Social Anxiety Disorder (SAD)

Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by a significant amount of fear in one or more social situations causing considerable distress and impaired ability to function in at least some parts of daily life. [1] Social anxiety can be triggered by perceived or actual scrutiny from others. According to ICD-10 guidelines, the main diagnostic criteria of social anxiety disorder are

  • fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating
  • avoidance and
  • anxiety symptoms. [2]

Social anxiety is the most common anxiety disorder with up to 10% of people being affected at some point in their life. [3]

Physical symptoms often include

  • excessive blushing
  • excess sweating
  • trembling
  • palpitations
  • nausea

and also

  • stammering and
  • rapid speech.

Panic attacks can occur under intense fear and discomfort.

SAD is sometimes referred to as an “illness of lost opportunities” where “individuals make major life choices to accommodate their illness”. [2][4]

Many people with social experience are overly conscious of themselves in social situations, which makes these situations less fulfilling and successful than they could otherwise be. They focus heavily on the effect of their behaviors on other people. Often, they assume that people think negatively about them (mind reading) without any concrete evidence. Embarrassment, shame and even guilt often are felt, leading to a sense of loneliness and disconnection from the world.

Distorted thoughts are often self-defeating and inaccurate. Those with social phobia tend to interpret neutral or ambiguous conversations with a negative outlook, and many studies suggest that socially anxious individuals remember more negative memories than those less distressed. [5]

A previous negative social experience can be a trigger to social phobia. [6][7] perhaps particularly for individuals high in ‘interpersonal sensitivity’. An example of an instance may be that of a man at a social event walking up to a woman. If he is unable to say something within the first few seconds he might become conscious of there being a problem, and then of himself. Even if she would like to help him, he may interpret her reaction of looking at him as indifference or even rejection for his inability to start a conversation. This cognitive thought propels further anxiety which compounds with further stuttering, sweating, and, potentially, a panic attack. The result is a negative memory of a social interaction which can then generalize into all interactions, and lead to social isolation and loneliness.

Physiological aspects

Physiological effects, similar to those in other anxiety disorders, are present in those with social anxiety. [8] In adults, it may be (as a result of the fight-or-flight response)

  • tears
  • excessive sweating
  • nausea
  • difficulty breathing
  • shaking
  • palpitations

Walk disturbance may appear, especially when passing a group of people.

Blushing is commonly exhibited by individuals suffering from social phobia. [9] These visible symptoms further reinforce the anxiety in the presence of others.


Studies suggest that genetics can play a part in combination with environmental factors. Generally, social anxiety begins at a specific point in an individual’s life. As the individual tries hard to counter the social anxieties, they often become even stronger. Eventually, mild social awkwardness can develop into symptoms of social anxiety or phobia.

It is still not clear which proportion is inheritable, and which is learned. Studies of identical twins brought up (via adoption) in different families have indicated that, if one twin developed social anxiety disorder, then the other was between 30 percent and 50 percent more likely than average to also develop the disorder. [10] However, it may not social anxiety that is heritable, but rather anxiety or depression in general. [11]

Studies suggest that parents of those with social anxiety disorder tend to be more socially isolated themselves (Bruch and Heimberg, 1994; Caster et al., 1999), and shyness in adoptive parents is significantly correlated with shyness in adopted children (Daniels and Plomin, 1985). It has been shown that there is a two to threefold greater risk of having social phobia if a first-degree relative also has the disorder, but this could also be transmitted through rearing and social education.

Adolescents who were rated as having an insecure (anxious-ambivalent) attachment with their mother as infants were twice as likely to develop anxiety disorders by late adolescence, [12] including social phobia. Absent parents or an unpredictable parenting style can also contribute to problems in developing a healthy and complete self-image and security in human interactions.

For around half of those diagnosed with social anxiety disorder, a specific traumatic or humiliating social event appears to be associated with the onset or worsening of the disorder. [13] Often this may be related to a situation where a sense of individual performance is important, for example regarding public speaking.

Shy adolescents or avoidant adults have emphasized unpleasant experiences with peers [14] or childhood bullying or harassment. In one study, popularity was found to be negatively correlated with social anxiety, and children who were neglected by their peers reported higher social anxiety and fear of negative evaluation than other categories of children. [15] Socially phobic children appear less likely to receive positive reactions from peers [16] and anxious or inhibited children may isolate themselves. [17]

Important may also be how a society views shyness and social anxiety. The more a culture emphasizes as extroversion and being outgoing as a desirable trait, the more inept and socially inadequate may feel those who feel socially sensitive and anxious.

People with social anxiety may not have lower social skills, but they often attach a greater importance to how the social interaction unfolds. Research has indicated the role negative beliefs play, which can be ‘core’ or ‘unconditional’ beliefs, such as “I am inept”, or ‘conditional’ beliefs, such as “If I show myself, I will be rejected”. Negative beliefs are thought to develop based on personality and adverse experiences and to be activated when the person feels under threat. [18]

One model [19] emphasizes the development of a distorted mental representation of the self and overestimates of the likelihood and consequences of negative evaluation, and of the performance standards that others have. Negatively biased memories of the past often seem to play a role, leading to anxiety before an interaction and unhelpful interpretations and ruminations after it.

Studies have highlighted the role of subtle avoidance and defensive factors, and shown how attempts to avoid feared negative evaluations or use ‘safety behaviors’ (Clark & Wells, 1995) can make social interaction more difficult and the anxiety worse in the long run.


The neural foundations of social anxiety disorder have been studied extensively. [20] [21] A 2006 study found that the area of the brain called the amygdala, part of the limbic system, is hyperactive when patients are shown threatening faces or confronted with frightening situations. They found that patients with more severe social phobia showed a correlation with the increased response in the amygdala. [22] The amygdala is part of the limbic system which is related to fear cognition and emotional learning. Individuals with social anxiety disorder have been found to have a hypersensitive amygdala; for example, in relation to social threat cues (e.g. perceived negative evaluation by another person), angry or hostile faces, and while waiting to give a speech. [23]

Sociability seems to be tied closely tied to dopamine neurotransmission. [24] and social anxiety disorder may involve reduced serotonin receptor binding. [25] A recent study reports increased serotonin transporter binding in psychotropic medication-naive patients with generalized social anxiety disorder. [26]

Recent research has also indicated that another area of the brain, the anterior cingulate cortex, which was already known to be involved in the experience of physical pain, also appears to be involved in the experience of ‘social pain’, for example perceiving group exclusion. [27] A 2007 meta-analysis also found that individuals with social anxiety had hyperactivation in the amygdala and insula areas which are frequently associated with fear and negative emotional processing. [28]


Psychotherapy is the first line of treatment.

Medication can be a valuable support. The serotonin reuptake inhibitors (SSRIs) have been helpful in the treatment of social anxiety in a number of cases. Paroxetine and sertraline are two SSRIs that have been confirmed by the FDA to treat social anxiety disorder.


[1] National Institute for Health and Clinical Excellence: Guidance. Social Anxiety Disorder: Recognition, Assessment and Treatment. Leicester (UK): British Psychological Society; 2013. PMID 25577940


[3] Craske, MG; Stein, MB (24 June 2016). “Anxiety.”. Lancet (London, England). PMID 27349358.

[4] Shields, Margot (2004). “Social anxiety disorder— beyond shyness” (PDF). How Healthy are Canadians? Statistics Canada Annual Report. 15: 58. Retrieved 17 March2014.

[5] Furmark, Thomas. Social Phobia – From Epidemiology to Brain Function. Retrieved February 21, 2006.

[6] National Center for Health and Wellness.Causes of Social Anxiety Disorder. Retrieved February 24, 2006.

[7] phobia. 1999. Retrieved February 24, 2006.

[8] eNotes. Social phobia – Causes. Retrieved February 22, 2006.

[9] Furmark, Thomas. Social Phobia – From Epidemiology to Brain Function. Retrieved February 21, 2006.

[10] Kendler K, Karkowski L, Prescott C (1999). “Fears and phobias: reliability and heritability”. Psychol Med. 29 (3): 539–53. doi:10.1017/S0033291799008429. PMID 10405076.

[11] Merikangas, Avenevoli S., Dierker L., Grillon C. (1999). “Vulnerability factors among children at risk for anxiety disorders”. Biol Psychiatry. 46 (11): 1523–1535. doi:10.1016/S0006-3223(99)00172-9. PMID 10599480.

[12] Warren S, Huston L, Egeland B, Sroufe L (1997). “Child and adolescent anxiety disorders and early attachment”. J Am Acad Child Adolesc Psychiatry. 36 (5): 637–644. doi:10.1097/00004583-199705000-00014. PMID 9136498.

[13] Mineka S, Zinbarg R (1995) Conditioning and ethological models of social phobia. In: Heimberg R, Liebowitz M, Hope D, Schneier F, editors. Social Phobia: Diagnosis, Assessment, and Treatment. New York: The Guilford Press, 134–162

[14] Ishiyama F (1984). “Shyness: Anxious social sensitivity and self-isolating tendency”. Adolescence. 19 (76): 903–911. PMID 6516936.

[15] La Greca A, Dandes S, Wick P, Shaw K, Stone W (1988). “Development of the social anxiety scale for children: Reliability and concurrent validity”. J Clin Child Psychol. 17: 84–91. doi:10.1207/s15374424jccp1701_11.

[16] Spence SH, Donovan C, Brechman-Toussaint M (May 1999). “Social skills, social outcomes, and cognitive features of childhood social phobia”. J Abnorm Psychol. 108 (2): 211–21. doi:10.1037/0021-843X.108.2.211. PMID 10369031.

[17] Rubin KH, Mills RS (December 1988). “The many faces of social isolation in childhood”. J Consult Clin Psychol. 56 (6): 916–24. doi:10.1037/0022-006X.56.6.916. PMID 3204203.

[18] Beck AT, Emery G, Greenberg RL (1985) Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books.

[19] Rapee RM, Heimberg RG (August 1997). “A cognitive-behavioral model of anxiety in social phobia”. Behav Res Ther. 35 (8): 741–56. doi:10.1016/S0005-7967(97)00022-3. PMID 9256517.

[20] M. S. Marcin; C. B. Nemeroff (2003). “The neurobiology of social anxiety disorder:the relevance of fear and anxiety”. Acta Psychiatr Scand. 108 (417): 51–64. doi:10.1034/j.1600-0447.108.s417.4.x.

[21] Sanjay J. Mathew; Jeremy D. Coplan; Jack M. Gorman (2001). “Neurobiological Mechanisms of Social Anxiety Disorder”. Am J Psychiatry. 158 (10): 1558–1567. doi:10.1176/appi.ajp.158.10.1558PMID 11578981.

[22] Studying Brain Activity Could Aid Diagnosis Of Social Phobia. Monash University. January 19, 2006.

[23] Davidson RJ, Marshall JR, Tomarken AJ, Henriques JB (January 2000). “While a phobic waits: regional brain electrical and autonomic activity in social phobics during anticipation of public speaking”. Biol. Psychiatry. 47 (2): 85–95. doi:10.1016/S0006-3223(99)00222-X. PMID 10664824.

[24] Rammsayer T. H. (1998). “Extraversion and dopamine: Individual differences in response to changes in dopaminergic activity as a possible biological basis of extraversion”. European Psychologist. 3 (1): 37–50. doi:10.1027/1016-9040.3.1.37.

[25] Lanzenberger, R. R.; Mitterhauser, M.; Spindelegger, C.; Wadsak, W.; Klein, N.; Mien, L. K.; Holik, A.; Attarbaschi, T.; Mossaheb, N.; Sacher, J.; Geiss-Granadia, T.; Kletter, K.; Kasper, S.; Tauscher, J. (2007). “Reduced Serotonin-1A Receptor Binding in Social Anxiety Disorder”. Biological Psychiatry. 61 (9): 1081–1089. doi:10.1016/j.biopsych.2006.05.022PMID 16979141.

[26] van der Wee; et al. (May 2008). “Increased Serotonin and Dopamine Transporter Binding in Psychotropic Medication–Naïve Patients with Generalized Social Anxiety Disorder Shown by 123I-ß-(4-Iodophenyl)-Tropane SPECT”. The Journal of Nuclear Medicine. 49 (5): 757–63. doi:10.2967/jnumed.107.045518PMID 18413401.

[27] Eisenberger NI, Lieberman MD, Williams KD (October 2003). “Does rejection hurt? An FMRI study of social exclusion”. Science. 302 (5643): 290–2. doi:10.1126/science.1089134. PMID 14551436.

[28] Etkin, Amit; Wager, Tor D. (2007-10-01). “Functional Neuroimaging of Anxiety: A Meta-Analysis of Emotional Processing in PTSD, Social Anxiety Disorder, and Specific Phobia”. The American Journal of Psychiatry. 164 (10): 1476–1488. doi:10.1176/appi.ajp.2007.07030504. ISSN 0002-953X. PMC 3318959. PMID 17898336.

Further reading

  • American Psychiatric Association. (2000). Anxiety disorders. In Diagnostic and statistical manual of mental disorders (4th ed., text rev., pp. 450–456). Washington, D.C.: American Psychiatric Association.
  • Beidel, D. C., & Turner, S. M. (2007). Shy children, phobic adults: Nature and treatment of social anxiety disorders (2nd ed.) (pp. 11–46). Washington, DC US: American Psychological Association. doi:10.1037/11533-001
  • Bruch M. A. (1989). “Familial and developmental antecedents of social phobia: Issues and findings”. Clinical Psychology Review. 9: 37–47. doi:10.1016/0272-7358(89)90045-7.
  • Crozier, W. R., & Alden, L. E. (2001). International Handbook of Social Anxiety: Concepts, Research, and Interventions Relating to the Self and Shyness. New York: John Wiley & Sons, Ltd. ISBN 0-471-49129-2.


© Dr Christian Jonathan Haverkampf. All rights reserved.

Psychotherapy & Counselling, Communication, Medicine (Psychiatry); Dublin, Ireland

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This article is solely a basis for academic discussion and no medical advice can be given in this article, nor should anything herein be construed as advice. Always consult a professional if you believe you might suffer from a physical or mental health condition.

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