Social Anxiety Disorder (SAD) is a mental disorder characterized by intense, persistent and irrational fear in social situations or in contexts where the individual may be evaluated by others. Defined in DSM-5 as “Social Anxiety Disorder,” it is part of the spectrum of anxiety disorders and can significantly restrict social functioning. Typically emerging during adolescence, if untreated, it tends to become chronic and co-occur with other psychiatric conditions.

Individuals with social phobia excessively fear being negatively evaluated, humiliated or embarrassed. Due to this fear, they may develop avoidance behaviors toward social situations, or when forced to face them, they experience intense anxiety. SAD is not simply shyness; it is a clinical condition that significantly impairs functioning and often coexists with disorders such as depression and substance use.

DSM-5 Diagnostic Criteria for Social Anxiety Disorder

According to DSM-5, the following criteria must be met for a diagnosis of SAD:

• The individual experiences marked fear or anxiety in one or more social situations (for example, giving a speech, interacting with unfamiliar people, eating in public) where they may be evaluated by others.
• The person fears negative evaluation (embarrassment, rejection, humiliation) and responds with intense anxiety in such situations.
• Social situations are either avoided or endured with great distress.
• The fear or anxiety is disproportionate to the actual threat posed by the social situation.
• Symptoms persist for at least six months.
• Anxiety causes significant impairment in work, school or social functioning.
• Symptoms are not attributable to another psychiatric disorder, medical condition or substance/medication use.

Symptoms of Social Anxiety Disorder

Symptoms of social phobia manifest at both psychological and physical levels. Common psychological symptoms include intense shame, expectation of failure, self-focused attention, negative automatic thoughts and excessive worry about future social situations. These individuals believe others are judging them negatively and feel that their social performance is consistently inadequate.

Physical symptoms include blushing, trembling, sweating, palpitations, voice trembling, muscle tension, nausea and dizziness. These reactions may lead the individual to quickly leave social settings or avoid performance-based situations entirely.

Etiology of Social Anxiety Disorder

The etiology of SAD is multifaceted, with biological, psychological and environmental factors interacting in its development.

Genetic predisposition is a significant factor. Family studies show that first-degree relatives of individuals with SAD have higher prevalence of similar disorders. Twin Registry studies have found concordance rates of 30–40% among monozygotic twins (Stein et al., 2002).

At the neurobiological level, increased amygdala activity is thought to underlie heightened emotional reactivity to social stimuli. Functional imaging studies demonstrate hyperactivation in the medial prefrontal cortex, insula and amygdala during social evaluative tasks in individuals with SAD (Phan et al., 2006).

Psychosocial factors also play an important role. Overly critical, protective or rejecting parental attitudes in childhood may hinder social skill development. Traumatic social experiences such as bullying, humiliation or ridicule are linked to the onset of SAD. Cognitive models propose that these individuals unrealistically misinterpret their own performance as poor and perceive the external world as threatening.

Risk Factors

Risk factors contributing to the development of SAD include:

• Family history of anxiety disorders
• Childhood temperament characterized by shyness (behavioral inhibition)
• Early social traumas
• Critical, authoritarian or overprotective parenting
• Deficits in social skill development
• Female gender (SAD is more common in women, though it may present more severely in men)

Diagnosis

Diagnosis of SAD is made through clinical interviews, with DSM-5 criteria serving as the primary framework. Psychometric tools may also be used to support diagnosis, including:

• Liebowitz Social Anxiety Scale (LSAS)
• Social Phobia Inventory (SPIN)
• Beck Anxiety Inventory (BAI)

Differential diagnosis must consider generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, autism spectrum disorder and avoidant personality disorder.

Treatment of Social Anxiety Disorder

SAD can be largely controlled with appropriate treatment. Clinical guidelines recommend psychotherapy and pharmacotherapy as first-line treatments, either individually or in combination.

1. Cognitive Behavioral Therapy (CBT)

CBT is the most effective psychotherapeutic approach for SAD. It helps individuals challenge distorted beliefs about themselves and others. Dysfunctional cognitions related to social interactions (such as “I will embarrass myself”) are addressed and replaced with alternative perspectives.

• Exposure therapy involves gradual confrontation with feared social situations to reduce avoidance behaviors.
• Cognitive restructuring transforms negative automatic thoughts into more balanced cognitions.

2. Pharmacotherapy

In targeting the biological basis of SAD, selective serotonin reuptake inhibitors (SSRIs) are the first-line pharmacological option. Effective agents include sertraline, paroxetine, escitalopram and fluoxetine.

• Therapeutic response typically begins within 4–6 weeks.
• Doses must be individualized.
• For patients unresponsive to SSRIs, venlafaxine (an SNRI) or short-term benzodiazepines may be considered.

3. Other Psychotherapies

• Mindfulness-Based Stress Reduction (MBSR) enhances present-moment awareness and reduces anxiety in social contexts.
• Group therapy encourages social skill development and reduces feelings of isolation through interaction with peers facing similar challenges.

Family Counseling and Social Support

In adolescents, family participation in psychoeducation enhances treatment outcomes. Family members should encourage, rather than reinforce avoidance behaviors.

Impact on Daily Life

Social anxiety disorder can profoundly impact quality of life. Academic performance, occupational success and social relationships may be severely impaired. Routine activities such as giving a presentation, attending a job interview, speaking in public or engaging in simple social interactions may provoke intense anxiety.

Individuals with SAD often withdraw from social environments, leading to loneliness, low self-esteem, depression and substance use. It may hinder career advancement or result in school dropout or job resignation. Moreover, suicidal ideation and behaviors occur more frequently in individuals with SAD compared to the general population.

Social Anxiety Disorder is a prevalent yet frequently underrecognized mental disorder. Its symptoms can affect multiple aspects of life, but with early diagnosis and effective treatment recovery is possible. Cognitive behavioral therapy and SSRIs represent first-line treatments. Psychoeducation, family support and social skill training can further enhance functioning. Combating stigma and expanding access to mental health services are crucial for improving outcomes in individuals with SAD.