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It's normal to feel nervous in some social situations. Going on a date or giving a presentation may give you that feeling of having butterflies in your stomach, for instance. This isn't social anxiety disorder. In social anxiety disorder, everyday interactions cause extreme fear and self-consciousness. It may become impossible for you to eat with acquaintances or write a check in public, let alone go to a party with lots of strangers. If your life is disrupted by this kind of fear, you may have social anxiety disorder. If you or a loved one has social anxiety disorder, take heart. Effective treatment — often with cognitive behavioral therapy, medication and positive coping skills — can improve the symptoms of social anxiety disorder and open up new opportunities.

Alternative Names of Social Phobia are: Social Anxiety Disorder.

Complications of Social Phobia

Left untreated, social anxiety disorder can be debilitating. Your anxieties may run your life. They can interfere with work, school, relationships or enjoyment of life. You may be considered an "underachiever," when in reality it's your fears holding you back from excelling. In severe cases, you may drop out of school, quit work or lose friendships.

Social anxiety disorder can also lead to other health problems, such as:

  • Substance abuse
  • Excessive drinking
  • Depression
  • Suicide

Causes of Social Phobia

Like many other mental health conditions, social anxiety disorder likely arises from a complex interaction of environment and genes. Researchers continue to study possible causes, including:

  • Genes. Researchers are seeking specific genes that play a role in anxiety and fear. Social anxiety disorder seems to run in families. But evidence suggests that the hereditary component of this condition is due at least in part to anxious behavior learned from other family members.
  • Biochemistry. Researchers are exploring the idea that natural chemicals in your body may play a role in social anxiety disorder. For instance, an imbalance in the brain chemical serotonin (ser-oh-TOE-nin) could be a factor. Serotonin, a neurotransmitter, helps regulate mood and emotions, among other things. People with social anxiety disorder may be extra-sensitive to the effects of serotonin.
  • Fear responses. Some research suggests that 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.

Signs & Symptoms of Social Phobia

Social anxiety disorder is a chronic mental health condition that causes an irrational anxiety or fear of activities or situations in which you believe that others are watching you or judging you. You also fear that you'll embarrass or humiliate yourself. Social anxiety disorder can have emotional, behavioral and physical signs and symptoms.

Emotional and behavioral signs and symptoms of social anxiety disorder include:

  • Intense fear of being in situations in which you don't know people
  • Fear of situations in which you may be judged
  • Worrying about embarrassing or humiliating yourself
  • Fear that others will notice that you look anxious
  • Anxiety that disrupts your daily routine, work, school or other activities
  • Avoiding doing things or speaking to people out of fear of embarrassment
  • Avoiding situations where you might be the center of attention

Physical signs and symptoms of social anxiety disorder include:

  • Blushing
  • Profuse sweating
  • Trembling or shaking
  • Nausea
  • Stomach upset
  • Difficulty talking
  • Shaky voice
  • Muscle tension
  • Confusion
  • Palpitations
  • Diarrhea
  • Cold, clammy hands
  • Difficulty making eye contact

You may also be affected by:

  • Low self-esteem
  • Trouble being assertive
  • Negative self-talk
  • Hypersensitivity to criticism
  • Poor social skills

Worrying about having symptoms

When you have social anxiety disorder, you realize that your anxiety or fear is out of proportion to the situation. Yet you're so worried about developing social anxiety disorder symptoms that you avoid situations that may trigger them. And indeed, just worrying about having any symptoms can cause them or make them worse.

Diagnosis of Social Phobia

When you decide to seek treatment for symptoms of possible social anxiety disorder, you may have both a physical and psychological evaluation. The physical exam can determine if there may be any physical causes triggering your symptoms. There's no laboratory test to diagnose social anxiety disorder, however. Your doctor or mental health provider will ask you to describe your signs and symptoms, how often they occur and in what situations. He or she may review a list of situations to see if they make you anxious or have you fill out psychological questionnaires or self-assessments to help pinpoint a diagnosis. To be diagnosed with social anxiety disorder, a person must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Criteria for social anxiety disorder to be diagnosed include:

  • A persistent fear of social situations in which you believe you may be scrutinized or act in a way that's embarrassing or humiliating
  • These social situations cause you a great deal of anxiety
  • You recognize that your anxiety level is excessive or out of proportion for the situation
  • You avoid anxiety-producing social situations
  • Your anxiety or distress interferes with your daily living

Treatments of Social Phobia

Social anxiety disorder typically persists for life, often waxing and waning. But don't lose hope. Treatment can help you control symptoms and become more confident and relaxed in social situations. The two most effective types of treatment are medications and a form of psychotherapy called cognitive behavioral therapy. These two approaches are often used in combination.

Psychotherapy

Cognitive behavioral therapy improves symptoms in up to 75 percent of people with social anxiety disorder. This type of therapy is based on the idea that your own thoughts — not other people or situations — determine how you behave or react. Even if an unwanted situation won't change — you still have to give a presentation to management, for instance — you can change the way you think and behave in a positive way. In therapy, you learn how to recognize and change negative thoughts about yourself. Cognitive behavioral therapy may also include exposure therapy. In this type of therapy, you gradually work up to facing the situations you fear most. This allows you to become better skilled at coping with these anxiety-inducing situations and to develop the confidence to face them. You may also participate in skills training or role-playing to practice your social skills and gain comfort and confidence relating to others. Relaxation or stress management techniques may be included in your treatment plan.

First choices in medications

Several types of medications are used to treat social anxiety disorder. However, selective serotonin reuptake inhibitors (SSRIs) are generally considered the safest and most effective treatment for persistent symptoms of social anxiety. SSRIs your doctor may prescribe include:

  • Paroxetine (Paxil, Paxil CR)
  • Sertraline (Zoloft)
  • Fluvoxamine (Luvox, Luvox CR)
  • Fluoxetine (Prozac, Sarafem, others)

The serotonin and norepinephrine reuptake inhibitors (SNRI) drug venlafaxine (Effexor, Effexor XR) also may be used as a first-line therapy for social anxiety disorder. To reduce the risk of side effects, your doctor will start you at a low dose of medication and gradually increase your prescription to a full dose. It may take up to three months of treatment for your symptoms to noticeably improve.

Other medication options

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

  • Other antidepressants. You may have to try several different antidepressants to find which one is the most effective and has the fewest unpleasant side effects.
  • Anti-anxiety medications. A type of anti-anxiety medication called benzodiazepines (ben-zo-di-AZ-uh-penes) may reduce your level of anxiety. Although they often work quickly, they can be habit-forming. Because of that, they're often prescribed for only short-term use. They may also be sedating.
  • 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.

Stick with it

Don't give up if treatment doesn't work quickly. You can continue to make strides in therapy over several weeks or months. And remember that 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.

When to seek Medical Advice

If your fears or anxieties don't really bother you, you may not need treatment. For instance, you may not like making speeches but you do so anyway without being overwhelmed by anxiety. What sets social anxiety disorder apart from everyday nervousness is that its symptoms are much more severe and last much longer. If social anxiety disorder disrupts your life, causes you distress and affects your daily activities, call your doctor. Common, everyday experiences that may be difficult to endure when you have social anxiety disorder include:

  • Using a public restroom or telephone
  • Returning items to a store
  • Interacting with strangers
  • Writing in front of others
  • Making eye contact
  • Entering a room in which people are already seated
  • Ordering food in a restaurant
  • Being introduced to strangers
  • Initiating conversations

Social anxiety disorder symptoms can change over time. They may flare up if you're facing a lot of stress or demands. Or if you completely avoid situations that would usually make you anxious, you may not have symptoms. Although avoidance may allow you to feel better in the short term, your anxiety is likely to persist over the long term if you don't get treatment.


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