Social phobia (social anxiety): Symptoms, diagnosis and treatment

By Cristiano Antonino On Jan 16, 2023

The main characteristic of social phobia is the fear of acting, in front of others, in an embarrassing or humiliating way and of receiving negative judgement

Social anxiety can lead sufferers to avoid most social situations, for fear of behaving ‘wrong’ and being misjudged.

Social phobia is a widespread disorder among the population

According to some studies, the percentage of people who suffer from it ranges from 3% to 13%.

Also according to these studies, it seems that social anxiety characterises women more than men.

Usually, the situations most feared by those who suffer from social phobia (or social anxiety) are those that involve having to do something in front of other people, such as presenting a report or even just signing, phoning or eating; sometimes it can create social anxiety simply to enter a room where people are already sitting, or to talk to a friend.

Characteristics of social phobia

People who suffer from social phobia are afraid of appearing anxious and showing the ‘signs’ of it, i.e. they are afraid of turning red in the face, of shaking, of stuttering, of sweating, of having a pulse, or of remaining silent without being able to talk to others, without having the ‘ready’ joke.

Finally, it often happens that those who experience social anxiety, when they are not in a feared situation, recognise their fear as unreasonable and consequently tend to blame themselves and reproach themselves for not being able to do things that everyone else does.

Social phobia, if left untreated, tends to remain stable and chronic, and can often give rise to other disorders such as depression.

This disorder normally seems to begin in adolescence or early adulthood.

Two types of Social Phobia are usually distinguished:

simple, when the person experiences social anxiety in only one or a few types of situations (e.g. is unable to speak in public, but has no problems in other social situations such as attending a party or talking to a stranger);
generalised, when the person fears almost all social situations. In the more severe and pervasive forms, the diagnosis of Avoidant Personality Disorder tends to be preferred.

Social phobia symptoms

The main characteristic of social phobia is the fear of being in social situations or of being observed while doing something, such as speaking in public or, more simply, talking to a person, writing, eating or telephoning.

In feared social situations, individuals with social anxiety are worried about appearing embarrassed and, above all, are afraid that others will judge them anxious, weak, ‘crazy’, or stupid.

Symptoms of social phobia include fear of speaking in public out of concern that one will suddenly forget what one is supposed to say or fear that others will notice one’s hands or voice shaking, or extreme anxiety when conversing with others out of fear of appearing unclear.

The most commonly perceived (anxiety-related) symptoms of social phobia are: palpitations (79%), trembling (75%), sweating (74%), muscle tension (64%), nausea (63%), dry mouth (61%), flushing (57%), redness (51%), headaches (46%).

Consequential avoidances

The symptoms of social phobia may lead the subject to avoid eating, drinking or writing in public, for fear of being embarrassed that others might see his or her hands shaking.

Obviously, these people try hard to avoid such situations or, if they are forced to, they endure them with a very high burden of discomfort.

Anticipatory anxiety

Another typical feature of this disorder is a marked social anxiety that precedes dreaded situations and is called anticipatory anxiety.

Thus, already before facing a social situation (e.g. going to a party or going to a business meeting), people begin to worry about such an event.

As is often the case with phobic disorders, people experiencing such a disorder recognise, when they are far away from the feared situations, that their fears are only completely unreasonable, excessive and silly.

They thus come to further blame themselves for the symptoms of social phobia themselves and for their own avoidant behaviour.

Social phobia, the cure

As with other anxiety disorders, cognitive behavioural psychotherapy has generally proven to be very effective in treating social phobia.

Certain medications can sometimes be helpful.

Psychotherapy

Cognitive behavioural psychotherapy focuses on the ‘here and now’, on the direct treatment of the symptom.

It aims, on the one hand, to change dysfunctional thoughts and, on the other hand, to provide the person with better skills and abilities to cope with feared situations.

Dysfunctional or irrational beliefs are thoughts that people have about events, in which they find themselves involved and which stem, in turn, from rigid and unadaptive cognitive schemata.

Such as, for example, the belief that showing anxiety is a sign of weakness or the belief that one is always closely watched by others.

Such thoughts only come into operation, so to speak, when a person has to face a social situation.

That is, he has to expose himself to possible judgement from others, thus triggering anxiety and the consequent feeling of losing control.

The treatment of social phobia, on the one hand, aims at modifying such assumptions during psychotherapeutic work, on the other hand, it tries to teach skills to handle social situations better.

These skills usually involve both techniques (such as relaxation training) for managing anxiety and techniques for managing verbal interaction.

Cognitive behavioural therapy for the treatment of social phobia can best be conducted in individual sessions.

This does not detract from the fact that, whenever possible, group treatment has considerable advantages, starting with the obvious fact of already being in a social situation.

Pharmacological therapy

The pharmacological treatment of social phobia, although generally not very effective, is basically based on two classes of drugs: benzodiazepines and antidepressants.

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The prescription of benzodiazepines alone is rarely decisive.

In the case of social anxiety, however, both alprazolam and clonazepam have proven to be of some effectiveness.

In spite of this, the use of these molecules must always be carefully evaluated because of the addictive and abusive effects that can develop.

As well as for the possible difficulties (such as the development of ‘rebound’ anxiety) that can be generated when they are discontinued.

Among the tricyclic antidepressants, usually the most widely used molecule in this class is imipramine.

The use of these drugs in the treatment of social phobia, however, does not appear to be particularly promising.

Among the selective serotonin reuptake inhibitors (SSRIs), the following have been used to treat social anxiety: fluvoxamine, fluoxetine, sertraline and paroxetine.

To a greater or lesser extent, all have shown some efficacy in symptomatic remission, although it must be emphasised that the results are not always maintained when the drug is discontinued.

If nothing else, these molecules have fewer side effects than the other drug classes.