Social anxiety disorder

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 10 Apr 2025

Last updated: 12 Nov 2024

Social anxiety disorder is characterized by an excessive fear of social and performance situations where the individual is afraid of being negatively evaluated or rejected by others.

One of the most common and impairing mental disorders with a high risk for comorbid anxiety, depressive, and substance-use disorders; it may be associated with severe impairments in daily functioning, including reduced quality of life, difficulty forming relationships, and impaired school and work performance.

Assessment is based on self-reporting, clinical interview, and behavioral observation.

Selective serotonin-reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and cognitive behavioral therapy are considered the first-line treatments.

Long-term clinical management and monitoring are typically required, as patients are prone to relapse following discontinuation of acute treatment.

Definition

The condition involves an excessive fear of social or performance situations. The individual will often fear being rejected or negatively evaluated by others. Anticipatory anxiety and situational avoidance are common, and the individual may endure social situations with a high level of discomfort. The scope of the anxiety may be focused on specific types of social situations or generalized to almost any social encounter.

History and exam

Key diagnostic factors

history of psychiatric comorbidity
positive family history of social anxiety
anticipatory anxiety and worry
tachycardia
hyperventilation
sweating
flushing
muscle tension

Full details

Other diagnostic factors

post-event processing
attentional biases
social skills deficits
crying, tantrums, or "freezing"
selective mutism

Full details

Risk factors

psychiatric comorbidity (e.g., anxiety, mood, and substance-use disorders)
genetic
temperamental factors
parenting style
psychological disorder
life stressors
environmental factors

Full details

Diagnostic tests

1st tests to order

clinical diagnosis

Full details

Tests to consider

blood glucose
serum thyroid-stimulating hormone
toxicology screen (urine and blood)

Full details

Treatment algorithm

ONGOING

adults: no comorbidity

adults: comorbidities

children and adolescents

Contributors

Authors

Craig N. Sawchuk, PhD

Professor

Department of Psychiatry and Psychology

Mayo Clinic

Rochester

Disclosures

CNS declares that he has no competing interests.

Jason P. Veitengruber, MD

Associate Professor

Department of Psychiatry and Behavioral Sciences

University of Washington School of Medicine

Seattle

Disclosures

JPV is an author of a reference cited in this topic.

Bunmi O. Olatunji, PhD

Professor

Department of Psychological Sciences

Vanderbilt University

Nashville

Disclosures

BOO declares that he has no competing interests.

Stacy Shaw Welch, PhD

Director

Anxiety and Stress Reduction Center of Seattle

University of Washington

Seattle

Disclosures

SSW declares that she has no competing interests.

Peer reviewers

Stefan G. Hofmann, PhD

Alexander von Humboldt Professor

Department of Psychology

Philipps University Marburg

Germany

Disclosures

SGH is an author of a number of references cited in this topic.

Fallon R. Goodman, PhD

Assistant Professor of Psychology

George Washington University

Washington

Disclosures

FRG declares that she has no competing interests.

Richard P. Swinson, MD, FRCPC, FRCPsych

Emeritus Professor

Medical Director

Anxiety Treatment and Research Centre

McMaster University and St Joseph’s Hospital

Hamilton

Canada

Disclosures

RPS declares that he has no competing interests.

David Baldwin, MD

Professor of Psychiatry

University of Southampton

Southampton

Disclosures

DB has acted as a consultant for and held research grants from Cephalon, Eli Lilly, GSK, Lundbeck, Organon, Pfizer, Pharmacia, Roche, and Wyeth and has also acted as a consultant to Asahi, AstraZeneca, Grunenthal, Pierre Fabre, Servier, Sumitomo, and Wyeth. He has accepted paid speaking engagements in industry-supported satellite symposia and is co-author of the BAP evidence-based guidelines on the treatment of anxiety disorders. He is also a Medical Patron of Anxiety UK.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed., text revision (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022.

National Institute for Health and Care Excellence. Social anxiety disorder: recognition, assessment and treatment. May 2013 [internet publication].Full text

Katzman MA, Bleau P, Blier P, et al; Canadian Anxiety Guidelines Initiative Group on behalf of the Anxiety Disorders Association of Canada/Association Canadienne des troubles anxieux and McGill University. Canadian clinical practice guidelines for the management of anxiety, posttraumatic stress and obsessive-compulsive disorders. BMC Psychiatry. 2014;14(suppl 1):S1.Full text Abstract

Williams T, Hattingh CJ, Kariuki CM, et al. Pharmacotherapy for social anxiety disorder (SAnD). Cochrane Database Sys Rev. 2017 Oct 19;(10):CD001206.Full text Abstract

Schaffer A, McIntosh D, Goldstein BI, et al. The CANMAT task force recommendations for the management of patients with mood disorders and comorbid anxiety disorders. Ann Clin Psychiatry. 2012 Feb;24(1):6-22. Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials
- Phobias
- Panic disorder
- Agoraphobia
More Differentials
Guidelines
- Anxiety and depression in children and youth: diagnosis and treatment
- WFSBP guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and posttraumatic stress disorders- version 3. part I: anxiety disorders
More Guidelines
Patient information
Anxiety
Panic attacks
More Patient information
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Social anxiety disorder

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

adults: no comorbidity

adults: comorbidities

children and adolescents

Contributors

Authors

Craig N. Sawchuk, PhD

Disclosures

Jason P. Veitengruber, MD

Disclosures

Bunmi O. Olatunji, PhD

Disclosures

Stacy Shaw Welch, PhD

Disclosures

Peer reviewers

​Stefan G. Hofmann, PhD

Disclosures

Fallon R. Goodman, PhD

Disclosures

Richard P. Swinson, MD, FRCPC, FRCPsych

Disclosures

David Baldwin, MD

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice

Stefan G. Hofmann, PhD