Social anxiety disorder causes people to feel uncomfortable and self-conscious in social situations.
Social anxiety disorder is extremely common affecting 15 million American adults.
Being shy is not the same as having social anxiety disorder. See a medical professional for diagnosis.
For people with social anxiety disorder, everyday interactions with strangers, coworkers, or even friends can trigger significant self-consciousness, embarrassment, and make it difficult to live a normal life.
“Social anxiety disorder is a mental health diagnosis in which social situations almost always provoke feelings of anxiety. People with social anxiety will often avoid social situations altogether due to fear or anxiety,” says Brent Metcalf, LCSW at Tri-Star Counseling.
Social anxiety disorder, aka social phobia, affects 15 million American adults, making it the second most common anxiety disorder after specific phobia. However, there are ways to manage your anxiety.
Learning coping skills, taking medication, and therapy can help you feel more comfortable in front of others and improve your ability to connect with those around you.
Social anxiety disorder (SAD) has several potential causes:
You’re more likely to develop SAD or another anxiety disorder if your parents or siblings struggle with anxiety. However, it’s not clear how much of this is due to genetics or learning anxious behaviors from your family.
Note: The acronym SAD is also used to refer to seasonal affective disorder. However, all mentions of SAD in this article are references to social anxiety disorder.
The amygdala and dorsomedial prefrontal cortex are the complex structures of cells in the brain that control your emotional learning and socially directed thoughts. In fact, research suggests that children with high levels of anxiety also have a larger amygdala than peers with low levels of anxiety.
Research from 2016 of unmedicated patients with SAD found that participants with social anxiety disorder experienced larger responses in these brain regions in social contexts than those without the condition. It’s also been shown people with overactive amygdalas can have heightened fear responses, causing increased anxiety in social situations.
Negative social experiences
Children who have experienced bullying, rejection, or abuse have an increased risk of developing SAD.
“Social anxiety disorder may stem out of a childhood history of social inhibition or shyness, but it can also be caused by a stressful, traumatic, or a humiliating situation or event,” says Metcalf.
But it’s not just your childhood. SAD can develop in adulthood as the result of negative social experiences, as well. When the condition leads people to avoid social situations to prevent anxiety, it can lead to a vicious psychological cycle.
People who were shy, withdrawn, or anxious in childhood are more likely to develop SAD. However, these traits are distinct from having a diagnosis of social anxiety disorder.
“Shyness can be a symptom of social anxiety, but being shy is not the same as having SAD. Being shy may cause some nervousness in social situations, but shyness alone typically doesn’t create avoidance of social interactions with others,” says GinaMarie Guarino, LMHC at PsychPoint.
Perceived physical differences
Tremors from conditions like Parkinson’s disease, discrimination from others due to facial disfigurement, or speech impediments can trigger SAD and self-consciousness in some people. Guarino also notes that people with low self-esteem are at higher risk of suffering from social anxiety disorder.
Feelings of shyness or getting stressed in certain situations aren’t always signs of social anxiety disorder.
Everyone gets anxious sometimes, and some people are naturally more outgoing or comfortable in public settings than others.
SAD goes beyond shyness or being quiet in front of others.
Symptoms in anticipation of or during social situations can include:
Intense fear of judgment
Trouble speaking or thinking coherently
Increased heart rate
Difficulty making or maintaining eye contact
Feelings of self-consciousness
Avoiding places where there might be people
Difficulty doing tasks or activities when others might be watching
Many of these symptoms are out of your control because you’re having an involuntary response. You’re releasing a rush of adrenaline and cortisol, hormones that tell your body to take immediate action because of a perceived threat. These are controlled in part by the brain structures mentioned above.
“Individuals with social anxiety disorder experience an ‘amygdala hijack’ in social situations, where the amygdala becomes the brain structure in charge and stops listening to reason. This causes them to feel overcome with fear, so they may feel little to no control over managing their reaction when this happens,” says Rebecca Phillips, LPC at Mend Modern Therapy.
Thankfully, you can train your brain to help you control your amygdala, the hormones at play, and the symptoms they cause.
A therapist, psychologist, psychiatrist, social worker, nurse practitioner, or medical doctor can diagnose you with SAD.
Your provider will start by discussing your existing symptoms. This may include reviewing a list of situations that trigger your anxiety, identifying how often your symptoms occur, and noting any patterns.
After that, a physical exam can help determine if you have another medical condition that may be causing your symptoms. For example, SAD commonly occurs with attention-deficit/hyperactivity disorder (ADHD), substance use disorders, and post-traumatic stress disorder (PTSD), autism spectrum disorder, and body dysmorphic disorder, says Guarino.
Your doctor can also help determine if your anxiety is a side effect of a medication you’re currently taking.
Self-report questionnaires like this one from the Anxiety and Depression Association of America (ADAA) can be accessed for free online, and others may be provided by your doctor. These questionnaires about your anxiety can be helpful for a thorough overview of symptoms.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) from the American Psychiatric Association is the primary text your doctor will use to diagnose social anxiety disorder.
DSM-5 criteria for social anxiety disorder includes:
Marked anxiety about one or more social situations in which you are vulnerable to possible scrutiny by others.
Fearing you might act in a way that will be negatively evaluated by others.
Social situations almost always create fear or anxiety.
Social anxiety are avoided or uncomfortably endured with intense fear.
Anxiety is out of proportion to the actual threat of the situation.
Your fear, anxiety, or avoidance lasts 6 months or more.
Your anxiety is not the result of a substance (prescription medication, marijuana, caffeine, etc.) or medical condition.
Your anxiety is not better explained by symptoms of another disorder, like panic disorder, body dysmorphic disorder, or autism spectrum disorder.
If another medical condition (Parkinson’s disease, obesity, disfigurement from bums or injury) is present, the fear, anxiety, or avoidance is unrelated or is excessive.
It’s a good idea to see your provider if you think you have SAD, especially if it’s having a significant impact on your life. Getting diagnosed is the first step toward finding the best treatment.
Depending on the severity of your SAD, you may be able to treat this condition without help from a doctor or therapist.
For example, if you’re struggling with panic attacks when anticipating social situations, your provider might suggest relaxation techniques, medication, therapy, or a combination of these.
Exposure therapy is a type of therapy that involves putting yourself in low-key social situations like getting coffee with a friend and working up to more friends and eventually strangers.
Working your way up from easier to more challenging situations can help you learn to tolerate your anxiety.
Psychotherapy can teach you how to identify and change negative thoughts about yourself while developing skills to help you gain confidence in social situations.
Cognitive behavioral therapy (CBT) techniques focus on modifying your thinking patterns to reduce the belief that social failure or rejection is likely. CBT also uses exposure therapies designed to gradually help you enter anxiety-inducing social situations so you can become more comfortable over time.
Intensive CBT (I-CBT), is another option, which features longer sessions concentrated into a month, week, or weekend. This means you might not need to stay in treatment for several years. Treatment of social anxiety via CBT can create long-lasting or permanent relief from social anxiety.
If relaxation techniques and therapy are of little or no help, then your provider might try prescribing you medication. Some of the common options include:
Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) are antidepressants commonly used to reduce symptoms of both depression and SAD. While these generally cause fewer side effects than other mood medications, they may take a few weeks to start working. Tell your provider about any side effects you notice.
Beta-blockers can help with performance anxiety (intense anxiety during speaking or performing in public but not in general social situations) by reducing symptoms like rapid heart rate, sweating, and tremors. However, beta-blockers aren’t recommended for general treatment of social anxiety disorder.
Benzodiazepines may be prescribed for severe social anxiety. These powerful sedatives start working within the hour to reduce anxious feelings. However, many people build up a tolerance to them and need increasingly larger doses to reduce their symptoms leading to dependency. Given their potentially addictive nature, your health care provider may prescribe them for only short periods.
Important: Many treatments don’t work overnight, so don’t give up if you’re not seeing an immediate improvement. It might take you weeks to successfully use skills you learn in psychotherapy, or for an SSRI to start working. Likewise, finding the right medication could take a little trial and error.
Social anxiety disorder can feel disabling to many people. If you’re struggling with symptoms of SAD, you’re not alone — social anxiety disorder is common but treatable.
The right treatment, whether done at home or with your doctor, can help you develop relaxation skills and challenge your negative self-talk so you can feel more comfortable around others.
“If you feel social anxiety is holding you back from being able to thrive in an area of your life — relationships, career goals, or being able to maintain friendships — proper diagnosis and treatment can help you feel better,” says Guarino.
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