Social anxiety/phobia

Social anxiety (or Social Anxiety Disorder) is characterised by an intense and lasting fear of others' judgment in social interactions (such as speaking with acquaintances outside one's close circle or approaching a stranger) or performance situations (such as public speaking, eating in public, or paruresis). Fearing humiliation or rejection, individuals develop safety behaviours and systematically avoid anxiety-inducing situations. While avoidance offers immediate relief, it maintains the vicious cycle of fear and can escalate into a severely debilitating social phobia.

CBT is the first-line psychotherapeutic treatment recommended by international health guidelines to overcome social anxiety (Mayo-Wilson et al., 2014). Grounded in cognitive models of anxiety (Clark & Wells, 1995; Hofmann, 2007), therapy targets three complementary areas:

- cognitive restructuring: Identifying and challenging negative automatic thoughts ('people will judge me', 'I must be perfect') to develop more realistic interpretations.

- gradual exposure: Step-by-step exposure to feared situations to desensitise the emotional alarm system and reduce avoidance.

- social skills training: Practising communication skills (eye contact management, assertiveness, conversation flow) to enhance self-efficacy.

ASocial Anxiety and Neurodiversity (ASD, ADHD, Giftedness)

For neurodivergent individuals, social anxiety often stems from experiences of rejection, social disconnect, or exhaustion from social masking. CBT is tailored to specific profiles (Spain et al., 2015):

Autism Spectrum Disorder (ASD): CBT incorporates clear psychoeducation on implicit social rules, sensory overload regulation, and strategies to reduce the cognitive burden of masking.

ADHD: Interventions focus on managing conversational impulsivity (e.g. accidentally interrupting), regulating rejection sensitivity, and building joint attention tools.

Giftedness (HPI / High Intellect): Therapy addresses feelings of disconnect regarding interest areas and conversational pace, while loosening relational perfectionism ('fear of not being interesting enough or boring others').

(sources : Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In Social phobia: Diagnosis, assessment, and treatment (pp. 69-93). Guilford Press; Hofmann, S. G. (2007). Cognitive factors that maintain social anxiety disorder: a comprehensive model and its treatment implications. Cognitive Behaviour Therapy, 36(4), 193-209; Mayo-Wilson, E., et al. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), 368-376; Spain, D., et al. (2015). Cognitive behaviour therapy for social anxiety in adults with autism spectrum disorders: a systematic review. Research in Autism Spectrum Disorders, 15, 34-45.)

School refusal

It can have a social component (social anxiety), a performance component (fear of not meet academic expectations) or a combination of both. It can have real somatic symptoms of stress (getting sick before an exam, etc.), of psychological symptoms (panic attacks, depressive episodes, etc.) or both. If these symptoms happen in the first week of school and disappear or if they are related to current harassment in the school, they cannot be defined as school refusal.

Selective mutism

Selective mutism is a complex anxiety disorder characterised by a persistent inability to speak in specific social settings (such as at school or with individuals outside the immediate family circle), despite speaking comfortably in other environments (American Psychiatric Association, 2013).

- It is not a speech or communication disorder: The individual possesses all the necessary language skills to communicate.

- It is not "just shyness": It is not a temporary personality trait that someone will "grow out of", but rather an involuntary anxiety-driven response.

- It is not necessarily linked to Autism Spectrum Disorder (ASD): Although co-occurrence is possible, selective mutism is an independent anxiety disorder rather than an autistic feature (Muris & Ollendick, 2015)

The anxiety underlying selective mutism is profoundly debilitating. During episodes of mute freezing, individuals may find themselves completely unable to request basic help or express essential needs (such as asking for water, using the toilet, or reporting physical pain) or refuse consent. This acute vulnerability leaves children and young people particularly susceptible to rejection, bullying, and severe psychological trauma (Cohan et al., 2006).

Overwhelmed by this daily distress, individuals and their families frequently give up extracurricular activities, holiday trips, or even schooling altogether. This creates a vicious cycle where avoidance feeds anxiety, deepening social isolation.

Cognitive Behavioural Therapy (CBT) and integrated behavioural approaches are the gold-standard treatment for selective mutism (Bergman et al., 2013). Therapy relies on systematic desensitisation, highly gradual exposure techniques (such as stimulus fading and shaping), and positive reinforcement, whilst strictly removing all speech pressure.

The practice provides a safe and supportive environment : removal of speech pressure (no expectations of forced speaking, right to remain silent), tailored materials and activities (use of non-verbal mediums to foster self-expression and enjoyment), pacing at the patient's speed to reconnect with social interactions without stress, gradually reducing anxiety and rebuilding relational trust.

Selective mutism and bilingualism

Children raised in bilingual or language-minority environments show a higher prevalence of selective mutism (Elizur & Perednik, 2003; Toppelberg et al., 2005). However, it is essential to distinguish selective mutism from the normal "silent period" experienced during second-language acquisition: in a bilingual child with selective mutism, non-verbal behaviour does not stem from a lack of language proficiency, but from severe social anxiety triggered or intensified within the language learning context. Rigorous differential diagnosis is therefore vital.

(sources : American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA; Bergman, R. L., Gonzalez, A., Piacentini, J., & Keller, M. L. (2013). Integrated behavior therapy for selective mutism: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 81(6), 1051–1060; Cohan, S. L., Chavira, D. A., & Stein, M. B. (2006). Practitioner review: Psychosocial interventions for children with selective mutism. Journal of Child Psychology and Psychiatry, 47(11), 1085–1097; Elizur, Y., & Perednik, R. (2003). Prevalence and description of selective mutism in immigrant and native families: a controlled study. Journal of the American Academy of Child & Adolescent Psychiatry, 42(12), 1451–1459; Muris, P., & Ollendick, T. H. (2015). Children who are anxious in silence: a review on selective mutism, the new anxiety disorder in DSM-5. Clinical Child and Family Psychology Review, 18(2), 151–169; Toppelberg, D. R., Tabors, P., Coggins, A., Lum, K., & Burger, C. (2005). Differential diagnosis of selective mutism in bilingual children. Journal of the American Academy of Child & Adolescent Psychiatry, 44(6), 592–595.)

Hikikomori syndrom

First defined in Japan by psychiatrist Tamaki Saitō (Saitō, 1998), Hikikomori syndrome refers to a profound and prolonged social and relational withdrawal from society, affecting professional, academic, and interpersonal life (Kato et al., 2019, 2020). Long viewed as an extreme form of social phobia, it is now understood as a complex psychosocial condition where performance pressure and social evaluation anxiety lead to a protective self-isolation (Teo & Gaw, 2010).

Social isolation typically develops gradually through three distinct stages:

1) Partial withdrawal : the individual reduces social commitments whilst continuing to leave the home occasionally (2 to 3 times a week), usually for essential errands or during quiet hours.

2) Severe withdrawal : leaving the home becomes extremely rare and involves little to no social interaction. Communication with household members, however, is partially preserved.

3) Total isolation : complete breakdown of all direct interactions, including with family members living under the same roof (meals left outside the door, absolute verbal and visual avoidance).

In severe cases of social withdrawal, intense shame and anxiety reinforce a vicious cycle of avoidance. For advanced stages, therapeutic engagement adapts to the patient's initial unavailability (Nonaka & Sakai, 2021): initial sessions are held with a close relative or family member rather than directly with the client. This indirect approach provides crucial support to families, helps adjust domestic relational dynamics, and gradually establishes a safe communication bridge towards direct engagement.

(sources: Kato, T. A., Kanba, S., & Teo, A. R. (2019). Hikikomori: Multidimensional understanding and clinical interventions. Psychiatry and Clinical Neurosciences, 73(8), 427–440; Kato, T. A., Kanba, S., & Teo, A. R. (2020). Defining pathological social withdrawal: Proposed diagnostic criteria for hikikomori. World Psychiatry, 19(1), 116–117; Nonaka, S., & Sakai, M. (2021). Psychological interventions for hikikomori: A systematic review. Frontiers in Psychiatry, 12, 712002; Saitō, T. (1998/2013). Hikikomori: Adolescence without end. University of Minnesota Press; Teo, A. R., & Gaw, A. C. (2010). Hikikomori, a Japanese culture-bound syndrome or a global psychiatric problem? The Journal of Nervous and Mental Disease, 198(6), 444–449)