Social anxiety disorder is the fear of being judged by others in a social setting. Social anxiety can affect people of all ages and significantly interfere with day-to-day functioning.
What is social anxiety disorder?
Social anxiety disorder is a psychiatric condition affecting both males and females of all ages. This condition is characterized by fear of judgment by others in social situations such as parties, speaking in public, or using public restrooms . Other symptoms include anxiety, blushing, palpitations, sweating, trembling, shortness of breath, and nausea. Treatment options include cognitive behavioral therapy and medications.
You should visit your primary care physician, who can diagnose you based on an interview. He/she can refer you to a psychiatrist or psychologist for cognitive behavioral therapy (CBT). Medications may also be appropriate.
Social anxiety disorder symptoms
The main symptoms of social anxiety disorder include the following.
- Excessive fear of scrutiny: People with social anxiety disorder often feel scrutinized or intensely watched in everyday social situations.
- Avoidance: People with social anxiety disorder may isolate themselves or avoid day-to-day activities in an effort to not experience symptoms.
- Difficulty speaking in public
- Shortness of breath
- Postural rigidity: When in social situations, people with social anxiety disorder may feel like they have difficulty moving their limbs.
The diagnosis of social anxiety disorder is based on meeting the criteria detailed in DSM-IV.
- Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.
- The patient fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated.
- Social situations almost always provoke fear or anxiety.
- Social situations are avoided or endured with intense fear or anxiety.
- The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
- The fear, anxiety, or avoidance is persistent, typically lasting for six months or more.
- The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., an abused drug or medication) or another medical condition.
- 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.
- Fear or anxiety cannot be due to another medical disorder.
People with social anxiety disorder commonly present with other psychiatric conditions as well. The following are the most common comorbidities:
- Other anxiety disorders (49%)
- Affective disorder (38%)
- Alcohol dependence (9%)
- Eating disorders
Social anxiety disorder causes
While social anxiety disorder may present as early as elementary school age, it usually first presents in the mid-teen years. It is uncommon for social anxiety to present for the first time after age 30. Social anxiety disorder is thought to be caused by a mix of . While specific genes have not yet been identified, the areas of the brain thought to be most implicated are the , prefrontal cortex, and amygdala. Many people with social anxiety disorder experience an alleviation of symptoms with the class of drugs called selective serotonin reuptake inhibitors (SSRIs), which increase the amount of available serotonin. The improvement in the condition with this medication suggests that a biological decrease in serotonin levels may play a role in the development of this disorder.
Treatment options and prevention
The treatment course for social anxiety disorder is aimed at both symptom management and using tools to measure continued response to pharmacologic or therapy-based treatment regimens.
- Cognitive behavioral therapy (CBT): CBT has been proven to be equally effective as pharmacotherapy in treating . This method of therapy involves identifying errors or unhelpful patterns in thinking processes.
- Selective serotonin reuptake inhibitors (SSRIs): These drugs increases the amount of serotonin available within the brain. In trials comparing SSRIs to placebo, the treatment group showed significant improvement compared to the control group.
- Serotonin-norepinephrine reuptake inhibitors (SNRIs): This class of drugs increases the amount of serotonin and norepinephrine available for the brain to use. The SNRI drug venlafaxine has been proven to be equally effective for the treatment of .
- Monoamine oxidase inhibitors and benzodiazepines: These pharmacotherapies were historically used for the treatment of social anxiety disorder. However, given their extensive side effect profiles, they are now largely reserved for conditions refractory to other treatments.
Currently, no preventable risk factors for social anxiety disorder have been identified. There have been reports indicating that a highly-observed social situation (e.g. public speaking) followed by criticism can condition an individual to feel social anxiety when being in similar situations in the future. Therefore, prevention can in part be managed by those in educating roles (teachers, parents, etc.) to provide feedback that is not overly harsh or critical.
Questions your doctor may ask
- A panic attack is a sudden surge of intense fear combined with other symptoms that peaks quickly and then is over within minutes. Have you ever experienced a panic attack?
- Do you have a cough?
- How severe is your anxiety?
- Have you ever suffered from a concussion or traumatic brain injury?
- Are you feeling irritable (easily made upset)?
- Berger FK. Social anxiety disorder. U.S. National Library of Medicine: MedlinePlus. Updated December 6, 2018.
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013.
- Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.
- Grant BF, Hasin DS, Blanco C, et al. The epidemiology of social anxiety disorder in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry. 2005;66(11):1351-1361.
- Kendler KS, Neale MC, Kessler RC, Heath AC, Eaves LJ. The genetic epidemiology of phobias in women. The interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia. Arch Gen Psychiatry. 1992;49(4):273-281.
- Kawaguchi A, Nemoto K, Nakaaki S, et al. Insular Volume Reduction in Patients with Social Anxiety Disorder. Front Psychiatry. 2016;7:3. Published 2016 Jan 21.
- Davidson JR, Foa EB, Huppert JD, et al. Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia. Arch Gen Psychiatry. 2004;61(10):1005-1013.
- Stein DJ, Ipser JC, Balkom AJ. Pharmacotherapy for social phobia. Cochrane Database Syst Rev. 2004;(4):CD001206.
- Mayo-Wilson E, Dias S, Mavranezouli I, et al. Psychological and pharmacological interventions for social anxiety disorder in adults: A systematic review and network meta-analysis. The Lancet Psychiatry. 2014;1(5):368-376.