Social anxiety disorder is sometimes referred to as social phobia. A phobia is an irrational fear of certain situations, objects, or environments.
It is estimated that 7 percent of adults in the United States have experienced social anxiety over the last year and that 12.1 percent of the same population will do so at some point in their lives.
- People with social anxiety disorder are disproportionately nervous in social situations.
- Symptoms can include abdominal discomfort, lightheadedness, and a 'negative loop' of feeling anxious about any anxious feelings. Panic attacks may also occur.
- It is more common in females than males.
- Treatment can include psychotherapy and medication.
What is social anxiety disorder?
Social anxiety can involve a fear of being judged by others.
A person with social anxiety disorder may be extremely fearful of embarrassment in social situations. This fear can affect personal and professional relationships.
Social anxiety often occurs early in childhood as a normal part of social development and may go unnoticed until the person is older. The triggers and frequency of social anxiety vary depending on the individual.
Many people feel nervous in certain social situations, such as when giving a presentation, going out on a date, or taking part in a competition. This is normal and would not qualify as social anxiety disorder.
Social anxiety becomes a medical condition when everyday social interactions cause excessive fear, self-consciousness, and embarrassment.
Trivial, everyday tasks, such as filling in a form with people around and eating in public places or with friends, may become highly stressful for somebody with social anxiety.
There may be physical, emotional, and behavioral symptoms. Social anxiety can affect daily tasks, including school life, work, and other activities.
Behavioral and emotional signs and symptoms include:
- avoiding situations where the individual feels they may be the center or focus of attention
- fear of being in situations with strangers
- dread concerning how they will be presented to others
- excessive fear of embarrassment and humiliation, being teased and criticized, or other people noticing that a person with social anxiety disorder looks anxious
- a fear of being anxious that makes the anxiety worse
- fear of meeting people in authority
- severe anxiety or panic attacks when experiencing the feared situation
- refraining from certain activities or talking to people because of a fear of embarrassment
- a blank mind in social situations that cause anxiety
Children with possible social anxiety disorder tend to be worried about being embarrassed in front of peers but not adults.
Physical signs and symptoms include:
- heart palpitations
- abdominal pain
- avoiding eye contact
- weeping, tantrums, clinging to parents, or isolation in children
- clammy and cold hands
- difficulty talking, sometimes including a shaky voice
- dry mouth and throat
- excessive sweating
- muscle tension
- shaking and trembling
- walk disturbance, in which the individual becomes so worried about how they walk that they lose balance or maybe stumble when passing a group of people
An individual with social anxiety disorder may also:
- be over-sensitive to criticism
- have low self-esteem
- have poor social skills
- not be assertive
- talk negatively about themselves, with inaccurate and self-defeating thoughts
Individuals with social anxiety disorder sometimes underachieve at school or work to avoid the attention of being promoted or having to participate in group tasks. In severe or chronic cases of social anxiety, the person may develop other psychological conditions, such as depression.
A person with social anxiety disorder may find the following situations extremely difficult to face:
- being introduced to and talking to new people
- going into a room where the people are already settled
- making eye contact
- ordering a meal in a restaurant
- starting a conversation
- using a public telephone or public restroom
- writing in front of other people
People with social anxiety disorder usually know that their anxiety is irrational. However, in many cases, the anxiety persists and does not get better without appropriate treatment.
Stimulating positive thoughts before a potentially intimidating social encounter, such as by listening to music you love, will help to nurture positive emotions during the encounter.
One of the factors that make symptoms of social anxiety worse is the fear of becoming anxious itself.
The more anxious a person feels about social situations, the less likely it is they will expose themselves to the social situations.
Being exposed to social situations, however, is necessary to overcome anxiety, and the less a person exposes themselves to social interaction, the more extreme the anxiety becomes.
It is important to break the cycle of anxious thoughts. There are steps proven to help prepare a person for social interactions that may feel nervous ahead of having to face them.
Stimulating positive thoughts before social engagements: Activities that make you happy can release feel-good chemicals in the brain that relax you during potentially stressful encounters. Listen to music you love, watch a little TV, or play video games. Maybe engage in some mild exercise or meditation.
Reframing negative thought processes: Telling yourself you are a shy person will reinforce current anxieties about talking to people or being in public. Thoughts fuel behavior patterns. A technique carried out in cognitive behavioral therapy involves guiding patients through the reframing process.
Writing down these thought processes can help. For example, "I am a shy person" can become "I acted like a shy person at the gathering." It helps people to know they can change how they perceive themselves and how they feel others see them.
Not relying on alcohol or narcotics: Not only can these form a dependency later on in life, but they also do not help the problem at the core of the social anxiety. Try to manage negative feelings in social situations without chemicals or follow a medically supported course of medications prescribed by a doctor.
While some cases of social anxiety can be so severe that these steps will not resolve the condition without treatment, they can help a person approach social interaction with a positive mindset.
A doctor, often a primary care physician, may carry out a physical evaluation, as well as a basic psychiatric examination. The physical exam helps the doctor rule out any physical causes for the symptoms.
A GP will probably refer the individual to a mental health professional, usually a psychiatrist or psychologist.
The mental health practitioner will ask the person with suspected social anxiety to describe symptoms, when they occur, how often, and how long they have been occurring. They may then ask the patient to complete a questionnaire.
In the U.S., symptoms must meet the Diagnostic and Statistical Manual (DSM) criteria for social anxiety before a diagnosis can be given, including:
- avoiding situations that might produce anxiety.
- a persistent fear of social situations in which they believe they will be scrutinized or act in a way that is embarrassing or humiliating.
- excessive or disproportionate levels of anxiety for the situation
- daily living being affected by the anxiety
- a great deal of anxiety brought on by social situations
Social anxiety disorder is a lifelong condition for many people, usually changing in how severe it is. Treatments can help people control their symptoms and gain confidence.
Psychotherapy and medications are considered to be the most effective treatments.
This is a psychological treatment that uses a wide variety of techniques to help the person view themselves and their problems in a more realistic light and overcome and cope with them effectively.
There are many types of psychotherapy, including cognitive therapy, interpersonal therapy, psychodynamic therapy, and family therapy.
Cognitive behavioral therapy
Cognitive behavioral therapy (CBT) has been shown to improve symptoms a great deal.
CBT helps the patient realize that it is their own thoughts, rather than other people, that determine how they react or behave. In this type of psychotherapy, the patient learns how to recognize and change negative thoughts about themselves.
This type of therapy has two main parts:
- a cognitive element, designed to limit distorted or disproportionate thinking
- a behavioral element, designed to change the way people react to objects or situations that trigger anxiety
The individual may also receive exposure therapy, in which they gradually work up to facing the situations they fear.
With cognitive delivered exposure (CDE), the patient safely confronts the situations or places that cause problems, often in the company of the therapist.
Selective serotonin reuptake inhibitors (SSRIs) are the most common medications prescribed for people with social anxiety disorder.
They are thought to be the safest and most effective treatment for persistent symptoms. Examples may include:
- paroxetine (Paxil, Paxil CR)
- sertraline (Zoloft)
- fluvoxamine (Luvox, Luvox CR)
- fluoxetine (Prozac, Sarafem)
Possible side effects may include:
A doctor may prescribe serotonin and norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor, Effexor XR). They will usually start by prescribing a small dose, which is gradually increased. It may take up to 3 months for any improvement in symptoms to be noticeable.
Benzodiazepines are a class of drug also used as anti-anxiety medications. Examples include alprazolam (Xanax) and clonazepam (Klonopin). Courses of benzodiazepines are usually short as they may cause dependence.
Side effects may include:
- loss of balance
- memory loss
Beta-blockers help block the stimulating effects of adrenaline. They are usually prescribed for specific situations, such as having to make a presentation. They are not used for ongoing treatment.
Experts say that social anxiety disorder has both environmental and genetic causes.
- Genetic causes: As the condition appears to run in families, genetic links are being investigated. There is ongoing research that attempts to find out how much of this is genetic and how much is acquired.
- Chemicals in the body: Scientists are currently researching which chemicals in the body might promote the development of social anxiety disorder. Serotonin, a brain chemical, may play a key role when levels are not right or if an individual is extremely sensitive.
- Brain structure: Some researchers believe the amygdala in the brain may play a role in fear response, resulting in excessive reactions.
- Weather and demographics: Mediterranean countries have lower rates of social anxiety disorder compared to Scandinavian countries. This could be due to warmer weather as well as a higher population density. Warmer weather may reduce the avoidance of social situations and increase contact with other people. Others suggest that cultural factors may contribute to reduced social anxiety rates.
Depression can be a complication of social anxiety.
Social anxiety disorder can persist throughout a person's life if it is left untreated. Their anxieties may end up dominating their lifestyle.
This can interfere with daily life, school work, professional work, relationships, and general happiness.
In severe cases, the individual may quit work, drop out of school, and become isolated.
There is also a risk of alcohol or substance abuse, depression, and suicidal thoughts.
Social anxiety disorder typically starts in the early- to mid-teens but can sometimes start much earlier or later.
The following factors may increase the risk of developing social anxiety disorder:
- Gender: The disorder is significantly more common among females than males.
- Genetics: The risk of developing the condition may be higher if a person's parents or siblings have the condition.
- Nurture: Some people believe that social anxiety disorder may develop in people who have witnessed anxious behavior in others. There may be a link between social anxiety and overprotective parenting.
- Some life experiences: Children who have experienced bullying, ridicule, humiliation, or rejection are said to be more susceptible to social anxiety when compared to other people. Factors can also include sexual abuse, a family conflict, or another negative experience.
- Personality: Withdrawn, restrained, shy, or timid children are thought to be more prone to developing social anxiety disorder.
- A demanding ordeal: Some people may experience social anxiety for the first time when they have to make an important presentation. Actors may experience stage fright or social phobia when they are on stage.
Humans are social animals, and the negative spiral of thoughts that contribute to social anxiety can turn a mild hangup with talking to large groups of people into a serious mental health issue. Learning to enjoy socializing before the thought process reaches this stage is vital for improved quality of life.
Social anxiety disorder is sometimes called social phobia. Social anxiety disorder is not just shyness; it is more severe than this.
Social anxiety disorder is sometimes called social phobia. Social anxiety disorder is not just shyness; it is more severe than this. With social anxiety disorder you become very anxious about what other people may think of you, or how they may judge you. As a result you have great difficulty in social situations, which can affect your day-to-day life.
- A marked fear or dread of social situations. You fear that you will act in an embarrassing or humiliating way and that other people will think you are stupid, inadequate, foolish, etc:
- In some cases the fear is only for certain situations where you will be looked at by others, even if they are known to you. For example, you become very anxious if you have to 'perform' in some way, such as giving a talk or presentation, taking part in a discussion at work or school, etc. However, you are OK in informal social gatherings.
- In other cases the fear occurs for most social situations where you may meet strangers. This can even include eating in public places, as you fear you may act in an embarrassing way.
- You may have weeks of anxiety prior to a social event or an event where you have to 'perform'.
- You avoid such situations as much as possible.
- If you go to the feared situation:
- You become very anxious and distressed.
- You may develop some physical symptoms of anxiety. These may include:
- A fast heart rate.
- The sensation of having a 'thumping heart' (palpitations).
- Shaking (tremor).
- Feeling sick (nausea).
- Chest pain.
- Stomach pains.
- A 'knot in the stomach'.
- Fast breathing.
- Blushing easily.
- You may have an intense desire to get away from the situation.
- You may even have a panic attack. Read more about panic attack and panic disorder.
- However, you will usually know that your fear and anxiety are excessive and unreasonable.
Social anxiety disorder can greatly affect your life. You may not do as well at school or work as you might have done, as you tend to avoid any group work, discussions, etc. You may find it hard to obtain, or keep, a job. This may be because you feel unable to cope with the social aspects needed for many jobs, such as meeting with people. You may become socially isolated and find it difficult to make friends.
Who has social anxiety disorder?
It is one of the most common mental health conditions. As many as 1 in 10 adults have social anxiety disorder to some degree. It usually develops in the teenage years and is usually a lifelong problem unless treated. Just over twice as many women as men are affected.
What causes social anxiety disorder?
The cause is probably a combination of bad experiences as a child and your genetic 'makeup' which makes you more prone to this condition. In one study about half of affected people said their phobia began after one memorable embarrassing experience. The other half said it had been present for 'as long as they could remember'.
How is it diagnosed?
You must have three features to be diagnosed with social anxiety disorder:
- Your symptoms must not be the result of some other mental health condition (for example, a delusion).
- You feel anxious entirely or mostly in social situations.
- One of your main symptoms will be the avoidance of social situations.
As well as discussing your problems your doctor or practice nurse may use a short questionnaire to obtain extra information on how severely you are affected.
What are the treatment options for social anxiety disorder?
Cognitive and behavioural therapies
Cognitive behavioural therapy (CBT) is a type of therapy that deals with your current thought processes and/or behaviours and aims to change them by creating strategies to overcome negative thought patterns, which may help you to manage your social anxiety. See separate leaflet called Cognitive Behavioural Therapy (CBT) for more details.
You can obtain leaflets, books, CDs, DVDs or MP3s, etc, on how to relax and how to combat anxiety. They teach simple deep-breathing techniques and other measures to relieve stress and anxiety.
Medicines for social anxiety
Although mainly prescribed for the treatment of depression, they can also lessen the symptoms of anxiety. They interfere with brain chemicals (also called neurotransmitters) such as serotonin, which are thought to cause anxiety symptoms. There are lots of different antidepressants, but selective serotonin reuptake inhibitors (SSRIs) seem best for anxiety disorders. Escitalopram and sertraline are two SSRIs commonly prescribed..
Benzodiazepines such as diazepam used to be the most commonly prescribed medicines for anxiety. They were known as the minor tranquilisers but they do have some serious known side-effects. They often work well to ease symptoms. The problem is they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Now they are not used much for persistent anxiety conditions. A short course of up to two weeks may be an option for:
- Anxiety which is very severe and short-term; or
- 'Now and then' treatment to help you over a bad spell if you have persistent anxiety symptoms.
A beta-blocker (for example, propranolol) can ease some of the physical symptoms such as trembling and the sensation of having a 'thumping heart' (palpitations). They do not directly affect the mental symptoms such as worry. However, some people relax more easily if their physical symptoms are eased. These tend to work best in short-lived (acute) anxiety. For example, if you become more anxious before performing in a concert then a beta-blocker may help to ease 'the shakes'.
In some cases a combination of treatments such as cognitive therapy and an antidepressant may work better than either treatment alone.
Social anxiety and alcohol
Although alcohol may ease symptoms in the short term, don't be fooled that drinking helps to cure social anxiety. In the long run, it does not. Drinking alcohol to 'calm nerves' can lead to problem drinking and may make problems with social anxiety (and the depression that often accompanies it) worse in the long term. See a doctor if you are drinking alcohol (or taking street drugs) to ease social anxiety.
What is the outlook for social anxiety disorder?
Not much is known about the natural progress of the condition. However, with treatment there is a good chance that symptoms can be greatly improved. Without treatment, social phobia can be associated with depression in later life.