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Guide

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US English

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Social Anxiety

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Understanding

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Introduction

It is common to feel a bit of anxiety around

other people from time to time. If the anxiety
is more severe than regular shyness, and is
interfering with your ability to live your life, you
may be suffering from social anxiety: one of the
most common anxiety disorders. It is thought
that between 2 and 7 people out of every 100

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or
experience social anxiety disorder every

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year [1, 2]. The good news is that Cognitive

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Behavioral Therapy (CBT) is an effective

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psychological treatment for social anxiety pl

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disorder, and with the right treatment you can

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recover.

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This guide will help you to understand:

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• What social anxiety is.
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• Why social anxiety might not get better by

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itself.
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• Treatments for social anxiety.

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1
What is social anxiety?

Do you ever feel anxious when you’re around

other people, or if you might have to be the
center of attention? Do you worry that other
people will notice something about you – or
about the way you behave – and judge you for
it? Social anxiety is the name for feeling these
kinds of fears in social situations. Symptoms of

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or
social anxiety disorder include:

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Feeling self-conscious

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and anxious in social
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situations where you
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might be exposed to

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scrutiny by other
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Your anxiety is out of ith Fear that you will behave

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proportion to the actual in a way that will be

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situation. people.
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What is it like?
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Social
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The kind of social situations

Avoiding social situations, or
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that bother you almost

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enduring them with great

always provoke fear or
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difficulty.
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anxiety.
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Worrying what other

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people think of you.

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2
What is social anxiety?

Do any of these symptoms feel familiar to you?

We can separate the effects of social anxiety
into how you might think, how you might feel,
how you might act, and what you might pay
attention to:

How you might think How you might feel

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• Worry about what other people think of you. • Fear or discomfort when you are interacting with

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• Worry that other people will judge you. other people, or anxiety just being around other

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people.

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• Worry that other people will notice that you are
• Physical symptoms of anxiety including: blushing,

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anxious, or will notice your symptoms of anxiety e.g.

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shaking or blushing. fast heartbeat, trembling, sweating, shaking, upset
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stomach, nausea, dizziness or lightheadedness.
• Expect the worst from social situations.

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• Dread activities such as starting conversations,
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speaking on the telephone, meeting people.

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• “They’ll notice I’m anxious”

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• “They’ll think I’m weird because I’m blushing”
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• “I’m making a mess of this”

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• “I won’t be able to get my words out”

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How you might act What you might pay attention to

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• Avoid situations where you might be the center • The negative impression (or image) you have of
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of attention, or where you you worry you might yourself.

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embarrass yourself. E.g. speaking to unfamiliar

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• How you are coming across to other people.

people, attending parties, starting conversations,
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• Feelings of self-consciousness, and self-awareness.

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dating, going to work or school.

• Do things to control how you come across to other
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people (sometimes called ‘safety behaviors’). E.g.

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preparing what you might say, trying not to be

noticed, speaking quietly, hiding your face, staying
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cool.
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• Spend time after a social situation ‘post-morteming’

and analyzing your performance – particularly flaws
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in your performance.

3
What is it like to have social anxiety?

Keira and Alvin both struggled with social

anxiety. Their stories illustrate what it can feel
like to be affected in this way.

Keira’s fear of public speaking

I was 20 when I went to the university counseling My therapist asked me to describe a recent time

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service. I’d started my course seven months ago, was when I felt anxious, and I described a recent seminar.
enjoying living away from home, and had a good It was my turn to present something to the group,

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group of friends. I’d always been a good student, and and I’d spent a lot of time preparing exactly what I

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tried to do everything as well as I could. I was enjoying was going to say. While I was speaking, I felt like I was

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some aspects of my course, but was struggling in
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my group seminars. It was very difficult to contribute because I was coming across as nervous, and thought

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to the group, and I found it excruciating to give my peers would think I was incompetent. I felt very
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presentations. My anxiety got so bad that I avoided anxious, hot, sweaty, and shaky. I was worried that
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other people would hear my voice shaking, so I spoke

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some of my seminars, to the extent that I might not
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have been able to progress to the next year. very quickly to get my presentation over with and
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quietly to hide my shaky voice. I avoided eye contact

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and kept my eyes fixed on my presentation because I

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was so self-conscious. After the presentation I made

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a swift exit, and spent the rest of the day berating

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myself for how badly I had performed.

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4
What is it like to have social anxiety?

Alvin’s social anxiety

I first went to see a psychologist when I was 33, after
my GP referred me for longstanding depression and
anxiety. My therapist asked me to describe a recent
time when I felt anxious and I told him about a recent
occasion when my sister and brother in law invited
My social anxiety meant that I had no close
friends, and had never had a relationship. I worked
in construction, but kept to myself and avoided
socializing with my workmates. I was lonely and
depressed, and felt like life was passing me by.

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me to a family barbeque. I arrived early and, in the

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back of my mind, had planned to use the excuse that

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I had to leave early to attend another appointment.

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During the party I was very aware of how hot I felt, pl

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was afraid of appearing anxious, and worried that

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other people would think I was weird because I was
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blushing. There were a number of moments where
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I felt extremely self-conscious, and was convinced

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I was blushing red in my face. During the party, I
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volunteered to get drinks for people and to clean up,
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both as ways to avoid having to talk to people. When

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I couldn’t avoid talking to people, I tried to make sure

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I was standing in the shade, so that I could stay cool

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and avoid blushing. If I felt myself getting hot I would

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try to turn my face or cover it with my hand.

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5
Do I have social anxiety?

Social anxiety should only be diagnosed by a

mental health professional or a doctor. However,
answering the screening questions below can
give you an idea of whether you might find it
helpful to have a professional assessment.

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I avoid situations where I might be the centre of attention.

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Never Occasionally Sometimes Often

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Fear of embarrassment causes me to avoid doing things or speaking to people.

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Never Occasionally Sometimes Often

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When I’m with other people I worry about being embarrassed, looking stupid, or doing something to humiliate
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myself.
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Never Occasionally
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If I have to endure a social situation it makes me feel very anxious.

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Never Occasionally Sometimes Often

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Speaking in front of a group of people makes me feel anxious.

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Never Occasionally Sometimes Often

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If you answered ‘often’ to most of these

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questions, and you find that these fears cause

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hindrance in your life, then you might be

suffering from social anxiety. You might find it
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helpful to speak to your general practitioner, or

a mental health professional about how you are
feeling.

6
What causes social anxiety?

There is no single cause for social anxiety. Some
things that make you more likely to experience
social anxiety include:
• Evolution. Like many mammals, human
beings have evolved to care about our
place in our social group. In the distant past,
• Your beliefs and assumptions about yourself,
how others see you, and how you think you
need to behave in public. We all have internal
‘rules’ about how we think we need to behave,
and how we expect other people to act. If you
have beliefs or assumptions that other people
will be very critical, it can put you on ‘edge’,

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being kicked out of your pack or tribe could
and make you feel more anxious around other
mean death. To some extent, we are still

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people.

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‘programmed’ or ‘hardwired’ to worry about

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being excluded or rejected. This in-built • Having an appearance or condition that

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draws attention. Not everybody who has a
concern means that all of us are likely to feel
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a bit socially anxious on occasion. If you feel physical difference develops social anxiety,

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anxiety in social situations you might find
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looks different. However, you may have had
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it helpful to remind yourself that there is

negative reactions from others about your
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nothing wrong with you – it is just that your

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natural instinct to care about what others height, weight, hair color, or appearance,
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think of you is taking the driving seat. and this can increase feelings of self-
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consciousness [5].
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• Personality. From a very early age, children

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Research evidence suggests that there may

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vary from being outgoing and adventurous

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to shy and timid. Psychologists talk about be genes which make you likely to develop
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children (and adults) having a personality that emotional problems in general, but none which
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make you likely to develop social anxiety.

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makes them likely to ‘approach’ or ‘avoid’. If

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you are naturally more withdrawn, cautious,

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or restrained you are more likely to develop

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social anxiety disorder [3].

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• The way that other people have treated you.

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People with social anxiety have sometimes

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suffered difficult experiences at the hands of

others. These might include experiences of
bullying, teasing, ridicule, humiliation, trauma,
or abuse. You might have strong memories or
mental images of humiliating things that have
happened to you [4].

7
What triggers social anxiety?

Social anxiety is worse in situations where you
fear you might be evaluated or judged by other
people. These situations can be in-person,
online, or on the telephone, and situations
where you are the center of attention are often
described as the most anxiety-provoking.
Some situations that have been described as
triggering by people who suffer from social
anxiety include:

Being at a party

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Answering where there are Being asked
the people who I to perform

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telephone

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don’t know in any way

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Asking a Posting
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Speaking
to shop question comments
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in a group
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Having to
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Talking Speaking
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a speech at social to senior

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events people at
work

8
What keeps social anxiety going?

Research studies have shown that Cognitive
Behavior Therapy (CBT) is the most effective
treatment for social anxiety [6]. CBT therapists
work a bit like firefighters: while the fire is
burning they’re not so interested in what caused
it, but are more focused on what is keeping it
going, and what they can do to put it out. This
• The impression you have of yourself (your
self-image).
• Your beliefs and assumptions.
• Negative automatic thoughts (NATs) and
images.
• Self-consciousness and self-focused

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is because if they can work out what keeps a attention.

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problem going, they can treat the problem

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• Safety behaviors and avoidance.

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by ‘removing the fuel’ and interrupting this
• Anticipatory anxiety and worry.

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maintaining cycle. In 1995 the psychologists pl

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David Clark and Adrian Wells published an • ‘Replaying’ social events (postmorteming)

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influential model of social anxiety which and rumination.

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describes some of the ‘parts’ that keep social

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The diagram on the next page shows how these
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anxiety going [7]. factors have unintended consequences, which

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ith can keep the social anxiety going, or even make
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it worse.
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What keeps social anxiety going?

People with social anxiety tend to hold an

impression of themselves that is very
negative. As a result they are very fearful
that other people will view them negatively.
They also tend to have strict beliefs, such as:
• High standards for how they think they
‘should’ perform in social situations.
• Strong beliefs about how they think other
Negative automatic thoughts that people with
social anxiety have in social situations
include:
• Predictions: “They will think I look anxious.”
• Worries: “What if I say something and
nobody replies?”

:
people will respond to them. • Judgements: “I’m making such a mess of

or
• Negative beliefs about themselves. this.”
Having a negative self-image can prompt you • Doubts: “I’ll never be able to do this.”

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to behave in unhelpful ways. Our beliefs can Negative automatic thoughts and images

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be so strong that they feel like facts, when aren’t always accurate. People with social

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actually they are more like opinions. If your pl anxiety often fall into the trap of emotional

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self-impression is not entirely accurate it reasoning: feeling something and thinking

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may put you under a lot of unnecessary that it must be true just because it feels

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pressure. that way.
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Your self-impression, Negative automatic

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self-image, and beliefs ith thoughts and images
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What keeps it going?

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Social
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Anxiety
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Self-consciousness & Avoidance and

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self-focused attention safety behaviors

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If you pay attention to how you think you are If you are socially anxious you might avoid
coming across to other people then you might situations that make you feel anxious
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focus your attention inwards - towards your (avoidance), or you might do things to control
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own body feelings, thoughts, feelings, and how you come across to other people (safety
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judgements about your performance. Some behaviors). For example, you might stay quiet
people say they do this so that they can in groups, or you might ask questions to keep
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‘catch’ themselves making mistakes before attention away from you.

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other people notice. Safety behaviors are well-intended, but they

Self-consciousness is the opposite of a
performance enhancer (ask any sports-
person). Worse, it gives you a biased
impression of how you are really coming
across to people.
can lead to a lot of problems:
• They prevent you from learning the truth.
• They heighten your self-focus.
• They sometimes lead to the result that you
were trying to prevent.
• They can make you appear unfriendly or
uninterested.
• They can draw attention towards you.

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The impression you have of yourself

We all have an impression in our minds of what
kind of person we are and how we come across
to other people.
This is your ‘self-image’ or ‘self-impression’. If you
have social anxiety, you are likely to hold an
impression of yourself that is very negative. As
a result, you may worry that other people will
think negatively of you as well. Put into words,
your self-impression might sound like:

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I’m weird I’m
I’m shaking Other people

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I look and

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boring and I look will think I’m
dumb awkward

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anxious disgusting

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The impression you have of yourself might not oa One fairly straightforward problem of having

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necessarily be in the form of words. Instead, a negative self-image is that it makes you feel
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you might have an image of yourself, or even a bad or vulnerable – it just feels nicer to judge
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feeling about how others see you. For example, yourself positively. There are other problems
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some people with social anxiety described their too. One is that having a negative self-image
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own self-images: can make you more likely to behave in unhelpful

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ways (which we will discuss in a later section).

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• I have an image of myself being excluded and

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Another problem is that negative self-images

pushed to the edge of things.
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can make you pay attention to ‘evidence’ that

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• My image is of myself looking sweaty and supports the negative idea about yourself, and
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flustered. ignore ‘evidence’ that doesn’t fit: with the result

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that you end up with a biased view of who you

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• The image I have is of other people sneering

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at me as I awkwardly get things wrong. are and how you appear to the people around
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you.
What sort of image do you have of yourself? A
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psychologist might ask you the question “What

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do you think that other people think of you?”

or “How do you think you are coming across to
others?”. How might you answer?

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Your beliefs and assumptions

As we live our lives we develop ideas about
ourselves, other people, and the world.
Psychologists call these beliefs and assumptions.
Sometimes our beliefs can be quite flexible (e.g.
“It’s not possible for everyone to like me, but it’s
OK to just carry on being me”, “I can do things
even when I feel afraid”) but other times they
One of the tricky things about our beliefs is that
they might have been accurate and helpful at
some point in our lives. This is no guarantee
that they remain true though: often our beliefs
can hold us back because they haven’t adjusted
to our new reality. For example, someone who
grew up in a household where their parents

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can be quite absolute and negative (e.g. “I’m were very critical of the things that they did

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weird”, “I never get it right”) or they can set us might learn to pay a lot of attention to their

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up to feel anxiety (e.g. “If I make a mistake then ‘performance’. Unfortunately these habits of

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other people will humiliate me”). paying attention can persist even once they
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have moved away from their parents and
Psychologists have found that people with social

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started to live independently. Examples like

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anxiety tend to hold certain types of beliefs and
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this show how beliefs can become outdated

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assumptions. These include:

and unhelpful. Cognitive behavioral therapy
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ith for social anxiety pays attention to testing and
• Excessively high standards for how they
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challenging your beliefs and assumptions in

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think they ‘should’ perform in social

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case they are holding you back.

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situations. For example, believing “I should

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never look anxious”, “I need to look casual

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when I’m around other people”, or “I must

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always have interesting things to say”.

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• Strong beliefs about how other people will

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respond to their ‘performance’ and how

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judgemental they will be. For example,

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believing “If I make a mistake then people will

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pounce on it and humiliate me” or “People will

think I’m weird for blushing”.
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• Negative beliefs about themselves. For

example, believing “I’m odd”, or “I’m awkward”.

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Negative automatic thoughts and images

Automatic thoughts are thoughts which ‘pop’
automatically into your mind. Everybody has
them. Your thoughts might take the form of
predictions, judgements, worries, or doubts.
Negative automatic thoughts (NATs) are
thoughts which are negative, frighting, or
unpleasant. We all have these too – people with
• Predictions. “They will think I look anxious”, “I
will be laughed at”.
• Worries. “What if I say something and nobody
replies?”, “If I don’t control myself I will do
something embarrassing”.
• Judgements. “I’m making such a mess of this”,

:
or
“I look stupid”.
social anxiety included.
• Doubts. “I’ll never be able to do this”, “Will my

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People suffering from social anxiety often report

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anxiety show?”
having negative automatic thoughts when

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As well as being distracting, negative automatic
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they are in social situations, such as “I’ll run out

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thoughts aren’t always accurate. Everyone’s
of things to say”, “They think I’m stupid”, or “I’m

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thinking can become ‘biased’ in different ways,
embarrassing myself”. They often find that the
oa

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and psychologists have helpful ways of working
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thoughts get worse when they notice unwanted

with these biases. One of the biases that matters
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body sensations (“Oh no, I’m blushing, everyone

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a lot in social anxiety is called ‘emotional
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will notice”). You might also have negative

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reasoning’. This is when we make the mistake

images which spontaneously pop into your
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of feeling something and thinking that it must

mind. For example, David worried that he would
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be true. For example, you might feel anxious

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‘freeze’ if he was asked a question and had an

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during a conversation and think that you look

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image of himself standing alone, frozen stiff,

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noticeably anxious, or you might feel like you

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with his eyes darting around. Images which pop

are shaking and believe that you are shaking so
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into your mind can be so vivid and compelling

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violently that it is visible to other people.

that it feels as if it must be a true reflection of
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how you look to others. Trying to carry on a Another big problem of NATs is that they keep
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conversation with this negative ‘chatter’ in the you ‘stuck in your head’, which makes it difficult
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back of your mind is difficult and distracting. to act naturally in social situations.
Negative automatic thoughts that you might
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have in a social situation include:

13
Self-consciousness and self-focused attention

Your attention is a bit like a flashlight shining in
the darkness. Whatever you focus your attention
on is what you are aware of. Just like you can
decide where to point a flashlight, when you are
in a social situation you can choose where you
focus your attention:
• Inwards. Where you notice your own
thoughts, feelings, body sensations, and
actions.
‘Self-focused attention’ describes attention we
pay towards ourselves: towards our thoughts,
feelings, body sensations, and behaviors. With

:
social anxiety, you tend to automatically

or
• Outwards. Towards the real world – you will
notice the other people, what is going on focus your attention inwards when you are in

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around you, how they are reacting, and all the social situations, with the result that you feel

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sights, sounds, smells. extremely self-conscious. When you are socially

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anxious you may focus your attention on:
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Thoughts that pop How you think you Your internal body
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into your mind (e.g. appear to others sensations, which you

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“they’re bored”, “I’m ith might use as a guide

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messing up”)
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to how you’re doing

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Images that come into

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Focus of attention
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your mind (e.g. of Your performance, or

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Social
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yourself going red, Anxiety how ‘well’ you’re doing

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blushing, shaking)
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How sweaty you are How much you are

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blushing
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How fluent your

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speech is
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On the face of it, if you are worried about how
you appear to others then it might seem to
make sense to focus inwards because:
• You might be able to ‘catch’ yourself making
mistakes and rectify things before other
people notice.
• You might notice something ‘wrong’ before
others do, giving you a chance to fix or hide it.

14
Self-consciousness and self-focused attention

In the right circumstances, a little bit of self-
monitoring can be a good thing and keep us
on track (we’ve all met people who don’t do
enough self-monitoring and who tell stories that
go on and on!). Too much self-consciousness is
a problem, though. It keeps social anxiety going
because:
• It magnifies signs of danger. Being overly
focused on what is going on inside your
body means that you easily notice bodily
feelings that you have learned to associate
with danger. For example, you might notice
yourself sweating or blushing. If you interpret
these changes as being a problem (e.g. “Other

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or
people will notice and think I”m anxious”),
• Focusing on how we are doing inhibits our

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you will feel even more anxious, and the

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performance. Self-focus doesn’t improve

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feelings and body sensations can become
performance. Sportsmen and sportswomen

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pleven stronger. Psychologists call this a ‘vicious
know this – golfers and tennis players often

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cycle’.
talk about their game falling apart when they

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‘overthink’ it. To function at our best we often
oa • It can result in the thing that you are trying

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to prevent. For example, focusing inwards
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have to take our conscious experience out of

and trying very hard to ‘not appear odd’ by
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it and just ‘be in the moment’. Psychologists

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call this ‘flow’. monitoring and controlling your behavior can

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do

unintentionally lead to you behaving oddly

• Self-focus gives us a biased impression.
to

– your behavior might appear ‘unnatural’,

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When we focus inwards we are often only

‘inauthentic’, or ‘superior’ to others because
fre
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paying attention to our mistakes, our flaws,

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it is overcontrolled rather than relaxed and

our discomfort, or our negative thoughts
-

natural.
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and images. Self-focus means that we can

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• It can mean that you are not really ‘present’

pg

end up missing or ignoring the things that

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we are doing well. This stops us from getting in conversations. Other people might
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a complete and accurate picture of how we interpret this as rudeness, aloofness, or

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are really performing. You might become so disinterest.

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focused on your (perceived) flaws that you

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miss important and helpful social cues such as

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other people’s faces.

15
Safety behaviors and avoidance

People with social anxiety often describe
avoiding situations that make them feel anxious
or self-conscious.
When complete avoidance isn’t possible, a
common strategy is to try to control how you’re
coming across to other people – these strategies
are called ‘safety behaviors’. Some people
with social anxiety described their own safety
behaviors:

:
or
Don’t talk about

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myself in case I

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Don’t meet Don’t make

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one to one say something eye contact
a

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stupid
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Rehearse Drink
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Don’t eat
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do

messy food what I am alcohol to

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in public going to say relax

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pg

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Cover my Ask questions

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face to Stay on the so I don’t have

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hide my edge of the to talk about

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blushing group myself

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16
Safety behaviors and avoidance

Although the intention of safety behaviors is to • Safety behaviors can sometimes result in
help us give a good impression, more often than the outcome that you are trying to prevent.
not they have unintended outcomes: Here are some examples:

• Safety behaviors prevent you from learning • Diane was worried that her hand would
the truth. One of the biggest problems of shake, that she would drop her glass, and
safety behaviors is that they prevent you that people around her would think that

:
she was silly. She held on very tightly to

or
from getting a clear picture of how much
danger you are in (or even if you are in any her glass, so tightly that her colleague

s
danger at all!). For example, if you worry that commented that she her knuckles had

nt
people might think you are stupid, you might gone white – this made Diane feel even

ie
more self-conscious and anxious.
stay quiet in conversations. The problem of
pl

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this strategy is that you don’t have many • Abdul was worried that people wouldn’t

ds

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id
opportunities to discover that people might like him, so he pre-planned conversations
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yo
a

find you interesting when you open up. to keep people entertained, but this meant
p

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• Safety behaviors make you more self-

ith that he wasn’t paying much attention to
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other people, and so he came across as

a

conscious. Because you are focused on trying

w
do

to prevent a disaster, your safety behaviors unfriendly.

to

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e
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draw your attention inwards, and you spend • Felix was worried that he would sweat
fre
de

your time monitoring how close you are to and that other people would think he is
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disaster. Inward focus is a problem in social disgusting. He kept his arms tightly by
-
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ra

rs

anxiety because it doesn’t enhance your his side. This made him sweat even more,
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pg

performance, and it stops you from getting a which made him even more anxious and
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realistic picture of how you are doing. self-conscious.

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• Amara was worried that she would blush

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and other people would think she was

anxious. She would cover her face, and turn
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away when she felt hot. She didn’t realize,

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but this made people pay more attention

to her face.

17
Anticipatory anxiety and worry

If you struggle with social anxiety then you

probably feel anxious in anticipation of social
situations. A strategy often used by people with
social anxiety is to worry about future events.
You might find yourself thinking about who will
be at an event, what you might say, or what you
might do to prevent your fears from coming

:
or
true. Like many safety strategies this worrying

f
is well-intended – but it can have unintended

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nt
effects.

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Research has shown that when people with
pl

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social anxiety worry about future events

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they often have unhelpful habits of thinking.
oa

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You might find that you become focused on

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memories of past failures. Or you might find

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negative images of yourself popping into your

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do

mind. You might find yourself predicting or

to

expecting terrible things to happen. It’s not

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rin
fre

deliberate, but your thoughts might be quite

de

ha

pessimistic.
-
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ra

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The problem of thinking about possible future

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pg

fo

outcomes, focusing on negative images, or

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remembering past failures is that you’re only

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seeing the worst part of the picture. And it

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can make you feel terrible! What you’re not

remembering are the times that things have
ic

gone OK, when you’ve done well, or when things

-L

went better than you expected. By focusing on

the negative – even if you don’t mean to – your
anxiety is prolonged.

18
‘Replaying’ social events (post-morteming) and rumination

Have you ever come home from a social event,

and then gone over what happened in your
mind? Have you ever thought later-on of the
things that you should have said that would
have been funnier or cleverer? Post-morteming
is the tendency to go over social events in
our minds, to check how we performed, and

:
or
even to think about what we could have done

f
differently.

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n

nt
Most people will say that they have looked back

ie
at a conversation they’ve had in the past and
pl

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cringed at what they said or did, or regretted not

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id
doing something different. Everybody reviews
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their interactions a little bit, it is a natural thing
p a
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to do. ith
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Unfortunately, post-morteming in social anxiety

w
do
to

is often too intense, and too biased. People with

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e
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social anxiety tend to focus on the worst bits,

fre
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or the wrong bits. Research shows that people

ha
-

with social anxiety spend a lot of time focusing

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on their own thoughts and feelings during

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pg

fo

the social interaction (often lots of negative

thoughts, and anxious feelings). These are easily
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accessible, but it doesn’t mean that they’re an

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at

accurate reflection of how the social interaction

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actually went. In fact, it is highly likely that

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if you postmortem something, you will miss

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the positive signals that are present: like your

successes, or things that went OK.

19
Treatments for social anxiety disorder

Psychological treatments for social
anxiety disorder
The psychological treatment for social anxiety
which has the strongest research support is
individual (one to one) cognitive behavioral
therapy (CBT) specifically designed for social
After talking things through so that they can
understand your problem, you can expect
your therapist to set goals with you so that you
both know what you are working towards. You
should seek out a therapist who has specialist
training and experience in treating social anxiety
disorder. At the start of most sessions you

:
anxiety [6, 8]. This is sometimes called cognitive

or
will set an agenda together so that you have
therapy for SAD, or CT-SAD.

f
agreed what that session will concentrate on.

s
n

nt
CBT is a popular form of talking therapy. CBT ‘Ingredients’ of effective CBT treatment for social

ie
therapists understand that what we think and pl anxiety disorder include [6]:

cl
do affects the way we feel. Unlike some other

ds

ur
therapies, it is often quite structured.
id
oa

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Developing a
a

personalized
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ith
cognitive model of
w

Experimenting with your

a

w
do

your social anxiety. attention and safety

to

Developing a therapy
g

behaviors in
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blueprint. conversations.
fre
de

ha

Video and
Memory work to
-

photographic
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‘process’ memories of
feedback to correct
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Treatments
socially traumatic
pg

fo

experiences. Social your negative

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Anxiety self-imagery.
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Targeting anticipatory
at

Attention training to
anxiety and
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practice focusing
post-event
externally.
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rumination.
-L

Using surveys to Behavioral

understand what experiments to test
other people think. your specific negative
beliefs and
assumptions.

20
Treatments for social anxiety disorder

Do you remember Keira from earlier? Here’s
what therapy was like for her:
I’d had medication for my anxiety before but it hadn’t
helped, so I wasn’t that hopeful about therapy when
it started. This therapist started by spending time
exploring how I felt in different social situations, and
Alvin had a positive experience of therapy too:
I had always been nervous around people but I had
ways of coping. I only went to therapy when it got
so bad that I couldn’t cope anymore. I just felt like I
couldn’t carry on living like that.

:
or
I was surprised by how carefully my psychologist
what was going through my mind. She drew a picture
listened to me, and how she wrote down lots of the

f
on a board in her office to explain how the pieces fit

s
things I said, and checked them out with me.

nt
together. We talked a lot about the impression I have

ie
of myself when I’m around other people – normally plI’m not going to lie, therapy was one of the hardest

cl
that I think I look stupid and incompetent. This was things I’ve ever done. There were loads of things I did

ds

ur
good because it put lots of stuff out in the open.
id
when I was around other people and she got me
oa

yo
to be honest about them, and then to try not to do
a

My therapist got me to do lots of ‘experiments’ to test

p

nl
ith them. For example, whenever I felt like I was blushing
whether some of my thoughts about myself were fair.
w

I would always cover my face or make an excuse

a

We did quite a lot of things where she recorded me

w
do

about it being hot to kind of normalize it, you know?

on video while she got me to do different things, as a
to

She went right to it and took a video of how red I was

way of testing whether I actually looked like I thought
e
rin

when I was talking to people.

fre
de

I did. Lots of the therapy was like that. One of the big
ha

things that I took away was that I don’t look as stupid

-

I think one of the things that has changed for me is

rk
ra

rs

or anxious as I thought I did. This has really helped that I accept myself more now. I still get thoughts
en ma

because I’m just more confident doing things now

pg

fo

when I’m with other people that I’m messing it up,

and I don’t avoid my seminars or presentations any but I’m much better at focusing on what’s going
er

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more.
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on around me rather than getting caught up in my

at

own thoughts, and it makes a difference. I don’t feel

-W

hopeless anymore. I’ve even registered on a dating

ic

website and started to go to the Friday evening

-L

socials at work.

21
Treatments for social anxiety disorder

Medical treatments for social anxiety

disorder
Medical treatments for social anxiety disorder
are typically recommended as a second-line
treatment if CBT is refused. The UK National
Institute for Health and Care Excellence (NICE)

:
guidelines recommend that the class of

or
medications called Selective Serotonin Reuptake

s
Inhibitors (SSRIs) such as escitalopram or

nt
sertraline should be offered [9].

ie
pl

cl
ds

ur
id
oa

yo
p a
nl
ith
w
a

w
do
to

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e
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fre
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ha
-
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en ma
pg

fo
er

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-W

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22
References

[1] Stein, D. J., Lim, C. C., Roest, A. M., De Jonge, P., Aguilar-Gaxiola, S., Al-Hamzawi, A., ... & De Girolamo, G.
(2017). The cross-national epidemiology of social anxiety disorder: Data from the World Mental Health
Survey Initiative. BMC medicine, 15(1), 143.

[2] Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E. (2005). Prevalence, severity, and comorbidity of
12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry,
62(6), 617-627.

[3] Fox, N. A., Henderson, H. A., Marshall, P. J., Nichols, K. E., & Ghera, M. M. (2005). Behavioral inhibition: Linking

:
or
biology and behavior within a developmental framework. Annual Review of Psychology, 56, 235-262.

f
[4] Bjornsson, A. S., Hardarson, J. P., Valdimarsdottir, A. G., Guðmundsdottir, K., Tryggvadottir, A., Thorarinsdottir,

s
n

nt
K., ... & Thorisdottir, A. S. (2020). Social trauma and its association with post-traumatic stress disorder and
social anxiety disorder. Journal of Anxiety Disorders, 102228.

ie
pl

cl
[5] Clarke, A., Thompson, A. R., Jenkinson, E., Rumsey, N., & Newell, R. (2013). CBT for appearance anxiety:

ds
Psychosocial interventions for anxiety due to visible difference. John Wiley & Sons.

ur
id
oa

yo
[6] Warnock-Parkes, E., Wild, J., Thew, G. R., Kerr, A., Grey, N., Stott, R., ... & Clark, D. M. (2020). Treating social
a

anxiety disorder remotely with cognitive therapy. The Cognitive Behaviour Therapist, 13.
p

nl
ith
w

[7] Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz, D. A. Hope,
a

w
do

& F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 69–93). New York: Guildford
to

Press.
g
e
rin

[8] Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological
fre
de

and pharmacological interventions for social anxiety disorder in adults: a systematic review and network
ha
-

meta-analysis. The Lancet Psychiatry, 1(5), 368-376.

rk
ra

rs

[9] National Institute for Health and Care Excellence (NICE: 2013). Social; anxiety disorder: recognition,
en ma
pg

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assessment, and treatment. Retrieved from: https://www.nice.org.uk/guidance/cg159/resources/social-

anxiety-disorder-recognition-assessment-and-treatment-pdf-35109639699397
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Resource details
Title: Understanding Social Anxiety
Language: English (US)
Translated title: Understanding Social Anxiety
Type: Guide
Document orientation: Portrait
URL: https://www.psychologytools.com/resource/understanding-social-anxiety/
Version: PTG221212
Last updated by: MW

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Disclaimer
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