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Guide
US English

Anxiety
Understanding Social
 Understanding Social Anxiety

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 experience social anxiety disorder
every year [1, 2]. The good news is that Cognitive Behavioral Therapy (CBT) is an effective
psychological treatment for social anxiety disorder, and with the right treatment you can
recover.

This guide will help you to understand:

• What social anxiety is.

• Why social anxiety might not get better by itself.

• Treatments for social anxiety.

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 Understanding Social Anxiety

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 social anxiety disorder include:

Feeling self-conscious
and anxious in social
situations where you
might be exposed to
scrutiny by other
people.
Your anxiety is out of Fear that you will behave
proportion to the actual in a way that will be
dangers posed by the judged negatively by other
situation. What is it like? people.
Social
The kind of social situations Anxiety
Avoiding social situations, or
that bother you almost
enduring them with great
always provoke fear or
difficulty.
anxiety.
Worrying what other
people think of you.

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:
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 Understanding Social Anxiety

How you might think How you might feel

• Worry about what other people think of you. • Fear or discomfort when you are interacting with
• Worry that other people will judge you. other people, or anxiety just being around other
• Worry that other people will notice that you are people.
anxious, or will notice your symptoms of anxiety • Physical symptoms of anxiety including:
e.g. shaking or blushing. blushing, fast heartbeat, trembling, sweating,
• Expect the worst from social situations. shaking, upset stomach, nausea, dizziness or
• Dread activities such as starting conversations, lightheadedness.
speaking on the telephone, meeting people.
• “They’ll notice I’m anxious”
• “They’ll think I’m weird because I’m blushing”
• “I’m making a mess of this”
• “I won’t be able to get my words out”
How you might act What you might pay attention to
• Avoid situations where you might be the center • The negative impression (or image) you have of
of attention, or where you you worry you might yourself.
embarrass yourself. E.g. speaking to unfamiliar • How you are coming across to other people.
people, attending parties, starting conversations, • Feelings of self-consciousness, and self-
dating, going to work or school. awareness.
• Do things to control how you come across
to other people (sometimes called ‘safety
behaviors’). E.g. preparing what you might say,
trying not to be noticed, speaking quietly, hiding
your face, staying cool.
• Spend time after a social situation
‘post-morteming’ and analyzing your
performance – particularly flaws in your
performance.
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 Understanding Social Anxiety

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 service. I’d started my course seven
months ago, was enjoying living away from home, and had a good group of friends. I’d
always been a good student, and tried to do everything as well as I could. I was enjoying
some aspects of my course, but was struggling in my group seminars. It was very difficult
to contribute to the group, and I found it excruciating to give presentations. My anxiety got
so bad that I avoided some of my seminars, to the extent that I might not have been able
to progress to the next year.

My therapist asked me to describe a recent time when I felt anxious, and I described a
recent seminar. It was my turn to present something to the group, and I’d spent a lot of time
preparing exactly what I was going to say. While I was speaking, I felt like I was stumbling
over my words. I thought I looked like a fool because I was coming across as nervous,
and thought my peers would think I was incompetent. I felt very anxious, hot, sweaty,
and shaky. I was worried that other people would hear my voice shaking, so I spoke very
quickly to get my presentation over with and quietly to hide my shaky voice. I avoided eye
contact and kept my eyes fixed on my presentation because I was so self-conscious. After the
presentation I made a swift exit, and spent the rest of the day berating myself for how badly
I had performed.

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 me to
a family barbeque. I arrived early and, in the back of my mind, had planned to use the
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excuse that I had to leave early to attend another appointment. During the party I was very
aware of how hot I felt, was afraid of appearing anxious, and worried that other people
would think I was weird because I was blushing. There were a number of moments where I

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 Understanding Social Anxiety

felt extremely self-conscious, and was convinced I was blushing red in my face. During the
party, I volunteered to get drinks for people and to clean up, both as ways to avoid having to
talk to people. When I couldn’t avoid talking to people, I tried to make sure I was standing
in the shade, so that I could stay cool and avoid blushing. If I felt myself getting hot I would
try to turn my face or cover it with my hand.

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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 Understanding Social Anxiety

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.

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

☐ Never ☐ Occasionally ☐ Sometimes ☐ Often

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

☐ Never ☐ Occasionally ☐ Sometimes ☐ Often

When I’m with other people I worry about being embarrassed, looking stupid,
or doing something to humiliate myself.

☐ Never ☐ Occasionally ☐ Sometimes ☐ Often

If I have to endure a social situation it makes me feel very anxious.

☐ Never ☐ Occasionally ☐ Sometimes ☐ Often

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

☐ Never ☐ Occasionally ☐ Sometimes ☐ Often

If you answered ‘often’ to most of these questions, and you find that these fears cause
hindrance in your life, then you might be suffering from social anxiety. You might find it
helpful to speak to your general practitioner, or a mental health professional about how
you are feeling.
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 Understanding Social Anxiety

What causes social anxiety?

There is no single cause for social anxiety. Some things that make you more likely to expe-
rience social anxiety include:
• Evolution. Like many mammals, human beings have evolved to care about our place
in our social group. In the distant past, being kicked out of your pack or tribe could
mean death. To some extent, we are still ‘programmed’ or ‘hardwired’ to worry about
being excluded or rejected. This in-built concern means that all of us are likely to feel a
bit socially anxious on occasion. If you feel anxiety in social situations you might find
it helpful to remind yourself that there is nothing wrong with you – it is just that your
natural instinct to care about what others think of you is taking the driving seat.

• Personality. From a very early age, children vary from being outgoing and adventurous
to shy and timid. Psychologists talk about children (and adults) having a personality
that makes them likely to ‘approach’ or ‘avoid’. If you are naturally more withdrawn,
cautious, or restrained you are more likely to develop social anxiety disorder [3].

• The way that other people have treated you. People with social anxiety have sometimes
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].

• 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’, and make you feel more
anxious around other people.

• Having an appearance or condition that draws attention. Not everybody who has a
physical difference develops social anxiety, and not everybody with social anxiety looks
different. However, you may have had negative reactions from others about your height,
weight, hair color, or appearance, and this can increase feelings of self-consciousness [5].
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Research evidence suggests that there may be genes which make you likely to develop
emotional problems in general, but none which make you likely to develop social anxiety.

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 Understanding Social Anxiety

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, on-line, 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
Answering where there are Being asked
the people who I to perform
telephone don’t know in any way

Speaking Asking a Posting

to shop question comments
assistants in a group online

Having to
Chairing Speaking to speak to
a meeting my child’s someone of
teacher the opposite
sex

Talking Speaking
Giving to people to senior
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a speech at social people at

events work

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 Understanding Social Anxiety

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 is because if they can work out
what keeps a problem going, they can treat the problem by ‘removing the fuel’ and inter-
rupting this maintaining cycle. In 1995 the psychologists David Clark and Adrian Wells
published an influential model of social anxiety which describes some of the ‘parts’ that
keep social anxiety going [7].

• The impression you have of yourself (your self-image).

• Your beliefs and assumptions.

• Negative automatic thoughts (NATs) and images.

• Self-consciousness and self-focused attention.

• Safety behaviors and avoidance.

• Anticipatory anxiety and worry.

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

The diagram on the next page shows how these factors have unintended consequences,
which can keep the social anxiety going, or even make it worse.
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 Understanding Social Anxiety
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
people will respond to them.
• Negative beliefs about themselves.
Having a negative self-image can prompt you
to behave in unhelpful ways. Our beliefs can
be so strong that they feel like facts, when
actually they are more like opinions. If your
self-impression is not entirely accurate it
may put you under a lot of unnecessary
pressure.
Your self-impression,
self-image, and beliefs
What keeps it going?
Social
Anxiety
Self-consciousness &
self-focused attention
If you pay attention to how you think you are
coming across to other people then you might
focus your attention inwards - towards your
own body feelings, thoughts, feelings, and
judgements about your performance. Some
people say they do this so that they can
‘catch’ themselves making mistakes before
other people notice.
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.
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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?”
• Judgements: “I’m making such a mess of
this.”
• Doubts: “I’ll never be able to do this.”
Negative automatic thoughts and images
aren’t always accurate. People with social
anxiety often fall into the trap of emotional
reasoning: feeling something and thinking
that it must be true just because it feels
that way.
Negative automatic
thoughts and images
Avoidance and
safety behaviors
If you are socially anxious you might avoid
situations that make you feel anxious
(avoidance), or you might do things to control
how you come across to other people (safety
behaviors). For example, you might stay quiet
in groups, or you might ask questions to keep
attention away from you.
Safety behaviors are well-intended, but they
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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 Understanding Social Anxiety

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:

I’m weird I’m

I’m shaking Other people
I look and will think I’m
dumb boring awkward and I look
anxious disgusting

The impression you have of yourself might not necessarily be in the form of words. Instead,
you might have an image of yourself, or even a feeling about how others see you. For
example, some people with social anxiety described their own self-images:

• I have an image of myself being excluded and pushed to the edge of things.

• My image is of myself looking sweaty and flustered.

• The image I have is of other people sneering at me as I awkwardly get things wrong.

What sort of image do you have of yourself ? A psychologist might ask you the question
“What do you think that other people think of you?” or “How do you think you are coming
across to others?”. How might you answer?

One fairly straightforward problem of having a negative self-image is that it makes you feel
bad or vulnerable – it just feels nicer to judge yourself positively. There are other problems
too. One is that having a negative self-image can make you more likely to behave in
unhelpful ways (which we will discuss in a later section). Another problem is that negative
self-images can make you pay attention to ‘evidence’ that supports the negative idea about
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yourself, and ignore ‘evidence’ that doesn’t fit: with the result that you end up with a biased
view of who you are and how you appear to the people around you.

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 Understanding Social Anxiety

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 can be quite absolute and negative
(e.g. “I’m weird”, “I never get it right”) or they can set us up to feel anxiety (e.g. “If I make
a mistake then other people will humiliate me”).

Psychologists have found that people with social anxiety tend to hold certain types of
beliefs and assumptions. These include:

• Excessively high standards for how they think they ‘should’ perform in social
situations. For example, believing “I should never look anxious”, “I need to look casual
when I’m around other people”, or “I must always have interesting things to say”.

• Strong beliefs about how other people will respond to their ‘performance’ and how
judgemental they will be. For example, believing “If I make a mistake then people will
pounce on it and humiliate me” or “People will think I’m weird for blushing”.

• Negative beliefs about themselves. For example, believing “I’m odd”, or “I’m awkward”.

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 were very critical of the things
that they did might learn to pay a lot of attention to their ‘performance’. Unfortunately
these habits of paying attention can persist even once they have moved away from their
parents and started to live independently. Examples like this show how beliefs can become
outdated and unhelpful. Cognitive behavioral therapy for social anxiety pays attention to
testing and challenging your beliefs and assumptions in case they are holding you back.
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 Understanding Social Anxiety

Negative automatic thoughts & 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 un-
pleasant. We all have these too – people with social anxiety included.

People suffering from social anxiety often report having negative automatic thoughts
when they are in social situations, such as “I’ll run out of things to say”, “They think I’m
stupid”, or “I’m embarrassing myself ”. They often find that the thoughts get worse when
they notice unwanted body sensations (“Oh no, I’m blushing, everyone will notice”). You
might also have negative images which spontaneously pop into your mind. For example,
David worried that he would ‘freeze’ if he was asked a question and had an image of
himself standing alone, frozen stiff, with his eyes darting around. Images which pop into
your mind can be so vivid and compelling that it feels as if it must be a true reflection of
how you look to others. Trying to carry on a conversation with this negative ‘chatter’ in the
back of your mind is difficult and distracting. Negative automatic thoughts that you might
have in a social situation include:

• 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”, “I look stupid”.

• Doubts. “I’ll never be able to do this”, “Will my anxiety show?”

As well as being distracting, negative automatic thoughts aren’t always accurate.

Everyone’s thinking can become ‘biased’ in different ways, and psychologists have helpful
ways of working with these biases. One of the biases that matters a lot in social anxiety
is called ‘emotional reasoning’. This is when we make the mistake of feeling something
and thinking that it must be true. For example, you might feel anxious during a
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conversation and think that you look noticeably anxious, or you might feel like you are
shaking and believe that you are shaking so violently that it is visible to other people.

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 Understanding Social Anxiety

Another big problem of NATs is that they keep you ‘stuck in your head’, which makes it
difficult to act naturally in social situations.

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:

• Outwards. Towards the real world – you will notice the other people, what is going on
around you, how they are reacting, and all the sights, sounds, smells.

• 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
focus your attention inwards when you are in social situations, with the result that you feel
extremely self-conscious. When you are socially anxious you may focus your attention on:

Thoughts that pop How you think you Your internal body
into your mind (e.g. appear to others sensations, which you
“they’re bored”, “I’m might use as a guide
messing up”) to how you’re doing

Images that come into Focus of attention

your mind (e.g. of Social Your performance, or
yourself going red, Anxiety how ‘well’ you’re doing
blushing, shaking)
How sweaty you are How much you are
blushing
How fluent your
speech is
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 Understanding Social Anxiety

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.

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:

• Focusing on how we are doing inhibits our performance. Self-focus doesn’t improve
performance. Sportsmen and sportswomen know this – golfers and tennis players often
talk about their game falling apart when they ‘overthink’ it. To function at our best
we often have to take our conscious experience out of it and just ‘be in the moment’.
Psychologists call this ‘flow’.

• Self-focus gives us a biased impression. When we focus inwards we are often only
paying attention to our mistakes, our flaws, our discomfort, or our negative thoughts
and images. Self-focus means that we can end up missing or ignoring the things that we
are doing well. This stops us from getting a complete and accurate picture of how we are
really performing. You might become so focused on your (perceived) flaws that you miss
important and helpful social cues such as other people’s faces.

• 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 people will notice and think I”m anxious”),
you will feel even more anxious, and the feelings and body sensations can become even
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stronger. Psychologists call this a ‘vicious cycle’.

• It can result in the thing that you are trying to prevent. For example, focusing inwards
and trying very hard to ‘not appear odd’ by monitoring and controlling your behavior can
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 Understanding Social Anxiety

unintentionally lead to you behaving oddly – your behavior might appear ‘unnatural’,
‘inauthentic’, or ‘superior’ to others because it is overcontrolled rather than relaxed and
natural.

• It can mean that you are not really ‘present’ in conversations. Other people might
interpret this as rudeness, aloofness, or disinterest.

Safety behaviors & 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:

Don’t talk about

Don’t meet myself in case I Don’t make
one to one say something eye contact
stupid

Don’t eat Rehearse Drink

messy food what I am alcohol to
in public going to say relax

Cover my
Stay on the
Ask questions
face to
edge of the
so I don’t have
hide my to talk about
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blushing group myself

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 Understanding Social Anxiety

Although the intention of safety behaviors is to help us give a good impression, more often
than not they have unintended outcomes:

• Safety behaviors prevent you from learning the truth. One of the biggest problems
of safety behaviors is that they prevent you from getting a clear picture of how much
danger you are in (or even if you are in any danger at all!). For example, if you worry that
people might think you are stupid, you might stay quiet in conversations. The problem
of this strategy is that you don’t have many opportunities to discover that people might
find you interesting when you open up.

• Safety behaviors make you more self-conscious. Because you are focused on trying to
prevent a disaster, your safety behaviors draw your attention inwards, and you spend
your time monitoring how close you are to disaster. Inward focus is a problem in social
anxiety because it doesn’t enhance your performance, and it stops you from getting a
realistic picture of how you are doing.

• Safety behaviors can sometimes result in the outcome that you are trying to prevent.
Here are some examples:

• Diane was worried that her hand would shake, that she would drop her glass, and that
people around her would think that she was silly. She held on very tightly to her glass,
so tightly that her colleague commented that she her knuckles had gone white – this
made Diane feel even more self-conscious and anxious.

• Abdul was worried that people wouldn’t like him, so he pre-planned conversations to
keep people entertained, but this meant that he wasn’t paying much attention to other
people, and so he came across as unfriendly.

• Felix was worried that he would sweat and that other people would think he is
disgusting. He kept his arms tightly by his side. This made him sweat even more,
which made him even more anxious and self-conscious.

• Amara was worried that she would blush and other people would think she was
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anxious. She would cover her face, and turn away when she felt hot. She didn’t realize,
but this made people pay more attention to her face.

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 Understanding Social Anxiety

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 true. Like many safety strategies
this worrying is well-intended – but it can have unintended effects.

Research has shown that when people with social anxiety worry about future events they
often have unhelpful habits of thinking. You might find that you become focused on
memories of past failures. Or you might find negative images of yourself popping into
your mind. You might find yourself predicting or expecting terrible things to happen. It’s
not deliberate, but your thoughts might be quite pessimistic.

The problem of thinking about possible future outcomes, focusing on negative images,
or remembering past failures is that you’re only seeing the worst part of the picture. And
it can make you feel terrible! What you’re not remembering are the times that things
have gone OK, when you’ve done well, or when things went better than you expected. By
focusing on the negative – even if you don’t mean to – your anxiety is prolonged.

‘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 even to think about what we could have done
differently.

Most people will say that they have looked back at a conversation they’ve had in the past
and cringed at what they said or did, or regretted not doing something different. Everybody
reviews their interactions a little bit, it is a natural thing to do.
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Unfortunately, post-morteming in social anxiety is often too intense, and too biased.
People with social anxiety tend to focus on the worst bits, or the wrong bits. Research

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 Understanding Social Anxiety

shows that people with social anxiety spend a lot of time focusing on their own
thoughts and feelings during the social interaction (often lots of negative thoughts, and
anxious feelings). These are easily accessible, but it doesn’t mean that they’re an accurate
reflection of how the social interaction actually went. In fact, it is highly likely that if
you postmortem something, you will miss the positive signals that are present: like your
successes, or things that went OK.
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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 anxiety [6, 8]. This is sometimes called cognitive therapy for SAD, or
CT-SAD.

CBT is a popular form of talking therapy. CBT therapists understand that what we think
and do affects the way we feel. Unlike some other therapies, it is often quite structured.
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 will set an agenda together so
that you have agreed what that session will concentrate on. ‘Ingredients’ of effective CBT
treatment for social anxiety disorder include [6]:
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 Understanding Social Anxiety

Developing a
personalized
cognitive model of Experimenting with your
your social anxiety. attention and safety
Developing a therapy behaviors in
blueprint. conversations.
Video and
Memory work to
photographic
‘process’ memories of Treatments feedback to correct
socially traumatic
experiences. Social your negative
Anxiety self-imagery.
Targeting anticipatory
Attention training to
anxiety and
practice focusing
post-event
externally.
rumination.
Using surveys to Behavioral
understand what experiments to test
other people think. your specific negative
beliefs and
assumptions.

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 what was going through my mind. She drew a picture on a
board in her office to explain how the pieces fit together. We talked a lot about the impres-
sion I have of myself when I’m around other people – normally that I think I look stupid
and incompetent. This was good because it put lots of stuff out in the open.

My therapist got me to do lots of ‘experiments’ to test whether some of my thoughts about

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myself were fair. We did quite a lot of things where she recorded me on video while she got
me to do different things, as a way of testing whether I actually looked like I thought I did.
Lots of the therapy was like that. One of the big things that I took away was that I don’t

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 Understanding Social Anxiety

look as stupid or anxious as I thought I did. This has really helped because I’m just more
confident doing things now and I don’t avoid my seminars or presentations any more.

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.

I was surprised by how carefully my psychologist listened to me, and how she wrote down
lots of the things I said, and checked them out with me.

I’m not going to lie, therapy was one of the hardest things I’ve ever done. There were loads
of things I did when I was around other people and she got me to be honest about them,
and then to try not to do them. For example, whenever I felt like I was blushing I would
always cover my face or make an excuse about it being hot to kind of normalize it, you
know? She went right to it and took a video of how red I was when I was talking to people.

I think one of the things that has changed for me is that I accept myself more now. I still get
thoughts when I’m with other people that I’m messing it up, but I’m much better at focusing
on what’s going on around me rather than getting caught up in my own thoughts, and it
makes a difference. I don’t feel hopeless anymore. I’ve even registered on a dating website
and started to go to the Friday evening socials at work.

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 medications called Selective Serotonin
Reuptake Inhibitors (SSRIs) such as escitalopram or sertraline should be offered [9].
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 Understanding Social Anxiety

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 biology and behavior within a developmental framework. Annual Review of Psy-
chology, 56, 235-262.

[4] Bjornsson, A. S., Hardarson, J. P., Valdimarsdottir, A. G., Guðmundsdottir, K., Tryggvadottir, A.,
Thorarinsdottir, K., ... & Thorisdottir, A. S. (2020). Social trauma and its association with post-
traumatic stress disorder and social anxiety disorder. Journal of Anxiety Disorders, 102228.

[5] Clarke, A., Thompson, A. R., Jenkinson, E., Rumsey, N., & Newell, R. (2013). CBT for appearance
anxiety: Psychosocial interventions for anxiety due to visible difference. John Wiley & Sons.

[6] Warnock-Parkes, E., Wild, J., Thew, G. R., Kerr, A., Grey, N., Stott, R., ... & Clark, D. M. (2020).
Treating social anxiety disorder remotely with cognitive therapy. The Cognitive Behaviour Therapist,
13.

[7] Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In R. Heimberg, M. Liebowitz,
D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment and treatment (pp. 69–93).
New York: Guildford Press.

[8] Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014).
Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic
review and network meta-analysis. The Lancet Psychiatry, 1(5), 368-376.

[9] National Institute for Health and Care Excellence (NICE: 2013). Social; anxiety disorder:
recognition, 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:
Type: Guide
Document orientation: Portrait
URL: https://www.psychologytools.com/resource/understanding-social-anxiety/

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