Social Anxiety Disorder (Social Phobia)

Social anxiety disorder, formerly referred to as social phobia, is an anxiety disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. People with social anxiety disorder have a persistent, intense, and chronic fear of being watched and judged by others and of being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work, school, or other activities. While many people with social anxiety disorder recognize that their fear of being around people may be excessive or unreasonable, they are unable to overcome it. They often worry for days or weeks in advance of a dreaded situation. In addition, they often experience low self-esteem and depression.

Social anxiety disorder can be limited to only one type of situation—such as a fear of public speaking—or a person can experience symptoms whenever they are around other people. If left untreated, social phobia can have severe consequences. For example, it may keep people from going to work or school or prevent them from making friends.

Physical symptoms, which often accompany the intense stress of social anxiety disorder, include blushing, sweating, trembling, nausea, and difficulty speaking. Because these visible symptoms heighten the fear of disapproval, they themselves can become an additional focus of fear, creating a vicious cycle: As people with social anxiety disorder worry about experiencing these symptoms, the greater their chances are of developing them.

Social anxiety disorder often runs in families and may be accompanied by depression or other anxiety disorders, such as panic disorder or obsessive-compulsive disorder. Some people with social anxiety disorder self-medicate with alcohol or other drugs, which can lead to addiction.

About 7 percent of the U.S. population is estimated to have social anxiety disorder within a given 12-month period. Social anxiety disorder occurs about twice as often in women as in men, although a higher proportion of men seek help for the condition. The disorder typically begins in childhood or early adolescence and rarely develops after age 25.

Symptoms

A diagnosis of social anxiety disorder is made only if this avoidance, fear, or anxious anticipation of a social or performance situation interferes with daily routine, occupational functioning, and social life or if there is marked distress as a result of the anxiety. The DSM-5 provides the following criteria for diagnosing social anxiety disorder:

  • The individual fears one or more social or performance situations in which he or she is exposed to possible scrutiny by others. Examples include meeting unfamiliar people, being observed eating or drinking, or giving a speech or performance.
  • The individual fears behaving in a manner that causes embarrassment or being negatively evaluated.
  • Exposure to social situations almost always causes intense anxiety.
  • The feared situation is avoided or endured with anxiety and distress.
  • The fear or anxiety is out of proportion to the actual threat posed by the social situation.
  • The fear or anxiety is persistent and typically lasts for six months or longer.
  • The avoidance, anxious anticipation, or distress interferes significantly with the person's social, academic, or occupational functioning.

The physical symptoms of social anxiety disorder include the following:

  • Blushing, sweating, trembling, experiencing a rapid heart rate, or feeling the “mind going blank”
  • Nausea or upset stomach
  • Displaying a rigid body posture, poor eye contact, or speaking too quietly

Additionally, the diagnosis can specify whether the anxiety or fear is present only when the person is speaking or performing in public.

Causes

While research to better understand the causes of social anxiety disorder is ongoing, some investigations implicate a small structure in the brain called the amygdala. The amygdala is believed to be a central site in the brain that controls fear responses.

Social anxiety disorder is heritable. In fact, first-degree relatives have a two to six times higher chance of developing social anxiety disorder. Research supported by the National Institute of Mental Health (NIMH) has also identified the site of a gene in mice that affects learned fearfulness. Scientists are exploring the idea that heightened sensitivity to disapproval may be physiologically or hormonally based. Other researchers are investigating the environment's influence on the development of social phobia. Childhood maltreatment and adversity are risk factors for social anxiety disorder.

Treatment

Most anxiety disorders can be treated successfully by a trained mental health care professional. Social anxiety disorder is often treated effectively with two forms of treatment: psychotherapy and medications.

Therapy

Cognitive-behavioral therapy (CBT) is a form of psychotherapy that is very effective in treating severe social anxiety. A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the anxiety disorder. For example, avoidance of a feared object or situation prevents a person from learning that it is harmless.

A key element of CBT for anxiety is exposure, in which people confront the things they fear. The exposure process generally involves three stages. First, a person is introduced to the feared situation. The second step is to increase the risk for disapproval in that situation so a person can build confidence that he or she can handle rejection or criticism. The third step involves teaching a person techniques for coping with disapproval. In this stage, people are asked to imagine their worst fear and are encouraged to develop constructive responses to this fear and perceived disapproval.

These stages are often accompanied by anxiety management training—for example, teaching people techniques such as deep breathing to control their anxiety. If this is done carefully and with support from a therapist, it may be possible to defuse the anxiety associated with feared situations. If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission. You will work with the therapist to determine how much you can handle and at what pace you can proceed.

CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well-trained in the techniques of the treatment for it to work as desired. During treatment, the therapist will likely assign homework—specific problems that the patient will need to work on between sessions. CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Supportive therapy, such as group, couples, or family therapy can be helpful to educate significant others about the disorder. Sometimes people with social anxiety also benefit from social skills training.

Medications

Proper and effective medications may also play a role in treatment, along with psychotherapy. Medications include antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as drugs known as high-potency benzodiazepenes. Some people with a form of social anxiety that presents itself only when they have to perform in front of others have been helped by beta-blockers, which lower heart rate and reduce physical symptoms of anxiety.

It is important to understand that treatments for social anxiety disorder do not work instantly and that no one plan works well for all patients. Treatment must be tailored to the needs of each individual. A therapist and patient should work together to determine which treatment plan will be most effective and to assess whether the treatment plan seems to be on track. Adjustments to the plan are sometimes necessary since patients respond differently to treatment.

References

  • American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition  
  • American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition
  • National Institute of Mental Health

Last reviewed 02/07/2019