How to help social anxiety: practical steps and therapy

What is social anxiety?

These situations are “consistently avoided or endured with intense fear or anxiety”, and the problem lasts for at least several months^[1]. In the US, a diagnosis needs the feelings to last at least 6 months and get in the way of daily life^[2]. It usually starts in childhood or the teenage years, and most cases begin between the ages of 8 and 15^[1][2]. And it “can be effectively treated”^[8]. For anxiety more broadly, see stress vs anxiety.

How to help social anxiety: 9 steps you can start today

These steps come from CBT for social anxiety^[8]. They work best practised together, not as one-off tricks. Each one says how strong the evidence is.

Expect setbacks, and “try not to give up”. There is no quick cure: CBT “can take a little time to work”^[7]. Avoiding situations “might actually make our anxiety worse”, while slowly facing up to them might help^[27].

Social anxiety symptoms

Someone with social anxiety feels “overly worried before, during and after” social situations^[3]. Common signs include:

• Worrying about everyday things such as meeting strangers, starting conversations, speaking on the phone, working or shopping^[3]
• Avoiding, or worrying a lot about, group conversations, eating with company and parties^[3]
• Fearing criticism, avoiding eye contact, or having low self-esteem^[3]
• Blushing, sweating, trembling, feeling sick or a pounding heart, and sometimes panic attacks^[3]
• Your mind “going blank”, a rigid posture, or speaking very softly^[2]
• Worrying for weeks before an event, then picking over your “flaws” afterwards^[2]

Some people notice their body first. The WHO’s manual says people may talk about blushing, sweating or trembling “rather than initially endorsing fears of negative evaluation”, and may not see their fear as excessive^[1]. For some, the anxiety comes up only when they have to perform, such as giving a talk^[2].

Signs of social anxiety in children

In children it can look like crying or anger more than usual, avoiding other children and adults, fear of school, and relying heavily on a parent or carer^[3]. Some complain of stomach-aches or headaches, or refuse to speak^[2]. If you are worried about a child, talk to a doctor.

Is there a social anxiety test?

No online quiz can diagnose it. UK guidance tells clinicians to ask two questions: “Do you find yourself avoiding social situations or activities?” and “Are you fearful or embarrassed in social situations?” A yes to either, or a score of 6 or more on a short questionnaire called the Mini-SPIN, means the next step is a full assessment^[8]. It does not mean you have the disorder. Bliss Therapy also has a free anxiety self-test. It can tell you whether to talk to someone, but it cannot diagnose you.

Social anxiety vs shyness vs avoidant personality disorder

The WHO’s manual calls shyness a normal personality trait. Social anxiety disorder is only considered when fear and avoidance are “clearly in excess of what is normative for the specific cultural context” and cause significant distress or problems^[1]. In a US survey of over 10,000 teenagers, only 12% of those who called themselves shy also met the criteria for social anxiety disorder, and they had far more problems in daily life^[9]. Introversion is different again: a preference for quieter, smaller-scale social time, not fear.

Avoidant personality disorder (AvPD), in the US manual, involves “extreme shyness related to low self-esteem and sensitivity to rejection and criticism”^[10]. It overlaps a lot with social anxiety disorder^[13], and many researchers see it as a more severe form of the same problem, though not all agree^[11]. In community studies, about two-thirds of people with AvPD did not also meet the criteria for social anxiety disorder^[11].

Based on the WHO, the NHS, NIMH, the APA, NICE and research reviews^{[1][3][5][8][9][10][11][12]}. A guide to how clinicians tell them apart, not a self-diagnosis checklist.

The WHO’s ICD-11 has no separate “avoidant” type; it rates personality disorder by severity and traits^[1]. Clinicians look out for AvPD when assessing social anxiety^[8], as it can affect “engagement and retention in therapy”^[12]. Only a professional can tell the two apart. See also therapy for self-esteem.

Why social anxiety keeps going

CBT models see social anxiety as a loop, in which biased ways of reading social situations raise anxiety and keep it going^[18]:

1. Before: you worry about the event, sometimes for weeks^[2], and may brood over past social experiences^[17].
2. During: your attention turns inwards. In the Clark and Wells model, this brings up negative thoughts and stops you seeing evidence that your fears are wrong. Many people also picture themselves in a distorted way, as if seen by others^[14].
3. Safety behaviours: you stay quiet or keep someone close. They stop you gathering evidence against your fears, so they keep the anxiety going over time^[16].
4. After: you replay the event, going over and even reconstructing how you did^[17].

Avoidance feeds the loop. “The longer you spend avoiding social situations, the more frightening the idea of being in one becomes”^[7]. If it has left you cut off, see therapy for loneliness.

What causes social anxiety?

There is usually no single cause, and it is “most likely” a combination of factors^[7]:

• Temperament. Some children are “slow to warm up”. This is normal, but also a risk factor^[1]: in a meta-analysis of only 7 studies, it was linked with a more than sevenfold increase in risk^[19].
• Family and genes. It “may run in families”, but no one knows for sure why some family members have it and others do not^[2].
• Experiences. Being bullied or embarrassed in a social situation can play a part^[7], and it can start suddenly after a stressful or humiliating social experience^[1].

How common is social anxiety?

In the US, about 7.1% of adults had social anxiety disorder in the past year, and about 12.1% have it at some point in their lives, according to a national survey from 2001–2003^[5][4]. Across 28 countries in the WHO’s World Mental Health surveys, about 4% of people had it at some point. Rates were highest in high-income countries and the Americas^[6]. In about half of people with it, it has started by age 11^[20]. Yet people with social anxiety are less likely to seek help^[2].

Culture, language and living abroad

Culture shapes what counts as too much fear, so clinicians judge it against your own cultural context^[1]. Moving country is not a proven cause: one small study found immigration “per se is not a universal risk factor”^[29]. Speaking a second language can bring its own nerves, which tend to be lower in people who use it more often, with more people^[30], but that is early research on language anxiety, not social anxiety disorder. Guidance for generalised anxiety, not social anxiety, recommends therapy in your preferred language where possible^[31], and in general healthcare, same-language care tends to improve outcomes^[32]. See our page on therapy for expats.

Therapy for social anxiety: what works best

UK guidance recommends individual CBT “specifically developed to treat social anxiety disorder”, based on the Clark and Wells model or the Heimberg model^[8]. A review of 101 trials with over 13,000 people found individual CBT had the largest effect, and concluded it “should be regarded as the best intervention for the initial treatment of social anxiety disorder”^[21].

In UK guidance, a course runs for about 4 months: up to 14 sessions of 90 minutes, or 16 sessions, most of them an hour long^[8]. Sessions cover the steps above, plus video feedback to correct a distorted self-image, work on painful social memories and core beliefs, and planning for setbacks^[8]. In one trial by the model’s developers, 84% of people no longer met the criteria after cognitive therapy, against 42% after exposure plus relaxation and 0% on a waiting list, and the differences held a year later^[22]. Treatment does not work for everyone^[20].

• One-to-one or group? Group CBT works, but it is “less clinically and cost effective than individual CBT”^[8].
• ACT and mindfulness. Acceptance and commitment therapy (ACT) has “a growing body of research” for social anxiety^[2]. It is a newer option, not equal to CBT. UK guidance says not to routinely offer mindfulness-based interventions for it^[8], and individual CBT did better than mindfulness in trials^[21].
• By video. Therapy “can be effective when delivered in person or virtually via telehealth”^[2]. Remote CBT has done at least as well as face-to-face CBT, though few studies compared them^[24]. In one trial of CBT by video, 68% no longer met the criteria three months later, similar to results usually seen in person. It was compared with a waiting list, not with in-person therapy^[25].

On Bliss Therapy

On Bliss Therapy you choose a therapist who speaks your language, by video from home, with no waitlist. 52 psychologists and counsellors list anxiety and stress, with sessions from €30 (about £25); 42 of them list CBT.

Our therapists are based outside the UK and the US, so they are unlikely to be on UK registers or covered by US health insurance. Ask any therapist about their training and their registration in the country where they practise.

Self-help CBT for social anxiety

Self-help “can help reduce social anxiety” and can be “a useful first step before trying other treatments”^[3]. In trials, self-help beat a waiting list, a little more so with support^[21], and internet CBT did well across 21 trials^[23].

For adults who decline CBT, UK guidance suggests supported self-help: “typically up to 9 sessions of supported use of a CBT-based self-help book over 3 to 4 months”, with about 3 hours of support in total^[8]. A free place to start is the NHS inform social anxiety self-help guide, based on CBT and meant for mild to moderate symptoms^[7]. If self-help is not enough after a fair try, step up to therapy.

Medication for social anxiety

Some people are offered medication, usually an SSRI antidepressant such as escitalopram or sertraline, often if they prefer it to therapy^[8]. For people who decline therapy, SSRIs show “the most consistent evidence of benefit”^[21], though a Cochrane review rated the evidence that they help as very low quality, and the evidence that they prevent relapse as moderate^[26]. They may take several weeks to work, and beta-blockers are sometimes used for performance anxiety^[2]. UK guidance advises against routinely offering benzodiazepines^[8], which can lead to tolerance and dependence^[2]. Whether medication is right for you, and which one, is a decision to make with a doctor or psychiatrist.

How to help someone with social anxiety

If you are worried about a friend, partner or child:

• Learn about it. Read up on the signs, symptoms and treatment options^[2].
• Pick a calm time to talk. Tell them you are concerned, and reassure them of your support^[2].
• Understand why they may not ask for help. They may not know it is treatable, may see it as a personal failing, or find doctors hard to talk to^[8].
• Notice small steps. Be patient and acknowledge progress, “no matter how small”^[2].
• Encourage professional help if it is causing problems in everyday life^[2].
• For a child, guidance recommends CBT focused on social anxiety, and suggests involving parents or carers. Medication is not routinely offered^[8].

When to get help

See a doctor or therapist if social fear is causing problems in everyday life, at work, in your studies or in relationships^[2]. Using alcohol or drugs to cope should not stop you getting treatment^[8]. In the UK, “it’s a good idea to see a GP if you think you have social anxiety”, and a GP “will try to put you at ease”^[3]. In England, adults can also refer themselves to NHS talking therapies^[27]. In the US, start with a primary care doctor, psychiatrist, psychologist or clinical social worker^[2]. You do not need to wait until it is bad enough.