performing poorly in feared social situations (Hirsch & Clark, 2004; Hulme et al., 2012) and their anticipation of repudiation motivates them to dismiss overtures to offset any possibility of rejection (Tsitsas & Paschali, 2014). SAD is repressive and intractable, imposing irrational thought and behavior (Richards, 2014; Zimmerman, Dalrymple, Chelminski, Young, & Galione, 2010). It establishes its authority through its subjects’ defeatist measures produced by distorted and unsound interpretations of actuality that govern perspectives of personal attractiveness, intelligence, competence, and other errant beliefs (Ades & Dias, 2013).

We are all familiar with the free association test. The person in the white coat tosses out seemingly random words and the recipient responds with the first word that comes to mind. Consider the following reactions: boring, stupid, worthless, incompetent, disliked, ridiculous, inferior (Hulme et al., 2012). Most people use personal pejoratives daily, but few personalize and take them to heart like a SAD person. These maladaptive self-beliefs, over time, become automatic negative thoughts (Amen, 1998) implanted on the neural network (Richards, 2014). They determine initial reactions to situations or circumstances. They inform how to think and feel and act. The ANT voice exaggerates, catastrophizes, and distorts. SAD persons crave the company of others but shun social situations for fear of being found out as unlikeable, stupid, or annoying. Accordingly, they avoid speaking in public, expressing opinions, or even fraternizing with peers … People with social anxiety disorder are typified by low self-esteem and high self-criticism. (Stein & Stein, 2008)

Anxiety and other personality disorders are branches of the same tree. “There is a significant degree of comorbidity between social anxiety disorder and other mental health problems, most notably depression (19%), substance-abuse disorder (17%), GAD [generalized anxiety disorder] (5%), panic disorder (6%), and PTSD (3%)” (Tsitsas & Paschali, 2014). The Anxiety and Depression Association of America (ADAA, 2019a) includes many emotional and mental disorders related to, components of, or a consequence of social anxiety disorder including avoidant personality disorder, panic disorder, generalized anxiety disorder, depression, substance abuse, eating disorders, OCD, and schizophrenia.

Personality disorders are a group of mental illnesses. They involve long-term patterns of thoughts and behaviors that are unhealthy and inflexible. The behaviors cause serious problems with relationships and work. People with personality disorders have trouble dealing with everyday stresses and problems. (UNLM, 2018)

Personality reflects deep-seated patterns of behavior affecting how individuals “perceive, relate to, and think about themselves and their world” (HPD, 2019). A personality disorder denotes a “rigid and unhealthy pattern[s] of thinking, functioning and behaving,” which potentially leads to “significant problems and limitations in relationships, social activities, work and school” (Castella et al., 2014). A recent article in Scientific American speculates that “mental illnesses are so common that almost everyone will develop at least one diagnosable mental disorder at some point in their life” (Reuben & Schaefer, 2017).

59.1.1. SAD and Interpersonal Love

In unambiguous terms, the desire-for-love is at the heart of social anxiety disorder (Alden, Buhr, Robichaud, Trew, & Plasencia, 2018). Interpersonal love relates to communications or relationships of love between or among people. The diagnostic criteria for SAD, outlined in the DSM-V (APA, 2017), include: “Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.” SAD persons find it inordinately difficult to establish close, productive relationships (Castella et al., 2014; Fatima, Naizi, & Gayas, 2018). Their avoidance of social activities limits the potential for comradeship (Desnoyers, Kocovski, Fleming, & Antony, 2017; Tsitsas & Paschali, 2014), and their inability to interact rationally and productively (Richards, 2014; Zimmerman et al., 2010) makes long-term, healthy relationships unlikely. SAD persons frequently demonstrate significant impairments in friendships and intimate relationships (Castella et al., 2014). According to Whitbourne (2018), SAD persons’ avoidance of other people puts them at risk of feeling lonely, having fewer friendships, and being unable to take advantage of the enjoyment of being with people who share their hobbies and interests.

There is a death of research directly investigating the relationship between SAD and interpersonal love (Montesi, Conner, Gordon, & Fauber, 2013; Read, Clark, Rock, & Coventry, 2018). A study on friendship quality and social anxiety by Rodebaugh, Lim, Shumaker, Levinson, and Thompson (2015) notes the lack of relative quality studies; Alden et al. (2018) report on the lack of attention paid to the SAD person’s inability or refusal to function in close relationships. The few studies that do exist report that the SAD person exhibits inhibited social behavior, shyness, lack of assertion in group conversations, and feelings of inadequacy while in social situations (Darcy, Davila, & Beck, 2005). This dominant culture of maladaptive self-beliefs results in the tendency to avoid new people and experiences, making the development of “adequate and close relationships (e.g., family, friends, and romantic relationships)” extremely challenging (Cuming & Rapee, 2010). Experiencing social anxiety disorder translates to less trust and perceived support from close interpersonal relationships (Topaz, 2018).

Although intimately related, the desire-for-love and the means-of-acquisition are binary operations. Most forms of interpersonal love require the successful collaboration of wanting and obtaining. The desire-for-love is the non-consummatory component of Freud’s eros life instinct (Abel-Hirsch, 2010). The means-of-acquisition are the methods and skills required to complete the transaction―techniques that vary depending upon the type of love in the offing. Let us visualize love as a bridge, with desire (thought) at one end and acquisition at the other; the span is the means-of-acquisition (behavior). The SAD person cannot get from one side to the other because the means of acquisition are structurally deficient (Desnoyers et al., 2017; Tsitsas & Paschali, 2014). They grasp the fundamental concepts of interpersonal love and are presented with opportunities but lack the skills to close the deal. Painfully aware of the tools of acquisition, they cannot seem to operate them.

59.2. Cognitive-Behavioral Therapy

CBT purposed for SAD is typically conceptualized as a short-term, skills-oriented approach aimed at exploring relationships among a person’s thoughts, feelings, and behaviors while changing the culture of maladaptive self-beliefs into productive, rational thought and behavior (Richards, 2019). CBT focuses on “developing more helpful and balanced perspectives of oneself and social interactions while learning and practicing approaching one’s feared and avoided social situations over time” (Yeilding, 2017). Almost 90% of the approaches empirically supported by the “American Psychological Association’s Division 12 Task Force on Psychological Interventions” involve cognitive-behavioral treatments, according to Lyford (2017). “Individuals who undergo CBT show changes in brain activity, suggesting that this therapy improves your brain functioning as well” (NAMI, 2019).

Recent meta-analytic evidence suggests that CBT as an effective treatment for SAD compares favorably with other psychological and pharmacological treatment programs (Cuijpers, Cristea, Karyotaki, Reijnders, & Huibers, 2016). There is no guarantee of success, however, and standard CBT is imperfect (David, Cristea, & Hoffman, 2018; Mullen, 2018). The best outcome a SAD sufferer can hope for is mitigation of symptoms through thought and behavior modification and the simultaneous restructuring of the neural network, along with other supported and non-traditional treatments..

“[M]any patients, although being under drug therapy, remain symptomatic and have a recurrence of symptoms,” according to the Brazilian Journal of Psychiatry. “40–50% are better but still symptomatic, and 20–30% remain the same or worse.” (Manfro, Heldt, Cordiol, & Otto, 2008)

Behavioral and cognitive treatments are globally proven methodologies. There are multiple associations worldwide, “devoted to research, education, and training in cognitive and behavioral therapies” (McGinn, 2019). CBT Conferences (2019) are offered across the globe, “where knowledge transfer takes place through debates, round table discussions, poster presentations, workshops, symposia, and exhibitions.” David et al. (2018) credit CBT as the best standard we have in the field currently available—for the following reasons: (1) CBT is the most researched form of psychotherapy. (2) No other form of psychotherapy is systematically superior to CBT in the treatment of anxiety, depression, and other disorders; if there are systematic differences between psychotherapies, they typically favor CBT. (3) Moreover, the CBT theoretical models/mechanisms of change have been the most researched and are in line with the current mainstream paradigms of the human mind and behavior (e.g., information processing).

The Association for Behavioral and Cognitive Therapies (ABCT) is “a worldwide humanitarian organization,” fostering the “dissemination of evidence-based prevention and treatments through collaborations with the World Health Organization (WHO) and the United Nations Educational, Scientific and Cultural Organization (UNESCO)” (McGinn, 2019). The World Confederation of Cognitive and Behavioural Therapies (WCCBT) is a global multidisciplinary organization promoting health and well-being through the scientific development and implementation of “evidence-based cognitive-behavioral strategies designed to evaluate, prevent, and treat mental conditions and illnesses” (ACBT, 2019).

Cognitive-behavioral therapy is arguably the gold standard of the psychotherapy field. David et al. (2018) maintain, “there are no other psychological treatments with more research support to validate.” Studies of CBT have shown it to be an effective treatment for a wide variety of mental illnesses including depression, SAD, generalized anxiety disorders, bipolar disorder, eating disorders, PTSD, OCD, panic disorder, and schizophrenia (Kaczkurkin & Foa, 2015; NAMI, 2019). However, David et al. (2018) suggest if the gold standard of psychotherapy defines itself as the best in the field, then CBT is not the gold standard. There is clearly room for further improvement, “both in terms of CBT’s efficacy/effectiveness and its underlying theories/mechanisms of change.”

Lyford (2017) provides two examples of criticism. A 2013 meta-analysis published in Clinical Psychology Review comparing CBT to other therapies, failed to “provide corroborative evidence for the conjecture that CBT is superior to bona fide non-CBT treatments.” An 8-week clinical study by Sweden’s Lund University in 2013, concluded that “CBT was no more effective than mindfulness-based therapy for those suffering from depression and anxiety.”

Another meta-analysis conducted by psychologists Johnsen and Friborg (2015) tracked 70 CBT outcome studies conducted between 1977 and 2014 and concluded that “the effects of CBT have declined linearly and steadily since its introduction, as measured by patient self-reports, clinician ratings, and rates of remission.” According to the authors, “Just seeing a decrease in symptoms,” he says, “doesn’t translate into greater well-being.” This is reflective of most one-size-fits-all approaches.

While this study recognizes CBT as the best foundation for addressing the SAD culture of maladaptive self-beliefs, it makes the point standard CBT, alone is not necessarily the most productive course of treatment. New and innovative methodologies supported by a collaboration of theoretical construct and integrated scientific psychotherapy are needed to address mental illness as represented in this era of advanced complexity. A SAD person subsisting on paranoia sustained by negative self-evaluation is better served by multiple non-traditional and supported approaches, including those defined as new (third) wave (generation) therapies, developed through client trust, cultural assimilation, and therapeutic innovation with CBT and positive psychology serving as the foundational platform for integration.

59.3. Categories of Interpersonal Love

In Nicomachean Ethics, Aristotle (1999) encapsulates love as “a sort of excess of feeling.” Utilizing the classic Greek categories of interpersonal love is vital to this study; each classification illustrates how SAD symptoms thwart the subject’s means-of-acquisition in seven of eight categories (with the notable exception of healthy philautia). The three primary categories: (1) philia (comradeship), (2) eros (sexual), and (3) agape (selfless and unconditional), are followed by (4) storge (family), (5) Ludus (provocative), (6) pragma (practical), and the two extremes of philautia: (7) narcissistic and, (8) positive self-qualities. Forms of inanimate love are excluded from this study, “including love for experiences (meraki), objects (érōs), and places (chōros)” (Lomas, 2017).

1. Aristotle called philia “one of the most indispensable requirements of life” (Grewal, 2016). Philia is a bonding of individuals with mutual experiences―a “warm affection in intimate friendship” (Helm, 2017). This platonic love subsists on shared experience and personal disclosure. A core symptom of a SAD person is the fear of revealing something that will make them appear “boring, stupid or incompetent” (Ades & Dias, 2013). Even the anticipation of interaction causes “significant anxiety, fear, self-consciousness, and embarrassment” (Richards, 2014) because of the fear of being scrutinized or judged by others (Mayoclinic, 2017b).

2. Eros is reciprocal feelings of shared arousal between people physically attracted to each other, the fulfillment declared by the sexual act. The SAD person’s self-image of unlikability (Stein & Stein, 2008) coupled with the fear of intimacy (Montesi et al., 2013) and rejection (Tsitsas & Paschali, 2014) has significant consequences in terms of acquiring a sexual partner, and satisfaction of the sexual act (Montesi et al., 2013). SAD’s culture of maladaptive self-beliefs poses severe challenges to their ability to establish, develop, and maintain romantic relationships (Cuncic, 2018; Topaz, 2018). A study by Montesi et al. (2013), examining the SAD’s person’s symptomatic fear of intimacy and sexual communication concluded, “socially anxious individuals experience less sexual satisfaction in their intimate partnerships than nonanxious individuals, a relationship that has been well documented in previous research.” The study reported a lacuna of literature, however, examining the sexual communication of SAD persons.

3. Through the universal mandate to love thy neighbor, the concept of agape embraces unconditional love that transcends and persists regardless of circumstance (Helm, 2017). SAD generally infects adolescents who have experienced detachment, exploitation, and or neglect (Steele, 1995). This form of love characterizes itself through unselfish giving; the SAD person’s maladaptive self-belief that she or he is the constant focus-of-attention is a form of self-centeredness bordering on narcissism (Mayoclinic, 2017a).

4. Again, the primary cause of SAD stems from childhood hereditary, environmental (Felman, 2018; NAMI, 2019), or traumatic events (Mayoclinic, 2017b). In each case, the SAD person is exploited (unconsciously or otherwise) in the formative stages of human motivational development: those of physiological safety and belongingness, and love (Maslow, 1943). As a result, storge or familial love and protection, vital to the healthy development of the family unit, is severely affected. The exploited adolescent (Steele, 1995) faces serious challenges recognizing or embracing familial love as an adolescent or adult.

5. A SAD person’s conflict with the provocative playfulness of Ludus is evident by the fear of being judged and negatively evaluated by others (Mayoclinic, 2017b) as well as themselves (Hulme et al., 2012; Ritter et al., 2013). Persons experiencing SAD do not find social interaction pleasurable (Richards, 2019) and have limited expectations things will work out advantageously (Mayoclinic, 2017b). Finally, SAD persons’ maladaptive self-beliefs generally result in inappropriate behavior in social situations (Kampmann, Emmelkamp, & Morina, 2019).

6. The obvious synonym for pragma is practicality―a balanced and constructive quality counterintuitive to someone whose modus operandi is discordant thought and behavior (Richards, 2014; Zimmerman et al., 2010). Pragma is mutual interests and goals securing a working and endurable partnership, facilitated by rational behavior and expectation. The SAD personality sustains itself through irrationality (Felman, 2018) and maladaptive self-beliefs (Hulme et al., 2012; Ritter et al., 2013). The pragmatic individual deals with relationships sensibly and realistically, conforming to standards considered typical. The overriding objective of a SAD person is to “avoid situations that most people consider “’normal’ ” (WebMD, 2019).

The onset of SAD is a consequence of early psychophysiological disturbance (Felman, 2018; Mayclinic, 2019a). The receptive juvenile might be the product of bullying (Felman, 2018), abuse (NAMI, 2019), or a broken home. Perhaps parental behaviors are overprotective or controlling or do not provide emotional validation (Cuncic, 2018). Subsequently, the SAD person finds it difficult to let his or her guard down and express vulnerability, even with someone they love and trust (Cuncic, 2018). Alden et al. (2018) note that SAD persons “find it difficult, in their intimate relationships, to be able to self-disclose, to reciprocate the affection others show toward them.”

There is a large body of research linking love with positive mental and physical health outcomes (Rodebaugh et al., 2015). Relationships, love, and associations with others lead one to recognition of their value to society “and motivates them towards building communities, culture and work for the welfare of others” (Capon & Blakely, 2007). Love is developed through social connectedness. Social connectedness, essential to personal development, is one of the central psychological needs “required for better psychological development and well-being” (Deci & Ryan, 2000). Social connectedness plays a significant role as mediator in the relationship between SAD and interpersonal love (Lee, Dean, & Jung, 2008) and is strongly associated with the level of self-esteem (Fatima et al., 2018).

59.4. Philautia

The seventh and eighth categories of interpersonal love are the two extremes of philautia: narcissism and positive self-qualities. To Aristotle, healthy philautia is vigorous “in both its orientation to self and to others” due to its inherent virtue (Grewal, 2016). “By contrast, its darker variant encompasses notions such as narcissism, arrogance and egotism” (Lomas, 2017). In its positive aspect, any interactivity “has beneficial consequences, whereas in the latter case, philautia will have disastrous consequences” (Fialho, 2007).

The good man should be a lover of self (for he will both himself profit by doing noble acts, and will benefit his fellows), but the wicked man should not; for he will hurt both himself and his neighbors, following as he does evil passions. (Grewal, 2016)

59.4.1. Unhealthy Philautia

Unhealthy philautia is akin to clinical narcissism―a mental condition in which people function with an “inflated sense of their own importance [and a] deep need for excessive attention and admiration.” Behind this mask of extreme confidence, the Mayoclinic report (2017a) states, “lies a fragile self-esteem that’s vulnerable to the slightest criticism.” SAD persons live on the periphery of morbid self-absorption through their self-centeredness. Their obsession with excessive attention (ADAA, 2019b) mirrors that of unhealthy philautia. In Classical Greece, persons could be accused of unhealthy philautia if they placed themselves above the greater good. Today, hubris has come to mean “an inflated sense of one’s status, abilities, or accomplishments, especially when accompanied by haughtiness or arrogance” (Burton, 2016). The self-centeredness and self-absorption of a SAD person often present themselves as arrogance; in fact, the words are synonymous. The critical difference is that SAD persons do not possess an inflated sense of their own importance but one of insignificance.

59.4.2. Healthy Philautia

Aquinas’ (1981) response to demons and disorder states, “evil cannot exist without good.” The Greeks believed that the narcissism of unhealthy philautia would not exist without its complementary opposition of healthy philautia, which is commonly interpreted as the self-esteeming virtue―an unfortunate and wholly incomplete definition. Rather than self-esteem only, philautia incorporates the broader spectrum of all positive self-qualities.

Rather, we are concerned here with various positive qualities prefixed by the term self, including -esteem, -efficacy, -reliance, -compassion, and -resilience. Aristotle argued in Nichomachean Ethics that self-love is a  precondition for all other forms of love. (Lomas, 2017)

Positive self-qualities determine one’s relation to self, to others, and the world. They provide the recognition that one is of value, consequential, and worthy of love. “Philautia is important in every sphere of life and can be considered a basic human need” (Sharma, 2014). To the Greeks, philautia “is the root of the heart of all the other loves” (Jericho, 2015). Gadamer (2009) writes of philautia: “Thus it is; in self-love one becomes aware of the true ground and the condition for all possible bonds with others and commitment to oneself.” Healthy philautia is the love that is within oneself. It is not, explains Jericho (2015) “the desire for self and the root of selfishness.” Ethicist John Deigh (2001) writes:

Accordingly, when Aristotle remarks that a man’s friendly relations with others come from his relations with himself … he is making the point that self-love (philautia), as the best exemplar of love … is the standard by which to judge the friendliness of the man’s relations with others.

Positive self-qualities are obscured by SAD’s culture of maladaptive self-beliefs and the interruption of the normal course of natural motivational development. Positive psychology embraces “a variety of beliefs about yourself, such as the appraisal of your own appearance, beliefs, emotions, and behaviors” Cherry, 2019). It points to measures “of how much a person values, approves of, appreciates, prizes, or likes him or herself” (Blascovich & Tomaka, 1991). Ritter et al. (2013) conducted a study on the relationship between SAD and self-esteem. The research concluded that SAD persons have significantly lower implicit and explicit self-esteem relative to healthy controls, which manifest in maladaptive self-beliefs of incompetence, unattractiveness, unworthiness, and other irrational self-evaluations.

Healthy philautia is essential for any relationship; it is easy to recognize how the continuous infusion of healthy philautia into a SAD person supports self-positivity and interconnectedness with all aspects of interpersonal love. “One sees in self-love the defining marks of friendship, which one then extends to a man’s friendships with others” (Deigh, 2001). Self-worthiness and self-respect improve self-confidence, which allows the individual to overcome fears of criticism and rejection. Risk becomes less potentially consequential, and the playful aspects of Ludus less threatening. Self-assuredness opens the door to traits commonly associated with successful interpersonal connectivity―persistence and persuasiveness, optimism of engagement, a willingness to vulnerability. A SAD person’s recognition of her or his inherent value generates the realization that they “are a good person who deserves to be treated with respect” (Ackerman, 2019). A good person is, spiritually, one that is loved by God; reciprocation is instinctive and effortless. “To feel joy and fulfillment at being you is the experience of philautia” (Jericho, 2015). The philautia described by Aristotle, “is a necessary condition to achieve happiness” (Arreguín, 2009) which, as we continue down the classical Greek path, is eudemonic. In the words of positive psychologist Stephen (2019), eudaimonia

describes the notion that living in accordance with one’s daimon, which we take to mean ‘character and virtue,’ leads to the renewed awareness of one’s ‘meaning and purpose in life’.

Aristotle touted the striving for excellence as humanity’s inherent aspiration (Kraut, 2018). He described eudaimonia as “activity in accordance with virtue” (Shields, 2015). Eudaimonia reflects the best activities of which man is capable. The word eudaimonia reflects personal and societal well-being as the chief good for man. “The eudaimonic approach … focuses on meaning and self-realization and defines well-being in terms of the degree to which a person is fully functioning” (Ryan & Deci, 2001). It is through recognition of one’s positive self-qualities and potential productive contribution to the general welfare that one rediscovers the intrinsic capacity for love. Let us view this through the symbolism of Socrates’ tale of the Cave (Plato, 1992). In it, we discover SAD persons chained to the wall. Their perspectives generate from the shadows projected by the unapproachable light outside the cave. They name these maladaptive self-beliefs: useless, incompetent, timid, ineffectual, ugly, insignificant, and stupid. The prisoners have formed a subordinate dependency on their surroundings and resist any other reality until, one day, they find themselves loosed from their bondage and emerge into the light. Like the cave dwellers, the SAD person breaks away from maladaptive self-beliefs into healthy philautia’s positive self-qualities, which encourage and support connectivity to all forms of interpersonal love.

A study published in Cognitive Behaviour Therapy (Hulme et al., 2012) looked at the effect of positive self-images on self-esteem in the SAD person. Eighty-eight students were screened with the Social Interaction Anxiety Scale (SIAS) and divided between the low self-esteem group or the high self-esteem group. The study had two visions. The first was to study the effect of positive and negative self-beliefs on implicit and explicit self-esteem. The second was to investigate how positive self-beliefs would affect the negative impact of social exclusion on explicit self-esteem, and whether high socially anxious participants would benefit as much as low socially anxious participants. The researchers used a variety of measures and instruments. The Social Interaction Anxiety Scale is standard in SAD therapy and CBT workshops; the Implicit Association Test (IAT) reveals the strength of the association between two different concepts. The Rosenberg Self-Esteem Scale (RSES) is a 10-item self-report measure of explicit self-esteem; the State-Trait Anxiety Inventory-Trait (STAI-T) is a 20-item scale that measures trait anxiety; and the Depression Anxiety Stress Scale-21 (DASS-21) is a self-report scale measuring depression, anxiety, and general distress.

Social exclusion is inherently aversive and reduces explicit self-esteem in healthy individuals … the effect of exclusion has been measured in terms of its impact on positive affect and on four fundamental need scores (self-esteem, control, belonging, and meaningful existence) which contribute to psychological well-being. (Hulme et al., 2012)

The study’s results were consistent with evidence-based on implicit self-esteem in other disorders; it found that negative self-imagery reduces positive implicit self-esteem in both high and low socially anxious participants. It provided supporting evidence of the effectiveness of promoting positive self-beliefs over negative ones, “because these techniques help patients to access a more positive working self” (Hulme et al., 2012). It also demonstrated that positive self-imagery maintained explicit self-esteem even in the face of social exclusion.

59.5. Conclusion

For 25 years, since the appearance of SAD in DSM-IV, the cognitive-behavioral approach has reportedly been effective in addressing social anxiety disorder. It is structurally sound and would conceivably remain the foundation for future programs, however, it is not the therapeutic gestalt it claims to be. Productive cognitive-behavioral approaches emphasize the replacement of SAD’s automatic negative thoughts and behaviors (ANTs) with automatic rational ones (ARTs). As defined by UCLA psychologists Hazlett-Stevens and Craske (2002), CBT approaches treatment with the assumption that a specific central or core feature is responsible for the observed symptoms and behavior patterns experienced (i.e., lawful relationships exist between this core feature and the maladaptive symptoms that result). Therefore, once the central feature is identified, targeted in treatment, and changed, the resulting maladaptive thoughts, symptoms, and behaviors will also change.

Clinicians and researchers have reported the lack of a clear diagnostic definition for social anxiety disorder; features overlap and are comorbid with other mental health problems (ADAA, 2019a; Tsitsas & Paschali, 2014). Experts cite substantial discrepancies and disparities in the definition, epidemiology, assessment, and treatment of SAD (Nagata et al., 2015). More specifically, according to a study published in the Journal of Consulting and Clinical Psychology (Alden et al., 2018), “there is not enough attention paid in the literature to the ability to function in the close relationships” required for interpersonal love.

Standard CBT also lacks methodological clarity. Johnsen and Friborg (2018) cite the varying forms of CBT used in study and therapy over the years. Experts point to two predominant types of CBT: “the unadulterated CBT created by Beck and Ellis, which reflects the protocol-driven, highly goal-oriented, more standardized approach they first popularized,” and the more integrative and collaborative approaches of “modern” CBT (Wong et al., 2013). This study maintains neither faction should be ignored if we are to effectively challenge the evolving complexities of positive self-qualities and their importance to the individual’s psychological well-being.

The deficit of positive self-qualities in individuals impaired by SAD’s symptomatic culture of maladaptive self-beliefs combined with the interruption of the natural course of human motivational development is a new psychological concept in our evolving conscious complexity. Cognitive-behavioral therapies focus on resolving negative self-imaging and irrationality through programs of thought and behavioral modification.  Positive self-qualities in healthy philautia is not a new concept; it was being discussed in symposia almost two-and-a-half centuries ago. The psychological ramifications and methods to address it, however, are in their formative stages. There is a need for innovative psychological and philosophical research to address the broader implications of healthy philautia’s positive self-qualities, which could deliver the potential for self-love and societal concern to the SAD person, opening the bridge to the procurement of all forms of interpersonal love.

Kashdan, Weeks, and Savostyanova (2011) cite the “evidence that social anxiety is associated with diminished positive experiences, infrequent positive events, an absence of positive inferential biases in social situations, fear responses to overtly positive events, and poor quality of life.” Models of CBT that attempt only to reduce the individual’s avoidance behaviors would benefit from addressing more specifically the relational deficits that such people experience, as well as positive psychological measures to counter SAD’s culture of maladaptive self-beliefs. Non-traditional and supported approaches, including those defined as new (third) wave (generation) therapies, with CBT serving as the foundational platform for integration, would widen the scope and perspective in comprehending SAD’s evolving intricacies.

One such step is the integration of positive psychology within the cognitive behavioral therapy model which, “despite recent scientific attention to the positive spectrum of psychological functioning and social anxiety/SAD … has yet to be integrated into mainstream accounts of assessment, theory, phenomenology, course, and treatment” (Kashdan et al., 2011). CBT would continue to modify automatic maladaptive self-beliefs, thoughts, and behaviors, and positive psychology would replace them with positive self-qualities.

Training in prosocial behavior and emotional literacy might be useful supplements to typical interventions. Behavioral exercises can be used to practice the execution of considerate and generous social skills. Positive affirmations have enormous subjective value as well. Data provide evidence for mindfulness and acceptance-based interventions, where the goal is not only to respond to the negativity of maladaptive self-beliefs but to pursue positive self-qualities despite the presence of unwanted negative thoughts, feelings, images, or memories. Castella et al. (2014) suggest motivational enhancement strategies to help clients overcome their resistance to new ideas and concepts. Ritter et al. (2013) tout the benefits of positive autobiography to counter SAD’s association with negative experiences, and self-monitoring helps  SAD persons to recognize and anticipate their maladaptive self-beliefs (Tsitsas & Paschali, 2014). Finally, the importance of considering the “nuanced and unique dynamics inherent in the relationships among emotional expression, intimacy, and overall relationship satisfaction for socially anxious individuals” should be thoroughly considered (Montesi et al., 2013). As positive psychology turns its attention to the broader spectrum of philautia’s positive self-qualities, integration with CBT’s behavior modification, neuroscience’s network restructuring, and other non-traditional and supported approaches would establish a working platform for discovery.

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