Last Updated on March 13, 2023 by Mike Robinson

Social phobia is characterized by an excessive fear of relating in social situations, of being publicly humiliated, or of acting in public. It is estimated that it affects up to 13% of the population at some vital moments.

It usually begins in adolescence and is more common in young people aged 15–29 with little education, who are single, and from low socioeconomic backgrounds.

History of social phobia

Descriptions of shyness have been appearing in literature since 400 BC with Hippocrates, who made this description:

“He does not dare to be in company for fear of being dishonored or used; he thinks that other men are watching him. “

The first mention of the term social phobia was made at the beginning of the 20th century. Psychologists used the term “social neurosis” to describe extremely shy patients. The idea that social phobia was a separate entity from other phobias came with psychiatrist Isaac Marks in the 1960s.

This idea was accepted by the American Psychiatric Association (APA) and was officially included in the third edition of the DSM-5.

Its definition was revised in 1989 to allow for its comorbidity with avoidant personality disorder.

Symptoms of social phobia

Just because you are nervous in some social situations does not mean that you have social phobia (FS). Many people are shy or too self-conscious, and that does not cause them big problems in their daily lives.

If it interferes with your routine, it can cause anxiety and stress and decrease your quality of life.

For example, many people get nervous when speaking in public , although people with FS feel worried for weeks or months before doing so or literally become paralyzed when they do.

Emotional symptoms

• Extreme fear of being observed or judged by others.
• Excessive anxiety in everyday social situations
• Intense worry for weeks or even months before a social situation
• afraid that others will realize that you are nervous.
• fear of acting and being humiliated.

Physical symptoms

• Fast breathing.
• Turn red.
• nausea and stomach pain
• chest pressure or tachycardia.
• Trembling voice.
• feeling dizzy or lightheaded.

Behavioral symptoms

Avoid social situations to the degree that they limit your activities or interrupt your life.

Escape from social situations

The need to always be surrounded by someone you know

Drink before social situations to reduce your nerves.

In children

It is normal for a child to be shy. However, when you have FS, you experience extreme discomfort when engaging in daily activities such as playing with other children, reading in class, talking to other adults, or acting in front of others.

Stressful situations

The following situations are often stressful for people with FS:

• Meet new people.
• Be in the limelight.
• Be observant when doing something.
• to speak in public.
• acting in front of people.
• be criticized in court.
• Talk to “important” people or authority figures.
• Go on a date.
• Make phone calls.
• Use public toilets.
• Do tests.
• Eat or drink in public.
• Go to parties or social events.

The following descriptions could be from people with FS:

“In any social situation, I am afraid. I am anxious before leaving home and even more during the whole event. The closer I am to the social situation, the more anxious I am. My heart starts beating and I start to sweat when I think about social situations. “

“When I walk into a room full of people, I blush and feel as if everyone is looking at me.”

“At school, I was always afraid of being called on, even when I knew the answers. When I had work, I hated to see my boss. I could not eat with my colleagues or go to corporate parties. I worried about being tried or looked at; I did not want to look silly. Sometimes I could not eat or sleep for days before a meeting. “

Causes of Social Phobia

Currently, it is considered an integrative model. That is, the causes that intervene in the development of social phobia are biological, psychological, and social.

Scientists have yet to determine the exact causes. Additionally, studies suggest that genetics play an important role along with environmental factors.

Usually the FS begins at a specific point in life, from which it develops.

Biological causes

It seems that, by evolution, the human being is prepared to fear people who reject us, criticize us, or show anger. Thousands of years ago, our ancestors would avoid hostile rivals who might harm or kill them. This is something that actually occurs in all species.

This theory would argue that we have inherited the genes of those people who learned to move away from these signs of violence.

As early as 4 months, some babies show patterns of shyness when they cry or are agitated by social stimuli or toys. It can inherit a tendency to be socially inhibited.

Consequently, growing up with overprotective or hypercritical parents is also associated with FS.

Psychological Causes

This factor intervenes with the learning that is not in control of the events. In addition, an unexpected panic attack can occur in a social situation that causes their association with social situations.

In this case, the person would feel anxiety every time he encountered a social situation similar to the one that caused the attack. Real situations that produce trauma, such as bullying in adolescence or childhood, can also be given.

On the other hand, it is also influenced by the fact that parents transmit to their children a concern for the opinions of others.

Social Causes

A negative social experience can cause FS to develop, with interpersonally sensitive people more likely to develop it. Approximately 50% of people diagnosed with social anxiety have had a traumatic or humiliating social event.

Like direct experiences, observing or hearing about the negative experiences of other people can develop the FS. Also, FS may be triggered by the long-term effects of not fitting in or being bullied, rejected, or ignored.

Cultural Influences

Attitudes towards shyness and avoidance are factors that have been related to FS. One study found that the effects of education on the part of the parents depended on the culture.

American children seemed to be more likely to develop FS if their parents emphasized the importance of others’ opinions or used shame as a disciplinary tactic.

However, that association was not found in Chinese children. In China, shy or inhibited children are more accepted than their peers and are more likely to be considered leaders, unlike in Western countries.

Physiological Mechanisms

Although the exact neuronal mechanisms have not been found, there is evidence linking FS with imbalances in some neurotransmitters and hyperactivity in some brain areas.

Dopamine

Sociability is closely linked to dopaminergic neurotransmission.

The misuse of stimulants, such as amphetamines, to increase self-esteem and improve social performance is common.

Although there is little evidence of abnormalities in serotonin neurotransmission, the limited efficacy of drugs that affect serotonin levels may indicate the role of this neurotransmitter.

Paroxetine and sertraline are two SSRIs (selective serotonin reuptake inhibitors) that have been confirmed by the FDA to treat social anxiety disorder. Additionally, SSRIs are believed to decrease the activity of the amygdala.

There is also a growing focus on other transmitters, such as norepinephrine and glutamate, which could be more active in social anxiety disorder, and the transmitter inhibitor GABA, which could be less active in the thalamus.

Brain Effect

The amygdala is part of the limbic system, which is related to fear and emotional learning. People with social anxiety have a hypersensitive amygdala in threatening social situations or hostile facial faces.

On the other hand, recent research has indicated that the anterior cingulate cortex, which is related to the experience of physical pain, also seems to be related to “social pain,” for example with group rejection.

Diagnosis

Diagnostic criteria according to DSM-IV

1. A) Accused and persistent fear of one or more social situations or actions in public in which the subject is exposed to people outside the family or possible evaluation by others. The individual is afraid to act in a way that is humiliating or embarrassing. Note: In children, it is necessary to have demonstrated that their abilities to socially relate to their relatives are normal and have always existed and that social anxiety appears in meetings with individuals of the same age and not only in any relationship with an adult.
2. B) Exposure to dreaded social situations almost invariably causes an immediate anxiety response, which can take the form of a situational crisis of angst or be more or less related to a situation. Note: In children, anxiety can result in crying, tantrums, inhibition, or withdrawal in social situations where the attendees belong to the family setting.
3. C) The individual recognizes that this fear is excessive or irrational. Note: Children may miss this recognition.
4. D) Social situations or feared public performances are avoided or experienced with intense anxiety or discomfort.
5. E) Avoidance behaviors, anxious anticipation, or discomfort in feared public situations strongly interfere with the individual’s normal routine, labor, academics, or social relationships or produce clinically significant discomfort.
6. F) In individuals younger than 18 years, the duration of the symptomatic picture should be prolonged for at least 6 months.
7. G) The avoidance behavior or behavior is not due to the direct physiological effects of a substance or a medical illness and cannot be better explained by the presence of another mental disorder.
8. H) If there is a medical illness or other mental disorder, the fear described in Criterion A is not related to these processes.

Specify if:

Generalized: If fears refer to most social situations,

Comorbidity

FS shows a high degree of comorbidity (co-occurrence) with other psychiatric disorders.

In fact, one population study found that 66% of people with FS had one or more additional mental disorders.

FS often occurs along with low self-esteem and clinical depression, perhaps due to a lack of personal relationships and long periods of social isolation.

To try to reduce anxiety and depression, people with social phobia can use alcohol or other drugs, which can lead to substance abuse.

It is estimated that one in five people with FS also suffer from alcohol dependence, although other researchers suggest that FS is unrelated or that it is protective against problems with alcohol.

Other disorders common with FS are:

• The Depression.
• Anxiety disorders, particularly generalized anxiety disorder
• Personality avoidance disorder

Treatment

The most effective treatments for social phobia are behavioral and cognitive.

Cognitive-behavioral therapy

Cognitive behavioral therapy aims to modify thoughts and behaviors into more adaptive ones.

Suitable treatments may include:

• Group exhibition.
• social skills training.
• Cognitive restructuring

1-Exhibition

It is an effective treatment for social phobia. Its intent is for the person to faces his fears. Consequently, he will accustom himself to the situations until the anxiety diminishes.

Some indications for exposure sessions are:

• Repeated and short exposure sessions
• Teach students to take advantage of situations in daily life.
• Accept that the behavior of others is unpredictable.
• Explain how the problem originates and persists.

2-Cognitive techniques

The most commonly used techniques are Beck cognitive therapy and Ellis rational emotional therapy.

The goals are:

• Gain expectations of control over behavior and events.
• Change attention by increasing activation and physical symptoms.
• Remove repetitive thoughts about the occurrence of the symptoms or consequences that are feared.
• Encourage proactivity and value achievements.

3-Social Skills Training

If, for any reason, the person has not been able to learn social skills , it will be important to establish this training.

When the person is afraid to show physiological symptoms such as turning red, tremoring, or sweating, they may:

• The paradoxical intention
• The rational-emotional therapy
• The exhibition.
• In people with high levels of anxiety, relaxation techniques can complement the exposure well.

For people with social phobia and some personality disorders, cognitive-behavioral therapies will have to be longer.

Group therapy may be too scary for some people, although it has certain advantages:

• Encouraging trust rather than reliance on the therapist.
• allows group exhibition tasks.
• It allows you to make a commitment publicly, which increases motivation .
• The person perceives that there are other people with the same problem.
• Create social resources.

Group Therapy

Other cognitive-behavioral techniques for FS include role-playing and training in social skills as part of group therapy.

Medication

The medication can be used to decrease the symptoms associated with FS, although it is not a cure. Conversely, the medication is stopped, the symptoms reappear. Therefore, medication is most useful when taken together with therapy.

Three types of drugs are used:

• Beta-blockers are used to decrease anxiety. They work by blocking the flow of adrenaline when you’re anxious. They do not affect emotional symptoms, although they do affect physical ones such as sweating or tachycardia.
• Selective serotonin reuptake inhibitors (SSRIs) are the first choice of drugs. Compared with other forms of medication, there is less risk of tolerance and dependence.
• Benzodiazepines act quickly, although they are addictive and sedatives, which is why they are only prescribed when other drugs do not work.
• Selective norepinephrine reuptake inhibitors (NRTIs) have shown similar effectiveness to SSRIs. Some are venlafaxine or milnacipran.

Self-help tips

Challenge negative thoughts

If you have FS, you are very likely to have negative thoughts and beliefs that contribute to anxiety.

You may have thoughts like:

• “I’m going to look like a fool.”
• “I will feel nervous and be humiliated.”
• “People will think I’m incompetent.”
• “I have nothing to say.”

Challenge these negative thoughts for yourself or with a therapist as a way to reduce FS symptoms.

First, identify what negative thoughts underlie your fear of social situations.

Then challenge them and change them to more positive and realistic ones with questions like:

• Am I sure that you seem incompetent?
• Are you sure I have nothing to say?

Here are some thought patterns that are common in FS:

Read the mind: Assume that you know what other people are thinking and that they see you in the same negative way in which you see yourself.

Predict the future: assume that the worst will happen.

Catastrophic thoughts: getting things out of their real importance. For example, believe that if people notice that you are nervous, it will be terrible or disastrous.

Customize: Assume that people focus on you in a negative way.

How do you stop thinking that everyone is watching you?

To reduce self-attention, pay attention to what is happening around you instead of looking at yourself or focusing on your anxiety symptoms.

• Observe the people in your environment.
• Listen to the word spoken, not your thoughts.
• Do not take all the responsibility for trying to keep the talks going; the silences are good, and others can contribute.

Control your breathing.

A change in your body when you are anxious is that you begin to breathe quickly, which leads to other symptoms such as nausea, dizziness, hot flashes, tachycardia, or muscle tension.

Learning to control your breathing can help reduce those symptoms. You can practice this exercise by:

• Sit comfortably and straight in a chair, leaving your body relaxed. Put one hand on your chest and the other on your stomach.
• Inhale slowly and deeply through your nose for four seconds. The hand of your stomach should ascend, while the hand of your chest should move very little.
• Hold your breath for two seconds.
• Exhale slowly through your mouth for six seconds, expelling as much air as you can. The hand on your stomach should move as you exhale, and your other hand should move very little.
• Continue breathing through your nose and expelling through your mouth. Focus on slowly breathing in a pattern of: inhale for 4 seconds, hold for 2 seconds, and exhale for 6 seconds.

Practice relaxation techniques.

In addition to deep breathing exercises, regular practice of relaxation techniques such as yoga, medication, or progressive muscle relaxation will also help control the symptoms of anxiety.

One of the most valuable things you can do to overcome the FS is to face your fears in social situations.

Avoidance helps to maintain the disorder. Which is not what you want.  Although it makes you more comfortable in the short term, it prevents you from being more comfortable in social situations that you will have to face.

Avoidance prevents you from doing things you would like to do, reaching certain goals, or participating in social activities.

Follow these tips:

• Face situations slowly: if you are afraid to speak in public, you do not face a room of 100 people. For example, it begins by having people participate in groups by raising their hands. Subsequently, it begins to make activities increasingly difficult.
• Be patient. Overcoming the FS requires practice and patience. It is a gradual process, and at the beginning, it is normal that things do not go as well as you would like. The most important thing is to act.
• Use the skills explained above to relax.
• build personal relationships.

The following tips are good ways to start interacting with other people:

• Take social skills classes.
• Participate in volunteering.
• Work on your communication skills .
• Join social activities such as group sports, workshops, dance, etc.
• Change your lifestyle.

The following tips can help you reduce your anxiety levels in social situations:

• Avoid or limit caffeine: Coffee, tea, or energy drinks act as stimulants that increase your anxiety symptoms.
• Avoid alcohol, or at least drink in moderation. Alcohol increases your chances of having an anxiety attack.
• Stop Smoking: Nicotine is a strong stimulant that leads to higher levels of anxiety.
• Get enough sleep. When you lack sleep, you are more vulnerable to anxiety. Getting enough rest will help you to relax in social situations.