Social Anxiety Disorder

Existing treatments can be highly effective for social anxiety disorder, and new approaches may offer new options for people suffering from this condition.

Key takeaways

• Social anxiety disorder is a common disorder affecting around 15 million Americans every year

• People with social anxiety disorder experience intense fear in social situations, especially if there is a risk that others might view them negatively

• Treatment for social anxiety disorder usually starts with psychotherapy. Medications are also available to help

Understanding social anxiety

Social anxiety is an anxiety disorder in which people experience intense fear around social situations, especially about what other people think of them. For someone with social anxiety, the thought of people having a negative opinion of them is extremely distressing.^[2]

Social anxiety disorder is relatively common, affecting 7.1% of US adults (15 million) each year. Approximately 12.1% of the population will experience the condition at some point in their lives.^[3]Social anxiety disorder usually first appears during adolescence.^[4]

Is it the same as social phobia?

Social anxiety disorder was first described in 1965 and was called “social phobia”.^[5]In 1994, it was given the alternative name of social anxiety disorder, and the term social phobia was dropped in 2013.^[6]

Causes of social anxiety disorder

As with most mental health conditions, social anxiety disorder doesn’t have a simple cause. Instead, it is due to a combination of different factors, each of which affects the likelihood of someone developing the disorder.

Some people have a genetic susceptibility to social anxiety disorder, and having a close relative, such as a parent or sibling, with the condition increases the risk of developing it. Estimates suggest that genetics accounts for about 25-50% of the probability.^[7]

Life experiences play an important role. Stressful life events, especially those occurring during childhood or involving social situations, can increase the risk of developing social anxiety disorder. Conversely, experiencing social connectedness can decrease that risk.^[8]Some researchers suggest that an overprotective parenting style may also increase the probability that someone will develop social anxiety disorder.^[9]

Given the effectiveness of certain antidepressants, specifically SSRIs and MAOIs, researchers believe that people with social anxiety probably have some form of hormone imbalance that contributes to their symptoms. This hasn’t been proven yet, however.^[4]

Social anxiety and the brain

Social anxiety disorder is associated with different patterns of activation in several regions of the brain, most commonly the amygdala and the prefrontal cortex (PFC).^[10]

The amygdala is strongly associated with fear, including focusing attention on threatening stimuli and trying to avoid those threats. There is limited evidence that children with behavioral inhibition (a common precursor to social anxiety disorder) have larger amygdalas than others.^[11]People with social anxiety disorder have increased amygdala responses to threatening and non-threatening social stimuli.^[11][12]

The PFC can regulate the amygdala response, but this is less effective in people with social anxiety disorder. Children with social anxiety disorder take longer to go back to normal after experiencing stressful social situations.^[13]

Other research suggests that people with social anxiety disorder have greater brain activation to social rewards, especially in the striatum, which means they place a higher value on achieving positive outcomes in social situations.^[14]This appears to be specific to social anxiety disorder, as the same pattern isn’t seen in those with generalized anxiety disorder.^[10]

Normal brain development includes significant reorganization of these brain regions during adolescence and young adulthood, which could explain why social anxiety disorder almost always appears during this period.^[10]

Who is most likely to develop social anxiety disorder?

Women are approximately 50% more likely than men to develop social anxiety disorder, but men with the disorder are more likely to seek treatment.^[15][16]

Developing social anxiety disorder for the first time is less likely in adults. 90% of people with social anxiety disorder first experienced it by the time they were 23.^[17]

Children who show behavioral inhibition (nervousness and avoidance of new situations or people) are more likely to develop social anxiety during adolescence. There is also some evidence that people who internalize their problems are at greater risk.^[14]

Social anxiety symptoms

Social anxiety causes physical, emotional, and cognitive symptoms. Common symptoms include^[14][18]

• Blushing

• Sweating

• Shaking

• Accelerated heart rate or palpitations

• Nausea

• Mind goes blank

• Extremely quiet speech

• Difficulty with eye contact

• Fear

• Avoidance

• Diarrhea and stomach upset

• Frequent need to urinate

• Dizziness or feeling faint

• Panic attacks

• Negative rumination (overthinking and worrying)

Social anxiety and selective mutism

Selective mutism is a condition, usually affecting children, where someone can speak in certain situations but does not speak in others.^[19]Almost all children diagnosed with selective mutism also receive a diagnosis of social anxiety disorder.^[20]Some researchers believe that selective mutism is an early or severe form of social anxiety, while others suggest that the disorders have different causes.^[21][22]

Diagnosing social anxiety disorder

Social anxiety disorder may be diagnosed by your doctor, or they may refer you to a mental health specialist, such as a psychologist or psychiatrist. They will ask you about your experiences of social situations, as well as other questions about your health, lifestyle, and well-being.

During this conversation, they will be trying to assess whether you fit the criteria set out in DSM-V.^[6]These are

• That you experience ongoing fear of social situations based on how you are perceived by others

• That you either avoid these social situations or experience fear and anxiety while you tolerate them

• That your anxiety is out of proportion to the risk involved or the fear that other people experience

• That this fear is causing you distress or making it difficult for you to live your life

• That this fear is not due to another medical condition, medication, or drug use

• That these symptoms have lasted for at least 6 months

As part of this diagnosis, your medical practitioner may ask for some tests to rule out other causes for your symptoms. They may also ask you to complete a screening test, such as the Liebowitz Social Anxiety Scale, to help them understand your symptoms.^[23]

Risk factors and complications

Social anxiety disorder can negatively impact many aspects of people’s lives. Children may refuse to attend school because of their anxiety, leading to lower educational achievements.^[24]People with social anxiety disorder typically have fewer friends, are less likely to be married, and are more likely to divorce.^[25]

80% of people with social anxiety disorder will experience another mental health condition at some point in their lives.^[26]Common disorders related to social anxiety disorder are depression and substance use disorder. Some people may misuse substances as a way to deal with their social anxiety, and severe social anxiety can leave people feeling hopeless and prone to depression.^[4]Alternatively, some social anxiety can result from depression and may go away if the depression is successfully treated.

Treatment for social anxiety disorder

Treatments are available for social anxiety disorder, but only about half of people with this diagnosis seek help.^[4]For children, in particular, there can be a misconception that they will ‘grow out of it’. Unfortunately, social anxiety disorder rarely goes away without treatment.^[27]

Therapy

The most common form of psychotherapy (also known as talking therapy) for social anxiety disorder is cognitive behavioral therapy (CBT). This is designed to challenge the false beliefs you might hold about how others see you.^[28]

A variation of CBT is exposure therapy, where a therapist works with you to slowly face your fears in manageable amounts. This allows you to experience situations that trigger your anxiety and learn that the negative outcomes you fear don’t happen.

Acceptance and commitment therapy (ACT) can also be used for people with social anxiety disorder. This doesn’t necessarily aim to remove the negative feelings, but instead helps you learn to accept that you have them and allow them to pass while treating yourself with compassion.^[29]

Interpersonal psychotherapy (IPT) typically focuses on framing a disorder as an illness (to remove guilt and shame) and building up strong social relationships. This can be helpful for people with social anxiety disorder.^[30]

Some treatments offer people with social anxiety disorder social skills training to improve their performance in social environments. While this can help some people, there is little evidence that people with social anxiety disorder usually lack these skills.^[4]

Medication

Medications for social anxiety disorder can be effective, helping to reduce the symptoms. For some patients, relieving the symptoms allows people to develop healthy, supportive social relationships and improve their condition long-term.

Antidepressants, especially selective serotonin reuptake inhibitors (SSRIs) and selective serotonin-norepinephrine inhibitors (SNRIs), are the first-line treatment for social anxiety disorder.^[31]These medications can take several weeks to take effect, so patients will usually need to continue them for an extended period to know whether they are helpful.

If these medications are not effective, doctors may prescribe benzodiazepines. These are effective at reducing the symptoms of anxiety, but can cause dependence and are open to abuse. Doctors will usually only prescribe benzodiazepines, such as clonazepam, for a few weeks or months. Gabapentin and pregabalin are sometimes used as less addictive alternatives to benzodiazepines.

Beta-blockers, such as propranolol, are also offered to many patients with social anxiety disorder to help reduce their symptoms.^[32]

Alternative

Few alternative treatments are currently being investigated for social anxiety disorder. Some possible therapies, such as repetitive transcranial magnetic stimulation (rTMS), have been used effectively for depression and OCD and may be useful for patients with social anxiety in the future. At the moment, however, there is insufficient evidence as to whether this will be effective.^[33]

Self-managing social anxiety disorder

Social anxiety disorder rarely goes away without help, but asking for help can be difficult, especially for people who are concerned about negative judgments from others.

Consider how to make it easier to ask for help. This will be different for each person, so take any option that feels best for you.

• Writing an email lets you get your thoughts straight before sending, but it can leave you worrying before receiving a reply

• A phone call avoids the need for eye contact

• Face-to-face conversations let you read the other person’s body language

• Talking to a close friend can feel easier

• Talking to a healthcare professional can feel less personal.

There is no right or wrong decision.

Final thoughts

Social anxiety disorder is a distressing disorder that disrupts patients’ lives. Only about half of all patients with the disorder seek treatment, but they rarely recover without help. If you’re worried about social anxiety disorder, contact your doctor or healthcare provider as soon as possible. Effective treatments are available, and you don’t need to suffer alone.