Social anxiety disorder: Treatments and tips for managing this challenging condition

Many of us experience social anxiety from time to time, such as feeling uneasy before attending a cocktail party, or having "butterflies" before a presentation at work. It is normal to feel shy, nervous, or anxious in situations where we are outside of our comfort zone. But when this social anxiousness causes intense distress and starts to impact daily life, it could be indicative of a common condition called social anxiety disorder.

What is social anxiety disorder?

Social anxiety disorder (SAD), also called social phobia, is a common mental health disorder that is estimated to affect up to 7% of adults in the US every year. SAD is characterized by an extreme fear of social situations, from giving performances or speeches to attending a party. Those who suffer from SAD fear they will be scrutinized and humiliated by other people. This fear causes intense distress and can keep those affected from doing things they want to do.

Symptoms of social anxiety disorder

The main symptom of social anxiety disorder is an extreme fear of being scrutinized or embarrassed by other people. The fear is so great that it can cause a person to avoid social settings altogether.

There are also physical symptoms of anxiety that may accompany the fear. For example:

• feeling sweaty
• blushing
• having a rapid heartbeat
• trembling
• nausea
• feeling short of breath.

There are two types of social anxiety disorder. Most people with SAD have generalized social anxiety, meaning they fear all social situations, such as meetings or parties. In people with SAD, discomfort with social situations usually begins during the childhood or teenage years. Symptoms typically get worse over time. Symptoms of social anxiety disorder, as opposed to normal everyday nervousness, are constant and severe. This stress starts to affect relationships, jobs, daily routines, and overall quality of life.

Another type of SAD, performance-only social anxiety, is much less common. People with performance anxiety only fear times when they are the center of attention, such as giving a speech or a performance. Performance anxiety is not as impairing as generalized social anxiety and starts later in life.

Causes and risk factors

Social anxiety disorder is thought to be caused by both biological and environmental factors: an influence of both nature and nurture. Scientists believe SAD develops in response to a complex interaction of neural factors (meaning what's going on in the brain and nervous system), as well as psychosocial factors — the influence of life events, thoughts, and behaviors.

Causes of SAD related to the brain and nervous system include:

• a hyperactive nervous system. This means even small emotional triggers can result in the release of cortisol, a stress hormone in the body.
• decreased amounts of serotonin (a hormone involved in controlling mood) in the brain
• abnormal levels of glutamate and oxytocin in the brain. These hormones control how you respond in social settings and the intensity of anxiety symptoms.
• increased sensitivity in areas of the brain that control mood and emotion.

Psychosocial causes of SAD include early childhood trauma, such as a history of abuse and neglect, and childhood teasing. Overprotective and hypercritical parenting styles have also been associated with the disorder. These events influence how you interact with others and respond in social situations.

Other risk factors for development of social anxiety disorder include:

• female sex
• family history of social anxiety disorder
• shy personality
• demonstrating intense fear of new people and withdrawal from new situations during childhood.

How is social anxiety disorder diagnosed?

Your doctor can help distinguish social phobia from other anxiety disorders. He or she uses certain criteria to make the diagnosis. You may be diagnosed with social anxiety disorder if you:

• have extreme fear of social interactions (such as having a conversation, attending a party, or meeting new people), being observed (such as while eating or drinking), or performing in front of people (such as giving a speech)
• worry about being judged, embarrassed, or humiliated by other people
• avoid social situations because of your fear and anxiety
• feel that your social anxiety hinders your social and personal life.

These symptoms must be present for at least six months in order to be diagnosed with the condition.

If you are concerned you may have SAD, talk with your doctor. Because people who suffer from SAD are at increased risk of developing depression and other mental health problems, proper diagnosis and treatment are important.

Treatment options

The two most common treatment approaches for social anxiety disorder are cognitive behavioral therapy and prescription medications.

Cognitive behavioral therapy (CBT)

Cognitive behavioral therapy (CBT), a type of psychotherapy, is a first-line treatment for SAD. Trained professionals help you understand your triggers and learn coping strategies. The goal of CBT is to challenge your negative thoughts and learn behaviorial strategies to overcome them.

CBT can be done in an individual or group setting. Most people start with a weekly session and gradually decrease the frequency. Once your symptoms are well controlled, attending two to four sessions per year is recommended to prevent relapse.

Medications

Your doctor may prescribe medications to use alone or in combination with CBT. Antidepressants are usually prescribed first for social anxiety disorder. Even in people who do not have depression, these medications can help with symptoms of anxiety. The two most prescribed antidepressant drug classes are:

• selective serotonin reuptake inhibitors (SSRIs), such as paroxetine (Paxil) and sertraline (Zoloft)
• serotonin-norepinephrine reuptake inhibitors (SNRIs), such as venlafaxine (Effexor).

These medications help normalize the levels of hormones in the brain that contribute to SAD. It may take up to three months of treatment before you notice the full effect of these medications on your symptoms, but you should begin to notice some benefit before then.

If you suffer from performance anxiety, your doctor may prescribe an anti-anxiety medication to use on an as-needed basis, such as before you give a presentation. These include:

• beta blockers such as propranolol (Inderal)
• benzodiazepines such as clonazepam (Klonopin) and lorazepam (Ativan).

These medications provide short-term relief by slowing the heart rate and calming the nervous system, and can be taken as needed before an anxiety-producing situation.

Complementary strategies

Self-help techniques can be used to complement other treatments. Many of these measures are easy to implement and may provide benefits beyond building social confidence.

• Practice mindfulness. Mindfulness refers to the practice of being present without judgement. When you are mindful, you are aware of your surroundings and emotions but do not react to them. Research shows that mindfulness can improve symptoms of SAD and overall quality of life.
• Treat sleep problems. Studies have shown that people who suffer from social anxiety disorder have higher rates of sleep problems. Poor sleep is linked to worsening anxiety and may increase social avoidance over time. Consider creating a relaxing sleep routine and avoiding screen time later in the day to improve the quality of your sleep.
• Exercise. Regular exercise can help improve anxiety symptoms. Research suggests aerobic exercise is even more beneficial for social phobia when combined with CBT.
• Avoid or minimize alcohol and caffeine intake. Many people use alcohol as a way to lessen their social anxiety, but alcohol has been shown to worsen anxiety in the long run. Similarly, caffeine can cause or worsen anxiety, especially at higher doses.
• Find a support group. Talking through your fears and hearing the experiences of others can help to validate your emotions and reduce social isolation. It may also help enhance your coping skills as you practice vulnerability in a social setting. The Anxiety and Depression Association of America (ADAA) provides a list of virtual and in-person support groups, including one for individuals with social anxiety.