What are the symptoms of Social Anxiety Disorder?

Core symptoms

Associated symptoms

  • Notable anxiety or fear related to one or more situations wherein the individual may be exposed to peer scrutiny
  • Excessive anxiety or fear about being embarrassed, humiliated, or rejected by others
  • Social situations consistently provoke anxiety or fear
  • Social situations are either avoided or met with notable anxiety or fear
  • The anxiety or fear is out of proportion with the social situation

  • Physical symptoms, like shaking, sweating, dry mouth and shortness of breath
  • Lots of anxious questions: “What if I say something dumb?” “What if everyone thinks I’m a loser?”
  • Tantrums and crying, especially in younger children
  • Getting upset long before a feared situation

How is Social Anxiety Disorder diagnosed?

A child psychiatrist may diagnose Social Anxiety Disorder if a child’s or teen’s symptoms are persistent, lasting for six months or more, and they result in significant distress and impairment in other aspects of everyday functioning (e.g., social, familial, academic, etc.).

The child-adolescent psychiatrist may interview and/or assess both the child and a caregiver in order to determine the specific nature of the child’s social anxiety, although many practitioners also use questionnaires or behavior/emotion rating form results to support the diagnosis and quantify the severity of the problem. The practitioner will also seek to determine that the child’s or teen’s anxiety is not related to something unforeseen.

Social Anxiety Disorder Facts

Worldwide frequency of the condition

Social Anxiety Disorder is estimated to be present in about 2.3% of the European population, similar to other worldwide estimates. Anxiety Disorders, in general, are estimated to be present in 6.5% of the world's population. While there is no recent, specific epidemiological data for Greece, a recent review of European countries reported a 7.9% frequency.

Burden of the condition in Greece

Anxiety accounts for 9.8% for all disability adjusted life years (DALYs) lost to health conditions in Greece for 5- to 14-year-old children and adolescents. It is the most prominent mental health condition adding to the health burden of the Greek child and adolescent population.

Gender ratio

Social Anxiety Disorder is diagnosed marginally more frequently in girls than boys, although estimates vary from sample to sample, and some samples report more boys than girls.

Peak age of onset

The peak age of onset for Social Anxiety Disorder is estimated to be 14.5 years. This is later than the peak age of onset for anxiety disorders, in general, which is 5.5 years.

Proportion of the condition that emerges before age 18

According to recent data, 79.1% of individuals with Social Anxiety Disorder will have been diagnosed by the time they are 18 years old.

What are the associated factors for Social Anxiety Disorder?

Some common factors associated with Social Anxiety Disorder are:

  • Genetic and familial factors. Predisposition toward an anxiety disorder most likely results from a combination of multiple genes that interact in a complex way with multiple environmental factors. Also, there is a greater likelihood that a child may develop Social Anxiety Disorder if a first-degree relative has the disorder.
  • Environmental factors. These include child maltreatment (e.g., physical or sexual abuse) and other childhood adversities, including peer victimization and rejection. On the contrary, positive peer relationships appear to buffer against the development of social anxiety.
  • Temperament. Including behavioral inhibition early in life.

What other disorders co-occur with Social Anxiety Disorder?

Even though each child and adolescent is different, Social Anxiety Disorder is usually comorbid with other anxiety disorders, including Generalized Anxiety Disorder and Selective Mutism, depressive disorders, and high functioning Autism Spectrum Disorder. Also, Social Anxiety Disorder frequently leads to Substance Use Disorder, given individuals with Social Anxiety Disorder are more likely to dangerously use substances as a way to “self medicate” and reduce their anxiety levels.

How is Social Anxiety Disorder treated?

Social Anxiety Disorder is usually treated with psychotherapy or a combination of psychotherapy and medication. Caregivers and other family members are an important part of treatment, since they can help kids and teens practice the skills they learn in therapy.

There are multiple therapies that have been shown to effectively treat symptoms of Social Anxiety Disorder, but the one with the most evidence is a type of therapy called cognitive-behavioral therapy (CBT). CBT is an umbrella term that refers to a wide range of different cognitive and behavioral techniques. One technique called exposure. Using this technique, a therapist exposes the child to something that triggers anxiety, beginning with something very small. As the child becomes upset, the therapist teaches them ways to handle their fear. They repeat this process with bigger and bigger stressors. The therapist also works with the child to change or restructure their thinking about their anxiety by identifying unhelpful thoughts or beliefs, raising the child’s awareness of them, and helping to reframe them. They repeat this process with bigger and bigger stressors. Group-based CBT has been shown to be particularly effective for children and adolescents.

Children and adolescents with Social Anxiety Disorder tend to respond well to certain antidepressant medications called selective serotonin reuptake inhibitors (SSRIs). These include fluoxetine, sertraline, citalopram, escitalopram, and paroxetine. Other medications called serotonin and norepinephrine reuptake inhibitors (SNRIs), such as duloxetine and venlafaxine, may also be effective at reducing anxiety in children and adolescents. Benzodiazepines (e.g., alprazolam, lorazepam, diazepam) and tricyclic antidepressants (e.g., clomipramine, amitriptyline) are not effective in children and adolescents and should not be used. Medications can have side effects, but they are safe for kids to use with proper monitoring by their doctor and close supervision from their caregivers. A child or adolescent who is taking one of these medications should see their doctor regularly, especially if their dosage has recently changed.

The combination of CBT and SSRIs/SNRIs can also be considered, given some studies show evidence that the combination is better than either treatment in isolation in children and adolescents.

Where to find more information

If you need more information on social anxiety and reasons for concerns, you can also go to "Excessive shyness" in our website.

To learn more about the technical work conducted to develop this guide, please consult our reference list here:

References

Clinical description, symptoms, and diagnostic information

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.
  • Child Mind Institute. (2021, September 7). Social Anxiety Disorder in children: A quick guide. https://childmind.org/guide/quick-guide-to-social-anxiety-disorder/
  • World Health Organization. (2022, February). ICD-11 for mortality and morbidity statistics. 6B04 Social Anxiety Disorder. https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f2062286624

Facts

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.
  • Institute for Health Metrics and Evaluation (IHME). (2019). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington, Available from http:// vizhub.healthdata.org/gbd-compare. (Accessed 11/15/2022)
  • Jefferies, P., & Ungar, M. (2020). Social anxiety in young people: A prevalence study in seven countries. PLOS ONE, 15(9), e0239133. https://doi.org/10.1371/journal.pone.0239133
  • Polanczyk, G. V., Salum, G. A., Sugaya, L. S., Caye, A., & Rohde, L. A. (2015). Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. Journal of Child Psychology and Psychiatry, 56(3), 345–365. https://doi.org/10.1111/jcpp.12381
  • Sacco, R., Camilleri, N., Eberhardt, J., Umla-Runge, K., & Newbury-Birch, D. (2022). A systematic review and meta-analysis on the prevalence of mental disorders among children and adolescents in Europe. European Child & Adolescent Psychiatry. https://doi.org/10.1007/s00787-022-02131-2
  • Solmi, M., Radua, J., Olivola, M., Croce, E., Soardo, L., Salazar de Pablo, G., Il Shin, J., Kirkbride, J. B., Jones, P., Kim, J. H., Kim, J. Y., Carvalho, A. F., Seeman, M. V., Correll, C. U., & Fusar-Poli, P. (2022). Age at onset of mental disorders worldwide: Large-scale meta-analysis of 192 epidemiological studies. Molecular Psychiatry, 27(1), 281–295. https://doi.org/10.1038/s41380-021-01161-7
  • Somers, J. M., Goldner, E. M., Waraich, P., & Hsu, L. (2006). Prevalence and Incidence Studies of Anxiety Disorders: A Systematic Review of the Literature. The Canadian Journal of Psychiatry, 51(2), 100–113. https://doi.org/10.1177/070674370605100206
  • Tang, X., Liu, Q., Cai, F., Tian, H., Shi, X., & Tang, S. (2022). Prevalence of social anxiety disorder and symptoms among Chinese children, adolescents and young adults: A systematic review and meta-analysis. Frontiers in Psychology, 13, 792356. https://doi.org/10.3389/fpsyg.2022.792356

Associated factors

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.
  • Arango, C., Dragioti, E., Solmi, M., Cortese, S., Domschke, K., Murray, R. M., Jones, P. B., Uher, R., Carvalho, A. F., Reichenberg, A., Shin, J. I., Andreassen, O. A., Correll, C. U., & Fusar‐Poli, P. (2021). Risk and protective factors for mental disorders beyond genetics: An evidence‐based atlas. World Psychiatry, 20(3), 417–436. https://doi.org/10.1002/wps.20894
  • Ayano, G., Betts, K., Maravilla, J. C., & Alati, R. (2021). The risk of anxiety disorders in children of parents with severe psychiatric disorders: A systematic review and meta-analysis. Journal of Affective Disorders, 282, 472–487. https://doi.org/10.1016/j.jad.2020.12.134
  • Baba, A., Kloiber, S., & Zai, G. (2022). Genetics of social anxiety disorder: a systematic review. Psychiatric genetics, 32(2), 37–66. https://doi.org/10.1097/YPG.0000000000000310
  • Brühl, A., Kley, H., Grocholewski, A., Neuner, F., & Heinrichs, N. (2019). Child maltreatment, peer victimization, and social anxiety in adulthood: A cross-sectional study in a treatment-seeking sample. BMC Psychiatry, 19(1), 418. https://doi.org/10.1186/s12888-019-2400-4
  • Bruijnen, C. J. W. H., Young, S. Y., Marx, M., & Seedat, S. (2019). Social anxiety disorder and childhood trauma in the context of anxiety (behavioural inhibition), impulsivity (behavioural activation) and quality of life. South African Journal of Psychiatry, 25. https://doi.org/10.4102/sajpsychiatry.v25i0.1189
  • Caldiroli, A., Capuzzi, E., Affaticati, L. M., Surace, T., Di Forti, C. L., Dakanalis, A., Clerici, M., & Buoli, M. (2023). Candidate Biological Markers for Social Anxiety Disorder: A Systematic Review. International Journal of Molecular Sciences, 24(1), 835. https://doi.org/10.3390/ijms24010835
  • Kendler, K. S. (2013). What psychiatric genetics has taught us about the nature of psychiatric illness and what is left to learn. Molecular Psychiatry, 18(10), 1058–1066. https://doi.org/10.1038/mp.2013.50

Co-occurring disorders

  • American Psychiatric Association. (2022). Diagnostic and Statistical Manual of Mental Disorders: Fifth Edition Text Revision DSM-5-TR. American Psychiatric Association Publishing, Washington, DC.
  • Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: Diagnostic and therapeutic challenges. Drugs in Context, 8, 1–13. https://doi.org/10.7573/dic.212573
  • Muris, P., & Ollendick, T. H. (2021). Selective Mutism and Its Relations to Social Anxiety Disorder and Autism Spectrum Disorder. Clinical Child and Family Psychology Review, 24(2), 294–325. https://doi.org/10.1007/s10567-020-00342-0
  • Saha, S., Lim, C. C. W., Cannon, D. L., Burton, L., Bremner, M., Cosgrove, P., Huo, Y., & McGrath, J. (2021). Co‐morbidity between mood and anxiety disorders: A systematic review and meta‐analysis. Depression and Anxiety, 38(3), 286–306. https://doi.org/10.1002/da.23113
  • Spain, D., Sin, J., Linder, K. B., McMahon, J., & Happé, F. (2018). Social anxiety in autism spectrum disorder: A systematic review. Research in Autism Spectrum Disorders, 52, 51–68. https://doi.org/10.1016/j.rasd.2018.04.007

Interventions

  • Correll, C. U., Cortese, S., Croatto, G., Monaco, F., Krinitski, D., Arrondo, G., Ostinelli, E. G., Zangani, C., Fornaro, M., Estradé, A., Fusar‐Poli, P., Carvalho, A. F., & Solmi, M. (2021). Efficacy and acceptability of pharmacological, psychosocial, and brain stimulation interventions in children and adolescents with mental disorders: An umbrella review. World Psychiatry, 20(2), 244–275. https://doi.org/10.1002/wps.20881Institute for Health Metrics and Evaluation (IHME). (2019). GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington, Available from http:// vizhub.healthdata.org/gbd-compare. (Accessed 11/15/2022)
  • Cuijpers P, Cristea IA, Karyotaki E, Reijnders M, Huibers MJH. How effective are cognitive behavior therapies for major depression and anxiety disorders? A meta-analytic update of the evidence. World Psychiatry. 2016;15(3):245-258. doi:10.1002/wps.20346
  • Gosmann NP, Costa M de A, Jaeger M de B, et al. Selective serotonin reuptake inhibitors, and serotonin and norepinephrine reuptake inhibitors for anxiety, obsessive-compulsive, and stress disorders: A 3-level network meta-analysis. Patel V, ed. PLoS Med. 2021;18(6):e1003664. doi:10.1371/journal.pmed.1003664
  • Scaini S, Belotti R, Ogliari A, Battaglia M. A comprehensive meta-analysis of cognitive-behavioral interventions for social anxiety disorder in children and adolescents. Journal of Anxiety Disorders. 2016;42:105-112. doi:10.1016/j.janxdis.2016.05.008
  • Schopf K, Mohr C, Lippert MW, Sommer K, Meyer AH, Schneider S. The role of exposure in the treatment of anxiety in children and adolescents: protocol of a systematic review and meta-analysis. Syst Rev. 2020;9(1):96. doi:10.1186/s13643-020-01337-2
  • Snir A, Moskow DM, Hofmann SG. When is it appropriate to treat children with social anxiety, pharmacologically? Expert Opinion on Pharmacotherapy. 2021;22(18):2423-2426. doi:10.1080/14656566.2021.1948015
  • Wang Z, Whiteside SPH, Sim L, et al. Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: A systematic review and meta-analysis. JAMA Pediatr. 2017;171(11):1049. doi:10.1001/jamapediatrics.2017.3036
  • Zhou, X., Zhang, Y., Furukawa, T. A., Cuijpers, P., Pu, J., Weisz, J. R., Yang, L., Hetrick, S. E., Del Giovane, C., Cohen, D., James, A. C., Yuan, S., Whittington, C., Jiang, X., Teng, T., Cipriani, A., & Xie, P. (2019). Different types and acceptability of psychotherapies for acute anxiety disorders in children and adolescents: A network meta-analysis. JAMA Psychiatry, 76(1), 41. https://doi.org/10.1001/jamapsychiatry.2018.3070

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