Shyness (social anxiety disorder)
Social anxiety disorder (social phobia) is a persistent and overwhelming fear of social situations. It's one of the most common anxiety disorders.
Social anxiety disorder is much more than "shyness". It can be intense fear and anxiety over simple everyday activities, such as shopping or speaking on the phone.
Many people sometimes worry about certain social situations, but someone with social anxiety disorder will worry excessively about them before, during and afterwards. They fear doing or saying something they think will be embarrassing or humiliating, such as blushing, sweating or appearing incompetent.
Social anxiety disorder is a type of complex phobia. This type of phobia has a disruptive or disabling impact on a person's life. It can severely affect a person's confidence and self-esteem, interfere with relationships and impair performance at work or school.
Social anxiety disorder often starts during childhood or adolescence and tends to be more common in women. It's a recognised disorder that can be effectively treated, so you should see your GP if you think you have it.
Signs of social anxiety disorder
A child with social anxiety disorder may cry more than usual, freeze, or have tantrums. They may fear going to school and taking part in classroom activities and school performances.
Teens and adults with social anxiety disorder may:
dread everyday activities, such as:
talking in groups or starting conversations
speaking on the telephone
talking to authority figures
eating or drinking with company
have low self-esteem and feel insecure about their relationships
fear being criticised
avoid eye-to-eye contact
misuse drugs or alcohol to try to reduce their anxiety
The National Institute for Health and Care Excellence (NICE) has produced guidance that includes more about the signs and symptoms of social anxiety disorder (PDF, 45kb).
The fear of a social situation can sometimes build up to a panic attack, where you feel an overwhelming sense of fear, apprehension and anxiety. This usually only lasts a few minutes.
You may also experience physical symptoms, such as feeling sick, sweating, trembling and heart palpitations. These symptoms often reach a peak before quickly passing. Although these type of symptoms can be alarming, they don't cause any physical harm.
Other mental health problems
Many people with social anxiety disorder will also have another mental health problem, such as:
generalised anxiety disorder
post-traumatic stress disorder
Some people may also have a substance or alcohol misuse problem because they use drugs or alcohol as a way of coping with their anxiety.
What causes social anxiety disorder?
As with many mental health conditions, social anxiety disorder is most probably the result of a combination of genetic and environmental factors.
Anxiety disorders often run in families, so you're more likely to have social anxiety disorder if a close family member is affected. However, the exact nature of the relationship between genetics and learned behaviour is uncertain.
The behaviour of parents may also have an influence on whether their child will develop social anxiety disorder. If you have worried or anxious parents, it can often affect your ability to cope with anxiety during childhood, adolescence and adulthood.
People with social anxiety disorder often describe their parents as:
not affectionate enough
constantly criticising them and worrying they may do something wrong
overemphasising the importance of manners and grooming
exaggerating the danger of approaching strangers
If you think you may have social anxiety disorder, you should try to see your GP for help.
Your GP should make it as easy as possible for you to have a consultation with them. For example, they may offer you an assessment over the phone if it's easier, or they may give you an appointment when the surgery is less busy - for example, before or after normal hours.
If your anxiety is severe, or you'd like your child to be assessed, your GP may be able to visit you at home.
Diagnosing social anxiety disorder
Your GP may ask you some questions from a diagnostic questionnaire, such as the Social Phobia Inventory, Social Phobia Scale or Social Interaction Anxiety Scale. These give a score that indicates your level of anxiety in social situations (there are similar scales designed for use on children).
The type of questions your GP might ask you are:
do you/does your child tend to avoid social places or activities?
do you/does your child get scared about doing things with other people, like talking, eating and going to parties?
do you/does your child find it difficult to do things when others are watching?
Your GP will want to rule out other possible causes of your fear, such as generalised anxiety disorder or agoraphobia (a fear of being in situations where escape might be difficult, or where help wouldn't be available if things go wrong).
They'll also want to explore whether you have any other problems that would need to be treated separately, such as depression or an alcohol or drugs problem.
Treating social anxiety disorder in adults
If you've been diagnosed with social anxiety disorder, there are a number of different treatment options available.
Cognitive behavioural therapy
Cognitive behavioural therapy (CBT) is one of the most effective treatments for social anxiety disorder. You may be offered individual CBT specially developed for social anxiety disorder. This usually involves 15 hourly sessions, plus one session that lasts 90 minutes, over approximately four months.
Generally, CBT works by helping you identify unhelpful and unrealistic beliefs and behavioural patterns. You and your therapist work together to change your behaviour and replace unhelpful beliefs with more realistic and balanced ones.
CBT teaches new skills and helps you understand how to react more positively to situations that would usually cause you anxiety.
Your therapy sessions may include learning about social anxiety, graduated exposure to feared social situations (which may include some homework), examining and modifying your core beliefs and helping prevent relapse.
If you wish to try a different psychological therapy, you may be offered supported self-help. For example, this could be in the form of a CBT-based book or computer programme to try over three to four months.
Some people may benefit from trying a type of antidepressant medication, usually a selective serotonin reuptake inhibitor (SSRI), either instead of or in combination with individual CBT.
SSRIs increase the level of a chemical called serotonin in your brain. They can be taken on a long-term basis.
As with all antidepressants, SSRIs can take several weeks to start working. You'll usually be started on a low dose, which will gradually be increased as your body gets used to the medicine.
Escitalopram or sertraline are the two SSRIs often prescribed to treat social anxiety disorder. If you're prescribed one of these, you'll initially be asked to see your GP every few weeks to check on your progress and see if you're responding well to it.
Common side effects of SSRIs include:
feeling agitated, shaky or anxious
feeling or being sick
diarrhoea or constipation
loss of appetite and weight loss
thirst or dry mouth
sleeping problems (insomnia)
low sex drive (loss of libido)
difficulty achieving orgasm during sex or masturbation
in men, difficulty obtaining or maintaining an erection (erectile dysfunction)
When you and your GP decide that it's appropriate for you to stop taking your SSRI medication, your dose will gradually be reduced. You should only stop taking your medication when your GP advises you to do so.
If all of the above interventions aren't right for you, for whatever reason, you may be offered interpersonal psychotherapy or short-term psychotherapy specifically designed for social anxiety disorder.
Psychotherapy generally involves talking to a trained therapist either one-to-one, in a group, or with your wife, husband or partner. It allows you to look deeper into your problems and worries and deal with troublesome habits and a wide range of mental disorders.
Interpersonal psychotherapy aims to link social anxiety to relationship problem areas and address these. You'll probably be offered 16-20 sessions over four to five months.
Short-term psychotherapy for social anxiety disorder aims to improve your social skills, and encourage you to face feared social situations outside therapy sessions. A course of treatment usually consists of 25-30 sessions that last 50 minutes, over a six to eight month period.
Treating social anxiety disorder in children
The psychological therapies offered to adults outlined above should also be considered for children aged 15 and older.
Both group-based and individual CBT should take into account how well the child or young person can process emotions and thoughts.
For individual CBT, the recommended number of sessions is eight to 12, each one lasting 45 minutes. Sessions will include gradually exposing the child to feared or avoided social situations and training them in social skills, rehearsing their use in social situations. There will also be training for parents.
Group-based CBT may be offered for children and young people aged seven and older. As with individual CBT, group sessions aim to gradually expose affected children to feared or avoided social situations, and train them in social skills. There may be eight to 12 sessions, each lasting 90 minutes.
Parent-driven CBT is more appropriate for younger children. Parents are trained to use CBT-based materials with their children, such as books designed to treat their child's anxiety problem.
You can read the NICE guidance about social anxiety disorder: recognition, assessment and treatment (PDF, 276kb) for further information about social anxiety disorder.