Social anxiety disorder: symptoms, causes and treatment

Key points

• Social anxiety disorder is a lasting, out-of-proportion fear of being watched or judged in social situations [2][3].
• It is not shyness, which NICE notes does not cause disability or wide interference with life [2].
• Median age of onset is in the early to mid-teens, and people often reach treatment 15 to 20 years later [1][2].
• Avoidance and safety behaviours ease fear in the moment and keep the disorder going [1][2].
• NICE recommends individual CBT built specifically for social anxiety disorder, ahead of self-help and medication [1].
• Adults in England can self-refer to NHS Talking Therapies [3][5].

What social anxiety disorder is

Social anxiety disorder, also called social phobia, is a long-term and overwhelming fear of being watched, judged or humiliated in social situations [3]. The fear is out of proportion to the situation, and the person avoids social contact or endures it with intense distress [2].

If you need help now. Samaritans: call 116 123, free, 24/7. Shout: text SHOUT to 85258. NHS 111, then choose the mental health option. Call 999 if anyone is in immediate danger.

It is not shyness. NICE states that social anxiety disorder should not be confused with normal shyness, which is not linked to disability or interference with most areas of life [2]. Nor is it introversion, a preference for quieter settings rather than a fear of them.

No reliable UK figure exists for social anxiety disorder alone. The Adult Psychiatric Morbidity Survey 2023/4 groups all phobias together, and found 2.6% of adults in England met the criteria for a phobia in the previous week [4].

Symptoms

Symptoms build before, during and after social situations [3].

Psychological:

• worry about meeting strangers, speaking in groups or eating in front of others [3]
• fear of being embarrassed or judged, and of others noticing blushing, sweating or shaking [3]
• going over the event afterwards, picking apart what was said [2]

Physical:

• a pounding heartbeat, sweating, trembling or nausea [3]
• panic attacks in more severe cases [3]

Behavioural:

• avoiding parties, group conversations, phone calls or eating with others [3]
• avoiding eye contact, or difficulty doing tasks while being watched [3]
• rehearsing sentences, staying quiet, or hiding shaking hands

The last group keeps the condition running. Safety behaviours lower anxiety at the time but stop the fear being disproved. NICE names the maintaining processes as self-focused attention, a distorted self-image, and safety-seeking behaviours [2].

It is commonly mistaken for shyness, low confidence or poor social skills [9]. NICE notes that GPs often fail to recognise it, and that many people in primary care report being treated for depression alone [2]. It overlaps with avoidant personality disorder [2].

Types

Social anxiety disorder has no formal subtypes. NICE describes two presentations, separated by how far the fear reaches [2].

• Generalised. Fear covers most social situations. NICE reports greater impairment and higher rates of accompanying conditions [2].
• Non-generalised, or performance-only. Fear is limited to a narrower set of situations, which often but not always involve performance tasks such as public speaking [2].

Causes and risk factors

There is no single cause. It develops from a mix of inherited tendency, temperament and experience, and the balance differs between people [2].

• Genetics. Heritability is estimated at 25 to 50%, so environment carries at least as much weight [2].
• Early social events. Bullying, family abuse, public embarrassment or a mind going blank during a performance are commonly reported [2].
• Parenting. Parental modelling of fear of social situations, and overprotective parenting, have both been linked to it developing [2].

Two popular explanations are weaker than they sound. One is poor social skills; the evidence points instead to fear, self-focused attention and a misjudged self-image [2][9]. The other is that it fades with age: in one long-term study, 37% of people recovered over 12 years, against 58% for generalised anxiety disorder and 82% for panic disorder without agoraphobia [2].

How it is diagnosed

In the UK a GP, a psychiatrist or a qualified psychological professional can identify social anxiety disorder, from an interview rather than a scan or blood test.

NICE recommends screening with the three-item Mini-Social Phobia Inventory, or by asking two questions: “Do you find yourself avoiding social situations or activities?” and “Are you fearful or embarrassed in social situations?” [1]. A score of 6 or above, or a yes to either, prompts a full assessment [1].

That assessment covers which situations are feared and avoided, what the person expects to happen, which safety-seeking behaviours are used, and what else is present, such as depression or alcohol use [1][2]. Diagnostic descriptions require the fear to last at least six months [9].

Referral in England can come from a GP or the person directly [3][5]. NHS Talking Therapies received 1.81 million referrals in 2024/25 and 1.21 million accessed the service. Of referrals completing a course of treatment, 91.6% waited less than six weeks from referral [6].

A diagnosis names a recognised and treatable condition, not a personality [2].

Treatment

NICE guideline CG159 sets an order for adults, talking therapy first [1].

• Individual CBT developed specifically for social anxiety disorder, in one of two models NICE names. Clark and Wells runs to up to 14 sessions of 90 minutes over about four months, using video feedback, attention training and behavioural experiments. Heimberg runs to 15 sessions of 60 minutes plus one 90-minute exposure session, using cognitive restructuring and graduated exposure [1].
• CBT-based supported self-help, if individual CBT is declined. Typically up to nine sessions over three to four months, with about three hours of practitioner support [1].
• Medication, if psychological treatment is declined or medication is preferred. NICE names escitalopram or sertraline first, then fluvoxamine, paroxetine or venlafaxine, then phenelzine or moclobemide [1]. Any decision is made with a GP or prescriber.
• Short-term psychodynamic psychotherapy developed for social anxiety disorder, if both cognitive behavioural and medication options are declined [1].

NICE advises against routinely offering group CBT in preference to individual CBT, which is more cost effective [1]. Mindfulness-based interventions, supportive therapy, benzodiazepines, anticonvulsants, tricyclic antidepressants, antipsychotics and St John’s wort are not recommended for this condition [1]. For children and young people NICE recommends CBT, not medication [1].

Social anxiety disorder has its own route through NHS Talking Therapies. The service manual states that high-intensity treatment comes first for social anxiety disorder and PTSD, because the low-intensity evidence base is not strong [5]. A network meta-analysis of treatments for adults was published in Lancet Psychiatry in 2014 [7].

Living with social anxiety disorder

Treatment does most of the work, but what you do between sessions matters.

• Keep an anxiety diary of situations, thoughts and actions, so patterns become visible [3].
• Practise breathing exercises, and face feared situations in graded steps [3].
• Notice safety behaviours such as rehearsing lines, and test what happens without one [1][2].
• Watch alcohol use before social events, since drinking to cope is a common route into a second problem [2].

At work or university you do not have to disclose a diagnosis. If you do, ask for specific adjustments: questions circulated before a meeting, a smaller seminar group, or notice before presenting.

Support outside the NHS includes Mind’s Side by Side community, local Mind branches, the Hub of Hope directory, Anxiety UK, No Panic and Triumph Over Phobia UK [8].

When to speak to a professional

Speak to a GP, or refer yourself to NHS Talking Therapies, if fear of social situations is affecting your work, study, relationships or daily life [3].

Get in touch sooner if:

• you are turning down work, study or medical appointments to avoid people
• you are drinking or using drugs to get through social situations [2]
• low mood has developed alongside the social fear [2]
• panic attacks are happening in or before social situations [3]

If you are thinking about harming yourself, contact Samaritans on 116 123, free and 24/7, text SHOUT to 85258, or call NHS 111 and choose the mental health option. Call 999 if anyone is in immediate danger.

Common questions

Is social anxiety the same as being shy?

No. Shyness is a personality trait that does not usually cause disability or interfere with most areas of life [2]. Social anxiety disorder involves fear that is out of proportion, lasts at least six months and leads to avoidance or intense distress [9].

Is social anxiety disorder the same as introversion?

No. Introversion is a preference for smaller or quieter settings, not a mental health condition. Social anxiety disorder is driven by fear of judgement and by avoidance that narrows life over time [2][3].

What therapy does the NHS offer for social anxiety?

NICE recommends individual CBT designed specifically for social anxiety disorder, using either the Clark and Wells or the Heimberg model [1]. NHS Talking Therapies starts at high intensity rather than with guided self-help [5].

Clinical review pending

References

1. National Institute for Health and Care Excellence. Social anxiety disorder: recognition, assessment and treatment. NICE clinical guideline CG159, published 22 May 2013. https://www.nice.org.uk/guidance/cg159/resources/social-anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397
2. National Collaborating Centre for Mental Health, commissioned by the National Institute for Health and Care Excellence. Social anxiety disorder: recognition, assessment and treatment. Full guideline, 2013. https://www.nice.org.uk/guidance/cg159/evidence/full-guideline-pdf-189895069
3. NHS. Social anxiety (social phobia). nhs.uk. https://www.nhs.uk/mental-health/conditions/social-anxiety/
4. NHS England Digital. Adult Psychiatric Morbidity Survey: Survey of Mental Health and Wellbeing, England, 2023/4. Chapter 1: Common mental health conditions. https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/survey-of-mental-health-and-wellbeing-england-2023-24/common-mental-health-conditions
5. NHS England. NHS Talking Therapies for anxiety and depression Manual, version 7.1. https://www.england.nhs.uk/wp-content/uploads/2018/06/nhs-talking-therapies-manual-v7.1-updated.pdf
6. NHS England Digital. NHS Talking Therapies, for anxiety and depression, Annual reports, 2024-25. https://digital.nhs.uk/data-and-information/publications/statistical/nhs-talking-therapies-for-anxiety-and-depression-annual-reports/2024-25
7. Mayo-Wilson E, Dias S, Mavranezouli I, Kew K, Clark DM, Ades AE, Pilling S. Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. Lancet Psychiatry, 2014, volume 1, issue 5, pages 368 to 376. https://ora.ox.ac.uk/objects/uuid:08250d06-3cc4-4403-9d21-307602288d70
8. Mind. Anxiety and panic attacks: self-care. mind.org.uk. https://www.mind.org.uk/information-support/types-of-mental-health-problems/anxiety-and-panic-attacks/self-care/
9. American Psychiatric Association. Social Anxiety: More Than Just Shy or Self-Conscious. APA blog, psychiatry.org. https://www.psychiatry.org/news-room/apa-blogs/social-anxiety-more-than-just-shy-or-self-consciou