Social anxiety disorder is also known as social phobia. It is a fear of behaving in an embarrassing way whilst you talk or meet with other people, especially strangers. It can greatly affect your life. Treatment works well in many cases. Treatment options include cognitive behavioural therapy and medication, usually with a selective serotonin reuptake inhibitor antidepressant.
What is social anxiety disorder?
Social anxiety disorder is sometimes called social phobia. Social anxiety disorder is not just shyness; it is more severe than this. With social anxiety disorder you become very anxious about what other people may think of you, or how they may judge you. As a result you have great difficulty in social situations, which can affect your day-to-day life.
- A marked fear or dread of social situations. You fear that you will act in an embarrassing or humiliating way and that other people will think you are stupid, inadequate, foolish, etc:
- In some cases the fear is only for certain situations where you will be looked at by others, even if they are known to you. For example, you become very anxious if you have to 'perform' in some way, such as giving a talk or presentation, taking part in a discussion at work or school, etc. However, you are OK in informal social gatherings.
- In other cases the fear occurs for most social situations where you may meet strangers. This can even include eating in public places, as you fear you may act in an embarrassing way.
- You may have weeks of anxiety prior to a social event or an event where you have to 'perform'.
- You avoid such situations as much as possible.
- If you go to the feared situation:
- You become very anxious and distressed.
- You may develop some physical symptoms of anxiety. These may include:
- A fast heart rate.
- The sensation of having a 'thumping heart' (palpitations).
- Shaking (tremor).
- Feeling sick (nausea).
- Chest pain.
- Stomach pains.
- A 'knot in the stomach'.
- Fast breathing.
- Blushing easily.
- You may have an intense desire to get away from the situation.
- You may even have a panic attack. See separate leaflet called Panic Attack and Panic Disorder for more details.
- However, you will usually know that your fear and anxiety are excessive and unreasonable.
Social anxiety disorder can greatly affect your life. You may not do as well at school or work as you might have done, as you tend to avoid any group work, discussions, etc. You may find it hard to obtain, or keep, a job. This may be because you feel unable to cope with the social aspects needed for many jobs, such as meeting with people. You may become socially isolated and find it difficult to make friends.
Who has social anxiety disorder?
It is one of the most common mental health conditions. As many as 1 in 10 adults have social anxiety disorder to some degree. It usually develops in the teenage years and is usually a lifelong problem unless treated. Just over twice as many women as men are affected.
What causes social anxiety disorder?
The cause is probably a combination of bad experiences as a child and your genetic 'makeup' which makes you more prone to this condition. In one study about half of affected people said their phobia began after one memorable embarrassing experience. The other half said it had been present for 'as long as they could remember'.
How is it diagnosed?
You must have three features to be diagnosed with social anxiety disorder:
- Your symptoms must not be the result of some other mental health condition (for example, a delusion).
- You feel anxious entirely or mostly in social situations.
- One of your main symptoms will be the avoidance of social situations.
As well as discussing your problems your doctor or practice nurse may use a short questionnaire to obtain extra information on how severely you are affected.
What are the treatment options for social anxiety disorder?
Cognitive and behavioural therapies
These, if available in your area, can work well for social anxiety disorder.
- Cognitive therapy is based on the idea that certain ways of thinking can trigger, or fuel, certain mental health problems such as anxiety and depression. The therapist helps you to understand your current thought patterns - in particular, to identify any harmful, unhelpful, and false ideas or thoughts which you have that can make you anxious (or depressed). The aim is then to change your ways of thinking to avoid these ideas. Also, to help your thought patterns to be more realistic and helpful. Therapy is usually done in weekly sessions of about 50 minutes each, for several weeks. You have to take an active part and are given homework between sessions. For example, you may be asked to keep a diary of your thoughts which occur when you become anxious or develop physical symptoms of anxiety.
- Behavioural therapy aims to change any behaviours which are harmful or not helpful. For example, with phobias your behaviour or response to the feared object is harmful and the therapist aims to help you to change this. Various techniques are used, depending on the condition and circumstances. As with cognitive therapy, several sessions are needed for a course of therapy.
- Cognitive behavioural therapy (CBT) is a mixture of the two where you may benefit from changing both thoughts and behaviours.
Note: cognitive and behavioural therapies do not look into the events of the past. They deal with (and aim to change) your current thought processes and/or behaviours. See separate leaflet called Cognitive Behavioural Therapy (CBT) for more details.
You can obtain leaflets, books, CDs, DVDs or MP3s, etc, on how to relax and how to combat anxiety. They teach simple deep breathing techniques and other measures to relieve stress and anxiety.
These are commonly used to treat depression but also help to reduce the symptoms of anxiety even if you are not depressed. They work by interfering with brain chemicals (neurotransmitters) such as serotonin, which may be involved in causing anxiety symptoms.
- Antidepressants do not work straightaway. It takes two to four weeks before their effect builds up and the anxiety symptoms are helped. A common problem is that some people stop the medicine after a week or so, as they feel that it is doing no good. This is often too soon to know if the medication will work.
- Antidepressants are not tranquillisers and are not usually addictive.
- There are several types of antidepressants, each with various pros and cons. They may differ in their possible side-effects. However, selective serotonin reuptake inhibitor (SSRI) antidepressants are the ones most commonly used for anxiety disorders. Two examples of SSRIs are escitalopram and sertraline.
Note: after first starting an antidepressant, in some people the anxiety symptoms become worse for a few days before they start to improve. Your doctor or practice nurse will want to keep a check on you in the first few weeks of treatment to see if you have any problems.
Benzodiazepines such as diazepam used to be the most commonly prescribed medicines for anxiety. They were known as the minor tranquilisers but they do have some serious known side-effects. They often work well to ease symptoms. The problem is they are addictive and can lose their effect if you take them for more than a few weeks. They may also make you drowsy. Now they are not used much for persistent anxiety conditions. A short course of up to two weeks may be an option for:
- Anxiety which is very severe and short-term; or
- 'Now and then' treatment to help you over a bad spell if you have persistent anxiety symptoms.
A beta-blocker (for example, propranolol) can ease some of the physical symptoms such as trembling and the sensation of having a 'thumping heart' (palpitations). They do not directly affect the mental symptoms such as worry. However, some people relax more easily if their physical symptoms are eased. These tend to work best in short-lived (acute) anxiety. For example, if you become more anxious before performing in a concert then a beta-blocker may help to ease 'the shakes'.
In some cases a combination of treatments such as cognitive therapy and an antidepressant may work better than either treatment alone.
Alcohol and anxiety
Although alcohol may ease symptoms in the short term, don't be fooled that drinking helps to cure anxiety. In the long run, it does not. Drinking alcohol to 'calm nerves' can lead to problem drinking and may make problems with anxiety and depression worse in the long term. See a doctor if you are drinking alcohol (or taking street drugs) to ease anxiety.
What is the outlook (prognosis) for social anxiety disorder?
Not much is known about the natural progress of the condition. However, with treatment there is a good chance that symptoms can be greatly improved. Without treatment, social phobia can be associated with depression in later life.
Dr Tim Kenny
Dr Roger Henderson
Dr Laurence Knott