Social Phobia (Social Anxiety Disorder)

Social phobia vs shyness

Symptoms

Emotional and thinking

• intense fear of being judged, criticized or rejected
• fear that others will notice your anxiety, such as blushing or shaking
• worrying for days or weeks before an event
• replaying conversations afterward and focusing on perceived mistakes
• expecting the worst outcome

Physical

• blushing
• sweating
• trembling or shaky voice
• racing heart, nausea, dizziness
• mind going blank
• panic attacks

Behavior

• avoiding social situations, eye contact or speaking up
• staying at the edges of groups, arriving late or leaving early
• relying on "safety behaviors," such as rehearsing sentences, holding a drink to hide trembling, or wearing clothes to hide sweating
• using alcohol or drugs to cope

Common feared situations

• talking to strangers or people in authority
• speaking in meetings or class, public speaking
• eating, drinking or writing in front of others
• dating and parties
• using public restrooms
• phone calls and video calls

In children

Children may cry, freeze, cling, have tantrums or refuse to speak in social settings. Selective mutism, consistently not speaking in specific situations such as school, is closely related.

Causes and risk factors

• Genetics: anxiety disorders run in families.
• Temperament: a shy, behaviorally inhibited temperament in childhood.
• Experiences: bullying, teasing, rejection, humiliation or family conflict.
• Brain factors: an overactive fear response in the amygdala.
• Visible conditions: stuttering, facial differences or tremor can increase self-consciousness.

Related conditions

Social anxiety disorder often occurs with depression, panic disorder, agoraphobia, generalized anxiety and substance misuse. Avoidant personality disorder is a more pervasive, lifelong pattern of social avoidance and feelings of inadequacy. For specific phobias and fears more generally, see fears and phobias.

Diagnosis

A primary care doctor, psychologist or psychiatrist will ask about which situations you fear, how you react, how long it has lasted and how it affects your life. Diagnosis requires marked fear and avoidance lasting at least 6 months, out of proportion to the situation, and causing significant distress or impairment. Questionnaires such as the Social Phobia Inventory help measure severity. The clinician will also screen for depression, other anxiety disorders and alcohol use.

Treatment

Cognitive behavioral therapy (CBT)

The most effective treatment, typically 12 to 16 weekly sessions. It involves:

• identifying and challenging negative predictions ("everyone will think I'm stupid")
• dropping safety behaviors
• gradual exposure to feared situations
• shifting attention outward rather than monitoring yourself
• behavioral experiments to test beliefs

Guided self-help and online CBT programs also help many people.

Medicines

• SSRIs (such as sertraline, paroxetine, escitalopram) and the SNRI venlafaxine are first-line medicines. They take 4 to 8 weeks to work and are usually continued for at least 6 to 12 months after improvement.
• Beta-blockers such as propranolol can reduce trembling and racing heart before specific performances, but do not treat the underlying fear.
• Benzodiazepines are generally avoided because of dependence risk.

CBT and medicine can be combined, especially for severe cases.

Self-help strategies

• Practice slow breathing (in for 4 seconds, out for 6) to calm physical symptoms.
• Set small, gradual social goals and build up.
• Notice and question catastrophic thoughts.
• Limit caffeine and alcohol.
• Join structured groups such as Toastmasters or social skills groups.
• Exercise regularly and protect sleep.

Outlook

Without treatment, social anxiety disorder often persists for years. With CBT and/or medication, most people improve substantially, gaining confidence and widening their social and work lives. Starting treatment early, especially in teenagers, improves outcomes.

Frequently asked questions

What is social phobia?

Social phobia, also called social anxiety disorder, is an intense and lasting fear of being judged, embarrassed or humiliated in social or performance situations. It leads to avoidance and distress that interfere with daily life, work or school, and is more severe than ordinary shyness.

What are the symptoms of social anxiety?

Symptoms include intense fear of social situations, worry before events, replaying conversations afterward, avoiding people or speaking up, and physical signs like blushing, sweating, trembling, a racing heart, nausea and the mind going blank.

Is social anxiety disorder curable?

Many people recover fully or improve greatly with treatment. Cognitive behavioral therapy is highly effective, and SSRI or SNRI medicines also help. Some people have occasional symptoms later, but the skills learned in therapy help manage them.

What is the difference between social anxiety and introversion?

Introversion is a personality trait: introverts prefer quieter settings and recharge alone, but are not afraid of social situations. Social anxiety involves fear and distress about being judged, and often avoidance of situations a person would actually like to take part in.

What medicine is used for social anxiety disorder?

The main medicines are SSRIs, such as sertraline, paroxetine and escitalopram, and the SNRI venlafaxine. Beta-blockers like propranolol are sometimes used before performances to reduce physical symptoms. Medicines work best combined with cognitive behavioral therapy.