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What Is Social Anxiety?

By Dr. Eappen

Social anxiety is defined as a marked and persistent fear of social or performance situations. It includes symptoms such as sweating, racing heartbeat, shaking, and shortness of breath. Social anxiety can either be specific—where it only happens in one or two situations—or generalized. The potential for embarrassment often fuels the fear. 

While the dividing line between social anxiety disorder and everyday shyness is not always clear, the anxiety often causes serious distress and interferes with relationships and daily functioning. Shyness is much less disruptive. 

Treatment for social anxiety can be very effective and consists of medication, psychotherapy, or a combination of both. Left untreated, the consequences can be tremendous. People who experience social anxiety may make drastic life choices to accommodate their symptoms, such as dropping out of school or quitting a job.

Types of Social Anxiety

There are two types of social anxiety disorders: specific and generalized. Specific social anxiety is usually confined to 1 or 2 performance situations, such as speaking, musical performance, or writing. Generalized social anxiety is triggered by nearly all social situations, whether it’s answering a phone call, mingling at a party or making eye contact.

At the far extreme of social anxiety severity is a condition called “avoidant personality disorder.” It is characterized by an extensive pattern of chronic social withdrawal, feelings of inadequacy, and hypersensitivity to negative evaluation that begins by early adulthood. Avoidant personality disorder is viewed as a severe form of generalized social anxiety disorder, and treatments used for conventional social anxiety are just as effective for it.

Signs and Symptoms of Social Anxiety

People with social anxiety show signs of being shy, timid, quiet in groups, and uncomfortable being the center of attention. They crave the company of others but fear being found out as unlikable, stupid or boring. They avoid speaking in public, expressing opinions, or hanging out with peers. As a result, they are sometimes mistakenly labeled as “snobs.”

Many with social anxiety lack self-esteem. They find it difficult to deal with people in authority, and are unable to speak or perform in front of even small groups of people.

The key feature of social anxiety disorder is a persistent fear of social or performance situations in which embarrassment may occur. Exposure to such situations can produce feelings of considerable anxiety, often as intense as a panic attack, with physical symptoms such as sweating, shaking, garbled speech, blushing, racing heartbeat, upset stomach, and shortness of breath.

Do you avoid social or performance situations? When you encounter these situations, do you have any of these symptoms below?

    • Worry
    • Panic
    • Sweating
    • Shaking
    • Garbled speech
    • Blushing
    • Upset stomach
    • Shortness of breath
    • Racing heartbeat

If so, you might have social anxiety.


Consequences of Untreated Social Anxiety

The consequences of untreated social anxiety are tremendous and can affect a person’s educational, occupational, social and romantic life. This is a disorder of lost opportunities—individuals make major life choices to accommodate their illness. For example, they drop out of school early because of their fears of speaking in front of groups, or they take jobs that permit them to avoid interacting with others. They often do not date at all, and many become lonely and isolated.

Social Anxiety Test

If you find yourself wondering if you have social anxiety, you can take a test with 17 questions that can help answer this. It’s called the SPIN (or Social Phobia INventory, and you can find it here).

If you want the shorter version of the SPIN, there’s the Mini-SPIN which uses just the top three questions. A score of 6 or greater on the MINI-Spin has 90% accuracy in detecting social anxiety.

Answer with:
0 = not at all
1 = a little bit
2 = somewhat
3 = very much
4 = extremely

Question 1: Fear of embarrassment causes me to avoid doing things or speaking to people
Question 2: I avoid activities in which I am the center of attention
Question 3: Being embarrassed or looking stupid are among my worst fears

If you score a 6 or higher after adding up your ratings for the above three questions, then you might have social anxiety. An appropriate next step would be to obtain your score on the 17 question SPIN above. If both tests are indicative of potential social anxiety, then treatment could be helpful.

How to Treat Social Anxiety

Although social anxiety is common and disabling, the available treatments are straightforward, simple, and extremely effective. The effectiveness is striking given that most patients try to manage social anxiety on their own for decades before seeking treatment. The average duration of illness prior to seeking treatment ranged from 15 years in one study, to over 20 years in another.

I’ve witnessed the positive change that comes from treatment and have eliminated social anxiety in all of my patients who followed my treatment recommendations.

The first step in treating social anxiety is providing an educational foundation about the illness. Given the early onset and long duration of the illness in most patients who seek help, most have accepted it as a permanent part of their personalities, Unfortunately, it can be difficult to understand that real change can happen. Further, when change does happen, it can disrupt the dynamic of the patient’s relationships, which can cause new problems. Most patients require additional work in therapy to manage those disruptions.

The next step is to choose whether you want treatment via psychotherapy, medication, or both. The primary forms of psychotherapy are as follows:

  • Exposure therapy involves continued exposure to feared situations, which leads to anxiety reduction over time. The first step might include cold calling some local retail stores, for example, to ask simple questions like the store’s hours of operation, until the phone calls become comfortable. Once that process becomes routine, the next step would involve physically going into the stores and asking a question or two, until that becomes comfortable. The final part of treatment might involve delivering a speech in front of a large audience. In general, exposure needs to be repeated, lengthy and increasingly challenging over time in order to be effective.
  • Social skills training involves teaching patients the essential verbal and nonverbal skills needed to effectively and comfortable interact with others.
  • Cognitive therapy focuses on correcting irrational thoughts or beliefs that contribute to inappropriate social anxiety. 
  • Cognitive-behavioral therapy (CBT) is the best-studied psychotherapeutic approach to social anxiety disorder. CBT blends elements of both exposure therapy and cognitive therapy. CBT in a group setting (CBGT) has been found to be as effective as medications in treating social anxiety and may have a higher likelihood of maintaining long-term response after treatment is terminated.

The final step is to consider whether a medication is warranted. For specific social anxiety, psychotherapy should be the core treatment, with medication only used as needed. For generalized social anxiety, the use of a daily medication can be very helpful when combined with psychotherapy.

  • Beta blockers are effective in treating both public speaking and musical performance anxiety. They work by reducing physical symptoms of anxiety (less tremor, heart palpitations, sweating), which helps interrupt the progression of anxiety. These medicines are usually taken 1 hour before a performance. While beta blockers on an as-needed basis may benefit performance anxiety, they are not useful when taken daily to treat generalized social anxiety.
  • Selective serotonin reuptake inhibitors (SSRIs) are the medication treatment of choice for generalized social anxiety disorder. Paxil is the only SSRI that is FDA approved for social anxiety disorder, but there are plenty of high quality studies that establish the effectiveness of Zoloft, Luvox, Celexa, and Prozac as well. There are no studies comparing one SSRI with another for treating social anxiety disorder, and there is no evidence that one is more effective than another. These medicines must be taken daily, and can take several weeks to become fully effective.

Barriers to Treating Social Anxiety

Common social anxiety treatment barriers include not knowing where to go for help, choosing to handle symptoms on one’s own, inability to afford treatment, inadequate recognition of symptoms by healthcare professionals, and embarrassment of discussing symptoms with others. Not knowing where to go for help is the most commonly reported barrier.

Many individuals with social anxiety choose not to seek treatment earlier because they believed they could handle their symptoms by themselves. The decision to seek treatment may occur only when their symptoms become so severe and disruptive that they can no longer manage them without assistance.

Economic stress, including lack of insurance and inability to afford treatment, are common in this group. There is a strong reverse correlation between social anxiety and socioeconomic status, meaning that those with social anxiety tend to have lower educational, financial and professional accomplishments. This comes as no surprise, as social anxiety can adversely affect your ability to effectively interact with your bosses, teachers, clients and peers. This can affect one’s ability to rise through the ranks in their career, gain clients, manage employees, obtain favorable letters of recommendations, and network successfully—all of which are crucial skills needed for professional advancement.

A fear of what others might think or say frequently inhibits treatment seeking. Socially anxious people are often ashamed of their symptoms and are embarrassed to discuss them with friends or healthcare professionals. It is ironic that the very symptoms socially anxious individuals seek to relieve may interfere with their ability to seek treatment.

Inadequate recognition of social anxiety by healthcare professionals may further hinder treatment. There is a low rate of referral for evaluation of social anxiety, and this may be due to healthcare professionals’ unfamiliarity with social anxiety, as well as an unawareness of the availability of effective treatments for social anxiety.

My Take on Social Anxiety

Less than 1% of the patients who come to the Eappen Clinic report social anxiety as their primary concern. However, I’ve found that a substantial number of patients who come in for treatment of depression, panic attacks or generalized anxiety often have an unrecognized problem of social anxiety. This is consistent with the literature cited above: most people with social anxiety don’t come to the doctors office for treatment due to not recognizing they have the disorder, embarrassment with discussing it, or believing they could handle it without help.

If you recognize having social anxiety, are motivated to treat it, and have the patience, discipline and resilience to follow my recommendations, then the success rate is very high. If someone comes into our office looking to fully overcome their symptoms, then I will typically start them on an SSRI, and introduce them to a trusted psychologist who specializes in CBT for social anxiety. The three of us will collaborate with each other throughout the course of treatment. It’s a team effort.

The speed of symptom relief depends on the following factors: severity of symptoms when you begin treatment, sticking with your medication plan, willingness to change the type or dose of medication if needed, attending all the recommended psychotherapy sessions, and doing all your homework and exposure exercises between therapy sessions.

Social anxiety doesn’t have to limit your life. You can feel well again with the right treatment plan. 

About the Author

Seth Eappen, MD, is a board-certified adult, child and adolescent psychiatrist. Dr. Eappen completed medical school at the University of Illinois at Chicago and a residency at the University of Michigan, Ann Arbor. He completed his child psychiatry fellowship at MUSC in Charleston, SC, where he served as chief fellow. He is the founder of the Eappen Clinic, a private outpatient mental health practice with locations in Chicago and Oak Brook, IL.