Psychiatric Care for Social Anxiety

Social anxiety is an intense, lasting fear of being watched, judged or embarrassed in social or performance situations. People may avoid meetings, presentations, parties or phone calls, or endure them with great distress. It is more than shyness, and it can limit careers, friendships and school life.

How our physicians help

Our physicians take time to understand where the anxiety shows up and how it affects your life. Care can include cognitive behavioral therapy with gradual practice in feared situations, and medication when appropriate, from the same physician. For young people, we work with parents and, with permission, with schools.

What social anxiety feels like for adults

At its core, social anxiety is the belief that others will notice a flaw and think less of you.

• You dread being introduced to a group, or eating or signing your name while someone watches.
• You worry people can see you blush, sweat, shake or lose your words.
• You rehearse what to say, then replay it for hours afterward, hunting for mistakes.
• You get through events by staying on your phone or having a drink first.
• You have turned down a promotion or a date to avoid being the focus.

Social anxiety in children and teens

Socially anxious young people often seem quiet and well behaved, so adults can miss it.

• Crying, freezing or clinging before a birthday party or class presentation.
• Talking freely at home but going silent at school, which may be selective mutism.
• Never raising a hand, even when they know the answer.
• Teens living mostly online while skipping plans with classmates.

Is it social anxiety or something else?

Feeling nervous before a wedding toast is ordinary. A diagnosis fits when the fear is out of proportion, has lasted for months, and limits your life. We ask what you fear others will see, which situations are hardest and what you do to cope. For some people the fear covers most social contact. For others it appears only during performance, such as a recital.

Other conditions can look similar. In panic disorder, the fear centers on the attack itself. In depression, people may pull away because they have lost interest or energy. Autism involves differences in social communication and can occur along with social anxiety.

How social anxiety is treated

Cognitive behavioral therapy (CBT) for social anxiety works on the predictions behind the fear. If you expect everyone to stare at your shaking hands, you and your therapist set up a small real-life test and compare what you expected with what happened. You practice dropping safety behaviors, the habits that feel protective but keep the fear alive, such as scripting every sentence. You also learn to focus on the conversation instead of watching yourself. This can feel awkward, and it takes repeated practice.

SSRIs and SNRIs, two antidepressant classes, can turn down the background fear so that practice feels more possible. It can be several weeks before they help, and nausea or sexual side effects are possible. Beta blockers, a different class, quiet a pounding heart or shaky hands for a specific event, but they do not change fearful thoughts, and they are not safe for everyone, including some people with asthma or heart conditions. For young people, therapy with parents involved usually comes first. Antidepressants carry a warning about suicidal thoughts in children, teens and young adults, so we watch closely after starting one.

How family and friends can help

Stepping in can feel kind, but ordering for someone, answering for them or making their calls can keep the fear in place. Ask what small stretch they would be willing to try, and praise the effort, whatever the result. With a child, wait through the pause and let them answer.

It is time to reach out when fear is shaping choices about work, school or relationships. Years of avoiding people can also lead to loneliness and low mood. If you or a loved one feels hopeless or is thinking about suicide, call or text 988 (the Suicide & Crisis Lifeline) or call 911. We are not an emergency service.

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