Nearly everyone experiences social anxiety at least once in their life, regardless of whether they have social anxiety disorder. Being nervous during the first big meeting of a new job, for example, is a feeling of social anxiety. Your heart rate may be elevated. Maybe you didn’t sleep well the night before. Nonetheless, you function well enough. There is stress, but it feels manageable.
Social anxiety disorder, also called social phobia, occurs when social situations cause stress to the point where quality of life takes a nosedive. People who suffer from this condition often withdraw from social situations, ruminate endlessly on worst-case social scenarios, and feel intense physiological symptoms when interacting with others. Imagine feeling “frozen” or experiencing an increased heart rate and nausea.
Fortunately, there are proven methods, such as therapy, for treating social anxiety disorder. Understanding the disorder is the first step toward relief, so let’s start there.
What is social anxiety disorder?
According to The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), social anxiety disorder, also known as social phobia, is characterized by an intense and persistent fear of one or more social situations where an individual might be observed, judged, or scrutinized by others. These situations can include everyday interactions, such as talking to strangers, eating in public, or giving a presentation.
In other words, while many people may occasionally feel nervous about social situations, those with social anxiety disorder experience a level of fear and anxiety that is so strong it interferes with daily life. To avoid potential embarrassment or criticism, individuals often go to great lengths to avoid social settings, which can lead to significant disruption in their personal and professional relationships.
What are the causes of social anxiety?
Social anxiety disorder can arise from multiple contributing factors rather than a single cause. Below are some of the key factors that can contribute to the onset and maintenance of social anxiety disorder. We’ll also explore the research and theories behind each in more detail.
Genetic predisposition
Stressful or traumatic life events related to social anxiety, and how someone understands or makes sense of those events
Comorbidity with other mental health conditions, such as depression, can increase vulnerability to social phobia
Neuroticism
The fear of visible symptoms (e.g., blushing, sweating, trembling)
The diathesis-stress model: a lens for understanding genetics and stress
The Diathesis-Stress Model is a widely used framework that explains how genetic vulnerability and life stressors interact to increase the likelihood of developing mental health conditions. This model is often applied to anxiety disorders, including social anxiety, because it helps explain why some people are more sensitive to social stress and how stressful experiences can activate underlying vulnerabilities.
The diathesis is any type of pre-existing vulnerability, in this case a biological or genetic vulnerability. If your parents have social anxiety disorder, your chance of developing it is much higher compared to someone without a genetic history.
The stress aspect comes from stressful and/or traumatic life events and how we attribute meaning to them. For example, being pushed by a bully in grade school might be an experience many people can move on from easily when they understand it as a painful but isolated event, or that the experience said more about the bully than about them. For others, however, that same event becomes internalized as a reflection of their worth or safety. That one push is viewed as evidence of personal inadequacy, fueling long-term self-criticism and anxiety that contribute to SAD.
Think of a person’s mind as a glass of water. When the glass reaches its brim or begins to overflow, symptoms of the disorder may emerge. For some people, this shift happens quickly; for others, it develops gradually over time.
In this metaphor, the diathesis represents the amount of water already in the glass, the vulnerabilities a person starts with. Stressful or traumatic events related to social anxiety add more water. Depending on how someone interprets these experiences, the glass may fill even faster.
A peaceful childhood may help keep the glass relatively steady, even for someone with certain vulnerabilities. However, factors such as genetic predisposition, insecure attachment style, heightened sensitivity to anxiety-related sensations, or higher levels of neuroticism can mean the starting water level is somewhat higher than average. People aren’t born already “near full,” but closer to the point where stressful experiences have a stronger impact.
Stressful social events, like being bullied in front of classmates or making a mistake during a public performance, add water to the glass. How a person interprets these events also matters. Viewing events as evidence of a deep personal flaw or a sign that future social situations are unsafe can increase the water level more quickly. Rumination can accelerate this process as well.
Different anxiety types and other disorders often co-occur with social anxiety disorder. These comorbidities are crucial to consider. The presence of one condition can impact the nature and severity of social anxiety symptoms.
Environmental and identity factors
In 2020, researchers conducted a social anxiety survey of 6,825 people, ages 16 to 29, across seven countries: Brazil, China, Indonesia, Russia, Thailand, the United States, and Vietnam. Here are some key findings related to causes:
The U.S. had the highest average amount of social anxiety, especially in the 25-29 age range
Unemployment was a predictor of higher social anxiety
Suburban areas, as opposed to rural and urban, produced more social anxiety
People from Asian countries tend to experience more social anxiety when interacting with authority figures
A lower level of education correlated with more social anxiety
Many research endeavors, including this scientific review, have indicated that women are more likely than men to have social anxiety disorder. There are exceptions, though. The 2020 study mentioned above did not find significant differences between the sexes, perhaps because it only surveyed younger people. The gap between men and women may widen after the age of 30. These patterns highlight an important gap in the literature. More research is needed to help us understand many aspects of social anxiety, including the mechanisms that drive increasing sex differences over time.
What are the common symptoms of social anxiety?
Similar to many other mental illnesses, there are behavioral, mental, and physical symptoms. Let’s break them down:
Behavioral:
Avoiding social situations
Avoiding eye contact
Not speaking more than necessary
Soft speaking
Rigid posture
Freezing while socializing
Ensuring that others can’t see certain behaviors, such as eating
Mental:
A feeling of the mind “going blank”
Feeling self-conscious
Analyzing and criticizing self-performance after a social event
Expecting worst-case scenarios from social interactions
Difficulty connecting with a group of people
Feeling intense anxiety in anticipation of a social event
Fear that people will notice the social anxiety
Worry that people are talking about you behind your back
Physical:
Profuse sweating
Nausea, dizziness, and stomach aches
Constipation, diarrhea, and frequent urination
Blushing
Accelerated heartrate
Muscle tension
Trembling
How is social anxiety diagnosed by healthcare professionals
Published by the American Psychiatric Association (APA) in 2022, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) is the guidebook that helps providers diagnose social anxiety disorder.
Here are the main symptoms the manual lays out:
Notable fear or anxiety in social situations where others may observe or evaluate the individual.
Social situations that often provoke feelings of fear or anxiety.
The level of fear or anxiety is greater than expected given the situation and cultural context.
The individual may limit their involvement in social situations or participate with heightened fear or anxiety.
Fear, anxiety, or avoidance lead to significant distress or interfere with key functioning areas, including social relationships or work responsibilities.
The fear, anxiety, or avoidance pattern is persistent andtypically lasts for six months or longer.
Fear, anxiety, or avoidance symptoms are not caused by a substance or another health condition.
Fear, anxiety, or avoidance is distinct from the symptoms of other mental disorders, such as panic disorder or autism spectrum disorder.
If another health condition (e.g., Parkinson’s disease, disfigurement from burns or injury) exists, the fear, anxiety, or avoidance is unrelated or excessive.
Mental health professionals diagnose social anxiety disorder by assessing whether a client meets the DSM-5-TR criteria. Several types of licensed providers can diagnose mental health conditions, including MFTs, LPCCs, LCSWs, LMHCs, psychologists (PsyD/PhD), psychiatrists (MD), and psychiatric nurse practitioners (PMHNPs).
As part of this process, therapists conduct a psychosocial assessment, which is a structured overview of the client’s symptoms, strengths, life context, and treatment goals. While the format varies by provider and setting, a psychosocial assessment often includes sections such as identifying information, presenting concerns, relevant history (e.g., medical, social, developmental), significant life events or trauma, current functioning, and the initial treatment plan.
Some clinicians rely on outcome measures such as scales and questionnaires. Here are some samples of the top scales/questionnaires utilized in studies:
Severity measure for social anxiety disorder (social shobia)
Found in the DSM-5, this scale is likely the most popular and understood. It has 10 statements that range from Never (0 points) to All of the time (4 points). Clinicians designed the scale to be administered to patients who have already received a SAD diagnosis. Therapists may use the scale to measure symptom severity and progress.
Social interaction anxiety scale (SIAS)
This scale has 20 items. You read the statement and rate how much you agree with it on a scale from 0 (not at all) to 4 (extremely). The first statement is: “I get nervous if I have to speak with someone in authority (teacher, boss, etc.).” After you take the assessment, the person administering it will add up your scores for each statement.
Clinicians have debated which total scores should qualify a diagnosis, as well as whether outcome measure scores should qualify a diagnosis. In 1992, Richard G. Heimberg, a top social anxiety academic, recommended that a score of 34 or above be used as a threshold for elevated symptom severity.
Liebowitz social anxiety scale (LSAS)
One of the more popular and studied scales, the LSAS presents social situations and asks respondents to rate their fear and avoidance on a scale from 0 to 3. Unlike many other scales, this one has well over two score ranges for levels of social anxiety:
0-29: No social anxiety
30-49: Mild social anxiety
50-64: Moderate social anxiety
65-79: Marked social anxiety
80-94: Severe social anxiety
≥ 95: Very severe social anxiety
Below are a few other notable scales. Each offers different strengths, such as brevity, clinician rating, or DSM-aligned scoring, that may fit particular clinical needs.
What is the best treatment for social anxiety?
A 2023 clinical review from UCLA identifies cognitive-behavioral therapy (CBT) as the most well-supported psychosocial treatment for social anxiety disorder. Other evidence-based approaches include acceptance and commitment therapy (ACT) and exposure-based therapies, which can be delivered in person or virtually.
In terms of medication, SSRIs and SNRIs are typically considered first-line pharmacologic options. Other medications, including azapirones, certain beta-adrenergic agents (such as propranolol), and GABAergic agents like pregabalin or gabapentin, may be used in specific situations. Benzodiazepines are generally reserved for short-term or targeted use due to their risk of dependence.
How to find a therapist for social anxiety
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