Social Anxiety Disorder

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Social Anxiety Disorder

Topic Overview

What is social anxiety disorder?

People with social anxiety disorder (or social phobia) are extremely anxious about what they will say or do in front of other people. This includes public speaking and day-to-day social situations. But it is more than just being shy or nervous before public speaking. The fear can begin weeks or months before an event. It can cause a fast heartbeat and make it hard to focus.

Some people fear only one or a few types of social situations. For other people, many situations cause stress. This problem affects your daily life. You may be so stressed or afraid that you avoid public situations, including missing work and school.

What causes social anxiety disorder?

Doctors don't know what causes social anxiety disorder. They think it may run in families. But they are not sure if it's because of genetics or a response to a traumatic situation.

What are the symptoms?

Social anxiety disorder causes both emotional and physical symptoms:

  • It can make you nervous, sad, or easily upset before or during a social event. You may worry a lot or be afraid that something bad will happen.
  • The anxiety can cause you to blush, sweat, and feel shaky. Your heart may beat faster than normal, and you may have a hard time focusing.

How is social anxiety disorder diagnosed?

To diagnose social anxiety disorder, your doctor will examine you and ask about your symptoms. He or she may ask other questions to see how you are doing emotionally. This is called a mental health assessment.

Your doctor may also do blood or urine tests to rule out other conditions, such as thyroid problems that can cause similar symptoms.

How is it treated?

Treatment of social anxiety disorder includes counselling and sometimes medicine, such as antidepressants. Whether you need medicine depends on how much the problem affects your daily life. If you already feel anxious around other people, it may be hard to ask for help. But treatment for social anxiety disorder works for many people.

Some people with social anxiety disorder turn to alcohol or drugs to help them relax. This can lead to addiction problems. They may also have depression. It is important to treat these issues too.

Frequently Asked Questions

Learning about social anxiety disorder:

Being diagnosed:

Getting treatment:

Ongoing concerns:


Social anxiety disorder causes unreasonable, debilitating fear of being judged or publicly humiliated. You may avoid or severely limit encounters with other people—which can keep you from daily activities. You may develop physical symptoms such as a rapid heartbeat, shortness of breath, or tightness in your chest when faced with a feared social situation.

When you have social anxiety disorder, common social situations—such as eating in public, writing in front of other people, using a public restroom, or speaking in front of others—can cause overwhelming fear and anxiety.

You may be more afraid of people noticing your anxiety than of the actual feared situation. A vicious cycle can emerge of avoiding or worrying about the social event (such as speaking in public) because you are afraid others will see you as weak, anxious, or foolish—this, in turn, leads to more anxiety. This may lead to avoiding or limiting contact with other people.

Symptoms of social anxiety disorder may differ in adults and children. Adults and teenagers with social anxiety disorder usually recognize their fears of being publicly humiliated are unreasonable or excessive. But children who have this disorder may not.

Expressions of anxiety in adults or adolescents include:1

  • Having persistent but unreasonable fear of a situation that involves unfamiliar people or being judged by others. The fear is that you will be embarrassed or humiliated by something that you say or do.
  • Developing severe anxiety or panic attacks when in the feared situation.
  • Recognizing that your fears are excessive or unreasonable.
  • Avoiding social situations that you fear or enduring them with intense anxiety or distress.
  • Avoiding or anxiously anticipating feared situations so much it interferes with daily activities and relationships.
  • Worrying about being anxious.

Expressions of anxiety in children include:1

  • Worrying about being embarrassed in front of their peers but not usually in front of adults or teenagers.
  • Expressing anxiety by frequently crying, throwing tantrums, "freezing" in social situations, or "shrinking back" from unfamiliar people.
  • Denying or not realizing the fears are excessive or unreasonable.
  • Fearing performance situations, such as having to speak in front of the class. This fear doesn't come and go. It is continuous and lasts for 6 months or longer.

People with social anxiety disorder often underachieve at work or at school to avoid the attention of a promotion or to avoid being forced to participate in a group. They tend to have few friendships and have trouble dating or developing relationships. In prolonged or severe cases, many people develop other psychological conditions (such as depression or substance abuse).

Social anxiety disorder is among several types of phobias that many people experience, such as agoraphobia or specific phobia (fearing an object, like a spider, or a frightening situation, such as being stuck in an elevator).

Examinations and Tests

Social anxiety disorder is diagnosed based on your medical history, physical examination, and sometimes a mental health assessment, which is an evaluation of psychological symptoms.

Blood or urine tests may also be done to rule out other medical conditions that can cause similar symptoms (such as hyperthyroidism).

Treatment Overview

Treatment for social anxiety disorder involves psychological counselling and sometimes medicines (such as antidepressants) to reduce associated anxiety and depression.

A combination of medicines and professional counselling may be effective for long-term treatment for people who have generalized anxiety and fear over many social situations.2 For those who fear only one or a few social situations (such as public speaking or eating in front of others), professional counselling to overcome the fear may be all that is needed.

Unfortunately, many people don't seek treatment for anxiety disorders. You may not seek treatment because you think the symptoms are not bad enough or that you can work things out on your own. But getting treatment is important.

If you need help deciding whether to see your doctor, see some reasons why people don't get help and how to overcome them.

Initial and ongoing treatment

Initial treatment of social anxiety disorder is based on how bad your emotional and physical symptoms are and how able you are to function in daily activities. People who have social anxiety disorder often have depression also. They may also have alcohol or substance abuse problems. Your doctor may ask you certain questions to see whether you might be drinking too much or abusing drugs.

Social anxiety disorder often goes undetected for years before treatment is sought. By that time, you may have developed behaviours that accommodate the fears. These habits or behaviours must be overcome to successfully manage social anxiety disorder.

First, your doctor must determine whether you are generally anxious about all social encounters or whether a specific situation triggers anxiety.

Treatment with a combination of medicines and professional counselling is often effective for generalized social anxiety disorder (fear of most public interaction). Some people need treatment throughout their lives, while others may recover completely after a period of treatment with counselling and medicines

It is possible to overcome the fears associated with social anxiety disorder. Working through fears with a specific type of therapy—cognitive-behavioural therapy that includes exposure therapy—may be the best approach for treating your anxiety. It is important to continue professional counselling even if you are taking medicines to reduce anxiety.

Types of counselling most often used to treat social anxiety disorder include:

  • Cognitive-behavioural therapy, which helps you identify anxieties and the situations that provoke the anxiety. At first you may feel uncomfortable while addressing the feared situations, but it is an important part of your recovery. Several types of cognitive-behavioural therapy are used to treat social anxiety disorder, including:
    • Exposure therapy. You will be guided by a professional counsellor to imagine you are facing the feared situation until you no longer fear it, such as eating in public. Next, you may go with your counsellor to a public place and eat until, eventually, you can eat by yourself in public without fear.
    • Social skills training. This therapy helps you develop the skills you need in social situations through rehearsing and role-playing. Your anxiety is reduced as you become more comfortable with and prepared for the feared social situations.
    • Cognitive restructuring. This therapy helps you learn to identify and improve fearful thinking to help you better handle social situations. For more information, see:
      Click here to view an Actionset. Positive thinking: Stopping unwanted thoughts.
      Click here to view an Actionset. Anxiety: Using positive thinking.
      Positive Thinking With Cognitive-Behavioural Therapy.
    • Symptom management skills. This therapy teaches you how to reduce stress by controlling your breathing and other physical responses to anxiety.
  • Supportive therapy. This can include:
    • Education about the disorder.
    • Family therapy, to support loved ones affected by your condition.
    • Group therapy or support groups, to seek support from others also diagnosed with the disorder.

Medicines often used for chronic, severe, or generalized social anxiety disorder include:

  • Selective serotonin reuptake inhibitors (SSRIs), to relieve anxiety. SSRIs are often the first type of medicine used to treat generalized social anxiety disorder.3
  • Benzodiazepines, to relieve anxiety. They are fast-acting. But they may be habit-forming and are not generally used in those who have substance abuse problems.
  • Monoamine oxidase inhibitors (MAOIs), to relieve depression and anxiety. MAOIs have potentially serious side effects when they are taken with certain foods (such as some cheeses and red wine).
  • Beta-blockers, to reduce anxiety. Beta-blockers are sometimes used to treat physical symptoms of anxiety (such as tremors or rapid heart rate).
  • Venlafaxine, to help relieve anxiety and depression.

Ongoing treatment of social anxiety disorder usually includes continuing psychological counselling and regular checkups to monitor any medicines you may be taking. If professional counselling alone has not reduced your anxiety symptoms, medicines may be added to your treatment.

If your anxiety is triggered by many social situations (generalized), you may need continuous and prolonged treatment with a combination of counselling and medicines. During this time, your doctor will need to monitor your medicines. If one medicine doesn't work for you, you and your doctor may decide you should try another.

Treatment if the condition gets worse

With social anxiety disorder, it is possible to progress from debilitating fear of one social situation to having anxiety about all social encounters (generalized). If this occurs, additional treatment is needed that usually includes adding medicines and increasing the amount of professional counselling you receive.

You may also feel more anxious when you start professional counselling. This is because you are thinking about the situations that cause you fear and anxiety. After the situations have been identified, the fears can be addressed through counselling—especially cognitive-behavioural therapy which includes exposure therapy—gradually exposing you to your fear.

If you are taking medicines to treat social anxiety disorder, you will need regular checkups to monitor the medicines (such as selective serotonin reuptake inhibitors) and their potential side effects. The medicines may cause bothersome side effects that may make your anxiety worse at first. These side effects may get better over time. But if they do not, you may need to take a different medicine.

If social anxiety disorder is left untreated or improperly treated, it can cause debilitating distress that interferes with daily activities. Physical symptoms such as rapid heart rate, blushing, shortness of breath, and dizziness can occur and need to be assessed.

Other psychological conditions (such as depression or substance abuse) may accompany social anxiety disorder, and these conditions need additional treatment. If left untreated, the combination of social anxiety disorder and another psychological condition (such as depression) can increase the risk of attempted suicide.4

Home Treatment

While counselling and medicines are the most effective treatments for social anxiety disorder, you may wish to reduce your anxiety level at home by practicing a healthy lifestyle.

If you drink alcohol or use drugs in an attempt to gain confidence to face feared social situations, it is possible to develop substance abuse problems in addition to social anxiety disorder. For more information, see the topic Alcohol Abuse and Dependence or the topic Drug Abuse and Dependence.

Other Places To Get Help


Anxiety Disorders Association of Canada
Phone: 1-888-223-2252
Web Address:

The Anxiety Disorders Association of Canada is a non-profit corporation that promotes public and professional awareness of anxiety disorders, encourages research into the causes of anxiety disorders, and advocates for improved access to treatment and support for people experiencing anxiety disorders and their families.

Canadian Mental Health Association
595 Montreal Road
Suite 303
Ottawa, ON  K1K 4L2
Phone: (613) 745-7750
Fax: (613) 745-5522
Web Address:

The Canadian Mental Health Association (CMHA) promotes mental health and focuses on combatting mental health problems and emotional disorders. The organization offers workshops, pamphlets, newsletters, and other educational materials.

Canadian Psychological Association
141 Laurier Avenue West
Suite 702
Ottawa, ON  K1P 5J3
Phone: 1-888-472-0657
(613) 237-2144
Fax: (613) 237-1674
Web Address:

The Canadian Psychological Association is a professional organization that develops standards and principles for education, training, and practice in psychology.

Health Canada, Mental Health Promotion Unit
Web Address:

The Mental Health Promotion Unit of Health Canada helps maintain and improve the mental health and well-being of Canadians. The organization develops and implements policies, programs, and activities to promote mental health and address the needs of people with mental health problems or disorders.



  1. American Psychiatric Association (2000). Anxiety disorders. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 450–456. Washington, DC: American Psychiatric Association.
  2. Hollander E, Simeon D (2008). Social phobia (Social anxiety disorder). In RE Hales et al., eds., American Psychiatric Publishing Textbook of Psychiatry, 5th ed., pp. 536–546. Washington, DC: American Psychiatric Publishing.
  3. Wagstaff AJ, et al. (2002). Spotlight on paroxetine in psychiatric disorders in adults. Drugs, 62(4): 655–703.
  4. Schneier FR (2006). Social anxiety disorder. New England Journal of Medicine, 355(10): 1029–1036.
  5. Canadian Society for Exercise Physiology (2011). Canadian Physical Activity Guidelines For Adults. Available online:

Other Works Consulted

  • Zal HM (2003). Social phobia: Treatment issues. Psychiatric Times, 20(6): 80–83.
  • Merikangas KR (2005). Anxiety disorders: Epidemiology. In BJ Sadock, VA Sadock, eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 8th ed., vol. 1, pp. 1720–1728. Philadelphia: Lippincott Williams and Wilkins.
  • Shear MK (2003). Anxiety disorders. In DC Dale, DD Federman, eds. Scientific American Medicine, section 13, chap. 8. New York: WebMD.


By Healthwise Staff
Primary Medical Reviewer Kathleen Romito, MD - Family Medicine
Specialist Medical Reviewer Lisa S. Weinstock, MD - Psychiatry
Specialist Medical Reviewer Andrew Swan, MD, CCFP, FCFP - Family Medicine
Last Revised February 24, 2011

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