Social Anxiety: Causes, Symptoms, and Solutions

Social anxiety is not about being shy, awkward, introverted, or on the spectrum. It's about wanting connection, struggling with attention, and fearing rejection. Hi, I'm psychologist Dr. Sajid Khan. I've had social anxiety since I was a kid. I spent the first part of my career treating it as an anxiety specialist at Columbia University. In this title, I'm going to explain social anxiety disorder: what it is, why it's important, how it works, and what to do about it.

We all get socially anxious every now and then, but for people who have social anxiety disorder, their anxiety really starts to get in the way of their life. People with social anxiety disorder experience a lot of fear when they think people are looking at them or when they feel like they're performing in front of others. There are a lot of anxiety sensations that might get triggered in these situations, but some of the most common are a racing heart rate, difficulty breathing, a lot of sweating, or trembling or shaking. This makes it really hard to be fully present in that social situation. All these thoughts start to bubble up about how you're stupid, strange, awkward, dumb, weird, don't belong here, you should get out of here because you're probably going to embarrass yourself, and you're also just offensive to everyone around you. This feels terrible, so maybe you drop eye contact and you start hiding and escape the first moment you can, and then you stop going to these kinds of social situations in the future.

Now, for those of you who've never experienced social anxiety, I know this might be hard to understand, so I'm going to make it really simple for you. Think about the worst, most difficult presentation you've ever given for work or school. Remember how anxious you were leading up to it, how worried you were. Maybe you practiced over and over again or you tried avoiding thinking about it as much as you could. And then remember the day of, how you had all these butterflies in your stomach. It was hard for you to digest anything; you couldn't think about anything else but this presentation. And when you finally got up there, it was hard to get the words out. Even though you got through it and some people said you did a good job, you were doubting those people. That's what social anxiety is like, except not for the worst presentation you've ever given but every day of your life with regular social situations like returning a text message, ordering something at the restaurant, or asking your teacher or your boss for help.

One of the first times I remember experiencing social anxiety was in first grade. The girl I really liked—let's call her Stephanie—invited me over for her birthday party. Now, she invited the whole class. I didn't know that, but I was super excited to go. It was a pool party, so I showed up, changed into my swim trunks, and then I jumped into the pool. When I got up, everyone was pointing and laughing. No, my swim trunks didn't fall off, but I forgot to take off my socks, and everyone there thought that was really funny. That image of everyone pointing and laughing—I couldn't quite shake that. After that, I sort of stopped going to birthday parties, and because I stopped going, I stopped getting invited. It became the cycle that started repeating itself over and over again.

Eighteen percent of the people in your community are experiencing social anxiety disorder. That's a lot of people. If you think about a class of 20 students, that means at least four of them are going to be experiencing social anxiety disorder. It starts really early too. About 50% of the people who develop social anxiety disorder do so by age 11, and then 80% have developed it by age 20. Because social anxiety disorder shows up so early in life, it can have some huge impacts on your future. It's the only mental health disorder that's consistently linked to dropping out of school. If you're alone a lot, you're not that active, you feel terrible about yourself—well, now you're vulnerable to depression. We know that people with social anxiety disorder are also really vulnerable to substance use problems because they might use substances as the only way they're able to participate in a social situation.

My social anxiety really kicked up in middle school, and I thought I was so ugly and hideous. But the thing I hated most about myself is I didn't stand up for myself and I didn't stand up for other people. When I saw someone else being bullied, I didn't step in. I didn't say stop, and when my friends would bully someone else, I'd go along with it because it was too hard for me to say anything.

The image you probably have in your head right now is someone who is shy, introverted, neurodiverse, or just awkward, and that is completely wrong. Well, not for everyone, but for a lot of people, shyness does not equal social anxiety. It's very common to be shy when you're a kid, and when that happens, you're really overwhelmed in a social situation. You're not really comfortable with it. It takes you some time to warm up to that situation. But most shy kids do tend to warm up over time, and most shy children do not become socially anxious adults.

Introversion also does not equal social anxiety. Think of introversion and extroversion as this continuum about how much social interaction might drain your battery or how much it might energize it. People who are introverted just get more tired from social situations and enjoy having more time to themselves. That doesn't make them socially anxious. Neurodiversity also doesn't equal social anxiety. Just because you have an ADHD brain, you're on the autism spectrum, or you have Tourette's, it doesn't mean you're going to develop social anxiety. Each of these conditions creates certain strengths as well as certain challenges. Yes, some of those challenges relate to interacting with other people in social contexts, but it's complicated. This graphic does a good job of showing how some of these conditions are related to social anxiety. It might make you a little bit more vulnerable to it, but none of them mean you're going to develop social anxiety.

Yes, some people with social anxiety are really awkward. I thought I was super awkward in middle school, but the reality is most people with social anxiety are just kind of quiet. That's the feedback I've gotten from other people—they said you weren't strange or weird, you just didn't really talk much; you were just kind of there. What I want you to know about people who have social anxiety disorder is that they want connection, they want to fit in, they want to talk to you, they want to be a part of the group, but their brain keeps telling them that they don't belong.

So now you're probably wondering, well, what exactly is going on inside the brain of someone who has social anxiety disorder? It starts with your genetics. A lot of people who develop anxiety disorders are more vulnerable to experiencing anxiety. Specifically, they have this thing called behavioral inhibition to the unknown. What that means is when you're in a new situation, you back off, and it's something that you can spot really early in kids, in the first few years of their lives. It's something I did all the time—always hiding behind my mom or hiding behind my dad when I was in a new or uncomfortable situation. For some reason, you might go through life and experience a situation where other people were associated with danger. Now your mind starts to make more and more associations with people representing danger. I kept thinking about all those kids laughing at me because I jumped in the pool with my socks on. Then I started thinking, well, why was I the only one who did that? Then I was thinking about all the other things that made me different, like how I was the only brown kid in my class, how I thought my nose was really big, and how I thought my voice didn't sound good.

That's unique to the rest of the class. Brush my hair, and then your mind just starts associating all these things. Pretty soon you're thinking how weird, strange, and unusual you are. When you have social anxiety disorder, you don't see the big picture. Your attention becomes really narrow and distorted. If you have social anxiety disorder, the amygdala—the part of your brain that processes fear—is more active when you're looking at faces, which means your mind literally sees faces as more dangerous. Fear gets activated in your body, making your heart race, making it hard to breathe, making you sweat, making you shake. Now you're wired to see threats in the environment, so someone with a neutral face, which is most people, you start to experience that as a threat. You start to believe that they are thinking harshly of you because of all these sensations in your body, all these thoughts floating around in your head, and how your attention is only focused on these dangers. It is so hard to speak; it is so hard to interact with anyone, to hold a conversation, and to just be there. All those things rob you of getting the real-world data of what people are actually thinking about you.

I remember being trapped in that cycle throughout PE in middle school. The moment I'd walk into the locker room, I would look straight down, try not to have any eye contact with anyone around me because I thought they were all looking at me and smirking and laughing inside because I looked so strange and awkward. I would grab my clothes from my locker and run to a bathroom stall to change into the stall. I was like the only one in my class who did that, and that just made me stick out even more. All the ways I was trying to cope with that anxiety—by not looking, by changing in the stall, by avoiding it—made it all worse. It made me stick out even more. Just thinking about it right now makes me feel very uncomfortable.

Here's the good news: we have treatments that are pretty effective at treating social anxiety disorder. Medications like SSRIs and psychotherapies like cognitive-behavioral therapy have both been shown to help a lot of people who are struggling with this problem. Research has shown medications might work a little bit faster, but therapies might have a longer-lasting impact. It doesn't really matter too much. I would say move forward with whatever you feel most comfortable with. If you pursue psychotherapy, the thing to look out for is making sure it has all the components that have been shown to be effective at treating social anxiety disorder. The terms you should look for are exposure therapy—that's where you actually practice talking to other people through your therapy, people who are not your therapist. You want to look for emotion regulation or distress tolerance skills—that is, how you learn to deal with all the stuff inside of you. You should focus on exposures where you are asked to do things like maintain eye contact, like looking at the things that scare you so your attention is less in your head and more on gathering real data on what's actually happening. The exposure should have things like title recordings where you're actually watching yourself and how you really come across, where you're getting critical feedback from other people about what you did well and getting comfortable with positive evaluation. Social anxiety is not just about negative evaluation, but a lot of people are anxious about trying to meet those high standards that people might have for themselves. Getting comfortable with that and getting comfortable with negative evaluation as well—what are the things that you need to improve on and getting comfortable with rejection because sometimes people aren't going to like you, and that's okay.

I got to experience all of this when I took a public speaking class in high school. I didn't realize it was about giving public speeches; I thought it was about studying public speeches. Then I was too socially anxious to drop out of that class, so I stuck with it. What I learned through that semester is even the popular kids in school who were in this class, they experienced those same worries that I did. I got a lot of practice speaking in front of other people, getting that critical feedback, and learning how to focus my attention. That changed my life, and I wanted to do the same for other people. When I became an anxiety specialist, I saw the fastest progress through social anxiety group therapy, where I would ask my patients to do public speaking exposures, practicing speed dating, learning social anxiety improv skills, and going out into the local community and practicing doing embarrassing things, asking rude questions, and coming across as not having a clue what you're talking about. When people were able to practice these things in the safety of therapy with the support of someone who knew what they were talking about, I saw that same type of change that my high school teacher, Ms. Hayes, was able to give me.

If you're reading this title to better understand someone else and you're thinking, what can I do to help them? There are three things I want you to remember. The first thing you can do is make it easy for someone to talk about their social anxiety. Ask someone if they're experiencing social anxiety right now. Ask them what's popping up in their head. People with social anxiety disorder don't get a lot of opportunities to talk about these experiences, and if you make it easy for them to talk about it, that takes a lot of the power away from the social anxiety.

The second thing you can do is ask the person what would help them feel more courageous about the situation they're struggling with right now. Maybe you can go with them to the party that they're avoiding. May be you can help them write a text message they've been avoiding. Maybe you can rehearse and practice with them how to ask for help for this conversation they've been avoiding.

The last thing I want you to do is don't invalidate them. Don't tell them to just relax. Don't tell them this is all in your head. Don't tell them you're wrong; no one thinks this about you. If it was that easy to solve these problems, this wouldn't be one of the most common psychiatric problems in the world.