Social Anxiety Disorder

What social anxiety disorder is

Social anxiety disorder, also called social phobia, is a marked and persistent fear of being scrutinised in social situations.¹ Scrutinised means closely watched and judged by other people; marked and persistent mean strong and long-lasting. The worry centres on one thing: being judged, embarrassed, or thought badly of.

The feared situations include everyday interactions, being observed while eating or drinking, and performing in front of others.¹ The fear is of acting in a way, or showing visible anxiety, that others will judge harshly.

Almost always, these situations bring on the fear, and they are then avoided, or endured with real distress. To meet the diagnosis, the pattern is out of proportion to the situation and lasts six months or more.¹

Living with social anxiety is hard, and it is also common. It responds well to treatment, and reaching out early makes a real difference.⁸

More than shyness

Shyness is a normal personality trait, and in some societies it is viewed positively.¹ Many people feel nervous before speaking in public, and that does not make it a disorder.

Social anxiety disorder is considered only when the fear is clearly in excess of what the situation warrants. It must also cause significant distress, or interfere with work, study or relationships.⁴

The manuals do not set a fixed quantity of fear. The ICD-11 states it this way: the fear, anxiety and avoidance must be clearly in excess of what is normative for the specific cultural context. They must also result in significant distress or impairment.⁴

Normative means usual or expected for the people around you.

Coping is not the same as being unaffected, and a person may keep functioning. That still counts if functioning is only maintained through significant additional effort.⁴

The gap between the two is wide. Among people in the United States who call themselves shy, only about 12% meet the criteria for social anxiety disorder.¹ The disorder is the more intense and more disabling form of a common human experience.

How common it is, and who it affects

Social anxiety disorder is one of the more common anxiety conditions; how common depends on where the study was done.

Reported rates vary a great deal across the world:

The lower figures are not other countries applying a looser definition. The roughly 7% and the 0.5% to 2.0% band in the table come from the same diagnostic instrument, applied in different places.¹¹ Taking those two endpoints, the top of the range is roughly fourteen times the bottom.

The pattern is not only between countries. Within the United States, reported rates are higher in American Indians than in non-Hispanic white people. They are lower in people of Asian, Latino, African American and Afro-Caribbean descent.¹¹

Immigrant status is associated with significantly lower rates in both Latino and non-Latino white groups.¹¹ Read together, those figures say as much about where the diagnostic threshold is set as about how much fear people feel.

It usually starts young: the median age of onset is around 13 years. Roughly three-quarters of people first develop it between the ages of 8 and 15.³ A first onset in adulthood is less common.

In the community, the disorder is reported more often in women than in men.² In clinical samples the gender difference is not observed.⁵ That gap has been attributed to gender role expectations. Men with greater symptom severity are more willing to seek professional services.

What it can feel like

Social anxiety shows up in the mind, the body and in what a person does, and most people notice a mix of the three.

In the mind, there is intense fear of being judged, and a dread of embarrassment or rejection. The anxiety often starts days or weeks ahead of an event. Afterwards, many people go back over what happened, looking for mistakes.

In the body, the fear is physical. Blushing is a hallmark sign,¹ alongside a racing heart, sweating, trembling, nausea or a shaky voice. Some people fear that others will see these very symptoms.

In behaviour, the response is usually to avoid; some avoidance is obvious, like skipping parties or staying quiet in class. Some is subtle, such as over-preparing, avoiding eye contact, or rehearsing every word.¹

Self-medicating means using drink or drugs to manage symptoms without medical advice. Doing this to get through social situations is common, and it tends to make things worse over time.¹ None of this is weakness. It is a fear response.

The situations it centres on

The fear is not random: it clusters around moments where a person feels exposed to judgement.

Common triggers include meeting new people, speaking in a meeting, eating in front of others, dating, job interviews, and using a public toilet.¹ Everyday tasks can also be hard, such as phone calls, small talk, or asking for help in a shop.

Clinicians recognise a narrower, performance-only form. Here the fear is limited to speaking or performing in public.¹ It is often most disabling for people whose work depends on it, such as musicians, teachers or presenters.

What causes it, and who is more vulnerable

There is no single cause: social anxiety disorder comes from a mix of temperament, biology, experience and circumstance.

Some children are born more cautious. Behavioural inhibition, a tendency to be wary of new people and places, is a known temperament and risk factor.⁴ A fear of being judged negatively often occurs with it.¹

Anxiety disorders like this one involve altered communication between the amygdala, the hippocampus, and parts of the prefrontal cortex.⁶ Those are the brain areas that handle fear and its regulation.

Onset can follow a stressful or humiliating moment, such as being bullied.³ It can also build slowly, with no single starting point. Childhood adversity raises the risk, though no one event causes the disorder on its own.¹

How it is diagnosed

There is no blood test for social anxiety disorder; a mental health professional makes the diagnosis by talking with the person. The questions cover the fears themselves, and how far those fears reach.

The two main manuals agree closely. The American DSM-5-TR and the international WHO ICD-11 both centre the diagnosis on a persistent, out-of-proportion fear of social scrutiny. The feared situations are avoided, or endured with distress, and everyday life is impaired.¹⁴ The fear needs to have lasted several months, not days.

Part of the work is telling social anxiety apart from conditions it resembles:

• Ordinary shyness: nervousness that does not significantly impair a person's life.⁴
• Panic disorder: the fear is of the panic attacks themselves, not of being judged.¹
• Generalised anxiety disorder: worry spreads across many areas of life, not only social ones.⁴
• Autism spectrum disorder: social difficulty comes from communication differences rather than fear of judgement.⁴
• Avoidant personality disorder: a broader, more pervasive pattern of avoidance that often overlaps with social anxiety.¹

A clinician may also use a brief standardised questionnaire to gauge severity and track change over time.

The duration requirement is a general guide, not a strict count. Some degree of flexibility is allowed in applying it.¹¹

Culture and social anxiety

Both manuals build the person's setting into the criterion itself.

The ICD-11 is direct about this. The disorder should only be considered where the fear, anxiety and avoidance are clearly in excess of what is normative for the specific cultural context. Significant distress or impairment must follow as well.⁴

The DSM sets out who makes that judgement. People with social anxiety disorder often overestimate the negative consequences of social situations. So the judgement that a fear is out of proportion is made by the clinician, and the person's sociocultural context has to be taken into account. In certain cultures, behaviour that might otherwise appear socially anxious may be considered appropriate, and may be taken as a sign of respect.¹¹

Which situations count as demanding varies. Identifying the disorder may depend on working out which social situations are relevant to the person's cultural group. Being expected to dance in public in some Latin American cultures is an example. It then depends on whether the degree of anxiety falls outside the cultural norms for that person.⁵

Anxiety and avoidance of certain situations may be considered normative in some cultural groups. Public speaking or voicing dissent in some Asian cultures are examples. Such anxiety may not indicate a disorder, unless the fear is out of proportion to the actual danger the situation poses, considered in sociocultural context.⁵

Culture is not applied from the outside. The ICD-11 is explicit that to avoid stereotyping, people should be asked openly about the social situations that cause them excessive anxiety.⁵ Cultural context guides that conversation rather than settling it in advance.

The fear can centre on something different. Among Japanese people, and in related conditions among people in the Republic of Korea, taijin kyofusho may represent a form of social anxiety disorder. The fear there is that others will be offended by one's own behaviour: an inappropriate gaze or facial expression, blushing, body odour, loud bowel sounds.⁵

Some presentations are better captured by a different diagnosis.⁵ The same fear of making others uncomfortable may also be found in non-Asian settings.¹¹

A lower rate can be read in two ways. A collectivistic orientation places high value on the group over the individual. Societies of that kind may report high levels of social anxiety and a lower prevalence of the disorder.⁵ Prevalence does not always follow self-reported anxiety within the same culture.

The ICD-11 gives two possible reasons. Higher tolerance for socially reticent and withdrawn behaviour may leave people functioning better. Or the disorder may be recognised less often.⁵ It does not choose between them.

Descriptions written elsewhere carry their own norms. A description written for a British or American audience takes its examples, and the level of sociability it treats as ordinary, from those settings.

Two errors follow, in opposite directions. The first is reading your own ordinary reserve as a disorder, because a description written elsewhere treats it as unusual. The second is dismissing genuinely disabling anxiety, because the behaviour is unremarkable where you live and nobody around you names it. The ICD-11 note that a lower recorded prevalence may reflect lower recognition is why the second matters.⁵

The test that holds across countries is not how you compare with a described norm. It is whether the fear causes you significant distress. It also counts if the fear interferes with your personal, family, social, educational or working life, or if that life is only maintained through significant extra effort.⁴

Treatment: what actually helps

Social anxiety disorder responds well to treatment. Most people improve, especially when they start sooner rather than later.⁸

First-line means the treatment tried first. Talking therapy is the first-line treatment, and for this kind of fear it is often preferred to medication.⁷

• Cognitive behavioural therapy (CBT): the best-supported approach. It helps a person notice and test the harsh predictions behind the fear.
• Exposure: a core part of CBT. Feared situations are faced gradually, starting small, so avoidance becomes less necessary.
• Acceptance and commitment therapy: makes room for anxious feelings while a person acts on what matters to them.
• Social skills work: practising conversation and assertiveness, useful where anxiety has limited experience.

Medication can help, usually as a complement to therapy. The selective serotonin reuptake inhibitors (SSRIs) are an established first-line medication for social anxiety disorder.⁷ The serotonin-noradrenaline reuptake inhibitor (SNRI) venlafaxine is another medication a doctor may consider.

Other medicines have narrower roles. A beta-blocker can ease the physical signs of performance anxiety. Benzodiazepines are used only briefly and with care, because of the risk of dependence.

Which medicines are approved, and under what names, varies by country. Any decision is one to make with a doctor.

Some people do best with therapy and medication together.⁹ The right plan depends on the person, their preferences and how the anxiety affects them.

This is general information, not medical advice. Treatment decisions should be made with a qualified professional who knows your situation.

Helping yourself alongside treatment

Self-help is not a replacement for treatment, but it supports it well.

A few habits tend to help:

• Test the fearful thought: ask whether the worst prediction is realistic, and what actually tends to happen.
• Approach, in small steps: face manageable situations often, and stay long enough for the anxiety to settle.
• Steady the body: slow breathing and muscle relaxation reduce physical symptoms.
• Mind the basics: sleep, exercise and limiting caffeine all lower baseline anxiety.
• Go easy on alcohol: it may seem to help in the moment, but it tends to deepen social anxiety over time.¹⁰

Progress is rarely steady. Courage shown in facing a feared situation counts, whatever the outcome on the day.

Course, outlook and recovery

The outlook is genuinely hopeful; the course of the condition varies from person to person.

Left untreated, social anxiety disorder tends to persist. In the community, about 30% of people improve within a year, and around half within a few years.³ For many others without specific treatment, it continues for several years or longer.

In Western societies only about half of people with the disorder ever seek treatment. Those who do tend to seek it only after 15 to 20 years of symptoms.¹¹ That is a long time to live with a treatable condition, and effective treatment can change the course.

With support, most people find the fear eases. They take up chances they once avoided, at work, in study and in relationships. Social life becomes something to take part in rather than endure.⁸

When to reach out, and finding a therapist

It is worth speaking to someone when the fear starts shaping your choices.

The threshold is set against your own life. What matters is not whether your fear would look excessive to someone in another country.

Someone afraid of speaking in public would not receive the diagnosis. That holds if public speaking is not routinely encountered in their job or their studies, and they are not significantly distressed about it. If that same person avoids, or is passed over for, the job or the education they really want because of social anxiety, the impairment requirement is met.¹¹

Reach out when:

• you are avoiding work, study or events that matter to you;
• the distress is considerable, or it is exhausting you;
• you are turning to alcohol or other substances to cope;
• low mood or hopelessness has developed, which is common alongside social anxiety;¹
• you are having thoughts of harming yourself, in which case please use the crisis numbers at the top of this page now.

A family doctor can be a good first step and can refer you onward. Online therapy is another option, and it can feel less exposing at the start. When you are ready, you can find the right therapist through our directory.

Supporting someone who is struggling

If someone you care about lives with social anxiety, your patience matters more than the perfect words.

What helps:

• Take the fear seriously, without treating the person as fragile.
• Encourage small steps, and notice the effort rather than only the result.
• Gently support professional help if the anxiety is limiting their life.

What to avoid:

• Do not push someone into a feared situation before they are ready.
• Do not tell them to just relax, or dismiss the fear as silly.
• Do not speak for them in a way that removes every chance to practise.

Related terms

• Generalised anxiety disorder: persistent worry across many areas of life.
• Panic attacks: sudden surges of intense fear and physical arousal.
• Avoidant personality disorder: a broad, pervasive pattern of social inhibition and sensitivity to judgement.
• Selective mutism: a consistent failure to speak in specific social settings, often in children.
• Behavioural inhibition: a cautious temperament that is a risk factor for later social anxiety.

This article is for general information and is not a substitute for professional assessment or care. If social anxiety is affecting your life, consider reaching out to a qualified mental health professional in your country.

References

1. [1] American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). The DSM-5-TR defines social anxiety disorder (social phobia) as a marked, persistent (typically six months or longer) fear of one or more social situations involving possible scrutiny, in which the person fears acting or showing anxiety in a way that will be negatively evaluated; the situations are avoided or endured with intense fear, the fear is out of proportion to the actual threat and sociocultural context, blushing is a hallmark physical response, and a performance-only specifier applies when the fear is limited to speaking or performing in public. Only about 12% of people in the United States who describe themselves as shy meet full criteria for the disorder. doi.org/10.1176/appi.books.9780890425787.
2. [2] American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.), Social Anxiety Disorder, Prevalence. The 12-month prevalence of social anxiety disorder is approximately 7% in the United States, with lower estimates across much of the world clustering around 0.5% to 2.0% and a median European prevalence of about 2.3%; the 12-month prevalence for older adults ranges from about 2% to 5%, and rates are generally higher in females than males in community samples (odds ratios of about 1.5 to 2.2). doi.org/10.1176/appi.books.9780890425787.
3. [3] American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.), Social Anxiety Disorder, Development and Course. The median age at onset is 13 years, with about 75% of individuals developing the disorder between ages 8 and 15; onset may follow a stressful or humiliating experience or be insidious. In the community roughly 30% of people experience remission within one year and about 50% within a few years, while for approximately 60% of individuals without specific treatment the course runs several years or longer. doi.org/10.1176/appi.books.9780890425787.
4. [4] World Health Organization. (2024). Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders, 6B04 Social anxiety disorder. The ICD-11 requires a marked and excessive fear or anxiety that occurs consistently in one or more social situations (social interactions, being observed, or performing), a concern about being negatively evaluated, consistent avoidance or endurance with intense fear, symptoms persisting for an extended period (at least several months), and significant distress or impairment; it distinguishes the disorder from the normal personality trait of shyness and from developmentally normative fears, and notes behavioural inhibition as an associated temperament and risk factor. icd.who.int.
5. [5] World Health Organization. (2024). Clinical Descriptions and Diagnostic Requirements for ICD-11, 6B04 Social anxiety disorder, Culture-related and Sex/gender-related features. The ICD-11 notes that anxiety or avoidance of certain social situations may be considered normative in some cultural groups, that the culture-bound concept taijin kyofusho among Japanese people and related conditions in the Republic of Korea may represent a form of social anxiety disorder centred on the fear of offending others, and that societies with strong collectivistic orientations may report high levels of social anxiety yet lower prevalence of the disorder; prevalence is higher for women in community samples but gender differences are not observed in clinical samples, a disparity attributed to gender-role expectations around help-seeking. icd.who.int.
6. [6] Sadock, B. J., Sadock, V. A., & Ruiz, P. (Eds.). (2017). Kaplan & Sadock's Comprehensive Textbook of Psychiatry (10th ed.), Neuroimaging and the Neuroanatomical Circuits Implicated in Anxiety, Fear, and Stress-Related Disorders. Neuroimaging data from studies of panic disorder, specific phobias, social anxiety disorder and generalised anxiety disorder support models that depend on altered interactions among the amygdala, the hippocampus, and the medial and orbital prefrontal cortex.
7. [7] Sadock, B. J., Sadock, V. A., & Ruiz, P. (Eds.). (2017). Kaplan & Sadock's Comprehensive Textbook of Psychiatry (10th ed.), Anxiety disorder treatment. For phobic disorders the treatment of choice is behavioural (cognitive-behavioural) therapy rather than pharmacotherapy; among medications, the selective serotonin reuptake inhibitors are an established, indicated treatment for social anxiety disorder (social phobia).
8. [8] National Institute of Mental Health. (2023). Social Anxiety Disorder: More Than Just Shyness. An overview of social anxiety disorder describing its symptoms, typical onset, and the evidence that it is treatable, most often with psychotherapy (including cognitive behavioural therapy), medication, or a combination, and encouraging people to seek help from a health professional. nimh.nih.gov.
9. [9] Anxiety and Depression Association of America. (2023). Social Anxiety Disorder. A consumer overview of social anxiety disorder outlining its features and evidence-based treatment, including cognitive behavioural therapy, exposure, medication such as SSRIs, and the use of therapy and medication in combination, together with self-help and support strategies. adaa.org.
10. [10] Mayo Clinic. (2023). Social anxiety disorder (social phobia). A patient-facing overview of the symptoms, causes, complications, and self-care of social anxiety disorder, noting that the disorder is often accompanied by attempts to self-medicate with alcohol or other substances and advising professional help when fear and avoidance interfere with daily life. mayoclinic.org.
11. [11] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.), Anxiety Disorders: Social Anxiety Disorder. The DSM-5 gives a 12-month prevalence estimate of approximately 7% for the United States, with lower estimates seen in much of the world using the same diagnostic instrument and clustering around 0.5% to 2.0%; within the United States prevalence is higher in American Indians and lower in persons of Asian, Latino, African American and Afro-Caribbean descent compared with non-Hispanic whites, and immigrant status is associated with significantly lower rates in both Latino and non-Latino white groups. It states that individuals with the disorder often overestimate the negative consequences of social situations, so the judgement of being out of proportion is made by the clinician with the individual's sociocultural context taken into account, since in certain cultures behaviour that might otherwise appear socially anxious may be considered appropriate and seen as a sign of respect; that taijin kyofusho symptoms may also be found in non-Asian settings; that the duration criterion should be used as a general guide with allowance for some degree of flexibility; that the impairment criterion is met where a person avoids or is passed over for the job or education they really want because of social anxiety symptoms; and that only about half of individuals with the disorder in Western societies ever seek treatment, tending to do so only after 15 to 20 years of symptoms. doi.org/10.1176/appi.books.9780890425596.