Social anxiety

Most people feel nervous before a speech or when meeting someone new. Social anxiety disorder is different. It is a strong, lasting fear of being watched, judged or embarrassed by other people. The fear is big enough to get in the way of work, friendships, errands or family life.¹

The good news is that social anxiety responds well to treatment. A kind of talk therapy called CBT helps many people, and some medicines help too.^1,4 This page explains the signs, why avoiding people makes the fear grow, and the steps that help.

What social anxiety feels like

Social anxiety shows up in your body, your thoughts and what you do.¹

In your body, you may notice:¹

• Blushing, sweating or shaking
• A racing heart or an upset stomach
• A stiff body, a very soft voice, or trouble making eye contact
• Your mind going blank

In your thoughts, you may:¹

• Expect others to judge you badly or think you look foolish
• Go over every conversation afterward, looking for mistakes
• Picture the worst possible outcome before an event

In what you do, you may avoid places and people where you might have to talk or be noticed.¹ Common hard spots include phone calls, eating in front of others, speaking up in a group, meeting new people, and talking to a boss or a doctor.

Some people fear only one kind of situation, such as giving a talk or playing music in public. This is often called performance anxiety.¹

Shyness or social anxiety?

Shyness is a personality trait. A shy person may warm up slowly but still does the things that matter to them. Many people with social anxiety disorder were very shy as children, but the disorder is not the same thing.³

Doctors think about social anxiety disorder when the fear:¹

• Is strong and out of proportion to the situation
• Has lasted at least 6 months
• Gets in the way of work, school, relationships or daily tasks

How common is it?

In a large U.S. survey, about 7 in 100 adults (7.1%) had social anxiety disorder in the past year. About 1 in 8 adults (12.1%) have it at some point in life. It was a little more common in women than in men.²

The same survey found it less often in people 60 and older (3.1% in a year) than in young adults (9.1%).² It usually starts in childhood or the teen years.¹

Many people live with it for a long time before seeking care. The Anxiety and Depression Association of America reports that fewer than 5 in 100 people get treatment in the first year. More than 1 in 3 have symptoms for 10 years or more before they ask for help.³ If that sounds like you, it is not too late. Treatment works at any age.

The avoidance cycle: why the fear grows

Social anxiety tends to feed itself. The cycle often goes like this:

1. A trigger. You are invited to a party, or you need to make a phone call.
2. Scary predictions. "I'll say something stupid." "They'll see my hands shake."
3. Body alarm. Your heart races, you sweat, your mind goes blank.
4. Escape or hide. You stay home, or you go but stand in a corner and say little.
5. Quick relief. You feel better right away. Your brain learns that avoiding kept you safe.
6. Bigger fear next time. You never get to find out that things might have gone fine. The next invitation feels even harder.

There is a quieter form of avoidance too. Therapists call these safety behaviors. They are small habits people use to get through a situation, such as rehearsing every sentence, avoiding eye contact, holding a glass tightly so your hand won't shake, or keeping your phone out.⁴

Safety behaviors feel helpful, but they keep your attention turned inward on how you look and feel. That inward focus makes you feel more awkward. It also stops you from learning that you can cope without them.⁴ Leading CBT programs teach people to notice this and practice dropping these habits.⁴

Treatment: what works

Cognitive behavioral therapy (CBT)

CBT helps you notice the thoughts and habits that keep fear going, and then change them.¹ In CBT for social anxiety, you and your therapist might:⁴

• Test your predictions with small real-life experiments
• Practice turning your attention outward, to the other person and the conversation, instead of inward to your own body
• Drop safety behaviors and see what happens
• Watch a video of yourself talking. Many people find they look much calmer than they felt.

The NICE guideline says individual CBT works better and is better value than group CBT, though group CBT also has good evidence.⁴ To try CBT skills on your own first, see our free CBT course, starting with week 1 and the behavior experiments lesson.

Building an exposure ladder

An exposure ladder (also called a fear ladder) is a list of feared situations, ranked from easiest to hardest. You start near the bottom and climb one rung at a time.¹ Our exposure therapy page explains the method in more detail.

1. Pick one goal. For example: "I want to be able to talk with neighbors at the community center."
2. List 8 to 10 steps. Write situations that lead toward the goal. Rate each from 0 (no fear) to 100 (the most fear you can imagine).
3. Put them in order. Start with something that feels about 30 to 40 out of 100.
4. Practice the first step often. Repeat it several times a week. Stay until the fear starts to ease, instead of leaving at its peak.
5. Drop your safety behaviors. Try the step without rehearsing, hiding or looking at your phone.
6. Write down what happened. Compare it with what you feared would happen.
7. Move up a rung when a step feels clearly easier. Setbacks are normal. Go back a step and keep going.

A sample ladder (yours will be different):

If a ladder feels too hard to start alone, a therapist can guide you. That is what therapists trained in CBT do every day.

Medicines for social anxiety

Medicine can help, on its own or along with therapy. Your doctor will talk through the choices with you. Do not start, stop or change a medicine without talking with your doctor or pharmacist first. See medicines for anxiety for more.

SSRIs and SNRIs. These are antidepressants. U.S. drug information from the National Library of Medicine lists social anxiety disorder as a use for sertraline (Zoloft), paroxetine (Paxil) and venlafaxine (Effexor).^8,9,10 In the NICE guideline, escitalopram or sertraline come first. If they do not help, it suggests another SSRI or venlafaxine.⁴

• A Cochrane review of 24 trials found SSRIs helped more people than a placebo (a look-alike pill with no medicine). The quality of the evidence was rated very low to moderate. SSRIs were the only medicines shown to lower the chance of symptoms coming back.⁵
• It may take a few weeks or longer to feel the full benefit.^1,8
• Some people get side effects and stop. In trials, this happened more often than with placebo, but still in a small share of people.⁵
• These medicines carry a warning about a higher risk of suicidal thoughts in children, teens and young adults under 24, mainly in the first months.^8,9

Beta-blockers such as propranolol are sometimes prescribed for performance nerves. They can calm a racing heart and shaking.¹ But a 2016 review found too little evidence to support using propranolol routinely for any anxiety disorder, including social anxiety.⁶ Beta-blockers are not safe for everyone, such as some people with asthma or certain heart conditions. Ask your doctor.

Benzodiazepines (such as alprazolam, clonazepam or lorazepam) work fast. But the body gets used to them, and people can become dependent, so they are usually given only for short periods.¹ In 2020 the FDA required its strongest warning on these medicines. It covers misuse, addiction, dependence and dangerous withdrawal if they are stopped suddenly.⁷ For older adults, the American Geriatrics Society advises avoiding them because they raise the risk of falls and confusion.¹¹

Social anxiety in later life

Social anxiety is less common after 60, but it does happen.² For some people it is a lifelong pattern they have worked around for decades. Retirement, moving or losing a spouse can remove the routines that once made social contact easier.

Later life can also bring new reasons to pull back from people. Hearing loss can make group talk stressful. Shaking from a health condition, changes in speech, or worry about bladder control can make people self-conscious. These are real concerns to raise with your doctor, and many have treatments, such as hearing aids. See hearing loss and loneliness and loneliness in later life.

If an older person who used to enjoy company starts avoiding people, it is worth a checkup. Withdrawal can also be a sign of depression, hearing loss or early memory changes. See anxiety in later life for more.

Some practical points for older adults:

• Screening. The U.S. Preventive Services Task Force recommends screening adults 64 and younger for anxiety. It found too little evidence to advise for or against routine screening at 65 and older, so you may need to bring it up yourself.¹²
• Medicare. Medicare Part B covers outpatient talk therapy from many types of providers. These include psychologists, clinical social workers, counselors, and marriage and family therapists. You usually pay 20% after the deductible. Telehealth is an option.¹³ See what Medicare covers for mental health.
• Medicine safety. Ask for a review of all your medicines, especially sleep aids and sedatives.¹¹

Common questions

Can social anxiety get better without medicine?

Yes. CBT designed for social anxiety is the best-studied treatment, and many people improve with therapy alone.^1,4 Some people do best with both therapy and medicine.

Is it too late to get help in my 60s or 70s?

No. Treatment can help at any age. Talk therapy is covered by Medicare Part B, including by telehealth.¹³

When to get help

Talk with a doctor or a mental health professional if social fear:

• Has lasted 6 months or more¹
• Keeps you from work, family events, medical visits or things you used to enjoy
• Leaves you lonely or isolated
• Comes with low mood, heavy drinking, or panic attacks (see panic attacks)

Your primary care doctor is a good place to start. You can also take our private check-in or see where to find help.

If you have thoughts of hurting yourself or ending your life, call or text 988, the Suicide & Crisis Lifeline, any time. If someone is in immediate danger, call 911.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.