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Social Anxiety Disorder


John W. Barnhill

, MD, New York-Presbyterian Hospital

Reviewed/Revised Aug 2023
Topic Resources

Social anxiety disorder is characterized by fear or anxiety about certain social or performance situations. These situations are often avoided or endured with much distress.

Humans are social animals, and their ability to relate comfortably in social situations affects many important aspects of their lives, including family, education, work, leisure, dating, and relationships.

In social anxiety disorder, certain situations or objects make people fearful and anxious and cause them to avoid those things. The fear and anxiety are out of proportion to the actual threat.

Although some anxiety in social situations is normal, people with social anxiety disorder have so much anxiety that they either avoid social situations or endure them with distress. About 13% of people have social anxiety disorder sometime in their life. The disorder affects about 9% of women and 7% of men yearly.

Overview of Phobias

Some adults with social anxiety disorder were shy as children, while others did not develop significant anxiety symptoms until after puberty.

People with social anxiety disorder are concerned that their performance or actions will seem inappropriate. Often, they worry that their anxiety will be obvious—that they will sweat, blush, vomit, or tremble or that their voice will quaver. They also worry that they will lose their train of thought or that they will not be able to find the words to express themselves.

Some social anxiety is tied to specific performance situations, producing anxiety only when the people must perform a particular activity in public. The same activity performed alone produces no anxiety. Situations that commonly trigger anxiety among people with social anxiety disorder include the following:

  • Public speaking

  • Performing publicly, such as reading in church or playing a musical instrument

  • Eating with others

  • Meeting new people

  • Having a conversation

  • Signing a document before witnesses

  • Using a public bathroom

Some people have social anxiety symptoms in one or a few specific situations, while others experience them in a broader range of settings. In either type of social anxiety, people fear that if they fail to meet other people's expectations or are scrutinized in social interactions, they will feel embarrassed, humiliated, or rejected, or will offend others.

People may or may not recognize that their fears are excessive.

Diagnosis of Social Anxiety Disorder

  • A doctor's evaluation, based on standard psychiatric diagnostic criteria

Doctors diagnose social anxiety disorder when people have fear or anxiety that involves all of the following:

  • Is intense and has been present for 6 months or longer

  • Concerns one or more social situations

  • Nearly always occurs in the same situation or situations

  • Involves fear of a negative evaluation by others

  • Leads the person to avoid the situation or uncomfortably endure it

  • Is out of proportion to the actual danger

  • Causes significant distress or significantly impairs functioning

Treatment of Social Anxiety Disorder

  • Exposure therapy

  • Cognitive-behavioral therapy

  • Antidepressants, usually selective serotonin reuptake inhibitors (SSRIs)

Like other anxiety disorders, social anxiety disorder varies in severity over time. Social anxiety often persists if left untreated, causing many people to avoid activities that they would otherwise like to do. Many people with social anxiety never seek treatment but instead develop their own strategies for managing it. For example, they might avoid social situations, "self-medicate" with alcohol or marijuana, or just uncomfortably grit their way through social obligations. However, there are effective treatment options for social anxiety disorder.

Exposure therapy is usually effective. But arranging for exposure to last long enough to allow people to get used to the anxiety-provoking situation and grow comfortable in that situation may not be easy. For example, people who are afraid of speaking in front of their boss may not be able to arrange a series of speaking sessions in front of that boss. Substitute situations may help, such as joining a community group that helps with public speaking or reading a book to nursing home residents.

Cognitive-behavioral therapy may also help. With this therapy, people learn to do the following:

  • Use relaxation techniques

  • Identify patterns of thinking and behavior that may trigger anxiety or panic

  • Adjust those patterns of thinking

  • Modify their behavior accordingly

Antidepressants Drug Treatment for Depression Agomelatine, a new type of antidepressant, is a possible treatment for major depressive episodes. Several types of drugs can be used to treat depression: Selective serotonin reuptake inhibitors... read more , such as SSRIs, and benzodiazepines (antianxiety medications) can often help people with social anxiety. SSRIs are usually preferred because they, unlike benzodiazepines, are unlikely to interfere with cognitive-behavioral therapy. Benzodiazepines affect the central nervous system (brain and spinal cord) and can cause sleepiness and memory problems.

Beta-blockers may be used to reduce the increased heart rate, trembling, and sweating experienced by people who are distressed by performing in public, but these medications do not reduce anxiety itself.

More Information

The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.

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