Social Anxiety Disorder

Overview

Social anxiety disorder involves excessive fear of negative evaluation, embarrassment, or humiliation in social or performance situations. It can be specific (e.g., public speaking) or generalized (most social interactions). The condition typically begins in adolescence and, if untreated, follows a chronic course. It significantly impairs occupational, academic, and social functioning. CBT and pharmacotherapy are effective treatments.

Symptoms

• Marked fear or anxiety about social situations involving potential scrutiny
• Fear of acting in a way that will be negatively evaluated
• Social situations almost always provoke fear or anxiety
• Avoidance of social situations or endurance with intense anxiety
• Fear is disproportionate to the actual threat posed by the social situation
• The anxiety or avoidance persists for six months or more
• Physical symptoms such as blushing, trembling, sweating, or nausea in social situations
• Difficulty making eye contact, speaking, or initiating conversations

Causes

• Dysregulation of social threat-detection systems (amygdala, anterior cingulate cortex)
• Genetic factors � heritability estimated at 30-40%
• Behavioral inhibition temperament in childhood as a risk factor

Risk factors

• Family history of social anxiety disorder
• Behavioral inhibition or shyness in childhood
• History of bullying, social exclusion, or humiliating experiences
• Overprotective or controlling parenting styles
• Comorbid depression or substance use disorders

Diagnosis

Clinical diagnosis based on DSM-5 or ICD-11 criteria: marked fear or anxiety about social situations with fear of negative evaluation, persisting for at least six months, causing significant distress or functional impairment. The Liebowitz Social Anxiety Scale (LSAS) and Social Phobia Inventory (SPIN) are validated severity measures. Differential diagnosis includes normal shyness, social anxiety due to medical conditions, and other anxiety disorders.

Treatment & management

CBT with cognitive restructuring (challenging negative beliefs about social evaluation) and graduated exposure to feared social situations is first-line. Social skills training may be helpful when skill deficits exist. SSRIs (sertraline, paroxetine) and SNRIs (venlafaxine) are first-line pharmacotherapy. Beta-blockers (propranolol) may be used for performance-specific anxiety. Group CBT can be particularly effective as it provides a built-in exposure context.

Management is individualized and discussed with benefits, limitations, and follow-up.

Prevention & self-care

Early identification of social anxiety symptoms in children and adolescents, supportive parenting that encourages social engagement, school-based social skills programs, and early intervention to prevent chronicity and secondary complications (depression, substance use for self-medication).

When to seek medical attention

• Fear or avoidance of social situations interferes with work, school, or relationships
• Physical symptoms (blushing, trembling, nausea) occur in social settings
• You avoid social situations entirely or endure them with significant distress
• Social anxiety has led to depression or substance use as self-medication
• Social anxiety symptoms have persisted for more than six months

Frequently asked questions