Social Anxiety Disorder


The most common type of anxiety disorder, social anxiety disorder, also known as social phobia affects millions of people across the globe. Under-recognized and under-treated, social phobia and its related conditions are the cause of much suffering. Virtually everyone knows what it is like to feel worried or lacking in social confidence, oftentimes to an extent that can be restrictive of one’s happiness. Approximately 13.3% of the general population may meet criteria for Social anxiety disorder at some point in their lives, according to the highest survey estimate, with the male: female ratio being 2:3 (Source, SAUK). Because social anxiety issues are still relatively unknown amongst the wider public, most aren’t even aware that the thing which can have such a huge impact on their lives has a name.

What Is social anxiety disorder?

Simply put social anxiety is nervousness in social situations. Social anxiety disorder, however, is more than just the occasional nerves. It is a long-lasting and overwhelming fear of certain social situations, resulting in significant distress and impaired ability to function in at least some parts of daily life. Those may be unfamiliar situations or events in which one fears that they will be watched or judged by others. Indeed, fears can be triggered by perceived or actual scrutiny from others or embarrassment in public. The amount of worry about specific social situations may be so frightening that the sufferer may turn to great measures in order to avoid them, disrupting their personal life in the process.

Symptoms of social anxiety disorder

Shyness is not criteria for diagnosis. Many feel shy or self-conscious on some occasions, but this doesn’t interfere with their everyday life. As we established, social anxiety is more than just nerves. Dreading daily activities, such as meeting new people, conversing with others, speaking on the phone, working or shopping, fearing almost any type of social interaction, especially within small groups, dating, parties, restaurants, interviews etc. Normally it starts during the teenage years and while for some, it may get better with time, for many social phobias does not go away on its own.

There are emotional, physical and behavioral signs and symptoms recognized with social phobia and its related conditions. Red face or blushing, shortness of breath, nausea, shaking, including ‘shaky’ voice, tightness in the chest, dizziness or excessive sweating are typical physical example symptoms. At the extreme, panic attacks may occur. While emotional signs of the disorder may include excessive self-consciousness, anxiety and intense worry for days, weeks, or even months before an upcoming social situation. Sufferers experience extreme fear of being scrutinized or judged by others, particularly unknown people, fear of embarrassment or humiliation or even fear that others will notice the distress, experienced at the exact time. At a deeper level, sufferers can endure prolonged insecurity about their relationships with others, hypersensitivity to criticism, or dread of being rejected by others.

Social phobia exceeds typical ‘shyness’  and can lead to the utmost social avoidance. Minor avoidance behaviors are detected when a person avoids eye contact and crosses arms to avoid handshaking. While major avoidance behaviors could include an almost pathological or compulsive lying behavior to preserve self-image and avoid judgment in front of others. Indeed many people can go through such experience during adolescence, however, the problems can continue well beyond those years. It can go as far as drinking before social situations in order to ease one’s nerves. Over time, many sufferers become extremely restrained or defensive in situations, often leading to isolation and depression. Because sufferers of social phobia often self-medicate, particularly if they are undiagnosed, untreated, or both, this may result in alcoholism, eating disorders or other kinds of substance abuse. Perhaps due to a lack of personal relationships and long periods of isolation related to social avoidance, social anxiety disorder generally occurs alongside low self-esteem and more commonly depression.

What causes social anxiety disorder?

Exact causes of social anxiety disorder are yet to be identified. However, social phobia is not caused by other mental disorders or substance abuse. There are suggestions that genetics can play a part in combination with environmental factors. As mentioned before, social anxiety can develop at a specific point in one’s life. For around half of the diagnosed with social anxiety disorder, a specific traumatic or humiliating social event appears to be associated with the origin or worsening of the disorder. This then can escalate over time as the person struggles to recover until eventually, mild social discomfiture can develop into symptoms of social anxiety or phobia. In fact, cultural factors can be related to social anxiety disorder too. These include a society’s attitude towards shyness and avoidance, affecting the ability to form relationships or access employment or education. Children appear more likely to develop social anxiety disorder if their parents emphasize the importance of others’ opinions and use shame as a disciplinary tactic. (Leung, 1994)

Diagnosing social anxiety disorder

Given the evidence that social anxiety disorder may predict subsequent development of other psychiatric disorders such as depression, early diagnosis and treatment are important. Social anxiety disorder continues to be under-recognized, with patients often presenting for treatment after the onset of complications such as clinical depression. After examining certain behavioral patterns and symptoms, a healthcare provider can diagnose a social phobia. Standardized rating scales such as the Social Phobia Inventory, the SPAI-B, Liebowitz Social Anxiety Scale, and the Social Interaction Anxiety Scale can also be used to screen and measure the severity of the anxiety.

Treatment for social anxiety disorder

There are a number of treatments available for social anxiety, the two main are medication and Cognitive Behaviour Therapy (CBT). Widely considered the best treatment for social phobia is CBT, however, other methods may help too. Some people may be treated with a combination of treatments. The first-line treatment for social anxiety disorder is indeed CBT in combination with medications such as selective serotonin reuptake inhibitors (SSRIs) used only with those who are not interested in therapy. The second-line treatment is a self-help guide, based on principles of CBT.

Cognitive-behavioral therapy

As the name suggests, the CBT has two main components, cognitive and behavioral. As a psychosocial approach, CBT looks at the individual in the context of the combined influence that psychological factors and the surrounding social environment exert on their physical and mental wellbeing and their ability to function. CBT is based on the basis that what a sufferer thinks affects how they feel, and feelings affect behavior. Therefore if the way one thinks about social situations that give anxiety is changed, then one feels and functions better. CBT focuses on challenging and breaking the unhelpful behaviors and cognitive distortions such as thoughts, beliefs and attitudes, improving emotional self-regulation, and the development of personal coping strategies that address the problem. Initially, it was designed to treat depression, but its uses have been expanded to include treatment of social phobia and other mental health conditions. In cases of social anxiety, the cognitive component can help sufferers question how they can be so sure that others are watching and judging them, serving as a logical extension, whereby patients are given evidence in the real world that their dysfunctional thought processes are unrealistic.

Exposure therapy

Gradual exposure is a key element in CBT, in which the sufferer is confronted by the things they fear in a structured method. This may be essentially an unpleasant treatment, as it involves exposure to an anxiety source, for as long as possible. Usually, the treatments include creating a hierarchy of feared steps and the patient is exposed to each step progressively. This is done with the support and guidance, and when the therapist and patient feel ready. The patient can end the procedure at any time.

There are three types of exposure methods. The first is in vivo or ‘real life’. This type exposes the patient to actual fear-inducing situations. For example, if someone fears public speaking, the person may be asked to give a speech to a small group of people. The second type of exposure is imaginal, where patients are asked to imagine a situation that they are afraid of. This procedure is helpful for people who need to confront feared thoughts and memories. The third type of exposure is interoceptive, which may be used for more specific disorders such as panic or post-traumatic stress disorder. All types of exposure may be used together or separately.

Parallels between exposure therapy and mindfulness, have been studied, stating that mindful meditation ‘resembles an exposure situation because mindfulness practitioners ‘turn towards their emotional experience’, bring acceptance to bodily and affective responses, and refrain from engaging in internal reactivity towards it.’ (Tang, 2015)

Avoiding caffeine

Evidence suggests that the way one treats their body can have a vital impact on their anxiety levels and the ability to manage anxiety symptoms and overall self-confidence.

Indeed lifestyle changes alone aren’t enough to combat social phobia, yet they can help the overall treatment progress. For example, avoiding caffeine can help reduce anxiety levels. Coffee, tea, soda, and energy drinks act as stimulants that increase anxiety symptoms. Cutting out caffeine entirely, or keeping a low intake will set the stage for a successful treatment.

Getting plenty of sleep

The relationship between sleep deprivation and anxiety goes both ways, meaning that sleep problems can cause anxiety, and anxiety can disrupt a goodnight’s sleep. It has been estimated that over 20% of adults suffer from some form of sleep deprivation. Most adults need seven to eight hours of sleep a night, while teenagers need about nine hours a night. Less than that causes a person to experience the symptoms of sleep deprivation, even if they feel like they are functioning normally. The first symptoms are usually loss of good judgment, slowed reaction time and memory loss. However, addressing sleep deprivation without taking steps to manage anxiety and reduce stress is unlikely to have any actual impact. Some of the treatments such as limiting caffeine and CBT were analyzed in previous paragraphs. In addition to that, mental health professionals can provide sleep education and help with designing an action plan to treat anxiety conjointly with sleep problems. Professionals may recommend medication, therapy, or a combination of treatments. Mindfulness meditation can also be a tool for calming busy minds.

Sum up on social anxiety disorder

In conclusion, the text illustrated that social anxiety disorder is an overwhelming fear of being scrutinized, watched, embarrassed or humiliated in public. In contrast to the feeling of shyness or nerves, people suffering from social phobia experience long-term extreme symptoms of anxiety. The text identified and analyzed three types of signs and symptoms related to a social phobia which evidently are emotional, physical and behavioral. Any visible symptoms, such as blushing, shaking and loss of voice, and trouble breathing, can further reinforce the anxiety in the presence of others. Acute and utmost severe cases of anxiety can result in panic attacks or major avoidance behaviors, such as pathological lying. Even though the social anxiety disorder is the most common type of anxiety disorders found globally, due to its wide-ranging causes and its close relationship and overlapping symptoms, the disorder continues to be under-recognized. The text has shown that Cognitive Behaviour Therapy is a highly effective treatment of anxiety disorders, especially social phobia. The text also examined one key element of CBT therapy – the gradual exposure therapy and its three methods of exposure. The first observed exposure is real life or ‘in vivo, then the imaginable exposure and the last one, the interoceptive exposure. Coming to an end the text looked at how specific daily actions, such as caffeine consumption, can have a negative impact on treating social phobia. Finally, the text examines the case of a combination of sleep deprivation and social phobia, providing recommendations and guidance on managing the issue.

The text sole aim is to inform and give an in-depth overview of social phobia and its relevant conditions, however, it is not a screening test or a diagnosis instrument. The reader is advised to consult with a professional, if recognizing any of the symptoms, in order to receive a specialist evaluation and tailored to the individual treatment if necessary.