Social Anxiety Disorder is a mental health condition that will affect 12% of adults in America at some point in their lives. This condition is characterized by excessive fear of certain social situations and specific concerns of being negatively judged by others. Often, social anxiety leads to avoidance of these situations, impairing a person’s ability to function and affecting their quality of life.
Social Anxiety Disorder, also called Social Phobia, is highly treatable. Treatment for social anxiety may include medication or therapy, or a combination of the two. Therapy is often the first treatment for social anxiety, as it carries fewer risks than certain anxiety medications. The most common and proven form of therapy for social anxiety disorder is Cognitive Behavioral Therapy, or CBT.
Types of Social Anxiety Disorder
Social anxiety disorder is one of several types of anxiety disorders. While all anxiety disorders share a common symptom of excessive fear or worrying, people with this disorder only experience symptoms in response to social situations. These symptoms might occur before, during, or even after a social interaction or event, but are always related to social aspects. Specifically, social anxiety is driven by concerns about being judged, critiqued, or disliked by others.
People with social anxiety disorder may fear different types of interactions and situations. Some people develop anxiety in any social situation, including when they are with people they know well. Others might only experience social anxiety around people they do not know well or when in large groups of people. Others may experience social anxiety that is setting-specific, like people who are afraid of party settings, work settings, or of being in crowded places.
The four types of social anxiety are:
1. Performance Anxiety
There is only one official subtype of social anxiety disorder, which is performance anxiety. Performance anxiety is not a distinct diagnosis, but rather a specifier sometimes added to a social anxiety disorder diagnosis. While many might think of performance anxiety as something only experienced by people in specific professions like music, dance, or theatre, performance anxiety can be experienced by anyone.
Performance anxiety can occur in any situation where a person must speak, talk, or complete a task (even a small, easy task) in front of others. Having to perform a task while being observed leads many people to become uncomfortable, but for people with social anxiety disorder it is debilitating. What distinguishes performance anxiety from typical social anxiety disorder is the fact that anxiety is only experienced in these specific situations where there is a performance element.
2. Glossophobia
A phobia is a specific fear, and phobic disorders are those where anxiety is only experienced in response to very specific cues or situations. Glossophobia is one of the most common phobias – a fear of public speaking. While performance anxiety might be related to any task a person has to do in front of others, glossophobia is a specific fear of public speaking. Glossophobia is a common fear and while related to social anxiety, it is distinct from social anxiety disorder. Social anxiety disorder includes anxiety which is experienced in a broader scope than just public speaking events.
3. Agoraphobia
Again considered a separate disorder, agoraphobia is also related to social anxiety. Agoraphobia means having a specific fear of being in certain public places. Agoraphobia often results in avoidance of being in certain public spaces and when untreated, can become an avoidance of virtually all public spaces. Often, agoraphobia begins as social anxiety disorder and gradually develops into agoraphobia as more social situations are avoided. While the avoidance provides short term relief from anxiety, it tends to worsen anxiety in the long run.
4. Panic Attacks & Panic Disorder
Many, but not all, people with social anxiety disorder also experience panic attacks. Panic attacks are sudden and intense symptoms of uncontrollable anxiety. When having a panic attack, people often describe having a racing heart, shortness of breath, pain or tension in their chest, throat or muscles, and dizziness. These symptoms generally last a few minutes but are intense enough that many people go to the emergency room, mistaking their symptoms for a heart attack. When panic attacks are regular, sometimes people develop a separate anxiety disorder known as panic disorder, where they develop an intense fear of having another panic attack.
Signs of Social Anxiety Disorder
Humans are social creatures, and it is normal to experience a degree of social anxiety. Having anxiety in social situations, even when it is intense, does not necessarily mean that a person is struggling with social anxiety disorder. For the diagnosis to be made, the anxiety must cause significant distress, disruptions, or impairments for a person over a long period of time.
Social anxiety disorder affects people of all ages but is more common in teens and adults. Regardless of age, social anxiety disorder can be experienced differently, sometimes in ways that make it difficult to detect. All mental health disorders involve changes in a person’s thoughts, feelings, and emotions. People with social anxiety may experience more changes in one of these categories than the others.
Thought Changes Common with Social Anxiety Disorder
Many people find that anxiety has a lot of cognitive involvement and that during times when they are anxious, their mind is very active. Overthinking or overfocusing on specific things that evoke anxiety is common.
In social anxiety disorder, the thoughts that people commonly get fixated on include:
- Personal flaws or insecurities
- Self-critical thoughts
- Beliefs that other people are looking or laughing at them
- Beliefs that other people are judging them or that their anxiety is obvious to others
- Beliefs that other people dislike them
- Replaying select interactions that “prove” people dislike them
- Replaying certain interactions that were awkward or embarrassing
- Imagining awkward, embarrassing or negative interactions that haven’t happened
- Inner “debates” between anxious thoughts and rational thoughts
Emotion Changes Common with Social Anxiety Disorder
The most obvious emotional change that occurs in people who have social anxiety is that they feel anxious. Aside from fear, there are sometimes other emotional changes that occur in people with social anxiety disorder.
These emotional changes include:
- Irritability that occurs because of feeling constantly nervous, uptight or on-edge
- Sadness or loneliness that occurs as a result of social avoidance and isolation
- Frustration or anger with themselves as a result of being so anxious or avoidant
- Shame that results from over-focusing on flaws, insecurities, and mistakes
- Guilt that arises when important relationships are damaged because of avoidance
Behavior Changes Common with Social Anxiety Disorder
Some people notice that their social anxiety results in specific changes to the way they act or communicate.
These behavior changes might include:
- Avoidance is the most common behavior seen in people with social anxiety disorder, and includes actively avoiding any situations or settings that trigger anxiety
- Nervous “tics” that a person does automatically without thinking when nervous like fidgeting, nail biting, or blinking excessively
- Misrepresenting, including any way of speaking, acting, or representing themselves differently in order to be liked or accepted
- Communication differently than normal, which could include a person who is quiet rambling on, a funny person becoming very serious, or an outspoken person being silent and withdrawn
- Losing track of conversations or not listening to what is being said because of being so distracted by thoughts and feelings of self-consciousness
Signs of Social Anxiety in Children
While it is normal for a child to experience some shyness, a social anxiety disorder could be suspected if this anxiety is severe, persistent, and leads to avoidance of social situations. Children sometimes lack the ability to identify and talk about their emotions and it is not uncommon that children instead complain about physical ailments like a stomachache or headache. On rare occasions, children with social anxiety may withdraw from peers or even refuse to talk to people they don’t know.
Signs of Social Anxiety in Teens
In teens, social anxiety can be difficult to detect because a normal part of development for teens is to be more focused on approval from their peers. A more serious problem may be suspected if the teen becomes so anxious that they often cancel plans or refuse to participate in activities or if their anxiety causes them a lot of distress (like having panic attacks).
Teens who are anxious may be more snappy, irritable, and on-edge or might even act out at school to get out of social situations. Teens with social anxiety may be more likely to be heavy social media users, as this can be a less anxiety-provoking way to connect with their peers. Watching for changes in eating and sleeping patterns is also important, as these can be indicators of a mental health issue.
Signs of Social Anxiety in Adults
In adults, social anxiety may occur in a broad variety of social settings or might be localized to specific settings. A social anxiety disorder diagnosis can sometimes result in overt forms of avoidance, like a person who often cancels plans because of anxiety, but is sometimes less obvious. Some people might have orchestrated their lives carefully so that their social anxiety is not triggered until they find themselves in a new or unfamiliar social situation. For this reason, social anxiety may peak during times of stress or transition.
Symptoms of Social Anxiety Disorder
All mental health and substance use disorders have a standardized set of symptoms that act as “criteria” that a person must meet in order to receive the diagnosis. The criteria for each mental health condition, including social anxiety disorder, can be found in the 5th edition of the Diagnostic and Statistical Manual of Psychiatric Disorders (DSM V). This manual is used by licensed professionals who have the qualifications to diagnose and treat these disorders. Each criteria outlines a set of symptoms and several symptoms that need to be met in order for the diagnosis to be given.
According to the DSM V, the symptoms of social anxiety disorder are:
- Significant fear of one or more social situations in which the person is exposed to possible scrutiny by others
- Fear or embarrassment that other people will notice symptoms of anxiety
- Exposure to social situations almost always causes intense anxiety, which may escalate into a panic attack
- A recognition that the fear is irrational or excessive
- Avoidance of the feared situations or extreme distress when they are not avoided
- The anxiety and/or resulting avoidance leads to an interference in normal routine, functioning, social activities or relationships, or leads to marked distress
- The anxiety/avoidance has been occurring for at least 6 months
Causes & Triggers of Social Anxiety Disorder
A combination of environmental, biological, and psychological factors place some people at higher risk than others for developing social anxiety disorder. Certain factors are known to increase risk for almost any mental health condition. These include things like having a family history of mental illness, experiencing early trauma, lacking a social support system, or having an existing mental health or substance use disorder.
Aside from general risk factors for mental illness, there are some specific to social anxiety disorder. People who grew up in homes where they were overly sheltered or controlled are at higher risk, as are those raised by detached, neglectful, overly critical or anxious parents. Growing up socially isolated also increases the risk of developing social anxiety disorder, as does having parents who were overly concerned with the opinions of others. Finally, being raised by a parent or caregiver with a mental illness or substance use disorder is also a risk factor (FN).
Adverse life events, especially those occurring in childhood, are a known risk factor for a variety of mental health issues. Specific adverse events, however, are more closely linked to an increased risk for developing social anxiety disorder. These include having a parent separate, divorce or leave the home or having a new stepparent become involved. In addition, children and teens who experience bullying are more likely to develop social anxiety disorder. Women are more likely to develop social anxiety disorder than men, although this disparity is not clearly understood (FN).
Triggers for Social Anxiety
Social anxiety symptoms can be triggered by a variety of situations and circumstances, many of which are highly individualized.
Some situations and circumstances that can trigger social anxiety include:
- Large social gatherings, events or parties
- Being the center of attention
- Introductions or meeting others for the first time
- Interacting with authority figures
- Physical signs of embarrassment like blushing or shaking
- Having to speak or perform in front of others
- Having to eat or drink in front of others
- Dating and intimate or romantic interactions
- Receiving compliments or praise
- Being asked questions
- Having to engage in small talk
- Basic interactions like making an appointment or placing an order
- Giving or receiving constructive feedback
- Confrontation or difficult conversations
Treatment of Social Anxiety Disorder
Social anxiety disorder is highly treatable. Treatment for social anxiety might include medication, therapy, or a combination of the two. Therapy is considered a frontline treatment for social anxiety, as it carries fewer risks than certain anxiety medications. Therapy also helps people learn skills to manage symptoms and reduce avoidant behaviors, improving their overall level of functioning. The most common and proven form of therapy for social anxiety disorder is Cognitive Behavioral Therapy, or CBT (FN).
Cognitive Behavioral Therapy
CBT is a form of treatment that is generally provided by a licensed counselor or psychologist. This form of treatment helps people learn skills to restructure thoughts that feed into their anxiety. Social anxiety disorder tends to lead people to make assumptions that others are perceiving them in negative ways, and CBT treatment would focus on helping a person challenge these assumptions. CBT also focuses on behavior changes that can interrupt anxiety, including sometimes encouraging people to intentionally put themselves in social situations where they will experience anxiety. This kind of CBT therapy is called exposure therapy. Learn more about CBT for Anxiety.
Exposure Therapy
Exposure therapy encourages clients to expose themselves to anxiety provoking situations in order to become de-sensitized. While this type of therapy can be difficult, it is highly effective. The therapy begins by having clients learn relaxation skills to regulate anxiety, and then encourages them to use these skills in response to situations that trigger mild social anxiety. Gradually, a person is encouraged to expose themselves to situations that cause higher levels of anxiety. Over time, the result is typically that the person experiences less anxiety and has learned skills to manage their anxiety instead of just avoiding these social situations.
Third Wave Behavior Therapies
Third wave behavior therapies may also be effective in treating social anxiety disorder (FN). These include therapies like Dialectical Behavioral Therapy, Acceptance and Commitment Therapy, and Metacognitive Therapy. These therapies all promote use of a skill called mindfulness to help treat anxiety. Mindfulness is a skill that can help people be aware and present in their current experience, instead of getting entangled in unhelpful thoughts and feelings related to their anxiety. While CBT teaches clients to try to actively change their thoughts, third wave therapies encourage people to simply notice the thoughts, without getting actively involved.
Medication
Medication is also sometimes recommended to certain patients, normally in addition to counseling. The most common forms of anti-anxiety medications prescribed are Benzodiazepines, selective serotonin reuptake inhibitors (SSRIs), and selective-norepinephrine reuptake inhibitors (SNRIs).
Benzodiazepines are central nervous system depressants and while they can be effective in the short-term treatment of anxiety, they carry high risk for abuse and dependence. Examples of benzodiazepines include lorazepam (Ativan), clonazepam (Klonopin), and alprazolam (Xanax).
SSRIs and SNRIs are antidepressants that are prescribed because they sometimes also improve anxiety symptoms. Examples of SSRIs include citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil), and sertraline (Zoloft). Examples of SNRIs include desvenlafaxine (Pristiq), venlafaxine (Effexor), duloxetine (Cymbalta), and levomilnacipran (Fetzima).
Beta-blockers, which are typically prescribed to manage high blood pressure, are sometimes prescribed for performance anxiety. Less commonly, antipsychotic or antiepileptic medications are prescribed to treat social anxiety disorder (FN). Propranolol is a beta blocker that has been used off label to treat performance anxiety, (off label means it is not FDA approved, but doctors prescribe it because they believe the clinical data shows it has a benefit).
Medication can be prescribed by doctors, psychiatrists, and sometimes nurse practitioners or physician assistants.
How to Get Help for Social Anxiety Disorders
If you or someone you care about is struggling with social anxiety, getting treatment is recommended. Many people do not get treatment for their anxiety disorder, which often results in a worsening of symptoms and impairment. Luckily, treatments for social anxiety disorders have impressive track records for success, helping some people reduce and, in some cases, even resolve, their symptoms.
If you have health insurance, it is possible that your treatment could be at least partially covered. Calling the number on the back of your insurance card or going online to use the insurance company’s search tool will result in a list of in-network providers close to you. You could use these search options to find licensed counselors, psychologists, or psychiatrists, depending on your treatment needs and preferences. It is recommended that you call more than one provider to ask questions, see if they are accepting new patients, and whether they have specific experience in treating social anxiety disorder.
Unfortunately, social anxiety disorder often goes untreated. Research has found that people with social anxiety disorder are less likely to seek treatment than others with similarly serious mental health conditions (FN). It is likely that setting up and attending an appointment is triggering for those with social anxiety disorder.
Luckily, there are new ways of establishing care that may be easier for those with social anxiety disorder, including options for online therapy. Conducting a search for counselors using a directory can also help locate therapists who offer online counseling. It is recommended that people check with their insurance company first to see if online therapy is covered under their plan.
Social Anxiety Disorder Statistics
Anxiety disorders are the most common type of mental illness in America, affecting almost one in three people at some point in their lives. Social anxiety disorder is one of the most common forms of anxiety disorders affecting Americans.
According to the National Institute of Mental Health, statistics show:
- Social anxiety disorder has affected 7.1% of Americans adults in the past year
- Social anxiety disorder affected more adult women (8%) than men (6.1%) in the past year
- Social anxiety severity varies; 29.9% of adults report serious impairment, 38.8% report moderate impairment, and 31.3% report mild impairment
- Social anxiety disorder affected an estimated 9.1% of teens in the past year
- Female adolescents were affected (11.2%) at higher rates than males (7%) in the past year
- In the course of their lifetime, 12.1% of Americans will experience social anxiety disorder
Social Anxiety Disorder vs Other Disorders
Due to similarities in symptoms, such as high levels of anxiety and isolation, it is often easy to confuse social anxiety disorder with other types of anxiety or mental health disorders. While other mental health issues may manifest in similar ways, the key difference is that social anxiety is always tied to anxiety that arises from social situations, and not any other triggers.
Social Anxiety Disorder & Generalized Anxiety Disorder
These disorders are somewhat similar in their symptoms, both featuring excessive nervousness and worry. Both also may lead to avoidance of situations and triggers for anxiety, and both tend to negatively impact people’s lives and routines. The main difference between social anxiety disorder and generalized anxiety disorder is that social anxiety disorder occurs only in response to specific social interactions and situations. People with generalized anxiety disorder experience anxiety in response to several different situations, and sometimes even when there is no identifiable trigger.
Social Anxiety Disorder & Major Depressive Disorder
Sometimes symptoms of social anxiety disorder can look like major depressive disorder. Both disorders often result in people isolating themselves and giving up activities that matter to them. The difference is that in social anxiety disorder, the avoidance is driven by nervousness and worry about being judged by others. In depression, social avoidance and isolation is usually driven by sadness and a lack of interest, energy, or motivation that is characteristic of the disorder.
Social Anxiety Disorder & Other Mental Health Disorders
Social anxiety disorder can co-occur with other mental health or substance use disorders. It is possible, for instance, to be diagnosed with social anxiety disorder and major depressive disorder. It is even possible to be diagnosed with social anxiety disorder and another anxiety disorder like OCD, PTSD, or Panic Disorder. It is also not uncommon for social anxiety disorder to co-occur with substance or alcohol use disorders, as these substances are sometimes used by anxious people to self-medicate their symptoms.
Social Anxiety Disorder Tests & Quizzes
Like all mental health conditions, social anxiety disorder cannot be self-diagnosed. Only a licensed professional counselor, psychologist, or other licensed professional can confirm a diagnosis. There are many different standardized assessment tools that a professional may use to aid in the diagnosis of social anxiety disorder. Some of the more common ones include the Social Phobia Inventory, the Social Anxiety Interaction Scale and the Social Phobia Scale (FN). While these scales have been validated and deemed reliable, they are not for public use and cannot be used to self-diagnose social anxiety disorder.
Still, many people may be interested in taking a screening to help determine whether they have some of the symptoms of social anxiety disorder. One available screening tool was developed by the Anxiety and Depression Association of America, and can be found here. Keep in mind that social anxiety disorder, like other mental health disorders, are not diagnosed solely based on a checklist of symptoms. Careful consideration is also given to a person’s environment and any current stressors or recent transitions.
Additional Resources for Social Anxiety Disorder
For those interested in learning more about social anxiety disorder, consider looking into these resources:
The Anxiety and Depression Association of America website
