Updated: Jan 12
In this article
What is social anxiety disorder?
Social anxiety Disorder (SAD), or social phobia, is a type of anxiety disorder where one suffers from the acute and constant fear of being judged or watched by other people. Evolution-wise, this social awareness is adaptive behavior – it’s how we map out the environment around us and react accordingly so that we fit into society.
Amplified, that constant awareness of being viewed by people negatively results in social anxiety.
Social anxiety or just plain shy?
“They’re just painfully shy” Perhaps the difference between social anxiety and shyness is “painfully” because for people suffering from the phobia, interaction with other people can be a very emotionally and mentally difficult process.
While shyness and social anxiety are often presumed to be the same thing, Dr Kristy Dalrymple highlights the importance of drawing boundaries between the two. This prevents over or underdiagnosing social anxiety disorder .
In her paper Treating Social Anxiety, she wrote that shy people don’t have the same level of fear that denotes social anxiety. She also noted that some shy people saw their personality trait as a good quality, similar to sensitivity.
In short, shyness is a disposition that does not disrupt social interactions, while social anxiety disorder is a fear that may lead to an avoidance of interaction at all costs.
How does social anxiety affect your life?
Avoiding social interaction is nearly impossible in daily life. Getting lunch at the shops, shopping for the week’s groceries, working or going to school, these activities have some sort of contact with people and while seemingly mundane activities, they may cause great stress and fear in people with anxiety.
Without treatment, social anxiety may spiral and lead to other dire consequences:
Worsening of self-esteem
The basis of social anxiety is low confidence and the fear of being judged. If left untreated, social anxiety and low self-esteem feed into each cyclically, making even more difficult to treat.
Developing other mental health issues
A study also showed that socially anxious people desired company but was impaired by their anxiety outside a trusted group. Due to the nature of social anxiety, people suffering from the mental illness are bound to feel deep-seated loneliness which may develop into depression .
Social anxiety and avoidance behaviors have long had ties. In efforts of self-preservation, a person suffering from social anxiety may avoid social situations to alleviate that anxiety and fear, and the exhaustion of constantly living with that fear.
However, research shows the negative effects of avoidance behaviours as a coping mechanism for social phobia.
In the Journal of Behaviour Therapy and Experimental Psychiatry, The Relationship Between Maladaptive Self-Beliefs Characteristic of Social-Anxiety and Avoidance, we learn that avoidance behaviour is an effective coping mechanism because it is reinforced by alleviating anxiety, thus allowing for the behavior to carry on in a vicious, unhealthy cycle .
What causes of social anxiety?
It is difficult to pinpoint exact causes of one’s social anxiety. Mental illnesses are often a culmination of different triggers, as is social anxiety.
Studies have shown that if there has been a family member with social anxiety, chances of its manifestation in an individual was higher at 44% .
Scientists have yet to pinpoint an exact gene that causes social anxiety. Research hypothesise that though one may be more susceptible to social anxiety through genetics, other factors are largely contributors for the disorder's development .
Introverted individuals tend towards a more passive approach to social situations, and introversion is correlated to neuroticism. Neuroticism is characterized as the likelihood to experience negative emotions.
As such, there is research to suggest that temperament may lend to a higher chance of suffering from social anxiety disorder .
We react to social situations based on the experiences we have had – if we have had more favourable social interactions, the more likely we feel safer to continue making connections with people.
Published in 2019 on the Contemporary School of Psychology, research backed up the fact that bullying, both traditional and cyber, had adverse effects for social interaction in adolescents. The research did highlight, however, that this was more prevalent in girls than boys.
In addition, the presence of abuse in the individual’s environment can also trigger social anxiety .
What can trigger social anxiety?
A misconception that many have is that someone with social anxiety is fearful of every social situation they face. This is not true. Social anxiety is divided into two subtypes: generalized and non-generalized.
Generalized social anxiety, the more prevalent subtype is where an individual feels anxious in almost all of the social situations they face. Non-generalized social anxiety would refer to the individual having more specific triggers situations .
Some situations that may trigger social anxiety are:
Being mentally prepared is a method of handling someone’s anxiety, and being thrown into a spontaneous situation induces anxiety.
Meeting new people, interviews and meeting authority figures
Socially anxious people not only fear judgement, they also have a lot of worry and self-doubt. Meeting new people is about forming impressions and for someone with social anxiety, the brain may be overrun with worry about how to say, how to act, making comparisons between the other individual and themselves.
Authority figures can be very intimidating for anyone, which will add another stressor to someone with SAD.
Being the centre of attention
This includes public speaking, put on the spot as well as being embarrassed and humiliated. Being judged by one person may already be a difficult experience to go through, but to have a roomful of people scrutinizing your every move is hellish.
A study titled Gaze Perception in Social Anxiety and Social Anxiety Disorder also found through neuroimaging that the brain’s fear circuits were more active, and eye-tracking technology showed that patients with social anxiety “avoided the eye region” .
What are the symptoms of social anxiety?
Bashfulness is not necessarily social anxiety. People rely on their experiences in prior social situations to decide how they should act and when in a new environment, a good number of people are likely to be more reserved to assess and act accordingly.
Social anxiety, on the other hand, persists in most if not all the situations that a person might face, and interferes with one’s ability to function in daily activities. Some symptoms of social anxiety include:
Intense and constant fear in social settings
Fear of potentially embarrassing and humiliating situations
Fidgeting and showing small signs of discomfort
Avoidance of speaking to people
Avoidance of situations where one may be center of attention
Replaying interactions with other people to look for flaws
Worrying about events before it happens
Mind going blank in social situations, or when put on the spot
What is high-functioning social anxiety?
The term “high-functioning” in relation to mental disorder refers to individuals who, despite their mental condition, are able to go through daily routines without significant problems.
People with high-functioning social anxiety may exude confidence and look calm and comfortable in social situations while fighting their mental battles. However, people with high-functioning social anxiety should not dismiss their feelings. These conditions are still valid and if possible, the individual should seek help.
How is social anxiety diagnosed?
Like other mental disorders, there is no definite test to diagnose social anxiety. Doctors come to a conclusion after looking at several aspects of the individual.
Social anxiety may be the result of another more physical medical condition. For example, someone who has certain body irregularities may suffer from social anxiety due to the unwanted negative attention they get to their physical condition. Treatment of those root causes, if possible will then be more effective in treating the social phobia.
Medical history would also include genetics. Looking through an individual as well as their family’s medical history can determine the vulnerability to a mental disease such as social anxiety.
The Diagnostic and Statistical Manual of Mental Disorders contains the standard criteria for diagnosing mental conditions. Individuals will be assessed against a list of major symptoms.
Social anxiety is one of the most common misdiagnosed mental illnesses because of the thin boundaries that may separate one’s disposition and the actual fear. In the medical report The History, Epidemiology and Differential Diagnosis of Social Anxiety Disorder, it writes that “patients are often not willing to discuss symptoms with clinicians and rarely seek care from a mental health practitioner”. This leads to many cases of social anxiety going untreated .
Social anxiety treatment
Social anxiety, like all mental illnesses, falls on a scale of severity. It is encouraged to get professional help as soon as you can, if the resources are available to you, especially if your phobias are greatly affecting daily life.
Treatment for social anxiety comes in two different forms, talk therapies and medication. These two methods of treatment are usually combined.
The two main types of talk therapies that are practiced with patients with social anxieties are Cognitive Behavioural Therapy (CBT) and Psychodynamic Therapy.
Comparatively, CBT is rooted in conscious thoughts and the present, and is problem-focused, while PDT takes a more holistic approach, looking into past and present, conscious and unconscious cognition. CBT also usually has shorter treatment periods.
However, both types have similarly high efficacy rates, especially with follow-up in the months after treatment sessions have concluded .
Cognitive Behavioral Therapy
Cognitive research shows that social phobia, and many other behavioral and mental disorders, are a result of dysfunctional interpretations of their own experiences and beliefs that induce fear, also known as distorted information processing .
While methods may differ slightly, the main focus of CBT is tackling distorted information processing. Exercises done between the health professional and the individual with social phobia help to identify the wrong beliefs and maladaptive behaviors, and shift them to more positive adaptive behaviors .
Psychodynamic therapy (PDT) is a constantly evolving form of therapy that relies a lot on the relationship between patient and health professional to explore strategies of healing.
The goal of PDT is for patients to gain self-awareness through techniques that are based on “concepts of defense, conflict, symptoms as meaningful representations, conscious and unconscious levels of mental activity, transference, countertransference, and the therapeutic relationship”.
Medication for social anxiety
Selective Serotonin Reuptake Inhibitors (SSRIs)
Originally created to treat depression, clinical studies found that SSRIs also improved social anxiety symptoms. These drugs help to slow the reabsorption of the neurotransmitter serotonin by neurons so it can bring serotonin levels back to normal and regulate anxiety.
In the analysis Pharmacological Treatment of Social Anxiety Disorder: A meta-analysis, SSRIs showed slightly better efficacy as compared to other drugs in the improvement of social phobia symptoms. SSRIs are the first drug to be given to patients due to the milder side effects .
Some examples of SSRIs commonly prescribed are Prozac, Lexapro and Zoloft.
Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
Similar to SSRIs, SNRIs block the reuptake of serotonin by the neurons, allowing for more of the active neurotransmitter in the brain to help regulate anxiety. However, SNRIs are different because they also block the reabsorption of norepinephrine, a neurotransmitter that helps to manage stress in the body.
The most commonly prescribed SSNI drug is Venlafaxine.
Tricyclic antidepressants (TCAs)
Tricyclic antidepressants are similar to SNRIs but they are less selective and thus, affects other receptors and may lead to more and adverse side effects .
Known as Benzos for short, these drugs are considered one of the best suited to treat social phobias. Benzos enhance the gamma-aminobutyric acid (GABA) neurotransmitters, which helps to slow down signals in the brain, thus alleviating anxiety .
However, due to the risks of dependency on benzos, it is rarely the go-to prescription for those being treated for social anxiety. In addition, Benzos are ineffective at treating comorbidities such as depression .
Most well-known benzo used in the treatment of social anxiety is Xanax.
How do you talk to someone with social anxiety?
It can be difficult to approach or connect with someone with social anxiety. More times than not, they are fighting an internal battle against negative irrational fears. Here are some ways you can help them to feel more comfortable around you.
The basis of social anxiety is irrational fears of judgement and are usually an amalgamation of bad past experiences – it is a lot to work through. With time and the right support, socially anxious will be able to open up to you.
Social anxiety is a projection of a person’s own insecurities, traumatic experiences and their own beliefs. It will be helpful to ask for the thoughts and feelings of someone with social anxiety and try to rewire those thoughts by offering a different perspective.
Are there any self-care methods that can help manage social anxiety?
Lockdowns have been particularly harsh on people with mental illness. There is a whole other laundry list of fears that come with zoom calls though there is the added benefit of being in the comfort of home with the option of not sharing your video feed.
However, a bigger worry for the socially anxious is meeting people in real life again. Life away from people for the most part is stress-free and many have grown comfortable. Self-care methods like mindfulness can help to redirect the negative, nervous energy into strategies to cope.
In a report by BBC, psychotherapist Charley Gavigan advice to ignore bad negative social experiences and instead expand energy into asking after other people than worrying about what they think of you .
Social anxiety tests
Google and a myriad of social anxiety tests are available. While diagnosis should always be left up to professionals, people who cannot get to that resource may use online tests to see if they have symptoms similar to social anxiety, and take steps to plan self-care strategies to manage their phobia.
Some tests include:
Liebowitz social anxiety scale as a self-test
Anxiety and Depression Association of America Screening for Social Anxiety Disorder
Social Anxiety Questionnaire
Social anxiety can be crippling, affecting areas of life that other people seamlessly go through. It is not uncommon but if possible, seek professional help as soon as you can. For those who have no access or are facing difficulty consulting a professional, online resources can help with your phobia.
At frankie, we make mental healthcare and wellness easy for all with just one small task a day. Head on guided wellness journeys that understand your stressors or triggers or work with our behavioural and wellness professionals - all from the comfort and privacy of your home. Sign up for our Closed BETA here.
This editorial section solely expresses the opinion of frankie and is not endorsed nor commissioned by any external party. The list is non-exhaustive. At frankie, we believe that your best provider of medical advice is your doctor. Please consult a doctor before undergoing any treatment or procedure.
1. Social anxiety disorder. Diseases & Conditions. (n.d.). Retrieved January 5, 2022, from https://www.nuh.com.sg/Health-Information/Diseases-Conditions/Pages/Social-phobia.aspx
2. Dalrymple, Kristy & Zimmerman, Mark. (2013). When does benign shyness become social anxiety, a treatable disorder?. Current Psychiatry. 12. 21-38. https://cdn.mdedge.com/files/s3fs-public/Document/September-2017/021_1113CP_Dalrymple_FINAL.pdf
3. Brown, L. H., Silvia, P. J., Myin-Germeys, I., & Kwapil, T. R. (2007). When the need to belong goes wrong. Psychological Science, 18(9), 778–782. https://doi.org/10.1111/j.1467-9280.2007.01978.x
4. Wong, Q. J. J., & Moulds, M. L. (2010, November 25). The relationship between the maladaptive self-beliefs characteristic of social anxiety and avoidance. Journal of Behavior Therapy and Experimental Psychiatry. https://www.sciencedirect.com/science/article/abs/pii/S0005791610001084?casa_token=fnWSbfCS_gUAAAAA%3AYBFPKXtdWSqVLwWYbgQh5GltmZnigFNUzHRMTkd8CYZSRyzMRVqrfkdTRgTj_fGtKRuR9paWXAs.
5. Villafuerte, S., & Burmeister, M. (2003). Genome Biology, 4(8), 224. https://doi.org/10.1186/gb-2003-4-8-224
6. Beidel, D. C., Turner, S. M., & Morris, T. L. (2010, January 4). Psychopathology of childhood social phobia. Journal of the American Academy of Child & Adolescent Psychiatry. https://www.sciencedirect.com/science/article/abs/pii/S0890856709631737.
7. Mairet, Kathleen, & Boag, Simon, & Warburton, Wayne (2014). How important is temperament? The relationship between coping styles, early maladaptive schemas and social anxiety. International Journal of Psychology and Psychological Therapy, 14(2),171-190.[fecha de Consulta 2 de Agosto de 2021]. ISSN: 1577-7057. Disponible en: https://www.redalyc.org/articulo.oa?id=56031293003
8. Coyle, S., Malecki, C. K., & Emmons, J. (2019). Keep your Friends Close: Exploring the associations of Bullying, peer social support, and social anxiety. Contemporary School Psychology, 25(2), 230–242. https://doi.org/10.1007/s40688-019-00250-3
9. Moutier, C. Y., & Stein, M. B. (1999). The history, epidemiology, and differential diagnosis of social anxiety disorder. The Journal of clinical psychiatry, 60 Suppl 9, 4–8.
10. Schulze, L., Renneberg, B., & Lobmaier, J. S. (2013). Gaze perception in social anxiety and social anxiety disorder. Frontiers in Human Neuroscience, 7. https://doi.org/10.3389/fnhum.2013.00872
11. Schulze, L., Renneberg, B., & Lobmaier, J. S. (2013). Gaze perception in social anxiety and social anxiety disorder. Frontiers in Human Neuroscience, 7. https://doi.org/10.3389/fnhum.2013.00872
12. Haverkampf, C. J. (2017). CBT and psychodynamic psychotherapy-A comparison. J Psychiatry Psychotherapy Communication, 6(2), 61-68.
13. Kuru, E., Safak, Y., Özdemir, İ., Tulacı, R. G., Özdel, K., Özkula, N. G., & Örsel, S. (2018). Cognitive distortions in patients with social anxiety disorder: Comparison of a clinical group and healthy controls. The European Journal of Psychiatry, 32(2), 97–104. https://doi.org/10.1016/j.ejpsy.2017.08.004
14. Bond, F. W. (2005). Handbook of brief cognitive behaviour therapy. J. Wiley.
15. Blanco, C., Schneier, F. R., Schmidt, A., Blanco-Jerez, C.-R., Marshall, R. D., Sánchez-Lacay, A., & Liebowitz, M. R. (2003). Pharmacological treatment of social anxiety disorder: A meta-analysis. Depression and Anxiety, 18(1), 29–40. https://doi.org/10.1002/da.10096
16. Wedekind, D., Bandelow, B., & Michaelis, S. (2017). Treatment of anxiety disorders. Generalized Anxiety Disorders, 19(2), 93–107. https://doi.org/10.31887/dcns.2017.19.2/bbandelow
17. Jefferson J. W. (2001). Benzodiazepines and anticonvulsants for social phobia (social anxiety disorder). The Journal of clinical psychiatry, 62 Suppl 1, 50–53.
18. Silberman, E. K. (2014). The role of benzodiazepines in treating social anxiety disorder. American Journal of Psychiatry, 171(7), 795–795. https://doi.org/10.1176/appi.ajp.2014.14010048
19. Rackham, A. (2021, May 17). Covid: How to deal with social anxiety as RESTRICTIONS EASE. BBC News. https://www.bbc.com/news/newsbeat-56323453.