Social anxiety disorder (social phobia)

Definition

It's normal to feel nervous and awkward in some social situations. Going on a first date or giving a presentation may give you that uncomfortable feeling of having butterflies in your stomach, for instance.

For some people, though, common, everyday social situations cause extreme anxiety, fear and self-consciousness, and they may become impossible to engage in. You may go to great lengths and come up with many excuses to avoid dating or giving presentations. You may not even be able to eat with acquaintances or write a check at the grocery store, let alone go to a party with lots of strangers.

With anxiety this extreme, you may have social anxiety disorder. Social anxiety disorder is a chronic mental health condition that causes an irrational anxiety or fear of activities or situations in which you believe that others are watching you or judging you. You also fear that you'll embarrass or humiliate yourself.

If you or a loved one has social anxiety disorder, take heart. Effective treatment — often with cognitive behavior therapy, medication and positive coping skills — can improve your quality of life and open up new opportunities.

Symptoms

Social anxiety disorder can have emotional, behavioral and physical signs and symptoms.

Emotional and behavioral signs and symptoms of social anxiety disorder include:

• Intense fear of being in situations in which you don't know people
• Fear of situations in which you may be judged
• Worrying about embarrassing or humiliating yourself
• Fear that others will notice that you look anxious
• Anxiety that disrupts your daily routine, work, school or other activities
• Avoiding doing things or speaking to people out of fear of embarrassment
• Avoiding situations where you might be the center of attention

Physical signs and symptoms of social anxiety disorder include:

• Blushing
• Profuse sweating
• Trembling or shaking
• Nausea
• Stomach upset
• Difficulty talking
• Shaky voice
• Muscle tension
• Confusion
• Palpitations
• Diarrhea
• Cold, clammy hands
• Difficulty making eye contact

Associated characteristics include:

• Low self-esteem
• Trouble being assertive
• Negative self-talk
• Hypersensitivity to criticism
• Poor social skills

Worrying about having symptoms

When you have social anxiety disorder, you realize that your anxiety or fear is out of proportion to the situation. Yet you're so worried about developing social anxiety disorder symptoms that you avoid situations that may trigger them. And indeed, just worrying about having any symptoms can cause them or make them worse.

Causes

Like many other mental health conditions, social anxiety disorder likely arises from a complex interaction of environment and genes. Researchers continue to study possible causes, including:

• Genes. Researchers are seeking out specific genes that play a role in anxiety and fear. Social anxiety disorder seems to run in families. But it's not clear whether that hereditary component is related to genetics or to anxious behavior you learn from other family members.
• Biochemistry. Researchers are exploring the idea that natural chemicals in your body may play a role in social anxiety disorder. For instance, an imbalance in the brain chemical serotonin (ser-oh-TOE-nin) could be a factor. Serotonin, a neurotransmitter, helps regulate mood and emotions, among other things. People with social anxiety disorder may be extra-sensitive to the effects of serotonin.
• Fear responses. Some research suggests that a structure in the brain called the amygdala (uh-MIG-duh-luh) may play a role in controlling the fear response. People who have an overactive amygdala may have a heightened fear response, causing increased anxiety in social situations.

Risk factors

Social anxiety disorder is one of the most common of all mental disorders. Up to 13 percent of people in Western countries experience social anxiety disorder at some point in their lives. Social anxiety disorder usually begins in the early to midteens, although it can sometimes begin earlier in childhood or in adulthood.

A number of factors can increase the risk of developing social anxiety disorder, including:

• Your sex. About twice as many women as men have social anxiety disorder.
• Family history. Some research indicates that you're more likely to develop social anxiety disorder if your biological parents or siblings have the condition.
• Environment. Some experts theorize that social anxiety disorder is a learned behavior. That is, you may develop the condition after witnessing the anxious behavior of others. In addition, there may be an association between social anxiety disorder and parents who are more controlling or protective of their children.
• Negative experiences. Children who experience teasing, bullying, rejection, ridicule or humiliation may be more prone to social anxiety disorder. In addition, other negative events in life, such as family conflict or sexual abuse, may be associated with social anxiety disorder.
• Temperament. Children who are shy, timid, withdrawn or restrained when facing new situations or people may be at greater risk.
• New social or work demands. Meeting new people, giving a speech in public or making an important work presentation may trigger social anxiety disorder symptoms for the first time. These symptoms usually have their roots in adolescence, however.

When to seek medical advice

Feeling shy at parties or nervous about giving a speech doesn't necessarily mean you have social anxiety disorder. If your fears or anxieties don't really bother you, you may not need treatment. For instance, you may not like making speeches but you do so anyway without being overwhelmed by anxiety.

What sets social anxiety disorder apart from everyday nervousness is that its symptoms are much more severe and last much longer. Social anxiety disorder disrupts your life, causes you distress and affects your daily activities.

Common, everyday experiences that may be difficult to endure when you have social anxiety disorder include:

• Using a public restroom or telephone
• Returning items to a store
• Interacting with strangers
• Writing in front of others
• Making eye contact
• Entering a room in which people are already seated
• Ordering food in a restaurant
• Being introduced to strangers
• Initiating conversations

Social anxiety disorder symptoms can change over time. They may flare up if you're facing a lot of stress or demands. Or if you completely avoid situations that would usually make you anxious, you may not have symptoms. Although avoidance may allow you to feel better in the short term, your anxiety is likely to persist over the long term if you don't get treatment.

Tests and diagnosis

When you decide to seek treatment for symptoms of possible social anxiety disorder, you may have both a physical and psychological evaluation. The physical exam can determine if there may be any physical causes triggering your symptoms.

There's no laboratory test to diagnose social anxiety disorder, however. Your doctor or mental health provider will ask you to describe your signs and symptoms, how often they occur and in what situations. He or she may review a list of situations to see if they make you anxious or have you fill out psychological questionnaires or self-assessments to help pinpoint a diagnosis.

To be diagnosed with social anxiety disorder, someone must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health professionals to diagnose mental conditions and by insurance companies to reimburse for treatment.

Criteria for social anxiety disorder to be diagnosed include:

• A persistent fear of social situations in which you believe you may be scrutinized or act in a way that's embarrassing or humiliating
• These social situations cause you a great deal of anxiety
• You recognize your anxiety level is excessive or out of proportion for the situation
• You avoid anxiety-producing social situations
• Your anxiety or distress interfere with your daily living

Complications

Left untreated, social anxiety disorder can be debilitating. Your anxieties may run your life. They can interfere with work, school, relationships or enjoyment of life. You may be considered an "underachiever," when in reality it's your fears holding you back from excelling. In severe cases, you may drop out of school, quit work or lose friendships.

Social anxiety disorder can also lead to other health problems, such as:

• Substance abuse
• Excessive drinking
• Depression
• Suicide

Treatments and drugs

Social anxiety disorder typically persists for life, often waxing and waning. But don't lose hope. Treatment can help you control symptoms and become more confident and relaxed in social situations.

The two most effective types of treatment are medications and a form of psychotherapy called cognitive behavior therapy. For the greatest effectiveness, they're often used in combination.

Psychotherapy
Cognitive behavior therapy is the only type of therapy that has been shown to be effective in treating social anxiety disorder. This type of therapy is based on the idea that your own thoughts — not other people or situations — determine how you behave or react. Even if an unwanted situation won't change — you still have to give a presentation to management, for instance — you can change the way you think and behave in a positive way. In therapy, you learn how to recognize and change negative thoughts about yourself.

Cognitive behavior therapy may also include exposure therapy. In this type of therapy, you gradually work up to facing the situations you fear most. This allows you to become better skilled at coping with these anxiety-inducing situations and to develop the confidence to face them. You may also participate in skills training or role-playing to practice your social skills and gain comfort and confidence relating to others. You may also learn relaxation or stress management techniques.

First choices in medications
Several types of medications are used to treat social anxiety disorder. However, the Food and Drug Administration has specifically approved only three medications, all antidepressants, to treat social anxiety disorder.

Those antidepressants are:

• Paroxetine (Paxil, Paxil CR)
• Sertraline (Zoloft)
• Venlafaxine (Effexor)

Other medication options
Your doctor or mental health provider may also prescribe other medications that haven't been specifically approved for social anxiety disorder. This is a common and legal practice called off-label use. These medications may include:

• Other antidepressants. You may have to try several different antidepressants to find which one is the most effective and has the fewest unpleasant side effects.
• Anti-anxiety medications. A type of anti-anxiety medication called benzodiazepines (ben-zo-di-AZ-uh-penes) may reduce your level of anxiety. Although they often work quickly, they can be habit-forming. Because of that, they're often prescribed for only short-term use. They may also be sedating.
• Beta blockers. These medications work by blocking the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs. Because of that, they may work best when used infrequently to control symptoms for a particular situation, such as giving a speech. They're not recommended for general treatment of social anxiety disorder.

Stick with it
Don't give up if treatment doesn't work quickly. You can continue to make strides in therapy over several weeks or months. And remember that finding the right medication for your situation can take some trial and error.

For some people, the symptoms of social anxiety disorder may fade over time, and medication can be discontinued. Others may need to take medication for years to prevent a relapse.

Lifestyle and home remedies

Although social anxiety disorder generally requires help from a medical expert or qualified psychotherapist, you can try some self-help techniques to handle situations likely to trigger social anxiety disorder symptoms.

First, assess your fears to identify what situations cause the most anxiety. Apply these techniques to those situations. Practicing these techniques regularly can help you manage or reduce your anxiety. You may need to begin with small steps in situations that aren't overwhelming.

These techniques include:

• Eating with a close relative, friend or acquaintance in a public setting.
• Making eye contact and returning greetings from others, or being the first to say hello.
• Preparing for conversation. For instance, read the newspaper to identify an interesting story you can talk about.
• Giving someone a compliment.
• Focusing on personal qualities you like about yourself.
• Showing an interest in others. Ask about their homes, children, grandchildren, hobbies or travels, for instance.
• Asking a retail clerk to help you find an item.
• Getting directions from a stranger.

In addition, be sure to keep your medical or therapy appointments, take medications as directed, and talk to your doctor about any changes in your condition.

Coping and support

Coping with social anxiety disorder can be challenging. Having social anxiety disorder can make it difficult for you to go to work or school, to interact with other people, or even to visit the doctor. But maintaining connections and building relationships are key ways to help cope with any mental disorder.

Over time, treatment can help you feel more comfortable, relaxed and confident in the presence of others. In the meantime, don't use alcohol or illicit drugs to try to get through an event or situation that makes you anxious.

Some positive coping methods include:

• Banishing negative thoughts about yourself
• Practicing relaxation exercises
• Adopting stress management techniques
• Reaching out to people you do feel comfortable around
• Joining a support group
• Engaging in pleasurable activities, such as exercise or hobbies, when you feel anxious
• Getting enough sleep
• Eating a well-balanced diet
• Setting realistic goals

As difficult or painful as it may seem initially, don't avoid situations that trigger your symptoms. By regularly facing these kinds of situations, you'll continue to build and reinforce your coping skills.

Over time, doing this can help control your symptoms and prevent a relapse of your condition. Remind yourself that you can get through anxious moments, that your anxiety is short-lived, and that the negative consequences you worry about so much rarely come to pass.