Social Anxiety Disorder (Social Phobia)

Social anxiety vs shyness

Symptoms

Emotional and thinking symptoms

• intense fear of being judged, criticized or rejected
• worry about doing something embarrassing or showing anxiety
• fear that others will notice blushing, sweating or trembling
• worry for days or weeks before an event
• replaying conversations afterward and focusing on perceived mistakes
• expecting the worst outcome

Physical symptoms

• blushing
• sweating, trembling or shaking voice
• racing heart, fast breathing
• nausea or upset stomach
• muscle tension
• mind going blank
• sometimes panic attacks in feared situations

Behavior

• avoiding social situations, or enduring them with intense distress
• staying quiet or in the background
• avoiding eye contact
• relying on "safety behaviors," such as rehearsing what to say, holding a phone, or drinking alcohol

Common feared situations

• meeting new people or talking to strangers
• speaking in class, meetings or in public
• making phone calls
• eating or drinking in front of others
• using public restrooms
• dating
• being the center of attention

When fear is limited to speaking or performing in public, it is called the performance only type.

Causes and risk factors

• temperament: behaviorally inhibited or shy children
• family history of anxiety disorders
• brain factors: an overactive fear response in the amygdala
• life experiences: bullying, teasing, rejection, humiliation or overly critical or controlling parenting
• a visible difference or health condition, such as stuttering or a skin condition, that draws attention

Related conditions

• depression
• other anxiety disorders, including panic disorder and generalized anxiety disorder
• avoidant personality disorder, a more pervasive pattern
• alcohol and substance misuse
• in children, selective mutism

Diagnosis

A doctor or mental health professional will ask about your fears, which situations you avoid, how long it has lasted and how it affects your life. Questionnaires such as the Social Phobia Inventory can help. Diagnosis requires that the fear is out of proportion to the actual threat, lasts 6 months or more, and causes significant distress or impairment. Medical causes and substances are considered.

Treatment

Cognitive behavioral therapy

CBT is the most effective treatment and usually involves 12 to 20 sessions. It helps you:

• identify and challenge anxious predictions, such as "everyone will think I'm stupid"
• drop safety behaviors that keep anxiety going
• practice exposure: gradually facing feared situations, starting small, so anxiety reduces over time
• shift attention away from yourself and onto the conversation
• build social skills and confidence

CBT can be delivered individually, in groups, or through guided online programs.

Medicines

• SSRIs (sertraline, paroxetine, escitalopram, fluvoxamine) and the SNRI venlafaxine are first-line medicines. Effects build over 4 to 8 weeks
• beta-blockers (such as propranolol) can reduce shaking and racing heart before a specific performance, but are not effective for generalized social anxiety
• benzodiazepines are generally avoided because of dependence risk

Combining CBT and medicine can help people with severe symptoms.

Self-help

• start with small, manageable social steps, and build up
• prepare, but avoid over-rehearsing
• practice slow breathing before and during anxious situations
• limit alcohol and caffeine
• join a structured group based on an interest
• consider self-help books or apps based on CBT

Outlook

Without treatment, social anxiety disorder tends to be long-lasting. With CBT, medicine or both, most people improve significantly and can do things they previously avoided. Early treatment in young people prevents years of missed opportunities and lowers the risk of depression and substance misuse.

Frequently asked questions

What are the symptoms of social anxiety disorder?

Symptoms include intense fear of being judged or embarrassed, avoiding social situations, worrying for days before events, and physical signs such as blushing, sweating, trembling and a racing heart. Symptoms last at least 6 months and interfere with daily life.

Is social anxiety the same as being shy?

No. Shyness is a common personality trait that usually fades as people warm up. Social anxiety disorder involves intense, persistent fear that leads to avoidance and significantly affects school, work or relationships.

What is the best treatment for social anxiety?

Cognitive behavioral therapy with gradual exposure to feared situations is the most effective treatment. SSRIs or venlafaxine also help, especially for moderate to severe symptoms. Many people benefit from combining therapy and medicine.

Can social anxiety go away on its own?

It rarely resolves fully without treatment and often lasts for years. Avoidance tends to keep it going. With therapy and gradual exposure, however, most people improve substantially.