January 15, 2025
Dear Colleagues,
The National Social Anxiety Center (NSAC) provides information about relevant and current research in service of disseminating and promoting evidence-based treatment. This month’s summary is written by Susan Barrett, PsyD, A-CBT representing NSAC South Central Idaho. It examines the 2024 article “‘It’s not always textbook social anxiety’: A survey-based study investigating the nature of social anxiety and experiences of therapy in autistic people” by Wilson & Gullon-Scott.
The purpose of this survey-based study was to address two gaps in the existing literature relating to social anxiety and autism: 1. the lack of a large-scale study aiming to construct a model of potential differences in autistic experiences of social anxiety; and 2. the lack of data about how autistic people experience the currently available interventions in routine clinical practice for social anxiety. Using a mixed-method approach to examine the data collected from 338 adults (232 autistic and 76 non-autistic individuals), the study identified both shared and distinct factors contributing to social anxiety in the autistic community compared to the general population. Notably, autistic individuals often experience social anxiety differently, which can influence their engagement with therapeutic interventions.
Empirical research is consistent with the idea that autistic people may present with conventionally defined anxiety as well as more autism-specific presentations. In particular, an autism-specific presentation of social anxiety may involve distress in social situations without the fears of negative evaluation identified by the DSM and ICD diagnostic criteria for social anxiety disorder. This distress may represent effects of autistic features, like sensory sensitivity; uncertainty about a given social situation; underdeveloped social skills; or increased likelihood of negative interactions with others, each of which may then cause anxiety, or fearfulness, in social situations. While this presentation of anxiety in social situations would not be strictly diagnosable as social anxiety disorder, it has been denoted by some researchers as an ‘atypical’ social anxiety and by others as ‘social fearfulness.’ Of additional relevance, studies to date have focused on autistic children, so it remains unclear whether this category of ‘social fearfulness’ necessarily applies to adults.
The authors also point out that the mental health needs of autistic people are not well met by current services, and necessary adjustments are not routinely made in clinical practice. Additionally, well-designed research studies on the efficacy, for the autistic population, of common interventions for social anxiety is limited. For example, the authors found no randomized controlled trial of CBT for social anxiety in autistic adults.
A key target for intervention in CBT for social anxiety, typically is reducing an individual’s use of safety behaviors; however, people in this study sometimes felt that their resources were removed by CBT, suggesting that intervention may need to be approached differently if it inadvertently depletes an individual’s coping skills. Where therapy experiences were more helpful, this outcome tended to flow from a good understanding of neurodiversity, a strong therapeutic relationship and slightly different focuses in therapy, including: 1. more emphasis on understanding/acceptance rather than change; and 2. helping a person find workaround solutions to deal with stressful social situations.
Take-away: social anxiety needs to be understood specifically within the context of autism, and if this is neglected, therapy is unlikely to be helpful.
For clinicians: How would you characterize your training on neurodivergent populations and your ability to modify your therapeutic approach(es) to social anxiety in order to recognize and accommodate the unique experiences of social anxiety in autistic individuals?
Wilson, A.C. & Gullon-Scott, F. (2024). ‘It’s not always textbook social anxiety’: A survey-based study investigating the nature of social anxiety and experiences of therapy in autistic people. Autism, 28(11), 2923-2936.
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Susan Barrett, PsyD, A-CBT
Representing NSAC South Central Idaho
(Ready for Change)