Merck Manual

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Social Phobia

(Social Anxiety Disorder)

By

John W. Barnhill

, MD, Weill Cornell Medical College and New York Presbyterian Hospital

Last full review/revision Apr 2020| Content last modified Apr 2020
Click here for the Professional Version
Topic Resources

Social phobia is 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.

Phobias are a type of anxiety disorder in which certain situations or objects make people fearful, anxious and cause them to avoid those things. The fear and anxiety are out of proportion to the actual threat. There are many specific phobias.

Although some anxiety in social situations is normal, people with social phobia have so much anxiety that they either avoid social situations or endure them with distress. About 13% of people have social phobia sometime in their life. The disorder affects about 9% of women and 7% of men during any 12-month period.

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

People with social phobia 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 phobias are 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 phobia 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

A more general type of social phobia is characterized by anxiety in many social situations.

In both types of social phobia, 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 irrational and excessive.

Diagnosis

  • A doctor's evaluation, based on specific criteria

Doctors diagnose social phobia 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

Also, doctors rule out other mental disorders that can cause similar symptoms, such as agoraphobia, panic disorder, or body dysmorphic disorder.

Treatment

  • Exposure therapy

  • Cognitive-behavioral therapy

  • Antidepressants, usually selective serotonin reuptake inhibitors (SSRIs)

Social phobia often persists if left untreated, causing many people to avoid activities that they would otherwise like to do.

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 Toastmasters (an organization for those who have anxiety about speaking in front of an audience) 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, such as SSRIs, and benzodiazepines (antianxiety drugs) can often help people with social phobia. 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 drugs do not reduce anxiety itself.

More Information

NOTE: This is the Consumer Version. DOCTORS: Click here for the Professional Version
Click here for the Professional Version
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