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Social anxiety disorder (social phobia)

Definition

It's normal to feel nervous in some social situations. Going on a date or giving a presentation may cause that feeling of butterflies in your stomach, for instance. But in social anxiety disorder, also called social phobia, everyday interactions cause irrational anxiety, fear, self-consciousness and embarrassment.

Social anxiety disorder is a chronic mental health condition, but treatment such as psychological counseling, medication and learning coping skills can help you gain confidence and improve your ability to interact with others.

Symptoms

Social anxiety disorder affects your emotions and behavior. It can also cause significant physical symptoms.

Emotional and behavioral social anxiety disorder signs and symptoms include:

  • Intense fear of interacting with strangers
  • Fear of situations in which you may be judged
  • Worrying about embarrassing or humiliating yourself
  • Fear that others will notice that you look anxious
  • Anxiety that disrupts your daily routine, work, school or other activities
  • Avoiding doing things or speaking to people out of fear of embarrassment
  • Avoiding situations where you might be the center of attention
  • Difficulty making eye contact
  • Difficulty talking

Physical social anxiety disorder signs and symptoms include:

  • Blushing
  • Sweating
  • Trembling or shaking
  • Fast heartbeat
  • Upset stomach
  • Nausea
  • Shaky voice
  • Muscle tension
  • Confusion
  • Diarrhea
  • Cold, clammy hands

Worrying about having symptoms
When you have social anxiety disorder, you realize that your anxiety or fear is out of proportion to the situation. Yet you're so worried about developing social anxiety disorder symptoms that you avoid situations that may trigger them. This type of worrying creates a vicious cycle that can make symptoms worse.

When to see a doctor
See your doctor or mental health provider if you fear and avoid normal social situations because they cause embarrassment, worry or panic. If this type of anxiety disrupts your life, causes severe stress and affects your daily activities, you may have social anxiety disorder or another mental health condition that requires treatment to get better.

Feelings of shyness or discomfort in certain situations aren't necessarily signs of social anxiety disorder, particularly in children. Comfort levels in social situations vary from individual to individual due to personality traits and life experiences. Some people are naturally reserved and others are more outgoing. What sets social anxiety disorder apart from everyday nervousness is that its symptoms are much more severe, causing you to avoid normal social situations.

Common, everyday experiences that may be difficult to endure when you have social anxiety disorder include:

  • Using a public restroom or telephone
  • Returning items to a store
  • Interacting with strangers
  • Writing in front of others
  • Making eye contact
  • Entering a room in which people are already seated
  • Ordering food in a restaurant
  • Being introduced to strangers
  • Initiating conversations

Social anxiety disorder symptoms can change over time. They may flare up if you're facing a lot of stress or demands. Or if you completely avoid situations that would usually make you anxious, you may not have symptoms. Although avoidance may allow you to feel better in the short term, your anxiety is likely to persist over the long term if you don't get treatment.

Causes

Like many other mental health conditions, social anxiety disorder likely arises from a complex interaction of environment and genes. Possible causes include:

  • Inherited traits. 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.
  • Brain chemistry. Natural chemicals in your body may play a role in social anxiety disorder. For instance, an imbalance in the brain chemical serotonin (ser-oh-TOE-nin) 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.
  • Brain structure. A structure in the brain called the amygdala (uh-MIG-duh-luh) 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.
  • Negative experiences. 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.

Risk factors

Social anxiety disorder is one of the most common mental disorders. It usually begins in the early to midteens, although it can sometimes begin earlier in childhood or in adulthood.

A number of factors can increase the risk of developing social anxiety disorder, including:

  • Being female. Females are more likely than males to have social anxiety disorder.
  • Family history. You're more likely to develop social anxiety disorder if your biological parents or siblings have the condition.
  • Environment. Social anxiety disorder may be a learned behavior. That is, you may develop the condition after witnessing the anxious behavior of others. In addition, there may be an association between social anxiety disorder and parents who are more controlling or protective of their children.
  • Temperament. Children who are shy, timid, withdrawn or restrained when facing new situations or people may be at greater risk.
  • New social or work demands. Meeting new people, giving a speech in public or making an important work presentation may trigger social anxiety disorder symptoms for the first time. These symptoms usually have their roots in adolescence, however.
  • Having a health condition that draws attention. Facial disfigurement, stuttering, Parkinson's disease and other health conditions can increase feelings of self-consciousness and may trigger social anxiety disorder in some people.

Complications

Left untreated, social anxiety disorder can be debilitating. Your anxieties may run your life. They can interfere with work, school, relationships or enjoyment of life. You may be considered an "underachiever," when in reality it's your fears holding you back, not your ability or motivation. In severe cases, you may drop out of school, quit work or lose friendships. Social anxiety disorder can cause:

  • Low self-esteem
  • Trouble being assertive
  • Negative self-talk
  • Hypersensitivity to criticism
  • Poor social skills

Social anxiety disorder can also result in:

  • A poor work record
  • Low academic achievement
  • Isolation and difficult social relationships
  • Substance abuse
  • Excessive drinking, particularly in men
  • Suicide

Preparing for your appointment

You may start by seeing your family doctor. After your initial appointment, your doctor may refer you to a mental health provider who can help make a firm diagnosis and create the right treatment plan for you.

Here's some information to help you prepare for your appointment, and what to expect from your doctor.

What you can do

  • Write down any symptoms you've been experiencing, and for how long. Social anxiety disorder often first appears in your teens. Your doctor will be interested to hear how your symptoms may have waxed or waned since they began.
  • Write down your key personal information, especially any significant events or changes in your life shortly before your symptoms appeared. For example, your doctor will want to know if your social anxiety seemed to be triggered by a promotion, meeting new people, or another new work or social demand.
  • Write down all of your medical information, including other physical or mental health conditions with which you've been diagnosed. Also write down the names of any medications you're taking.
  • Ask a trusted family member or friend to be present for your appointment, if possible. Sometimes it can be difficult to soak up all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
  • Write down questions to ask your doctor.

Questions to ask your doctor at your initial appointment may include:

  • What do you believe is causing my symptoms?
  • Are there any other possible causes?
  • How will you determine my diagnosis?
  • Should I see a mental health specialist?

Questions to ask if you are referred to a mental health provider include:

  • Is my condition likely temporary or chronic?
  • Are effective treatments available for this condition?
  • With treatment, could I eventually be comfortable in the situations that make me so anxious now?
  • Am I at increased risk of other mental health problems?
  • Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you've prepared in advance, don't hesitate to ask questions at any time during your appointment.

What to expect from your doctor
A doctor or mental health provider who sees you for possible social anxiety disorder may ask:

  • Does fear of embarrassment cause you to avoid doing things or speaking to people?
  • Do you avoid activities in which you are the center of attention?
  • Would you say that being embarrassed or looking stupid is among your worst fears?
  • When did you first notice these symptoms?
  • When are your symptoms most likely to occur?
  • Does anything seem to make your symptoms better or worse?
  • How are your symptoms affecting your life, including your work and personal relationships?
  • Do you ever have symptoms when you're not being observed by others?
  • Have any of your close relatives had similar symptoms?
  • Have you been diagnosed with any medical conditions?
  • Have you been treated for other psychiatric symptoms or mental illness in the past? If yes, what type of therapy was most beneficial?
  • Have you ever thought about harming yourself or others?
  • Do you drink alcohol or use illegal drugs? If so, how often?

Tests and diagnosis

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.

Treatments and drugs

The two most common types of treatment for social anxiety disorder are medications and psychological counseling (psychotherapy). These two approaches may be used in combination.

Psychotherapy
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.

First choices in medications
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 (ben-zo-di-AZ-uh-peens) 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.

Stick with it
Don't give up if treatment doesn't work quickly. You can continue to make strides in psychotherapy over several weeks or months. And finding the right medication for your situation can take some trial and error.

For some people, the symptoms of social anxiety disorder may fade over time, and medication can be discontinued. Others may need to take medication for years to prevent a relapse.

To make the most of treatment, keep your medical or therapy appointments, take medications as directed, and talk to your doctor about any changes in your condition.

Lifestyle and home remedies

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.

The following techniques can help you begin to face situations that make you nervous:

  • Prepare for conversation. For instance, read the newspaper to identify an interesting story you can talk about.
  • Focus on personal qualities you like about yourself.
  • Practice relaxation exercises.
  • Adopt stress management techniques.
  • Set realistic goals.
  • Pay attention to how often the embarrassing situations you're afraid of actually take place. You may notice that the scenarios you fear usually don't come to pass.
  • When embarrassing situations do happen, remind yourself that your feelings will pass, and you can handle them until they do.

Avoid using alcohol to calm your nerves. It may seem like it helps, but in the long run it can make you feel more anxious.

Alternative medicine

Certain supplements may help relieve anxiety, although it isn't clear about how much they help or what possible side effects they might have. Some supplements used to treat anxiety include:

  • Kava. This herb is reported to relax you without making you feel sedated. Some studies have linked kava to liver problems, so it isn't a good idea to take it if you have a liver condition, drink alcohol daily or take medications that affect your liver.
  • Valerian. Most commonly used as a sleep aid, valerian has a sedative effect and may also relieve anxiety.
  • Vitamin B and folic acid. These nutrients may relieve anxiety by affecting the production of chemicals needed for your brain to function (neurotransmitters).

Talk to your doctor before taking herbal remedies or supplements to make sure they're safe for you and won't interact with any medications you take.

Coping and support

Some coping methods that may help ease your anxiety include:

  • Reaching out to people with whom you feel comfortable
  • Joining a local or Internet-based support group
  • Joining a group that offers opportunities to improve communication and public speaking skills, such as Toastmasters International
  • Doing pleasurable activities, such as exercise or hobbies, when you feel anxious
  • Getting enough sleep
  • Eating a well-balanced diet

Over time, these coping methods can help control your symptoms and prevent a relapse. Remind yourself that you can get through anxious moments, that your anxiety is short-lived, and that the negative consequences you worry about so much rarely come to pass.

Prevention

There's no way to predict for certain what will cause someone to develop an anxiety disorder in the first place, but you can take steps to reduce the impact of symptoms if you're anxious:

  • Get help early. Anxiety, like many other mental health conditions, can be harder to treat if you wait.
  • Keep a journal. Keeping track of your personal life can help you and your mental health provider identify what's causing you stress and what seems to help you feel better.
  • Prioritize your life. You can reduce anxiety by carefully managing your time and energy.
  • Avoid unhealthy substance use. Alcohol and drug use and even caffeine or nicotine use can cause or worsen anxiety. If you're addicted to any of these substances, quitting can make you anxious. If you can't quit on your own, see your doctor or find a support group to help you.
Updated: 8/23/2011

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