Social anxiety attack

Social anxiety disorder (social phobia) - Symptoms and causes


It's normal to feel nervous in some social situations. For example, going on a date or giving a presentation may cause that feeling of butterflies in your stomach. But in social anxiety disorder, also called social phobia, everyday interactions cause significant anxiety, self-consciousness and embarrassment because you fear being scrutinized or judged negatively by others.

In social anxiety disorder, fear and anxiety lead to avoidance that can disrupt your life. Severe stress can affect your relationships, daily routines, work, school or other activities.

Social anxiety disorder can be a chronic mental health condition, but learning coping skills in psychotherapy and taking medications can help you gain confidence and improve your ability to interact with others.

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Feelings of shyness or discomfort in certain situations aren't necessarily signs of social anxiety disorder, particularly in children. Comfort levels in social situations vary, depending on personality traits and life experiences. Some people are naturally reserved and others are more outgoing.

In contrast to everyday nervousness, social anxiety disorder includes fear, anxiety and avoidance that interfere with relationships, daily routines, work, school or other activities. Social anxiety disorder typically begins in the early to mid-teens, though it can sometimes start in younger children or in adults.

Emotional and behavioral symptoms

Signs and symptoms of social anxiety disorder can include constant:

  • Fear of situations in which you may be judged negatively
  • Worry about embarrassing or humiliating yourself
  • Intense fear of interacting or talking with strangers
  • Fear that others will notice that you look anxious
  • Fear of physical symptoms that may cause you embarrassment, such as blushing, sweating, trembling or having a shaky voice
  • Avoidance of doing things or speaking to people out of fear of embarrassment
  • Avoidance of situations where you might be the center of attention
  • Anxiety in anticipation of a feared activity or event
  • Intense fear or anxiety during social situations
  • Analysis of your performance and identification of flaws in your interactions after a social situation
  • Expectation of the worst possible consequences from a negative experience during a social situation

For children, anxiety about interacting with adults or peers may be shown by crying, having temper tantrums, clinging to parents or refusing to speak in social situations.

Performance type of social anxiety disorder is when you experience intense fear and anxiety during speaking or performing in public but not in other types of more general social situations.

Physical symptoms

Physical signs and symptoms can sometimes accompany social anxiety disorder and may include:

  • Blushing
  • Fast heartbeat
  • Trembling
  • Sweating
  • Upset stomach or nausea
  • Trouble catching your breath
  • Dizziness or lightheadedness
  • Feeling that your mind has gone blank
  • Muscle tension
Avoiding common social situations

Common, everyday experiences may be hard to endure when you have social anxiety disorder, including:

  • Interacting with unfamiliar people or strangers
  • Attending parties or social gatherings
  • Going to work or school
  • Starting conversations
  • Making eye contact
  • Dating
  • Entering a room in which people are already seated
  • Returning items to a store
  • Eating in front of others
  • Using a public restroom

Social anxiety disorder symptoms can change over time. They may flare up if you're facing a lot of changes, stress or demands in your life. Although avoiding situations that produce anxiety may make you feel better in the short term, your anxiety is likely to continue over the long term if you don't get treatment.

When to see a doctor

See your doctor or a mental health professional if you fear and avoid normal social situations because they cause embarrassment, worry or panic.

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Like many other mental health conditions, social anxiety disorder likely arises from a complex interaction of biological and environmental factors. Possible causes include:

  • Inherited traits. Anxiety disorders tend to run in families. However, it isn't entirely clear how much of this may be due to genetics and how much is due to learned behavior.
  • Brain structure. A structure in the brain called the amygdala (uh-MIG-duh-luh) may play a role in controlling the fear response. People who have an overactive amygdala may have a heightened fear response, causing increased anxiety in social situations.
  • Environment. Social anxiety disorder may be a learned behavior — some people may develop significant anxiety after an unpleasant or embarrassing social situation. Also, there may be an association between social anxiety disorder and parents who either model anxious behavior in social situations or are more controlling or overprotective of their children.

Risk factors

Several factors can increase the risk of developing social anxiety disorder, including:

  • Family history. You're more likely to develop social anxiety disorder if your biological parents or siblings have the condition.
  • Negative experiences. Children who experience teasing, bullying, rejection, ridicule or humiliation may be more prone to social anxiety disorder. In addition, other negative events in life, such as family conflict, trauma or abuse, may be associated with this disorder.
  • Temperament. Children who are shy, timid, withdrawn or restrained when facing new situations or people may be at greater risk.
  • New social or work demands. Social anxiety disorder symptoms typically start in the teenage years, but meeting new people, giving a speech in public or making an important work presentation may trigger symptoms for the first time.
  • Having an appearance or condition that draws attention. For example, facial disfigurement, stuttering or tremors due to Parkinson's disease can increase feelings of self-consciousness and may trigger social anxiety disorder in some people.


Left untreated, social anxiety disorder can control your life. Anxieties can interfere with work, school, relationships or enjoyment of life. This disorder can cause:

  • Low self-esteem
  • Trouble being assertive
  • Negative self-talk
  • Hypersensitivity to criticism
  • Poor social skills
  • Isolation and difficult social relationships
  • Low academic and employment achievement
  • Substance abuse, such as drinking too much alcohol
  • Suicide or suicide attempts

Other anxiety disorders and certain other mental health disorders, particularly major depressive disorder and substance abuse problems, often occur with social anxiety disorder.


There's no way to predict what will cause someone to develop an anxiety disorder, but you can take steps to reduce the impact of symptoms if you're anxious:

  • Get help early. Anxiety, like many other mental health conditions, can be harder to treat if you wait.
  • Keep a journal. Keeping track of your personal life can help you and your mental health professional identify what's causing you stress and what seems to help you feel better.
  • Set priorities in your life. You can reduce anxiety by carefully managing your time and energy. Make sure that you spend time doing things you enjoy.
  • Avoid unhealthy substance use. Alcohol and drug use and even caffeine or nicotine use can cause or worsen anxiety. If you're addicted to any of these substances, quitting can make you anxious. If you can't quit on your own, see your health care provider or find a treatment program or support group to help you.

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Social anxiety disorder (social phobia) - Diagnosis and treatment


Your health care provider will want to determine whether other conditions may be causing your anxiety or if you have social anxiety disorder along with another physical or mental health disorder.

Your health care provider may determine a diagnosis based on:

  • Physical exam to help assess whether any medical condition or medication may trigger symptoms of anxiety
  • Discussion of your symptoms, how often they occur and in what situations
  • Review of a list of situations to see if they make you anxious
  • Self-report questionnaires about symptoms of social anxiety
  • Criteria listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association

DSM-5 criteria for social anxiety disorder include:

  • Persistent, intense fear or anxiety about specific social situations because you believe you may be judged negatively, embarrassed or humiliated
  • Avoidance of anxiety-producing social situations or enduring them with intense fear or anxiety
  • Excessive anxiety that's out of proportion to the situation
  • Anxiety or distress that interferes with your daily living
  • Fear or anxiety that is not better explained by a medical condition, medication or substance abuse

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Treatment depends on how much social anxiety disorder affects your ability to function in daily life. The most common treatment for social anxiety disorder includes psychotherapy (also called psychological counseling or talk therapy) or medications or both.


Psychotherapy improves symptoms in most people with social anxiety disorder. In therapy, you learn how to recognize and change negative thoughts about yourself and develop skills to help you gain confidence in social situations.

Cognitive behavioral therapy (CBT) is the most effective type of psychotherapy for anxiety, and it can be equally effective when conducted individually or in groups.

In exposure-based CBT, you gradually work up to facing the situations you fear most. This can improve your coping skills and help you develop the confidence to deal with anxiety-inducing situations. You may also participate in skills training or role-playing to practice your social skills and gain comfort and confidence relating to others. Practicing exposures to social situations is particularly helpful to challenge your worries.

First choices in medications

Though several types of medications are available, selective serotonin reuptake inhibitors (SSRIs) are often the first type of drug tried for persistent symptoms of social anxiety. Your health care provider may prescribe paroxetine (Paxil) or sertraline (Zoloft).

The serotonin and norepinephrine reuptake inhibitor (SNRI) venlafaxine (Effexor XR) also may be an option for social anxiety disorder.

To reduce the risk of side effects, your health care provider may start you at a low dose of medication and gradually increase your prescription to a full dose. It may take several weeks to several months of treatment for your symptoms to noticeably improve.

Other medications

Your health care provider may also prescribe other medications for symptoms of social anxiety, such as:

  • Other antidepressants. You may have to try several different antidepressants to find the one that's most effective for you with the fewest side effects.
  • Anti-anxiety medications. Benzodiazepines (ben-zoe-die-AZ-uh-peens) may reduce your level of anxiety. Although they often work quickly, they can be habit-forming and sedating, so they're typically prescribed for only short-term use.
  • Beta blockers. These medications work by blocking the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs. Because of that, they may work best when used infrequently to control symptoms for a particular situation, such as giving a speech. They're not recommended for general treatment of social anxiety disorder.

Stick with it

Don't give up if treatment doesn't work quickly. You can continue to make strides in psychotherapy over several weeks or months. Learning new skills to help manage your anxiety takes time. And finding the right medication for your situation can take some trial and error.

For some people, the symptoms of social anxiety disorder may fade over time, and medication can be discontinued. Others may need to take medication for years to prevent a relapse.

To make the most of treatment, keep your medical or therapy appointments, challenge yourself by setting goals to approach social situations that cause you anxiety, take medications as directed, and talk to your health care provider about any changes in your condition.

Alternative medicine

Several herbal remedies have been studied as treatments for anxiety, but results are mixed. Before taking any herbal remedies or supplements, talk with your health care team to make sure they're safe and won't interact with any medications you take.

More Information

  • Social anxiety disorder (social phobia) care at Mayo Clinic
  • Cognitive behavioral therapy
  • Psychotherapy

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Lifestyle and home remedies

Although social anxiety disorder generally requires help from a medical expert or qualified psychotherapist, you can try some of these techniques to handle situations that are likely to trigger symptoms:

  • Learn stress-reduction skills.
  • Get physical exercise or be physically active on a regular basis.
  • Get enough sleep.
  • Eat a healthy, well-balanced diet.
  • Avoid alcohol.
  • Limit or avoid caffeine.
  • Participate in social situations by reaching out to people with whom you feel comfortable.
Practice in small steps

First, consider your fears to identify what situations cause the most anxiety. Then gradually practice these activities until they cause you less anxiety. Begin with small steps by setting daily or weekly goals in situations that aren't overwhelming. The more you practice, the less anxious you'll feel.

Consider practicing these situations:

  • Eat with a close relative, friend or acquaintance in a public setting.
  • Purposefully make eye contact and return greetings from others, or be the first to say hello.
  • Give someone a compliment.
  • Ask a retail clerk to help you find an item.
  • Get directions from a stranger.
  • Show an interest in others — ask about their homes, children, grandchildren, hobbies or travels, for instance.
  • Call a friend to make plans.
Prepare for social situations

At first, being social when you're feeling anxious is challenging. As difficult or painful as it may seem initially, don't avoid situations that trigger your symptoms. By regularly facing these kinds of situations, you'll continue to build and reinforce your coping skills.

These strategies can help you begin to face situations that make you nervous:

  • Prepare for conversation, for example, by reading about current events to identify interesting stories you can talk about.
  • Focus on personal qualities you like about yourself.
  • Practice relaxation exercises.
  • Learn stress management techniques.
  • Set realistic social goals.
  • Pay attention to how often the embarrassing situations you're afraid of actually take place. You may notice that the scenarios you fear usually don't come to pass.
  • When embarrassing situations do happen, remind yourself that your feelings will pass and you can handle them until they do. Most people around you either don't notice or don't care as much as you think, or they're more forgiving than you assume.

Avoid using alcohol to calm your nerves. It may seem like it helps temporarily, but in the long term it can make you feel even more anxious.

Coping and support

These coping methods may help ease your anxiety:

  • Routinely reach out to friends and family members.
  • Join a local or reputable internet-based support group.
  • Join a group that offers opportunities to improve communication and public speaking skills, such as Toastmasters International.
  • Do pleasurable or relaxing activities, such as hobbies, when you feel anxious.

Over time, these coping methods can help control your symptoms and prevent a relapse. Remind yourself that you can get through anxious moments, that your anxiety is short-lived and that the negative consequences you worry about so much rarely come to pass.

Preparing for your appointment

You may see your primary care provider, or your provider may refer you to a mental health professional. Here's some information to help you get ready for your appointment.

What you can do

Before your appointment, make a list of:

  • Situations you've been avoiding, especially those that are important to your functioning
  • Any symptoms you've been experiencing, and for how long, including any symptoms that may seem unrelated to the reason for your appointment
  • Key personal information, especially any significant events or changes in your life shortly before your symptoms appeared
  • Medical information, including other physical or mental health conditions with which you've been diagnosed
  • Any medications, vitamins, herbs or other supplements you're taking, including dosages
  • Questions to ask your health care provider or a mental health professional

You may want to ask a trusted family member or friend to go with you to your appointment, if possible, to help you remember key information.

Some questions to ask your health care provider may include:

  • What do you believe is causing my symptoms?
  • Are there any other possible causes?
  • How will you determine my diagnosis?
  • Should I see a mental health specialist?
  • Is my condition likely temporary or chronic?
  • Are effective treatments available for this condition?
  • With treatment, could I eventually be comfortable in the situations that make me so anxious now?
  • Am I at increased risk of other mental health problems?
  • Are there any brochures or other printed material that I can have? What websites do you recommend?

Don't hesitate to ask other questions during your appointment.

What to expect from your health care provider

Your health care provider or a mental health professional will likely ask you a number of questions. Be ready to answer them to reserve time to go over any points you want to focus on. Your health care provider may ask:

  • Does fear of embarrassment cause you to avoid doing certain activities or speaking to people?
  • Do you avoid activities in which you're the center of attention?
  • Would you say that being embarrassed or looking stupid is among your worst fears?
  • When did you first notice these symptoms?
  • When are your symptoms most likely to occur?
  • Does anything seem to make your symptoms better or worse?
  • How are your symptoms affecting your life, including work and personal relationships?
  • Do you ever have symptoms when you're not being observed by others?
  • Have any of your close relatives had similar symptoms?
  • Have you been diagnosed with any medical conditions?
  • Have you been treated for mental health symptoms or mental illness in the past? If yes, what type of therapy was most beneficial?
  • Have you ever thought about harming yourself or others?
  • Do you drink alcohol or use recreational drugs? If so, how often?

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Social phobia: what it is, symptoms, causes, how to overcome it

Social phobia, or social anxiety disorder, is a psychological condition in which a person constantly experiences fear of interacting with other people. Even if he understands that this fear is irrational, he is still not able to change the situation. Social phobia can develop both because of traumatic experiences and because of a genetic predisposition. Today, with the help of specialists, getting rid of this disorder is not at all difficult.

  • What is
  • Symptoms
  • Causes
  • How to get rid of

The material was commented by Alexandra Menshikova, clinical psychologist, candidate of psychological sciences

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What is social phobia

Social phobia is a fairly common disease. According to a study by British scientists, in Europe it affects from 3.9 to 13.7% of the population [1]. Despite this, in Russia, according to psychologist Alexandra Menshikova, he is rarely diagnosed. Social phobia often manifests itself as one of the symptoms of another disease, such as an anxiety disorder, and Russian doctors view it from this point of view.

Social phobia should not be confused with shyness, which in certain situations manifests itself in almost everyone. In this disorder, intense fear is persistent and interferes with even daily tasks, such as school, work, public transportation, or even going out.

For some people with social phobia, anxiety occurs only in certain situations - for example, a child calmly goes to school and studies well, but is afraid to answer at the blackboard to the point of shaking in the knees.

Others are intimidated by telephone conversations, job interviews, public speaking, sports, dancing, dining out, talking to strangers, or going to a public restroom. Someone begins to experience discomfort immediately before a frightening event, and someone - even a few days or even weeks before it.

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Most often, people suffering from social phobia attribute their fear to fear of ridicule, judgment or other negative reactions from other people. However, they are often afraid to reveal their heightened anxiety. It turns out a vicious circle: the fear of showing signs of social phobia only strengthens it.

Many people with social phobia communicate easily with loved ones, such as relatives, but face great difficulty when they try to make social connections outside the family. The disease leads them to loneliness.

In addition, even if they find the strength to participate in fearful communication, the constant feeling of anxiety impairs their communication skills. For example, tension can make it difficult to articulate thoughts clearly, use facial expressions or gestures that are appropriate for the situation. This often scares off others and reduces a person's chances of making friends with someone or starting a relationship.

Alexandra Menshikova notes that people with social phobia often feel that avoiding uncomfortable situations protects them from anxiety. But this is not so: refusal only exacerbates the disease.

Studies of the brain activity of patients with social phobia show that their amygdala is too active - this part of the brain is responsible for fear reactions that mobilize the body to fight threats [2].

The result is increased heart rate, muscle tension and impaired thinking. In a situation of real danger, such a mobilization of the body's resources helps to fight the danger or simply escape.

In a healthy person, excessive activity of the amygdala is restrained by the prefrontal cortex of the brain. Its task is to assess whether there is a real threat. But in people with social phobia, this mechanism does not work as it should: the prefrontal cortex does not suppress, but only enhances the reaction of the amygdala.

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Symptoms of social phobia

Physical manifestations of social phobia include:

  • redness;
  • sweating;
  • trembling;
  • palpitations;
  • indigestion;
  • feeling as if all thoughts were gone;
  • inability to fully control one's posture, gaze or voice;
  • dizziness;
  • nausea.

Behaviorally, this disorder manifests itself through:

  • severe anxiety in situations that require interaction with other people;
  • avoidance of certain social contacts;
  • secrecy, the desire to "merge with the wall", to be unnoticed;
  • fear of putting oneself in an awkward position;
  • fear of betraying one's anxiety and worries;
  • missing work or school due to anxiety;
  • an overly critical assessment of one's behavior in society, self-flagellation for a "wrong" phrase or look.

Causes of social phobia

Modern scientists believe that both external factors, primarily traumatic experience, and genetic predisposition can lead to social phobia. Most often, the disease begins to develop in childhood or adolescence, but manifests itself after 20-25 years. Alexandra Menshikova notes that usually signs of social phobia appear in childhood, and most often in two periods: up to 10 years and from 14 to 18. The further development of the disease depends on the person's environment and his personal experience.

According to one study, the children of those who suffer from social phobia are 30-40% more likely to develop this disease [3]. Recent experiments show that the disorder may be associated with mutations in the SLC6A4 gene responsible for the transport of serotonin [4].

Traumatic situations that can lead to the development of social phobia include:

  • childhood bullying, bullying, bullying;
  • family quarrels;
  • loss of a parent or parents, such as death or abandonment of a child;
  • harassment and sexual assault.

Social phobia often develops in shy people - under the influence of the external environment, this natural trait can develop into a pathology. Some research has linked the disorder to an authoritarian parenting style. When parents put too much pressure on the child and tightly control him, the chance of developing a disorder increases. And vice versa: in families where relationships were rated as emotionally warm, the risk of developing social phobia was lower [5].

Alexandra Menshikova points out that anyone with any problem can get scared when they want to seek medical help. But people with social phobia should not be afraid to go to a psychologist: a qualified specialist will never harm him or provoke an anxiety attack.

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How to get rid of social phobia

The disorder responds well to treatment. Sometimes it is treated with medication, with the help of antidepressants and drugs for anxiety, anxiolytics. But the main method is cognitive behavioral therapy (CBT).

According to Alexandra Menshikova, there are many methods of treating social phobia within CBT. In the most general form, the work of any of them is aimed at changing irrational thoughts and cognitive distortions and coping with anxiety, developing the ability to cope with it.

The main tool is the exposure method. “A person is immersed in an anxious situation, and he learns to endure this anxiety, learns not to be afraid of it,” says Menshikova. - Exposure is the exposure of the patient to a stressful stimulus until his anxiety decreases. It has gradations. Treatment begins with simple situations that are easy to handle. Over time, situations become more and more difficult, and a person develops tolerance for them, anxiety decreases.

First, a psychologist or psychotherapist helps him to enact disturbing situations in his imagination. Later, when the patient is a little better prepared, the specialist may invite him to participate in a disturbing social situation together.

Another important method, says Menshikova, is relaxation exercises. The patient is taught various stress-relieving techniques, such as breathing exercises.

In addition, specialists help people with social anxiety cope with their prejudices during experiments. “Patients with social phobia often think that if they find themselves in some situation that causes them anxiety, then they may seem stupid or inadequate to others. Or that everyone will look only at them, - explains the psychologist. “But when we do an experiment, people realize that no one is really looking at them or thinking about them. Most do not care, but there are many who are quite benevolent.”

As such experiments, says Menshikova, a specialist can offer the patient to read poetry in public or even just talk to a sales assistant in a store. “Many of the people with social phobia are afraid that we will force them to do something uncomfortable - almost to run naked on the subway. Well, no, of course not. The main principle here is the environmental friendliness of the methods, in no case should we provoke an anxiety attack in a person.

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Tags: psychology

Symptoms of social anxiety - Psychologist in St. Petersburg Yushin Vyacheslav

What do you know about the symptoms of social anxiety? They fall into three main categories.

Emotional distress

People with social anxiety suffer from negative thoughts and self-doubt:

  • Should I look good?
  • Am I dressed appropriately?
  • Will I know what to talk about?
  • Will what I say be stupid and boring?
  • What if other people don't love me?
  • What should I do if people notice that I am nervous?
  • What if people think I'm too reserved and quiet?

Fear of possible rejection or disapproval from others appears primarily in the minds of socially concerned people, and they look for any signs in the behavior of others that confirm their negative expectations.

Physical symptoms

Many people do not realize that social anxiety can accompany real physical discomfort. For example, someone may experience a panic attack in an anxiety situation in which they feel a sudden and severe surge of fear and anxiety, accompanied by some or all of the following anxiety symptoms:

  • Shortness of breath
  • Chest tightness or pain
  • Rapid heartbeat
  • Tingling or numbness
  • Nausea
  • Diarrhea
  • Dizziness
  • Weakness
  • Sweating

It is important to note that many people mistakenly think of panic disorder as something that can actually be a manifestation of social anxiety. The key to understanding what the real problem is may be to recognize the roots of fear. In panic disorder, the person is afraid of the panic attacks themselves, and often feels as if he or she is dying during such an attack. In the case of social anxiety disorder, the fear is centered around the possibility that people might witness panic and be the result of humiliation. Some people may have both panic disorder and social anxiety disorder.

Loss avoidance

It is human nature to avoid pain and suffering. From an evolutionary point of view, we are programmed to either fight or run away from a dangerous situation. So it's not surprising that people with social anxiety disorder tend to avoid or painfully endure situations that they feel harm them.

Avoidance can be complete. This may mean that you never go to parties or restaurants. This may mean that you will only have a few friends, if any. This may mean that you will never have an intimate relationship. This may mean that you are dropping out of your studies or working towards your potential.

People with social anxiety may invent other, more sophisticated methods of preventing the occurrence of anxiety, which is called partial avoidance. You don't have to look far for examples, including drinking alcohol to cope with anxiety (drinking "for courage") or, for example, coming to a party just to show off for a short time.

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