You feel anxious, tense, and nauseated. Your heart is pounding and your hands are shaking. Beads of sweat have gathered on your forehead. No, you are not being chased by a wild animal or a serial killer: You are simply engaged in social interaction; for example, you are introducing yourself to strangers at a party. If such anxious responses to common social situations sound painfully familiar to you, you might have a mental health condition called social phobia.
Social phobia (also known as social anxiety disorder) is a psychological disorder associated with evaluation apprehension in social situations. According to the latest diagnostic manual of the American Psychiatric Association, DSM-5, individuals with social phobia fear that their behavior or anxiety symptoms will be seen in a negative light or have negative consequences, and result in rejection, embarrassment, humiliation, etc.
Therefore, people with social phobia avoid social gatherings whenever possible. When forced to attend, they endure social situations with great distress; some even self-medicate (e.g., drink alcohol) before the event.
Social phobia is not the same as shyness—which is a personality trait and not a mental illness—but the two are related. For instance, a diagnosis of phobia is more likely when shyness is so severe that it interferes with functioning at school or work.
The prevalence of social phobia in adults is 7% (i.e. over 15 million people in the US). It affects more women and men. The onset is usually during adolescence.
Risks factors for social phobia
An important environmental risk factor for social anxiety disorder is parenting.
Specifically, social phobia is associated with lack of warmth, parental rejection, and in particular, parental overcontrol. This is not surprising since children with controlling parents are rarely allowed to explore the environment, learn how to solve problems on their own, and develop confidence in their abilities in social situations.
Other environmental risk factors include parental mental illness and adverse childhood events—sexual abuse, parental separation or divorce, being bullied by peers, etc.
Social phobia aggregates in families, which suggests a genetic component to the disorder. DSM-5 notes genetic and environmental factors for social phobia interact. For example, children who are temperamentally inhibited (i.e. fearful and shy) are more strongly affected by the anxious or controlling behaviors of their caregivers.
Social phobia is commonly treated with psychotherapy, medications, or a combination of the two.
Medications for social anxiety include a variety of drugs, like antidepressants, benzodiazepines (often for short-term use only), and beta-blockers (for performance anxiety).
First-line pharmacotherapy, however, usually consists of selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft) or paroxetine (Paxil); and serotonin and norepinephrine reuptake inhibitor (SNRI), such as venlafaxine (Effexor).
As for psychotherapy, there is strong research support for the effectiveness of cognitive-behavioral therapy (CBT), particularly exposure-based CBT.
The goal of psychological therapy for social phobia is to help patients challenge their erroneous beliefs, face their fears, and gradually approach social situations previously avoided. By staying in the feared social situation for a sufficiently long time, fear begins to subside and habituation can occur. With repeated exposure, patients learn:
- Common social situations are not dangerous.
- Social blunders are not a cause for panic (e.g., spilling one’s drink is not a “disaster”).
- What they fear the most (e.g., that people will think they are weird or stupid) is very unlikely to happen.
With practice, social interactions become less anxiety-provoking. And gradually, self-confidence in social situations increases.