Social anxiety disorder is characterized by intense fear and worry when around other people. This condition is sometimes referred to as social phobia. Throughout this article, both terms will be used interchangeably.

The overbearing fear that someone with social anxiety disorder will experience in social situations may be enough for them to even experience full blown panic attacks. People who suffer from social phobia are overly concerned with being judged and are often very self-conscious and hard on themselves.

Constant worry thoughts about their appearance, the way they are speaking to others, the way they walk, how other people are looking at them, constantly analyzing and judging other people’s body language and facial expressions is a normal occurrence for someone suffering from social phobia.

Someone with social anxiety disorder may go out of their way to avoid people as they may see them as the problem. Such isolation may cause them to feel lonely, depressed, insecure, and overall less content with their life.




The essential feature of social anxiety disorder is a marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others. In children, the fear or anxiety must occur in peer settings and not just during interactions with adults.

When exposed to such social situations, the individual fears that he or she will be negatively evaluated. The individual is concerned that he or she will be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable.

Some individuals fear offending others or being rejected as a result. Fear of offending others–for example, by a gaze or by showing anxiety symptoms–may be the predominant fear in individuals from cultures with strong collectivistic orientations.

An individual with fear of trembling of the hands may avoid drinking, eating, writing, or pointing in public; an individual with fear of sweating may avoid shaking hands or eating spicy foods; and an individual with fear of blushing may avoid public performance, bright lights, or discussion about intimate topics.

The fear or anxiety is judged to be out of proportion to the actual risk of being negatively evaluated or to the consequences of such negative evaluation. Sometimes, the anxiety may not be judged to be excessive, because it is related to an actual danger (e.g., being bullied or tormented by others).

However, individuals with social anxiety disorder often overestimate the negative consequences of social situations, and thus the judgement of being out of proportion is made by the clinician (American Psychiatric Association, 2013, pp. 203-204).

Symptoms of Social Anxiety Disorder

Someone suffering from social anxiety disorder may often experience a fight or flight response when around other people. Being in or around large crowds may be virtually impossible for them as they will experience an overwhelming influx of dread and vulnerability. In such a situation, they may truly feel and react as if they were in mortal danger, even when there is absolutely no danger in sight.

Even though people with social phobia are often very fearful of other people judging them, they themselves are often very judgmental towards themselves. They may experience some narcissistic traits as well, such as feeling as though everyone is looking at them or that everyone is concerned with the way they behave or speak even though this is likely the antithesis of the truth.

People with social phobia may identify themselves as being loners and may deeply struggle with forming and maintaining healthy relationships with others as they are constantly concerned with being judged.




They may rarely leave the house as they may perceive their home to be a “safe space” for them where anxiety is minimal. Although this may help them reduce a lot of their anxiety, it may also help them to reinforce their irrational fears as well.

Individuals with social anxiety disorder may be inadequately assertive or excessively submissive or, less commonly, highly controlling of the conversation. They may show overly rigid body posture or inadequate eye contact, or speak with an overly soft voice.

These individuals may be shy or withdrawn, and they may be less open in conversations and disclose little about themselves. They may seek employment in jobs that do not require social contact.

They may live at home longer. Men may be delayed in marrying and having a family, whereas women who would want to work outside the home may live a life as a homemaker and mother. Self-medication with substances is common (e.g., drinking before going to a party).

Social anxiety among older adults may also include exacerbation of symptoms of medical illnesses, such as increased tremor or tachycardia. Blushing is a hallmark physical response of social anxiety disorder (American Psychiatric Association, 2013, p. 204).

Additional symptoms of social anxiety disorder:

  • Intense anxiety when around other people
  • Anxiety when thinking of being around other people
  • Overly concerned with being judged
  • Very judgmental of themselves
  • Avoiding places where people gather
  • Struggle with maintaining healthy relationships
  • Deep fear of being rejected or humiliated
  • Excessive sweating and shaking
  • Feeling nauseous or lightheaded

Causes of Social Anxiety Disorder

Temperamental. Underlying traits that predispose individuals to social anxiety disorder include behavioral inhibition and fear of negative evaluation.

Environmental. There is no causative role of increased rates of childhood maltreatment or other early-onset psychosocial adversity in the development of social phobia. However, childhood maltreatment and adversity are risk factors for social phobia.

Genetic and physiological. Traits predisposing individuals to social phobia, such as behavioral inhibition, are strongly genetically influenced. The genetic influence is subject to gene-environment interaction; that is, children with high behavioral inhibition are more susceptible to environmental influences, such as socially anxious modeling by parents. Also, social anxiety disorder is heritable (but performance-only anxiety less so). First-degree relatives have a two to six times greater chance of having social phobia, and liability to the disorder involves the interplay of disorder-specific (e.g., fear of negative evaluation) and nonspecific (e.g., neuroticism) genetic factors.

The median age at onset of social phobia in the United States is 13 years, and 75% of individuals have an age at onset between 8-15 years. Social anxiety disorder sometimes emerges out of a childhood history of social inhibition or shyness in U.S. and European studies.

Onset of social phobia may follow a stressful or humiliating experience (e.g., being bullied, vomiting during a public speech), or it may be insidious, developing slowly. First onset in adulthood is relatively rare and is more likely to occur after a stressful or humiliating event or after life changes that require new social roles (e.g., marrying someone from a different social class, receiving a job promotion).

Adolescents endorse a broader pattern of fear and avoidance, including of dating, compared with younger children. Older adults express social anxiety at lower levels but across a broader range of situations, whereas younger adults express higher levels of social anxiety for specific situations.

Detection of social phobia in older adults may be challenging because of several factors, including a focus on somatic symptoms, comorbid medical illness, limited insight, changes to social environment or roles that may obscure impairment in social functioning, or reticence about describing psychological distress (American Psychiatric Association, 2013, p. 205).



Diagnostic Criteria

A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).

Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.

B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others).

C. The social situations almost always provoke fear or anxiety.

D. The social situations are avoided or endured with intense fear or anxiety.

E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.

F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.

J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Specify if:

Performance only: If the fear is restricted to speaking or performing in public.

(American Psychiatric Association, 2013, pp. 202-203)

Prevalence of Social Phobia

The 12-month prevalence estimate of social anxiety disorder for the United States is approximately 7%. Lower 12-month prevalence estimates are seen in much of the world using the same diagnostic instrument, clustering around 0.5%-2.0%; median prevalence in Europe is 2.3%.

The 12-month prevalence rates in children and adolescents are comparable to those in adults. Prevalence rates decrease with age. The 12-month prevalence for older adults ranges from 2% to 5%. In general, higher rates of social phobia are found in females than in males in the general population, and the gender difference in prevalence is more pronounced in adolescents and young adults.

Prevalence of social phobia in the United States is higher in American Indians and lower in persons of Asian, Latino, African American, and Afro-Caribbean descent compared with non-Hispanic whites (American Psychiatric Association, 2013, p. 204).

Comorbidity of Social Phobia

Social anxiety disorder is often comorbid with other anxiety disorders, major depressive disorder, and substance use disorders, and the onset of social anxiety disorder generally precedes that of the other disorders, except for specific phobia and separation anxiety disorder.

Social anxiety disorder is frequently comorbid with bipolar disorder or body dysmorphic disorder; for example, an individual has body dysmorphic disorder concerning a preoccupation with a slight irregularity of their nose, as well as social phobia because of a severe fear of sounding unintelligent.

The more generalized form of social anxiety disorder, but not social anxiety disorder, performance only, is often comorbid with avoidant personality disorder. In children, comorbidities with high-functioning autism and selective mutism are common (American Psychiatric Association, 2013, p. 208).

Social Anxiety Disorder Treatment

Someone suffering with social anxiety disorder may greatly benefit from cognitive behavioral therapy (CBT). CBT works by helping the patient to change their thinking patterns by becoming more aware of the way they currently think about their fears, among other things. The therapist will help coach the patient by providing them with more productive ways of thinking, as well as introducing coping skills to them.

Exposure therapy may also be helpful for treating social phobia as it can be a way to desensitize them from their irrational fear of other people. This form of treatment is done by having the patient put themselves in anxiety provoking situations to help them overcome their intense fear.

Besides psychotherapy, someone suffering from social phobia may also greatly benefit by taking an antidepressant and/or an anti-anxiety medication. These drugs may be able to help minimize the amount of fear that someone with social phobia can expect to experience. However, this is something that you should first discuss with your doctor.

If you think you may have social anxiety disorder or if you are suffering from some of the symptoms outlined in this article, then you should talk to your doctor as soon as you can so that you can be properly diagnosed and treated. Upon seeing your doctor, you may be referred to see a mental health professional such as a psychologist or a psychiatrist for further treatment.


References:

  • American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5 (5th ed.). American Psychiatric Publishing.
  • NIMH » Social Anxiety Disorder: More Than Just Shyness. (2020, November 4). National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/social-anxiety-disorder-more-than-just-shyness/index.shtml
  • Social Anxiety Disorder | Anxiety and Depression Association of America, ADAA. (n.d.). Anxiety and Depression Association of America. Retrieved November 4, 2020, from https://adaa.org/understanding-anxiety/social-anxiety-disorder
  • Social anxiety disorder (social phobia) – Symptoms and causes. (2017, August 29). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/social-anxiety-disorder/symptoms-causes/syc-20353561