It's normal to feel nervous in some social situations. For example, going on a date or giving a presentation may cause that feeling of butterflies in your stomach. But in social anxiety disorder, also called social phobia, everyday interactions cause significant anxiety, fear, self-consciousness and embarrassment because you fear being scrutinized or judged by others.

Social anxiety disorder is a chronic mental health condition, but treatment such as psychological counseling, medication and learning coping skills can help you gain confidence and improve your ability to interact with others.

Feelings of shyness or discomfort in certain situations aren't necessarily signs of social anxiety disorder, particularly in children. Comfort levels in social situations vary, depending on the individual's personality traits and life experiences. Some people are naturally reserved and others are more outgoing.

In contrast to everyday nervousness, social anxiety disorder includes fear, anxiety and avoidance that interferes with your daily routine, work, school or other activities.

Emotional and behavioral symptoms

Signs and symptoms of social anxiety disorder can include persistent:

  • Fear of situations in which you may be judged
  • Worrying about embarrassing or humiliating yourself
  • Concern that you'll offend someone
  • Intense fear of interacting or talking with strangers
  • Fear that others will notice that you look anxious
  • Fear of physical symptoms that may cause you embarrassment, such as blushing, sweating, trembling or having a shaky voice
  • Avoiding doing things or speaking to people out of fear of embarrassment
  • Avoiding situations where you might be the center of attention
  • Having anxiety in anticipation of a feared activity or event
  • Spending time after a social situation analyzing your performance and identifying flaws in your interactions
  • Expecting the worst possible consequences from a negative experience during a social situation

For children, anxiety about interacting with adults or peers may be shown by crying, having temper tantrums, clinging to parents or refusing to speak in social situations.

Performance type of social anxiety disorder is when you experience intense fear and anxiety only during speaking or performing in public, but not in other types of social situations.

Physical symptoms

Physical signs and symptoms can sometimes accompany social anxiety disorder and may include:

  • Fast heartbeat
  • Upset stomach or nausea
  • Trouble catching your breath
  • Dizziness or lightheadedness
  • Confusion or feeling "out of body"
  • Diarrhea
  • Muscle tension

Avoiding normal social situations

Common, everyday experiences that may be hard to endure when you have social anxiety disorder include, for example:

  • Using a public restroom
  • Interacting with strangers
  • Eating in front of others
  • Making eye contact
  • Initiating conversations
  • Dating
  • Attending parties or social gatherings
  • Missing work or school
  • Entering a room in which people are already seated
  • Returning items to a store

Social anxiety disorder symptoms can change over time. They may flare up if you're facing a lot of stress or demands. Although avoiding anxiety-producing situations may make you feel better in the short term, your anxiety is likely to persist over the long term if you don't get treatment.

When to see a doctor

See your doctor or mental health provider if you fear and avoid normal social situations because they cause embarrassment, worry or panic. If this type of anxiety disrupts your life, causes severe stress and affects your daily activities, you may have social anxiety disorder or another mental health condition that requires treatment to get better.

Like many other mental health conditions, social anxiety disorder likely arises from a complex interaction of environment and genes. Possible causes include:

  • Inherited traits. Anxiety disorders tend to run in families. However, it isn't entirely clear how much of this may be due to genetics and how much is due to learned behavior.
  • Brain structure. A structure in the brain called the amygdala (uh-MIG-duh-luh) may play a role in controlling the fear response. People who have an overactive amygdala may have a heightened fear response, causing increased anxiety in social situations.
  • Environment. Social anxiety disorder may be a learned behavior. That is, you may develop the condition after witnessing the anxious behavior of others. In addition, there may be an association between social anxiety disorder and parents who are more controlling or protective of their children.

Social anxiety disorder is one of the most common mental disorders. It usually begins in the early to midteens, although it can sometimes start earlier in childhood or in adulthood.

Several factors can increase the risk of developing social anxiety disorder, including:

  • Family history. You're more likely to develop social anxiety disorder if your biological parents or siblings have the condition.
  • Negative experiences. Children who experience teasing, bullying, rejection, ridicule or humiliation may be more prone to social anxiety disorder. In addition, other negative events in life, such as family conflict or sexual abuse, may be associated with social anxiety disorder.
  • Temperament. Children who are shy, timid, withdrawn or restrained when facing new situations or people may be at greater risk.
  • New social or work demands. Meeting new people, giving a speech in public or making an important work presentation may trigger social anxiety disorder symptoms for the first time. These symptoms usually have their roots in adolescence, however.
  • Having a health condition that draws attention. Facial disfigurement, stuttering, Parkinson's disease and other health conditions can increase feelings of self-consciousness and may trigger social anxiety disorder in some people.

Left untreated, social anxiety disorder may run your life. Anxieties can interfere with work, school, relationships or enjoyment of life. Social anxiety disorder can cause:

  • Low self-esteem
  • Trouble being assertive
  • Negative self-talk
  • Hypersensitivity to criticism
  • Poor social skills
  • Isolation and difficult social relationships
  • Low academic and employment achievement
  • Substance abuse, such as drinking too much alcohol
  • Suicide or suicide attempts

Other anxiety disorders, major depressive disorder, substance abuse problems and certain other mental health disorders can often occur with social anxiety disorder.

You may start by seeing your family doctor. After your initial appointment, your doctor may refer you to a mental health provider who can help determine a diagnosis and create the right treatment plan for you.

What you can do

To prepare for your appointment, make a list of:

  • Any symptoms you've been experiencing, and for how long. Social anxiety disorder often first appears in the teens. Your doctor will want to know how your symptoms may have waxed or waned since they began.
  • Key personal information, especially any significant events or changes in your life shortly before your symptoms appeared. For example, your doctor will want to know if your social anxiety seemed to be triggered by meeting new people or a new work or social demand.
  • Medical information, including other physical or mental health conditions with which you've been diagnosed.
  • Any medications, vitamins or supplements you're taking and the dosages.
  • Questions to ask your doctor.

Ask a trusted family member or friend to go with you to your appointment, if possible, to help you remember key information.

During your initial appointment with your doctor, some questions to ask include:

  • What do you believe is causing my symptoms?
  • Are there any other possible causes?
  • How will you determine my diagnosis?
  • Should I see a mental health specialist?

If you're referred to a mental health provider, you may want to ask:

  • Is my condition likely temporary or chronic?
  • Are effective treatments available for this condition?
  • With treatment, could I eventually be comfortable in the situations that make me so anxious now?
  • Am I at increased risk of other mental health problems?
  • Are there any brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask other questions at any time during your appointment.

What to expect from your doctor

A doctor or mental health provider may ask:

  • Does fear of embarrassment cause you to avoid doing things or speaking to people?
  • Do you avoid activities in which you are the center of attention?
  • Would you say that being embarrassed or looking stupid is among your worst fears?
  • When did you first notice these symptoms?
  • When are your symptoms most likely to occur?
  • Does anything seem to make your symptoms better or worse?
  • How are your symptoms affecting your life, including your work and personal relationships?
  • Do you ever have symptoms when you're not being observed by others?
  • Have any of your close relatives had similar symptoms?
  • Have you been diagnosed with any medical conditions?
  • Have you been treated for other psychiatric symptoms or mental illness in the past? If yes, what type of therapy was most beneficial?
  • Have you ever thought about harming yourself or others?
  • Do you drink alcohol or use illegal drugs? If so, how often?

Your mental health provider will want to determine whether other conditions may be causing your social anxiety or if you have social anxiety disorder along with another mental health disorder.

When you decide to seek treatment for social anxiety disorder symptoms, your doctor may:

  • Perform a physical exam to determine if there may be any physical causes triggering your symptoms
  • Ask you to describe your signs and symptoms, how often they occur and in what situations
  • Review a list of situations to see if they make you anxious
  • Have you fill out psychological questionnaires to help pinpoint a diagnosis

Many experts use the criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, to diagnose mental conditions. This manual is also used by insurance companies to reimburse for treatment. Criteria include:

  • Persistent (typically 6 months or longer) fear of or intense anxiety about social situations in which you believe you may be scrutinized or act in a way that's embarrassing or humiliating
  • Avoidance of anxiety-producing social situations or enduring them with intense fear or anxiety
  • Excessive anxiety that's out of proportion to the situation
  • Anxiety or distress that interferes with your daily living
  • Fear or anxiety that is not better explained by a medical condition, medication or substance abuse

The two most common types of treatment for social anxiety disorder are medications and psychotherapy. These two approaches may be used in combination.

Psychotherapy

Psychological counseling (psychotherapy) improves symptoms in most people with social anxiety disorder. In therapy, you learn how to recognize and change negative thoughts about yourself and develop skills to help you gain confidence in social situations.

Cognitive behavioral therapy is the most common type of counseling for anxiety. In exposure-based cognitive behavioral therapy, you gradually work up to facing the situations you fear most. This therapy can improve your coping skills and help you develop the confidence to deal with anxiety-inducing situations. You may also participate in skills training or role-playing to practice your social skills and gain comfort and confidence relating to others.

First choices in medications

Several types of medications are used to treat social anxiety disorder. However, selective serotonin reuptake inhibitors (SSRIs) are often the first type of medication tried for persistent symptoms of social anxiety. Your doctor may prescribe Paroxetine (Paxil) or Sertraline (Zoloft).

The serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor XR) also may be an option for social anxiety disorder.

To reduce the risk of side effects, your doctor may start you at a low dose of medication and gradually increase your prescription to a full dose. It may take several weeks to several months of treatment for your symptoms to noticeably improve.

Other medications

Your doctor or mental health provider may also prescribe other medications for symptoms of social anxiety, such as:

  • Other antidepressants. You may have to try several different antidepressants to find one that's the most effective for you with the fewest side effects.
  • Anti-anxiety medications. Benzodiazepines (ben-zoe-die-AZ-uh-peens) may reduce your level of anxiety. Although they often work quickly, they can be habit-forming and sedating, so they're typically prescribed for only short-term use. If your doctor prescribes anti-anxiety medications, try taking them before you're in a social situation so you know how they'll affect you.
  • Beta blockers. These medications work by blocking the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs. Because of that, they may work best when used infrequently to control symptoms for a particular situation, such as giving a speech. They're not recommended for general treatment of social anxiety disorder. As with anti-anxiety medications, try taking them before you need them to see how they affect you.

Stick with it

Don't give up if treatment doesn't work quickly. You can continue to make strides in psychotherapy over several weeks or months. And finding the right medication for your situation can take some trial and error.

For some people, the symptoms of social anxiety disorder may fade over time, and medication can be discontinued. Others may need to take medication for years to prevent a relapse.

To make the most of treatment, keep your medical or therapy appointments, take medications as directed, and talk to your doctor about any changes in your condition.

Although social anxiety disorder generally requires help from a medical expert or qualified psychotherapist, you can try some self-help techniques to handle situations that are likely to trigger your symptoms:

  • Reach out to people with whom you feel comfortable
  • Join a local or Internet-based support group
  • Get physical exercise or be physically active on a regular basis
  • Get enough sleep
  • Eat a healthy, well-balanced diet
  • Avoid alcohol
  • Limit or avoid caffeine

Practice in small steps

First, consider your fears to identify what situations cause the most anxiety. Then gradually practice these activities until they cause you less anxiety. Begin with small steps in situations that aren't overwhelming.

Consider practicing these situations:

  • Eat with a close relative, friend or acquaintance in a public setting
  • Make eye contact and return greetings from others, or be the first to say hello
  • Give someone a compliment
  • Ask a retail clerk to help you find an item
  • Get directions from a stranger
  • Show an interest in others — ask about their homes, children, grandchildren, hobbies or travels, for instance
  • Call a friend to make plans

Prepare for social situations

At first, being social when you're feeling anxious is challenging. As difficult or painful as it may seem initially, don't avoid situations that trigger your symptoms. By regularly facing these kinds of situations, you'll continue to build and reinforce your coping skills.

These strategies can help you begin to face situations that make you nervous:

  • Prepare for conversation, for example, by reading the newspaper to identify an interesting story you can talk about.
  • Focus on personal qualities you like about yourself.
  • Practice relaxation exercises.
  • Adopt stress management techniques.
  • Set realistic goals.
  • Pay attention to how often the embarrassing situations you're afraid of actually take place. You may notice that the scenarios you fear usually don't come to pass.
  • When embarrassing situations do happen, remind yourself that your feelings will pass, and you can handle them until they do.

Avoid using alcohol to calm your nerves. It may seem like it helps, but in the long run it can make you feel more anxious.

Several herbal remedies have been studied as treatments for anxiety, but more research is needed to fully understand the risks and benefits. Here's what researchers know — and don't know:

  • Kava. Kava appeared to be a promising treatment for anxiety, but reports of serious liver damage — even with short-term use — caused several European countries and Canada to pull it off the market. The Food and Drug Administration has issued warnings but not banned sales in the United States. Avoid using kava until more rigorous safety studies are done, especially if you have liver problems or take medications that affect your liver.
  • Valerian. In some studies, people who used valerian reported less anxiety and stress, but in other studies, people reported no benefit. Discuss valerian with your doctor before trying it. While it is generally well-tolerated, there are a few case reports of people developing liver problems when taking preparations containing valerian. If you have been using valerian for a long time and want to stop using it, many authorities recommend that it be tapered down to prevent withdrawal symptoms.
  • Passionflower. A few small clinical trials suggest that passionflower might help with anxiety. In many commercial products, passionflower is combined with other herbs, making it difficult to distinguish the unique qualities of each herb. Passionflower is generally considered safe when taken as directed, but some studies found it can cause drowsiness, dizziness and confusion.
  • Theanine. This amino acid is found in green tea and some supplements. Preliminary evidence shows that theanine may make some people feel calmer, but there is limited evidence that it helps treat anxiety.

Before taking herbal remedies or supplements, talk to your doctor to make sure they're safe for you and won't interact with any medications you take.

These coping methods may help ease your anxiety:

  • Reach out to friends and family members
  • Join a local or Internet-based support group
  • Join a group that offers opportunities to improve communication and public speaking skills, such as Toastmasters International
  • Do pleasurable activities, such as hobbies, when you feel anxious

Over time, these coping methods can help control your symptoms and prevent a relapse. Remind yourself that you can get through anxious moments, that your anxiety is short-lived, and that the negative consequences you worry about so much rarely come to pass.

There's no way to predict what will cause someone to develop an anxiety disorder in the first place, but you can take steps to reduce the impact of symptoms if you're anxious:

  • Get help early. Anxiety, like many other mental health conditions, can be harder to treat if you wait.
  • Keep a journal. Keeping track of your personal life can help you and your mental health provider identify what's causing you stress and what seems to help you feel better.
  • Prioritize issues in your life. You can reduce anxiety by carefully managing your time and energy.
  • Avoid unhealthy substance use. Alcohol and drug use and even caffeine or nicotine use can cause or worsen anxiety. If you're addicted to any of these substances, quitting can make you anxious. If you can't quit on your own, see your doctor or find a treatment program or support group to help you.
Sep. 12, 2014