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  • Apr 1

Living in the Fear of Being Judged: Social Anxiety Disorder

Imagine this situation: you are giving a presentation in front of your classmates in a large lecture hall. You feel your heart beating out of your chest, your clothes feel drenched in sweat, and your legs feel like Jell-O. For most of us, this is just a normal, brief feeling of nervousness, but for some, these are characteristics of a chronic illness called Social Anxiety Disorder (SAD). Social Anxiety Disorder, also known as social phobia, is a mental health condition that causes fear and anxiety when you’re around people in social situations. People with SAD experience an intense and ongoing fear of being judged or watched by others (Cleveland Clinic, 2022). In social anxiety disorder, fear and anxiety lead to avoidance that can affect relationships and cause significant disruptions in one’s daily life. SAD is a common anxiety disorder, affecting about 5-10% of people worldwide. Symptoms often begin before the age of 20, and studies show that females are more affected than males. (Cleveland Clinic, 2022). Although social anxiety disorder can be detrimental to those affected, learning how to cope through talk therapy and medications can help manage and treat the condition. 

Three Levels of Social Anxiety Disorder:

Individuals with Social Anxiety Disorder can experience varying degrees of anxiety, which can be categorized as mild, moderate, or severe.

Mild Social Anxiety: A person with mild social anxiety may experience physical and psychological symptoms, but can still participate in social situations, even if they feel uncomfortable. They might find that their anxiety arises only in specific social contexts.

Moderate Social Anxiety: Those with moderate social anxiety experience similar symptoms but are more selective about their social engagements. They may participate in some social situations while actively avoiding others.

Severe Social Anxiety: Individuals with severe social anxiety experience intense symptoms, including panic attacks, and tend to avoid social situations altogether. Those with this extreme form of disorder are likely to feel symptoms in most, if not all, types of social interactions (Cleveland Clinic, 2022).

Another classification of SAD is performance type, where you experience intense fear and anxiety when speaking or performing in public but not in other, more general social situations.

Symptoms and Causes:

Emotional and behavioral symptoms:

  • Fear of others negatively judging you or rejecting you

  • Intense fear or anxiety during social situations

  • Worrying about embarrassing or humiliating yourself

  • Avoiding doing things or speaking to people out of fear of embarrassment

  • Avoiding situations where you may be the center of attention

  • Fear that others will notice you look anxious

  • Fear of physical symptoms that may cause you embarrassment (blushing, sweating, shaky voice)

  • Anxiety in anticipation of a feared event

  •  Analyzing your performance and identifying your own flaws in your interactions after a social situation

  • Expecting the worst possible consequence from a negative experience during a social situation (Mayo Clinic, 2021).

In children, anxiety can be presented as crying, temper tantrums, clinging to parents, or refusing to speak in social situations. According to the Cleveland Clinic (2022), physical symptoms may also accompany social anxiety, including blushing, a rapid heartbeat, trembling, sweating, an upset stomach or nausea, trouble catching one's breath, dizziness or lightheadedness, and muscle tension.

Figure 1. Social anxiety disorder symptoms (Psychological).

Figure 2. Social anxiety disorder symptoms (Physical).

The images above, adapted from Zoelife Psychiatric Services, illustrate the physical and psychological symptoms of social anxiety disorder (SAD). Understanding how these symptoms manifest in daily life can help individuals recognize when they may need help and seek treatment sooner. 

Social anxiety disorder does not arise from a single cause, but rather from a complex interaction between biological and environmental factors. Anxiety disorders usually run in families, but it isn’t fully known how much SAD can be attributed to genetics and how much is due to learned behavior. One key brain structure involved is the amygdala, which plays a major role in regulating the fear response. People with an overactive amygdala may show an exaggerated fear response, leading to increased anxiety in social situations. As mentioned, SAD may also be attributed to environmental factors or learned behavior. Children who observe anxious behavior from parents or who are raised in overly controlling or protective environments may be more prone to developing social anxiety disorder themselves (Mayo Clinic, 2021).

Researchers have linked social anxiety to a deficiency of an essential nutrient in the brain called choline. A 2025 study from UC Davis found that people with anxiety disorders, including SAD, had about 8% lower choline levels in their brains, particularly in their prefrontal cortex, which is the part of the brain that helps with planning and decision-making. Choline is only produced in small amounts by the body, so most of it must be obtained from the foods we eat (Clark, 2025). 

Diagnosis:

SAD can be diagnosed by a healthcare provider based on the criteria for Social Anxiety Disorder listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The criteria include:

  • Persistent and intense fear or anxiety about social situations, often due to worries about being judged negatively or humiliated by others. 

  • Avoiding social situations that trigger anxiety or enduring them with intense fear or anxiety. 

  • Feeling intense anxiety that's out of proportion to the actual situation. 

  • Experiencing anxiety and/or distress from social situations that interfere with your day-to-day life. 

  • Experiencing fear or anxiety in social situations that aren’t better explained by a medical condition, medication, or substance abuse (Cleveland Clinic, 2022).

Cleveland Clinic also states that a healthcare provider may ask questions regarding symptoms and history to see if the DSM-5 criteria match your experience. They may also ask questions about medications and perform a physical examination to confirm that the symptoms are not caused by the medication or a different medical condition. In order to be diagnosed with SAD, a person usually has to have had symptoms for at least 6 months.

Complications:

If SAD is left untreated, it can greatly disrupt a person’s ability to function at work, school, and in relationships, ultimately lowering their quality of life. People with untreated SAD may develop low self-esteem, struggle with being assertive, and engage in negative self-talk. They may become hypersensitive to criticism, exhibit poor social skills, avoid social interactions, or struggle to build and maintain healthy relationships. SAD may also interfere with academic and job performance and may increase substance abuse and excessive alcohol consumption. SAD may also lead to suicidal thoughts or attempts. Other anxiety and mental health disorders, especially major depressive disorder and substance abuse problems, commonly occur with SAD (Mayo Clinic, 2021).

Treatment and Prevention:

Treatment of Social anxiety disorder depends on how much it interferes with daily life, with the most common line of treatment involving psychotherapy (talk therapy) and/or medications such as antidepressants. Psychotherapy can improve symptoms in most people with SAD and change negative thoughts, as well as help one develop skills to gain confidence in social situations. The most effective form of psychotherapy for anxiety is cognitive behavioral therapy (CBT). In exposure-based CBT, individuals gradually work up to facing the situations they fear the most. This can help improve coping skills and confidence to deal with anxiety-inducing situations. A study done in 2020 found that after 20 weeks of CBT, SAD participants reported a decrease in their social anxiety levels and improvement in their quality of life (Butler et al., 2020).  A provider may also recommend skills training or role-playing to practice social skills.  (Mayo Clinic, 2021; Cleveland Clinic, 2022). As for medications, selective serotonin reuptake inhibitors (SSRIs) such as sertraline (Zoloft) or paroxetine (Paxil) are often the first type of medication prescribed. Serotonin and norepinephrine reuptake inhibitors (SNRIs) such as venlafaxine (Effexor XR) may also be prescribed. Benzodiazepines such as Lorazepam may also be used short-term in situations provoking anxiety and are not to be taken for extended periods. Some beta-blockers, such as propranolol, may also be used to treat or prevent physical symptoms, such as rapid heart rate (Mayo Clinic, 2021; Cleveland Clinic, 2022).

Living with Social Anxiety Disorder:

Along with help from a professional, there are some ways of handling situations that are likely to trigger symptoms of SAD:

  • Get enough sleep and exercise

  • Learn stress-reduction skills

  • Eat a healthy, well-balanced diet

  • Limit or avoid caffeine

  • Avoiding alcohol and recreational drugs

  • Take medication for social anxiety regularly and avoid missing doses

  • See your therapist regularly

  • Participate in social situations with those you feel comfortable with

  • Seek support from friends and family (Cleveland Clinic, 2022;  Mayo Clinic, 2021).

Critical Perspective:

Strengths: SAD is highly treatable with therapies such as CBT and medications.

Limitations: Treatment may be delayed due to SAD being mistaken or dismissed as “just shyness.”

Conclusion:

Social anxiety disorder is a common mental health condition that causes fear and anxiety in social situations. Although experiencing social anxiety can be frightening, it is important to note that it is treatable. Addressing your symptoms with your healthcare provider is very critical, and the sooner you seek treatment, the sooner your symptoms can improve. Recall the last time you felt extremely nervous about a social interaction. Now imagine feeling that amount of fear every moment of your waking life. How would you deal with that?

  • Did you know that social anxiety disorder is the 3rd most common mental health condition worldwide, after depression and substance use disorder?

 

About the author:

Camilla Arusei is a student at UT Dallas, majoring in Biology with a minor in Neuroscience. She works as a medical assistant at an OBGYN clinic and is passionate about women’s health.


References

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