Overview
Social Anxiety Disorder (Social Phobia)
1. Topic Overview (Clinical Overview)
Summary
Social Anxiety Disorder (SAD) is characterised by an intense, persistent fear of being negatively evaluated, embarrassed, or humiliated in social or performance situations. The fear is disproportionate to the actual threat posed by the situation. Unlike shyness, SAD causes significant functional impairment – individuals may avoid social situations entirely, leading to isolation, poor academic/career attainment, and increased risk of depression and substance misuse. It is one of the most common anxiety disorders, typically beginning in adolescence, and often goes unrecognised for years.
Key Facts
- Definition: Marked fear or anxiety about social situations where the individual may be scrutinised by others.
- Prevalence: Lifetime prevalence ~7-13%. One of the most common psychiatric disorders.
- Onset: Typically adolescence (12-17 years). Rarely starts after age 25.
- Key Feature: Fear of negative evaluation, NOT fear of the situation itself.
- Treatment: CBT (Individual or Group) is first-line. SSRIs (Sertraline, Escitalopram) if CBT fails or unavailable.
- Comorbidity: High rates of Depression (50%), Alcohol Use Disorder (20-30%), other Anxiety Disorders.
Clinical Pearls
"It's not shyness": Shyness is a personality trait. SAD is a disorder that impairs function. The shy person may feel awkward at parties. The SAD patient cannot attend the party, or attends in terror and leaves early.
The Alcohol Trap: Many patients self-medicate with alcohol. Ask specifically: "Do you need a drink before social events?"
Performance-Only Subtype: Some patients only fear specific performance situations (e.g., public speaking, musical performance) but are otherwise socially comfortable. Beta-blockers (Propranolol) are particularly effective here.
Why This Matters Clinically
SAD is massively underdiagnosed because patients are too anxious to seek help, and clinicians may dismiss symptoms as "just being shy". Early intervention (especially CBT in adolescence) can prevent a lifetime of impairment and the cascade into depression and substance misuse.
2. Epidemiology
Incidence & Prevalence
- Lifetime Prevalence: 7-13% (varies by country).
- 12-Month Prevalence: 2-5%.
- Rank: 3rd most common psychiatric disorder (after Depression and Alcohol Use Disorder).
Demographics
| Factor | Details |
|---|---|
| Sex | Female > Male (1.5-2:1) in community. Males may present more to services (occupational pressure). |
| Age of Onset | Peak at 12-17 years. 75% of cases onset before age 15. |
| Chronicity | Chronic and unremitting if untreated. Mean duration of illness at presentation: 15-20 years. |
Risk Factors
| Factor | Notes |
|---|---|
| Genetic | 2-6x increased risk if first-degree relative affected. |
| Temperament | Behavioural inhibition in childhood (shy, withdrawn toddler). |
| Parenting | Overprotective or controlling parents. Modelling of social anxiety. |
| Adverse Events | Bullying, humiliation, rejection experiences. |
| Trauma | History of abuse (less specific than for PTSD but contributes). |
3. Pathophysiology
Neurobiology: The Fear Circuit
The brain's alarm system is overactive.
1. The Amygdala
- The Amygdala is the brain's threat detector.
- In SAD, the Amygdala is hyperactive in response to social stimuli (e.g., faces, especially angry or neutral faces).
- It triggers the "fear cascade" even when no real danger exists.
2. The Prefrontal Cortex (PFC)
- The PFC normally regulates the Amygdala (top-down control).
- In SAD, there is reduced PFC activity and poor connectivity to the Amygdala.
- The PFC cannot "calm down" the Amygdala's false alarm.
3. Neurotransmitters
- Serotonin: Hypofunction. SSRIs restore serotonin transmission in frontal circuits.
- GABA: May be reduced. Alcohol and benzodiazepines enhance GABA (hence self-medication risk).
- Dopamine: Some evidence of dopaminergic dysfunction (especially related to reward processing).
Cognitive Model (Clark & Wells)
How the mind maintains the fear.
- Anticipatory Processing: Before the event, the person replays past failures and predicts disaster ("I will say something stupid").
- In-Situation Processing:
- Self-focused Attention: Instead of engaging with others, attention turns inward ("Am I blushing?").
- Safety Behaviours: Actions to hide or minimise perceived threat (avoiding eye contact, speaking quietly, gripping hands).
- Post-Event Processing: Afterwards, the person "autopsies" the event, focusing on perceived flaws and confirming negative beliefs ("I knew I'd fail").
- Reinforcement: Avoidance of future situations prevents learning that the feared outcome doesn't happen (or isn't catastrophic).
4. Clinical Presentation
Core Features (DSM-5 / ICD-11)
- Marked fear or anxiety about social situations where the individual may be scrutinised.
- Fear of acting in a way (or showing anxiety symptoms) that will lead to negative evaluation.
- Social situations almost always provoke fear or anxiety.
- Social situations are avoided or endured with intense fear.
- The fear is disproportionate to the actual threat.
- The fear/avoidance is persistent (typically ≥6 months).
- Causes clinically significant distress or functional impairment.
- Not attributable to substance use, medical condition, or another mental disorder.
Feared Situations (Common Triggers)
| Category | Examples |
|---|---|
| Performance | Public speaking, presentations, musical performance. |
| Observation | Eating in public, writing while observed, using public toilets. |
| Interaction | Starting conversations, meeting new people, talking to authority figures. |
| Assertion | Expressing disagreement, returning items to a shop, making a complaint. |
| Intimacy | Dating, attending parties, being the centre of attention. |
Physical Symptoms (Autonomic Arousal)
| Symptom | Notes |
|---|---|
| Blushing | The hallmark symptom. Fear of blushing ("Erythrophobia") can itself become a focus. |
| Tremor | Hands, voice. |
| Sweating | Palms, face. |
| Palpitations | Racing heart. |
| Nausea / "Butterflies" | GI upset. |
| Dry Mouth | Difficulty speaking. |
| Mind going blank | Unable to think of what to say. |
| Avoidance of Eye Contact | Safety behaviour AND symptom. |
Subtypes
| Subtype | Features |
|---|---|
| Generalised SAD | Fear of most social situations (interaction + performance). More severe. Earlier onset. Worse prognosis. |
| Performance-Only SAD | Fear only in specific performance situations (e.g., public speaking). Function good otherwise. Beta-blockers often effective. |
5. Clinical Examination
Mental State Examination (MSE)
| Domain | Expected Findings |
|---|---|
| Appearance | May appear anxious, avoid eye contact. May dress to "blend in". |
| Behaviour | Quiet, hesitant, may defer to accompanying person. May blush during interview. |
| Speech | Quiet, short answers, may trail off. |
| Mood | "Anxious", "Nervous", "On edge". |
| Affect | Anxious, restricted. |
| Thought Content | Fears of negative evaluation, low self-worth ("I'm boring", "I have nothing interesting to say"). |
| Cognition | May be impaired by anxiety during testing. |
| Insight | Usually good – recognises fear is excessive but feels unable to control it. |
| Risk | Assess for depression, suicidal ideation, substance misuse. |
Differential Diagnosis
| Condition | Distinguishing Feature |
|---|---|
| Shyness / Normal Anxiety | No functional impairment. |
| Generalised Anxiety Disorder | Worry is diffuse, not focused on evaluation. |
| Panic Disorder | Panic attacks occur unexpectedly, not just in social situations. |
| Agoraphobia | Fear of being trapped/unable to escape, not fear of evaluation. |
| Avoidant Personality Disorder | Pervasive, long-standing pattern. High overlap with SAD. |
| Autism Spectrum Disorder | Social difficulties due to lack of intuition, not fear. May not desire social connection. |
| Depression | Social withdrawal secondary to low mood/anhedonia. |
6. Investigations
SAD is a clinical diagnosis. Investigations are to exclude other causes or assess comorbidity.
Standardised Questionnaires
| Scale | Description |
|---|---|
| Liebowitz Social Anxiety Scale (LSAS) | Gold standard. Rates fear + avoidance of 24 social situations. Scores severity. |
| Social Phobia Inventory (SPIN) | Self-report. 17 items. Quick screening tool. |
| GAD-7 | Screen for co-morbid generalised anxiety. |
| PHQ-9 | Screen for co-morbid depression (ESSENTIAL). |
| AUDIT-C | Screen for alcohol misuse. |
Physical Investigations
- Usually not required.
- Thyroid Function Tests: If hyperthyroidism suspected (tremor, weight loss, heat intolerance).
- Consider: Pheochromocytoma if paroxysmal symptoms + hypertension (rare).
7. Management
Management Algorithm (NICE CG159)
┌─────────────────────────────────────────────────────────────────────┐
│ SOCIAL ANXIETY DISORDER DIAGNOSED │
├─────────────────────────────────────────────────────────────────────┤
│ │
│ STEP 1: Psychoeducation & Self-Help │
│ ├── Validate condition. Explain it's common, treatable. │
│ ├── Recommend self-help resources (books, apps, online CBT). │
│ └── For mild symptoms, may be sufficient. │
│ │
│ STEP 2: Psychological Therapy (First-Line) │
│ ├── **Individual CBT** (Clark & Wells or Heimberg model). │
│ │ - Typically 14-16 sessions. │
│ │ - Key components: Cognitive restructuring + Exposure. │
│ └── **Group CBT** (Alternative if individual unavailable). │
│ │
│ IF CBT declined, unavailable, or failed: │
│ │
│ STEP 3: Pharmacotherapy │
│ ├── **First-line SSRI**: Escitalopram or Sertraline. │
│ │ - Start low, titrate. Trial for 12 weeks before switching. │
│ ├── **Second-line**: Venlafaxine (SNRI) or another SSRI. │
│ └── Pregabalin may be considered (off-label in some regions). │
│ │
│ ADJUNCTS: │
│ ├── **Beta-blocker (Propranolol)**: For Performance-Only SAD. │
│ │ - 10-40mg PRN 30-60 mins before event. │
│ └── **Short-term Benzodiazepine**: Avoid if possible (dependence). │
│ │
│ COMORBID DEPRESSION: │
│ └── Treat with SSRI (addresses both). │
│ │
└─────────────────────────────────────────────────────────────────────┘
First-Line: Cognitive Behavioural Therapy (CBT)
The evidence-based gold standard.
Core Components (Clark & Wells Model):
- Psychoeducation: Explain the cognitive model (vicious cycle).
- Attention Training: Shifting attention outwards instead of self-monitoring.
- Behavioural Experiments: Testing beliefs in real-life situations (e.g., "If I drop my guard, what actually happens?").
- Video Feedback: Recording themselves in social situations to challenge distorted self-image.
- Dropping Safety Behaviours: Deliberately stopping avoidance manoeuvres.
- Graded Exposure: Building an "exposure hierarchy" and systematically facing fears.
- Addressing Anticipatory/Post-Event Processing: Breaking the rumination cycle.
Drill Down: Exposure Hierarchy
Building a fear ladder.
| Step | Fear Rating (0-100) | Example Task |
|---|---|---|
| 1 | 10 | Say "hello" to a shop assistant. |
| 2 | 20 | Ask a stranger for the time. |
| 3 | 30 | Order food in a busy café, slightly modifying order. |
| 4 | 40 | Make small talk with a colleague for 5 minutes. |
| 5 | 50 | Attend a small social gathering (stay 30 mins). |
| 6 | 60 | Give a short presentation to 3 colleagues. |
| 7 | 70 | Introduce yourself to a group of strangers at a party. |
| 8 | 80 | Give a formal presentation to 20 people. |
| 9 | 90 | Speak up in a meeting and disagree with someone. |
| 10 | 100 | Be the focus of attention (e.g., give a best man speech). |
Pharmacotherapy
| Drug | Dose (Adult) | Notes |
|---|---|---|
| Escitalopram (SSRI) | 5-20mg OD | First-line. Start 5mg, titrate. |
| Sertraline (SSRI) | 50-200mg OD | First-line alternative. Good evidence. |
| Paroxetine (SSRI) | 20-50mg OD | Licensed for SAD. Shorter half-life, more discontinuation issues. |
| Venlafaxine (SNRI) | 75-225mg OD | Second-line. Useful if SSRI fails. |
| Propranolol | 10-40mg PRN | For Performance-Only SAD. Reduces tremor, palpitations. |
| Pregabalin | 150-600mg/day | Consider if SSRIs fail. Watch for dependence. |
Drugs to AVOID
| Drug | Reason |
|---|---|
| Benzodiazepines (Long-term) | High dependence risk. Avoid except short-term crisis. |
| MAOIs (Phenelzine) | Effective but dietary restrictions and interactions. Specialist use only. |
| Antipsychotics | No evidence. Side effects. |
8. Complications
Complications of Untreated SAD
| Complication | Details |
|---|---|
| Major Depression | 50% lifetime comorbidity. Develops after SAD onset. |
| Alcohol Use Disorder | 20-30% develop AUD. Alcohol reduces fear short-term but worsens it long-term. |
| Other Substance Misuse | Cannabis, benzodiazepine misuse. |
| Educational Underachievement | Inability to participate in class, presentations, group work. |
| Occupational Impairment | Avoiding promotions, interviews, meetings. Underemployment. |
| Relationship Difficulties | Difficulty forming friendships and romantic relationships. Increased loneliness. |
| Suicidal Ideation | Increased risk especially if comorbid depression. |
Drill Down: Occupational / Workplace Impact
The hidden cost of SAD.
- Underemployment: Patients often work below their capabilities to avoid social demands.
- Avoidance of Promotion: Fear of increased visibility, meetings, presentations.
- Sick Leave: Anxiety before meetings/presentations leads to absenteeism.
- Performance Anxiety: Reduces quality of work.
- Reasonable Adjustments (Equality Act 2010): SAD can be a disability. Examples:
- Not requiring attendance at large social events.
- Allowing written updates instead of oral presentations.
- Flexible working (reduces commuting stress).
- Quiet workspace.
Drill Down: Common Safety Behaviours
What patients DO to "survive" social situations.
| Safety Behaviour | Reasoning | Problem |
|---|---|---|
| Avoiding eye contact | "They won't notice me" | Prevents connection; appears rude. |
| Speaking quietly/quickly | "Get it over with" | Makes interaction worse; harder to hear. |
| Holding hands tightly | "Hide the tremor" | Increases tension; doesn't address fear. |
| Rehearsing what to say | "Prevent mistakes" | Sounds robotic; increases cognitive load. |
| Standing near exit | "I can escape" | Prevents engagement; doesn't learn safety. |
| Drinking alcohol | "Dutch courage" | Short-term fix; long-term dependence. |
| Avoiding eating in public | "They'll see me shake" | Limits social life; reinforces fear. |
Drill Down: Selective Mutism
A childhood variant.
- Definition: Consistent failure to speak in specific social situations (e.g., school) despite speaking normally at home.
- Association: Strong overlap with SAD. May be early manifestation.
- Treatment: CBT adapted for child. "Brave talking" exposure therapy. Involves school. SSRIs if severe.
9. Prognosis & Outcomes
Natural History
- Without treatment, SAD is typically chronic and unremitting.
- Spontaneous remission is rare.
- Mean duration of illness at first presentation often 15-20 years.
Treatment Outcomes
| Intervention | Expected Outcome |
|---|---|
| CBT | 50-70% response rate. Effects are durable (maintain gains long-term). |
| SSRI | 50-60% response rate. Relapse risk higher on discontinuation than CBT. |
| Combined CBT + SSRI | May be superior for severe cases. |
Prognostic Factors
| Good Prognosis | Poor Prognosis |
|---|---|
| Early intervention | Delayed treatment |
| Performance-only subtype | Generalised subtype |
| Good social support | Isolation |
| Engagement with CBT | Refusal of therapy |
| No comorbidity | Comorbid depression, AUD |
Special Populations: Children & Adolescents (CAMHS)
Early intervention is key.
- Presentation: School refusal, inability to participate in class, no friends, selective mutism (refusal to speak in certain settings).
- Treatment (NICE):
- First-Line: Individual CBT adapted for age.
- If CBT fails/unavailable: SSRIs (Fluoxetine often first choice in under-18s).
- School Involvement: Crucial. Liaise with teachers, SENCO for accommodations (e.g., not forced to read aloud, small group work).
- Family Work: Include parents in therapy. Address parental modelling of anxiety. Reduce accommodation of avoidance.
Drill Down: School Adaptations for SAD
| Accommodation | Rationale |
|---|---|
| Not forcing oral presentations initially | Avoids traumatic escalation. Re-introduce with exposure hierarchy. |
| Allowing small group work instead of whole class | Reduces scrutiny. |
| Exam room in smaller group | Reduces performance anxiety. |
| Providing written alternatives to oral answers | Allows academic participation without verbal fear. |
| Buddy system for transitions | Reduces isolation risk. |
Exam Scenarios (Common Vivas)
Scenario 1:
- Stem: 15-year-old female refuses to go to school. She fears answering questions in class. PHQ-9: 8, GAD-7: 12. What is the most likely diagnosis and first-line treatment?
- Answer: Social Anxiety Disorder. First-line: Individual CBT.
Scenario 2:
- Stem: 28-year-old male only fears public speaking at work. Otherwise socially comfortable. He has a major presentation next week. What subtype and treatment?
- Answer: Performance-Only SAD. Consider Propranolol 10-40mg PRN 1 hour before presentations.
Scenario 3:
- Stem: 22-year-old male reports needing "a few drinks" before any social event. He is increasingly isolated. What is the concern and approach?
- Answer: SAD with self-medication with alcohol. Screen with AUDIT-C. Address both: SSRI for SAD, consider alcohol brief intervention/referral.
Scenario 4:
- Stem: A patient with SAD asks about CBT. What are the key components you would describe?
- Answer: Psychoeducation, Attention training (shifting focus outwards), Behavioural experiments, Video feedback, Dropping safety behaviours, Graded exposure, Addressing rumination.
Scenario 5:
- Stem: Patient with SAD started Sertraline 50mg 4 weeks ago. They feel "no different". What is your advice?
- Answer: SSRIs take 6-12 weeks for full effect. Continue. If no response at 12 weeks, consider increasing dose or switching SSRI.
Triage: When to Refer (Primary Care to Secondary Care)
| Scenario | Action |
|---|---|
| Mild SAD, good function | Self-help, IAPT (NICE Step 1-2). |
| Moderate SAD, impaired function | Refer to IAPT for CBT. Consider SSRI. |
| Severe SAD, housebound, unable to work/study | Urgent referral to CMHT. SSRI + intensive CBT. |
| Comorbid severe depression, suicidal ideation | Urgent Psychiatric assessment. Safety plan. |
| SAD in under-18s | Refer to CAMHS (if moderate-severe). |
10. Evidence & Guidelines
Key Guidelines
| Guideline | Organisation | Year | Key Points |
|---|---|---|---|
| CG159: Social Anxiety Disorder | NICE | 2013 | CBT first-line. SSRIs if CBT fails. Self-help for mild. |
| APA Guidelines: Anxiety Disorders | APA | 2021 | CBT or SSRIs. Emphasis on comorbidity screening. |
Landmark Trials
1. Clark et al. (2006) - CREST Trial (Lancet)
- Finding: Individual CBT (Clark model) was superior to Group CBT and Fluoxetine.
- Impact: Established individual CBT as gold standard.
2. Liebowitz et al. (2005) - SSRI vs CBT
- Finding: Both CBT and Paroxetine effective. CBT had more durable effects at 1-year follow-up.
11. Patient/Layperson Explanation
What is Social Anxiety?
Social Anxiety Disorder is more than just being shy. It's an intense fear of being judged, embarrassed, or humiliated in social situations. This fear can be so strong that it stops people from doing ordinary things like joining conversations, eating in public, or giving presentations.
Why does it happen?
It's a combination of things: your genes, your brain chemistry, and your life experiences. The part of the brain that detects danger (the amygdala) becomes overactive, making social situations feel threatening even when they're not.
How is it treated?
- Talking Therapy (CBT): The most effective treatment. You learn to challenge negative thoughts and gradually face the situations you fear.
- Medication (SSRIs): Antidepressants can reduce anxiety. They are helpful if therapy isn't available or isn't enough on its own.
- Self-Help: Books, online courses, and apps based on CBT principles.
Will I always have this?
Many people with social anxiety can recover or significantly improve with treatment. The key is to seek help early and not let avoidance become a habit. CBT, in particular, gives you skills that last a lifetime.
Self-Help Resources (For Patients)
| Resource | Type | Notes |
|---|---|---|
| "Overcoming Social Anxiety and Shyness" (G. Butler) | Book | CBT-based self-help. Highly regarded. |
| "The Shyness and Social Anxiety Workbook" | Workbook | Exercises and techniques. |
| NHS Apps Library: "Headspace", "Calm" | App | Mindfulness-based, useful adjunct. |
| FearFighter (NHS IAPT) | Online CBT | Free online CBT for anxiety. |
| Social Anxiety UK | Website/Support Group | Peer support and information. |
Key Counselling Points (For Clinicians)
- Normalise: "Social anxiety is incredibly common – you are not alone."
- Validate: "It takes courage to talk about this. Many people suffer in silence."
- Explain Treatability: "This is one of the most treatable conditions. Most people improve significantly with the right help."
- Avoid Dismissiveness: Do NOT say "just try to relax" or "fake it till you make it".
- Address Alcohol: "Do you find you need a drink to cope with social events?" Screen carefully.
- Explain CBT: "We teach you to challenge your thoughts and gradually face your fears at your own pace."
- Set Expectations for SSRIs: "Medication takes 6-12 weeks to fully work. Side effects often settle."
Quality Markers: Audit Standards
| Standard | Target |
|---|---|
| Patients screened for depression (PHQ-9) at diagnosis | 100% |
| Patients screened for alcohol misuse (AUDIT-C) at diagnosis | >0% |
| Patients offered CBT as first-line | >0% (unless unavailable) |
| Patients on SSRIs reviewed at 2-4 weeks for tolerability | 100% |
| Patients referred to CAMHS (under-18s, moderate-severe) | 100% |
12. References
- NICE Guideline [CG159]. Social anxiety disorder: recognition, assessment and treatment. 2013. Link
- Clark DM, et al. Cognitive therapy versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. J Consult Clin Psychol. 2003. PMID: 12699027
- Clark DM, et al. Individual cognitive therapy vs group cognitive therapy vs fluoxetine. Lancet. 2006. (CREST Trial).
- Liebowitz MR, et al. Social Anxiety Disorder. N Engl J Med. 2000. PMID: 10761833
Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Clinical decisions should account for individual patient circumstances. If you are struggling with anxiety, please speak to a healthcare professional.