Social Phobia, or Social Anxiety Disorder, is an anxiety disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. Social phobia can be limited to only one type of situation — such as a fear of speaking in formal or informal situations, or eating or drinking in front of others — or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people.
Fears can be triggered by perceived or actual scrutiny from others. While the fear of social interaction may be recognized by the individual as excessive or unreasonable, overcoming it can be quite difficult. Panic attacks may also occur under intense fear and discomfort. An early diagnosis may help minimize the symptoms and the development of additional problems, such as depression.
Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends. While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward. Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family. Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them.
When you decide to seek treatment for social anxiety disorder symptoms, you may have a physical exam and your doctor will ask a number of questions. The physical exam can determine if there may be any physical causes triggering your symptoms. Answering questions will help your doctor or mental health provider find out about your psychological state.
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 to help pinpoint a diagnosis.
To be diagnosed with social anxiety disorder, a person 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 providers 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 that your anxiety level is excessive or out of proportion for the situation.
- You avoid anxiety-producing social situations.
- Your anxiety or distress interferes with your daily living.
Social anxiety disorder shares symptoms with other psychological disorders, including other anxiety disorders. Your mental health provider will want to determine whether one of these other conditions may be causing your social anxiety, or if you have social anxiety disorder along with another mental health disorder. Often, social anxiety occurs along with other mental health conditions, such as substance abuse problems, depression and body dysmorphic disorder.
In general, anxiety disorders are treated with medication, specific types of psychotherapy, or both. Treatment choices depend on the problem and the person's preference. Before treatment begins, a doctor must conduct a careful diagnostic evaluation to determine whether a person's symptoms are caused by an anxiety disorder or a physical problem. If an anxiety disorder is diagnosed, the type of disorder or the combination of disorders that are present must be identified, as well as any coexisting conditions, such as depression or substance abuse. Sometimes alcoholism, depression, or other coexisting conditions have such a strong effect on the individual that treating the anxiety disorder must wait until the coexisting conditions are brought under control.
Several types of medications are used to treat social anxiety disorder. However, selective serotonin reuptake inhibitors (SSRIs) are often the first type of medication tried for persistent symptoms of social anxiety. SSRIs your doctor may prescribe include:
- paroxetine (Paxil)
- sertraline (Zoloft)
- fluvoxamine (Luvox)
- fluoxetine (Prozac, Sarafem, others)
The serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor) also may be an option for social anxiety disorder.
To reduce the risk of side effects, your doctor will start you at a low dose of medication and gradually increase your prescription to a full dose. It may take up to three months of treatment for your symptoms to noticeably improve.
Other medication options
Your doctor or mental health provider may also prescribe other medications for symptoms of social anxiety, including:
- 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 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. If your doctor does prescribe anti-anxiety medications, make sure you try taking them before you're in a social situation so that you know how they will affect you.
- 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. As with anti-anxiety medications, try taking them before you need them to see how they affect you.
Psychological counseling (psychotherapy) improves symptoms in most people with social anxiety disorder. In therapy, you learn how to recognize and change negative thoughts about yourself. Cognitive behavioral therapy is the most common type of counseling for anxiety. 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 can change the way you think and behave.
Cognitive behavioral 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.
Your mental health professional may help you develop relaxation or stress management techniques.
Like many other mental health conditions, social anxiety disorder likely arises from a complex interaction of environment and genes. Possible causes include:
- Anxiety disorders tend to run in families. However, it isn't entirely clear how much of this may be due to genetics and how much is due to learned behavior.
- Natural chemicals in your body may play a role in social anxiety disorder. For instance, an imbalance in the brain chemical serotonin may be a factor. Serotonin is a neurotransmitter that helps regulate mood and emotions, among other things. People with social anxiety disorder may be extra-sensitive to the effects of serotonin.
- A structure in the brain called the amygdala 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.
- 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.
<p>If you are concerned you may be suffering from social anxiety disorder, locate mental health services in your area. If unsure where to go for help, talk to someone you trust who has experience in mental health—for example, a doctor, nurse, social worker, or religious counselor. Ask their advice on where to seek treatment. If there is a university nearby, its departments of psychiatry or psychology may offer private and/or sliding-scale fee clinic treatment options. In times of crisis, the emergency room doctor at a hospital may be able to provide temporary help for a mental health problem, and will be able to tell you where and how to get further help.</p>
<p>Listed below are the types of people and places that will make a referral to, or provide, diagnostic and treatment services:</p>
<li>Mental health specialists, such as psychiatrists, psychologists, social workers, or mental health counselors</li>
<li>Health maintenance organizations</li>
<li>Community mental health centers</li>
<li>Hospital psychiatry departments and outpatient clinics</li>
<li>University- or medical school-affiliated programs</li>
<li>State hospital outpatient clinics</li>
<li>Social service agencies</li>
<li>Private clinics and facilities</li>
<li>Employee assistance programs</li>
<li>Local medical and/or psychiatric societies</li>
Social anxiety disorder can be associated with panic disorder, depression, and obsessive-compulsive disorder. In some cases theses disorders are the impetus for individuals to seek medical treatment.
Social anxiety disorder often occurs alongside low self-esteem and clinical depression, due to lack of personal relationships and long periods of isolation from avoiding social situations. To try to reduce their anxiety and alleviate depression, people with social anxiety disorder may use alcohol or other drugs, which can lead to substance abuse.
The most common complementary psychiatric condition is unipolar depression. Besides depression, the most common disorders diagnosed in patients with social anxiety disorder are panic disorder, generalized anxiety disorder, post-traumatic stress disorder, and substance abuse disorder. Avoidant personality disorder is also highly correlated with social anxiety disorder. Because of its close relationship and overlapping symptoms with other illnesses, treating social anxiety disorder may help understand underlying connection in other psychiatric disorders.
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 your symptoms.
First, consider your fears to identify what situations cause the most anxiety. Then gradually practice these activities until they cause you less anxiety. Begin with small steps in situations that aren't overwhelming.
Situations to practice may 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
- Giving someone a compliment
- Asking a retail clerk to help you find an item
- Getting directions from a stranger
- Showing an interest in others — ask about their homes, children, grandchildren, hobbies or travels, for instance
- Calling a friend to make plans
- At first, being social when you're feeling anxious is challenging. 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.