Social anxiety disorder (social phobia)

Diagnosis

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

Your health care provider may determine a diagnosis based on:

• Physical exam to help assess whether any medical condition or medication may trigger symptoms of anxiety
• Discussion of your symptoms, how often they occur and in what situations
• Review of a list of situations to see if they make you anxious
• Self-report questionnaires about symptoms of social anxiety
• Criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

DSM-5 criteria for social anxiety disorder include:

• Persistent, intense fear or anxiety about specific social situations because you believe you may be judged negatively, embarrassed or humiliated
• 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

Treatment

Treatment depends on how much social anxiety disorder affects your ability to function in daily life. The most common treatment for social anxiety disorder includes psychotherapy (also called psychological counseling or talk therapy) or medications or both.

Psychotherapy

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 (CBT) is the most effective type of psychotherapy for anxiety, and it can be equally effective when conducted individually or in groups.

In exposure-based CBT, you gradually work up to facing the situations you fear most. This 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. Practicing exposures to social situations is particularly helpful to challenge your worries.

First choices in medications

Though several types of medications are available, selective serotonin reuptake inhibitors (SSRIs) are often the first type of drug tried for persistent symptoms of social anxiety. Your health care provider 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 health care provider 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 health care 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 the one that's 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.
• 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 psychotherapy over several weeks or months. Learning new skills to help manage your anxiety takes time. 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, challenge yourself by setting goals to approach social situations that cause you anxiety, take medications as directed, and talk to your health care provider about any changes in your condition.

Alternative medicine

Several herbal remedies have been studied as treatments for anxiety, but results are mixed. Before taking any herbal remedies or supplements, talk with your health care team to make sure they're safe and won't interact with any medications you take.

Lifestyle and home remedies

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

• Learn stress-reduction skills.
• 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.
• Participate in social situations by reaching out to people with whom you feel comfortable.

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 by setting daily or weekly goals in situations that aren't overwhelming. The more you practice, the less anxious you'll feel.

Consider practicing these situations:

• Eat with a close relative, friend or acquaintance in a public setting.
• Purposefully 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 about current events to identify interesting stories you can talk about.
• Focus on personal qualities you like about yourself.
• Practice relaxation exercises.
• Learn stress management techniques.
• Set realistic social 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. Most people around you either don't notice or don't care as much as you think, or they're more forgiving than you assume.

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

Coping and support

These coping methods may help ease your anxiety:

• Routinely reach out to friends and family members.
• Join a local or reputable internet-based support group.
• Join a group that offers opportunities to improve communication and public speaking skills, such as Toastmasters International.
• Do pleasurable or relaxing 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.

Preparing for your appointment

You may see your primary care provider, or your provider may refer you to a mental health professional. Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

• Situations you've been avoiding, especially those that are important to your functioning
• Any symptoms you've been experiencing, and for how long, including any symptoms that may seem unrelated to the reason for your appointment
• Key personal information, especially any significant events or changes in your life shortly before your symptoms appeared
• Medical information, including other physical or mental health conditions with which you've been diagnosed
• Any medications, vitamins, herbs or other supplements you're taking, including dosages
• Questions to ask your health care provider or a mental health professional

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

Some questions to ask your health care provider may 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?
• 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 during your appointment.

What to expect from your health care provider

Your health care provider or a mental health professional will likely ask you a number of questions. Be ready to answer them to reserve time to go over any points you want to focus on. Your health care provider may ask:

• Does fear of embarrassment cause you to avoid doing certain activities or speaking to people?
• Do you avoid activities in which you're 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 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 mental health 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 recreational drugs? If so, how often?