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Shyness (social anxiety disorder) - Introduction

NHS Choices Medical Reference

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Social anxiety disorder (social phobia) is a persistent fear about social situations and being around people. It's one of the most common anxiety disorders.

Much more than just "shyness", social anxiety disorder causes intense, overwhelming fear over what may just be an everyday activity like shopping or speaking on the phone. People affected by it may fear doing or saying something they think will be humiliating.

Social anxiety disorder disrupts normal life, interfering with social relationships and quality of life, and impairing performance at work or school.

It's generally more common in women than men and often starts in adolescence, or sometimes as early as childhood.

If you think you may have social anxiety disorder, don't be afraid to see your GP. It is a recognised condition that can be effectively treated.

What are the signs of social anxiety disorder?

A child with social anxiety disorder may cry a lot, freeze, or have tantrums. They may fear going to school and participating in class and school performances.

Teens and adults with social anxiety disorder may:

  • dread everyday activities such as:
    • meeting strangers
    • talking in groups or starting conversations
    • speaking on the telephone
    • talking to authority figures
    • working
    • eating or drinking with company
    • going shopping
  • have low self-esteem and feel insecure about their relationships
  • fear being criticised
  • avoid eye-to-eye contact
  • misuse drugs or alcohol to try to reduce their anxiety  

They may just fear one particular situation, such as speaking on the phone, or all social situations.

Panic attacks

Sometimes, the fear and anxiety of a social situation can build up to a panic attack, a period of usually just a few minutes when the person feels an overwhelming sense of fear, apprehension and anxiety.

There may be physical symptoms too, such as feeling sick, sweating, trembling and having heart palpitations.

These feelings reach a peak and then pass rapidly. They are alarming but cannot cause any physical harm.

Learn how to deal with panic attacks

Other mental health problems

Many people with social anxiety disorder will also have another mental health problem, such as depression, generalised anxiety disorder, panic disorder and/or post-traumatic stress disorder.

Some people may have a substance or alcohol misuse problem, as they use drugs or alcohol as a way of coping with their anxiety.

What are the causes?

We don't really know what causes social anxiety disorder, but it is likely to involve a combination of factors. Genes may play a role.

Also, the behaviour of parents may have an influence on whether their child will develop social anxiety disorder. According to Anxiety UK, people with the disorder have described their parents as:

  • overprotective
  • not affectionate enough
  • constantly criticising them and worrying they may do something wrong
  • overemphasising the importance of manners and grooming
  • exaggerating the danger of approaching strangers

Getting help

If you think you may have social anxiety disorder, don't be afraid to see your GP for help.

They'll make it as easy as possible for you to have a consultation with them. You might be offered an assessment over the phone if you find that easier, or an appointment at a time when the surgery is less crowded or busy, before or after normal hours. 

If your anxiety is severe, or you'd like your child to be assessed, your GP may be able to visit you at home. 

Getting a diagnosis

Your doctor may ask you some questions from a diagnostic questionnaire such as the Social Phobia Inventory (PDF, 522kb), Social Phobia Scale or Social Interaction Anxiety Scale. These give a score that indicates your level of anxiety in social situations (there are similar scales designed for use on children).

The sorts of questions your GP might ask you are:

  • do you/does your child tend to avoid social places or activities?
  • do you/does your child get scared about doing things with other people, like talking, eating and going to parties?
  • do you/does your child find it difficult to do things when others are watching?

Your GP will want to rule out other possible causes of your fear, such as generalised anxiety disorder or agoraphobia (a fear of being in situations where escape might be difficult, or where help wouldn't be available if things go wrong).

Learn more about phobias.

They'll also want to explore whether you have any other problems that would need to be treated separately, such as depression or a drugs or alcohol problem.

Read about the treatment of depression, treatment of drug misuse and treatment of alcohol misuse.

Treating social anxiety disorder in adults

Cognitive behavioural therapy

Cognitive behavioural therapy (CBT) is one of the most effective types of treatment for social anxiety disorder. You'll be offered individual CBT specially developed for social anxiety disorder, which is usually 14 sessions over approximately four months. 

Generally, CBT works by helping you identify unhelpful and unrealistic beliefs and behavioural patterns. You and your therapist work together to change your behaviour and replace unhelpful beliefs with more realistic and balanced ones.

CBT teaches you new skills and helps you understand how to react more positively to situations that would usually cause you anxiety.

Your therapy sessions may include education about social anxiety, video feedback to correct distorted views of yourself, and behavioural exercises and experiments.

Supported self-help

If you wish to try a different psychological therapy to CBT, you may be offered supported self-help. You may, for example, be offered a CBT-based book or computer programme to try over three to four months.

Learn more about self-help therapies.

Antidepressants

Some people may benefit from trying a type of antidepressant medication, usually an SSRI (selective serotonin reuptake inhibitor), either instead of or in combination with individual CBT.

SSRIs increase the level of a chemical called serotonin in your brain. They can be taken on a long-term basis.

As with all antidepressants, SSRIs can take several weeks to start working. You will usually be started on a low dose, which will gradually be increased as your body adjusts to the medicine.

You will probably be offered escitalopram or sertraline, and should initially see your GP every few weeks to check your progress and see if you are responding well to it.

Common side effects of SSRIs include:

  • nausea (feeling sick)
  • low sex drive 
  • blurred vision 
  • diarrhoea or constipation 
  • dizziness 
  • dry mouth 
  • loss of appetite 
  • sweating 
  • feeling agitated 
  • insomnia (problems sleeping)

When you and your GP decide that it is appropriate for you to stop taking your SSRI medication, you will gradually be weaned off it by slowly reducing your dose. Only stop taking medication when your GP specifically advises you to.

Psychotherapy

If all of the above interventions are not right for you, for whatever reason, you may be offered interpersonal psychotherapy or short-term psychotherapy specifically designed for social anxiety disorder.

Psychotherapy generally involves talking to a trained therapist either one-to-one, in a group, or with your wife, husband or partner. It allows you to look deeper into your problems and worries and deal with troublesome habits and a wide range of mental disorders.

Interpersonal psychotherapy aims to link social anxiety to relationship problem areas and address these. You'll probably be offered 16-20 sessions over four to five months.

Short-term psychotherapy for social anxiety disorder aims to improve your social skills, among other things, and encourage you to face feared social situations outside therapy sessions. It is normally 25-30 sessions over six to eight months. 

Treating social anxiety disorder in children

The psychological therapies offered to adults outlined above should also be considered for children aged 15 and older.

Group-based CBT should be offered for children and young people aged seven and older. Group sessions aim to gradually expose affected children to feared or avoided social situations, and train them in social skills. There may be eight to 12 sessions, each 90 minutes long.

For younger children, parent-driven CBT is more appropriate. Parents are trained to use CBT-based materials with their children, such as books designed to treat their child's anxiety problem.

More information

NICE 2013 guidelines: social anxiety disorder 

Medical Review: April 14, 2013
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