What is social anxiety disorder

Social anxiety disorder, also known as social phobia, is a long-lasting and overwhelming fear of social situations. It’s normal to feel nervous in some social situations. For example, going on a date or giving a presentation may cause that feeling of butterflies in your stomach. But in social anxiety disorder, everyday interactions cause significant anxiety, fear, self-consciousness and embarrassment because you fear being scrutinized or judged by others.

• Social anxiety disorder means social anxiety affects your life and prevents you from participating in everyday social events in your personal, school or work life. It can be very distressing and have a big impact on your life, but there are ways to help you deal with it.

Social anxiety disorder is a common problem that usually starts during the teenage years. For some people it gets better as they get older, although for many it doesn’t go away on its own.

There are techniques for dealing with social anxiety for all levels of severity; learning about them could be helpful for you or someone you know.

It’s a good idea to see your doctor if you think you have social anxiety, especially if it’s having a big impact on your life.

It’s a common problem and there are treatments that can help.

Asking for help can be difficult, but your doctor will be aware that many people struggle with social anxiety and will try to put you at ease.

Your doctor will ask you about your feelings, behaviors and symptoms to find out about your anxiety in social situations.

If they think you could have social anxiety, you’ll be referred to a mental health specialist to have a full assessment and talk about treatments.

What is shyness or social anxiety?

People who suffer from shyness or social anxiety often believe that other people will think badly of them or that people will be judging them. They think that they are being closely observed by other people and they would like to give a good impression. At the same time they may fear that they are not as good as other people and can’t ‘come up to the mark’.

They suffer symptoms of anxiety such as tension, rapid heartbeat and light-headedness when they are in social situations. They may blush or stammer or be unable to speak.

Certain situations may seem to be more difficult than others. People may feel quite at ease speaking to people they know but feel very anxious with strangers. Eating or speaking in front of others can be very difficult, as can crowded places such as canteens, pubs, shops or queues.

Some people will begin to avoid difficult situations, often leading to great inconvenience, loss of social life or even career prospects. Other people will find ways of avoiding making a fool of themselves by carrying out ‘safety behaviors’. This can include not looking people in the eye so as not to draw attention to themselves, sitting down, holding on to something, staying close to someone they know, talking slowly and deliberately, keeping busy, moving quickly from conversation to conversation.

Social anxiety in children

Social anxiety can also affect children.

Signs of social anxiety in a child include:

• crying more than usual
• having frequent tantrums
• avoiding interaction with other children and adults
• fear of going to school or taking part in classroom activities, school performances and social events
• not asking for help at school
• being very reliant on their parents or carer

Speak to your doctor if you’re worried about your child. Your doctor will ask you about your child’s problems and talk to them about how they feel.

Treatments for social anxiety in children are similar to those for teenagers and adults, although medication isn’t normally used.

Therapy will be tailored to your child’s age and will often involve help from you (you may be given training and self-help materials to use between sessions). It may also take place in a small group.

Complications of social anxiety disorder

Left untreated, social anxiety disorder can run your life. Anxieties can interfere with work, school, relationships or enjoyment of life. Social anxiety disorder can cause:

• Low self-esteem
• Trouble being assertive
• Negative self-talk
• Hypersensitivity to criticism
• Poor social skills
• Isolation and difficult social relationships
• Low academic and employment achievement
• Substance abuse, such as drinking too much alcohol
• Suicide or suicide attempts

Other anxiety disorders and certain other mental health disorders, particularly major depressive disorder and substance abuse problems, often occur with social anxiety disorder.

Social anxiety disorder causes

It is not uncommon to feel nervous in some social situations. For some people, having to do a presentation at work or host a function where they become the center of attention can cause acute and overwhelming anxiety. Others find that meeting new people or having to confront someone about an issue can be distressing.

Social anxiety is something that very many people experience in a mild form but some people find themselves more seriously affected by it. It is not a sign of any more serious physical or mental illness, but can be extremely distressing.

Like many other mental health conditions, social anxiety disorder likely arises from a complex interaction of biological and environmental factors. Possible causes include

• Inherited traits. Anxiety disorders tend to run in families. However, it isn’t entirely clear how much of this may be due to genetics and how much is due to learned behavior.
• Brain structure. A structure in the brain called the amygdala 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.
• Environment. Social anxiety disorder may be a learned behavior — some people may develop the condition after an unpleasant or embarrassing social situation. Also, there may be an association between social anxiety disorder and parents who either model anxious behavior in social situations or are more controlling or overprotective of their children.

Social anxiety is often related to ‘low self esteem’ or a poor opinion of yourself, which may have begun in childhood. Some people seem to be naturally more anxious and have learned to worry. Others may have had stressful life events that have led them to feel like this.

Many people learn to manage their anxiety in these situations and develop ways of minimizing the physical symptoms. For someone with social anxiety disorder, these fears and physical symptoms may be much more extreme and they may need some help to manage.

Risk factors of developing social anxiety disorder

Several factors can increase the risk of developing social anxiety disorder, including:

• Family history. You’re more likely to develop social anxiety disorder if your biological parents or siblings have the condition.
• Negative experiences. Children who experience teasing, bullying, rejection, ridicule or humiliation may be more prone to social anxiety disorder. In addition, other negative events in life, such as family conflict, trauma or abuse, may be associated with social anxiety disorder.
• Temperament. Children who are shy, timid, withdrawn or restrained when facing new situations or people may be at greater risk.
• New social or work demands. Social anxiety disorder symptoms typically start in the teenage years, but meeting new people, giving a speech in public or making an important work presentation may trigger symptoms for the first time.
• Having an appearance or condition that draws attention. For example, facial disfigurement, stuttering or tremors due to Parkinson’s disease can increase feelings of self-consciousness and may trigger social anxiety disorder in some people.

What keeps social anxiety going?

Some people feel socially anxious when they are young but become more confident as they get older. For other people it can just go on and on and become a life-long problem. There can be a number of reasons for this:

1. If someone has an anxious personality they will be in the habit of feeling anxious and will have long-term beliefs that they are ‘no good in social situations’.
2. Avoidance of social situations keeps the person from becoming more used to social occasions. This stops them from learning that they can cope and feel fine. If a situation is avoided it feels even more difficult the next time they try and go into it. Some people have safety behaviors that don’t let them learn that they can cope. For example always sticking with a friend.
3. The person with social anxiety often holds an unpleasant image of how they look to others, in their mind. When mixing with others the anxiety tends to make them focus on themselves more. They think of this image, feel anxious and believe that they look terrible to others. They rarely look to see how the other person is really responding to them. They make negative guesses about what the other person is thinking and therefore never challenge their negative, unpleasant image of themselves.
4. ‘Fear of fear’ will sometimes take over so that the person will predict that they will be anxious in certain situations and expect certain symptoms, “I know I will go bright red when I speak”, “I won’t be able to get my words out” or “what if people notice my hands shaking”? These thoughts increase anxiety even before they go into the feared situation.

In summary – social anxiety is linked to low self-esteem and continues because people hold long-term beliefs that they are ‘no good in social situations’. These beliefs are never challenged because of avoidance safety behaviors and self focusing when faced with social situations.

Social anxiety disorder prevention

There’s no way to predict what will cause someone to develop an anxiety disorder, but you can take steps to reduce the impact of symptoms if you’re anxious:

• Get help early. Anxiety, like many other mental health conditions, can be harder to treat if you wait.
• Keep a journal. Keeping track of your personal life can help you and your mental health professional identify what’s causing you stress and what seems to help you feel better.
• Prioritize issues in your life. You can reduce anxiety by carefully managing your time and energy. Make sure that you spend time doing things you enjoy.
• Avoid unhealthy substance use. Alcohol and drug use and even caffeine or nicotine use can cause or worsen anxiety. If you’re addicted to any of these substances, quitting can make you anxious. If you can’t quit on your own, see your doctor or find a treatment program or support group to help you.

What are symptoms of social anxiety disorder

Social anxiety is more than shyness. It’s an intense fear, anxiety and avoidance that doesn’t go away and interferes your everyday activities, self-confidence, relationships and work or school life. Social anxiety disorder typically begins in the early to mid-teens, though it can sometimes start in younger children or in adults.

Many people occasionally worry about social situations, but someone with social anxiety feels overly worried before, during and after them.

Common anxiety symptoms such as excessive sweating, a pounding rapid heartbeat, nausea, shaking, blushing and stammering can be particularly stressful for someone with social anxiety disorder since these symptoms reinforce feelings of embarrassment and fear.

Many people with social anxiety also have other mental health issues, such as depression, generalized anxiety disorder or body dysmorphic disorder.

You may have social anxiety if you:

• dread everyday activities, such as meeting strangers, starting conversations, speaking on the phone, working or shopping
• avoid or worry a lot about social activities, such as group conversations, eating with company, and parties
• always worry about doing something you think is embarrassing, such as blushing, sweating or appearing incompetent
• find it difficult to do things when others are watching – you may feel like you’re being watched and judged all the time
• fear criticism, avoid eye contact or have low self-esteem
• often have symptoms such as feeling sick, sweating, trembling or a pounding heartbeat (palpitations)
• have panic attacks (where you have an overwhelming sense of fear and anxiety, usually only for a few minutes)

Emotional and behavioral symptoms

Signs and symptoms of social anxiety disorder can include persistent:

• Fear of situations in which you may be judged
• Worrying about embarrassing or humiliating yourself
• Intense fear of interacting or talking with strangers
• Fear that others will notice that you look anxious
• Fear of physical symptoms that may cause you embarrassment, such as blushing, sweating, trembling or having a shaky voice
• Avoiding doing things or speaking to people out of fear of embarrassment
• Avoiding situations where you might be the center of attention
• Having anxiety in anticipation of a feared activity or event
• Enduring a social situation with intense fear or anxiety
• Spending time after a social situation analyzing your performance and identifying flaws in your interactions
• Expecting the worst possible consequences from a negative experience during a social situation

For children, anxiety about interacting with adults or peers may be shown by crying, having temper tantrums, clinging to parents or refusing to speak in social situations.

Performance type of social anxiety disorder is when you experience intense fear and anxiety only during speaking or performing in public, but not in other types of social situations.

Physical symptoms

Physical signs and symptoms can sometimes accompany social anxiety disorder and may include:

• Blushing
• Fast heartbeat
• Trembling
• Sweating
• Upset stomach or nausea
• Trouble catching your breath
• Dizziness or lightheadedness
• Feeling that your mind has gone blank
• Muscle tension

Avoiding common social situations

Common, everyday experiences that may be hard to endure when you have social anxiety disorder include, for example:

• Interacting with unfamiliar people or strangers
• Attending parties or social gatherings
• Going to work or school
• Starting conversations
• Making eye contact
• Dating
• Entering a room in which people are already seated
• Returning items to a store
• Eating in front of others
• Using a public restroom

Social anxiety disorder symptoms can change over time. They may flare up if you’re facing a lot of stress or demands. Although avoiding situations that produce anxiety may make you feel better in the short term, your anxiety is likely to continue over the long term if you don’t get treatment.

Social anxiety disorder diagnosis

Your doctor 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 doctor 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 diagnostic criteria for social anxiety disorder include:

• A) Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech) .
  Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.
• B) The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated ( i.e., will be humiliating or embarrassing; will lead to rejection or offend others).
• C) The social situations almost always provoke fear or anxiety.
  Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
• D) The social situations are avoided or endured with intense fear or anxiety.
• E) The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
• F) The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
• G) The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• H) The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse , a medication) or another medical condition.
• I) The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
• J) If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from bums or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
• Specify if: Performance only: If the fear is restricted to speaking or performing in public.

Specifiers

Individuals with the performance only type of social anxiety disorder have performance fears that are typically most impairing in their professional lives (e.g.,  musicians, dancers, performers, athletes) or in roles that require regular public speaking. Performance fears may also manifest in work, school, or academic settings in which regular public presentations are required. Individuals with performance only social anxiety disorder do not fear or avoid nonperformance social situations.

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

Diagnostic Features

The essential feature of social anxiety disorder is a marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others. In children the fear or anxiety must occur in peer settings and not just during interactions with adults (Criterion A). When exposed to such social situations, the individual fears that he or she will be negatively evaluated. The individual is concerned that he or she will be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable. The individual fears that he or she will act or appear in a certain way or show anxiety symptoms, such as blushing, trembling, sweating, stumbling over one’s words, or staring, that will be negatively evaluated by others (Criterion B). Some individuals fear offending others or being rejected as a result. Fear of offending others-for example, by a gaze or by showing anxiety symptoms-may be the predominant fear in individuals from cultures with strong collectivistic orientations. An individual with fear of trembling of the hands may avoid drinking, eating, writing, or pointing in public; an individual with fear of sweating may avoid shaking hands or eating spicy foods; and an individual with fear of blushing may avoid public performance, bright lights, or discussion about intimate topics. Some individuals fear and avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or “shy bladder syndrome”).

The social situations almost always provoke fear or anxiety (Criterion C). Thus, an individual who becomes anxious only occasionally in the social situation(s) would not be diagnosed with social anxiety disorder. However, the degree and type of fear and anxiety may vary (e.g., anticipatory anxiety, a panic attack) across different occasions. The anticipatory anxiety may occur sometimes far in advance of upcoming situations (e.g., worrying every day for weeks before attending a social event, repeating a speech for days in advance). In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, or shrinking in social situations. The individual will often avoid the feared social situations. Alternatively, the situations are endured with intense fear or anxiety (Criterion D). Avoidance can be extensive (e.g., not going to parties, refusing school) or subtle (e.g., overpreparing the text of a speech, diverting attention to others, limiting eye contact).

The fear or anxiety is judged to be out of proportion to the actual risk of being negatively evaluated or to the consequences of such negative evaluation (Criterion E). Sometimes, the anxiety may not be j udged to be excessive, because it is related to an actual danger (e.g., being bullied or tormented by others) . However, individuals with social anxiety disorder often overestimate the negative consequences of social situations, and thus the judgment of being out of proportion is made by the clinician. The individual’s sociocultural context needs to be taken into account when this judgment is being made. For example, in certain cultures, behavior that might otherwise appear socially anxious may be considered appropriate in social situations (e.g., might be seen as a sign of respect) .

The duration of the disturbance is typically at least 6 months (Criterion F). This duration threshold helps distinguish the disorder from transient social fears that are common, particularly among children and in the community. However, the duration criterion should be used as a general guide, with allowance for some degree of flexibility. The fear, anxiety, and avoidance must interfere significantly with the individual’s normal routine, occupational or academic functioning, or social activities or relationships, or must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion G). For example, an individual who is afraid to speak in public would not receive a diagnosis of social anxiety disorder if this activity is not routinely encountered on the job or in classroom work, and if the individual is not significantly distressed about it. However, if the individual avoids, or is passed over for, the job or education he or she really wants because of social anxiety symptoms, Criterion G is met.

Associated features supporting diagnosis

Individuals with social anxiety disorder may be inadequately assertive or excessively submissive or, less commonly, highly controlling of the conversation. They may show overly rigid body posture or inadequate eye contact, or speak with an overly soft voice. These individuals may be shy or withdrawn, and they may be less open in conversations and disclose little about themselves. They may seek employment in jobs that do not require social contact, although this is not the case for individuals with social anxiety disorder, performance only. They may live at home longer. Men may be delayed in marrying and having a family, whereas women who would want to work outside the home may live a life as homemaker and mother. Self-medication with substances is common (e.g., drinking before going to a party). Social anxiety among older adults may also include exacerbation of symptoms of medical illnesses, such as increased tremor or tachycardia. Blushing is a hallmark physical response of social anxiety disorder.

Social anxiety disorder treatment

A number of treatments are also available for social anxiety.

The main options are:

• Cognitive behavioral therapy (CBT) with a therapist – therapy that helps you identify negative thought patterns and behaviors, and change them
• Supported self-help CBT – this involves using a CBT-based book or an online mental health service, with only occasional support from a therapist
• Antidepressant medication – usually a type of medicine called a selective serotonin reuptake inhibitor (SSRI), such as escitalopram or sertraline
• Psychotherapy – therapy that involves talking to a therapist about how your past influences what happens in the present and the choices you make

CBT is generally considered the best treatment, but other treatments may help if it doesn’t work or you don’t want to try it. Some people need to try a combination of treatments.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy (CBT) — a commonly used form of counseling for anxiety disorders — helps treat the symptoms in most people. It may be conducted in group sessions or as individual therapy.

The Royal College of Psychiatrists defines cognitive behavioral therapy as a way of talking about:

• How you think about yourself, the world and other people
• How what you do affects your thoughts and feelings.

They say that CBT can help you to change how you think (the cognitive part) and what you do (the behavioral part). These changes can help you to feel better. Unlike some of the other talking treatments, it focuses on the “here and now” difficulties. Instead of focusing on the causes of your distress or symptoms in the past, it looks for ways to improve your state of mind now.

If you are not sure you want to commit to a long course of sessions with a clinical psychologist, there are various resources on the Internet which will provide an introduction to CBT or even a course of computer-aided CBT sessions:

• Developed by the Australian National University, MoodGYM (https://moodgym.com.au/) is a fun, free interactive web program that teaches the principles of CBT using flashed diagrams and online exercises. MoodGYM (https://moodgym.com.au/) demonstrates the relationship between thoughts and emotions, and works through dealing with stress and relationship break-ups, as well as teaching relaxation and meditation techniques. It consists of five modules (why you feel the way you do, changing the way you think, changing ‘warped’ thoughts, knowing what makes you upset, assertiveness and interpersonal skills training), an interactive game, anxiety and depression assessments, downloadable relaxation audio, a workbook and feedback assessment. Scientific trials have shown that using two or more modules is linked to significant reductions in depression and anxiety symptoms. These benefits last after 12 months. MoodGYM has won several IT and health awards, and has over 1,000,000 users worldwide. MoodGYM (https://moodgym.com.au/)

• Living Life to the Full (https://llttf.com/) is a free online life skills course for people feeling distressed. It aims to provide easy access to CBT skills in a way that cuts through jargon. It helps you understand why you feel as you do, and to learn new ways of improving how you feel, by making changes in your thinking, activities, sleep and relationships. The course is based on the idea of helping you to help yourself. It is supported by a series of CBT self-help workbooks that can be used between the e-learning sessions. These encourage you to put what you are learning into practice, and to stop, think and reflect on what you are learning. Living Life to the Full (https://llttf.com/)

• FearFighter (http://www.fearfighter.com/) delivers CBT over the internet, useful for those who may be concerned about the stigma associated with seeing a therapist. Taking only three months to complete, with minimal telephone support, FearFighter helps you improve even if you have virtually no computer skills. You are encouraged to use FearFighter as often as you wish but for at least once a week. It helps you identify specific problems, work on realistic treatment goals, and monitor achievement of those goals by repeated self-exposure. You get scheduled brief helpline support to a total of one hour over 10 weeks. FearFighter helps you to work out exactly what brings on your fear, so you can learn how to face it until it subsides. This is called exposure therapy. It consists of nine steps that need to be worked through one by one to obtain the greatest benefits. Like a therapist, FearFighter asks you to return every week to report on how you’ve been doing. You can ask it to print out questionnaires and graphs of your progress. It guides you through CBT as much as a therapist does.
  • Step 1: Welcome to FearFighter – Introduces the system, asks you to rate your problem on the Fear Questionnaire (FQ) and Work & Social Adjustment Scale (WSA), and asks about suicidal feelings and alcohol misuse.
  • Step 2: How to Beat Fear – Explains the principles of CBT, with case examples. You are asked to keep a daily record of your triggers.
  • Step 3: Problem Sorting – Helps you identify your triggers, shows you scenarios relevant to your problem, and helps you personalise your triggers and rate them on a 0-8 scale.
  • Step 4: How to Get a Helper – Explains the value of recruiting a CBT co-therapist and gives hints on how to find one.
  • Step 5: Setting Goals – Guides you through the process of setting good goals and tests them. You record and rate these on the system and can print personalised homework diaries.
  • Step 6: Managing anxiety – Offers a menu of coping strategies for use during CBT homework.
  • Step 7: Rehearsing Goals – Guides you on how to practise personal coping strategies during both imagined and live CBT homework.
  • Step 8: Carrying On – Reviews progress with the help of graphs, allows new goals to be devised, and offers feedback and advice.
  • Step 9: Troubleshooting – Offers a menu of tips on overcoming common sticking points in treatment.

You may have found that when you avoid things that make you panic or feel uncomfortable, the situation tends to get worse and worse. FearFighter can teach you how to face your fear until you adapt and no longer want to run away from it. It helps you learn to face the things that make you panic, such that, with time, you’ll find that, one by one, they’ll get easier.

Self-exposure therapy guided by computer is as effective as clinician-guided therapy and both are superior to relaxation to improve phobia/panic. FearFighter has been tested in four clinical trials and is as effective as the best CBT therapists.

Approved by the National Institute of Clinical Excellence (NICE), free access can only be prescribed by your doctor in England and Wales. FearFighter (http://www.fearfighter.com/)

CBT for social anxiety disorder usually includes:

• cognitive therapy (identifying and challenging negative thinking patterns, and developing alternative ways of thinking and acting to reduce anxiety);
• exposure-based therapy (where you gradually work towards facing the social situations you fear); and
• social skills training.

CBT requires considerable practice, and successful treatment will involve exposure to some anxiety along the way. However, by regularly facing the social situations you fear you will continue to strengthen your coping skills and, with time, become less anxious.

Breathing and relaxation strategies are also often taught to help treat the physical symptoms of anxiety.

Support groups

There are several charities, support groups and online forums for people with social anxiety and other anxiety disorders

How you can overcome social anxiety

Social anxiety can be difficult to deal with, but there are things you can try yourself, as well as several effective treatments and support groups that can help you.

Things you can try

Self-help probably won’t cure your social anxiety, but it may reduce it and you might find it a useful first step before trying other treatments.

The following tips may help:

• try to understand more about your anxiety – think about what goes through your mind and how you behave in certain social situations to help you get a clearer idea of the problems you want to tackle
• replace your unrealistic beliefs with more rational ones – for example, if you feel a social situation went badly, think if there are any facts to support this or if you’re just assuming the worst
• don’t think too much about how others see you – pay attention to other people instead and remember that your anxiety symptoms aren’t as obvious as you might think
• start to do activities that you would normally avoid – this can be tough at first, so start with small targets and work towards more feared activities gradually.

Understanding social anxiety

You may already by now have some ideas about what is causing your social anxiety. In order to understand it even better it may help you to try the following exercises:

• Think back to number of actual occasions that you found difficult over the last month then try and understand in more detail what was happening.
• Try and draw out your own vicious cycle of social anxiety – think of a recent social situation you found difficult.

If you can’t get a clear picture of your difficulties by thinking back, then it may help to keep a social anxiety diary. For one or two weeks keep a diary of when you feel anxious and what was going on at the time Keep a note each time of thoughts, physical symptoms, avoidance or safety behaviors, what you did and what your thoughts were afterwards.

Once you have a much clearer view of your own problems then you can begin to tackle the various parts of it and break the vicious circle of anxiety.

How can I reduce my negative thoughts, beliefs and images?

You have seen the role that thoughts have in keeping going the vicious circle of social anxiety. Thoughts can be words or they can be pictures in your mind. The following examples may help you to identify your own thoughts and pictures.

It may help to write down your own negative thoughts and images:

Once you know what they are you can begin to fight back and break the vicious circle.

In particular ask yourself if you have any of the following unhelpful thinking styles?

1. Am I mind-reading? e.g. “he/she thinks I’m boring”.
   In this case you don’t tend to find out or look to see what the other person really thinks. You believe your own negative views and blame it on the other person! e.g. “he doesn’t like me”. This is a very common problem for socially anxious people who assume their own negative view of themselves is also held by others.
2. Am I fortune-telling or catastrophizing? e.g. “it’s going to be a disaster, everyone will be laughing at me”.
3. Am I personalizing this? e.g. “they are all laughing, they must be talking about me” or “he looks tense it’s probably because he thinks he’s got to sit with me”.
4. Am I focusing only on the bad things e.g. “I really clammed up when I tried to speak to Jane” (ignoring that you had been able to speak easily to other people that day).

These unhelpful thinking styles mean that you don’t view yourself in social situations in a fair way. It may help to begin to try and answer back to find a fairer picture of what is happening. A good way of doing this is to write two columns – one for your thoughts that make you anxious and the other for a fairer more balanced thought, e.g:

Write down some of your thoughts now and write as many answers or balanced thoughts as you can. Look out for unhelpful thinking. This question might also help, “what would you say to a friend who was thinking that way”?

The aim is to get faster at catching these anxious thoughts and answering back almost instantly. It takes a lot of practice, but really does work.

How can I stop thinking that everyone is looking at me?

Research has shown that people with social anxiety tend to show an increase in ‘self processing’ in situations where they feel anxious. This means that:

• They concentrate a lot on their own body, especially looking for the symptoms of anxiety, e.g. shaking, sweating, red face, difficulties in speaking.
• They focus on their own thoughts with the negative images and views of themselves mentioned in the previous section.
• They have a strong negative image of how they look to others.
• The image is not the way they appear to others.
• They feel that they are the center of attention and all this attention is critical and negative.

Ways of reducing self focus are:

• Do not ‘monitor’ yourself in social situations, pay attention to what is happening around you:
  • look at other people and the surroundings;
  • really listen to what is being said (not to your own negative thoughts);
  • don’t take all the responsibility for keeping conversations going – silence is OK, other people will contribute.
• Begin to recognize that your physical symptoms of anxiety are not as noticeable as you think. Focus on your own body less and you’ll stop noticing these symptoms.
• Begin to look at other people to see if they show symptoms of anxiety.
• Begin to believe that people will not dislike you because you are anxious – would you dislike someone just because they were anxious?
• Begin to note that you are not the central focus of everyone’s attention.

Try out some of these ideas and see if they work for you. Begin to challenge some of your long term beliefs that you are no good in social situations.

How can I change my own behavior?

Changing what you do is probably the most helpful way to overcome social anxiety. We have already talked of how avoidance and safety behaviors keep social anxiety going. It will help to be clear which behaviors you need to tackle. The following example may help you to pinpoint your own avoidance and safety behaviors.

All of these types of avoidance and safety behaviors keep the problem going. It is important to:

• Gradually reduce the avoidance and begin to face the things you fear.
• Begin by making a list of all the avoidance and safety behaviors that you aim to prevent.
• Next make an ‘anxiety ladder’ where those targets easiest to achieve are at the bottom and your most difficult situations are at the top.

You will need to practise regularly to manage thoughts and physical symptoms of anxiety using the skills you have learned in the other sections. You will gradually learn that you can cope and feel comfortable in social situations. It is worth remembering that many other people feel anxious in social situations too, it just doesn’t show. You are not the only one.

How can I reduce my physical symptoms?

Reducing Physical Symptoms

Relaxation

In order to reduce the severity of physical symptoms it is useful to ‘nip them in the bud’, by recognizing the early signs of tension.

Once you have noticed early signs of tension you can prevent anxiety becoming too severe by using relaxation techniques. Some people can relax through exercise, listening to music, watching TV, or reading a book.

For others it is more helpful to have a set of exercises to follow. Some people might find relaxation or yoga classes most helpful, others find CDs useful.
You can obtain a relaxation CD from your doctor and there are also a wide number of relaxation CDs available in the shops.

Relaxation is a skill like any other which needs to be learned, and takes time. The following exercise teaches deep muscle relaxation, and many people find it very helpful in reducing overall levels of tension and anxiety.

Deep muscle relaxation

It is helpful to read the instructions first and to learn them eventually. Start by selecting quite a warm, comfortable place where you won’t be disturbed.
Choose a time of day when you feel most relaxed to begin with. Lie down, get comfortable, close your eyes. Concentrate on your breathing for a few minutes, breathing slowly and calmly: in two-three and out two-three. Say the words “calm” or “relax” to yourself as you breathe out. The relaxation exercise takes you through different muscle groups, teaching you firstly to tense, then relax. You should breathe in when tensing and breathe out when you relax. Starting with your hands, clench one fist tightly. Think about the tension this produces in the muscles of your hand and forearm.

Study the tension for a few seconds and then relax your hand. Notice the difference between the tension and the relaxation. You might feel a slight tingling. This is the relaxation beginning to develop.

Do the same with the other hand.

Each time you relax a group of muscles think how they feel when they’re relaxed. Don’t try to relax, just let go of the tension. Allow your muscles to relax as much as you can. Think about the difference in the way they feel when they’re relaxed and when they’re tense. Now do the same for the other muscles of your body. Each time tense them for a few seconds and then relax. Study the way they feel and then let go of the tension in them.

It is useful to stick to the same order as you work through the muscle groups:

• Hands – clench fist, then relax.
• Arms – bend your elbows and tense your arms. Feel the tension especially in your upper arms. Remember, do this for a few seconds and then relax.
• Neck – press your head back and roll it from side to side slowly. Feel how the tension moves. Then bring your head forward into a comfortable position.
• Face – there are several muscles here, but it is enough to think about your forehead and jaw. First lower your eyebrows in a frown. Relax your forehead. You can also raise your eyebrows, and then relax. Now, clench your jaw, notice the difference when you relax.
• Chest – take a deep breath, hold it for a few seconds, notice the tension, then relax. Let your breathing return to normal.
• Stomach – tense your stomach muscles as tight as you can and relax.
• Buttocks – squeeze your buttocks together, and relax.
• Legs – straighten your legs and bend your feet towards your face. Finish by wiggling your toes.

You may find it helpful to get a friend to read the instructions to you. Don’t try too hard, just let it happen.

To make best use of relaxation you need to:

• Practice daily.
• Start to use relaxation in everyday situations.
• Learn to relax without having to tense muscles.
• Use parts of the relaxation to help in difficult situations, e.g. breathing slowly.
• Develop a more relaxed lifestyle.

Remember relaxation is a skill like any other and takes time to learn. Keep a note of how anxious you feel before and after relaxation, rating your anxiety 1-10.

Controlled Breathing

Over-breathing: it is very common when someone becomes anxious for changes to occur in their breathing. They can begin to gulp air, thinking that they are going to suffocate, or can begin to breathe really quickly. This has the effect of making them feel dizzy and therefore more anxious.

Try to recognize if you are doing this and slow your breathing down. Getting into a regular rhythm of in two-three and out two-three will soon return your breathing to normal. Some people find it helpful to use the second hand of a watch to time their breathing.

It takes at least three minutes of slow breathing for your breathing to return to normal.

Distraction

If you take your mind off your symptoms you will find that the symptoms often disappear. Try to look around you. Study things in detail, registration numbers, what sort of shoes people are wearing, conversations. Again, you need to distract yourself for at least three minutes before symptoms will begin to reduce.

Whilst relaxation, breathing exercises and distraction techniques can help reduce anxiety it is vitally important to realize that anxiety is not harmful or dangerous. Even if we did not use these techniques, nothing awful would happen. Anxiety cannot harm us, but it can be uncomfortable. These techniques can help reduce this discomfort.

Social anxiety disorder medication

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 doctor 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 doctor 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 doctor may also prescribe other medications for symptoms of social anxiety, such as:

• Other antidepressants. You may have to try several different antidepressants to find one that’s the most effective for you with the fewest side effects.
• Anti-anxiety medications. Benzodiazepines 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.

Alternative medicine

Several herbal remedies have been studied as treatments for anxiety. Results tend to be mixed, and in several studies people report no benefits from their use. More research is needed to fully understand the risks and benefits.

Some herbal supplements, such as kava and valerian, increase the risk of serious liver damage. Other supplements, such as passionflower or theanine, may have a calming effect, but they’re often combined with other products so it’s hard to tell whether they help with symptoms of anxiety.

Before taking any herbal remedies or supplements, talk with your doctor to make sure they’re safe and won’t interact with any medications you take.