Social anxiety disorder vs shyness: symptoms and how it is treated

What is social anxiety disorder, and how is it different from shyness?

Social anxiety disorder is an anxiety disorder that makes you intensely and persistently afraid of situations where others might watch or judge you, such as speaking in front of a group, eating in front of people or even answering a phone call. Shyness may make you uneasy at first without stopping you from doing what you want. Social anxiety, as the UK's National Health Service (NHS) describes it, is more than shyness: a fear that does not go away and affects your daily life, self-confidence, relationships, and study or work. It is also called social phobia, and many people think of it as extreme or "pathological" shyness.

Cleveland Clinic names three practical differences between the two: how intense the fear is, how much it disrupts daily life, and how much you avoid. You can compare for yourself:

• With shyness: you feel tense at a first meeting, then settle after a while and join in, and you don't cancel plans because of it.
• With social anxiety: you worry about a situation for days or weeks beforehand, feel intense distress during it, then keep replaying every word you said afterward.
• With shyness: you may prefer to stay quiet in large gatherings, but you still go.
• With social anxiety: you pull out of the lecture, the job interview or the first family visit before an engagement, because the fear is stronger than what you want.

It is not rare. Based on a US national survey carried out between 2001 and 2003, the US National Institute of Mental Health (NIMH) estimates that about 7.1% of US adults had social anxiety disorder in a given year and 12.1% experience it at some point in their lives, and that it is slightly more common among women (8.0%) than men (6.1%).

Social anxiety symptoms: what happens to your body and mind around people?

Social anxiety combines physical symptoms you feel clearly with thoughts that circle around judgment and embarrassment. Signs described by NIMH and Cleveland Clinic include:

• Blushing
• Sweating, and trembling hands or a shaky voice
• A racing heart
• Nausea or an upset stomach
• Your mind going blank: you forget what you were going to say and can't find the words
• A rigid body, a quiet voice, and difficulty making eye contact

The NHS notes that symptoms can build into a full panic attack; to understand these better, read our article on panic attacks and their symptoms.

On the inside, thoughts revolve around people noticing your nerves or judging you negatively. Situations many people avoid include speaking in public, eating in front of others, phone calls and getting-to-know-you meetings. The torment can continue after the situation as a repeated review of every detail, a loop close to what we explain in our article on overthinking.

Why does the fear of facing people grow the more you avoid them?

Avoidance is what feeds social anxiety most. When you pull out of a situation you feel instant relief, but that relief teaches your brain that the situation really was dangerous. A self-help guide published by an NHS trust in the UK explains that avoiding social situations stops you from getting used to them, so the next time the same situation feels even harder.

Safety behaviors: avoidance in disguise

Even when you do show up, you may use small tricks you believe protect you from embarrassment. Specialists call them "safety behaviors", and they include:

• Avoiding eye contact or keeping busy with your phone
• Preparing what you will say and rehearsing it in your head before speaking
• Staying next to someone you know the whole time
• Keeping answers short and ending conversations as fast as possible
• Constantly monitoring your face and voice to hide signs of nerves

The problem is that when you get through the situation safely, you credit the trick rather than yourself, so you never find out you would have coped without it. In an experimental study published in 2021 with adolescents aged about 11 to 14, participants felt more anxious, and believed they looked more anxious, when they were asked during a short conversation to focus on themselves and use safety behaviors, compared with focusing on the conversation without them; their conversation partners also rated them as looking more anxious.

Social anxiety in teenagers and university students

Social anxiety usually begins in childhood or adolescence, according to NIMH. Based on a US national survey of adolescents aged 13 to 18 carried out between 2001 and 2004, the same institute estimates that about 9.1% of them had it at some point, and that it was more common among girls (11.2%) than boys (7.0%).

In teenagers it does not always look like obvious shyness. As NIMH describes, it may show up as:

• Trying to avoid going to school
• Difficulty making friends
• Frequent complaints of stomachaches or headaches
• Emotional outbursts, such as crying or anger, in social situations
• Refusing to speak or take part, such as answering in class in front of classmates

At university the picture becomes clearer: a student avoids lectures that involve discussion, or is absent on presentation day. Cleveland Clinic notes that untreated social anxiety can lead to dropping out of school and poorer performance at work, which is why early help protects important years of life.

If you are a parent, try to understand your child's fear instead of mocking it, encourage small steps, and ask for a specialist assessment if it is affecting their studies. At Oxygen Center, teenagers aged 15 and over can start with an appointment with a psychiatrist, with a parent or guardian's consent for anyone under 18, and the family is involved in the plan; for a younger child, see a child psychiatrist.

Social anxiety disorder treatment: graded exposure and social skills

The reassuring news is that social anxiety responds well to treatment. NIMH describes cognitive behavioral therapy (CBT) as the gold standard of psychotherapy for it, and the NHS calls it the best treatment overall. A 2015 scientific commentary on a large network meta-analysis comparing treatments concluded that individual CBT deserves to be the first-choice treatment.

Treatment usually rests on three pillars:

• Graded exposure: with your therapist you build a "ladder" of feared situations, from easiest to hardest, and face them one rung at a time until the fear loses its power.
• Dropping safety behaviors and turning your attention to other people and the conversation instead of monitoring yourself, so you discover that your signs of nerves are less visible than you think.
• Social skills training: such as starting and keeping a conversation going and expressing your opinion, practiced in the session before you use it in your life.

CBT can also be delivered in a group, a format NIMH says can offer its own benefits. NIMH adds that a support group of people who all have social anxiety can give you frank, impartial feedback about how others see you.

As for the common question of whether social anxiety can be cured for good, there is no magic cure and no guaranteed timeframe, but the 2015 commentary mentioned above notes that some studies found the gains from CBT were maintained five years after treatment ended. Learn about psychotherapy sessions at Oxygen Center.

When does medication help, and what doesn't it do?

A psychiatrist may suggest medication alongside psychotherapy, or instead of it for someone who does not want therapy, depending on how severe the condition is and what comes with it. Options mentioned by NIMH and Cleveland Clinic include:

• Antidepressants from the SSRI and SNRI classes: the main medication option; they usually take several weeks to work. The NHS notes that they are not usually used to treat children and young people.
• Beta-blockers: often used for the "performance anxiety" type, such as public speaking, because they calm physical symptoms like a fast heartbeat and trembling.
• Benzodiazepine sedatives: they work quickly, but some people get used to them so they work less well, and some become dependent on them, so a doctor usually prescribes them only for short periods, if at all. If you take them regularly, do not stop them suddenly on your own: NIMH explains that a doctor reduces them slowly, because stopping too soon can cause unpleasant or even harmful withdrawal symptoms.

What medication doesn't do

Medication may take the edge off anxiety and make facing situations easier, but it does not teach you skills and does not, on its own, change the habit of avoidance. The same 2015 commentary points out that a large share of people who improve on medication may see symptoms return after stopping it, so it helps for medication to be part of a plan that includes psychotherapy. Never start, stop or change a medicine on your own; that decision is made with your psychiatrist.

How to overcome social anxiety: a realistic exercise for this week

If your symptoms are mild or moderate, try this exercise based on the graded-ladder idea in UK self-help guides. The goal is not for the nerves to disappear, but to test for yourself whether what you fear actually happens.

1. Write your list: note a few situations you avoid, then rank them like rungs on a ladder from easiest to hardest.
2. Pick an easy rung: start with the easiest situation on your list, such as asking a shop assistant about something, greeting a colleague first, or answering a call instead of letting it ring.
3. Write down your prediction first: what do you think will happen? For example: "Everyone will notice my voice shaking."
4. Do it and drop one safety behavior: look at the person instead of your phone, and focus on what they are saying instead of monitoring your face and voice.
5. Compare afterward: what actually happened? Was it close to what you predicted? Then try not to replay the situation in your head again and again.
6. Repeat, then climb: repeat the same situation several times during the week until your anxiety about it drops, then move to the next rung.

When should you get help?

Cleveland Clinic notes that social anxiety often does not go away on its own, and waiting makes avoidance run deeper. Ask for a specialist assessment if:

• The fear has lasted for months and now shapes your decisions: what you study, where you work, who you meet
• You have started missing school or work, or turning down job interviews and steps toward marriage because of fear
• It comes with panic attacks or ongoing sadness and loss of enjoyment, since social anxiety can come with depression or other anxiety disorders
• You have come to rely on alcohol, drugs or pills to face people
• Your teenager is refusing school or withdrawing from everyone

At Oxygen Center the path starts with a psychiatric assessment or a psychotherapy session to understand your situation, then we build a plan with you that fits its severity and your circumstances. The first step is smaller than you imagine: you can book an appointment or contact us at any time.