Psychiatry - Anxiety disorders

Social anxiety (social phobia)

Social anxiety disorder, also known as social phobia, is an anxiety disorder characterized by an intense, persistent and disproportionate fear of being observed, judged or evaluated negatively by others in social or performance situations. This fear goes beyond simple shyness and causes significant distress and avoidance of feared situations, to the point of disrupting the sufferer's professional, academic or relational functioning. According to epidemiological data, social anxiety disorder is one of the most common anxiety disorders, with an estimated lifetime prevalence of between 7 and 13 % in Western countries. It most often begins in adolescence, between the ages of 13 and 17, and develops chronically in the absence of treatment. Women are slightly more affected than men, although proportionally more men seek help. The disorder can present in a circumscribed way, limited to specific situations such as public speaking, or in a generalized way, involving the majority of social interactions. Despite its significant impact on quality of life, social anxiety remains under-diagnosed, with sufferers often waiting several years before consulting a health professional.

Frequent trigger situations

Social anxiety can be triggered by a wide range of situations involving exposure to the gaze or judgment of others. These situations vary in intensity according to the person's profile and the subtype of the disorder.

Category	Examples of trigger situations
Performance and exhibition	Public speaking, professional presentations, oral exams, artistic performances
Social interaction	Conversations with strangers, first dates, business meetings, group activities
Observation by others	Eating or drinking in public, writing in front of others, being watched while working
Assertive situations	Expressing disagreement, asking a question, returning an article, phoning a stranger
Collective environments	Parties, social gatherings, crowded public transport, queues

Clinical manifestations

The clinical picture of social anxiety combines cognitive, emotional, behavioral and somatic symptoms. Their intensity varies from one individual to another and according to the context of exposure.

Dimension	Typical manifestations
Cognitive	Fear of being judged, humiliated or ridiculed; catastrophic anticipation of social situations; ruminations after interactions; selective attention to self
Emotional	Intense fear, shame, embarrassment, feelings of inferiority, distress at exhibitions
Behavioral	Avoidance of social situations, safety behaviours (avoiding eye contact, speaking little, keeping to oneself), social procrastination
Somatic	Flushing, trembling, excessive sweating, palpitations, trembling voice, nausea, dry mouth, choking sensation

ℹ️ The fear of blushing (ereutophobia), sweating visibly or trembling in public is particularly common in social anxiety. These somatic symptoms themselves become a source of additional anxiety, fueling a cycle of self-monitoring and hypervigilance characteristic of the disorder.

Diagnostic criteria (DSM-5)

The diagnosis of social anxiety disorder is based on the criteria set out in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). These criteria distinguish the disorder from simple shyness or normal apprehension in social situations.

Marked and persistent fear of one or more social situations involving possible exposure to the gaze of others
Fear that the person will act in an embarrassing way or that their anxiety symptoms will be visible and judged negatively
Social situations almost always provoke immediate fear or anxiety.
Social situations are avoided or experienced with intense distress
Fear or anxiety is disproportionate to the real threat posed by the situation
Persistent fear, anxiety or avoidance, typically lasting six months or more
The disturbance results in clinically significant distress or impairment of social, occupational or other important functioning

Important diagnostic distinctions

Social anxiety shares certain manifestations with other psychiatric or medical conditions. A rigorous clinical evaluation can establish a precise differential diagnosis and guide appropriate treatment.

Condition	Distinction from social anxiety
Normal shyness	Transient discomfort without significant avoidance or lasting functional impact
Panic disorder with agoraphobia	Fear is about physical sensations and loss of control, not about the judgment of others.
Avoidant personality disorder	Significant overlap; avoidant personality involves a more pervasive social inhibition rooted in identity
Selective Mutism	Inability to speak in certain social contexts, mainly in children; may coexist with social anxiety
Dysmorphophobia	Social fear focuses on a perceived physical defect, real or imagined.
Autism spectrum disorder	Social difficulties stem from deficits in communication and reciprocity, not from fear of judgment.

Common comorbidities

Social anxiety rarely occurs in isolation. It is frequently accompanied by other psychiatric disorders, the presence of which can complicate diagnosis and management.

Major depression: most frequent comorbidity, often secondary to prolonged social isolation
Other anxiety disorders: generalized anxiety disorder, panic disorder, agoraphobia
Substance use disorders: alcohol and benzodiazepines used as self-medication to alleviate social anxiety
Obsessive-compulsive disorder (OCD): shares certain ruminations and ritualized behaviors
Attention Deficit Hyperactivity Disorder (ADHD): impulsivity and relationship difficulties can amplify social anxiety
Eating disorders: body image and fear of judgment frequently overlap

ℹ️ The use of alcohol as a coping strategy in social situations is particularly common among people suffering from social anxiety. This often socially trivialized use can develop into dependence, significantly complicating the clinical trajectory of the disorder.

Therapeutic approaches

Social anxiety is a well-documented disorder for which effective treatments exist. Psychotherapeutic and pharmacological approaches can be used alone or in combination, depending on the severity of the disorder and the individual's profile.

Approach	Description	Level of evidence
Cognitive behavioral therapy (CBT)	Restructuring of negative automatic thoughts, gradual exposure to feared situations, reduction of safety behaviours	High; first-line treatment
Selective serotonin reuptake inhibitors (SSRIs)	Paroxetine, sertraline, escitalopram; reduced anticipatory anxiety and avoidance	High; first-line pharmacological treatment
Serotonin and norepinephrine reuptake inhibitors (SNRIs)	Venlafaxine: comparable efficacy to SSRIs	High
Acceptance and Commitment Therapy (ACT)	Development of psychological flexibility and acceptance of anxious thoughts without avoidance	Moderate to high
Virtual reality exposure therapy	Simulated exposure to social situations in a controlled environment	Moderate; promising complementary approach
Beta-blockers (propranolol)	Reduction of situational somatic symptoms (tremors, palpitations) in specific performance contexts	Limited; occasional use only

ℹ️ Benzodiazepines are generally not recommended as background treatment for social anxiety, due to the risk of dependence and tolerance, as well as their lack of effect on the cognitive and behavioral mechanisms underlying the disorder.

Consult at Clinique Omicron

Clinique Omicron has points of service in Quebec offering mental health and general medical consultations for people with symptoms suggestive of social anxiety. The clinic's physicians and specialized nurse practitioners are able to assess the clinical situation and refer patients to the appropriate resources and professionals. To book an appointment at one of our Quebec locations, visit cliniqueomicron.ca or contact the clinic directly.

The content of this page is provided for informational purposes only and is not intended to replace the advice of a qualified healthcare professional. Consult a physician for any symptoms, questions or decisions you may have regarding your health.

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