The Experience Among College Students with Social Anxiety Disorder in Social Situations: A Qualitative Study

Introduction

The college period is important for the rapid maturation of the cognition, emotion and behavior of college students. Interpersonal communication is increasingly important to college students’ studies, lives and employment. However, interpersonal communication problems have become a common psychological problem faced by contemporary college students, and social anxiety is one of the most important psychological problems affecting college students’ studies and lives.¹ Studies have found that the proportion of moderate and severe social anxiety among college students was as high as 22.4% in China.² The social anxiety of college students should be given more attention by scholars in related fields and universities.

Social anxiety disorder (SAD) is a common psychological disorder that is regarded as introversion and shyness in personality and has been misdiagnosed as “shyness”.³ It is essentially a symptom of dysfunctional anxiety (psychological and/or autonomic nervous system) that is confined to specific social situations and leads to fear or avoidance.⁴

Epidemiological studies have found that SAD is a disease across the cultural spectrum, and there is a significant increase in social anxiety experience from childhood development to adolescence.⁵ Studies have shown that there are different degrees of social anxiety among college students that affect their social functions.⁶ The fear and avoidance of social occasions and crowds often lead to severe psychosocial impairment and other psychological disorders, such as depression and compulsion.⁵ Moreover, SAD mostly occurs in adolescents, and many patients have other mental disorders, which further lead to intense personal pain and increase social burden.⁷ If not treated in time, SAD will become chronic and progressive, seriously affecting the healthy development of personality.⁸

Previous studies have found that there were certain differences in epidemiological and clinical characteristics in different countries.⁹ At present, with the improvement and development of psychological counseling in China, an increasing number of SAD patients are seeking help in psychological clinics.¹⁰ At present, a large number of relevant investigations and experimental studies have been performed;^11–14 however, there are few studies from the perspective of SAD patients, which leads to the lack of findings of their inner experiences.

Qualitative research methods can precisely understand patients’ social process experience on their own and add missing or potential factors to quantitative research.¹⁵ In this study, the phenomenological research method was used to deeply explore the understanding and feelings of SAD students in social occasions, and to integrate and analyze them to provide a scientific basis for mental health and medical workers to implement prevention and intervention.

Methods

Participants

In this qualitative study, a purposive sampling method was used to select college students who were diagnosed with social anxiety disorder by SCID. A random sampling method was used to determine the diagnosis. A total of 1200 undergraduate students were screened using the Interaction Anxiety Scale (IAS) with the mean ± standard deviation (X ± SD) as the cutoff point. A total of 298 students with the highest score > (X + SD) were selected for the SCID interview. The interviewers were 2 schoolteachers and 2 clinical psychiatrists with many years of psychological counseling experience. A preinterview was conducted before the formal interview, and a consistency test was conducted. Ultimately, 93 college students were diagnosed with SAD, from which students were selected for qualitative interviews. Inclusion criteria: ① meeting the diagnostic criteria of DSM-4 social anxiety disorder and that being the primary diagnosis; ② age ≥16 years; ③ able to understand and communicate with others; and ④ willing to participate in this study with signed informed consent. Exclusion criteria: ① combined with other mental disorders, such as schizophrenia; ② personality disorder (including avoidant personality disorder); ③ severe brain and body diseases and psychoactive substance abuse. The sample size of this study was based on the saturation during data analysis, and a total of seven SAD college students whose codes were P1~P7 were selected. The mean age was 18.34±1.02 years, there were 3 males and 4 females, and 2 patients were hospitalized. The general situations of the patients are shown in Table 1.

Table 1 The General Information of Participants (n=7)

Data Collection

Using the phenomenological research method of qualitative research, in-depth interviews were conducted with the patients according to the semistructured interview outline. The interview outline was prepared according to the research content and was revised after 2 preinterviews. Finally, the interview outline was determined as follows: ① How do you feel in social occasions? ② What do you worry about in social situations? ③ How do you see yourself in this situation? ④ How do you think this will affect you? Since the subjects of this study are SAD patients who fear and avoid strangers, in view of this particularity, the researcher conducted a 30–40 min conversation with the interviewees before the formal interview to explain the purpose of the study and establish a sense of security and trust, which is conducive to the smooth progress of the interview. Two formal interviews were conducted for each person, with each time being 40–60 min. During the interview, the interviewees were encouraged to fully express their feelings and thoughts, and the interview contents were recorded to document the interviewees’ expressions, tone, movements and other nonverbal information at any time. The interview place was the psychological consulting room. The sample size was established on the basis that no new information appeared when the data reached saturation.

Data Analysis

At the end of each interview, all the contents of the interviewees’ statements and the researchers’ on-site records were translated into words, the materials were repeatedly read, word by word, sentence by sentence, and classified and inferred, and the recordings were repeatedly listened to and recalled. Colaizzi’s 7-step analysis method was adopted to summarize the common concepts as the theme of this study. The details were as follows: (1) thoroughly understand the interview data of this research; (2) extract meaningful viewpoints from the data; (3) encode ideas that repeatedly occur and conform to the phenomenon of this study; (4) cluster the views after coding; (5) provide a detailed description of the clustered views without omission; (6) identify similar viewpoints and form theme concepts; and (7) return the data to the interviewees for verification. During the analysis and induction, if there are new data, divide it or generate a new topic. The entire data analysis process was completed by two researchers and verified by consensus.

Ethical Considerations

This study was approved by the institutional review board of Shandong Traditional Chinese Medicine College, which complies with the Declaration of Helsinki. The study procedures were explained to the eligible patients; they were informed of their right to withdraw from the study at any time for any reason and of their right to treatment whether or not they decided to participate in this study. All participants signed an informed consent form. To maintain anonymity, all recognizable personal data of the patients were protected by replacing their names with code numbers.

Results

The anxiety experience among college students with social anxiety disorder in social situations can be classified into four major themes: (1) distorted self-consciousness, (2) fear of negative reactions from others, (3) negative psychosomatic experience, and (4) a strong desire to seek treatment.

Theme 1: Distorted Self-Consciousness

Low Self-Evaluation

In the study, the main problem of SAD students is that they lack objective self-knowledge and describe themselves with very poor evaluation, which is also an important factor causing their anxiety and fear in social occasions. Low self-evaluation makes them lose their willingness and courage to spend time with others.

P7: “Certainly not, even if I go up, also certainly not as good as others speak, finally still cannot choose.”

P4: “I just thought, is it okay? Is my speech reading all right? Or how do I sound? How was it?”

Interviewees are extremely unsure of themselves, always full of doubts and worries, and want to be recognized by others. For example,

P3: “When doing such things, I always want to be right or wrong and long to be accepted by others.”

Self-Experience Lacking Self-Confidence

People with SAD tend to have an “I cannot do it” mentality, which reflects their lack of self-worth. For example,

P3: “I will subconsciously feel that I am not good and will always deny myself, probably because I am not confident and inferior.”

This lack of self-experience not only causes anxiety and fear but also further affects one’s ability to expect to accomplish something, namely, self-efficacy. Therefore, it is difficult to avoid tension in social occasions, which then affects the normal level of self-play. For example,

P2: “When I’m nervous, I think of nothing but failure.”

Attitude and Avoidance Behavior

As an important part of self-consciousness, self-regulation can play a corresponding role in evaluation, feedback and control. SAD patients lack the ability of correct and objective self-regulation and cannot actively face social situations. They often avoid attitudes and engage in avoidance behavior. It is common for them to refuse to accept such assignments or arrangements.

P5: “If the teacher asks me to come to the platform, I will put it off as long as I can.”

P7: “Even if I prepared the best, I would run away if I could. I would only go if it was mandatory. I would never go if I could escape.”

In addition, this avoidance behavior is reflected not only in the refusal to participate in such occasions but also in the face of others. For example,

P1: “The people who dare not look at the people below want to finish and get down quickly.”

P6: “Every time I stood up to speak in class, I didn’t look at my classmates, nor did I dare to look at the teacher. I just looked at the wall or the window, and even then I couldn’t speak.”

Theme 2: Fear of Negative Reactions from Others

Excessive Concern About Other People’s Evaluation

In the interview, all 7 interviewees were afraid that others would not approve of them and worried about others’ opinions.

P5: “In front of people, I am mainly afraid that others will laugh at you (the patient himself). I am mainly afraid of this one.”

P4: “What do they think? The main problem is that reading what other people think makes me nervous.”

Because of their excessive worry about others’ feedback, SAD students cannot properly view others’ evaluation, which increases their anxiety level without good control of themselves. For example,

P2: “If the performance is not good, others will not be satisfied, so I want to show the good side as much as possible. But the more I think about it, the more nervous I get, the worse I get.”

Worry About Making a Bad Impression

The negative assessment of fear was echoed by the respondents’ concern about how they were perceived by others.

P7: “If I make mistakes, others will definitely criticize me, which gives a bad impression. I care about others’ impression and don’t want others to think I’m bad.”

P6: “At these times, I am mainly afraid of making a fool of myself. Making a fool of myself is easy to have a bad influence, so the first impression is very important.”

It can be seen from the interviews that SAD students pay too much attention to whether they are perfect or not and try their best to perform well in front of others and get acceptance and recognition from others. For example,

P5: “I feel more confident when others praise me.” This is a good example of SAD students’ need to be well evaluated by others.

Theme 3: Negative Psychosomatic Experience

Feelings of Pain and Helplessness

When SAD students are stressed, they are filled with feelings of pain and helplessness.

P4: “When I’m nervous, I just can’t control it. The more I control it, the more nervous I become. Sometimes I just stand there and ignore it.”

P1: “Even if I can ask questions, I will stand up and speak nervously (shaking my head) and feel very uncomfortable (lowering my head). Even if I am nervous, I cannot speak continuously.”

Most interviewees suffer from anxiety and are at a loss in the face of such situations. As a result, helpless psychology is formed over time.

For example,

P4: “Most of the time, I don’t know what to do, so I can only laugh or stay, just like this, very uncomfortable (breathe deeply).”

Ambivalence

The experience of ambivalence is mainly reflected in the cognitive level of the interviewees. SAD students can realize that their thoughts are incorrect, but they cannot correct them in time. Therefore, incorrect psychological cognition leads to tension and anxiety, resulting in inner conflict.

P7: “In fact, you know that people will not always be looking at you, but at that moment you feel that people will always be looking at you, looking for you to make mistakes, laughing at you. I know it’s not true, but it’s just scary.”

P6: “When I sit here, I always feel that someone is watching me. When I do things, I feel that many people are paying attention to me. Maybe no one is watching me at all, but I still don’t feel very relaxed.”

P3: “(At parties) I also know that other people are playing their own games and don’t even notice me, but I still get nervous.”

Anticipatory and Persistent Anxiety Experience

SAD students experience anxiety not only during social situations but also over a broader time horizon, such as before or after the social situation begins.

P1: “When the teacher asks a question and says, ‘I want to find someone to answer’, I will be nervous, and then I will be more nervous, and when the teacher has finished ordering a student, my heart is still nervous.”

P2: “I get nervous when I prepare, and then I get more and more nervous when I get close to me. (Deep breath) … After the end, I still think about how well I did.”

Physiological Reaction

Some SAD scales describe common physical reactions, such as “flushing”, “sweating”, “shaking”, and “panic.” The study also found other physical symptoms, such as involuntary movements.

P4: “I will scratch my head when I am nervous. I feel very deliberate and stuffy.”

P5: “Hands will be constantly moving, hair will be pulled, feet will be constantly moving.”

In addition, some SAD students experience the speed of speech (P7) or unclear pronunciation (P3) phenomenon.

Theme 4: A Strong Desire to Seek Treatment

During the interview, we learned that the interviewees were deeply troubled by social anxiety, which seriously affected their work and studies. In retrospect, they felt more pain, so they had a strong desire to get rid of this situation.

P6: “I am nervous all the time. It must be wrong. I must change.”

P3: “I really don’t know what to do. I’m too old to go to work. If I want to get well soon, I can go back to work.”

Most SAD college students can face their own problems with a positive attitude, as shown in P4:I think I should attend more such occasions and do more exercise. I don’t want to go on like this.

Discussion

Most current studies have focused on effective interventions to improve the SAD of college students; however, only a few studies have focused on the subjective experiences of the patients involved. To the best of our knowledge, this is the first qualitative study to explore the anxiety experience among college students with social anxiety disorder in social situations.

Improve Self-Esteem and Rebuild the Correct Self-Image

Studies have shown that one of the core psychological characteristics of SAD patients is low self-esteem.¹⁶ Self-esteem is an overall experience and cognition of whether a person is good enough for himself or not. It is the core of self-awareness and reflects the difference perceived by an individual between the actual self and ideal self.¹⁷ Low self-esteem makes SAD people develop negative self-evaluation and lack the ability to correctly recognize themselves.¹⁸ From the perspective of etiology, improper parenting style and family environment are closely related to it. The early upbringing of SAD patients is mostly negative, that is, negative evaluation and negative feedback, and the parent–child relationship is mainly rejection, rigor and negation,^19–22 resulting in the overall low sense of self-worth and self-ability, that is, low self-esteem and low self-efficacy. Due to low self-esteem and early experience, the negative interpersonal cognitive schema triggered by automation is generalized to the interpersonal situation: it affects self-cognition and makes the individual’s cognitive evaluation lose objectivity; it affects self-experience, forming a sense of shame and a lack of confidence; and it affects self-regulation, the formation of avoidance and avoidance behavior and attitude.²⁹ Therefore, psychological workers should comprehensively popularize family mental health knowledge using media in the community, which can help parents understand their children’s mental health status, create a warm family atmosphere, give them more affirmation and emotional support, and cultivate their children to form a high level of self-esteem and correct self-recognition ability.

Avoid Negative Comments and Correct Sensitive External Perspective Patterns

The interviewees’ low self-esteem and distorted self-awareness make them sensitive in social interactions so they easily perceive negative feedback from others. During individual development, infants are naturally well-behaved and crave positive feedback from their caregivers. If the external feedback is negative, sluggish, indifferent or rejected, infants will form low self-esteem, namely, the core self-concept diagram of “I am not good”, thus forming a lower level of security and a more sensitive external perspective.²³ In adulthood, when such sensitivity becomes an obstacle to adaptation, resulting in subjective pain and even avoidance behaviors, individuals suffer from SAD, which is often presented by negative automatic thinking and attention bias.²⁴ The specific manifestations are as follows: overly concerned about others’ evaluation, worried about leaving a bad impression on others, and other psychological experiences. Thus, when a traumatic event (being punished in public, humiliated by a teacher, ridiculed by a classmate, conflict between parents, etc.) occurs, the automated thinking centered on low self-esteem is quickly triggered, and shame is generated. These repetitive and persistent shame experiences are closely related to emotional and behavioral problems, making individuals anxious about social situations or attention and often contributing to SAD.^25–27 Therefore, SAD students pay more attention to the evaluation given by the outside world and form an external perspective to identify their social perception tendency. Therefore, it is particularly important to pay attention to those with early social anxiety. Due to the early onset of the SAD, is in the stage to accept education in school, and school of psychological prevention and intervention can effectively prevent the occurrence of anxiety disorders;^28,29 therefore, education workers need to students’ psychological development process and health prevention, reduce negative evaluations, provide positive affirmations, a timely support psychology found that anxiety of the students.

Reduce Negative Experiences and Promote the Harmony of Mind and Body

SAD students are very sensitive to feedback from others, including nonverbal information such as faces and postures that reflect emotional cues. This sensitivity is an automated, knee-jerk reaction mechanism.³⁰ This is the patient’s defense and survival strategy. When this defense or survival strategy affects self-functioning and social functioning, it is a pathological reaction. Schachter’s emotion theory holds that emotion is generated by experiencing a high degree of physiological arousal and certain cognition of its state changes; that is, people’s cognition and evaluation of physiological responses determine their final emotional experience. The secondary emotion generated after self-reflective cognition is self-conscious emotion, which plays an important role in the regulation of individual social behaviors.^18,31 The physiological response of SAD patients forms the emotional experience of anxiety after self-cognitive awakening. Patients in a social situation in automation stimulate physical arousal (sweating, flushed, flustered, voice, etc.), produce certain cognitive evaluations, such as he might be “caught” and “wrong”, “they would laugh at me”, etc., to evaluate their own performance, and others form automation of the cognitive processing model through the integration of the cerebral cortex to this information, concentrating on negative emotional experiences such as anxiety and fear. In this way, medical staff should understand the causes and inner experiences of SAD patients and correct distorted perceptions, formulate effective and targeted intervention programs to relieve patients’ sense of pain and helplessness, and give them hope and confidence to overcome psychological barriers.

Pay Attention to Social Anxiety Disorder and Improve Their Mental Health Level

Epidemiological surveys show that the incidence of SAD ranks fourth among many psychological disorders.³² Compared with foreign studies, China has not paid enough attention to this disease. This psychological disorder has a long course, accompanied by severe psychosocial impairment and a high social and economic burden.³³ Seven interviewees had a strong desire to seek treatment because the pain caused by symptoms had seriously affected their lives, studies and work, which was also a common feature of SAD patients in previous studies.^33,34 Therefore, the government and mental health departments should pay attention to adolescents and patients, actively improve the allocation of medical and health resources, provide economically convenient treatment and medical conditions for patients, and provide professional personnel and material support for the prevention and treatment of SAD.

Limitations

Our study has some limitations. First, this study enrolled only patients from one province in China. Patients from various regions were not enrolled in our study; thus, we may have failed to explore potentially different experiences by region. Moreover, this was a qualitative study with a relatively small sample size. For more generalized findings of a target population, further studies with larger sample sizes and studies using quantitative methodology may be necessary.

Conclusion

This study was designed to explore the SAD psychological experience of college students in social situations and found that respondents’ existence consciousness and cognitive deviation are sensitive to external evaluation and feedback, thus producing anxiety in social situations. The resulting fear and pain of patients prevent normal studies, work and lives, so they desperately want to change the status quo to seek treatment. Based on the results of this study, it is suggested that mental health workers should pay more attention to SAD adolescents, meet the psychological needs of SAD college students, and provide theoretical support for comprehensive and systematic psychological intervention management programs.