What Is Social Anxiety Disorder? Symptoms, Causes, Diagnosis, Treatment, and Prevention

Social anxiety disorder — previously known as social phobia — is an anxiety disorder in which you experience persistent fear of social or performance situations, according to the National Institute of Mental Health (NIMH). (1) People who have social anxiety disorder worry that they will behave in a way that will be embarrassing and humiliating and that they will be judged by others, particularly people they do not know well.

Suma Chand, PhD, director of the cognitive behavior therapy program in the department of psychiatry and behavioral neuroscience at St. Louis University School of Medicine in Missouri, says people who have social anxiety often feel they need to behave perfectly in social situations because they tend to imagine that others are superior to them and critical of them. They also have a longing for acceptance, but their fear of others’ judgment can keep them from finding it.

Social anxiety disorder consists of much more than the shyness or nervousness that many people feel in common social situations, such as going on a first date or giving a presentation (“stage fright”).

The condition can interfere with daily activities and even cause people to completely avoid social interactions, even though they often realize their anxiety is irrational. “I have often had my clients tell me how they are exhausted by social situations,” says Dr. Chand.

“This is because when they look back at these events, they see how their need to be perfect in social situations has caused them to experience high levels of anxiety before and during social situations,” she explains. “As a result, they often avoid many social situations — even though they feel bad about doing so.”

But, adds Chand, those with the disorder can learn to change the distortions in their thinking that lead to avoidance.

People who have social anxiety disorder tend to feel very anxious and self-conscious in common social situations. (2) Their fear that they will be judged by others can have a negative effect on school, work, and other daily activities, and can make it difficult for them to develop and sustain friendships.

When you have social anxiety disorder, common social fears include:

• Attending parties and other social occasions
• Eating, drinking, and writing in public
• Meeting new people
• Speaking in public
• Using public restrooms

The anxiety of social anxiety disorder can also cause physical symptoms such as: (3,4)

• Blushing
• Profuse sweating
• Nausea
• Difficulty talking
• Trembling
• Rapid heart rate
• Trouble catching your breath
• Dizziness or lightheadedness
• Muscle tension

According to the NIMH, when having to perform or be around other people, people who have social anxiety disorder tend to: (5)

• Feel their “mind going blank”
• Have a rigid body posture, make little eye contact, or speak with a very soft voice
• Find it scary and challenging to be with other people, particularly strangers, and have a difficult time talking to them even though they want to communicate
• Avoid places where there are other people

Signs and symptoms of social anxiety disorder can also include: (4)

• Fear of displaying physical symptoms of anxiety
• Avoiding situations where you might be the center of attention
• Having anxiety leading up to a feared activity or event
• Spending time after a social situation reviewing your performance and finding flaws
• Expecting the worst possible consequences from a negative social experience
• Difficulty starting conversations, dating, entering a room in which people are already seated, returning items to a store, and other day-to-day experiences
• Children may cry, have tantrums, cling to parents, or refuse to speak in social situations
• Intense fear and anxiety only about speaking or performing in public (performance type of social anxiety disorder)

There may be a genetic component to social anxiety disorder for some people. You’re more likely to develop the disorder if your biological parents or siblings have the condition. (4) However, scientists still don’t understand why some family members have the condition while others don’t. (5)

Research suggests that being raised by parents who engage in negative parental practices, such as being overprotective, overly anxious, or rejecting, may contribute to the development of social anxiety. (2)

Some researchers think misreading other people’s behavior may play a role in causing social anxiety or making it worse. For example, if you think people are staring or frowning at you when they are not. (5)

Underdeveloped social skills may also contribute to social anxiety disorder, although many people with the condition do not have a deficit in their social abilities.

Researchers are also investigating the roles that stress and environmental factors may play in causing social anxiety disorder.

Risk Factors

Several factors can increase your chances of developing social anxiety disorder, including: (4)

Negative life experiences Children who are teased, bullied, rejected, ridiculed, or humiliated may be more likely to develop social anxiety disorder. Family conflict, trauma, abuse, or other negative life events may also be linked to the condition.

New social or work demands Meeting new people, giving a speech, or having to make an important presentation at work may trigger social anxiety disorder symptoms.

Having an appearance or condition that attracts attention Facial disfigurement, stuttering, tremors due to Parkinson’s disease, and other conditions can make people feel self-conscious and may trigger social anxiety disorder.

Shy temperament Children who are shy, timid, withdrawn, or restrained when dealing with new situations or people may have an increased risk of developing the disorder. People who have social anxiety disorder commonly say they were extremely shy as children. (However, social anxiety disorder and shyness are not the same thing.) (3)

Learn More About Causes of Social Anxiety Disorder: Common Risk Factors, Genetics and More

To diagnose social anxiety disorder, your doctor may: (4)

• Conduct a physical exam to help determine whether any medical condition or medication may be triggering your symptoms
• Discuss your symptoms, how frequently they occur, and in what situations
• Ask you whether certain situations make you feel anxious
• Have you fill out self-report questionnaires about symptoms of social anxiety

Your healthcare provider will determine whether you have the criteria for social anxiety disorder as listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). These include:

• Persistent, intense fear or anxiety about specific social situations because you fear you may be judged, embarrassed, or humiliated
• Avoiding anxiety-provoking social situations or enduring them with intense fear or anxiety
• Excessive anxiety that’s out of proportion to the situation
• Anxiety or distress that interferes with your daily life
• Fear or anxiety that is not due to a medical condition, medication, or substance abuse

Prognosis of Social Anxiety Disorder

Social anxiety disorder is often successfully managed with treatment, depending on how severe your fears are. Antidepressant medicines can also be effective. (2)

Social anxiety disorder symptoms can change over time; for example, they may get worse if you’re dealing with a lot of stress or increased demands. (4) In other cases, the symptoms of social anxiety disorder may fade over time.

If it isn’t treated, social anxiety disorder can last for many years, or it can be a lifelong condition. It can also prevent you from reaching your full potential. (5) For example, a person with social anxiety disorder may avoid seeking a promotion at work because it would involve giving presentations in front of their coworkers.

More than one-third of people with social anxiety disorder have symptoms for at least 10 years before they get help. (3)

Treatment for social anxiety disorder is intended to help you function in your daily life. (2) The two most common types of treatment for social anxiety disorder are psychotherapy (psychological counseling or talk therapy), medications, or both. (4)

Psychotherapy helps most people with social anxiety disorder because it teaches you how to change negative thoughts about yourself. You also learn skills that help you gain confidence in social situations.

Cognitive behavioral therapy (CBT) has the most research support among psychotherapies for anxiety, and it works just as well whether it’s conducted individually or in groups.

In exposure-based cognitive behavioral therapy, you work up to facing the situations you fear most, little by little. This can help you develop the confidence you need to cope with anxiety-provoking social situations. You may also engage in social skills training or role-playing to practice your social skills.

CBT may even create positive changes in the brain. A study from 2017 found that when those with social anxiety disorder participated in 10 weeks of CBT group therapy, it led to changes in parts of the brain that process and regulate emotions. (6) The changes were more pronounced when the therapy was most successful.

Medication Options

Certain medications typically used to treat depression may be very helpful for social anxiety disorder, by preventing symptoms or making them less severe. (2) These medications include:

• Medications such as selective serotonin reuptake inhibitors (SSRIs) may be used when social anxiety is present with other anxiety or depressive disorders. In these cases, your healthcare provider may prescribe paroxetine (Paxil) or sertraline (Zoloft). (4)
• The serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor XR) is another medication option for social anxiety disorder. Other antidepressants may also be recommended.
• Beta-blockers block the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs, so they may be prescribed to control symptoms for a particular anxiety-inducing situation, like giving a speech or performing in a concert.

Alternative and Complementary Therapies

Various herbal supplements have been studied as treatments for anxiety, with mixed results. (4)

Supplements such as kava and valerian increase the risk of serious liver damage. Others, such as passionflower or theanine, may have a calming effect, but they’re often combined with other products, so their effectiveness on their own remains unclear. Talk to your doctor before taking any herbal remedies or supplements to make sure they’re safe for you and won’t interact with any medications you take.

Healthy lifestyle changes may help reduce the frequency of social anxiety attacks, including exercising regularly, getting enough sleep, and having regularly scheduled meals. (2) Reducing or avoiding the use of caffeine, some over-the-counter cold medicines, and other stimulants may also be beneficial. Joining a support group may also reduce the stress of having social anxiety.

The following tips may also help you avoid triggering your social anxiety symptoms:

• Learn stress reduction skills
• Eat a healthy, well-balanced diet
• Socialize with people you feel comfortable being around

Learn More About Treatment for Social Anxiety Disorder: Medication, Alternative and Complementary Therapies, and More 

Prevention of Social Anxiety Disorder

There’s no way to completely prevent social anxiety disorder, but these techniques can help you reduce anxiety symptoms: (4)

Get help as soon as possible. Anxiety can be more difficult to treat if you delay seeking treatment.

Start journaling. Keeping a record of your thoughts and experiences can help you and your healthcare provider figure out what’s causing your symptoms and what makes you feel better.

Figure out your priorities. Carefully manage your time and energy, and spend time doing things you enjoy.

Avoid unhealthy substance use. Using alcohol and drugs, as well as caffeine or nicotine, can cause anxiety or make it worse. But quitting can also cause anxiety. If you’re addicted to any substances, look for a doctor, treatment program, or support group that can help.

People with social phobia are at high risk for alcohol or other drug use, because they may wind up relying on substances to relax in social situations or to cope with their distress. (2)

Social anxiety disorder can also lead to loneliness and social isolation.

Without treatment, social anxiety disorder can interfere with work, school, relationships, and enjoyment of life. (4)

It can also cause:

• Low self-esteem
• Trouble asserting yourself
• Negative self-talk
• Oversensitivity to criticism
• Poor social skills
• Difficult social relationships
• Low academic and employment achievement
• Suicide or suicide attempts

Compared with other anxiety disorders, social anxiety disorder is fairly common. According to the National Institute of Mental Health, it affects 7.1 percent of the U.S. adult population in a given year. (1) The condition affects about 15 million American adults and is the second most commonly diagnosed anxiety disorder after specific phobia. (3)

Social anxiety disorder usually develops early in life, typically in the early to mid-teens. (4)

Men and women are equally affected with social anxiety disorder. (2)

Other anxiety disorders and other mental health disorders, particularly major depressive disorder, often occur with social anxiety disorder. (4)

A 2018 study also found that social anxiety disorder is more prevalent in people who have bipolar disorder. (7)

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National Institute of Mental Health

The NIMH is the lead federal agency for research on mental disorders and part of the National Institutes of Health (NIH), the largest biomedical research agency in the world. Their website offers information about the prevalence of social anxiety disorder, along with signs and symptoms, treatment, and more information.

MedlinePlus

MedlinePlus is a service of the National Library of Medicine (NLM), the world’s largest medical library, which is also part of the National Institutes of Health (NIH). It offers information about the causes, symptoms, diagnosis, treatment, prognosis, and complications of social anxiety disorder.

Anxiety and Depression Association of America (ADAA)

The ADAA aims to improve the quality of life for people with anxiety, depression, and related disorders.

Additional reporting by Carlene Bauer.