Social anxiety disorder, also called social phobia, is a long-term and overwhelming fear of being watched, judged or humiliated in social situations. The fear is out of proportion to the situation, and the person avoids social contact or endures it with intense distress. It is not shyness, which NICE notes does not cause disability or wide interference with life.
Key points
- Social anxiety disorder is a lasting, out-of-proportion fear of being watched or judged in social situations.
- It is not shyness, which NICE notes does not cause disability or wide interference with life.
- Median age of onset is in the early to mid-teens, and people often reach treatment 15 to 20 years later.
- Avoidance and safety behaviours ease fear in the moment and keep the disorder going.
- NICE recommends individual CBT built specifically for social anxiety disorder, ahead of self-help and medication.
Symptoms
- Worry about meeting strangers, speaking in groups or eating in front of others.
- Fear of being embarrassed or judged, and of others noticing blushing, sweating or shaking.
- Pounding heartbeat, sweating, trembling or nausea, and panic attacks in more severe cases.
- Avoiding parties, group conversations, phone calls or eating with others; avoiding eye contact.
- Rehearsing sentences, staying quiet, or hiding shaking hands.
Causes and risk factors
- Genetics: heritability is estimated at 25 to 50%, so environment carries at least as much weight.
- Early social events: bullying, family abuse, public embarrassment, or a mind going blank during a performance.
- Parental modelling of fear of social situations, and overprotective parenting.
Treatment
- Individual CBT developed specifically for social anxiety disorder, using either the Clark and Wells or the Heimberg model.
- CBT-based supported self-help, if individual CBT is declined.
- Medication if psychological treatment is declined: escitalopram or sertraline first, then fluvoxamine, paroxetine or venlafaxine.
- Short-term psychodynamic psychotherapy if both cognitive behavioural and medication options are declined.
When to speak to a professional
- Fear of social situations is affecting your work, study, relationships or daily life.
- You are turning down work, study or medical appointments to avoid people.
- You are drinking or using drugs to get through social situations.
- Low mood has developed alongside the social fear, or panic attacks are happening in social situations.
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.