Q&A: Managing social anxiety during the COVID-19 pandemic

As the COVID-19 pandemic and measures to curb its spread continue to evolve, social norms and responsibilities also remain in flux, which may place an additional burden on people with social anxiety disorder.

Research has begun to outline the effects of the pandemic on social anxiety generally and on those with social anxiety disorder. A study published in Psychiatry Research showed pre-pandemic social anxiety served as a statistically significant predictor of anxiety and depression during the lockdown orders, as well as a robust relationship between social anxiety and COVID-19-related worry and impairment. Authors of a paper published in Cognitive and Behavioral Practice noted that the combination of increased anxiety and diminished social opportunities have led to challenges for treating social anxiety among youths.

Healio Psychiatry spoke with Franklin Schneier, MD, co-director of the Anxiety Disorders Clinic at New York State Psychiatric Institute, about the effects of the pandemic on those with social anxiety disorder, how doctors can better help these individuals and opportunities and challenges the pandemic has presented for this patient population and their doctors.

Healio: How is social anxiety manifesting during the pandemic?

Schneier: My impressions of this are based on a few research papers that have been published and on my personal interactions with patients in my practice and during my research. A few studies have looked at social anxiety as a predictor of how people have been doing during the pandemic. By and large, they tend to show that people with significant social anxiety or social anxiety disorder have not fared well during the pandemic. Among socially anxious university students, there are higher levels of persisting anxiety, which usually goes down over the course of a normal school year. Another study showed that pre-pandemic social anxiety predicted greater anxiety, depression and COVID-19-related worries during the pandemic.

These findings are not surprising because people with social anxiety tend to have smaller support networks. Even though you might think people with social anxiety would not mind being isolated, they still do want social contact and connection. The obstacles related to COVID-19 have made that more difficult for people who are starting out with social challenges. I have also seen exceptions to that, however, with some socially anxious people enjoying the great relief from social obligations that the pandemic has provided. This subset of people with social anxiety disorder are pleased to not have the same demands to be around people, to be speaking up in meetings, etc. Wearing masks can also temporarily reduce some anxiety for people who are concerned about how they might appear to other people.

The downside is that as restrictions eventually ease and we go back to some form of normal social and work interactions, people who have been happy to avoid those interactions are going to have a doubly difficult time re-adjusting to the social demands.

Healio: Do social uncertainties related to the pandemic play a role in social anxiety?

Schneier: For many people, there is a lot of uncertainty in how to properly interact with people — whether one should mask, what to do if the other person isn't masking, questions surrounding potentially imposing on someone if you ask them to wear a mask, etc. These are the kinds of social uncertainties that people with social anxiety disorder find very challenging to navigate and very anxiety-provoking.

Also, the term social distancing has become a mantra that refers to physical space between people, but for a lot of people, it has also become associated with some fear of the other and some discomfort around other people that can add another layer of complexity to the challenge of interacting with people, especially for those with social anxiety disorder.

Healio: What can doctors do for their patients with social anxiety during the pandemic and after?

Schneier: Although some patients may have welcomed the avoidance opportunities of the pandemic, we need to encourage our patients to continue to engage and to work on putting themselves in situations in which they may feel uncomfortable but in which they would like to function well. They should try to limit their social avoidance to what is necessary for safety reasons around COVID-19. It's important to help patients recognize that the world is going to return to some kind of normality and social situations are not going away, so it will be important to keep up social skills and keep socially engaged. Behavioral therapy for social anxiety disorder focuses on helping patients enter their feared social situations with novel coping techniques, and this kind of work should continue even though opportunities to engage in some social situations may be limited by the pandemic. It is important for doctors to remind patients with social anxiety disorder, and all of our patients, to make that extra effort to keep in touch with the people we care about. Even when interactions must be remote, they can still help mitigate the loneliness and feelings of isolation that the pandemic can bring on.

Healio: Do you think the pandemic will have some long-lasting effects on social anxiety in the years to come?

Schneier: There is general evidence that this pandemic is going to have some lasting impact in terms of increased rates of anxiety and depression, and perhaps PTSD. For some, these conditions may linger. It's hard to say how long this could go on and whether people will bounce back from it quickly. There will likely be a range of responses as the pandemic abates, with some people who will glide right back into their everyday lives seamlessly and others who will find it to be a big adjustment.

Healio: Are there any macro-level/systemic interventions that may help people with social anxiety disorder during the pandemic?

Schneier: One thing that has been a lifesaver during the pandemic has been the ability to see patients remotely. Many of our patients like it a lot because they don't need to commute, and it can be highly effective, even if it's not quite the same as meeting people in person. For some people with social anxiety disorder, having the little bit of distance that is created through remote visits may make therapy or treatment more accessible to them, both practically and emotionally. Being able to continue support and insurance coverage for remote visits will be an important change that could be a lasting benefit in the way that our health system runs.