What Is Social Anxiety?
Recognizing Social Anxiety Disorder
- The mental anguish
- The physical distress
- The toll of avoidance
You’re Not Alone: Social Anxiety Affects Millions of People
You’re Not Crazy: Social Anxiety is Under-recognized, But It’s Real and Treatable

What Is Social Anxiety?

Social anxiety is a universal experience - one that’s necessary for survival. Perhaps it was easier to see its survival value in previous times when people had to band together to hunt food, build shelter, and ward off enemies. Social anxiety served the function of keeping people close to the “pack.” To veer off from the group was to risk death.

Even now, we’ve evolved in such a way that we’re motivated to remain a part of the group. We want to be accepted. We want to fit in. Thus, some social anxiety is normal and beneficial. After all, people who never care about others’ opinions are often not very pleasant to be around and have a completely different set of problems. 

But what exactly is social anxiety? It’s the experience of apprehension or worry that arises from the possibility, either real or imagined, that one will be evaluated or judged in some manner by others. We know, this definition is a mouthful. Perhaps it’s easier to explain what social anxiety is by listing some ordinary, everyday examples:

• embarrassment after spilling a drink
• “stage fright” before a big performance
• awkwardness while talking to someone you don’t know well
• nervousness during a job interview
• feeling jittery before giving a speech

These are common experiences almost everyone has experienced at one time or another. 

Since social anxiety is so universal, how do you know where your reactions fall? Are they within the range of normal? In other words, how can you tell when social anxiety becomes social anxiety disorder - a clinical diagnosis?

Recognizing Social Anxiety Disorder

Mental health professionals frequently use The Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV) to make diagnostic decisions. While it’s not a perfect system, diagnoses are important for a number of reasons. Without a name for the problem, research vital to understanding a problem and developing effective treatments for it simply doesn’t take place. On a practical level, if you try to receive mental health services for a problem that has no diagnosis, you’re not likely to get your health insurance to pay.

Let’s look at the specific criteria that must be met for a clinical diagnosis of social anxiety disorder. The DSM-IV says an individual with social anxiety disorder will:

• Show significant and persistent fear of social situations in which embarrassment or rejection may occur;
• Experience immediate anxiety-driven, physical reactions to feared social situations;
• Realize that his or her fears are greatly exaggerated, but feel powerless to do anything about them; and
• Often avoid the dreaded social situation - at any cost.

Someone may fear just one or a few social situations - public speaking being a common example - in which case the problem is referred to as a specific, or discrete social phobia. In contrast, generalized social anxiety disorder exists when a person is afraid and avoids many, or most social situations. 

Once these basic criteria are met for a diagnosis of social anxiety disorder, the individual symptoms can vary, but they generally fall into three categories: the cognitive or mental symptoms (what you think); the physical reactions (how your body feels); and the behavioral avoidance (what you do). Let’s look at these areas in more detail.

The mental anguish. People with social anxiety disorder are plagued with negative thoughts and doubts about themselves such as:

• Do I look okay?
• Am I dressed appropriately?
• Will I know what to talk about?
• Will I sound stupid, or boring?
• What if other people don’t like me?
• What if people notice I’m nervous?
• What if people think I’m too quiet?

The fear of possible rejection or disapproval is foremost in socially anxious people’s minds, and they scan for any signs that confirm their negative expectations. 

The pain that such pervasive, negative thinking patterns causes cannot be underestimated. Without appropriate intervention, these kinds of self-deprecating thoughts can lead to many other complications, including low self-esteem and deep feelings of inferiority.

The physical distress. Many people don’t realize that actual physical discomfort can accompany social anxiety. For example, someone may experience a panic attack in a social situation, in which they feel an acute and severe rush of fear and anxiety, accompanied by some or all of the following symptoms: shortness of breath, tightness or pain in the chest, racing heart, tingling or sensations of numbness, nausea, diarrhea, dizziness, shaking, and sweating. Panic attacks usually come on quite quickly, build to a peak in approximately five to 20 minutes, and then subside. It’s not uncommon to hear people say that their panic attacks last a lot longer; however, it’s probably the after-effects of the attack that they’re feeling, such as residual anxiety and increased alertness to bodily sensations, rather than the panic attack itself.

It’s important to note that many people are misdiagnosed with panic disorder when, in fact, they have social anxiety disorder. The key to knowing which of the two is the real problem lies in understanding the root fear. In panic disorder, the person fears the panic attack itself and often feels as if he or she is dying during such an episode.  In the case of social anxiety disorder, the fear is centered around the possibility that people might witness the panic attack and the resulting humiliation that would occur. Keep in mind, though, that some people have both panic disorder and social anxiety disorder.

Not everyone with social anxiety experiences full-blown panic attacks, though. Instead, some people are extremely bothered by and focused on a particular physical aspect of their condition. The most common examples include blushing, sweating, and shaking. 

Regardless of which particular physical symptoms someone experiences, anxiety is never pleasant. Having one’s body in a state of constant alert takes its toll and can lead to chronic fatigue, muscle tension, and sleep disturbances.  

The toll of avoidance. It’s human nature to avoid pain and suffering. From an evolutionary perspective, we’re “hard-wired” to either fight or flee from a dangerous situation. It’s no surprise then that people with social anxiety disorder tend to avoid or painfully bear situations that they believe will cause them harm. This might mean never attending a party or going to a restaurant. It might mean having few, if any, friends. It might mean never having an intimate relationship. It might mean dropping out of school or working at a job beneath one’s potential.

The consequences of avoidance will naturally vary depending upon the person and the severity of their anxiety.  In all cases, though, people with social anxiety disorder limit their choices out of fear. Decisions in life are based upon what they’re comfortable with rather than what they might truly want to do.

In addition to the outright avoidance of situations, people with social anxiety disorder may engage in other, more subtle methods of avoidance.  Examples of partial avoidance include using alcohol to cope with anxiety (drinking before a party in order to be able to go at all) and setting certain parameters on a social situation (only staying at the party a short period of time).  In avoiding threatening situations, you never realize that you actually can manage your anxiety and cope with your fears. In short, avoidance prevents learning.

You’re Not Alone: Social Anxiety Affects Millions of People

The most up-to-date information suggests that one in eight Americans will, at some point in his or her life, suffer from social anxiety disorder. This makes social anxiety disorder the third most common psychiatric disorder, after depression and alcoholism. Millions of people - from 10 to 19 million depending on the particular survey cited - are affected by social anxiety.

Who are these millions of people? The millions of people with social anxiety disorder are ordinary people, just like you and me. Included in these millions are not only men and women of all ages, but children and adolescents, as well.

In fact, social anxiety typically shows up before the age of 20, often during the teenage years. However, many people remember being shy and anxious even earlier - as far back as they can remember.

Current research suggests that several problems seen in the elementary grades, such as school phobia (refusing to go to school) and selective mutism (not speaking at school) are actually manifestations of social anxiety disorder. Because of the early age at which social anxiety can surface, it’s important to work toward increasing awareness and intervening as early as possible.

In addition to the age factor, many people want to know more about whom social anxiety disorder affects. In large studies of the general population, women outnumber men by a ratio of three to two. When looking at groups of people seeking treatment, however, the gender distribution is nearly equal. Social anxiety disorder appears to cut across racial and ethnic lines, although there may be some variations depending on cultural norms.

Some studies show that people with social anxiety disorder are less likely to be married and also are more likely to have occupational difficulties than others. These findings make sense when you think about the “normal” anxiety many people feel when they’re dating someone new or going on a job interview. Throw social anxiety disorder into the mix and you can probably imagine how trying these events can be. Despite these findings, we’ve worked with many individuals who function very well, people whom you’d never suspect had social anxiety. Still, what matters most is how someone feels on the inside. When someone is tormented by anxiety, even if it’s not readily apparent to others, it’s a problem worth addressing.

You’re Not Crazy: Social Anxiety is Under-recognized, But It’s Real and Treatable

Another crucial thing to know about having social anxiety disorder is you’re not “crazy.” You may, however, frequently feel like you’re crazy. A large part of this feeling comes from the general lack of awareness and understanding people have about social anxiety. 

Unfortunately, this lack of awareness and understanding extends to professional circles. It’s still unusual for healthcare professionals - physicians, psychiatrists, or psychologists - to make a primary diagnosis of social anxiety disorder. It’s frequently misdiagnosed as panic disorder or agoraphobia, or it’s not diagnosed at all. We have had very few people referred to us who have already been correctly diagnosed, much less been given the appropriate treatment.

In my own case, I was never diagnosed with social anxiety. The mental health professionals I saw focused on my depression and general tendency to worry too much. In fact, I had never heard mention of social anxiety or social phobia until I began my fellowship year at St. Louis University Medical Center’s Behavioral Medicine Department. There, while working in the Anxiety Disorders Center, I first learned about social anxiety and began to see patients who seemed to fight, perhaps to a more severe degree, the same fears I had. The people who came to the Center expressed so much relief when learning their problem had a name. It was real, and it was treatable.