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
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Topic Resources

Social phobia is fear of and anxiety about being exposed to certain social or performance situations. These situations are avoided or endured with substantial anxiety.

Phobias are a type of anxiety disorder in which 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 (taking social norms into account). There are many specific phobias.

Social phobia affects about 9% of women and 7% of men during any 12-month period, but the lifetime prevalence may be at least 13%. Men are more likely than women to also have avoidant personality disorder, which can be seen as an anxiety disorder that is severe and persistent enough to affect the person's personality.

Fear and anxiety in people with social phobia often center on being embarrassed or humiliated if they fail to meet people's expectations or are scrutinized by other people in social interactions. Often, the concern is that their anxiety will be apparent through sweating, blushing, vomiting, or trembling (sometimes as a quavering voice) or that the ability to keep a train of thought or find words to express themselves will be lost. Usually, the same activity done alone causes no anxiety.

Situations in which social phobia is common include public speaking, acting in a theatrical performance, and playing a musical instrument. Other potential situations include eating with others, meeting new people, having a conversation, signing a document before witnesses, or using public bathrooms. A more generalized type of social phobia causes anxiety in a broad array of social situations.

Most people recognize that their fears are unreasonable and excessive.

Diagnosis

  • Clinical criteria

Diagnosis is clinical based on criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).

To meet the DSM-5 criteria for diagnosis, patients must have a

  • Marked, persistent (≥ 6 months) fear of or anxiety about one or more social situations in which they may be scrutinized by others

Fear must involve a negative evaluation by others (eg, that patients will be humiliated, embarrassed, or rejected or will offend others). In addition, all of the following should be present:

  • The same social situations nearly always trigger fear or anxiety.

  • Patients actively avoid the situation.

  • The fear or anxiety is out of proportion to the actual threat (taking into account sociocultural norms).

  • The fear, anxiety, and/or avoidance cause significant distress or significantly impair social or occupational functioning.

Also, the fear and anxiety cannot be more correctly characterized as a different mental disorder (eg, agoraphobia, panic disorder, body dysmorphic disorder).

Treatment

  • Cognitive-behavioral therapy

  • Sometimes a selective serotonin reuptake inhibitor (SSRI)

Social phobia is almost always chronic, and treatment is needed.

Cognitive-behavioral therapy (CBT) is effective for social phobia. CBT involves teaching patients to recognize and control their distorted thinking and false beliefs as well as instructing them on exposure therapy (controlled exposure to the anxiety-provoking situation).

SSRIs and benzodiazepines are effective for social phobia, although benzodiazepines may be physically addictive and may also impair thinking and memory, faculties that are required for successful cognitive-behavioral therapy.

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

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