Social anxiety disorder: causes, symptoms, and treatments

Social anxiety disorder (SAD) is a type of anxiety disorder characterized by intense fear and worry when experiencing or anticipating social situations. People with SAD worry they will be embarrassed, humiliated, or judged. Social anxiety is debilitating because it strongly limits a person’s life and activities. People with SAD aren’t anti-social in a way they hate other people.

The causes of social phobia are inherited traits, brain structure abnormalities, and the environment. Symptoms of this condition include experiencing anxiety from people such as larger groups or strangers. When that happens, a person experiences physical reactions such as blushing, fast heartbeat, trembling, sweating, nausea, shortness of breath, dizziness, feeling that your mind has gone blank, and muscle tension.

Treatment for social anxiety disorder relies on cognitive-behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs).

What is social anxiety disorder?

Social anxiety disorder (SAD) is an overwhelming, long-term fear of social situations. Also known as social phobia, social anxiety disorder is intense and persistent, which is why it has a major impact on a person’s quality of life. This mental illness causes fear of being judged and watched by others in public. Social anxiety means extreme worry, discomfort, and frustration with exposure to situations that everyone else may perceive as completely normal.

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), released by the American Psychiatric Association, classifies social anxiety disorder as a type of anxiety disorder. However, social anxiety disorder is not a modern-day mental illness. It has been present since prehistoric times. For example, the concept of social fear dates back to 400 BC when Hippocrates described an overly shy person as someone who loves the darkness of life and believes everyone’s watching them.

In the early 20th century, the terms social phobia and social neurosis were used to describe extremely shy patients.

For many years social anxiety was poorly understood. One of the biggest breakthroughs in this field came in the 1950s when Joseph Wolpe, a South African psychiatrist, worked on developing systematic desensitization techniques, which contributed to advances in behavioral therapies for phobias.

During the next decade, in the 1960s, British psychiatrist Isaac Marks suggested that social phobias should be separated from other simple phobias, Very Well Mind reported. These phobias include animal phobias, bodily phobias, situational phobias, and environmental phobias.

In 1968 the release of DSM-2 described social fears as a specific phobia of social situations or excessive fear of being scrutinized by others. The definition of social phobia was very limited at that point.

The history was made with the release of DSM-3 in 1980, when social phobia was included as an official psychiatric diagnosis. This edition described social phobia as a fear of performance situations. However, DSM-3 didn’t include fear of casual conversations, which is a less formal circumstance. People with fears of less formal situations were more likely to be diagnosed with an avoidant personality disorder.

Seven years later, in 1987, a revision of DSM-3 (DSM-3-R) was published and featured some alterations in diagnostic criteria for this disorder. These changes implied that symptoms of this disorder cause interference or market distress, and it made it possible to diagnose both social phobia and avoidant personality disorder in the same patient, which was impossible before.

With the release of DSM-4 in 1994, the term social anxiety disorder replaced social phobia. Diagnostic criteria were similar i.e. slightly modified compared to that of DSM-3-R. The release of DSM-5, in 2013, didn’t change much in terms of diagnosis other than wording of the timeframe for diagnosis.

Overall, understanding of social anxiety disorder improved over the years. Celebrities and public figures aren’t immune to SAD. Some of the most well-known public figures with social anxiety disorder are Naomi Osaka, Barbara Streisand, and Kim Basinger.

How common is social anxiety disorder?

Social anxiety disorder is one of the most common mental illnesses. Estimates show that 12.1% of U.S. adults develop a social anxiety disorder at some point in their lifetime, according to the National Institute of Mental Health.

The same report showed the past-year prevalence of SAD among U.S. adults was 7.1%. This mental illness was more prevalent in women (8.0%) than men (6.1%). Of adults with SAD in the past year, 29.9% had a serious impairment, 38.8% had a moderate impairment, and 31.3% had a mild impairment.

The abovementioned report also showed a lifetime prevalence of social anxiety disorder in adolescents was 9.1%, while 1.3% of them had severe impairment. Prevalence was higher in female adolescents (11.2%) than in males (7.0%).

The September 2020 issue of journal PLoS One published an interesting study, by Dr. Philip Jefferies and Michael Ungar from the Dalhousie University in Halifax, Canada, on this subject. The study focused on exploring the prevalence of SAD in 16 to 29-year-olds from seven countries. For this purpose, researchers used a survey with 6825 respondents. Results showed that the prevalence of social anxiety was higher than previously reported. One in three (36%) respondents met the threshold criteria for SAD. The severity and prevalence of this mental illness didn’t differ between genders, but there was a difference in terms of age, work status, country, education level, and rural or urban place of living. Interestingly, one in six (18%) answered they didn’t think they had social anxiety, but they met the diagnostic criteria for SAD.

In a study by T. Aune et al. in the April 2022 issue of Journal of Anxiety Disorders, 2.6% of 8216 adolescents had SAD. The prevalence varied from 2.0% to 5.7%, depending on the criteria set.

A paper by C.A. Hitchcock et al. in the January 2009 issue of Israel Journal of Psychiatry and Related Sciences reported that rates of childhood social anxiety disorder range from 3% to 6.8% in pediatric primary care samples and from .5% to 9.0% in community studies, with an increased percentage for adolescents. In clinical settings, the prevalence of social phobia goes from 29% to 40%. That means SAD is among the more frequently observed anxiety disorders in children. The same paper also reported girls were more likely to have SAD than boys.

According to a paper that Dr. Kee-Lee Chou from University of Hong Kong published in the December 2009 issue of Journal of Affective Disorders, social anxiety disorder is more prevalent in younger age groups than in older adults. Not much is known about the prevalence of SAD in the elderly population. However, as per a paper titled Epidemiology of Social Phobia in Later Life from the March 2007 issue of American Journal of Geriatric Psychiatry, the lifetime and past-year prevalence of SAD in older adults was estimated at 4.94% and 1.32%, respectively.

When it comes to the prevalence of SAD; the paper by R.C. Kessler et al. in the Archives of General Psychiatry mentions this mental illness as the third most common psychiatric disorder. Only depression and alcohol dependence were more prevalent than social phobia. The paper was published in January 1994, and its main focus was on the prevalence of DSM-3-R disorders in the United States. It shows that even when knowledge of SAD was still limited, the prevalence was significant.

A review by H.U. Wittchen and L. Fehm from Technical University of Dresden in Germany, published in the December 2001 issue of The Psychiatric Clinics of North America revealed the past-year prevalence of social anxiety disorder was 4% to 6%, while lifetime risk ranged from 7% to 13%.

In the July 2017 issue of the journal BMC Medicine, D.J. Stein et al. published a research article that explored cross-national epidemiology of SAD, which found that past-month, past-year, and lifetime prevalence of this mental illness was 1.3%, 2.4%, and 4.0%, respectively across all countries. The prevalence of social anxiety disorder was the lowest in lower-middle-income countries and regions of Africa and the Eastern Mediterranean. The highest prevalence was observed in high-income countries and the Americas and the Western Pacific.

What are the causes of social anxiety disorder?

The causes of social anxiety disorder are similar to those of other anxiety disorders such as panic disorder. A combination of different causes is involved in the onset of social anxiety rather than a single factor only. The most significant causes of social anxiety disorder are listed below:

• Inherited traits
• Brain structure
• Environment

1. Inherited traits

Inherited traits are defined as variants encoded in DNA and passed from parents to children during reproduction, National Human Genome Research Institute explained. Classic examples of inherited traits are hair and eye color, but children may also inherit genes that increase their susceptibility to physical and mental illnesses. An article by J. Posner et al. in the June 2021 issue of Journal of the American Academy of Child and Adolescent Psychiatry explained mental illnesses tend to be polygenic, meaning multiple genes or genetic variants contribute to a small but meaningful risk in the development of mental illness. People can have a genetic susceptibility to develop an anxiety disorder. The duplication of part of chromosome 15 is considered a major genetic factor in the predisposition for panic and phobia, according to a paper titled “Are There Anxious Genes?” from the September 2002 issue of the Dialogues in Clinical Neuroscience. A lot more research is necessary to elucidate the link between this chromosome and symptoms of anxiety.

A review Genetic Factors in Anxiety Disorders from the September 2013 issue of the Modern Trends in Pharmacopsychiatry reported that multiple vulnerability genes are associated with anxiety disorders. These genes include 5-HT1A, 5-HTT, MAO-A, COMT, CCK-B, ADORA2A, ACE, FKBP5, CRHR1, RGS2/7, and NPSR1. The same review explained the vulnerability genes confer disease risk through intermediate phenotypes such as behavioral inhibition, anxiety sensitivity, and neurobiological traits, including enhanced startle reactivity or impaired corticolimbic activity during emotional processing.

Inherited traits become a cause of social anxiety disorder because children inherit specific genes or genetic variations from their parents. A study by M.B. Stein et al. in the February 2017 issue of the American Journal of Medical Genetics Part B Neuropsychiatric Genetics confirmed social anxiety involves a genetic basis, shared with extraversion and possibly less so with neuroticism. A comparative study by C. Lochner et al. in the April 2007 issue of the European Neuropsychopharmacology suggested a potential role for the polymorphism 5-HT(2A)T102C in the development of social anxiety disorder.

The February 2021 issue of the journal Translational Psychiatry published a study where A. Wiegand et al. explored DNA methylation differences in social anxiety disorder. The term DNA methylation is a biological process wherein methyl (CH3) group is added to DNA, thereby modifying the function of the genes. This particular study identified two differentially methylated regions (DMRs) associated with SAD located in genes SLC43A2 and TNXB. These particular genes are also associated with panic disorder. The study also identified DMRs linked to early life adversity in the SLC17A3 promoter area and the SIAH3 gene. The largest difference in DNA methylation was observed within regions C2CD2L and MRPL28.

Inherited traits are a cause of social anxiety disorder because certain genes and their variations can affect the way people respond to fear and stressful stimuli.

2. Brain structure

Brain structure refers to regions in the brain that have their specific functions, including fear response, emotional regulation, and cognition. In the context of SAD causes, brain structure involves abnormalities in brain structure (regions) and their functioning as well as imbalance of neurotransmitters, all of which can affect a person’s mental health. An article from Psychology Today suggests that mental illnesses are disorders of the brain in the sense that dysfunctional thoughts and behaviors they involve are enabled by the brain. That explains structural and functional differences in the brains of people with mental illnesses compared to healthy individuals, the article further elaborated. Brain structure plays an important role in the development of anxiety disorders, as well.

Brain structure is the cause of social anxiety disorder because abnormalities in certain areas and neurotransmitters can affect emotional processing, response to fear, and how a person handles stress-inducing social situations. A paper from the April 2020 issue of F1000 Research reported that the socially anxious brain is characterized by hyperactivation of the fear circuit consisting of the amygdala, insula, prefrontal cortex, and anterior cingulate cortex. Brains in people with SAD also display hyper-responsive parietal and occipital regions. The parietal lobe is a major sensory processing area of the brain, whereas the occipital region is responsible for visual perception. In the same paper authors Janna Marie Bas-Hoogendam and P. Michiel Westenberg from Leiden University in the Netherlands, reported hypoconnectivity in these areas, and changes in network structure reflect enhanced emotional arousal and elevated focus on potentially threatening stimuli that are associated with social anxiety disorder.

According to the abovementioned review, the striatum also plays a role in social anxiety disorder and intolerance of uncertainty. Striatum is a neuronal circuit necessary for voluntary movement control. People with social anxiety disorder tend to have increased striatal volume.

A research article by S. Tei et al. in the February 2020 issue of Proceedings of the National Academy of Sciences of USA (PNAS) suggested that certain aspects of social anxiety are linked to increased affective empathy and decreased cognitive empathy. Reduction in cognitive empathy points to decreased cognitive processing in embarrassing situations. This paper also confirmed the hyperactivity of the amygdala in people with social anxiety disorder. An overactive amygdala in people with SAD could be associated with oxytocin, a chemical messenger in the brain that reduces anxiety. According to a study that Inga D. Neumann and David A. Slattery from University of Regensburg in Germany published in the February 2016 issue of Biological Psychiatry, the amygdala isn’t hyperactive in response to fearful stimuli in the presence of oxytocin. This could indicate that levels of oxytocin are lower in people with social anxiety disorder, PsychCentral explained.

It’s also useful to mention that the amygdala is slightly larger in people with this mental illness as per a paper by J.H. Suor et al. in the September 2020 issue of the Journal of Psychiatric Research. What this means is that the brains of people with SAD have adjusted to spending more time and energy processing emotions and threats.

While the fear circuit, in general, is hyperactive in people with SAD, the activity of the prefrontal cortex alone is reduced. The prefrontal cortex plays a role in many aspects of human behavior, including decision-making, planning, and self-control. Its function is to send signals to the amygdala to prevent it from becoming overactive during routine social situations. In people with social anxiety disorder, the prefrontal cortex doesn’t work properly. PsychCentral explains that instead of reducing the activity of the amygdala, the prefrontal cortex increases it. As a result, a person experiences fear and anxiety. Speaking of the prefrontal cortex, yet another function is to control what our brain pays attention to. In people with SAD, the prefrontal cortex is more active in response to social threats.

When it comes to brain structures involved in social anxiety disorder, it’s useful to mention the fusiform gyrus and hippocampus. The fusiform gyrus is involved in processing faces and determining the emotional state of other people, which is why it’s important for social interactions. Hippocampus takes part in learning and memory.

Research by X. Yu et al. in the June 2021 issue of the International Journal of Environmental Research and Public Health suggested that the fusiform gyrus can be either overactive or underactive in persons with SAD. Activity depends on the coping strategies a person has developed.

The role of the hippocampus in SAD is that social anxiety can be a behavior that people learn after being exposed to bad social situations. With time, they get used to acting a certain way and expect people to react to them negatively. According to research “Slow to Warm Up: the Role of Habituation in Social Fear” from the November 2016 issue of Social Cognitive and Affective Neuroscience, when socially anxious individuals see the faces of people they haven’t seen before, their hippocampus becomes overactive. When they are exposed to these faces repeatedly, they never learn to become familiar with them in a way that a person without SAD would. Those faces continue to be perceived as threatening. This could explain why individuals with social anxiety disorder experience difficulties when meeting new people.

As mentioned above, an imbalance of neurotransmitters plays a role in the development of SAD, just like abnormalities in brain structure and function. According to a study by A. Frick et al. in the August 2015 issue of JAMA Psychiatry, people with social phobia produce excessive amounts of serotonin. The bigger the serotonin production, the more anxious they become in social situations. The overproduction of serotonin in people with SAD occurs in the amygdala. Serotonin is a neurotransmitter whose function is to help regulate sleep, digestion, bone health, wound healing, sexual desire, blood clotting, and mood.

A review “Neurology and Pharmacotherapy of Social Phobia” in the July-August 2004 issue of L’Encephale suggests social anxiety disorder is associated with specific neurotransmitter alterations involving dopaminergic, serotoninergic, and noradrenergic systems. Neuroscience News reported findings from one study, which showed that an imbalance between serotonin and dopamine in the amygdala contributes to the development of social anxiety disorder. The study suggested it’s important to focus on the balance between different systems rather than on one signal substance at a time.

Brain structure is a cause of social anxiety disorder because the hyperactivity or reduced activity of certain regions and neurotransmitters can affect how people react to new faces, process social situations, and cope with stressful stimuli.

3. Environment

The environment is an individual’s personal life, relationships, and social circumstances that may contribute to the worsening of their mental health. In 2010, a review by Debra Umberson and Jennifer Karas Montez from University of Texas at Austin, published in the Journal of Health and Social Behavior revealed both the quantity and quality of social relationships affect mental health, health behavior, physical health, and mortality risk of an individual. Good, healthy relationships have a meaningful impact on mental health even in tough times such as the COVID-19 pandemic, according to a paper by C. Pieh et al. in the March 2021 issue of International Journal of Environmental Research and Public Health. Good relationships with family members are significant for the well-being of a person across their lifetime, a paper by P.A. Thomas et al. in the November 2017 issue of Innovation in Aging revealed. Besides relationships, a person’s childhood and social experiences also shape their mental health and may contribute to the development of disorders such as anxiety.

Environment causes social anxiety disorder because this mental illness can be a learned behavior, Mayo Clinic explains. An embarrassing or unpleasant social situation may produce significant anxiety. Moreover, a child may develop social anxiety disorder because their parents exhibited anxiousness or if their parents were overprotective and controlling.

The December 2017 issue of the journal Emotion published a study by L. Koban et al, which investigated how social learning affects feelings toward the self and a person’s social performance. In other words, the study evaluated the extent to which healthy and socially anxious adults can be distinguished by distinct biases in social learning. Findings showed that positivity bias in the influence of social feedback on self-perception, observed in healthy adults, is absent or reversed in socially anxious subjects. The study confirmed that feelings about the self are learned or updated in response to social performance feedback. Negatively biased learning from social feedback can accumulate with time and lead to a vicious cycle of negative self-evaluation that worsens the symptoms of the disorder. People with social anxiety disorder, according to the abovementioned study, notice more negative than positive social cues in the environment. Environment and how people perceive social cues play a major role in the development and progression of SAD.

Circumstances in which a child is growing up play a role in mental health in adolescence and adulthood. A study by C.J.W.H. Bruijnen et al. in the January 2019 issue of South African Journal of Psychiatry found that childhood trauma can contribute to and worsen symptoms of social anxiety disorder. Exposure to early maternal stress predicted higher and more chronic inhibition and was linked to the development of SAD in adolescence.

Emotional abuse and neglect in childhood can also contribute to social anxiety disorder and its severity, according to a paper by L.C. Bruce et al. in the February 2012 issue Depression and Anxiety.

Social experiences of an individual shape their behaviors in social settings. For example, peer victimization is positively associated with social anxiety, as per M. Pontillo et al. who published a paper in the June 2019 issue of the journal Brain Sciences. That means victims of bullying in childhood are prone to the development of SAD later in life.

A paper “Familial Factors in the Development of Social Anxiety Disorder” from the July 2021 issue of Journal of Psychosocial Nursing and Mental Health Services reports that separation from or both parents can pave the way to social anxiety. Besides parents, familial relationships, such as those with siblings, can also contribute to the development of SAD. For example, if one sibling has a high level of anxiety or in cases of sibling bullying. The same report shows that stressful life events in childhood, particularly those with a social component such as family conflicts, can lead to the onset of SAD symptoms. Interparental conflict raises threat perceptions and social anxiety symptoms, thereby influencing interpersonal relationships with peers.

The environment is a cause of social anxiety disorder because relationships with family or peers and experiences to which a person has been exposed can cause either a positive or negative perception of self. It also affects how people perceive social situations. Negative experiences and unhealthy relationships instill a fear of being humiliated or embarrassed in social settings.

What are the symptoms of social anxiety disorder?

Symptoms of social anxiety disorder are intense anxiety, fear, and avoidance that affect a person’s daily routines, relationships, work, school, and overall quality of life. Although people with SAD are shy, shyness itself isn’t an indicator of a mental illness. People can be reserved and shy in social situations, but they don’t necessarily have social anxiety disorders because comfort levels vary. Social anxiety disorder is a serious mental illness with a significant impact on a person’s functioning in everyday life. The symptoms of social anxiety disorder are listed below:

• 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

1. Blushing

Blushing is defined as the reddening of a person’s face due to stress, embarrassment, or confusion. It is involuntary, meaning a person doesn’t induce or stop the reddening of the face on purpose. Psychological reasons trigger blushing, such as shyness, romantic stimulation, and even fear or anger. Blushing is a normal reaction whose intensity varies from one person to another. Extreme or intense blushing is present in people with social phobia.

Social anxiety disorder causes blushing because redness in the face is a part of the body’s fight-or-flight response. When that happens, adrenal glands release adrenaline, which causes vasodilation (widening of blood vessels) in the face and neck. As the blood flow to the face increases, a red complexion and sensation of warmth develop, The New York Times reported. When a person knows they’re blushing, they tend to blush even more. The reason for that is neurological arousal that causes a vicious self-perpetuating cycle. Looking flushed is a common indication of an active stress response that anxiety triggers.

Not only does SAD cause blushing, but vice versa can happen. A study by M. Nikolić et al. in the December 2020 issue of Journal of Child Psychology and Psychiatry and Allied Disciplines reported that blushing as temperature increases has a unique contribution to the development of social anxiety disorder from early to late childhood. The reason this happens is a heightened self-conscious emotional reactivity. For example, a four-year-old child begins to understand they can be judged by other people or children. That child may start blushing due to the concern they may be evaluated in a negative light. The uncomfortable feeling of warmth and redness on the face may signify to the child that the specific social situation is threatening. With time, this may contribute to social anxiety disorder.

Blushing is a symptom of social anxiety disorder because it is an involuntary reaction to the fear of being judged, embarrassed, and uncomfortable in social situations. It is identified as the formation of redness in cheeks and a feeling of warmth when a person faces social events or is supposed to do so.

2. Fast heartbeat

Fast heartbeat, or tachycardia, is a heart rate of over 100 beats per minute. A fast heartbeat isn’t always a cause for concern. It’s natural for the heart rate to go up during exercise or as a response to stress. Fast heartbeat also occurs as a symptom of anxiety disorders such as SAD.

Social anxiety disorder causes a fast heartbeat due to the fight-or-flight mechanism, which is a part of the autonomic nervous system (ANS). When fight-or-flight mode is activated, the body tries to take in more oxygen. As a result, the breathing rate becomes faster, and with the release of adrenaline, the heart starts beating more quicker.

The level of perceived anxiety plays an important role in causing a fast heart rate. A study by G.P. Trotman et al. in the November 2019 issue of the journal Anxiety, Stress, and Coping suggested that actual heart rate was unrelated to the intensity of anxiety, but was linked to a more debilitative interpretation of anxiety. Perceptions of heart rate change were strongly related to greater intensity of cognitive and somatic anxiety. The term cognitive anxiety refers to negative thoughts and doubts, whereas somatic anxiety relates to physiological symptoms. The abovementioned study indicates that a person’s perception of their anxiety causes a fast heartbeat. For example, if a person believes their anxiety is intense, their stress levels may react accordingly and cause a chain of reactions that results in a fast heartbeat.

A fast heartbeat is a symptom of social anxiety disorder because it’s a reaction to negative, stressful stimuli that a person can’t control. In this case, those stressful stimuli are a social event or situation. Physiological hyperactivity is a cardinal feature of social anxiety, according to a paper by L. Rosler et al. in the March 2021 issue of the Journal of Behavior Therapy and Experimental Psychiatry.

Identifying a fast heartbeat as a symptom of SAD isn’t complicated; it manifests itself in the form of a pounding heartbeat accompanied by chest pain, fainting, and shortness of breath in social situations.

3. Trembling

Trembling is an involuntary, rhythmic muscle contraction and relaxation of one or more body parts, usually the hands. Tremors occur due to various reasons ranging from lifestyle factors such as having too much caffeine to neurological conditions like Parkinson’s disease. Anxiety disorders can also cause trembling.

Social anxiety disorder causes trembling due to the activation of the fight-or-flight response. Healthline explains that when the body prepares to deal with a stressor by interpreting anxiousness as a signal that a person needs to stand their ground or escape from danger. At that point, the muscles are primed to act, which results in trembling sensation and shaking. Tremors caused by anxiety are called psychogenic tremors.

Trembling appears with other symptoms of SAD such as a fast heartbeat and shortness of breath. It’s also useful to mention that anxiety can trigger other existing conditions, such as essential tremors. As a result, anxiety becomes worse, and so do the symptoms of that specific condition. In the case of essential tremor, a neurological disorder that causes involuntary and rhythmic shaking, the symptoms can aggravate when a person is anxious, Medical News Today explained. According to D.A. Lundervold et al. who published a study in the July 2013 issue of Psychiatry Journal, around 30% of participants with essential tremors also had a social anxiety disorder.

Trembling is a symptom of social anxiety disorder because it happens involuntarily when a person faces the source of their anxiety, in this case, that source is a social situation. In this disorder, trembling appears as shaking (usually hands) when a person is anticipating social interaction, attends parties or gatherings, eats or drinks in public, goes on a date, makes phone calls, performs on stage, or speaks up in a meeting.

4. Sweating

Sweating is the release of salty liquid from the sudoriferous (sweat) glands. This process is called perspiration. As a normal process, sweating helps the body stay cool when people exercise or the weather is hot. Heavy sweating can result from health problems such as diabetes, heart failure, overactive thyroid, and anxiety.

Social anxiety disorder causes sweating because it triggers the well-known fight-or-flight response. When a person faces a threat, whether it’s real or perceived, the sympathetic nervous system engages this response, which requires higher energy expenditure. As a person expends energy, their body temperature goes up. Since overheating would make it difficult to keep fighting or escape the threat, the body sends signals to sweat glands to produce sweat.

In people with anxiety disorders, the body and brain are on the constant lookout for potential threats. That’s why a person may regularly experience emotional and physical symptoms, including sweating.

According to a report from the International Hyperhidrosis Society, between 25% and 32% of people with social anxiety disorder experience excessive sweating. A person who lives with SAD is constantly worried about being judged and goes to great lengths to avoid drawing attention to themselves and their appearance, including excessive sweating. Since fear and stress trigger sweating, a person with SAD experiences increased perspiration alongside other physical symptoms such as lightheadedness and nausea, Healthline explained.

Sweating is a symptom of social anxiety disorder because it is the key sign of the fight-or-flight mechanism. It’s a reaction to an uncomfortable social situation that a person can’t ignore. Sweating in people with SAD is similar to typical sweating, and it usually appears in the palms and soles of feet, but the forehead and under-arm areas are also affected. As a person is exposed to a social situation, such as public speaking or meeting larger groups of people, they may start producing more sweat instantly.

5. Upset stomach or nausea

An upset stomach or nausea is a feeling of sickness in the stomach that causes the urge to vomit. People can get nauseous due to bad food, side effects of medications, or due to anxiety. A study by T.T. Haug et al. in the March-April 2002 issue of General Hospital Psychiatry found that 48% out of 62,651 people who responded to the questionnaire reported one or several gastrointestinal complaints during the last year. Of these, 12.5% of responders complained of nausea and 15.3% had an anxiety disorder. The presence of anxiety disorders carried the highest risk for nausea.

Social anxiety disorder causes nausea because neurotransmitters released during the fight-or-flight response enter the digestive tract. In the digestive tract, these neurotransmitters impair the delicate balance of microorganisms that reside in the gut. An imbalance in gut microbiota can cause nausea. The same process can cause other digestive problems including heartburn, stomachache, gas, bloating, and diarrhea or constipation.

Nausea is a symptom of social anxiety disorder because processes in the brain also reflect on the gut. This makes a person feel sick or get the urge to vomit when facing or anticipating social situations such as spending time with larger groups of people.

As a symptom of SAD, nausea appears in the form of an urge to vomit but also a lack of appetite, weakness, and increased production of saliva. These symptoms appear instantly as a person’s anxiety levels go up with exposure to the trigger of their anxiety.

6. Trouble catching your breath

Trouble catching your breath, or shortness of breath, occurs when a person isn’t getting enough oxygen, which makes them feel like they need to breathe harder, deeper, or faster. Heart or lung conditions tend to cause shortness of breath, but it can also occur during exercise or in the presence of stress and anxiety disorders.

Social anxiety disorder causes shortness of breath because the body responds to the social situation as if a person is running for their life, even though they are not. Shortness of breath is a part of the fight-or-flight mechanism. The body is trying to get more oxygen to the muscles, preparing a person for flight. At this point, the heart rate increases, and more blood goes into the muscles thus making a person feel hot, which helps prepare for a fight. Due to a faster heart rate and increased need for oxygen, a person experiences trouble catching their breath.

Shortness of breath is a symptom of social anxiety disorder because it is a direct consequence of the protective mechanism activated in the presence of triggers. To identify it as a symptom of SAD, it is important to remember it makes a person feel like they can’t catch a breath or as if they are suffocating and hungry for air. Tightness in the chest accompanies shortness of breath, as well. In people with social anxiety disorder, shortness of breath may appear with other physiological symptoms such as muscle tension and fast heart rate.

7. Dizziness or lightheadedness

Dizziness is defined as the feeling of being lightheaded, off-balance, and woozy. Mayo Clinic reports that dizziness is among the most common reasons adults visit their doctors. People get dizzy for many reasons, including underlying health conditions, motion sickness, certain medications, poor circulation, infection, and problems such as anxiety disorder.

Social anxiety disorder causes dizziness due to sudden changes in blood pressure, which may happen in a fight-or-flight response. The abrupt change in blood pressure can make a person feel lightheaded. Additionally, stress hormones such as cortisol and adrenaline can affect the vestibular system of the inner ear, which is important for balance, according to a paper by Y. Saman et al. in the July 2012 issue of Frontiers in Neurology. People with SAD may hyperventilate, which deprives their brains of oxygen and causes dizziness.

When it comes to dizziness and social anxiety disorder, it’s useful to mention a study titled “Overview of Psychologic Effects of Chronic Dizziness and Balance Disorders” from the June 2000 issue of the journal Otolaryngologic Clinics of North America, which found that chronic dizziness can lead to psychological problems such as anxiety. The relationship between dizziness and anxiety is strong, especially because anxiety and avoidance of activity can worsen and perpetuate dizziness. This results in a vicious cycle of persistent disorientation and distress.

Dizziness is a symptom of social anxiety disorder because a patient may feel emotionally unsteady, which causes a subjective feeling of dizziness. It is also a consequence of physical reactions to stressful stimuli or triggers of anxiety.

This symptom is identified as lightheadedness or feeling faint, unsteadiness, and a feeling of floating when a person is in a social situation that causes anxiety and discomfort.

8. Feeling that your mind has gone blank

Feeling that your mind has gone blank refers to the decoupling of perception and attention wherein attention fails to bring any stimuli into a person’s conscious awareness. In other words, a person’s mind seems to be “nowhere”. People with anxiety may experience mind blanking or brain fog.

Social anxiety disorder causes mind blanking because this mental illness takes up mental resources. An individual with SAD may need to use more energy to focus on something else other than their anxiety. Anxious thoughts may intrude on a thought process. As a result, it becomes difficult to concentrate and think clearly.

For instance, a research paper by K.M. Lukasik et al. from the January 2019 issue of Frontiers in Psychology shows anxiety significantly affects mental processes such as working memory.

Feeling that your mind has gone blank is a symptom of SAD because the anxious thoughts in the social situation don’t allow a person to pay attention to anything else. This symptom is identified as forgetting about a task at hand, taking longer to complete simple tasks, and poor concentration when exposed to triggering social situations or when a person expects or anticipates it.

9. Muscle tension

Muscle tension is a condition wherein one or multiple muscles remain in semi-contraction for a prolonged period. Causes of muscle tension are numerous, including poor posture, over-exercising, and performing activities using poor techniques. Mental health can affect muscles and cause tension, which is why people with anxiety disorders may experience this problem.

Social anxiety disorder causes muscle tension because the natural stress response puts a person in a state of readiness, which involves both mental and physical tension. In the presence of a perceived threat, the body launches changes that make a person more alert and ready to face a threat or avoid it. For people who live with SAD, the body may frequently activate a fight-or-flight response, which is why the muscles are affected too. Muscle tension goes away when a stressful situation passes. However, anxiety causes feelings of stress and tension that may last for hours or days.

Muscle tension is a symptom of SAD because the trigger of anxiety puts the body in the mode of being ready to protect itself. This symptom is identified as muscle tightness in the neck, shoulders, and other areas, such as the jaw or stomach, in the presence of a social situation that causes anxiety.

What can I expect from social anxiety disorder?

People with social anxiety disorder tend to worry a lot about embarrassing or humiliating themselves. Interaction or communication with strangers may cause intense fear. A person with SAD may be afraid other people in a specific social situation may notice they look anxious. They may be afraid of getting embarrassed by physical symptoms of SAD, such as sweating or blushing.

The fear of embarrassment or facing humiliation prompts a person with SAD to start to avoid speaking to people or participating in activities with a larger group of people. They may also start avoiding situations where they are the center of attention. For example, a person with SAD may avoid meetings where they are required to speak up. People with SAD often focus on the worst-case scenarios during social situations, which only worsens their symptoms.

When left untreated, a social anxiety disorder can affect a person’s self-esteem and contribute to negative self-talk or hypersensitivity to criticism. In the most difficult cases, SAD can lead to social isolation, relationship problems, low academic or employment achievement, substance abuse, and suicidal thoughts and tendencies.

Who is at risk for social anxiety disorder?

People with a family history of social anxiety disorder are at a high risk of developing it as well. While social anxiety disorder can affect people at any age, it usually emerges during early to middle adolescence.

Children who were subjected to bullying, abuse, teasing, neglect, rejection, ridicule, and unstable familial relationships are more likely to develop social anxiety disorder later on. Experiencing or witnessing negative events such as family conflict and trauma is also among the risk factors for the onset of SAD. Children whose parents were controlling, critical, and overprotective are more likely to develop this type of anxiety disorder.

Temperament also plays a role in susceptibility to social anxiety disorder. For example, children who are shy, timid, or restrained when facing new situations could be more prone to developing this mental illness.

Social anxiety disorder can be triggered by a health problem that may draw the public’s attention, such as Parkinson’s disease. People who didn’t have SAD before may develop symptoms in situations when they are supposed to give a speech in public, meet new people, or hold an important presentation at work.

How is social anxiety disorder diagnosed?

A healthcare professional or psychiatrist diagnoses social anxiety disorder when a patient meets the diagnostic criteria from DSM-5. Before that happens, a doctor performs a physical exam and orders blood tests or urine tests to determine whether the symptoms have a physiological trigger.

When a physical exam doesn’t explain a patient’s symptoms, the doctor refers them to a psychiatrist for psychiatric evaluation. During the psychiatric evaluation, the mental health expert discusses a patient’s symptoms, their frequency, severity, and situations when they occur. A patient may need to complete a questionnaire about symptoms of social anxiety.

Upon psychiatric evaluation, the psychiatrist may use DSM-5 and diagnose social anxiety disorder if a patient meets the diagnostic criteria.

Criteria for SAD include persistent fear or anxiety about specific social situations because a person believes they may be judged negatively, avoidance of anxiety-inducing social situations, anxiety that is out of proportion to the situation and interferes with daily living, and anxiety that is not explained by substance abuse, medication, or a medical condition.

Social anxiety disorder is diagnosed when a patient has experienced symptoms for at least six months, Cleveland Clinic explained.

What are the available treatments for social anxiety disorder?

Treatments for social anxiety disorder depend on the extent this mental illness affects a person’s daily functioning. Patients usually need therapy, medications, or combinations of both. The available treatments for social anxiety disorder are listed below:

• Cognitive behavioral therapy
• Selective serotonin reuptake inhibitors (SSRIs)

1. Cognitive Behavioral Therapy

Cognitive-behavioral therapy (CBT) is a type of psychotherapy that helps patients manage their problems by changing the way they think and behave. It helps treat SAD by enabling them to identify negative or irrational thought patterns in order to replace them with more rational alternatives. The main premise behind cognitive behavioral therapy is that thoughts dictate emotions and behavior. By changing their thinking pattern, people can also change how they feel and act.

Cognitive-behavioral therapy is one of the treatments for social anxiety disorder because it is patient-centric and allows a therapist to adjust therapy sessions to meet the patient’s needs. Not only do patients learn to identify and change irrational thoughts that trigger their anxiety in social situations, but they also develop skills that improve their functioning. For example, patients may learn communication skills to improve their interactions with other people.

Cognitive-behavioral therapy is an effective treatment approach for patients with social anxiety disorder. The January-June 2009 issue of the Industrial Psychiatry Journal published a case study by R. Priyamvada et al. involving a 27-year-old man with social phobia. The patient was treated with cognitive behavioral techniques that resulted in significant improvements after 17 sessions. The patient was under follow-up for six months and recovered to the premorbid level of functioning.

A review by E. Mayo-Wilson et al. in the October 2014 issue of The Lancet evaluated 101 studies with 41 treatment approaches, including medications and self-help strategies but found that CBT had the most significant impact on the treatment of social anxiety.

Besides individual therapy sessions, patients can benefit from group therapy. A therapist may also opt for exposure-based CBT, which involves gradually working up to facing the situations that a patient is afraid of. Exposure-based CBT improves coping skills and boosts a patient’s confidence to handle triggers of their social anxiety.

The main goal of CBT for social anxiety disorder is to empower patients to gain a different perspective and cope with stress and anxiety in difficult situations. In order to do so, patients may need six to 20 sessions. The specific number of sessions varies from one patient to another based on the severity of their social anxiety. The sessions last 30 to 60 minutes.

2. Selective serotonin reuptake inhibitors (SSRIs)

Selective serotonin reuptake inhibitors (SSRIs) are a class of drugs called antidepressants. They are usually prescribed to help treat the major depressive disorder, but may also aid the management of other psychological conditions, including anxiety disorders.

These medications help treat SAD because they act on brain chemistry by slowing down the reabsorption of the neurotransmitter serotonin. Serotonin is a chemical that regulates anxiety and mood. People with social anxiety disorder tend to produce excessive amounts of serotonin, which worsens their symptoms. By slowing down the reuptake of these neurotransmitters, SSRIs may help reduce the intensity of symptoms of social anxiety disorder.

Selective serotonin reuptake inhibitors are a treatment for SAD because symptoms can be persistent. They are used in combination with psychotherapy. Patients may receive a prescription for paroxetine (Paxil) or sertraline (Zoloft).

A review by N. Mitsui et al. in the December 2022 issue of Neuropsychopharmacology Reports confirmed that SSRIs are a valid option for patients with social anxiety disorder. According to the meta-analysis that G.J. van der Linden et al. published in the August 2000 issue of the International Journal of Psychopharmacology, SSRI treatment for social anxiety disorder is effective in lowering total levels of social anxiety and improving overall clinical conditions among patients.

It takes two to four weeks to feel the effects of SSRIs.

What are the complications of social anxiety disorder treatment?

Complications of social anxiety disorder treatment are listed below:

• Difficulty to commit: in order for CBT to work for social anxiety disorder, a patient needs to commit to it firmly. A therapist can advise patients, but they need their cooperation. Difficulty in committing becomes a complication of CBT because symptoms of SAD can be so severe that a person is unable to do so. Difficult commitment is a complication because a patient can’t get the most from this type of therapy. It is identified as a patient’s inability to cooperate with a therapist and approach therapy with an open mind.
• Confrontation with anxiety: a major component of CBT for people with social anxiety is the confrontation with their fear or triggers of anxiety. It becomes a complication because a patient may experience periods when they are anxious and emotionally uncomfortable. This may be a problem for patients whose SAD is severe since they may believe the therapy isn’t working. It is identified as a complication of SAD when a patient needs to step out of their comfort zone for the purpose of therapy, and anxiety symptoms appear.
• Limited scope: CBT itself doesn’t address wider problems, such as family dynamics, that may have a major impact on a person’s mental health. The limited scope becomes a complication because family dynamics and a patient’s past have a significant influence on the development and progression of their social anxiety. It is a complication because a patient with SAD can’t address and manage all aspects that contribute to their condition. It is identified as a complication through the nature of the approach that focuses only on the present.
• Medication side effects: SSRIs can cause side effects as the body adjusts to the medication. They become a complication because a patient experiences agitation, indigestion, diarrhea or constipation, dizziness, loss of appetite, dry mouth, blurred vision, excessive sweating, insomnia, headaches, low libido, and erectile dysfunction. Side effects are a complication because they can worsen symptoms of SAD such as excessive sweating and dizziness. Additionally, a patient may have low confidence in the medication’s safety and efficacy. This complication is identified through the appearance of the abovementioned adverse reactions.

How to deal with social anxiety disorder?

In addition to a well-structured treatment, there’s a lot that people with social anxiety disorder can do to manage their condition and improve their overall quality of life. Tips to deal with social anxiety disorder are listed below:

• Practice relaxation techniques to manage stress
• Get enough sleep
• Exercise regularly and eat a well-balanced diet
• Avoid alcohol and drugs, and limit intake of caffeine
• Reach out to people with whom you feel comfortable and participate in social activities with them
• Consider joining a support group for people with social anxiety disorder
• Learn as much as possible about SAD and its effects on life
• Practice public speaking with experts
• Be kind to yourself
• Don’t be afraid to ask for help
• Combat negative thoughts by finding arguments that prove they’re irrational

Is social anxiety disorder a mental illness?

Yes, social anxiety disorder is a mental illness that belongs to a group of anxiety disorders and is included in DSM-5. While it can be a chronic mental health condition, people with SAD can manage their symptoms with therapy and medications. That way, they can improve their communication with other people. Social anxiety is a treatable condition. However, it shouldn’t be confused with shyness. Shyness is closely related to a person’s comfort zone and every individual has a different comfort zone level. But SAD is much more than that; it’s a mental health condition that strongly affects a person’s quality of life.