Department of Psychiatry

Penn Behavioral Health

Social Anxiety Disorder


Many people feel nervous in certain social settings. Meeting new people, going on a date, giving a performance - nearly everyone has experienced the anxiety that these situations can provoke. Social anxiety disorder, or social phobia, however, describes a marked, intense, and persistent fear of social situations that can be differentiated from the more typical fear that comes with discomforting situations.

The anxiety associated with SAD not only leaks into an individual’s social life but interferes with his or her everyday activities and professional life. While other mental health disorders cause social anxiety symptoms (e.g. sweating, palpitations, or panic attacks), social anxiety disorder refers only to individuals who specifically avoid or fear social situations.

Common Symptoms

The first mention of social anxiety disorder dates back to 400 B.C. It is popularly accepted that Hippocrates made mention of the disorder while describing a man who "loves darkness as life and...thinks every man observes him." The socially phobic person’s tendency to overestimate the extent to which others "observe him" is characteristic of the disorder.

Individuals suffering from social anxiety disorder typically experience the following symptoms:

  • Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others (e.g. having a conversation, meeting new people, giving a speech, eating in front of others)
  • The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (will be humiliating or embarrassing, or lead to rejection)
  • Social situations almost always provoke fear or anxiety, and are avoided or endured with fear or anxiety
  • The fear or anxiety is out of proportion to the actual threat posed by the situation and context

Those diagnosed with social anxiety disorder are continually hindered by the feeling that “all eyes are upon them.” While many people have memories of being discomforted by a social situation, an individual with social anxiety disorder is debilitated by the feeling. The anxiety may interfere with an individual’s professional life, academic life as well as his or her everyday activities, often hindering an individual’s ability to form intimate relationships. Importantly, a person also develops a fear of the phobia itself, reinforcing the initial avoidance reaction.

Social anxiety disorder is harder to diagnose in children. Because children do not have the means to describe the quality of their anxiety as effectively as adults, the disorder may go unrecognized despite a child developing habits frequently encountered with social anxiety. Some common personality and behavioral traits seen in children with social anxiety disorder are crying, tantrums, clinging to familiar people, extreme shyness, refusing to speak in front of their class, and fear or timidity in new settings and with new people. In order for a child to be diagnosed with social anxiety disorder, the child must experience anxiety with their peers as well as with adults but also show the capacity to form social relationships with familiar people.

Additional Symptoms

There are a number of traits frequently seen in individuals with social anxiety disorder that the clinical description of the disease does not take into account. Such traits include a difficulty being assertive, feelings of inferiority, and a hypersensitivity to criticism and other negative judgments that can lead to excessive anger. This hypersensitivity also results in fear of others making both direct and indirect judgments. Thus, individuals with social anxiety disorder may have extreme test anxiety or refuse to participate in class. This compromises academic performance and later professional performance and may lead to both dropping out of school and long-term unemployment.

Unsurprisingly, the social limitations of the disorder also make it more difficult for those with social anxiety disorder to develop intimate relations. They are less likely to marry, less likely to have fulfilling friendships, and more likely to live with members of their biological family. Suicidal thoughts are also associated with severe cases, particularly when other disorders are present. The strong feelings of fear and despair lead to substance abuse and the development of other anxiety and mood disorders. In addition, many other mental health disorders have features associated with social anxiety disorder.

Particularly, social anxiety disorder is highly correlated with the presence of avoidant personality disorder. There has, however, been a long-standing debate within the mental health community questioning whether avoidant personality disorder and social anxiety disorder are in fact distinct disorders. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) currently defines them as two separate disorders; however, many dispute this fact on the basis of both the overlapping clinical criteria and experimental evidence. Empirical results suggest that avoidant personality disorder is a more severe form of social anxiety disorder. Avoidant personality disorder is characterized as an inability to relate to others while social anxiety disorder is defined as an inability to perform in social situations. Nonetheless, the generalized form of social anxiety disorder does indeed seem to encompass an element of avoidant personality disorder, strengthening the argument that the difference between the disorders is a matter of severity.

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Onset & Course

Social anxiety disorder can affect people of any age. However, the disorder typically emerges during adolescence in teens with a history of social inhibition or shyness. The onset is usually accompanied by a stressful or humiliating experience and the severity varies by individual. Risks have been defined to be temperamental, environmental, genetic, and physiological. The disorder is divided into the following two categories:

  • Generalized: symptoms present in most social situations
  • Nongeneralized (specific): symptoms present in specific social situations

Individuals who develop generalized social anxiety disorder fear most social settings; this includes both social interactions as well as performance situations. Often the range of social fears is so large that individuals do not report the list in full. Individuals who identify a less extensive list of fears meet the criteria for nongeneralized social anxiety disorder. These individuals may fear one specific situation or several settings but they do not fear most situations and such cases typically do not involve symptoms as severe as generalized social anxiety disorder.

The severity of the disorder, both generalized and nongeneralized, may be influenced by a variety of stressors in an individual’s life. At times, the symptoms diminish for stretches of time during adulthood or they worsen with the events, such as a change in job or the loss of a spouse. Nonetheless, the symptoms typically persist in some form and intensity for the duration of one’s life.

Epidemiological Information

The lifetime prevalence of social anxiety disorder varies with respect to gender and ethnic background. Research estimates that 12% of the U.S. population meets the criteria for social anxiety disorder with rates in other countries varying widely. Women are more likely to develop the disorder than men.

The disorder is prevalent in other populations; however, the anxiety may present itself differently. One form of the disorder, Taijin Kyofusho, is strongly culture-specific. Taijin Kyofusho is primarily found in Japan and Korea, and many of the features of the disorder reflect cultural differences that exist between American and Japanese culture. Unlike the more westernized form of social anxiety disorder, individuals with Taijin Kyofusho do not fear embarrassing themselves but rather have an irrational fear that others will be embarrassed by their own smell, facial expression (e.g. blushing), or movements. They have a persistent fear that their physical presence will be offensive or displeasing.

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What Causes this Disorder

There is evidence that genetic factors may play a role in the development of social anxiety disorder, particularly in for the generalized form. There is a higher incidence of social anxiety disorder in individuals with first-degree relatives affected by other panic and anxiety disorders. However, there is no one gene that explains this biological trend. General findings indicate that personal experiences, social environment, and biology all play a role in the development of the disorder.

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More Information

National Institute of Mental Health (NIMH)
An organization with the National Institute of health dedicated to mental health research:

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