What Is Social Anxiety?

Social anxiety, also known as social anxiety disorder (SAD) or social phobia, is a mental health condition characterized by chronic and intense fear of being watched or judged by others, which can generate feelings of embarrassment, self-consciousness, and even depression. It typically presents during youth in people who are very shy. SAD can affect work, school, and other day-to-day activities, and can even make it hard to make and keep friends.

What Is Social Anxiety?

While it’s normal to experience anxiety in certain social situations like a first date or job interview, social anxiety is different because without treatment, it gets worse. The consequences can be isolation and loneliness, as well as a breakdown of relationships, including those with family, coworkers, and friends.

There are two types of social anxiety: specific and general. A specific social anxiety would be the fear of speaking in front of groups only, while people with generalized social anxiety are anxious, nervous, and uncomfortable in almost all social situations.

It is much more common for people with social anxiety to have a generalized type of this disorder. When anticipatory anxiety, worry, indecision, depression, embarrassment, feelings of inferiority, and self-blame are involved across most life situations, a generalized form of social anxiety is at work.

Symptoms

Experiencing symptoms of social anxiety does not necessarily mean someone has an anxiety disorder. However, if these symptoms result in persistent emotional distress or are disrupting everyday routines, that could be a sign of social anxiety disorder.

Physical

Physical symptoms can arise when a person with SAD is confronted with social situations like giving a speech, playing a sport, or performing in a recital. This happens because their fight-or-flight stress response has been activated into overdrive by the perceived threat of the other person.

People with SAD may experience the following when having to perform in front of or be around others:

• Blushing
• Sweating
• Trembling 
• Nausea 
• A rapid heart rate
• Rigid body posture, making little eye contact, or speaking with an overly soft voice

Psychological

The psychological symptoms of SAD may be largely invisible to others, but they are serious and have the ability to derail someone’s life. These symptoms include:

• Avoiding social situations
• Extreme and irrational anxiety
• Severe fear of judgement and rejection
• Intense feelings of self-consciousness 
• Desiring to talk to others but experiencing difficulty and fear

Complications

Without treatment, these symptoms can fester into significant problems. Difficulties being around, communicating, and connecting with others can mean lost opportunities:

• Fear of interviewing can hinder professional growth
• Anxiety about meeting new people can lead to isolation
• Avoidance of social situations can result in someone becoming homebound
• Alcohol and other substances may be used to self-medicate, creating further mental health and relationship issues
• Depression and self-harm or suicidality can result

Diagnosis

Your doctor will ask you questions about your symptoms and to describe your experience. The next common step is for your doctor to order lab tests to rule out potential underlying causes of your symptoms like tumors, hormonal imbalances, and infectious diseases like Lyme disease.

Once they determine that your symptoms are not caused by a physical illness, your doctor will then refer you to a psychiatrist or psychologist for diagnosis. Your mental health professional will use the criteria laid out in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) to gauge whether you have social anxiety disorder, which include:

• Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny
• The individual fears acting in a way or showing anxiety symptoms that will be negatively evaluated
• The social situations almost always provoke 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 social situations are avoided or endured with intense fear or anxiety
• 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 persistent, typically lasting for six months or more
• The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse) or another medical condition
• The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder
• 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 the fear is restricted to speaking or performing in public

Causes and Risk Factors

Many factors influence a person’s likelihood of developing social anxiety:

• Biological markers: Increased blood flow to the amygdala (a part of the limbic system responsible for fear) has been shown in brain images of people with SAD. Other parts of the brain involved in anxiety include the brain stem (controls heart rate and breathing), the prefrontal cortex (helps appraise risk and danger), and the motor cortex (controls your muscles)
• Genetic factors: People are 2% to 6% more likely to have an anxiety disorder if a first-degree relative does, but no specific genetic makeup has been identified for SAD
• Environment: Unhealthy coping mechanisms (like conflict avoidance) and anxious responses or behaviors can be learned by way of observation of authority figures and peer groups
• Physical appearance: Certain physical characteristics that stand out as unusual to the surrounding social norm can underlie social anxiety
• Temperament: Exhibiting excessive inhibitions to new activities, people, places, or things can be an early sign of SAD. This may look like extreme shyness or crying when confronted with new people
• New job or social situations: Any major life changes, whether positive or negative, may be an underlying trigger for SAD

Subtypes

The National Social Anxiety Center recognizes several subtypes of social anxiety disorder:

• Paruresis or shy bladder syndrome is centered on what others’ would think about them if they were unable to initiate the flow of urine
• Conversational anxiety involves experiencing distorted and negative thoughts about what strangers and acquaintances think about you
• Male sexual performance anxiety is a vicious cycle that occurs when feeling anxious about performing sexual activities turns to excessive self-monitoring and self-evaluating during sexual relations that can then prevent erection or orgasm
• Public speaking anxiety, or glossophobia, is one of the most common phobias, affecting about 73% of the population
• LGBTQ anxiety can occur both from internalized social stigmas about the community and from being bullied or ostracized

Treatment

Treatment options can include helping a person develop healthier thought patterns and coping mechanisms and other psychosocial improvements. They can also be used to help manage and reduce the associated symptoms of social anxiety disorder.

Psychotherapy

Many research studies have shown that anxiety-specific cognitive behavior therapy (CBT), a type of psychotherapy that teaches healthier ways of thinking, behaving, and reacting to situations, changes core brain structures in processing and regulating emotion.

Medication

Medications can be effective in the short term in managing symptoms of social anxiety. But if they are not used in conjunction with an active, structured CBT program, medications alone will have no long term benefits for people with SAD.

Medications that may be used to manage SAD include:

• Anti-anxiety medications: They work quickly, and include benzodiazepines such as Valium (diazepam), Xanax (alprazolam), Klonopin (clonazepam) and Ativan (lorazepam)
• Antidepressants: Namely selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors. It takes several weeks for these medications to begin working, but studies have found that 50% to 80% of patients with the general form of social anxiety disorder respond after taking venlafaxine or an SSRI for eight to 12 weeks
• Beta-blockers: They are used to help reduce the physical symptoms of anxiety, most commonly performance-type social anxieties

Coping

There are additional ways to help improve quality of life and reduce symptoms of anxiety when living with SAD:

• Join a support group to find support and a safe place to learn and begin to understand that your thoughts about judgment and rejection are not true or are distorted
• Challenge negative thinking patterns that involve trying to foreshadow events and thinking about worst-case scenarios. For example, can you really know what that person is thinking about you?
• Focus outward to help prevent hyper-focusing on your bodily sensations and physical reactions or appearance
• Take time to breathe deeply and fully, giving your nervous system a chance to calm down
• Avoid caffeine, including hidden sources of caffeine in chocolate and sodas, which can aggravate anxiety
• Add omega-3 fatty acids into your diet (think fatty fish and nuts) to support your overall mood health, outlook on life, and ability to handle anxiety
• Practice patience with yourself and others. Don’t expect perfection in social situations, and use the skills you’ve learned to stay or get calm