Social Anxiety Disorder (SAD) is a broad fear of being negatively evaluated in social and performance situations that prevent a person from enjoying time with other people and living a full and satisfying life. Although the prevalence of this disorder in the general population is higher in the United States (2.8% of the total population in a 12-month evaluation period), SAD is also prevalent in European (2.3%) and non-European countries. However, cross-cultural findings show that people’s social concerns need to be examined in the context of the person’s cultural, racial, and ethnic background in order to adequately assess the degree and expression of social anxiety and social anxiety disorder. As you might expect occurrence rates go up with the cultural value for avoiding social embarrassment, as in the non-European countries of Japan, Korea and China (Culture Social Anxiety and Social Anxiety Disorder).

Despite SAD’s high rates of occurrence, especially in the United States (5.3 million American Adults), and that it is the third most common U.S psychiatric disorder, the condition has only recently achieved recognition as a distinct anxiety disorder (also known as social phobia). This is partly due to the challenge in differentiating SAD from other mental health conditions. Social Anxiety Disorder shares the symptoms of excessive fears, self-consciousness and withdrawing from social situations with obsessive-compulsive disorder, body dysmorphic disorder, panic disorder, agoraphobia, and major depression (National Center for Biotechnology Information).

Also, SAD is often mistaken as shyness, which is more a trait of personality than a mental health disorder. But, SAD is much more than a little shyness. Counter to intuition, there is a weak relationship between social anxiety disorder and personality shyness. Although the prevalence of social phobia is significantly higher among shy persons (18%) compared with non-shy persons (3%), the majority of shy persons (82%) are not socially phobic (National Center for Biotechnology Information). In contrast to people with SAD, shy persons do not avoid social situations because of an intense, irrational, and persistent fear of being scrutinized or negatively evaluated by other people. Too, the positive suggestion of the term social plays into a misbelief that SAD is trivial and undermines people less than some of the other mental health conditions, so that it has not received the same attention from the public or mainstream media as other mental health disorders.

In spite of these diagnostic and public awareness issues, SAD is a distinct psychiatric behavioral disorder that is far from trivial. It usually makes it presence around 13 years of age and can affect people’s functioning for their entire lives, if left untreated. Actually, 36 percent of people with social anxiety disorder report symptoms for 10 or more years before seeking help (Anxiety and Depression Association of America), as they are too embarrassed to let anyone know that they are socially afraid. But, if left untreated, SAD can have a significant impact on an individual’s personal and professional life. It is associated with lower levels of educational attainment, single marital status, unemployment, fewer days worked, and reduced work productivity (SAD: More Than Just a Little Shyness).


Cause and Symptoms


SAD’s distinguishing feature is a “marked and persistent fear of social or performance situations in which intense anxiety and embarrassment may occur” ( anxiety disorder). Being socially introduced, meeting a person in authority, job interviews, telephone conversations, being called upon in a class, giving a class or work presentation, and even having to sign one’s name while being observed by another person can cause a person with SAD considerable anxiety and distress that can be as intense as a panic attack (sweating, shaking, garbled speech, blushing, heart racing, mental confusion, and gastrointestinal and respiratory distress). Awareness that others may see visible signs of their anxiety further compounds their physical and mental anguish (DSM V).

Routine activities, for you and me, are torturous to them. Although they fear being scrutinized and judged by others, it is actually the overwhelming discomfort of high arousal that reinforces socially-avoidant behaviors. People with SAD have a strong tendency to avoid situations that activate high arousal in them that usually begins in childhood. The normal activities of going to school, socializing with other children, giving class presentations, social introductions, attending school parties, and making friends is highly stressful for them. As adults, they may arrange to be sick on days of work presentations, choose jobs that socially require very little of them, and pass on social opportunities that would open them up to friendship and romance.

Socially anxious people are not unsociable. They are very unhappy about their condition. But, the extreme discomfort of high physiological arousal overshadows their longing for social contact. They have learned to regulate the negative emotions they have around their fears by avoiding and suppressing their emotions rather than exploring them.


Stop Avoiding and Suppressing and Start Exploring!


Research shows that we are more apt to use coping strategies that regulate our emotions, if we explore our emotions rather than avoid and suppress them. One study found that by reappraising the meaning of the threat, anxiety lowers to the point where people stay in social situations that they fear (Emotion Regulation Strategies Influence Anxiety, Huffington Post, 2013).

Cognitive reappraisal does alter emotional experience, and today, there’s brain research that supports these findings. When you get a person to look at a social stressor in a new way (alter perspective), the areas of the brain instrumental in creating positive emotions and mitigating negative ones (frontal lobes) activate so that feelings are brought into line with the realistic demands of a situation (

Dr. Salvatore R. Maddi’s hardiness approach to turning adversity into opportunity first identified the power of reappraisal (1984) in resilience and coping, in his landmark study on personality hardiness at the Illinois Bell Telephone Company (Turning Lemons into Lemonade, American Psychological Association, S. R. Maddi). By reframing and reappraising our emotions and ideas around stressful situations, we come to meanings that transform strong, negative emotions, gain distance from what is happening, and find healthier ways to cope with stressors. (Hardiness Institute, Inc).

Treatment of Social Anxiety Disorder


1. Treat the state of high-arousal. Remember, people with SAD are physiologically in distress. Although learning emotional regulation strategies is key in the recovery process, sometimes we have to treat the high arousal first, so that one can be calm enough to transform meanings around their fears. It’s hoped that over-time, when the person is calm enough to stay in situations he or she fears, they can cut back on medication or may no longer need it (SAD, Treatment and Drugs, Mayo Clinic).

2. Comprehensive Cognitive Behavioral Treatment (CBT). Cognitive-behavioral therapies include reappraisal techniques for regulating emotions. Treatment involves reappraising negative ideas around high arousal from a downfall to a benefit (“My arousal will do me  in” to “I need some arousal to perform well”). Such transformations promote approach-oriented patterns of responding to stressful social situations while still maintaining stress arousal necessary for optimal performance (Changing the Conceptualization of Stress in Social Anxiety Disorder). You can try reappraising your emotional fears on your own. Or seek out a trained CBT professional who can guide you in this treatment.

3. Mindfulness-Based Therapies (MBT)As you know by now, social anxiety disorder has to do with an unreasonable estimation of threat. Cognitive behavioral therapies (CBT) see the actual thoughts as causing the unrealistic estimation of threat. They aim at replacing distorted thoughts with more realistic ones, so that threat lowers and the person can approach situation once feared. Mindfulness-based therapies (MBT) see the relationship one has to thinking as the problem in social anxiety. If we believe that we are our thoughts, we give thinking great power over us. For example, I have the thought that I will fall apart in this social situation. In CBT, I actually fall apart because I am my thoughts. If we gain enough distance between our self and thinking, then thinking has less power over us. Now, when I have the thought that I may fall apart in this social situation, I do not, because I know that I am separate from my thoughts. The same idea applies to physical arousal involved in social anxiety. If we stay present to anxiety, observe it as a state that does not dictate our actions, then, it dissipates.

Also, people with social anxiety often try to avoid what they fear by diverting their gaze from people and things that threaten them. It is the fleeing part of the fight-or-flight response to threat. Meditation increases their ability to stay focused (visual attention) on the feared stimulus rather than running away from it. They learn to explore rather than to express their feelings around it, which in turn helps them to positively reappraise the threat  (Meditation Helps People with Social Anxiety).

Social anxiety disorder can be diagnosed through a careful history and can be treated successfully with the treatments I suggest here. Adequate relief from social anxiety is the goal. So that a comprehensive range of treatment is the best way to treat social anxiety disorder. Working with cognition, behavior, and self-awareness are critical to getting as much relief from SAD as possible. A trained and skilled CBT and MBT therapist will know the methods, strategies, and ideas most useful to treatment. As with all mental health disorders, there is no quick fix and recovery is a process. Embrace it and get better today!


By: Deborah Khoshaba, Psy.D.