Social anxiety disorder

Signs and symptoms

The 10th version of the International Classification of Diseases (ICD-10) classifies social anxiety as a mental and behavioral disorder.

Cognitive aspects

In cognitive models of social anxiety disorder, those with social phobias experience dread over how they will present to others. They may feel overly self-conscious, pay high self-attention after the activity, or have high performance standards for themselves. According to the social psychology theory of self-presentation, an affected person attempts to create a well-mannered impression towards others but believes they are unable to do so. Many times, before the potentially anxiety-provoking social situation, they may deliberately review what could go wrong and how to deal with each unexpected case. After the event, they may have the perception that they performed unsatisfactorily. Consequently, they will perceive anything that may have possibly been abnormal as embarrassing. These thoughts may extend for weeks or longer. Cognitive distortions are a hallmark and are learned about in CBT (cognitive-behavioral therapy). Thoughts are often self-defeating and inaccurate. Those with social phobia tend to interpret neutral or ambiguous conversations with a negative outlook and many studies suggest that socially anxious individuals remember more negative memories than those less distressed.

Behavioral aspects

Social anxiety disorder is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that they may do something or act in a way that will be humiliating or embarrassing. It exceeds normal "shyness" as it leads to excessive social avoidance and substantial social or occupational impairment.

Those who have social anxiety disorder fear being judged by others in society. In particular, individuals with social anxiety are nervous in the presence of people with authority and feel uncomfortable during physical examinations. People who have this disorder may behave a certain way or say something and then feel embarrassed or humiliated after. As a result, they often choose to isolate themselves from society to avoid such situations. They may also feel uncomfortable meeting people they do not know and act distant when they are with large groups of people. In some cases, they may show evidence of this disorder by avoiding eye contact, or blushing when someone is talking to them.

Physiological aspects

Physiological effects may include excessive sweating, nausea, difficulty breathing, shaking, palpitations, and increased heart rate.

Social aspects

People with SAD avoid situations that most people consider normal. People with SAD avoid all or most social situations and hide from others, which can affect their personal relationships. Social phobia can completely remove people from social situations due to the irrational fear of these situations. People with SAD may be addicted to social media networks, have sleep deprivation, and feel good when they avoid human interactions. SAD can also lead to low self-esteem, negative thoughts, major depressive disorder, sensitivity to criticism, and poor social skills that do not improve. People with SAD experience anxiety in a variety of social situations, from important, meaningful encounters to common situations. These people may feel more nervous in job interviews, dates, interactions with authority, or at work and school.

Comorbidity

SAD shows a high degree of co-occurrence with psychiatric disorders. In fact, a population-based study found that 66% of those with SAD had one or more additional mental health disorders. SAD often occurs alongside low self-esteem and most commonly clinical depression. Clinical depression is 1.49 to 3.5 times more likely to occur in those with SAD. Research also indicates that the presence of certain social fears (e.g., avoidance of participating in small groups, avoidance of going to a party) are more likely to trigger comorbid depressive symptoms than other social fears.

Anxiety disorders other than SAD are also common in people with SAD, in particular generalized anxiety disorder. Avoidant personality disorder is likewise highly correlated with SAD, with comorbidity rates ranging from 25% to 89%.

To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to substance use disorders. It is estimated that one-fifth of people with social anxiety disorder also have alcohol use disorder. However, some research suggests SAD is unrelated to, or even protective against alcohol-related problems. Those who have both alcohol use disorder and social anxiety disorder are more likely to avoid group-based treatments and to relapse compared to people who do not have this combination.

Causes

Research into the causes of social anxiety and social phobia is wide-ranging, encompassing multiple perspectives from neuroscience to sociology. Scientists have yet to pinpoint the exact causes. Studies suggest that genetics can play a part in combination with environmental factors. Social phobia is not caused by other mental disorders or substance use. Generally, social anxiety begins at a specific point in an individual's life. This will develop over time as the person struggles to recover. Eventually, mild social awkwardness can develop into symptoms of social anxiety or phobia. Passive social media usage may cause social anxiety in some people.

Genetics

It has been shown that there is a two to a threefold greater risk of having social phobia if a first-degree relative also has the disorder. This could be due to genetics and/or due to children acquiring social fears and avoidance through processes of observational learning or parental psychosocial education. Studies of identical twins brought up (via adoption) in different families have indicated that, if one twin developed social anxiety disorder, then the other was between 30 percent and 50 percent more likely than average to also develop the disorder. To some extent, this "heritability" may not be specific – for example, studies have found that if a parent has any kind of anxiety disorder or clinical depression, then a child is somewhat more likely to develop an anxiety disorder or social phobia. Studies suggest that parents of those with social anxiety disorder tend to be more socially isolated themselves, and shyness in adoptive parents is significantly correlated with shyness in adopted children.

Growing up with overprotective and hypercritical parents has also been associated with social anxiety disorder. Adolescents who were rated as having an insecure (anxious-ambivalent) attachment with their mother as infants were twice as likely to develop anxiety disorders by late adolescence, including social phobia.

A related line of research has investigated 'behavioural inhibition' in infants – early signs of an inhibited and introspective or fearful nature. Studies have shown that around 10–15 percent of individuals show this early temperament, which appears to be partly due to genetics. Some continue to show this trait into adolescence and adulthood and appear to be more likely to develop a social anxiety disorder.

Social experiences

A previous negative social experience can be a trigger to social phobia, perhaps particularly for individuals high in "interpersonal sensitivity". For around half of those diagnosed with social anxiety disorder, a specific traumatic or humiliating social event appears to be associated with the onset or worsening of the disorder; this kind of event appears to be particularly related to specific social phobia, for example, regarding public speaking. As well as direct experiences, observing or hearing about the socially negative experiences of others (e.g. a faux pas committed by someone), or verbal warnings of social problems and dangers, may also make the development of a social anxiety disorder more likely. Social anxiety disorder may be caused by the longer-term effects of not fitting in, or being bullied, rejected, or ignored. Shy adolescents or avoidant adults have emphasized unpleasant experiences with peers or childhood bullying or harassment. In one study, popularity was found to be negatively correlated with social anxiety, and children who were neglected by their peers reported higher social anxiety and fear of negative evaluation than other categories of children. Socially phobic children appear less likely to receive positive reactions from peers, and anxious or inhibited children may isolate themselves.

Parental influences

Different parenting styles can also contribute to the development of social anxiety disorder. The common negative parenting styles, such as overcontrol and criticism can be detrimental for a child to be able to overcome difficult situations. More aggressive and harsh parenting styles that include both verbal abuse and physical punishment are linked with an insecure attachment and risk for social anxiety disorder. On the contrary, positive parenting that fosters a more supportive and warm environment for the child is correlated to a decreased risk of developing this disorder. On the biological level as well, there is strong evidence that states how children from parents with social anxiety disorder have significantly increased risk to the disorder.

Cultural influences

Cultural factors that have been related to social anxiety disorder include a society's attitude towards shyness and avoidance, affecting the ability to form relationships or access employment or education, and shame. One study found that the effects of parenting are different depending on the culture: American children appear more likely to develop social anxiety disorder if their parents emphasize the importance of others' opinions and use shame as a disciplinary strategy, but this association was not found for Chinese/Chinese-American children. In China, research has indicated that shy-inhibited children are more accepted than their peers and more likely to be considered for leadership and considered competent, in contrast to the findings in Western countries. Purely demographic variables may also play a role.

Problems in developing social skills, or 'social fluency', may be a cause of some social anxiety disorder, through either inability or lack of confidence to interact socially and gain positive reactions and acceptance from others. The studies have been mixed, however, with some studies not finding significant problems in social skills while others have. What does seem clear is that the socially anxious perceive their own social skills to be low. It may be that the increasing need for sophisticated social skills in forming relationships or careers, and an emphasis on assertiveness and competitiveness, is making social anxiety problems more common, at least among the 'middle classes'. An interpersonal or media emphasis on 'normal' or 'attractive' personal characteristics has also been argued to fuel perfectionism and feelings of inferiority or insecurity regarding negative evaluation from others. The need for social acceptance or social standing has been elaborated in other lines of research relating to social anxiety.

Substance-induced

While alcohol initially relieves social phobia, excessive alcohol misuse can worsen social phobia symptoms and cause panic disorder to develop or worsen during alcohol intoxication and especially during alcohol withdrawal syndrome. This effect is not unique to alcohol but can also occur with long-term use of drugs that have a similar mechanism of action to alcohol such as the benzodiazepines which are sometimes prescribed as tranquillisers. Benzodiazepines possess anti-anxiety properties and can be useful for the short-term treatment of severe anxiety. Like the anticonvulsants, they tend to be mild and well-tolerated, although there is a risk of habit-forming. Benzodiazepines are usually administered orally for the treatment of anxiety; however, occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks.

The World Council of Anxiety does not recommend benzodiazepines for the long-term treatment of anxiety due to a range of problems associated with long-term use including tolerance, psychomotor impairment, cognitive and memory impairments, physical dependence and a benzodiazepine withdrawal syndrome upon discontinuation of benzodiazepines. Despite increasing focus on the use of antidepressants and other agents for the treatment of anxiety, benzodiazepines have remained a mainstay of anxiolytic pharmacotherapy due to their robust efficacy, rapid onset of therapeutic effect, and generally favorable side effect profile. Treatment patterns for psychotropic drugs appear to have remained stable over the past decade, with benzodiazepines being the most commonly used medication for panic disorder.

Many people who are addicted to alcohol or prescribed benzodiazepines when it is explained to them they have a choice between ongoing ill mental health or quitting and recovering from their symptoms decide on quitting alcohol or their benzodiazepines. Symptoms may temporarily worsen however, during alcohol withdrawal or benzodiazepine withdrawal.

Psychological factors

Research has indicated the role of 'core' or 'unconditional' negative beliefs (e.g. "I am inept") and 'conditional' beliefs nearer to the surface (e.g. "If I show myself, I will be rejected"). They are thought to develop based on personality and adverse experiences and to be activated when the person feels under threat. Recent research has also highlighted that conditional beliefs may also be at play (e.g., "If people see I'm anxious, they'll think that I'm weak").

A secondary factor is self-concealment which involves concealing the expression of one's anxiety or its underlying beliefs. One line of work has focused more specifically on the key role of self-presentational concerns. The resulting anxiety states are seen as interfering with social performance and the ability to concentrate on interaction, which in turn creates more social problems, which strengthens the negative schema. Also highlighted has been a high focus on and worry about anxiety symptoms themselves and how they might appear to others. A similar model emphasizes the development of a distorted mental representation of the self and overestimates of the likelihood and consequences of negative evaluation, and of the performance standards that others have. Such cognitive-behavioral models consider the role of negatively biased memories of the past and the processes of rumination after an event (also known as post-event processing), and fearful anticipation before it.

Studies have also highlighted the role of subtle avoidance and defensive factors, and shown how attempts to avoid feared negative evaluations or use of "safety behaviors" can make social interaction more difficult and the anxiety worse in the long run. This work has been influential in the development of cognitive behavioral therapy for social anxiety disorder, which has been shown to have efficacy.

Diagnosis

ICD-10 defines social phobia as fear of scrutiny by other people leading to avoidance of social situations. The anxiety symptoms may present as a complaint of blushing, hand tremor, nausea, or urgency of urination. Symptoms may progress to panic attacks.

Standardized rating scales such as the Social Phobia Inventory, the SPAI-B, Liebowitz Social Anxiety Scale, and the Social Interaction Anxiety Scale can be used to screen for social anxiety disorder and measure the severity of anxiety.

SAD is categorized into two main types:

Generalized Social Anxiety Disorder: Affects nearly all aspects of a person's social life, making everyday interactions extremely stressful.

Specific (Performance-Based) Social Anxiety Disorder: Individuals feel extreme nervousness in specific situations, like giving a speech or performing on stage.

DSM-5 diagnostic criteria

Although the DSM defines social anxiety disorder as an intense fear or anxiety of social situations, it makes clear a distinction to separate social anxiety disorder from simply social anxiety or social fear.

Social situations

• The anxiety must occur in a social setting under circumstances that are conducive to the possible scrutiny of others.
  • For children, the DSM-5 notes that the anxiety must be in a setting with other children and not with adults.
• Social situations induce and are avoided due to the intense feelings of anxiety or fear.
• Social situations must be the cause of anxiety or fear.

The DSM-5 notes that for social anxiety disorder, the fear must be attributed or correlated to social situations and not another condition.

Anxiety

• The fear or anxiety is out of reasonable proportion to the context of the situation.
• The fear or anxiety affects an individual for an abnormally long time – 6 months or more.
• There is a significant negative impact on an individual's life due to fear or anxiety in a social, professional, or other life event.

To determine a reasonable proportion, an individual's sociocultural situation is assessed. Different cultures have individual criteria for determining a reasonable fear to a learned behavior for a particular social situation. Criteria for anxiety assess whether a fear has a significant impact on social, professional, or other life function.

Other causes

• Condition is not a psychological effect induced by a substance (e.g., drugs, alcohol or other medication).
• Condition is not a psychological effect induced by another medical condition.
• Condition is not a psychological effect induced by another mental disorder.

Performance

• Fear is limited to only public speaking or public performing

The DSM-5 notes that performance only type of social anxiety disorder (a subset specific version of this disorder) often affects individual's professional lives of those involved with public speaking or public performing. These fears can arise in settings other than just an individual's professional life but are limited to only public social performance situations.

Differential diagnosis

The DSM-IV criteria stated that an individual cannot receive a diagnosis of social anxiety disorder if existing symptoms are better diagnosed by one of the autism spectrum disorders, such as autism or Asperger syndrome.

Social anxiety disorder is often linked to bipolar disorder and attention deficit hyperactivity disorder (ADHD), leading to an assumption of a shared cyclothymic-anxious-sensitive disposition. The co-occurrence of ADHD and social phobia is common, especially when cognitive disengagement syndrome is present.

Treatment

Psychotherapies

The first-line treatment for social anxiety disorder is cognitive behavioral therapy (CBT), with medications such as selective serotonin reuptake inhibitors (SSRIs) used for those who decline CBT. Combining CBT with escitalopram (a type of SSRI) is effective in treating social anxiety symptoms Self-help based on principles of CBT is a second-line treatment.

There is some emerging evidence for the use of acceptance and commitment therapy (ACT) in the treatment of social anxiety disorder. ACT is considered an offshoot of traditional CBT and emphasizes accepting unpleasant symptoms rather than fighting against them, as well as psychological flexibility – the ability to adapt to changing situational demands, to shift one's perspective, and to balance competing desires. ACT may be useful as a second line treatment for this disorder in situations where CBT is ineffective or refused.

Some studies have suggested social skills training can help with social anxiety. Examples of social skills that may be modified for social anxiety disorder include initiating conversations, establishing friendships, interacting with members of the preferred sex, constructing a speech, and assertiveness skills. However, it is not clear whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations.

Social anxiety disorder may predict subsequent development of other psychiatric disorders, such as depression. Social anxiety disorder remains under-recognized in primary care practice, with people presenting for treatment only after the onset of complications, such as clinical depression or substance use disorders.

Medications

A comparison of the treatment effects on social anxiety disorder showed that using a medication is faster, while CBT is longer-lasting. Using antidepressants for treating social anxiety disorder is typically not as effective as using CBT.

SSRIs & SNRIs

Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are the first choice of medication for generalized social phobia but a second-line treatment. Compared to older forms of medication, there is less risk of tolerability and drug dependency associated with SSRIs. Paroxetine and paroxetine CR, sertraline, venlafaxine XR and fluvoxamine CR (Luvox CR) are all approved and effective for treating social anxiety disorder. The effectiveness of medications other than paroxetine is small.

General side effects are common during the first weeks while the body adjusts to SSRI drugs. Symptoms may include headaches, nausea, insomnia and changes in sexual behavior.

Other drugs

Other prescription drugs are also used, if other methods are not effective. Before the introduction of SSRIs, monoamine oxidase inhibitors (MAOIs) such as phenelzine were frequently used in the treatment of social anxiety. Evidence continues to indicate that MAOIs are effective in the treatment and management of social anxiety disorder and they are still used, but generally only as a last resort medication, owing to concerns about dietary restrictions, possible adverse drug interactions and a recommendation of multiple doses per day. RIMAs have been found to be less efficacious for social anxiety disorder than irreversible MAOIs like phenelzine. Serotonergic anxiolytic buspirone may also be used.

Propranolol, a beta blocker commonly used to control high blood pressure, is used for performance anxiety specifically.

Pregablin at high doses appears to have modest efficacy. Gabapetin has been investigated for social anxiety disorder in preliminary long-term studies.

Anticonvulsants, tricyclic antidepressants, antipsychotic drugs, and St. John's wort should not be used. Guidelines vary regarding whether benzodiazepines should be used.

Epidemiology

Social anxiety disorder is known to appear at an early age in most cases. Fifty percent of those who develop this disorder have developed it by the age of 11, and 80% have developed it by age 20. This early age of onset may lead to people with social anxiety disorder being particularly vulnerable to depressive illnesses, substance use, and other psychological conflicts.

The National Comorbidity Survey of over 8,000 American correspondents in 1994 revealed 12-month and lifetime prevalence rates of 7.9 percent and 13.3 percent, respectively; this makes it the third most prevalent psychiatric disorder after depression and alcohol use disorder, and the most common of the anxiety disorders. According to US epidemiological data from the National Institute of Mental Health, social phobia affects 15 million adult Americans in any given year. Estimates vary within 2 percent and 7 percent of the US adult population.

The mean onset of social phobia is 10 to 13 years. Onset after age 25 is rare and is typically preceded by panic disorder or major depression. Social anxiety disorder occurs more often in females than males. The prevalence of social phobia appears to be increasing among white, married, and well-educated individuals. As a group, those with generalized social phobia are less likely to graduate from high school and are more likely to rely on government financial assistance or have poverty-level salaries. Surveys carried out in 2002 show the youth of England, Scotland, and Wales have a prevalence rate of 0.4 percent, 1.8 percent, and 0.6 percent, respectively. In Canada, the prevalence of self-reported social anxiety for Nova Scotians older than 14 years was 4.2 percent in June 2004 with women (4.6 percent) reporting more than men (3.8 percent). In Australia, social phobia is the 8th and 5th leading disease or illness for males and females between 15 and 24 years of age as of 2003. Because of the difficulty in separating social phobia from poor social skills or shyness, some studies have a large range of prevalence. The table also shows higher prevalence in Sweden.

History

Literary descriptions of shyness can be traced back to the days of Hippocrates around 400 BC. Hippocrates described someone who "through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him".

The first mention of the psychiatric term "social phobia" (phobie des situations sociales) was made in the early 1900s. Psychologists used the term "social neurosis" to describe extremely shy patients in the 1930s. After extensive work by Joseph Wolpe on systematic desensitization, research on phobias and their treatment grew. The idea that social phobia was a separate entity from other phobias came from the British psychiatrist Isaac Marks in the 1960s. This was accepted by the American Psychiatric Association and was first officially included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).

Research

Although social anxiety disorder has been under study for decades, the underlying neurobiology is not well understood. Neuroimaging technologies are in use to clarify brain regions involved.

Parenting that is intrusive or controlling and stressful life events may increase the risk for SAD development during childhood, extending into adult years. Genetic factors may have a role, although genetic biomarkers are not specifically identified.

References

References

1. (2025). "Social Anxiety Disorder". National Institute of Mental Health, US National Institutes of Health.
2. (2020). "Social anxiety in young people: A prevalence study in seven countries". [[PLOS One]].
3. (April 11, 2019). "Introversion, Shyness & Social Anxiety: What's the Difference?".
4. (13 March 2022). "Social Anxiety? Introvert? Or Shy?".
5. (2025). "Social Anxiety Disorder: Recognition, Assessment, and Treatment". National Institute for Health and Clinical Excellence.
6. (25 October 2022). "Social Anxiety Disorder". StatPearls, US National Library of Medicine.
7. (2022). "Social Anxiety Disorder: More Than Just Shyness". National Institute of Mental Health, US National Institutes of Health.
8. (19 June 2021). "Social anxiety disorder (social phobia)". Mayo Clinic.
9. Pilling, S. (May 22, 2013). "Recognition, assessment and treatment of social anxiety disorder: summary of NICE guidance.". BMJ (Clinical Research Ed.).
10. (2008). "Cognitive-behavioral therapy for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials". The Journal of Clinical Psychiatry.
11. (2012). "The evidence-based pharmacotherapy of social anxiety disorder". The International Journal of Neuropsychopharmacology.
12. (2013-02-01). "The evidence-based pharmacotherapy of social anxiety disorder". International Journal of Neuropsychopharmacology.
13. "The ICD-10 Classification of Mental and Behavioural Disorders Clinical descriptions and diagnostic guidelines". [[World Health Organization]].
14. (2017-06-08). "Social Anxiety Disorder". New England Journal of Medicine.
15. Schneier, Franklin. (7 September 2006). "Social Anxiety Disorder". The New England Journal of Medicine.
16. (1995). "Social Anxiety". The Guilford Press.
17. (2008). "Social phobia and number of social fears, and their association with comorbidity, health-related quality of life and help seeking". Social Psychiatry and Psychiatric Epidemiology.
18. (2014). "The Wiley Blackwell Handbook of Social Anxiety Disorder".
19. (2007). "Incidence of Social Anxiety Disorder and the Consistent Risk for Secondary Depression in the First Three Decades of Life". Archives of General Psychiatry.
20. (2001). "Social Anxiety Disorder and the Risk of Depression: A Prospective Community Study of Adolescents and Young Adults". Archives of General Psychiatry.
21. (2018). "Mapping network connectivity among symptoms of social anxiety and comorbid depression in people with social anxiety disorder". Journal of Affective Disorders.
22. (2003). "Considering comorbidity in social phobia". Social Psychiatry and Psychiatric Epidemiology.
23. (1990). "Syndrome comorbidity in patients diagnosed with a DSM-III--R anxiety disorder". Journal of Abnormal Psychology.
24. (2008). "Generalized social phobia and avoidant personality disorder: Meaningful distinction or useless duplication?". Depression and Anxiety.
25. (1991). "The relationship of social phobia subtypes and avoidant personality disorder". Comprehensive Psychiatry.
26. (2008). "Specificity of social anxiety disorder as a risk factor for alcohol and cannabis dependence". Journal of Psychiatric Research.
27. (2005). "The relationship between social anxiety disorder and alcohol use disorders: A critical review". Clinical Psychology Review.
28. (2011). "Social anxiety in adolescents and young adults: Translating developmental science into practice".
29. (2005). "Follow-up Study of Anxiety Disorder and Alcohol Dependence in Comorbid Alcoholism Treatment Patients". Alcoholism: Clinical & Experimental Research.
30. "Social anxiety disorder." CareNotes. Truven Health Analytics Inc., 2012. Health Reference Center Academic. Web. 15 Nov. 2012.
31. Erliksson, Olivia J.. (26 July 2020). "Measuring associations between social anxiety and use of different types of social media using the Swedish Social Anxiety Scale for Social Media Users: A psychometric evaluation and cross-sectional study". Scandinavian Journal of Psychology.
32. (1999). "Fears and phobias: reliability and heritability". Psychol Med.
33. Merikangas. (1999). "Vulnerability factors among children at risk for anxiety disorders". Biol Psychiatry.
34. (2021). "Parenting Characteristics among Adults With Social Anxiety and their Influence on Social Anxiety Development in Children: A Brief Integrative Review". Frontiers in Psychiatry.
35. (1989). "Social phobia and perceptions of early parental and personal characteristics". Anxiety Research.
36. Daniels and Plomin, 1985.
37. "The Relationship Between Parent Shyness and Child Shyness: Examining the Moderating Effect of Child Gender and Parenting Style".
38. (1985). "Origins of individual differences in infant shyness". Developmental Psychology.
39. (2011). "Family Factors in the Development and Management of Anxiety Disorders". Clinical Child and Family Psychology Review.
40. (1997). "Child and adolescent anxiety disorders and early attachment". J Am Acad Child Adolesc Psychiatry.
41. (1999). "Adolescent social anxiety as an outcome of inhibited temperament in childhood". J Am Acad Child Adolesc Psychiatry.
42. Athealth.com.[http://www.athealth.com/Consumer/disorders/SocialPhobia.html Social phobia]. 1999. Retrieved February 24, 2006.
43. "Causes of Social Anxiety Disorder".
44. Mineka S, Zinbarg R (1995) [[Classical conditioning. Conditioning]] and ethological models of social phobia. In: Heimberg R, Liebowitz M, Hope D, Schneier F, editors. Social Phobia: Diagnosis, Assessment, and Treatment. New York: The Guilford Press, 134–162
45. Stemberg ''et al.'', 1995.
46. Beidel, D.C., & Turner, S.M. (1998). Shy children, phobic adults: The nature and treatment of social phobia. American Psychological Association Books.
47. Ishiyama F. (1984). "Shyness: Anxious social sensitivity and self-isolating tendency". Adolescence.
48. Gilmartin, Brian. (1987). "Peer Group Antecedents of Severe Love-shyness in Males". Journal of Personality.
49. (1988). "Development of the social anxiety scale for children: Reliability and concurrent validity". Journal of Clinical Child Psychology.
50. (May 1999). "Social skills, social outcomes, and cognitive features of childhood social phobia". J Abnorm Psychol.
51. (December 1988). "The many faces of social isolation in childhood". J Consult Clin Psychol.
52. Olson, Christine M.. (July 2021). "Familial Factors in the Development of Social Anxiety Disorder". Journal of Psychosocial Nursing and Mental Health Services.
53. (2016-11-01). "The etiology of social anxiety disorder: An evidence-based model". Behaviour Research and Therapy.
54. Okano K. (1994). "Shame and social phobia: a transcultural viewpoint". Bull Menninger Clin.
55. (1994). "Social anxiety and perception of early parenting among American, Chinese American, and social phobic samples". Anxiety.
56. (1995). "Social and school adjustment of shy and aggressive children in China". Development and Psychopathology.
57. (November 1992). "Discrepancy between self- and observer ratings of performance in social phobics". J Abnorm Psychol.
58. (1993). "Cognitive processes in social phobia". Behav Res Ther.
59. (1995). "Social skills deficits among the socially anxious: Rejection from others and loneliness". Motivation and Emotion.
60. (2000). "Trends in the prevalence of social phobia in the United States: A synthetic cohort analysis of changes over four decades". European Psychiatry.
61. (1995). "The need to belong: desire for interpersonal attachments as a fundamental human motivation". Psychol Bull.
62. (August 2004). "Impact of alcohol intoxication and withdrawal syndrome on social phobia and panic disorder in alcoholic inpatients". Rev Hosp Clin Fac Med Sao Paulo.
63. BNF. (2008). "Anxiolytics". British National Formulary.
64. (August 2003). "WCA recommendations for the long-term treatment of generalized anxiety disorder". CNS Spectr.
65. (2005). "Benzodiazepines in clinical practice: consideration of their long-term use and alternative agents". J Clin Psychiatry.
66. (August 2003). "Are benzodiazepines still the medication of choice for patients with panic disorder with or without agoraphobia?". Am J Psychiatry.
67. Cohen SI. (February 1995). "Alcohol and benzodiazepines generate anxiety, panic and phobias". J R Soc Med.
68. Beck AT, Emery G, Greenberg RL (1985) Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books.
69. (2020). "Bridging maladaptive social self-beliefs and social anxiety: a network perspective". Journal of Anxiety Disorders.
70. "What is the core fear in social phobia {{!}} Request PDF".
71. (1988). "Self-presentational concerns and social anxiety: the role of generalized impression expectancies". Journal of Research in Personality.
72. (1995). "Social phobia: Diagnosis, assessment, and treatment". Guilford Press.
73. (1997). "A cognitive-behavioral model of anxiety in social phobia". Behaviour Research and Therapy.
74. Flynn, Aidan J.. (2025-01-01). "Post-event processing in social anxiety: A scoping review". Journal of Anxiety Disorders.
75. (June 2018). "Cognitive behavioral therapy for anxiety and related disorders: A meta-analysis of randomized placebo-controlled trials". Depression and Anxiety.
76. (2000). "Psychometric properties of the Social Phobia Inventory (SPIN): New self-rating scale". The British Journal of Psychiatry.
77. (Aug 2006). "Psychometric properties of the social phobia inventory: further evaluation". Behav. Res. Ther..
78. Liebowitz MR. (1987). "Anxiety".
79. (2008). "Brief form of the Social Phobia and Anxiety Inventory (SPAI-B) for adolescents". European Journal of Psychological Assessment.
80. (1998-04-01). "Development and validation of measures of social phobia scrutiny fear and social interaction anxiety". Behaviour Research and Therapy.
81. "Social Anxiety Disorder: Signs, Causes & Proven Ways to Cope".
82. (2022-12-04). "Social Anxiety Disorder: Associated Conditions and Therapeutic Approaches". Cureus.
83. (2022-03-18). "Anxiety Disorders". American Psychiatric Association Publishing.
84. (2010). "The Heavy Burden of Psychiatric Comorbidity in Youth with Autism Spectrum Disorders: A Large Comparative Study of a Psychiatrically Referred Population". J Autism Dev Disord.
85. (2006). "Social anxiety disorder comorbidity in patients with bipolar disorder: a clinical replication". J Anxiety Disord.
86. (December 2002). "The soft bipolar spectrum redefined: focus on the cyclothymic, anxious-sensitive, impulse-dyscontrol, and binge-eating connection in bipolar II and related conditions". Psychiatr. Clin. North Am..
87. (2006). "ADHD With Comorbid Anxiety: A Review of the Current Literature". Journal of Attention Disorders.
88. Lewis, C. (January 2012). "Efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders: systematic review". The British Journal of Psychiatry.
89. (2010). "Psychological flexibility as a fundamental aspect of health". Clinical Psychology Review.
90. (Aug 2014). "Acceptance and commitment therapy for anxiety and OCD spectrum disorders: an empirical review". J Anxiety Disord.
91. (2007). "SET-C Versus Fluoxetine in the Treatment of Childhood Social Phobia". Journal of the American Academy of Child & Adolescent Psychiatry.
92. (2008). "Social Skills Training Versus Cognitive Therapy for Social Anxiety Disorder Characterized by Fear of Blushing, Trembling, or Sweating". International Journal of Cognitive Therapy.
93. (2007). "Shy children, phobic adults: Nature and treatment of social anxiety disorders (2nd ed.)".
94. Stravynski & Amado, 2001
95. (1996). "Social phobia in general health care: An unrecognised undertreated disabling disorder". The British Journal of Psychiatry.
96. (2007). "Beyond shy: When to suspect social anxiety disorder". The Journal of Family Practice.
97. (2001). "Social anxiety disorder: An unrecognized problem in primary care". The Journal of Clinical Psychiatry.
98. (2001). "SSRIs in Depression and Anxiety". John Wiley and Sons.
99. Williams, Taryn. (2020). "Pharmacological treatments for social anxiety disorder in adults: a systematic review and network meta-analysis". Acta Neuropsychiatrica.
100. (14 April 2023). "Selective serotonin reuptake inhibitors". Drugs.com.
101. (August 2016). "MAOIs - does the evidence warrant their resurrection?". Australasian Psychiatry.
102. [https://pubmed.ncbi.nlm.nih.gov/9164427/ Clinical effects of buspirone in social phobia: a double-blind placebo-controlled study] National Library of Medicine. 1993. Retrieved 14 August 2025.
103. [https://pubmed.ncbi.nlm.nih.gov/8376612/ Buspirone in social phobia] National Library of Medicine. 1997. Retrieved 14 August 2025.
104. Hong, James S. W.. (2022). "Gabapentin and pregabalin in bipolar disorder, anxiety states, and insomnia: Systematic review, meta-analysis, and rationale". Molecular Psychiatry.
105. Caldiroli, Alice. (2023-01-22). "New frontiers in the pharmacological treatment of social anxiety disorder in adults: an up-to-date comprehensive overview". Expert Opinion on Pharmacotherapy.
106. Hong, James S. W.. (2022). "Gabapentin and pregabalin in bipolar disorder, anxiety states, and insomnia: Systematic review, meta-analysis, and rationale". Molecular Psychiatry.
107. Greenblatt, H. Karl. (2018). "Gabapentin and Pregabalin for the Treatment of Anxiety Disorders". Clinical Pharmacology in Drug Development.
108. "Adults and Mental Health".
109. "The mental health of young people looked after by local authorities in Scotland".
110. (2003-05-13). "Social phobia in the Australian National Survey of Mental Health and Well-Being (NSMHWB)". Psychological Medicine.
111. (September 2005). "Comparing the prevalence rates of social phobia in a community according to ICD-10 and DSM-III-R". Rev Bras Psiquiatr.
112. Khyati Mehtalia. (September 2004). "Social Anxiety in Adolescents". Indian J Psychiatry.
113. (2006). "Prevalence of social phobia and its comorbidity with psychiatric disorders in Iran". Depress Anxiety.
114. (September 2006). "Social phobia symptoms: prevalence, sociodemographic correlates, and overlap with specific phobia symptoms". Comprehensive Psychiatry.
115. (Jun 2009). "Social phobia in Nigerian university students: prevalence, correlates and co-morbidity". Soc Psychiatry Psychiatr Epidemiol.
116. (January 2007). "Social phobia in Swedish university students: prevalence, subgroups and avoidant behavior.". Soc Psychiatry Psychiatr Epidemiol.
117. (September 2004). "Social phobia among university students and its relation to self-esteem and body image.". Can J Psychiatry.
118. Rabe-Jabłońska J. (2002). "Fobia społeczna. Rozpowszechnienie, kryteria rozpoznawania, podtypy, przebieg, współchorobowość, leczenie.". Psychiatria W Praktyce Ogólnolekarskiej..
119. link. (2010). 張奕涵. 臺灣公共衛生雜誌
120. (Mar 2008). "Social anxiety disorder". Lancet.
121. [http://www.findarticles.com/p/articles/mi_m3225/is_8_60/ai_58266993 Social Anxiety Disorder: A Common, Underrecognized Mental Disorder] {{Webarchive. link. (2015-09-24 . American Family Physician. Nov 15, 1999.)
122. "Anxiety Disorders".
123. Surgeon General [http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c4.pdfAdults and Mental Health] 1999. Retrieved February 22, 2006.
124. (2000). "Social phobia in a population-based female adolescent twin sample: Co-morbidity and associated suicide-related symptoms". Psychological Medicine.
125. (2004). "The etiology of social phobia: empirical evidence and an initial model". Clin Psychol Rev.
126. (2012). "Gender differences in social anxiety disorder: Results from the national epidemiologic sample on alcohol and related conditions". Journal of Anxiety Disorders.
127. (December 1999). "Social Phobia's Traumas and Treatments".
128. National Statistics. [http://www.statistics.gov.uk/downloads/theme_health/Mentalhealth_Scotland.pdf The mental health of young people looked after by local authorities in Scotland] {{Webarchive. link. (2004-07-22 . 2002–2003. Retrieved February 23, 2006.)
129. Nova Scotia Department of Health.[http://www.gov.ns.ca/heal/downloads/CCHS_SocialAnxiety.pdf Social Anxiety in Nova Scotia] {{webarchive. link. (2006-03-25. June 2004. Retrieved February 23, 2006.)
130. "Submission to the Australian Senate Select Committee on Mental Health from the National Drug and Alcohol Research Centre, University of New South Wales".
131. (1999). "Social phobia in the general population: Prevalence and sociodemographic profile". Social Psychiatry and Psychiatric Epidemiology.
132. Burton, Robert. (1881). "The anatomy of melancholy". Chatto & Windus.
133. (2004). "À propos du centenaire de la psychasthénie (1903) Les troubles obsessionnels-compulsifs dans la psychiatrie française: revue historique". Annales Médico-Psychologiques.
134. (1985). "Social phobia. Review of a neglected anxiety disorder". Archives of General Psychiatry.