Social Anxiety Disorder
Social anxiety disorder is a chronic mental health condition characterized by ongoing feelings of intense, persistent fear caused by the anticipation of, or participation in, social situations. People with the condition are intensely afraid of others watching and/or judging them. Their fears are out of proportion with the actual threat of the situation. Those with the condition may have trouble functioning in any social situation, whether at work, at school, or with loved ones. Symptoms must last for at least six months for the condition to be diagnosed.
People with social anxiety disorder may have difficulty making friends and maintaining friendships out of fear of being embarrassed, humiliated, or rejected. The condition, a type of anxiety disorder, was originally known as social phobia. It often begins during the teenage years.
As many as 13% of Americans experience social anxiety disorder or some symptoms of social anxiety. Social anxiety is believed to be underdiagnosed and undertreated because people with this condition often don’t seek help. Women tend to have social anxiety disorder more often than men.
Some people have performance-only social anxiety disorder, which means that they are fearful of certain social situations, like going on a job interview or giving a presentation in front of classmates or colleagues, but not other social situations, such as riding a bus with strangers or talking to a waiter in a restaurant.
A person may experience social anxiety disorder for many years without proper diagnosis and treatment. Some people with the condition experience loneliness, depression, or suicidal thoughts, stemming from the isolation that the condition can cause. Treatments like psychotherapy and/or medication can help people manage the condition.
What is social anxiety disorder?
Social anxiety disorder is a type of anxiety disorder that makes people intensely fearful of participating in social situations. It may cause people to skip—or limit their participation in—social events out of fear of being judged, humiliated, or rejected by others. The feelings of fear are so intense, many people with the condition believe it is out of their control. The diagnosis of social anxiety disorder requires that the symptoms persist for six months or longer (more on that below).
Some social situations might make anyone uncomfortable, such as speaking in front of a crowd or attending a party where they won’t know anyone. But people with social anxiety disorder are often worried about social situations that don’t typically make others nervous or fearful, such as meeting someone new, eating where others can view them, talking to a cashier while paying for something, or using a public restroom. The feelings of fear they experience are more intense than would be expected in these situations.
Some people with social anxiety disorder limit where they go and what they do so that they won’t be observed or judged by others. This may hamper their ability to excel at school, hold a job, or participate in meaningful relationships. Other people with social anxiety disorder don’t limit their activity, but they experience intense fear, stress, and anxiety while going about their day.
What causes social anxiety disorder?
Doctors don’t know what causes social anxiety disorder. Because the condition runs in some families, there may be a genetic component. Experts also believe that environmental factors influence whether or not a person develops social anxiety disorder—for instance, being harshly disciplined throughout childhood, experiencing childhood trauma, or growing up with a parent who has social anxiety disorder.
What are the symptoms of social anxiety disorder?
People with social anxiety disorder are likely to avoid social settings if they can.
When they find themselves in social situations, they may experience the following physiological symptoms:
- A rapid heartbeat
- Chest pain
- Feeling as though they are choking
- Shortness of breath
People with social anxiety disorder may exhibit the following behaviors in social situations:
- Feel very self-conscious
- Have difficulty talking
- Speak in a very quiet voice
- Avoid eye contact
- Feel stiff or rigid rather than relaxed
- Believe that other people are judging or rejecting them
What are the risk factors for social anxiety disorder?
How is social anxiety disorder diagnosed?
Many people with social anxiety disorder do not seek diagnosis or treatment. Doctors may discover the condition while a person with social anxiety disorder is assessed for another health condition.
Doctors may diagnose social anxiety disorder after learning about a person’s medical history and performing a physical exam to rule out health conditions that may have similar symptoms. If a patient is too fearful to discuss their condition with the doctor, a family member may share information on their behalf. There are no diagnostic tests for social anxiety disorder.
When a doctor asks about a patient’s medical history, they will want to know if there is a family history of social anxiety disorder or a personal history of depression, anxiety disorders, or a substance use disorder. Doctors may also ask about a personal history of thyroid disease, heart disease, asthma, or other conditions that might cause some of the symptoms the person has experienced.
Doctors should perform a physical exam to look for signs and symptoms of thyroid disease, heart disease, asthma, or other conditions that could be causing the patient’s symptoms. During the assessment, they will ask the patient if they avoid social situations and activities.
If the patient acknowledges a fear of social situations, the doctor will ask about their symptoms, including what situations cause fear and anxiety, how they feel when they’re in those situations, and whether their fear or anxiety prevents them from living their life fully. Answers to these questions will help the doctor decide if they should refer the patient to a mental health professional.
If the patient is referred to a mental health specialist, the following criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), a diagnostic tool published by the American Psychiatric Association, may be used to diagnose social anxiety disorder:
- Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others.
- 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 substance use disorder 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.
- 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.
How is social anxiety disorder treated?
The most common treatment for social anxiety disorder is cognitive behavioral therapy (CBT), also known as talk therapy. Certain medications may also be used to treat the condition.
Cognitive Behavioral Therapy. Psychotherapists often rely on CBT to treat patients with social anxiety disorder. The therapy involves teaching patients new ways to think about social situations, how to behave in social settings, and how to react to social events, thereby reducing their fears and anxieties. Sessions may be scheduled weekly for several months. By the end of the sessions, patients should be open to participating in social activities.
Medications can also manage social anxiety disorder, with or without psychotherapy. Doctors may prescribe:
- Certain antidepressants, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs).
- Certain anti-anxiety drugs, such as benzodiazepines. These medications have a soothing effect and can work quickly to alleviate feelings of anxiety. Over time, people may build up a tolerance to these medications or become dependent on them. For these reasons, it’s better to limit the use of these drugs.
- Beta-blockers, which help to reduce symptoms, like sweating or trembling, among people with performance-related social anxiety disorder, especially when taken an hour before the patient is in a social situation.
What is the outlook for people with social anxiety disorder?
People who do not seek help for social anxiety disorder may continue to avoid social situations indefinitely, limiting their ability to thrive at work, school, or in interpersonal relationships. They may have a decreased quality of life—feeling lonely, depressed, or hopeless about their situation over time.
Patients with social anxiety disorder who seek treatment can often overcome their feelings of fear and anxiety related to social situations, enabling them to participate more fully and confidently in social events without overwhelming feelings of fear or anxiety.
Social anxiety disorder is a chronic condition. People may relapse months or years after successful treatment, requiring them to seek treatment again to manage symptoms.
What makes Yale unique in its treatment of social anxiety disorder?
“We rely on a comprehensive approach to the assessment and diagnosis of social anxiety and associated difficulties in social and professional functioning,” says Denis Sukhodolsky, PhD, a clinical psychologist in the Yale Child Study Center. “This assessment guides personalized treatment that starts with psychosocial interventions, such as cognitive behavior therapy, and may include psychiatric medication, if needed. Clinical care is also informed by ongoing research into improving the efficacy of treatments for social anxiety in special demographic and clinical populations.”