Social phobia is an anxiety disorder characterised by a marked and persistent fear of one or more social situations, in which the young person fears scrutiny and criticism by other people and avoids them. These fears are excessive and unreasonable with a debilitating effect on their functioning. This can include an intense fear of embarrassment or being humiliated by others in social situations. Social phobia is different from the occasional shyness or nervousness but it often preceded by this.
The estimated prevalence in children and adolescents is around 1%. This may not be an accurate estimation as symptoms may be incorrectly attributed to a shy and withdrawn personality. It is more commonly seen in females and typically starts in teenage years.
Symptoms of social phobia
The ICD-10 diagnostic criterion for social phobia involves a fear of scrutiny by others in relatively small groups leading to an avoidance of social situations.
It often begins around early adolescence or sometimes younger. Children who suffer from social phobia might appear to be excessively shy and have extreme anxieties around speaking or performing in the presence of others that could cause them embarrassment. These young people often have low self-esteem and may believe that others are more competent than them.
Socially phobic young people usually have negative thoughts about their abilities and they have thoughts that others will negatively judge their social behaviour. The most common fears for children and adolescents with social phobia are being in social settings such as parties, gatherings, and a fear of talking to others in public. They may also have a fear of talking to authority figures such as teachers. Other less common worries may include fears of using public toilets, fears of eating out or talking on the phone.
When confronted with phobic situations the young person may experience anxiety symptoms such as:
- shaking and trembling
- numbness or tingling
- hot/cold flashes
- shortness of breath
Social phobia differs from shyness as children or adolescents who are shy may feel uncomfortable being around others, but may not necessarily avoid situations that make them feel uncomfortable. Social phobia can cause impairments in the child’s typical functioning and can result in social isolation.
Causes of social phobia
The causes of social phobia are bio-psychosocial and multifactorial, and include the following.
- Family history: anxiety tends to run in families, there is an increased risk of developing social phobia if a close relative has the disorder.
- Adaptation: fear is an adaptive response and designed for safety, particularly maintaining close proximity to protective figures. This need to be close gradually decreases with age. With some young people, persistent reactions can be viewed as an overdevelopment of an adaptive mechanism.
- Temperament: studies suggest links between temperamental characteristics in in the first year of life and later anxiety disorders. Children who were shy and withdrawn early in life could have a predisposition to develop social phobia later in life.
- Parental attitudes: parental behaviour such as overprotection, which could be due to parents’ own anxieties such as separation anxieties.
- Social adversity: children living with adversities such as financial difficulties or marital conflicts are more likely to experience insecurities and thus predisposed to specific fears and anxieties.
- Learnt behaviour: children learn avoidance behaviour as a result of escaping from difficult situations. The escape will provide young people a temporary relief from the unpleasant situation of anxiety. If avoidance behaviour is rewarded or reinforced, it is more likely to reoccur.
Assessment and diagnosis
A young person with social phobia can be difficult to engage in the clinic. They are likely to give minimal information due to the nature of their symptoms. It is important to gather information from their carer (usually a parent). They tend to have low self-esteem and believe they are not good enough. They fear they will be perceived as stupid or foolish if they speak in public.
They also worry they may not be accepted by their peers or publically fail when performing school tasks. As a result, the child’s functioning will be impaired in several areas such as school attendance, academic performance, social skills, peer relationships and family life.
The onset of social phobia in children is often around age 12. This is when children are expected to engage in social activities with school and peers. Some children may not have an understanding of the excessiveness of their discomfort in social settings and may find it difficult to express these concerns. Children with social phobia may find it extremely distressing to separate from their parents, they may refuse to play with other children or complain about a physical illness when it is time to face a social event. Adolescents with social phobia may avoid social situations and may have no interest in making friends.
For a diagnosis to be made, the symptoms should be present most days of the week for at least several months at a time. Young people with social phobia may have more than one anxiety disorder, therefore diagnosing social phobia can be challenging. It is essential to gather information from home, school and the clinical visit to make a diagnosis.
Early diagnosis is vital, some children or adolescents with social phobia may try to hide symptoms due to embarrassment. Some young people also lack insight into their behaviours or reluctant to talk about them.
Phrasing questions with sensitivity can allow the young person to talk more openly about their difficulties (see box 1). When making a diagnosis it is important to consider:
- A developmental history
- Functional impairment, for example is the young person refusing to attend school or participate in innocuous activities with unfamiliar people?
- Symptoms of depression or the young person not wanting to be alive, which can arise if the child feels helpless and unable to relieve their symptoms.
- Assessment of risk to self or suicide
- Family history of psychiatric illness
- Mental state examination
- Physical examination as young people may complain about stomach aches, and rapid heartbeats.
Social phobia can be associated with other psychiatric disorders such as depression, anxiety disorders, attention deficit hyperactive disorders (ADHD) and intellectual disability.
|Box 1: Questions to ask|
Do you experience intense fear of situations involving meeting new people?
If the symptoms are mild (not significantly affecting their day-to day functioning) a referral for school counselling or advice on self-help strategies should be given (see resources).
A referral to the local child and adolescent mental health service should be made for moderate to severe symptoms.
Recent studies suggest the first line treatment for social phobia is cognitive behavioural therapy (CBT). Pharmacological intervention with selective serotonin reuptake inhibitors (SSRIs) should be reserved for severe symptoms with limited response to CBT.
CBT has been shown to result in long-term improvements and delivered by a trained specialist with experience in working with children and young people. The components of CBT include helping young people become aware of their negative thoughts, feelings and reactions around their fear of social encounters. Young people are taught new skills to reduce anxiety symptoms when interacting with others. Also, CBT can encourage young people to think of positive alternative thoughts when interacting with people. The young people practise the new skills in social situations and discuss their experience with the clinician.
- Faiben Yemane is assistant psychologist and Dr Vibhav Shetty Consultant is child and adolescent psychiatrist South Kent CAMHS
- Belzer, K. D., McKee, M. B., & Liebowitz, M. R. (2005, November). Social Anxiety Disorder: Current Perspectives on Diagnosis and Treatment. Primary Psychiatry, 12(11), 35-48.
- Culpepper, L. (2006). Social Anxiety Disorder in the Primary Care Setting. The Journal of Clinical Psychiatry, 67(12), 31-37.
- Davidson, J. R. (2006). Pharmacotherapy of Social Anxiety Disorder: What Does the Evidence Tell Us? The Journal of Clinical Psychiatry, 67(12), 20-26.
- Social anxiety disorder: recognition, assessment and treatment. NICE guidelines [CG159] Published date: May 2013
- Anxiety UK - A charity providing information and support for people suffering with anxiety problems.
- TheSite.org - Website by YouthNet UK, a charity provides factsheets and articles on all the key issues facing young people.
- The Child Anxiety Network - Provides thorough, user-friendly information about child anxiety.
- Young Minds Parents Helpline For any adult concerned about the emotions and behaviour of a child or young person. Parents' helpline 0808 802 5544
- Youth Access - Offers information, advice and counselling in the UK
Goldin, P.R., Ziv, M., Jazaieri, H., Hahn K., Heimberg, R. (2013, October). Impact of Cognitive-Behavioral Therapy for Social Anxiety Disorder on the Neural Dynamics of Cognitive Reappraisal of Negative Self-beliefs, JAMA Psychiatry, 70(10):1048-1056.
Worries and anxieties - helping children to cope: information for parents, carers and anyone who works with young people. Mental health and growing up factsheet. Royal College of Psychiatrists