Social Anxiety Disorder

What Is Social Anxiety Disorder? What Causes Social Anxiety Disorder?

Social anxiety disorder or social anxiety is an excessive emotional discomfort, anxiety, fear or worry about social situations. The individual is exceptionally worried about social situations, being evaluated or scrutinized by other people - there is a heightened fear of interactions with others. Social anxiety disorder is sometimes referred to as social phobia. A phobia is an irrational fear of certain situations, objects or environments.

A person with social anxiety disorder typically is excessively fearful of embarrassment in social situations - this fear can sometimes have a debilitating effect on personal and professional relationships.

An individual with social anxiety disorder may have signs and symptoms of blushing, trembling, accelerated heartbeat, muscle tension, nausea, sweating, abdominal discomfort and lightheadedness.

Social anxiety often occurs early in childhood as a normal part of social development and may go unnoticed until the person is older. The triggers and frequency of social anxiety vary considerably, depending on the individual.

Most of us may feel nervous in certain social situations, such as giving a presentation, going out on a date, or taking part in a competition (such as a quiz). This is normal and in most cases is not social anxiety disorder. Social anxiety disorder is when everyday social interactions cause excessive fear, self-consciousness and embarrassment. Such trivial tasks as filling a form with people around, or eating in public places or with friends may become considerable ordeals for somebody with social anxiety disorder.

According to Medilexicon's medical dictionary:

    Social phobia is "a persistent pattern of significant fear of a social or performance situation, manifesting in anxiety or panic on exposure to the situation or in anticipation of it, which the person realizes is unreasonable or excessive and interferes significantly with the person's functioning; 2. a DSM diagnosis that is established when specified criteria are met." (DSM = Abbreviation for the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.)

What are the signs and symptoms of social anxiety disorder?

A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign.

Social anxiety disorder is a chronic mental health condition in which the sufferer has an irrational fear or anxiety of situations or activities, believing he/she will be observed and judged by others. There is considerable fear of humiliation or embarrassment. There may be physical, emotional and behavioral signs and symptoms.
Behavioral and emotional signs and symptoms:
  • Anxiety reaches such a point that daily tasks, including school life, work and other activities become affected
  • Avoiding situations where the sufferer feels he/she may be the center of attention
  • Children with possible social anxiety disorder tend to be worried about being embarrassed in front of peers, but not generally in front of adults
  • Considerable fear of being in situations with strangers (people the sufferer does not know)
  • Dread over how they will be presented to others
  • Excessive fear of being teased or criticized
  • Excessive fear that other people may notice that the sufferer looks anxious
  • Excessive worry about being anxious, which makes the anxiety worse
  • Excessive worry about embarrassment and humiliation
  • Fear of meeting people in authority
  • Having severe anxiety or panic attacks when in the feared situation
  • Refraining from doing certain things or talking to people because of a fear of humiliation or embarrassment
  • The individual worries excessively about being in situations where he/she may be judged
  • When in a situation that causes anxiety the sufferer's mind may go blank
Physical signs and symptoms:
  • A feeling that the heart is either pounding too hard or fluttering (palpitations)
  • Abdominal pain and/or stomach upset
  • Avoiding eye contact
  • Blushing
  • Children with social phobia may weep, have tantrums, cling to parents, or shut themselves out
  • Clammy hands
  • Cold hands
  • Confusion
  • Crying
  • Diarrhea
  • Difficulty talking; this may include a shaky voice
  • Dry mouth
  • Dry throat
  • Excessive sweating
  • Muscle tension
  • Nausea
  • Shaking
  • Trembling
  • Walk disturbance - the individual is so worried about how they walk that they lose balance when passing a group of people
An individual with social anxiety disorder may also:
  • Be over-sensitive to criticism
  • Have low self-esteem
  • Have poor social skills
  • Not be assertive
  • Talk negatively about himself/herself - thoughts are often self-defeating and inaccurate
Individuals with social anxiety disorder sometimes underachieve at school or at work in order to avoiding the attention of being promoted or having to participate in group tasks. In severe or chronic (long-term) cases of social anxiety the person may develop other psychological conditions, such as depression.

A person with social anxiety disorder may find the following situations extremely difficult to face:
  • Being introduced to people they don't know
  • Talking to people they don't know
  • Going into a room where the people are already settled
  • Looking at people straight in the eye (eye contact)
  • Ordering a meal in a restaurant
  • Starting a conversation
  • Using a public telephone
  • Using a public toilet
  • Writing in front of other people
  • Doing anything where other people may be looking on
People with social anxiety disorder usually know that their anxiety is irrational. However, in many cases the anxiety persists and does not get better without appropriate treatment.

What are the risk factors for social anxiety disorder?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2.

According to The Mayo Clinic, USA, approximately 3% to 13% of people in Western countries experience social anxiety disorder at some time in their lives. The disorder typically starts in the early to midteens, but can sometimes start much earlier or later.

The following factors may increase the risk of developing social anxiety disorder:
  • Gender - social anxiety disorder is significantly more common among females than males.
  • Genetics - if a person's parents or a sibling has the condition his/her risk of developing it is higher, compared to other people.
  • Nurture - some people believe that social anxiety disorder may develop in people who have witnessed anxious behavior in others. Some experts believe there may be a link between the disorder and over-protective parenting.
  • Some life experiences - children who have experienced bullying, ridicule, humiliation or rejection are said to be more susceptible to social anxiety, compared to other people. Sexual abuse, a family conflict or some other negative experience may also be factors.
  • The individual's personality - children who are withdrawn, restrained, shy or timid when confronted with a new situation are thought to be more prone to developing social anxiety disorder.
  • A demanding ordeal - some people may experience social anxiety for the first time when they have to make an important presentation. Actors may experience stage-fright or some kind of social phobia when they are on stage.

What are the causes of social anxiety disorder?

Experts say that social anxiety disorder has both environmental and genetic causes.
  • Genetic causes - as the condition is more common in families (appears to run in families). There is ongoing research which attempts to find out how much of this is genetic versus acquired learning (if family members are anxious, the offspring will learn that behavior).
  • Chemicals in the body - scientists are currently undergoing research into what natural body chemicals might be playing a part in the development of social anxiety disorder. Serotonin, a brain chemical, may play a key role when its brain levels are not right or if the patient is extremely sensitive, some scientists suggest.
  • Brain structure - some experts believe the amygdala (part of the brain) may play a role in fear response, resulting in an excessive reaction in patients with an overactive amygdala.
  • Weather and/or demographics - Mediterranean countries have lower rates of social anxiety disorder compared to Scandinavian countries. This could be due to warmer weather as well as a higher population density in the Mediterranean countries. Warmer weather may reduce avoidance and increase interpersonal contact. Others suggest that the factors may be cultural.

Diagnosing social anxiety disorder

A doctor, often a GP (general practitioner, primary care physician) may carry out a physical as well as a psychological evaluation. The physical exam helps the doctor rule out any physical causes for the patient's symptoms. There is no current laboratory test that can diagnose social anxiety disorder.

A GP will probably refer the patient to a mental health provider, usually a psychiatrist or psychologist. The mental health provider will ask the patient to describe his/her symptoms, when they occur, how often, and how long they have been occurring. The health care professional may ask the patient to complete a questionnaire.

In the USA a patient must meet the DSM criteria (DSM = Abbreviation for the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders.) In the USA this manual is used by doctors and other mental health providers, as well as insurance companies when determining whether to reimburse the patient's treatment. The criteria include:
  • The patient avoids situations which may produce anxiety
  • The patient has a persistent fear of social situations in which they believe they will be scrutinized, or act in a way that's embarrassing or humiliating.
  • The patient recognizes that his/her anxiety level is excessive or out of proportion for the situation
  • The patient's daily living is affected by his/her anxiety
  • The social situations cause a lot of anxiety

What are the treatment options for social anxiety disorder?

In a significant number of patients, social anxiety disorder continues for life, usually fluctuating in its severity. Available treatments can help people control their symptoms considerably, as well as gaining confidence.

Psychotherapy together with medications are considered by most experts as the most effective treatments.


Psychotherapy is treatment by psychological means. Psychotherapy may utilize persuasion, suggestion, reassurance, insight (perceptiveness, self-awareness), and instruction so that the person can see himself/herself and their problems in a more realistic way and wish to overcome and/or cope with them effectively. There are many types of psychotherapy, including cognitive therapy, interpersonal therapy, psychodynamic therapy, and family therapy.

Cognitive behavioral therapy (CBT) has been shown to improve symptoms enormously. CBT helps the patient realize that it is their own thoughts, rather that the situations or other people, that determine how they react or behave. The way a person thinks may positively affect their behavior, even if the situation or people don't. In this type of psychotherapy the patient learns how to recognize and change negative thoughts about themselves.

This type of therapy has two main parts:
  • a cognitive part designed to limit distorted thinking.
  • a behavioral part designed to change the way people react to the objects or situations that trigger anxiety.
The patient may also receive exposure therapy where they gradually work up to facing situations they fear - the aim is to improve the patient's skills at coping with the anxiety-inducing situations and to develop confidence to face them. With cognitive delivered exposure (CDE), the patient safely confronts the situations or places that cause problems, often in the company of the therapist.


SSRIs (selective serotonin reuptake inhibitors) are the most common medications prescribed for patients with social anxiety disorder - they are thought to be the safest as well as most effective treatment for persistent symptoms. Examples may include Paroxetine (Paxil, Paxil CR), Sertraline (Zoloft), Fluvoxamine (Luvox, Luvox CR), or Fluoxetine (Prozac, Sarafem). Side effects may include: The patient may be prescribed an SNRI (serotonin and norepinephrine reuptake inhibitors), such as venlafaxine (Effexor, Effexor XR).

Patients usually start on a small dose, which is gradually increased. According to The Mayo Clinic, it may take up to three months for any changes in symptoms to be noticeable.

Benzodiazepines - these anti-anxiety medications help reduce anxiety levels. Examples include alprazolam (Xanax) and clonazepam (Klonopin). Because they may cause dependence, treatment courses are usually short. Side effects may include:
  • Confusion
  • Drowsiness
  • Light-headedness
  • Loss of balance
  • Memory loss
Beta-blockers - this type of medication helps block the stimulating effects of adrenaline (epinephrine). They are usually prescribed for specific situations, such as having to make a presentation. They are not used for general treatment.

What are the possible complications of social anxiety disorder?

In many cases, untreated social anxiety disorder can persist throughout the patient's life. The person's life may be dominated by his/her anxieties, which interfere with daily life, school work, professional work, relationships and general happiness.

In severe cases the individual may quit work, drop out of school and become isolated.

There is also a risk of alcohol and/or substance abuse, depression, and even suicide.

Many people, including some experts, argue that social anxiety is caused by inherent problems with society, including a competitive culture, power imbalances, lack of care and poor social education in families. They say the clinical boundaries of social anxiety disorder have been stretched too far - in other words, too many people are being diagnosed as having a medical problem when they don't


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