Many people experience some anxiety in certain social situations, such as going to a job interview or giving a speech at a wedding. It is normal to expect to feel nervous or worried about such situations.
However, for people with social anxiety disorder (or social phobia), these anxious feelings can occur in most or all social situations. They can be so intense that it negatively affects their life.
In This Article
What is Social Anxiety Disorder?
Social anxiety disorder is an intense, long-standing, and debilitating fear of social situations.
Individuals with social anxiety disorder may fear that they will embarrass themselves or believe they will be judged negatively and criticized by others in the social situation.
The anxiety in response to social situations can occur before, during, or after a social situation, quite often being experienced at all three times.
Individuals may find the social situation so distressing that they might avoid or escape it, so they do not have to face their fears.
Social anxiety disorder was recognized as an anxiety disorder in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-3) in 1980 and is believed to have a lifetime prevalence rate of 2-5%, being more common in females than males.
Social anxiety disorder can differ in range and severity, with some fearing most social situations, whilst others may only experience anxiety in one or two social situations.
Below is a list of some of the social situations that someone with social anxiety disorder may find challenging:
- Public speaking
- One-on-one conversations
- Group interactions
- Social events, e.g., parties
- Meeting new people
- Making phone calls
- Job interviews
- Initiating and maintaining conversations
- Giving presentations
- Work meetings
- Walking in view of others
- Using public toilets
- Eating or drinking in front of people
- Being assertive with others
- Talking to authority figures
What Keeps Social Anxiety Going?
With social anxiety, a big part that keeps it going is that individuals will think about the probability and cost of the feared social situation.
The probability is the idea of how likely they believe their fears will happen, whereas the cost is how bad they believe the situation will be if their fears come true.
For instance, if someone is planning to give a presentation to their class, they may believe it is highly likely that they will make a mistake or stutter when speaking – this is the probability.
If the mistake or stuttering happens, they may believe they will be criticized or laughed at by others – this is the cost. Due to these thoughts can cause the individual giving the speech to feel highly anxious, and they may tremble, blush, sweat, or feel nauseous as a result.
Other ways in which social anxiety can keep going are:
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- Being triggered by ‘social threats’
- Negative thoughts about the self
- How strongly we believe a ‘social catastrophe’ will occur
- Self and environment-focused attention
- Safety behaviors
- Avoidance strategies
- How you think others perceive you
- Core beliefs
Self Help
Overcoming Avoidance
Avoidance behaviors can be shown by those with social anxiety, who avoid the feared situation to reduce their anxiety levels.
This usually results in instant relief and a reduction in anxiety as the feared situation no longer must be faced. Individuals who use avoidance to cope may avoid unfamiliar people, large groups, phone calls, attending appointments, school, or work.
In the short term, avoiding social situations can make the socially anxious person feel safe, but this is a problem in the long term as avoidance can keep people anxious.
If social situations are avoided, individuals do not get the opportunity to challenge their negative thoughts.
Avoidance may strengthen their negative thoughts as they will be unable to see what would happen and how costly it accurately is.
They may miss out on opportunities as there will less chance for positive social experiences that would motivate them to engage in more social activities.
They may also miss opportunities to achieve in education or work. For instance, they may avoid a job interview for a position they really want for fear of being humiliated or not knowing what to say when put on the spot.
Those who avoid them may also have poorer self-esteem as they are not doing what they may want to do (e.g., having strong friendships) and may be more isolated and feel depressed.
The avoidance could even spread to other aspects of their lives where they could lose confidence, such as in their relationships or at work.
Moreover, suppose they are faced with a social situation in the future that they cannot avoid. In that case, the anxiety may be even more extreme as they have not given themselves opportunities to face their fears.
Thus, avoidance tends to strengthen negative expectations, which is the vicious cycle of anxiety and avoidance.
It is extremely difficult to overcome anxiety if the individual constantly avoids so this cycle needs to be broken. This can be done by approaching situations that make individuals anxious, which can temporarily elevate anxiety. In the long term, it will give them more opportunities to test their fears and build confidence in their coping skills.
Through this, more realistic expectations should be established, which should, in turn, reduce anxiety. In order to break the anxiety and avoidance cycle, individuals could gradually start initiating small talk, for instance.
They could also set themselves small social challenges such as challenging themselves to remain at the social event for one hour before leaving.
After the social situation is over, they could reflect on what happened – were the negative beliefs about the situation accurate? Did something go wrong? What went well? They could also rate their anxiety before and after the situation and how they feel about completing the social situation again.
Safety Behaviors
Safety behaviors can be used by those with social anxiety in situations that cannot be avoided. These are still avoidance behaviors but more subtle, used to prevent feared predictions from coming true and so that individuals feel more comfortable in social situations.
Some safety behaviors can be hard to notice, with many people not realizing they are performing them. Different behaviors could also be used in different situations.
Some safety behaviors include:
- Staying quiet in social situations
- Wearing headphones
- Planning out what to say ahead of time
- Limiting eye contact
- Using alcohol or drugs
- Speaking quietly
- Keeping the focus of the conversation on others
- Wearing inconspicuous clothing
- Carrying anxiety medication
The problem with safety behaviors, like avoidance behaviors, is that they only provide short-term relief. In the long term, they can make individuals more anxious.
Although individuals may not avoid the situation completely, safety behaviors prevent them from fully testing their fears.
Through repeated testing of negative thoughts, individuals may find that their predictions never come true, thus minimizing these negative thoughts.
Safety behaviors may provide worse outcomes than fully facing the situation. They could become ‘ self-fulfilling prophecies ’ in the sense that they could cause outcomes that are trying to be prevented.
For instance, if someone uses alcohol in social situations to help them feel more at ease, they could become visibly intoxicated and act in a way that they would embarrass themselves that wouldn’t have happened if they did not rely on alcohol.
If using safety behaviors in a social situation and the feared outcome does not come true, individuals may falsely attribute this success to their safety behaviors.
They may believe that the behaviors prevented a negative outcome and will then be more likely to depend on this behavior in more social situations and may become more anxious if they are unable to use their safety behaviors.
Also, when completing safety behaviors, individuals may become more focused on themselves. This self-focused attention can hijack attention from the social situation (e.g., a conversation), making it difficult to pay attention to what is going on, resulting in other problems.
When learning to drop safety behaviors, individuals with social anxiety may feel more anxious in the short term. The most efficient approach would be to stop the behaviors as soon as they are noticed in the social situation. If this is too difficult, the behaviors could be stopped more gradually.
The individuals could also ‘gather evidence’ which disproves their negative beliefs, such as noticing that nothing bad happens when they speak in a louder tone or when the attention is on them.
Individuals could also set challenges for themselves before a social situation. For example, if giving a presentation, instead of using the safety behavior of no eye contact, they could challenge themselves to make eye contact with five people.
Dealing with Setbacks
When managing social anxiety disorder, it is important to remember that it is normal to expect some setbacks. For instance, individuals may find themselves experiencing a difficult social situation where someone actually gives judgment or criticizes them.
Likewise, life circumstances can unexpectedly change, and individuals may not be as exposed to social situations as much as they were.
For example, the COVID-19 outbreak resulted in many people being isolated from social situations for extended periods.
Individuals with social anxiety disorder may find it extremely challenging to get back on track after these kinds of setbacks. It is important for those people to not focus too much on the setbacks and instead focus on what they can do to get back on track.
Individuals can learn from the negative experiences that they could use to build resilience over time and know what to do if they find themselves in a similar situation again.
It may be useful for individuals with social anxiety to create their own personalized action plans to deal with setbacks to prevent small setbacks from turning into larger ones.
This action plan could include documenting the triggers that may cause a setback and include their warning signs (emotional, thinking, behavioral, or physical signs) which may indicate a setback could occur.
They could then include details in their action plan of what they need to do or remind themselves of when a setback occurs or who they could contact if they need further help.
Causes
It is not known for certain what causes social anxiety disorder. Still, it is suggested that if there is a family history of social anxiety or depression, then this could be a probable cause for others to develop the condition.
Likewise, the stronger the anxiety or depression and the genetic closeness of the person with anxiety/depression (e.g., parent or sibling), the more likely it is that someone will develop social anxiety disorder.
Studies have suggested that imbalances of the neurotransmitters serotonin and dopamine could play a role in developing social anxiety disorder.
One study, for instance, found that there was increased serotonin and dopamine activity in brain regions associated with fear (amygdala) and rewards ( nucleus accumbens ), with greater activity being correlated to symptom severity (Hjorth et al., 2019).
Imaging studies have demonstrated that those with social anxiety disorder demonstrated selective activation of their amygdala when exposed to fear-relevant stimuli (Birbaumer et al., 1998) or showed abnormal patterns of amygdala activation during aversive conditioning (Schneider et al., 1999).
A further study found that those with social anxiety disorder had increased blood flow in their amygdala. In contrast, those without social anxiety disorder showed increased blood flow to their cerebral cortex (area of thinking and evaluation).
This suggests that those with social anxiety disorder have overstimulated fear regions that override parts of the brain that involve logical reasoning.
There could also be environmental factors that could contribute to the development of social anxiety disorder. Life stressors, such as work, school, or a traumatic event, could trigger the onset of social anxiety.
Early learning as a child could also be a potential contributing factor. If an individual’s family is overly critical of the child, controlling, or overly protective, this could make it more likely that a child will become anxious.
Also, fearful and anxious parents could unknowingly transfer their own worries and fears of social situations onto their children. If a parent worries excessively about what others think of them, this could be picked up by the child, who may then also have the same worries.
Those with social anxiety disorder often report being very shy or withdrawn as a child, which could stem from various environmental factors. If the shy child is the victim of bullying or abuse due to being shy, this could also reinforce shyness, which could develop into social anxiety.
Symptoms and Diagnosis
People with social anxiety disorder often experience a combination of cognitive, physical, and behavioral symptoms.
The cognitive symptoms are usually negative beliefs, biases, and thoughts about oneself or social situations.
The behavioral symptoms are the actions performed by the socially anxious individual, whereas the physical symptoms are those which are typically experienced before, during, and after a social situation; usually, symptoms also experienced during the fight or flight response.
These symptoms will not be the same for everyone with social anxiety disorder, as some may experience only a few whilst others may experience a lot more.
Cognitive symptoms:
- Fear of talking to strangers
- Worry of being embarrassed
- Fear of situations where there is the possibility of being negatively judged
- Fear that others will notice the anxiety
- Fear of physical symptoms
- Intense anxiety during social situations
- Fear of analysis of performance
- Dreading upcoming events
- Expecting the worst possible consequence from a negative experience during a social situation
Physical symptoms:
- Blushing
- Sweating
- Rapid heartbeat
- Nausea
- Feeling breathless
- Feeling as if the mind has gone blank
- Light-headedness
- Muscle tension
Behavioral symptoms:
- Avoiding speaking
- Avoiding being the center of attention
- Leaving or escaping social situations
- Using safety behaviors
- Missing school or work
Due to social anxiety, many complications can occur because of their symptoms. Individuals may find it difficult to make and maintain friendships or romantic relationships.
They might have poor social skills and thus may face isolation or feelings of loneliness. They may also have problems with academic and employment achievement if they are avoiding school or work or feel too afraid to ask for help or to go to a job interview for a position they want, for fear of being judged in the interview.
Individuals with social anxiety may also have low self-esteem, think negatively about themselves, abuse substances such as alcohol and drugs, or have comorbid mental health conditions such as depression due to their anxiety.
In this way, social anxiety can impact most parts of an individual’s life and have devastating effects if not treated.
Social anxiety disorder is diagnosed through the Diagnostic and Statistical Manual of mental disorders (DSM-5) as a marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny from others.
The social situations must almost always provoke fear or anxiety, which is out of proportion to the actual threat. The social situations are either avoided or endured with intense fear or anxiety. This fear or anxiety causes clinically significant distress or impairments in social, occupational, or other important areas of functioning.
The diagnostic criteria also state that the fear, anxiety, or avoidance must be persistent and typically last for at least six months.
Finally, the fear or anxiety must not be attributable to the physiological effects of substances and medical conditions. It cannot be better explained by another disorder (e.g., panic disorder, body dysmorphic disorder, or autism).
Treatment and Management
The most common treatments for social anxiety disorder are medications and cognitive behavioral therapy (CBT), usually a combination of both for the most effectiveness.
There are also some techniques that people can use independently to help them relax, such as breathing retraining and progressive muscle relaxation.
Medications
Some of the medications that are usually prescribed to treat the symptoms of social anxiety disorder are:
- Benzodiazepines – these are anti-anxiety medications that often work quickly. These can have immediate effects but can be sedating so they are not usually prescribed for long-term use.
- Beta-blockers – these work by blocking epinephrine’s stimulating effects (known as adrenaline). These may reduce heart rate, blood pressure, shaking voice, and trembling limbs. Due to these effects, they usually work best when taken to control the physical symptoms for a particular situation rather than as a general treatment.
- Monoamine oxidase inhibitors (MAOIs) – these work by blocking the enzymes which break down the neurotransmitters serotonin, dopamine, and norepinephrine. This means there will be more of these chemicals circulating in the brain, having a positive effect on mood and anxiety.
- Selective serotonin reuptake inhibitors (SSRIs) are the most common medication for anxiety because it is thought to be more tolerable than other medications. SSRIs work by blocking the reuptake of serotonin, so there will be more of the chemical circulating in the brain. These have been shown to have significant positive effects on mood and anxiety.
- Serotonin-norepinephrine reuptake inhibitors (SNRIs) work similarly to SSRIs in that they block the reuptake of serotonin, but they also block the reuptake of norepinephrine. SNRIs are typically only prescribed for short-term use because prolonged use has shown cases of people experiencing manic or hypomanic episodes.
Cognitive behavioral therapy (CBT)
CBT is a type of psychotherapy that has been found to be very effective for individuals with social anxiety disorder. This therapy involves working with a trained cognitive behavioral therapist to identify an individual’s negative thoughts and work together to challenge these thoughts, to replace them with more realistic thoughts.
CBT has many different techniques, all of which can be tailored to each individual and their own challenges. Some people with social anxiety may complete exposure-based therapy exercises with their therapist.
This means that they can gradually start facing feared social situations to help improve their confidence and coping skills to deal with these anxiety-inducing situations.
They may also participate in role-playing exercises to practice their social skills and to gain comfort and confidence relating to others.
Another technique of CBT is to challenge the individual’s thinking.
The therapist may ask the individual to think about a core belief that they hold about themselves. Core beliefs are strongly held, rigid, and inflexible beliefs that may stem from childhood, e.g., ‘Nobody wants to be my friend.’
With the therapist, the individual will be challenged to write down evidence that does or does not support this core belief. They will be challenged not to ignore the evidence that contradicts their belief, ultimately writing down a more appropriate and balanced core belief.
For example, ‘Nobody wants to be my friend’ could change to ‘Although I may find it hard to make friends, I have many positive qualities that people admire about me.’
Breathing Retraining
For many people with social anxiety disorder, their breathing may be more anxious and disordered. Unbalanced breathing can result in feelings of dizziness, headaches, weakness, and muscle stiffness.
Anxious breathing can also make people more likely to respond to stressful situations with intense anxiety or panic. Breathing retraining is a technique that can be learned to return to their baseline breathing pattern.
This is a simple technique of breathing in deeply, holding the breath for a few seconds, then slowly releasing the breath.
This technique can be practiced twice a day to be effective and can be used as a coping strategy in anxious social situations rather than unhelpful safety behaviors.
Progressive Muscle Relaxation
A common response to fear and anxiety is muscle tension, which can cause discomfort and, thus, even more anxiety. Progressive muscle relaxation is a technique that can be used whenever the individual is in a comfortable position, usually lying down.
When comfortable, the individual can purposely tense a muscle group (e.g., the feet or hands). They can tense this muscle group for a few seconds before releasing the tension.
After this, they can tense another muscle group and repeat each muscle group’s tensing and releasing technique until everything has been tensed and released.
People may find it useful to start at the bottom of the body and work their way up to the head. This progressive muscle relaxation aims to instantly relax each muscle group until the whole body feels relaxed.
This can be useful for those with social anxiety and could be used before a fearful social situation or afterward to help recover.
Do you need mental health support?
USA
If you or a loved one are struggling with symptoms of an anxiety disorder, contact the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline for information on support and treatment facilities in your area.
1-800-662-4357
UK
Contact the Samaritans for support and assistance from a trained counselor: https://www.samaritans.org/; email jo@samaritans.org .
Available 24 hours a day, 365 days a year (this number is FREE to call):
116-123
Rethink Mental Illness: rethink.org
0300 5000 927
References
Bank, S., Burgess, M., Sng, A., Summers, M., Campbell, B., & McEvoy, P. (2020). Stepping Out of Social Anxiety. Perth, Western Australia: Centre for Clinical Intervention
Substance Abuse and Mental Health Services Administration. (2016). DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet].
Pelissolo A, Abou Kassm S, Delhay L. Therapeutic strategies for social anxiety disorder: Where are we now? Expert Review of Neurotherapeutics. 2019;19(12).
