19. Social Anxiety Disorder

Social Anxiety Disorder and Social Phobia

Symptoms, Self-Help, and Treatment

Many people get nervous or self-conscious on occasion, like when giving a speech or interviewing for a new job. But social anxiety, or social phobia, is more than just shyness or occasional nerves. With social anxiety disorder, your fear of embarrassing yourself is so intense that you avoid situations that can trigger it. But no matter how painfully shy you may be and no matter how bad the butterflies, you can learn to be comfortable in social situations and reclaim your life.

What is social anxiety disorder / social phobia?

Social anxiety disorder, also known as social phobia, involves intense fear of certain social situations—especially situations that are unfamiliar or in which you feel you’ll be watched or evaluated by others.
These social situations may be so frightening that you get anxious just thinking about them or go to great lengths to avoid them.
Underlying social anxiety disorder or social phobia is the fear of being scrutinized, judged, or embarrassed in public. You may be afraid that people will think badly of you or that you won’t measure up in comparison to others. And even though you probably realize that your fears of being judged are at least somewhat irrational and overblown, you still can’t help feeling anxious.
While it may seem like there’s nothing you can do about the symptoms of social anxiety disorder or social phobia, in reality, there are many things that can help. It starts with understanding the problem.

Matthew’s story

Matthew skipped class today. It’s the first day of the new semester, and he’s afraid that the professor will go around the class and have the students introduce themselves. He knows it shouldn’t be a big deal, but it really stresses him out. Whenever he has to speak in front of more than just a few people, his voice starts shaking and his face gets red. He always feels so humiliated afterwards.
Since public speaking is Matthew’s worst nightmare, he’s been avoiding a speech class he has to take in order to graduate. He’s also dreading his brother’s wedding, even though it’s over six months away. As the best man, he’ll have to give a toast at the reception and he’s already nervous about it.

Common social phobia / social anxiety disorder triggers

Although it may feel like you’re the only one with this problem, social anxiety or social phobia is actually quite common. Many people struggle with these fears. But the situations that trigger the symptoms of social anxiety disorder can be different.
Some people experience anxiety in most social and performance situations, a condition known asgeneralized social anxiety disorder. For other people with social phobia, anxiety is connected with specific social situations, such as speaking to strangers, eating at restaurants, or going to parties.
The most common specific social phobia is fear of public speaking or performing in front of an audience.

Triggers for social anxiety disorder (social phobia)

The following situations are often stressful for people with social anxiety disorder:

Meeting new people Being the center of attention Being watched while doing something Making small talk Public speaking Performing on stage Being teased or criticized Talking with “important” people or authority figures

Being called on in class Going on a date Making phone calls Using public bathrooms Taking exams Eating or drinking in public Speaking up in a meeting Attending parties or other social gatherings

Signs and symptoms of social anxiety disorder / social phobia

Just because you occasionally get nervous in social situations doesn’t mean you have social anxiety disorder or social phobia. Many people are shy or self-conscious—at least from time to time—yet it doesn’t get in the way of their everyday functioning. Social anxiety disorder, on the other hand, does interfere with your normal routine and causes tremendous distress.
For example, it’s perfectly normal to get the jitters before giving a speech. But if you have social anxiety disorder or social phobia, you might worry for weeks ahead of time, call in sick to get out of it, or start shaking so bad during the speech that you can hardly speak.

Emotional symptoms of social anxiety disorder / social phobia

• Excessive self-consciousness and anxiety in everyday social situations
• Intense worry for days, weeks, or even months before an upcoming social situation
• Extreme fear of being watched or judged by others, especially people you don’t know
• Fear that you’ll act in ways that that will embarrass or humiliate yourself
• Fear that others will notice that you’re nervous

Physical symptoms of social anxiety disorder / social phobia

• Red face, or blushing
• Shortness of breath
• Upset stomach, nausea (i.e. butterflies)
• Trembling or shaking (including shaky voice)
• Racing heart or tightness in chest
• Sweating or hot flashes
• Feeling dizzy or faint

Behavioral symptoms of social anxiety disorder / social phobia

• Avoiding social situations to a degree that limits your activities or disrupts your life
• Staying quiet or hiding in the background in order to escape notice and embarrassment
• A need to always bring a buddy along with you wherever you go
• Drinking before social situations in order to soothe your nerves

Social anxiety disorder / social phobia in children

There’s nothing abnormal about a child being shy, but children with social anxiety disorder or social phobia experience extreme distress over everyday activities and situations such as playing with other kids, reading in class, speaking to adults, taking tests, or performing in front of others. Often, children with social phobia don’t want to go to school.

Social anxiety disorder treatment #1: Challenge negative thoughts

Social anxiety sufferers have negative thoughts and beliefs that contribute to their anxiety. If you have social anxiety disorder, or social phobia, you may find yourself overwhelmed by thoughts like:

“I know I’ll end up looking like a fool.” “My voice will start shaking and I’ll humiliate myself.”

“People will think I’m stupid.” “I won’t have anything to say. I'll seem boring.”

Challenging these negative thoughts, either through therapy or on your own, is one effective way to reduce the symptoms of social anxiety disorder.
The first step is to identify the automatic negative thoughts that underlie your fear of social situations. For example, if you‘re worried about an upcoming work presentation, the underlying negative thought might be: “I’m going to blow it. Everyone will think I’m completely incompetent.”
The next step is to analyze and challenge them. It helps to ask yourself questions about the negative thoughts: “Do I know for sure that I’m going to blow the presentation?” or “Even if I’m nervous, will people necessarily think I’m incompetent?” Through this logical evaluation of your negative thoughts, you can gradually replace them with more realistic and positive ways of looking at social situations that trigger your anxiety.

Unhelpful thinking styles involved in social phobia

In particular, ask yourself if you’re engaging in any of the following unhelpful thinking styles:

• Mind reading – Assuming you know what other people are thinking, and that they see you in the same negative way that you see yourself.
• Fortune telling – Predicting the future, usually while assuming the worst will happen. You just “know” that things will go horribly, so you’re already anxious before you’re even in the situation.
• Catastrophizing – Blowing things out of proportion. If people notice that you’re nervous, it will be “awful,” “terrible,” or “disastrous.”
• Personalizing – Assuming that people are focusing on you in a negative way or that what’s going on with other people has to do with you.

How can I stop thinking that everyone is looking at me?

In order to reduce self-focus, pay attention to what is happening around you, rather than monitoring yourself or focusing on symptoms of anxiety in your body:

• Look at other people and the surroundings.
• Really listen to what is being said (not to your own negative thoughts).
• Don't take all the responsibility for keeping conversations going—silence is okay, other people will contribute.

Adapted from: Moodjuice

Social anxiety disorder treatment #2: Learn to control your breath

Many changes happen in your body when you become anxious. One of the first changes is that you begin to breathe quickly. Overbreathing throws off the balance of oxygen and carbon dioxide in your body—leading to more physical symptoms of anxiety, such as dizziness, a feeling of suffocation, increased heart rate, and muscle tension.
Learning to slow your breathing down can help you bring your physical symptoms of anxiety back under control. Practicing the following breathing exercise will help you stay calm when you’re the center of attention.

A breathing exercise to help you keep your calm in social situations

• Sit comfortably with your back straight and your shoulders relaxed. Put one hand on your chest and the other on your stomach.
• Inhale slowly and deeply through your nose for four seconds. The hand on your stomach should rise, while the hand on your chest should move very little.
• Hold the breath for two seconds.
• Exhale slowly through your mouth for six seconds, pushing out as much air as you can. The hand on your stomach should move in as you exhale, but your other hand should move very little.
• Continue to breathe in through your nose and out through your mouth. Focus on keeping a slow and steady breathing pattern of 4-in, 2-hold, and 6-out.

Relaxation techniques for anxiety relief

In addition to deep breathing exercises, regular practice of relaxation techniques such as meditation, yoga, and progressive muscle relaxation will also help you get control over the physical symptoms of anxiety.
For step-by-step advice on getting started, see Relaxation Techniques for Stress Relief: Finding the Relaxation Exercises that Work for You.

Social anxiety disorder treatment #3: Face your fears

One of the most helpful things you can do to overcome social anxiety disorder, or social phobia, is to face the social situations you fear rather than avoid them. Avoidance keeps social anxiety disorder going.

Avoidance leads to more problems

While avoiding nerve-wracking situations may help you feel better in the short term, it prevents you from becoming more comfortable in social situations and learning how to cope. In fact, the more you avoid a feared social situation, the more frightening it becomes.
Avoidance may also prevent you from doing things you’d like to do or reaching certain goals. For example, a fear of speaking up may prevent you from sharing your ideas at work, standing out in the classroom, or making new friends.

Challenging social anxiety one step at a time

While it may seem impossible to overcome a feared social situation, you can do it by taking it one small step at a time. The key is to start with a situation that you can handle and gradually work your way up to more challenging situations, building your confidence and coping skills as you move up the “anxiety ladder.”
For example, if socializing with strangers makes you anxious, you might start by accompanying an outgoing friend to a party. Once you’re comfortable with that step, you might try introducing yourself to one new person, and so on.

Working your way up the social phobia “anxiety ladder”

• Don’t try to face your biggest fear right away. It’s never a good idea to move too fast, take on too much, or force things. This will backfire and reinforce your anxiety.
• Be patient. Overcoming social anxiety takes time and practice. It’s a gradual step-by-step progress.
• Use the skills you’ve learned to stay calm, such as focusing on your breathing and challenging negative assumptions.

Social anxiety disorder treatment #4: Build better relationships

Actively seeking out and joining supportive social environments is another effective way of tackling and overcoming social anxiety disorder or social phobia. The following suggestions are good ways to start interacting with others in positive ways:

• Take a social skills class or an assertiveness training class. These classes are often offered at local adult education centers or community colleges.
• Volunteer doing something you enjoy, such as walking dogs in a shelter, or stuffing envelopes for a campaign — anything that will give you an activity to focus on while you are also engaging with a small number of like-minded people.
• Work on your communication skills. Good relationships depend on clear, emotionally-intelligent communication. If you find that you have trouble connecting to others, learning the basic skills of emotional intelligence can help.

Social anxiety disorder treatment #5: Change your lifestyle

While lifestyle changes alone aren’t enough to overcome social phobia or social anxiety disorder, they can support your overall treatment progress. The following lifestyle tips will help you reduce your overall anxiety levels and set the stage for successful treatment:

• Avoid or limit caffeine. Coffee, tea, caffeinated soda, energy drinks, and chocolate act as stimulants that increase anxiety symptoms.
• Drink only in moderation. You may be tempted to drink before a party or other social situation in order to calm your nerves, but alcohol increases your risk of having an anxiety attack.
• Quit smoking. Nicotine is a powerful stimulant. Smoking leads to higher, not lower, levels of anxiety.
• Get adequate sleep. When you’re sleep deprived, you’re more vulnerable to anxiety. Being well rested will help you stay calm in social situations.

When self-help for social anxiety / social phobia isn’t enough

The best treatment approach for social anxiety disorder varies from person to person. You may find that self-help strategies are enough to ease your social anxiety symptoms. But if you’ve tried the techniques above and you’re still struggling with disabling anxiety, you may need professional help as well.

Therapy for social anxiety disorder / social phobia

Of all the professional treatments available, cognitive-behavioral therapy (CBT) has been shown to work the best for treating social anxiety disorder, or social phobia. Cognitive-behavioral therapy is based on the premise that what you think affects how you feel, and your feelings affect your behavior. So if you change the way you think about social situations that give you anxiety, you’ll feel and function better.
Cognitive-behavioral therapy for social phobia typically involves:

• Learning how to control the physical symptoms of anxiety through relaxation techniques and breathing exercises.
• Challenging negative, unhelpful thoughts that trigger and fuel social anxiety, replacing them with more balanced views.
• Facing the social situations you fear in a gradual, systematic way, rather than avoiding them.

While you can learn and practice these exercises on your own, if you’ve had trouble with self-help, you may benefit from the extra support and guidance a therapist brings.

Group therapy for social anxiety disorder / social phobia

Other cognitive-behavioral techniques for social anxiety disorder include role-playing and social skills training, often as part of a therapy group.
Group therapy for social anxiety disorder uses acting, videotaping and observing, mock interviews, and other exercises to work on situations that make you anxious in the real world. As you practice and prepare for situations you’re afraid of, you will become more and more comfortable and confident in your social abilities, and your anxiety will lessen.

Medication for social anxiety disorder / social phobia

Medication is sometimes used to relieve the symptoms of social anxiety, but it’s not a cure for social anxiety disorder or social phobia. If you stop taking medication, your symptoms will probably return full force. Medication is considered most helpful when used in addition to therapy and other self-help techniques that address the root cause of social anxiety disorder.
Three types of medication are used in the treatment of social anxiety disorder / social phobia:

• Beta blockers – Beta blockers are used for relieving performance anxiety. They work by blocking the flow of adrenaline that occurs when you’re anxious. While beta blockers don’t affect the emotional symptoms of anxiety, they can control physical symptoms such as shaking hands or voice, sweating, and rapid heartbeat.
• Antidepressants – Antidepressants can be helpful when social anxiety disorder is severe and debilitating. Three specific antidepressants—Paxil, Effexor, and Zoloft—have been approved by the U.S. Food and Drug Administration for the treatment of social phobia.
• Benzodiazepines – Benzodiazepines are fast-acting anti-anxiety medications. However, they are sedating and addictive, so they are typically prescribed only when other medications for social phobia have not worked.

Social Anxiety Overview

By JOHN M. GROHOL, PSY.D.

People with social anxiety disorder, also known as social phobia, suffer from an intense fear of becoming humiliated in social situations — specifically the fear of embarrassing oneself in front of other people. They worry that they will not measure up, or that they will mess up when talking, speaking to, or interacting with others.
In these feared performance and social situations, individuals with social anxiety experience concerns about embarrassment and are afraid that others will judge them to be anxious, weak, “crazy,” or stupid. They may fear public speaking because of concern that others will notice their trembling hands or voice or they may experience extreme anxiety when conversing with others because of fear that they will appear inarticulate.
A person with social anxiety disorder may avoid eating, drinking, or writing in public because of a fear of being embarrassed by having others see their hands shake. Individuals with social phobia almost always experience symptoms of anxiety — such as heart palpitations, dry mouth, tremors, sweating, gastrointestinal discomfort, diarrhea, muscle tension or trembling, a shaky voice, blushing, and even confusion. In severe cases, a person may experience a full-blownpanic attack.

People with social anxiety recognize their fear is excessive or unreasonable.

These symptoms can become a source of added concern where a person with social anxiety will worry that the symptoms they’re experiencing will result in unwanted and embarrassing attention. People with social phobia either avoid social or performance situations, or endure them with intense anxiety or stress. They can also suffer from anticipatory anxiety regarding the upcoming event or social situation. This can set up a vicious cycle of anticipatory anxiety leading to poor performance (whether real or just perceived) in the situation, which leads to even more anxiety for future situations.
Most people who have social anxiety recognize that their fear is excessive or unreasonable. They seek to avoid any of the feared situations in their life. If they are forced into one of their feared situations, they experience it with intense anxiety.
The incidence of social anxiety disorder in the United States is somewhere between 5 to 13 percent of people who will experience it during their lifetime.
Research indicates that women outnumber men three to two among those with symptoms of social phobia. Men, however, have been more likely to seek treatment.
A variety of studies have demonstrated that social phobia is most likely to develop in the teenage years, though it can start earlier or later. Mental health professionals report that many people suffer quietly for years, looking for help only when their fears have precipitated a major life crisis.
Social anxiety disorder is readily treated through a combination ofpsychotherapy and medications.

Types of Social Phobia

For some people, almost any social circumstance is a cause for fear and anxiety. These individuals are said to have generalized social phobia. People for whom just one or two situations produce anxiety are considered to have the nongeneralized form of the disorder.
Some researchers have suggested that another way to group people with social anxiety disorder is based on the kind of situation that triggers anxiety. Two primary categories have been proposed: performance and interactional.
The performance group includes people who have strong anxiety at the idea of doing something in front of, or in the presence of, other people. Such situations include dining out, working, giving a speech or using a public restroom.
The interactional group includes people whose fears center on circumstances where they have to converse or otherwise engage with others, such as meeting new people.
Mental health professionals also have recognized that some people develop symptoms of social phobia as an outgrowth of other medical or physical problems. Individuals with Parkinson’s disease, obesity, disfigurement or other conditions sometimes can have severe anxiety that their physical appearance or actions will attract attention and disdain. While sharing similar symptoms, the Diagnostic and Statistical Manual for Mental Disorders specifically excludes a diagnosis of social phobia if the fears exhibited can be tied to these medical or physical conditions.

Social Anxiety Disorder

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Social anxiety disorder, also called social phobia, is an anxiety disorder in which a person has an excessive and unreasonable fear of social situations. Anxiety (intense nervousness) and self-consciousness arise from a fear of being closely watched, judged, and criticized by others.

A person with social anxiety disorder is afraid that he or she will make mistakes, look bad, and be embarrassed or humiliated in front of others. The fear may be made worse by a lack of social skills or experience in social situations. The anxiety can build into a panic attack. As a result of the fear, the person endures certain social situations in extreme distress or may avoid them altogether. In addition, people with social anxiety disorder often suffer "anticipatory" anxiety -- the fear of a situation before it even happens -- for days or weeks before the event. In many cases, the person is aware that the fear is unreasonable, yet is unable to overcome it.

People with social anxiety disorder suffer from distorted thinking, including false beliefs about social situations and the negative opinions of others. Without treatment, social anxiety disorder can negatively interfere with the person's normal daily routine, including school, work, social activities, and relationships.

People with social anxiety disorder may be afraid of a specific situation, such as speaking in public. However, most people with social anxiety disorder fear more than one social situation. Other situations that commonly provoke anxiety include:

• Eating or drinking in front of others.
• Writing or working in front of others.
• Being the center of attention.
• Interacting with people, including dating or going to parties.
• Asking questions or giving reports in groups.
• Using public toilets.
• Talking on the telephone.

Social anxiety disorder may be linked to other mental illnesses, such as panic disorder, obsessive compulsive disorder, and depression. In fact, many people with social anxiety disorder initially see the doctor with complaints related to these disorders, not because of social anxiety symptoms.

Irrational Fears: The Three Different Kinds of Phobia

What Are the Symptoms of Social Anxiety Disorder?

Many people with social anxiety disorder feel that there is "something wrong," but don't recognize their feeling as a sign of illness. Symptoms of social anxiety disorder can include:

• Intense anxiety in social situations.
• Avoidance of social situations.
• Physical symptoms of anxiety, including confusion, pounding heart, sweating, shaking, blushing, muscle tension, upset stomach, anddiarrhea.

Children with this disorder may express their anxiety by crying, clinging to a parent, or throwing a tantrum.

How Common Is Social Anxiety Disorder?

Social anxiety disorder is the second most common type of anxiety disorder (after specific phobias) and the third most common mental disorder in the U.S., after depression and alcohol dependence. An estimated 19.2 million Americans have social anxiety disorder. The disorder most often surfaces in adolescence or early adulthood, but can occur at any time, including early childhood. It is more common in women than in men.

Social Anxiety Disorder

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What Causes Social Anxiety Disorder?

There is no single known cause of social anxiety disorder, but research suggests that biological, psychological, and environmental factors may play a role in its development.

• Biological: Social anxiety disorder is currently thought to be related to abnormal functioning of brain circuits that regulate emotion and the "fight or flight" response center in the brain.  Genetic factors may also contribute, because social anxiety may be somewhat more likely to occur when it is also present in a first-degree relative (parent, sibling, or child).
• Psychological: The development of social anxiety disorder may stem from  embarrassing or humiliating social experiences in the past, such as being bullied or neglected by peers.
• Environmental: People with social anxiety disorder may develop their fear from observing the behavior of others or seeing what happened to someone else as the result of their behavior (such as being laughed at or made fun of). Further, children who are sheltered or overprotected by their parents may not learn good social skills as part of their normal development.

How Is Social Anxiety Disorder Diagnosed?

If symptoms of social anxiety disorder are present, the doctor will begin an evaluation by asking questions about your medical history and performing a physical exam. Although there are no lab tests to specifically diagnose social anxiety disorder, the doctor may use various tests to make sure that a physical illness isn't the cause of the symptoms.

If no physical illness is found, you may be referred to a psychiatrist, psychologist, or other mental health professional who is specially trained to diagnose and treat mental illnesses. Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate a person for an anxiety disorder. The doctor bases his or her diagnosis of social anxiety disorder on reports of the intensity and duration of symptoms, including any problems with functioning caused by the symptoms. The doctor then determines if the symptoms and degree of dysfunction indicate social anxiety disorder.

How Is Social Anxiety Disorder Treated?

For social anxiety disorder, the most effective treatment currently available is cognitive behavioral therapy (CBT). Medication may also be used to help ease the symptoms of social anxiety disorder so that CBT is more effective. Drugs may also be used alone.

• Cognitive-behavior therapy: The goal of CBT is to guide the person's thoughts in a more rational direction and help the person stop avoiding situations that once caused anxiety. It teaches people to react differently to the situations that trigger their anxiety symptoms. Therapy may include systematic desensitization or real life exposure to the feared situation. With systematic desensitization, the person imagines the frightening situation and works through his or her fears in a safe and relaxed environment, such as the therapist's office. Real life exposure gradually exposes the person to the situation but with the support of the therapist.
• Medication: There are several different types of drugs used to treat social anxiety disorder, including: antidepressants, like Paxil; sedatives (benzodiazepines), such as Klonopin and Ativan; beta-blockers, often used to treat heart conditions, may also be used to minimize certain physical symptoms of anxiety, such as shaking and rapid heartbeat.

Counseling to improve self-esteem and social skills, as well as relaxation techniques, such as deep breathing, may also help a person deal with social anxiety disorder.

What Is the Outlook for People With Social Anxiety Disorder?

The outlook for those with social anxiety disorder is generally good with treatment. Many people improve and enjoy more productive lives.

Can Social Anxiety Disorder Be Prevented?

Unfortunately, social anxiety disorder cannot be prevented, but seeking help as soon as symptoms surface can help make treatment more effective.