Health Library Social Anxiety DisorderFrom Healthwise

What is social anxiety disorder?

People with social anxiety disorder (or social phobia) are extremely anxious about what they will say or do in front of other people. This includes public speaking and day-to-day social situations. But it is more than just being shy or nervous before public speaking. The fear can begin weeks or months before an event. It can cause a fast heartbeat and make it hard to focus.

Some people fear only one or a few types of social situations. For other people, many situations cause stress. This problem affects your daily life. You may be so stressed or afraid that you avoid public situations, including missing work and school.

What causes social anxiety disorder?

Doctors don't know what causes social anxiety disorder. They think it may run in families, but they are not sure if it's because of genetics or a response to a traumatic situation.

What are the symptoms?

Social anxiety disorder causes both emotional and physical symptoms:

• It can make you nervous, sad, or easily upset before or during a social event. You may worry a lot or be afraid that something bad will happen.
• The anxiety can cause you to blush, sweat, and feel shaky. Your heart may beat faster than normal, and you may have a hard time focusing.

How is social anxiety disorder diagnosed?

To diagnose social anxiety disorder, your doctor will examine you and ask about your symptoms. He or she may ask other questions to see how you are doing emotionally. This is called a mental health assessment.

Your doctor may also do blood or urine tests to rule out other conditions, such as thyroid problems that can cause similar symptoms.

How is it treated?

Treatment of social anxiety disorder includes counseling and sometimes medicine, such as antidepressants. Whether you need medicine depends on how much the problem affects your daily life. If you already feel anxious around other people, it may be hard to ask for help. But treatment for social anxiety disorder works for many people.

Some people with social anxiety disorder turn to alcohol or drugs to help them relax. This can lead to addiction problems. They may also have depression. It is important to treat these issues too.

Frequently Asked Questions

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	Anxiety: Using positive thinking
	Positive thinking: Stopping unwanted thoughts
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	Stress management: Doing meditation
	Stress management: Doing progressive muscle relaxation
	Stress management: Relaxing your mind and body

Social anxiety disorder causes unreasonable, debilitating fear of being judged or publicly humiliated. You may avoid or severely limit encounters with other people—which can keep you from daily activities. You may develop physical symptoms such as a rapid heartbeat, shortness of breath, or tightness in your chest when faced with a feared social situation.

When you have social anxiety disorder, common social situations—such as eating in public, writing in front of other people, using a public restroom, or speaking in front of others—can cause overwhelming fear and anxiety.

You may be more afraid of people noticing your anxiety than of the actual feared situation. A vicious cycle can emerge of avoiding or worrying about the social event (such as speaking in public) because you are afraid others will see you as weak, anxious, or foolish—this, in turn, leads to more anxiety. This may lead to avoiding or limiting contact with other people.

Symptoms of social anxiety disorder may differ in adults and children. Adults and teenagers with social anxiety disorder usually recognize their fears of being publicly humiliated are unreasonable or excessive, while children who have this disorder may not.¹

Expressions of anxiety in adults or adolescents include:^{1, 2}

• Having persistent but unreasonable fear of a situation that involves unfamiliar people or being judged by others. The fear is that you will be embarrassed or humiliated by something that you say or do.
• Developing severe anxiety or panic attacks when in the feared situation.
• Recognizing that your fears are excessive or unreasonable.
• Avoiding social situations that you fear, or enduring them with intense anxiety or distress.
• Avoiding or anxiously anticipating feared situations so much it interferes with daily activities and relationships.
• Worrying about being anxious.

Expressions of anxiety in children include:^{1, 2}

• Worrying about being embarrassed in front of their peers, but not usually adults or teenagers.
• Expressing anxiety by frequently crying, throwing tantrums, "freezing" in social situations, or "shrinking back" from unfamiliar people.
• Denying or not realizing the fears are excessive or unreasonable.
• Fearing performance situations, such as having to speak in front of the class. This fear doesn't come and go; it is continuous and lasts for 6 months or longer.

People with social anxiety disorder often underachieve at work or at school to avoid the attention of a promotion or to avoid being forced to participate in a group.¹ They tend to have few friendships and have trouble dating or developing relationships. In prolonged or severe cases, many people develop other psychological conditions (such as depression or substance abuse).³

Social anxiety disorder is among several types of phobias that many people experience, such as agoraphobia or specific phobia (fearing an object, like a spider, or a frightening situation, such as being stuck in an elevator).

Social anxiety disorder is diagnosed based on your medical history, physical exam, and sometimes a mental health assessment, which is an evaluation of psychological symptoms.

Blood or urine tests may also be done to rule out other medical conditions that can cause similar symptoms (such as hyperthyroidism).

Treatment for social anxiety disorder involves psychological counseling and sometimes medications (such as antidepressants) to reduce associated anxiety and depression.

A combination of medications and professional counseling is most effective for people who have generalized anxiety and fear over many social situations.⁴ For those who fear only one or a few social situations (such as public speaking or eating in front of others), professional counseling to overcome the fear may be all that is needed.²

Unfortunately, many people don't seek treatment for anxiety disorders. You may not seek treatment because you think the symptoms are not bad enough or that you can work things out on your own. But getting treatment is important.

If you need help deciding whether to see your doctor, see some reasons why people don't get help and how to overcome them.

Initial and ongoing treatment

Initial treatment of social anxiety disorder is based on the severity of your emotional and physical symptoms and your ability to function in daily activities. People who have social anxiety disorder often have depression as well. They may also have alcohol or substance abuse problems. Your health professional may ask you certain questions to see whether you might be drinking too much or abusing drugs.

Social anxiety disorder often goes undetected for years before treatment is sought—by that time, you may have developed behaviors that accommodate the fears. These habits or behaviors must be overcome to successfully manage social anxiety disorder.

First, your health professional must determine whether you are generally anxious about all social encounters, or whether a specific situation triggers anxiety.

Treatment with a combination of medications and professional counseling is often effective for generalized social anxiety disorder (fear of most public interaction). Some people need treatment throughout their lives, while others may recover completely after a period of treatment with counseling and medications.

It is possible to overcome the fears associated with social anxiety disorder. Working through fears with a specific type of therapy—cognitive-behavioral therapy that includes exposure therapy—may be the best approach for treating your anxiety. It is important to continue professional counseling even if you are taking medications to reduce anxiety.

Types of counseling most often used to treat social anxiety disorder include:²

• Cognitive-behavioral therapy, which helps you identify anxieties and the situations that provoke the anxiety. Initially, you may feel uncomfortable while addressing the feared situations, but it is an important part of your recovery. Several types of cognitive-behavioral therapy are used to treat social anxiety disorder, including:
  • Exposure therapy. You will be guided by a professional counselor to imagine you are facing the feared situation until you no longer fear it, such as eating in public. Next, you may go with your counselor to a public place and eat until, eventually, you can eat by yourself in public without fear.
  • Social skills training. This therapy helps you develop the skills you need in social situations through rehearsing and role-playing. Your anxiety is reduced as you become more comfortable with and prepared for the feared social situations.
  • Cognitive restructuring. This therapy helps you learn to identify and improve fearful thinking to help you better handle social situations. For more information, see:

    Positive thinking: Stopping unwanted thoughts.

    Anxiety: Using positive thinking.

    Positive Thinking With Cognitive-Behavioral Therapy.

  • Symptom management skills. This therapy teaches you how to reduce stress by controlling your breathing and other physical responses to anxiety.
• Supportive therapy. This can include:
  • Education about the disorder.
  • Family therapy, to support loved ones affected by your condition.
  • Group therapy or support groups, to seek support from others also diagnosed with the disorder.

Medications often used for chronic, severe, or generalized social anxiety disorder include:^{5, 2}

• Selective serotonin reuptake inhibitors (SSRIs), to relieve anxiety. SSRIs are often the first type of medication used to treat generalized social anxiety disorder.⁶
• Benzodiazepines, to relieve anxiety. They are fast-acting; however, they may be habit-forming and are not generally used in those with substance abuse problems.
• Monoamine oxidase inhibitors (MAOIs), to relieve depression and anxiety. MAOIs have potentially serious side effects when they are taken with certain foods (such as some cheeses and red wine).
• Beta-blockers, to reduce anxiety. Beta-blockers are sometimes used to treat physical symptoms of anxiety (such as tremors or rapid heart rate).
• Venlafaxine, to help relieve anxiety and depression.

Ongoing treatment of social anxiety disorder usually includes continuing psychological counseling and regular checkups to monitor any medications you may be taking. If professional counseling alone has not reduced your anxiety symptoms, medications may be added to your treatment.

If your anxiety is triggered by many social situations (generalized), you may need continuous and prolonged treatment with a combination of counseling and medications. During this time, your health professional will need to monitor your medications. If one medication is ineffective, you and your health professional may decide you should try another.

Treatment if the condition gets worse

With social anxiety disorder, it is possible to progress from debilitating fear of one social situation to having anxiety about all social encounters (generalized). If this occurs, additional treatment is needed that usually includes adding medications and increasing the amount of professional counseling you receive.

You may also feel more anxious when starting professional counseling. This is because you are thinking about the situations that cause you fear and anxiety. Once the situations have been identified, the fears can be addressed through counseling—especially cognitive-behavioral therapy which includes exposure therapy—gradually exposing you to your fear.

If you are taking medications to treat social anxiety disorder, you will need regular checkups to monitor the medications (such as selective serotonin reuptake inhibitors) and their potential side effects. The medications may cause bothersome side effects that may make your anxiety worse at first. These side effects may get better over time. But if they do not, you may need to take a different medicine.

If social anxiety disorder is left untreated or improperly treated, it can cause debilitating distress that interferes with daily activities. Physical symptoms such as rapid heart rate, blushing, shortness of breath, and dizziness can occur and need to be assessed.

Other psychological conditions (such as depression or substance abuse) may accompany social anxiety disorder, and these conditions need additional treatment. If left untreated, the combination of social anxiety disorder and another psychological condition (such as depression) can increase the risk of attempted suicide.³

While counseling and medications are the most effective treatments for social anxiety disorder, you may wish to reduce your anxiety level at home by practicing a healthy lifestyle.

• Get regular exercise. Start slowly so that you don't overdo it. Build up your exercise program bit by bit, and aim for at least 2½ hours a week of moderate exercise.⁷ It's fine to be active in blocks of 10 minutes or more throughout your day and week.⁷
• Get enough sleep by going to bed at nearly the same time every night. Also, keeping your room quiet and dark may reduce distractions and help you get a good night's rest.
• Eat a balanced diet by choosing foods low in fat and high in fiber.
• Avoid foods and beverages that contain caffeine, such as chocolate and coffee, since they may increase your anxiety.
• Try some relaxation exercises. Certain breathing exercises and muscle relaxation exercises help reduce anxiety. For information, see:

  Stress management: Breathing exercises for relaxation.

  Stress management: Doing guided imagery to relax.

  Stress management: Doing meditation.

  Stress management: Doing progressive muscle relaxation.

  Stress management: Relaxing your mind and body.

• Change how you think. This can change how you feel and can reduce your anxiety. For more information, see:

  Positive thinking: Stopping unwanted thoughts.

  Anxiety: Using positive thinking.

  Positive Thinking With Cognitive-Behavioral Therapy.

If you drink alcohol or use drugs in an attempt to gain confidence to face feared social situations, it is possible to develop substance abuse problems in addition to social anxiety disorder. For more information, see the topic Alcohol Abuse and Dependence.

Organizations

• Alcohol Abuse and Dependence
• Alcohol and Drug Problems
• Depression
• Depression in Children and Teens
• Panic Attacks and Panic Disorder

Citations

1. American Psychiatric Association (2000). Anxiety disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 450–456. Washington, DC: American Psychiatric Association.
2. Raj BA, Sheehan DV (2001). Social anxiety disorder. Medical Clinics of North America, 85(3): 711–733.
3. Hales, RE, Yudofsky SC, eds. (2003). Social phobia. Textbook of Clinical Psychiatry, 4th ed., pp. 572–580. Washington, DC: American Psychiatric Publishing.
4. Stein MB, Kean YM (2000). Disability and quality of life in social phobia: Epidemiologic findings. American Journal of Psychiatry, 157(10): 1606–1613.
5. Van Ameringen MA, et al. (2001). Sertraline treatment of generalized social phobia: A 20-week, double-blind, placebo-controlled study. American Journal of Psychiatry, 158(2): 275–281.
6. Wagstaff AJ, et al. (2002). Spotlight on paroxetine in psychiatric disorders in adults. Drugs, 62(4): 655–703.
7. U.S. Department of Health and Human Services (2008). 2008 Physical Activity Guidelines for Americans (ODPHP Publication No. U0036). Washington, DC: U.S. Government Printing Office. Available online: http://www.health.gov/paguidelines/pdf/paguide.pdf.

Other Works Consulted

• Zal HM (2003). Social phobia: Treatment issues. Psychiatric Times, 20(6): 80–83.
• Merikangas KR (2005). Anxiety disorders: Epidemiology. In BJ Sadock, VA Sadock, eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 8th ed., vol. 1, pp. 1720–1728. Philadelphia: Lippincott Williams and Wilkins.
• Shear MK (2003). Anxiety disorders. In DC Dale, DD Federman, eds. Scientific American Medicine, section 13, chap. 8. New York: WebMD.

Author:	Jeannette Curtis	Last Updated: August 27, 2007
Medical Review:	Kathleen Romito, MD - Family Medicine Lisa S. Weinstock, MD - Psychiatry
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