People who suffer from social anxiety may experience various types of emotional discomfort, including fear, apprehension or worry about social situations and being judged by others.

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Social anxiety (also known as social phobia) is the second most common phobia, where the person fears public events. The symptoms can range from being uncomfortable in a public place through to to a full disabling phobia. The person fears:

• public speaking
• social gatherings and parties
• being embarrassed or being criticised
• making a mistake in public
• writing under supervision
• eating and drinking in public
• dating

Worrying about it in advance just makes it worse. This is a serious and disabling anxiety disorder but only about one in twenty people with social anxiety get diagnosed. It occurs more often in women but men are more likely to seek treatment. It usually starts in the mid- to late-teens but the person often isn’t diagnosed until later in life.

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Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some other possible causes for the symptoms of social anxiety. This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed. Often it doesn't really matter anyway as the symptoms need to be treated anyway, no matter what causes them.

• Depression - social anxiety can appear as a symptom of, or part of, depression, psychosis, schizophrenia (up to 1 in 4 people with schizophrenia have social anxiety symptoms), eating disorders and GAD or Generalised Anxiety Disorder
• Agoraphobia
• Panic disorder - although Social Anxiety has panic attacks as a main symptom

Just to confuse matters further, sometimes people have more than one illness (sometimes called "co-morbidity"). For example, if 1 in 10 people get depressed and 1 in 10 people get anxiety, then just by chance 1 in 10 of the depressed people get anxiety as well. However, if you're depressed, you're more likely to be anxious. Co-morbidity means what else the person is more likely to have at the same time. This can make diagnosis more difficult. At least 1 in 2 people (50-80%) with social anxiety also have at least one other illness.

• Substance misuse e.g. drug or alcohol dependence is twice as likely, including nicotine, but not usually illicit drugs
• GAD or Generalised Anxiety Disorder - people with social anxiety are 3 times more likely to have GAD
• Depression - people with social anxiety are 2 to 3 times more likely to have depression
• Agoraphobia (with or without panic symptoms) - people with social anxiety are 4 times more likely to have agoraphobia
• PTSD (Post-Traumatic Stress Disorder) - people with social anxiety are 5 times more likely to have PTSD (post-traumatic stress disorder)
• Eating disorders - people with social anxiety are twice as likely to have an eating disorder
• OCD (Obsessive Compulsive Disorder) - people with social anxiety are 3 times more likely to have OCD, although it's still quite uncommon  
• Seasonal Affective Disorder
• Body Dysmorphic Disorder (very common) - where the person thinks there is a big problem with their body e.g. a defect in how they look etc.  

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Basically, anyone can get social anxiety. However, there are some "risk factors" that make it more likely that someone will get the symptoms of social anxiety. This is not a complete list but some of the main ones include:

• Being female - social anxiety is slightly more common in females (3:2 ratio)
• Being young
• Family history and genetics - if an identical twin has social anxiety disorder, 24% of the other identical twin will as well; if a non-identical twin has social anxiety disorder, only 15% of the other twins will as well. It is also more common in female twins
• Upbringing e.g. over-protective parents or rejection by parents, but this is not proven
• Low self-esteem or low self-confidence
• Poverty
• Having a medical or physical condition e.g. being very fat, having acne, a stutter, a tremor or shake, or another physical problem

We are not very sure what changes or imbalances in the brain might cause social anxiety. It is quite possible that low serotonin is involved.

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There are many risks of having untreated social anxiety. These can include:

• If you first get social anxiety early in life, you are three times as likely to get depressed later on in life (Beesdo et al, 2007). This is more likely if you are female and your parents have anxiety.
• Social anxiety may also double the risk of developing physical illnesses such as heart disease (Landen et al, 2004).
• People with social anxiety disorder have been shown to be more than twice as likely to be unemployed but expected to work more than others with a mental disorder (Moitra et al, 2011).
• They worked fewer months than those without social anxiety and their illness prevented them from working more than depression (Tolman, 2009)
• Some people resort to self-medication with alcohol. Up to 1 in 4 (25%) people with alcohol dependence started drinking alcohol to get over their social anxiety. A survey of 34,000 people over 3 years showed having Social Anxiety increased the risk of drug or alcohol dependence by 2-5 times (Robinson, 2011). It might help in the short-term but you can end up alcoholic, and alcohol can cause anxiety and depression. 
• Social anxiety has been identified as a significant risk factor for developing cannabis as well as alcohol dependence.

Overall, social anxiety is lasts longer than other anxiety disorders, there is a higher risk of getting depression, and ending up with an alcohol or other substance dependence. This leads to a lower chance of being able to lead a normal, productive and enjoyable life.

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We can only guess at what will or will not happen because the following things can have an influence and these are all different for everyone.

• Your age
• If you have had a similar illness before
• Whether you have done well in the past with a treatment
• How bad the symptoms are and how long you have had them
• Any other illnesses you may have at the same time
• The support your family is able to offer and your home-life
• Your Job and any stress at work
• Genes - your family history and what genes you might have inherited are often important
• What the words "well", "better", "the same" or "worse" mean to you
• What your expectations are - what you expect to be able to do when you are "well".
• Which side effects you find most troublesome and if they stop you taking a medicine
• How a treatment works for you, what side effects you have and how they affect your life
• How well you follow your doctor's or therapist's advice and instructions.
• Your chances of becoming well again are much lower if you don't take the medicines prescribed for you regularly and reliably, or you don't put what you learn from "talking therapies" into practice. You must do your homework!
• With medicines, the dose you actually take, how often you take it and when you take it are all important

What we can't do is use this to tell an individual person what might happen. Many other things will make the prognosis better or worse. So, read on...

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Here at C&M we have researched this extensively but don't feel a lot wiser. There are of course many studies to show what works and what doesn't and believe me, we've looked at thousands.

However, everyone is an individual. Specific symptoms are unique to that individual. Particular circumstances will also be unique. Some books give an idea of what used to happen years ago but of course the world has changed since modern treatments such as medicines and "talking therapies" first became available. It is important to remember that not all books agree with each other about what might happen if you do nothing.

To do nothing is a personal choice, unless you are a danger to yourself or others. However you need to know the risks and benefits of having no treatment. The up-side of no medication is no side-effects and perhaps getting better by yourself. The down-side is having symptoms for longer and the chance that without treatment, the illness may develop into something more serious or more difficult to treat if you do eventually decide to have treatment.  

Social anxiety is very often a long-term and sometimes life-long problem. The symptoms can also get better or worse by themselves. It seems that without any treatment:

• In 1 in 3 (35%) people the symptoms start but gradually go away without any formal treatment
• In 2 in 10 (20%) people, the symptoms start and slightly improve but are still there
• In 1 in 3 (35%) people the symptoms start and then stay fairly steady, not getting better but not getting worse
• In 1 in 10 (10%) people the symptoms continue to get worse if they have no treatment

The more severe your symptoms and the longer you have had them, the less chance you have of improving without any treatment. And the greater your chance of turning to self-medication with alcohol.

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The list here includes most of the main options but does not say what works and doesn't. Many may be used in combination. Most herbal and alternative therapies have not really been tested in the same rigorous way that medicines have.

Our aim is to try to help people who are taking medication (or should be) get the right medicine, dose and take it regularly for as long as is right. Any medicines should usually be part of the overall treatment, although some people are quite happy just to stick with drugs or talking treatments. If your medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse and self-help will not be as useful.

For social anxiety, there are a number of alternatives, depending on what you would prefer and how much distress the symptoms are causing you, when and how often.

Self-help

• Self-help – self-confidence or assertiveness courses at an Adult Education Centre may help if you are naturally shy
• Taking any medicines regularly and reliably
• Eating healthily and taking exercise  (“exercise to energise”) or being active

Help from others

• Behavioural therapies – these are most often used as first choice. They include social skills training (practicing with other people, watching yourself on video), exposure therapy (being helped to relax in stressful situations) and  Cognitive Behavioural Therapy (CBT) (being helped to change the way you think about a social situation)
• Alternative therapies such as  aromatherapy, hypnosis or hypnotherapy, homeopathy (treating like with like) can be used with (but not instead of) conventional treatments. Acupuncture is used extensively in many countries and may help anxiety, stress and insomnia. The evidence for these treatments is not very good. All of these can be used in conjunction with other therapies. If they work then that is fine and we wouldn’t knock them. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links).

Medicines

• Medicines may be useful (especially if used with talking therapies) but probably aren’t as good as talking therapies alone. Medicines that boost serotonin e.g. SSRIs seem to be quite helpful
• Many people self-medicate with alcohol (“Dutch courage”) and may have a drink problem as a result. This is not really alcoholism so it is best to treat the reason for drinking not just the alcohol drinking itself

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If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your area)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again)

The main medicine treatment options are listed below. They are divided into "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.

Main medicines

BNF Listed

• SSRIs (e.g. paroxetine at up to 50mg each day or escitalopram at up to 20mg each day)

Others

• SSRIs (other ones such as sertraline, fluoxetine, citalopram)
• Benzodiazepines (such as diazepam and clonazepam) to help treat the anxiety directly 
• Beta-blockers (such as propranolol) - to help reduce the increased heart rate and shaking or tremor that can occur in social anxiety and performance anxiety, although there is little evidence this works 
• Other serotonin or noradrenaline boosters (such as venlafaxine, mirtazapine, moclobemide)

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Download a handy summary chart (PDF format) comparing the main medicines for social anxiety e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

Alternatively you can read the chart now in the window below. Use the controls at the bottom of the window to navigate through the chart and magnify the information. The 'Download', 'Print' and 'Fullscreen' links at the top of the window are particularly helpful.  

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Well, here in the C&M bunker, we've had a good look at this. We've looked at every book in the medical library. We've researched information databases as well as medical journals. We've even resorted to Google. After this we can reveal that ... we don't know. It turns out however that this is true of very many illnesses, not just mental illness.

The trouble is, that trials are usually set up to show the maximum effect in a select group of people. Again, we have no idea if you are someone like those in that group. We've tried to use work done by experts in the field, who have added all the studies together to get an overall result. This is called a meta-analysis.

Whatever you decide to do, make sure you do it. If you decide to take medicines, then take them every day as prescribed, give them a good chance to work, and don't mess about with them. Medicines will only work if you take them properly as prescribed. If you decide to go for a "talking therapy", you need to take part fully and put it into practice - do your home work.

A medicine's chances of working will depend on:

• it being the right medicine for your diagnosis
• you taking the correct dose
• you taking the correct dose for long enough
• it not clashing with anything else you are taking

Medicines as well as "talking therapy" such as CBT (Cognitive Behavioural Therapy) have been shown to be effective Westernberg 2009 but they do not work for everyone.

About 40-85% (2-4 in 5) people with social anxiety respond to medicines despite long term symptoms Hansen 2008). The first choice is usually a serotonin-boosting medicine such as an SSRI (e.g. escitalopram, paroxetine) or venlafaxine. There is no evidence that any one of the main medicines is any more or less effective than any other.  The important thing is to choose one that suits you. As examples, here are some figures about how well you might do on a medicine:

All figures to nearest 5%.

As social anxiety is likely to be with you for many years, it may be important to have treatment for many years. There are a couple of long-term studies that have taken people who have got better on a medicine and then switched half of them to a dummy/placebo tablet (but those people don't know whether they have the medicine or the dummy or placebo). If there is a difference between the two groups, this gives us an idea if the medicine is keeping people well and, if so, by how much.

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"Prognosis" is the word used for the likely outcome of any condition. There are several things that will help or not help your prognosis or symptoms and the chances of improving. You should try to make the most or build on the good prognosis factors, and try to work on or minimise the poor prognosis factors. That will give you the best chance of doing well.  

Factors that may lead to a good outcome (good prognosis):

• Having the will or determination to overcome the symptoms
• Treatment - medicines or "talking therapies" make a huge difference
• Being able to increase your self-esteem or self-confidence - CBT can help with this
• Being willing to try out social situations rather than avoiding them. Again, talking therapies can give you some ways to help yourself. And we know that's easier said that done.

Factors which may lead to a poor outcome (poor prognosis):

• Not taking medicines regularly or not having "talking therapy" (or not putting what you have been taught into practice)
• Not having enough support from relatives and friends, both at home and in social situations
• Avoiding social situations just makes things worse.
• Suffering from another illness e.g. depression. Mind you, this also increases the chance of social anxiety being diagnosed and then treated correctly.
• Substance misuse - sufferers may turn to alcohol or other substances to control their symptoms, but while this helps some people in the short-term, they then tend to rely on alcohol too much and can't do anything without it.   
• Having a "personality disorder" (not a good name for a condition but if you have one, you are only a third as likely to get better)
• Problems such as having a stutter, a facial twitch or tic, or a physical problem can make it much harder to overcome social anxiety

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Before going onto another medicine, it is worth trying to get the best out of the first one. There is a risk that switching medicines too quickly means you don’t get the best out of one medicine. Then perhaps you start to search for the “magic bullet”, expecting the drugs to work quicker and having less patience. There are of course no “magic bullets”. Most symptoms have started to happen over a few weeks, months or years, not a few days, so it is perhaps unfair to expect them to go over a few days. The symptoms are more likely to go gradually over weeks or months. If side effects are the main problem with a medicine, try to cope with these by e.g. changing times, splitting the dose, manage side effects etc.

The best thing to do is set out your aims of success of any treatment in advance and be realistic. If you decide to stop, then that’s your decision, but make sure you consider the chances of becoming unwell again (and consequences of that to yourself and the people close to you).

• Serotonin or noradrenaline boosters such as SSRIs, venlafaxine, MAOIs and moclobemide – although you may get some positive effects in a few weeks, you should give these medicines at least 12 weeks before making a decision about how effective they are. 

• Benzodiazepines – these are usually fairly quick acting e.g. within a few hours to start with, and so you might be able to use them just when you need them rather than take them all the time. You can adjust the dosing easily. 

• Beta-blockers – these can help with the physical symptoms of anxiety such as a racing heart and tremor, so the effect is fairly quick e.g. a few hours or days, although the effect may build over several weeks. You might be able to use them just when you need them rather than take them all the time.

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This is not clear but the following may be helpful:

• The serotonin boosting medicines (e.g. SSRIs, venlafaxine, mirtazapine, moclobemide) have been shown to work for at least 6 months, if not longer. If you stop before six months you are quite likely to get your symptoms back.

• The beta-blockers and benzodiazepines can be effective and helpful long-term but you will need to consider the long-term risks. They can be taken when required.

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You should think carefully about taking any chemical that affects your body, including your brain. So think carefully before your next cup of tea or coffee!

Sometimes talking therapies work better with medicines e.g. CBT and an antidepressant together were better than either alone, or placebo ^{(Blanco 2010)}. 

For an appeal for everyone to have a sense of balance about medicines and talking therapies please click here for our take on it.

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There are no easy answers to this and it is a very individual choice. Generally one medicine should always be the aim but combinations (often called “polypharmacy”) sometimes help. It is rarely of any use to combine drugs with similar ways of working. Below are some of the combinations that are used with the reasons. This is not a complete list but you might want to talk to your prescriber about any combinations not on this list you may be prescribed.

Usually one regular medicine should be the main treatment e.g. an SSRI. Sometimes if you know a stressful situation is going to happen, or suddenly happens, taking a benzodiazepine or beta-blocker can be useful when you need help.

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If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have their own similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals (usually only a couple of pages)

• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE - there is also a guideline for Common mental health disorders, Identification and pathways to care, and this includes OCD. A full social anxiety guideline is being prepared, and is due some time in 2012.

• Scottish Intercollegiate Guidelines Network (SIGN)

• Northern Ireland 

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology).

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Use the resources below to find out more information about social anxiety. Please note that this is not an exhaustive list. We welcome your feedback on resources that you think should be listed here.

If you want a more in-depth read, you could no better than visit the BAP (British Association for Psychopharmacology) public web pages, where there are some fairly scientific articles, including about anxiety disorders so click here, to get there.

Mental Health Ireland has a great links page on this extensive site

Your Mental Health Ireland, with a young person’s page as well

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