Social Anxiety Disorder

Also known as a social phobia, social anxiety disorder involves an intense fear of being embarrassed or rejected during the course of social interaction or some form of public performance. The condition is more common among women when compared to men, and it is often treated with medication and therapy. ^[1]

What is social anxiety disorder?

Social anxiety disorder is a mental health condition that leads to fear in social situations where a person might be subject to evaluation or rejection by others. The condition was once called social phobia, but with newer editions of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), it is now referred to as social anxiety disorder, because mental health experts have determined that social anxiety disorder differs clinically from a specific phobia. ^[1]

People who live with social anxiety typically begin to experience symptoms during childhood. The condition makes it difficult to engage in social situations due to an extreme fear of being negatively judged. Some people with social anxiety disorder may avoid social situations altogether because of their intense fear and worry. ^[1]

Types of Social Anxiety Disorder

According to the DSM 5, there are two overarching types of social anxiety disorder. The first type is a general social anxiety disorder diagnosis, in which a person experiences social anxiety in one or more common social settings, such as at work, when having conversations, or when eating in a public setting.

The second type is a specific form of social anxiety, referred to as performance only. This type of social anxiety occurs only in cases of public performance, such as when giving a speech or presentation. ^[1]

Symptoms of social anxiety disorder

When a person lives with social anxiety disorder, there are some general symptoms that they will display. These symptoms can be divided into psychological symptoms, physical symptoms, and avoidance symptoms. ^[2]

Psychological symptoms of social anxiety disorder include: ^[2]

• Experiencing intense fear of social situations
• Having a level of anxiety that is out of control when faced with a social situation
• Worrying about being judged or ridiculed when doing everyday activities like using a public restroom
• Suffering through extreme anxiety when undergoing social situations, such as being at a party or giving a presentation
• Feeling extremely self-conscious in social settings
• Worrying about social events weeks in advance

Physical symptoms, which appear when a person is faced with a social interaction, include: ^[2]

• Sweating
• Blushing
• Trembling
• Feeling sick to the stomach
• Experiencing the sensation of the mind going blank
• Speaking in a very soft voice

Avoidance symptoms appear as follows ^[2]:

• Avoiding going to work because of anxiety
• Missing out on social gatherings
• Having a difficult time making conversation or maintaining eye contact
• Avoiding places where other people will be

Causes of social anxiety disorder

There is not one single cause of social anxiety disorder. Rather, a combination of risk factors can make a person more likely to develop the condition. Some common risk factors are described below:

• Genetics: Research shows that social anxiety disorder tends to run in families, with children being more likely to experience the mental health condition if their parents also have social anxiety. Estimates on the genetic contribution to social anxiety disorder range from 13% to 60%. Environmental factors beyond genetics are also believed to be at play, but genetics seem to be at least moderately linked to the development of social anxiety disorder. ^[3]
• Environmental factors: Factors within the environment, such as a child’s experience at school and their peer relationships, can also contribute to social anxiety. In addition, negative or stressful life events can increase the risk of social anxiety disorder. ^[1]
• Biological factors: Individuals with social anxiety disorder may have some functional abnormalities in certain areas of the brain, including the amygdala, which is responsible for processing emotional stimuli. Children with social anxiety disorder tend to show increased activation in the amygdala when processing emotional information, suggesting that this brain region may play a role in the development of the disorder. ^[3]
• Temperament: Children with social anxiety disorder display an inhibited temperament, meaning they have a tendency to avoid the unfamiliar and to be especially sensitive to new stimuli. Children who demonstrate behavioral inhibition tend to have more signs of physiological arousal at rest, and they respond more intensely to novel stimuli, as evidenced by increased heart rate and muscle tension when compared to uninhibited children. ^[3]
• Parenting: Having an overly controlling or intrusive parent can lead a child to develop an inhibited temperament, which can contribute to social anxiety disorder. ^[1] Severe and harsh parenting is also linked to social anxiety in children. ^[3]

Diagnosing social anxiety disorder

When a person presents with symptoms of social anxiety disorder, a mental health professional like a psychologist or clinical social worker will diagnose the condition using criteria in the DSM. The mental health professional will ask a series of questions to gather information about what symptoms the person is experiencing. They may also ask when symptoms began, as social anxiety disorder typically has an onset in childhood. ^[1]

A clinician making a diagnosis of social anxiety disorder may use standardized questionnaires or instruments that capture symptoms of the condition. Ultimately, a clinician must determine if a person meets diagnostic criteria for social anxiety disorder. The clinician may have to rule out alternative diagnoses, such as panic disorder, major depressive disorder, autism spectrum disorder, and personality disorders like avoidant personality disorder or schizoid personality disorder ^[1].

To receive a diagnosis of social anxiety disorder, a person must meet the following diagnostic criteria ^[4] in the DSM:

• Noticeable fear or anxiety related to at least one social situation, such as having conversations, meeting new people, being seen eating or drinking, or giving a presentation
• The fear or anxiety surrounding social situations is related to the person’s belief that they will act in a way that will cause negative judgment from others
• Social situations almost always cause fear and anxiety, and in children, this may manifest in the form of crying, tantrums, or clinging to an adult when faced with a social situation
• The fear of social situations exceeds any actual threat that the situation would present
• The person either avoids social situations altogether or suffers intense anxiety if they choose to participate in social interaction
• Symptoms of anxiety last for at least six months and are not better explained by substance misuse or another medical condition

Prevention of social anxiety disorder

There is no proven way to prevent social anxiety disorder, but if risk factors are present for the condition, there are things that can be done to promote mental health functioning and make anxiety symptoms more manageable. For example, seeking help when first noticing symptoms can connect a person to professional support and help them to develop coping skills for managing anxiety. Studies suggest that receiving treatment for social anxiety during the teen years is beneficial. ^[5]

Practicing good habits, such as maintaining a consistent sleep schedule, and avoiding the use of drugs and alcohol can also play a critical role in preventing complications from social anxiety disorder. There is evidence that treating insomnia may play a preventive role against social anxiety. ^[6]

Treatment for social anxiety disorder

Treatment for social anxiety disorder typically involves medication, therapy, or a combination of the two. These approaches are described in more detail below.

Medications

There are several classes of medications that are used in the treatment of social anxiety disorder. The most commonly utilized medications are as follows: ^[1]

• Antidepressant medications: Two classes of antidepressant drugs called SSRIs and SNRIs have been found to be effective for treating social anxiety disorder. The SSRI medications sertraline and paroxetine are FDA approved for treating social anxiety disorder. Other SSRI drugs include fluoxetine, fluvoxamine, citalopram, escitalopram, and vilazodone. ^[7] The SNRI medication venlafaxine is also FDA-approved for social anxiety. Other medications in this class include duloxetine, desvenlafaxine, milnacipran, and levomilnacipran.
• Anxiety medications: A class of anxiety medications called benzodiazepines may also be used to treat social anxiety disorder. These medications do come with a risk of physical dependence, so they should be used with caution. ^[1] Medications in this class include Xanax, Librium, Valium, Ativan, and Serax. ^[9]
• Propranolol: Propranolol is a beta-blocker used to treat high blood pressure. It is sometimes used to treat social anxiety disorder as an alternative to benzodiazepines, as it does not come with the risk of dependence like benzodiazepines do. ^[1]

Therapy

There are several therapeutic techniques that may be useful for social anxiety disorder. Some of the most common are described below: ^[10]

• Cognitive Behavioral Therapy (CBT): According to research, CBT is one of the most effective therapeutic modalities for treating social anxiety disorder. CBT teaches people to replace distressing or irrational thoughts with more rational ways of thinking.
• Psychodynamic Therapy: This therapeutic modality helps people to explore unresolved issues from childhood and other subconscious drives that may be leading them to experience symptoms of anxiety.
• Exposure Therapy: In this type of therapy, a mental health professional helps a patient to gradually expose themselves to the source of their anxiety. Exposure is said to reduce the fear associated with social situations.
• Interpersonal Therapy: This modality focuses on resolving interpersonal problems in order to reduce symptoms of social anxiety.

The best type of therapy for social anxiety disorder depends upon a patient’s specific needs. In general, therapy sessions can teach people with social anxiety how to cope with their symptoms and think differently about situations that cause fear and anxiety.

Self-care for social anxiety disorder

If you have social anxiety disorder, there are steps you can take to make anxiety more manageable, in addition to seeking treatment. Consider the self-care tips below:

• Establish a healthy sleep routine. Going to bed around the same time and waking up at the same time each day can help you to develop a healthy sleep schedule. If it’s a struggle to fall asleep or stay asleep at night, talk with a doctor. Research suggests that receiving treatment for insomnia can make social anxiety symptoms less severe. ^[6]
• Practice relaxation techniques. Relaxation techniques like deep breathing, meditation, and aromatherapy can be beneficial practices when living with social anxiety. One recent study found that learning about relaxation techniques reduced social anxiety symptoms in college students. ^[11]
• Avoid caffeine. If you’re prone to social anxiety, a cup of coffee in the morning may make matters worse. Studies have found that caffeine has an anxiety-inducing effect because it activates the brain’s amygdala, which is responsible for processing threats. ^[12] Switching to decaf or limiting your consumption before social events is a wise idea.

Helping someone with social anxiety disorder

If a friend or family member lives with social anxiety disorder, chances are that they would benefit from a loved one’s support. By learning more about the condition, a person has a far better understanding of what they are experiencing. It’s also important to be empathetic. Sometimes their reluctance to engage in social events can be frustrating, but remember, they are living with a diagnosable condition that makes these events seem quite threatening.

Perhaps one of the best things to do to help a loved one is encourage them to seek treatment. Left untreated, social anxiety disorder can lead to significant distress and make it difficult for people to function in everyday life. ^[1] However, treatment is effective and can improve an individual’s quality of life.

FAQs about social anxiety disorder

How Common is Social Anxiety Disorder?

Social anxiety disorder is the most common anxiety disorder, and it affects 8.4% to 15% of people during their lifetimes. It is more common in women when compared to men, and it is the third most common mental health condition, behind substance use disorders and depression. ^[1]

What is the Outlook for Social Anxiety Disorder?

There are effective treatments that can make symptoms of social anxiety disorder more manageable. Without treatment, people with this condition are at risk of low educational attainment, relationship problems, reduced quality of life, and poor work performance. Ultimately, social anxiety disorder can lead to unemployment, financial problems, suicidal ideation, and self-esteem problems. ^[1] This is why it’s so important to seek treatment.

What’s the Difference Between Social Anxiety Disorder vs. Avoidant Personality Disorder?

Social anxiety disorder appears similar to avoidant personality disorder, but the two mental health conditions are distinct. Social anxiety disorder involves irrational fear or anxiety surrounding social situations, as a person is worried they will be negatively evaluated or rejected. Similarly, individuals with avoidant personality disorder avoid social situations because they are fearful of being rejected or criticized. However, avoidant personality disorder has additional symptoms that are separate from what is seen in cases of social anxiety.

What is different about avoidant personality disorder is that individuals with this condition view themselves as being socially inept, inadequate, or otherwise inferior to other people, which leads them to avoid developing new relationships. They avoid taking risks or getting involved in new activities, and they will only interact with other people if they are sure they will be liked. ^[13]