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Social anxiety disorder (social phobia) involves marked, persistent fear of social situations where the person may be scrutinised or negatively evaluated by others. The fear is out of proportion to the actual threat and leads to avoidance. Unlike ordinary shyness, it causes significant distress and functional impairment.
Key Knowledge
●Persistent, intense fear of social situations involving potential scrutiny
●Fear of embarrassment, humiliation, or negative evaluation
●Social situations are avoided or endured with intense anxiety
●Physical symptoms include blushing, sweating, trembling, palpitations
●Onset is typically in adolescence
●Can be generalised (most social situations) or performance-type (specific situations like public speaking)
●Causes significant impairment in education, work, relationships
●May be comorbid with depression, other anxiety disorders, substance use
What is Social Anxiety Disorder?
What is Social Anxiety Disorder?
ICD-11 defines social anxiety disorder (6B04) as marked and excessive fear or anxiety that consistently occurs in one or more social situations such as social interactions, being observed, or performing in front of others.
Core features:
Fear of showing anxiety symptoms
●Fear of negative evaluation: The person fears being humiliated, embarrassed, rejected or offending others
●Social situations almost always provoke fear or anxiety
●Social situations are avoided or endured with intense distress
●Fear or anxiety is out of proportion to the actual threat posed by the social situation
●Symptoms persist for at least several months
●Significant distress or functional impairment in personal, social, educational, or occupational functioning
Physical symptoms during social situations:
●Blushing, sweating, trembling, palpitations
●Nausea, dry mouth, urgency to urinate
●Panic attacks may occur
Subtypes:
●Performance-only type: fear is limited to performance situations (public speaking, performing on stage). Generalised type involves fear across multiple social situations.
Differential Diagnosis for Generalised Anxiety Disorder
1. Agoraphobia
Key distinctions: In agoraphobia, fear relates to being in situations where escape might be difficult or help unavailable (crowds, public transport, open spaces). In social anxiety disorder, fear is specifically about being scrutinised or negatively evaluated.
2. Generalised anxiety disorder (GAD)
Key distinctions: GAD involves excessive worry across multiple domains (health, finances, work, relationships). Social situations may be one worry among many. In social anxiety disorder, worry is specifically focused on social evaluation.
3. Panic disorder
Key distinctions: In panic disorder, panic attacks occur unexpectedly or are triggered by fear of having another panic attack. In social anxiety disorder, panic attacks occur specifically in social situations due to fear of scrutiny.
4. Avoidant (anxious) personality disorder
Key distinctions: Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to criticism present since early adulthood. Social anxiety disorder and avoidant personality disorder overlap significantly and may coexist.
5. Body dysmorphic disorder (BDD)
Key distinctions: In BDD, social avoidance is driven by preoccupation with perceived appearance defects. In social anxiety disorder, fear is about being negatively evaluated in general, which is not specifically about appearance.
6. Specific phobia
Key distinctions: Specific phobia involves fear of a specific object or situation (e.g., spiders, heights), not social evaluation.
7. Normal shyness
Key distinctions: Shyness does not cause significant distress or functional impairment. Social anxiety disorder is disabling and persistent.
Risk Assessment in Generalised Anxiety Disorder
Risk Assessment in Social Anxiety Disorder
To self:
●Social isolation – Avoidance of social situations leads to loneliness and relationship difficulties
●Educational and occupational impairment – Difficulty attending school, university, or work; avoiding presentations or interviews
●Depression and suicide – Chronic social anxiety increases risk of comorbid depression and suicidal ideation
●Substance misuse – Alcohol or drugs used to cope with social situations
●Low self-esteem and self-criticism
To others:
●Low
From others:
●Risk of bullying or social rejection, which may worsen symptoms
Communication Tips
Social anxiety assessments involve exploring specific feared situations, cognitive features (fear of negative evaluation), avoidance, and impact on functioning.
Exploring feared situations:
●”Are there social situations that make you anxious or that you try to avoid?”
●”Can you give me some examples of situations that worry you?”
●”What about speaking in front of others, or being the centre of attention?”
●”How do you feel about meeting new people, or talking in groups?”
●”What about eating or drinking in front of others, or writing while being watched?”
Exploring fears and cognitions:
●”What goes through your mind in these situations?”
●”What are you worried might happen?”
●”Are you worried about what others might think of you?”
●”Do you worry about looking anxious, or doing something embarrassing?”
Exploring physical symptoms:
●”What do you notice happening in your body when you’re in these situations?”
●”Do you blush, sweat, shake, or feel your heart racing?”
Exploring avoidance:
●”Do you avoid these situations, or do you push through?”
●”If you do go into the situation, how do you feel?”
●”What do you do to try to cope, do you avoid eye contact, stay quiet, or leave early?”
Safety behaviours:
●”Do you do anything to try to feel safer in social situations, such as drinking alcohol beforehand, rehearsing what to say, avoiding certain topics?”
Impact on functioning:
●”How has this affected your life, such as your education, work, friendships, relationships?”
●”Are there things you’d like to do but can’t because of anxiety?”
●”Do you feel lonely or isolated?”
Timeline:
●”How long have you felt this way?”
●”When did it start? Was there anything that triggered it?”
Screen for comorbidities:
●Depression: mood, hopelessness, anhedonia
●Other anxiety disorders: GAD, panic, specific phobias
●Substance use: “Do you use alcohol or anything else to cope with social situations?”
●Suicidal ideation
CASC Practice Scenarios
Scenario 1: History Taking
Candidate Instructions:
You are the SpR in the general adult psychiatry outpatient clinic. You have been asked to see Miss Sophie Turn, a 23-year-old veterinary nurse, who has been referred by her GP. has requested help due to difficulties with work.
Your tasks are to:
●Take a psychiatric history
●Assess the nature and severity of her difficulties
Scenario Summary:
Sophie Turn is a 23-year-old woman with social anxiety disorder. She has experienced intense fear of social situations since her mid-teens, particularly situations involving potential scrutiny or evaluation by others. She fears blushing, trembling, saying something stupid, or being judged as incompetent. She experiences severe physical symptoms (blushing, sweating, palpitations, nausea) in social situations such as team meetings, speaking to clients at the veterinary practice, eating in public, and casual conversations with colleagues. She avoids social gatherings, has declined a promotion that would involve more client interaction, and uses alcohol to cope with unavoidable social situations. The anxiety has been lifelong but has worsened since starting work three years ago. She has very few friends and no romantic relationship history. She has secondary low mood and feels hopeless about ever being “normal.” There is no psychosis, no obsessive-compulsive features, no history of trauma.
Actor Brief:
You are Sophie Turner, a 23-year-old veterinary nurse. You live alone in a one-bedroom flat. You’ve struggled with anxiety in social situations for as long as you can remember, but it’s got to the point where it’s ruining your life, and your GP suggested you see a psychiatrist.
You’re terrified of social situations where you might be watched, judged, or evaluated. The worst situations are: speaking in team meetings at work, talking to clients when you’re assisting the vets, eating or drinking in front of other people, making phone calls when others can hear you, and any kind of social gathering like parties or work events. Even casual conversations with colleagues in the staff room make you anxious and you worry you’ll say something stupid or boring, and that people will think you’re weird.
When you’re in these situations, you experience intense physical symptoms. You blush, your face and neck go bright red, and you know people can see it, which makes it worse. You sweat, your hands shake, your heart pounds, you feel sick, and sometimes your voice trembles. The worst part is the blushing, you’re convinced everyone notices it and judges you for it. You spend a lot of mental energy trying to stay calm and not blush, but the more you try, the more it happens.
You’re constantly thinking about how you come across to others. After any social interaction, even just a brief chat with a colleague, you replay it in your head for hours, analysing what you said, how you said it, whether you looked stupid. You imagine people laughing about you later or thinking you’re incompetent. It’s exhausting.
You avoid social situations as much as possible. You’ve turned down every social invitation from colleagues over the past three years. You eat lunch alone at your desk. You’ve never been to a work night out. You declined a promotion six months ago that would have involved more client-facing work and supervising junior staff, because the thought of leading meetings or giving feedback to others was unbearable. Your manager was disappointed and suggested you “work on your confidence,” which made you feel even worse.
When you absolutely have to be in a social situation, like the annual work Christmas party, which you felt you couldn’t avoid, you drink beforehand to calm your nerves. You had three glasses of wine before last year’s party and another two when you arrived, and you felt much more relaxed. You’ve started doing this more often, having a glass or two of wine before any social event. It helps, but you’re aware it’s becoming a bad habit.
You don’t have many friends. You had a small group at school, but you’ve drifted apart. You find it hard to maintain friendships because socialising is so stressful. You’ve never had a romantic relationship and the idea of dating terrifies you. How do you meet someone? What do you talk about? What if they think you’re boring or awkward? It feels impossible.
Your mood has been low for the past year. You feel hopeless about ever being able to live a normal life. You’re lonely but too anxious to do anything about it. You sleep poorly, lying awake worrying about interactions you’ve had or dreading ones coming up. Your appetite is okay. You have fleeting thoughts that life is pointless if you’re always going to be like this, but you’ve never considered harming yourself.
You don’t use drugs. You’re drinking more alcohol than you used to, maybe a bottle of wine, sometimes more, three or four evenings a week, usually alone at home. It helps you unwind after a stressful day. You’re not drinking every day, and you don’t drink at work, but you’re aware it’s increasing.
You have had no previous psychiatric treatment. You saw a school counselor briefly when you were 15 because a teacher was worried about you being quiet and withdrawn, but it didn’t help. No one in your family has had psychiatric treatment that you know of, though your dad has always been shy and reserved.
During the interview, you’re polite but visibly anxious. You avoid prolonged eye contact, you glance at the doctor but look away quickly. You speak quietly. You blush within the first few minutes of the interview, and you’re clearly self-conscious about it, you touch your face, look down, apologise for being “useless at this.” When describing social situations, you become more animated and distressed, your voice trembles slightly, and you’re tearful at points. You’re desperate for help but also embarrassed to be here.
Feedback for Scenario 1
Knowledge & Clinical Skills
●Elicit the core diagnostic features of social anxiety disorder: marked, persistent fear of social situations involving potential scrutiny, fear of negative evaluation (being judged as stupid, boring, incompetent), social situations almost always provoking anxiety, avoidance or endurance with intense distress, and significant functional impairment
●Identify safety behaviours (avoiding eye contact, staying quiet, mental rehearsal, post-event rumination) and the use of alcohol as a coping mechanism
●Assess the impact on functioning: occupational (declined promotion, limited career progression), social (isolation, no friendships maintained), romantic (no relationship history), and psychological (secondary depression, hopelessness), recognising that social anxiety disorder can be profoundly disabling
●Differentiate social anxiety disorder from other conditions: generalised anxiety disorder (worry across multiple domains, not specifically social evaluation), avoidant personality disorder (pervasive pattern since early adulthood with significant overlap, although they may coexist), autism spectrum disorder (social difficulties due to impaired social communication, not fear of negative evaluation), body dysmorphic disorder (preoccupation with appearance defects rather than social performance), and agoraphobia (fear of being unable to escape)
Communication
A good candidate will:
●Create a safe environment that facilitates an open, honest discussion with the patient, to reduce any sense of shame and embarrassment
●Adapt communication style to the patient’s anxiety, allowing pauses, not pressuring for eye contact, and validating the difficulty of the interview.
●Explore the cognitive component sensitively, for example asking “What goes through your mind when you’re in those situations?” and “What are you worried might happen?” to understand the fear of negative evaluation and catastrophic thinking that maintain the disorder
Video
All our videos can be found here! CASC Scenario Videos – PsychPanda
Authors/Reviewers
Dr Damir Rafi is a Psychiatry Speciality Registrar in forensics, currently working in London.
Dr Rebecca Goodall is a Psychiatry Specialty Registrar, specialising in children & adolescents.
References and Resources
World Health Organization. (2019). International classification of diseases for mortality and morbidity statistics (11th ed.). https://icd.who.int/browse11/l-m/en
National Institute for Health and Care Excellence. (2013). Social anxiety disorder: Recognition, assessment and treatment (CG159). https://www.nice.org.uk/guidance/cg159
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
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