Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations. People with social phobia have an intense, persistent, and chronic fear of being watched and judged by others and of doing things that will embarrass them. They can worry for days or weeks before a dreaded situation. This fear may become so severe that it interferes with work, school, and other ordinary activities, and can make it hard to make and keep friends.

While many people with social phobia realize that their fears about being with people are excessive or unreasonable, they are unable to overcome them. Even if they manage to confront their fears and be around others, they are usually very anxious beforehand, are intensely uncomfortable throughout the encounter, and worry about how they were judged for hours afterward.

Social phobia can be limited to one situation (such as talking to people, eating or drinking, or writing on a blackboard in front of others) or may be so broad (such as in generalized social phobia) that the person experiences anxiety around almost anyone other than the family.
Physical symptoms that often accompany social phobia include blushing, profuse sweating, trembling, nausea, and difficulty talking. When these symptoms occur, people with social phobia feel as though all eyes are focused on them.

Social phobia affects about 15 million American adults. Women and men are equally likely to develop the disorder, which usually begins in childhood or early adolescence. There is some evidence that genetic factors are involved.Social phobia is often accompanied by other anxiety disorders or depression, and substance abuse may develop if people try to self-medicate their anxiety.

Social phobia can be successfully treated with certain kinds of psychotherapy or medications.

Emotional Symptoms:
Disabling fear of one or more social situations, fear of being watched or judged by others fear that others will notice your physical symptoms of anxiety, fear of embarrassing yourself in public.

Physical Symptoms:
Racing heart or palpitations, blushing, excessive sweating, dry throat and mouth, trembling, muscle tension, trouble talking, nausea, stomach upset, diarrhea

What are the different types of social anxiety disorder? Social anxiety disorder is often classified into three different types or levels:

Generalized social phobia - This is the most common type of social anxiety disorder. Generalized social phobia affects a person in most social and performance situations. A person with this type of social anxiety disorder experiences anxiety in the majority of interactions with others.

Specific social phobia - In some cases, social anxiety is connected with specific social situations, such as meeting new people, using public restrooms, or eating in front of others. Fear of public speaking is the most common specific social phobia. Fear of public speaking is a type of performance anxiety. Performance anxiety, or stagefright, involves intense fear over performing in front of an audience, whether it be playing a piece of music at a recital or giving a presentation to your boss.

Avoidant personality disorder - Avoidant personality disorder is considered by many mental health professionals to be the most severe form of social anxiety. The disorder is characterized by a lifelong pattern of extreme shyness to the point of self-isolation. If you have avoidant personality disorder, loss and rejection may be so painful for you that you choose a solitary life and avoid connecting with others.

What causes social phobia? Many social, psychological, and biological factors are believed to contribute to the development of social anxiety disorder or social phobia. These factors are interrelated and interact with each other, so it is impossible to pinpoint exact causes. For example, although social phobia tends to run in families, it is unknown whether this is because of genetics or social learning from family members.

Social & Environmental Causes

Learning from your environment
Some researchers and professionals assert that social anxiety disorder is a learned behavior; that is, it can be developed from observing and interacting with others who experience similar anxiety. There may be association between parents who are controlling and overprotective and the development of social phobia. Parents often are not able to acknowledge the disorder in their children because they experience the anxiety themselves and think of it as normal.
Previous negative social experiences Some individuals may develop social phobia after a particularly negative social experience. For children, such experiences can include teasing, bullying, or a particularly embarrassing incident in public. Problems in speech or language, disfigurement, sexual or physical abuse, family conflict, and neglect can also contribute to social phobia.

Psychological Causes
Emotional or psychological trauma
Researchers have turned an increased focus to the relationship between early-life emotional trauma and the development of social anxiety disorder. Your current social anxiety symptoms may be a result of unresolved trauma that you experienced earlier in life, regardless of whether you recall any traumatic circumstances.
Poor attachment with primary caretaker during stages of early-life development If you were unable to develop an adequate bond with your primary caretaker as a child, you may lack self-regulatory skills to calm, focus, and soothe yourself in situations you perceive as stressful or chaotic. Attachment specialists point to this as a possible cause of social anxiety disorder and other anxiety, depression, and stress-related disorders.

Biological Causes

Genetics/Heredity
Many research studies suggest a modest genetic component to social phobia. Behavioral inhibition is believed to be the biggest inherited risk factor. Behaviorally inhibited infants are upset easily by things that are unfamiliar and are likely to develop into fearful children. By adolescence, they show an increased risk for social anxiety disorder.

Brain Structure
The amygdala is the part of the brain that controls your fear response. Recent brain-imaging research has indicated that people who frequently experience social anxiety have an overactive amygdala and an underactive prefrontal cortex.

Biochemistry
Other research studies have focused on the notion of a biochemical basis for social anxiety disorder. An imbalance in the brain chemical serotonin may be a factor. Other neurotransmitters that may be involved include dopamine and GABA.

Cognitive behavioral therapy (CBT) and exposure therapy are both very effective in the treatment of social anxiety disorder. Certain medications can also be helpful for social anxiety disorder. Sometimes, CBT or other behavior therapies are combined with medication. But regardless of the treatment approach, you will need a qualified therapist to oversee the process.

Cognitive Behavioral Therapy
The most frequently used form of psychotherapy for the treatment of social anxiety disorder, or social phobia, is cognitive behavioral therapy (CBT). This type of therapy is based on the premise that your own thoughts — not other people or situations — determine how you behave or react. Even if an unwanted situation doesn’t change — you still have to make that presentation at work; your sister still expects you at her wedding — you can change the way you think and behave in a positive way. CBT teaches you how to quell the anxiety you feel in social situations so you can face such situations, rather than avoiding them.
In CBT for social phobia, a therapist will first help you identify the automatic negative thoughts that underlie your fear of social situations. These negative assumptions might include thoughts such as “I don’t have anything interesting to say” or “I’m going to look stupid.” Once you’ve identified these negative thoughts, you and your therapist will analyze and challenge them. For example, you may ask yourself questions about the negative thoughts: “Do I know for sure that I won’t think of anything interesting to say?” or “Even if I’m nervous, will people necessarily think I look stupid?” Through this logical evaluation of your negative thoughts, you can gradually change them into more realistic and positive ways of perceiving anxiety-triggering situations. Other CBT techniques for social anxiety disorder might include role-playing and social skills training. As you act out and prepare for situations you are afraid of, you will become more and more comfortable and confident in your social abilities.

Exposure Therapy
In exposure therapy for social anxiety disorder, you are exposed in a safe and controlled way to the social situation you fear. Just as it is used in the treatment of other types of phobias exposure therapy for social phobia involves gradual, repeated encounters with the situation you fear. If you’re uncomfortable in large social gatherings, your therapist may first have you imagine being at a large party. Using relaxation techniques, you will imagine this anxiety-producing party until the fear begins to subside. Once you are able to imagine going to a party without fear, you may expose yourself to a party in real life. With each successful exposure experience, you feel an increasing sense of control over your social phobia and you become desensitized to your fear.

Three types of medication are sometimes used in the treatment of social anxiety disorder. However, because social anxiety disorder is typically a chronic condition, relapse rates are high when drug treatment is stopped. The advantage of CBT and exposure therapy is that improvement lasts once treatment is stopped.

Antidepressants - Antidepressants are considered to be the most effective medications for full-blown social anxiety disorder. Three specific antidepressants - Paxil, Effexor, and Zoloft - have been approved by the U.S. Food and Drug Administration for the treatment of social phobia, although others are used off-label.

Benzodiazepines - The class of anti-anxiety medications called benzodiazepines (including Valium, Xanax, and Ativan), can also be prescribed to reduce anxiety. However, because benzodiazepines are habit-forming, they are less often prescribed and then only for short-term use.

Beta blockers - For specific social phobias such as performance anxiety, beta blockers such as Inderal can be effective. Beta blockers work by blocking the flow of adrenaline that often occurs during a stressful event. While they don’t affect emotional symptoms of anxiety such as nervousness, beta blockers control physical symptoms such as sweating, rapid heart rate, and shaking hands or voice.

If you think you have an anxiety disorder, the first person you should see is your family doctor. A physician can determine whether the symptoms that alarm you are due to an anxiety disorder, another medical condition, or both.

If an anxiety disorder is diagnosed, the next step is usually seeing a mental health professional. The practitioners who are most helpful with anxiety disorders are those who have training in cognitive-behavioral therapy and/or behavioral therapy, and who are open to using medication if it is needed. You should feel comfortable talking with the mental health professional you choose. If you do not, you should seek help elsewhere. Once you find a mental health professional with whom you are comfortable, the two of you should work as a team and make a plan to treat your anxiety disorder together.

Remember that once you start on medication, it is important not to stop taking it abruptly. Certain drugs must be tapered off under the supervision of a doctor or bad reactions can occur. Make sure you talk to the doctor who prescribed your medication before you stop taking it. If you are having trouble with side effects, it’s possible that they can be eliminated by adjusting how much medication you take and when you take it.
Most insurance plans, including health maintenance organizations (HMOs), will cover treatment for anxiety disorders. Check with your insurance company and find out. If you don’t have insurance, the Health and Human Services division of your county government may offer mental health care at a public mental health center that charges people according to how much they are able to pay. If you are on public assistance, you may be able to get care through your state Medicaid plan.

Ways to Make Treatment More Effective
Many people with anxiety disorders benefit from joining a self-help or support group and sharing their problems and achievements with others. Internet chat rooms can also be useful in this regard, but any advice received over the Internet should be used with caution, as Internet acquaintances have usually never seen each other and false identities are common. Talking with a trusted friend or member of the clergy can also provide support, but it is not a substitute for care from a mental health professional.

Stress management techniques and meditation can help people with anxiety disorders calm themselves and may enhance the effects of therapy. There is preliminary evidence that aerobic exercise may have a calming effect. Since caffeine, certain illicit drugs, and even some over-the-counter cold medications can aggravate the symptoms of anxiety disorders, they should be avoided. Check with your physician or pharmacist before taking any additional medications.
The family is very important in the recovery of a person with an anxiety disorder. Ideally, the family should be supportive but not help perpetuate their loved one’s symptoms. Family members should not trivialize the disorder or demand improvement without treatment. If your family is doing either of these things, you may want to show them this booklet so they can become educated allies and help you succeed in therapy.