Social Anxiety

“I dread going to places where I may have to talk to people.  Before I set off I just think I’m going to do or say something stupid, and that people will think I’m an idiot.  No one else seems to be like this and I really feel there is something wrong with me.  The only way I can face people is if my girlfriend is with me. It’s not fair, she is full of confidence...”

“If I have to talk in a meeting I just can’t cope.  My legs go wobbly, I flush up and I feel quite sick.  I feel everyone is watching me closely.  I know it is silly and other people don’t seem to have the same difficulty.  I keep thinking afterwards that they must feel I’m not really up to the job...”

These are the thoughts of two people who have a problem with social anxiety.  This is a common problem though people don't often talk about it.  

This guide aims to help you to:

• Recognise whether you may have a problem with social anxiety.
• Understand what it is, what can cause it, and what can help keep it going.
• Look at ways you can help yourself to overcome social anxiety.

Social anxiety is one of the most common sorts of anxiety and it can affect almost anybody from children to older people.  Most of us feel shy or anxious in social situations at some point. However, this can be much more persistent and serious for some people who find that their relationships, education or career are deeply affected by their problem.

There is a lot of information in this guide and it may be helpful to read it several times, or to read it a bit at a time, to get the most from it.

In order to check whether you may be suffering from social anxiety place a tick next to those symptoms you experience regularly. 

What happens to your body

What you experience in your body with social anxiety is exactly the same as any anxiety reaction. It is your body's basic response to threat; the fight and flight response. It is not dangerous, and is in fact a helpful response for dealing with a real physical threat, which has helped us survive as a species. With social anxiety, these body symptoms are all about social situations. When you go into a situation with others and you suffer from social anxiety, you may have some of the following feelings in your body:

What you feel/think

What you do

If you have ticked most of the boxes then you may have social anxiety. 

People who suffer from social anxiety often believe that others will think badly of them or that people will be judging them. They think and feel that they are being watched closely and feel very self conscious.  At the same time they want to come across well but fear that they are not as good as other people and are not ‘up to the mark'. Before, during or after a social situation they suffer symptoms of anxiety such as tension, rapid heartbeat and light-headedness.  In the situation, their mind may go black, they may struggle to speak or they feel hot or blush.

Certain situations may be more difficult than others.  Some socially anxious people feel quite at ease speaking to those they know well, but feel very anxious with strangers. Sometimes it may be the other way round. Eating in front of others can be very difficult for some people, as can crowded places such as canteens, pubs, shops or queues or just being seen in public. For some people, their social anxiety is mainly about talking or doing something in front of others, for example, giving a presentation. Others may fear talking to authority figures or being seen in public can also be very anxiety provoking. 

Social anxiety is seen in cultures across the world; the things that drives self consciousness or embarrassment will vary subtly from one culture to another.  For instance, in some cultures the social fear might be more about offending or embarrassing the other person rather than embarrassing oneself.

Many actors, comedians and musicians suffer from social anxiety when performing in public, and have had to seek help in order to continue with their career.

Some people will begin to avoid difficult situations completely, often leading to loneliness or loss of social life.  It can result in severe disruption to their education, career or life goals.

Other people will cope with their anxiety by doing certain things that make them feel more confident and 'safe' in what feel like scary situations.  These 'safety seeking behaviours' can include things like: not looking people in the eye so as not to draw attention to themselves, sitting on the edge of a group so you are not notices; staying close to someone they know so they can do the talking for them; hiding visible signs of anxiety (such as wearing a jacket to avoid people seeing sweat or make-up to hide blushing); finding a task to look busy to avoid eye contact and social interaction; asking lots of questions to keep focus on the other person or saying very little; repeatedly using alcohol or recreational drugs because the person things they need help  to relax in a social situation; wearing sunglasses or a hat to hide in plain sight. The list of possible safety seeking behaviours is endless. 

It makes sense to use them to protect ourselves when we feel threatened, scared or uncomfortable.  Unfortunately these behaviours keep the problem going because we never learn that the situation is not as threatening as we thought it was and we never find out that we can manage without them.  

The person might think, “phew!  I only coped because… I had a drink, or I made a list of things to say, or because I kept to the edge of the group, or because I avoided eye contact and so on. The person never learns that they could have coped without needing to do these things.

You may recognise some of these in yourself and we will look at how we can start to ‘drop our safety seeking behaviours’ later in this guide. People may fear that they cannot control their anxiety in these social situations and that they will make a bad impression on others. 

Social anxiety is something that most people experience in a mild form at some point, and as we have said it is one of the most common forms of anxiety.  When severe it can be extremely distressing, and can have a huge impact on someone's life.

It is often related to ‘low self-esteem’ or a poor opinion of self, which may have begun in childhood or adolescence.  Some people seem to be naturally more anxious and have learned to worry about social situations.  Others may have had stressful or distressing life experiences, such as bullying or a critical parent, which have led them to feel like this. Experiences of racial or sexual discrimination can also influence the development of social anxiety.  Most social anxiety begins in adolescence, and sometimes runs in families, but really no-one knows for sure what causes it. We do know quite a lot about what keeps it going, however, which is very important when it comes to dealing with it!

There are some other health conditions where social anxiety is present along with other difficulties. These include severe depression and excessive worry (called generalised anxiety disorder). People diagnosed with autism or attention deficit hyperactivity disorder (ADHD) may also experience social anxiety. If you feel any of these may be the case for you it is important to discuss with your doctor so that you may get the correct help. You can find out more about autism and ADHD at 

• www.nhs.uk/conditions/autism/
• www.nhs.uk/conditions/attention-deficit-hyperactivity-disorder-adhd/

Some people feel socially anxious when they are young but become more confident as they get older.  For other people it can just go on and on and become a life-long problem.  There is one very good reason for this which is that a vicious circle develops involving the following:

1. If someone has been socially anxious for many years, say from childhood, they may have long-term beliefs that they are ‘no good in social situations’. They may recall difficult social situations from their past. Research has shown that a person with social anxiety has equal social skills to others but does not believe this.  People with social anxiety tend to wrongly believe that they are not socially skilled.
2.  Avoidance of social situations keeps the person from becoming more used to social occasions. This stops them from learning that they can cope and feel fine.  If a situation is avoided it feels even more difficult the next time.  As mentioned, most socially anxious people also have 'safety seeking behaviours’ that stop them learning that they are doing fine.  For example, I can only manage by not making eye contact.
3. As well as lots of negative thoughts, the person with social anxiety often holds unpleasant negative images in their mind of how they look to others.  These images can pop into their mind before, during or after social situations.  The images fuel anxiety and strengthen the idea that they look terrible to others.  They might not even notice the negative images as they can be so used to having them and they don’t ‘sense check’ them with the actual reality of the situation or their life now.  For example, having a distressing, repetitive image of seeing yourself as a teenager at school, when you are now an adult in a meeting at work.
4. ‘Fear of fear’ will sometimes take over so that the person will predict that they will be anxious in certain situations and expect certain symptoms, “I will act embarrassed”, “I won’t be able to get my words out” or, “what if people notice my hands shaking?”  These thoughts increase anxiety even before they go into the feared situation, and unfortunately some of the feared symptoms may actually happen.
5. The spotlight of attention turns within; the person notices strong bodily reactions, or the sound of their voice, or how they are standing and so on.  This makes it very hard to pay attention to the other person, the conversation or the situation.
6. After a social situation the person is likely to look back with lots of negative thoughts about how badly things went, such as “I looked stupid” (self criticism) and “they must have thought I was an idiot” (expecting others to be critical).
7.  With all these negative thoughts going on before, during and after social situations, the feared symptoms such as having a hot face or blushing, shaking, sweating or mind going blank do actually happen.  It is important to know however that the internal experience of these symptoms is often an exaggerated version when compared to what is actually seen.  All the same, having these symptoms strengthens beliefs and increases fear for future situations and we come to believe that we cannot cope or control our feelings.

So putting these all together, a vicious circle of social anxiety can develop. 

There are a number of ways you can begin to help yourself overcome social anxiety.  

The approaches we suggest are:

1. Understanding social anxiety;
2. Understanding and reducing negative thoughts, beliefs and images;
3. Reducing how much you focus on yourself;
4. Becoming more comfortable with uncertainty;
5. Tackling avoidance and dropping safety seeking behaviours;
6. Tackling the physical symptoms of social anxiety;
7. Seeking further help.

These are tried and tested approaches which do work, although they can take a lot of time and effort. They are based on cognitive behaviour therapy (CBT).
 

You may already by now have some ideas about what is causing your social anxiety, but to understand this even better, it may help to try the following:

Think back to a recent social occasion you found difficult over the last month and try to work out what was happening for you by drawing out your own vicious circle to include:

• Your long held beliefs
• Your negative automatic thoughts before a social situation
• Your physical symptoms
• The negative picture of yourself which you hold in your mind
• Your avoidance or safety behaviours
• Your negative thoughts after a social event

If you can’t get a clear picture of your difficulties by thinking back, then it may help to keep a social anxiety diary. For one or two weeks only, keep a diary of when and where you felt anxious and what was going on at the time. Keep a brief note of the thoughts, physical symptoms, and safety seeking behaviours you are aware of having had; before, during and after each situation. 

Once you have a clearer view of your own problem then you can begin to tackle the various parts of it and break the vicious circle of anxiety.
 

We have seen the role that thoughts have in keeping the vicious circle of social anxiety going.  Thoughts can be words or they can be pictures in your mind.  The following examples may help you to identify your own thoughts and pictures.

It may help to write down your own negative thoughts and images:

Once you know what they are you can begin to fight back and break the vicious circle.

In particular ask yourself if you have any of the following unhelpful thinking styles?

1. Am I mind-reading? e.g. “he/she thinks I’m boring”. In this case you don’t tend to find out or look to see what the other person really thinks.  You believe your own negative views and blame it on the other person! e.g. “he doesn’t like me”.  This is a very common problem for socially anxious people who assume their own negative view of themselves is also held by others.
2. Am I fortune-telling? e.g. “I'm going to have an awful time, everyone will be laughing at me”.
3. Am I catastrophising? e.g. “If this talk doesn't go right, I will lose my job” or “If they notice I am anxious, they won't want to know me”.
4. Am I personalising the situation? e.g. “they are all laughing, they must be talking about me” or “he looks fed up, it’s probably because he thinks he’s got to sit with me”.
5. Am I focusing only on the bad things e.g. “I really clammed up when I tried to speak to Jane” (ignoring that you had been able to speak easily to other people that day).

These unhelpful thinking styles mean that you don’t view yourself in social situations in a fair way.  It may help to begin to try and answer back to find a clearer picture of what is happening.  A good way of doing this is to write two columns – one for your anxious thoughts and the other for a fairer more balanced thought: 

Write down some of your thoughts now and write as many answers or balanced thoughts as you can.  Look out for unhelpful thinking.  This question might also help, “What would you say to a friend who was thinking that way”?

The aim is to get better at catching these anxious thoughts and answering back almost instantly. In time, you may also begin to challenge your long term and faulty beliefs if you have some. You need to accept that a thought is just a thought and is not always true. It takes a lot of practice, but really does work.

Research has shown that people with social anxiety tend to show an increase in self-focus in situations where they feel anxious.  This means that:

• They concentrate a lot on their own body, especially looking for the symptoms of anxiety, e.g. shaking, sweating, blushing, difficulties in speaking.
• They focus on their own thoughts with the negative images and views of themselves mentioned in the previous section.
• They have a strong negative image of how they look to others.
• The image is often not the way they appear to others as it is driven by anxiety not reality.
• They believe they are the focus of everyone else's negative and critical attention. 
• They expect themselves to be perfect in social situations, which very few people actually are.
• They judge themselves really harshly after the event. Often going over this again and again, thinking how they could have done better.

Ways of reducing self focus are:

• Do not 'monitor' yourself in social situations, pay attention to what is happening around you:
  • look at other people and the surroundings;
  • really listen to what is being said (not to your own negative thoughts);
  • don’t take all the responsibility for keeping conversations going – silence is OK, other people will contribute.
• Begin to recognise that your physical symptoms of anxiety are not as noticeable as you think.  If you focus less on your own body then you’ll stop noticing these symptoms.
• Begin to look at other people to see if they show signs of anxiety.
• Begin to believe that people will not dislike you because you are anxious – would you dislike someone just because they were anxious?
• Begin to note that you are really not the central focus of everyone’s attention.
• Try not to go over social situations in your head after the event. Remind yourself that negative judgements are unhelpful and try to move on. One good way of doing this is to distract yourself with another activity as soon as you start to have negative thoughts about how a social situation has gone. This might be playing on a game, reading, watching TV. Anything that takes your mind off it. 

We never quite know how people will respond or react to us in social situations and depending on your point of view this can either make the situations interesting or stressful or both!  Uncertainty, like gravity, is ever present, and is found within all social situations. Often people who have social anxiety would prefer to have as much certainty about what will happen as possible.  In order to manage uncertainty people can either put off or avoid social situations or might over prepare for them (e.g. planning what to say in advance). Both avoiding and over preparing are an attempt to manage uncertainty and both tend to back fire and make the uncertainty worse. For example, avoiding a social engagement might mean that we feel more uncertain as we don’t know whether we were talked about, what was said or how other’s said it.  Or, having planned what to say, finding that the conversation took a turn away from the things that we had planned to talk about.  These efforts to  manage uncertainty can be thought of as safety seeking behaviours.
 
Trying to reduce uncertainty is not limited to social settings we might also try this in our everyday lives.  For example, we might try to reduce uncertainty by shopping in the same supermarket, buying the same kinds of food, watching the same stuff on TV or, checking things on our phone, etc.  While it might feel safer to run on familiar tracks - living in this way can be very limiting and does not enable us to make friends with a companion who is always with us, whether we like it or not – namely uncertainty!

If we can start to make friends with uncertainty in our everyday lives then perhaps we can then do the same in our social lives. Are there are other parts of your life that you could start to welcome in a little more uncertainty.  Perhaps, trying new foods, not checking your mobile for an hour, or watching a film without knowing anything about it.  Notice how allowing uncertainty into your life can actually improve it.  Take small manageable risks.

Once you have experimented in other parts of your life, you can begin to welcome uncertainty into social settings.  For example, reducing your tendency to ‘over plan’, or try to be a little more spontaneous or let go of control of some events and allow others to plan things for you. 

It’s hard to do this at first and you will feel anxious, but keep your eye on what you get from making friends with uncertainty; like being more present in social interactions, being happier to go with the flow, learning new things, having new experiences  etc. By letting go of trying to control the impossible uncertainty), and making friends with it you can use the emotional energy you save for other things. 

Changing what you do is probably the most helpful way to overcome social anxiety.  We have already talked of how avoidance and safety seeking behaviours keep social anxiety going. It will help to be clear which behaviours you need to tackle. The following examples may help you to pinpoint your own avoidance and safety seeking behaviours.

Tick the boxes, or write your own list.

All of these types of avoidance and safety seeking behaviours keep the problem going.  It is important to: 

• Gradually reduce the avoidance and begin to face the things you fear.
• Begin by making a list of all the avoidance and safety seeking behaviours that you aim to prevent.

It may help to look at this example:

Fear of talking in front of a group of people
John fears talking in front of others.  In the past he has managed this by using safety seeking behaviours such as drinking alcohol, not looking at others, keeping busy, speaking very quickly and staying next to a close friend who talks a lot.  Recently his problem has got worse and he has stopped going to his local social club, because of his fear.  He really misses this.  He has made up the following 'anxiety ladder' where those targets easiest to achieve are at the bottom and the most difficult situations are at the top. 

Graphic showing John’s anxiety ladder. His easiest target, Step 1, is meeting a friend and going into the club.
Step 2 -  to go to the club on his own and meet friends inside.
Step 3 -  to stay with people instead of keeping busy with jobs the whole time.
Step 4 – to look at people in a group, and not monitor his own symptoms and thoughts.
Step 5 – to mix with people other than close friends.
Step 6 - his most difficult - is to say more and speak slower in a group.

John will begin with step 1 and gradually work towards step 6.  He will gradually reduce or drop his safety seeking behaviours and make sure not to take on new ones!

Anxiety is a normal everyday experience that we all have from time to time; while it is felt strongly within the body, and can be 
uncomfortable, it is not harmful. When we are trying to help ourselves, we might need a little help as we start to address our 
social anxiety. What follows are some general ideas aimed at helping you to manage your anxiety.

As anxiety is largely physical, our body is one of the first things to be affected. In order to reduce the severity of physical symptoms it is useful to ‘nip them in the bud’, by recognising the early signs of tension.

Once you have noticed early signs of tension you can prevent anxiety becoming too severe by learning to relax.  Some people can relax through exercise, listening to music, watching TV, or reading a book. Relaxation or yoga classes may also be useful. For others it is more helpful to have a set of exercises to follow.  Controlled breathing, deep muscle relaxation, mindful breathing and distraction can all help in reducing tension and switching off some of the physical signs of anxiety.

Take things one step at a time
You will need to practice regularly to manage thoughts and physical symptoms of anxiety using the skills you have learned in the other sections.  You will gradually learn that you can cope and feel comfortable in social situations.  It is worth remembering that many other people feel anxious in social situations too, it just doesn’t show.  You are not the only one.

We hope you will use the exercises suggested in this guide.  They may help you overcome social anxiety and return to normal life.

If you feel you are making little progress or the problem is getting worse then seek help in overcoming your problem.

Your GP is the best person to talk to first.  Your GP may suggest a talking treatment or tablets or both.  He or she may suggest you see a mental health worker who can offer expert help with your problems. Cognitive behaviour therapy (CBT) one to one with a therapist or in a group has been found to be very successful for most people with social anxiety. Medication prescribed by your doctor may also help.

If you feel so distressed that you have thoughts of harming yourself then visit your doctor as soon as possible and explain to him or her how you are feeling.
 

• Anxiety UK
  Infoline: 03444 775 774
  Text service: 07537 416 905
  Email: support@anxietyuk.org.uk
  www.anxietyuk.org.uk
  Provides information and support to people suffering from anxiety disorders.
• Anxiety Care UK
  www.anxietycare.org.uk
  Provides information and support to those suffering from anxiety. For emotional support please  contact recoveryinfo@anxietycare.org.uk

• British Association for Behavioural and Cognitive Psychotherapies
  Email: babcp@babcp.com
  www.babcp.com
  Information and advice for people about behavioural and cognitive psychotherapy (CBT).

• Healthwatch
  www.healthwatch.co.uk
  If you use GPs and hospitals, dentists, pharmacies, care homes or other support services, we want to hear about your experiences. As an independent statutory body, we have the power to make sure NHS leaders and other decision makers listen to your feedback and improve standards of care.
• Mental Health Matters
  Tel: 0191 516 3500
  Email: info@mhm.org.uk
  www.mhm.org.uk
  A national organisation which provides support and information on employment, housing, community support and psychological services.
• Mind Infoline
  Tel: 0300 123 3393
  Email: info@mind.org.uk
  www.mind.org.uk
  Provides information on a range of topics including types of mental distress, where to get help, drug and alternative treatments and advocacy. Also provides details of help and support for people in their own area. 
  Helpline available Mon - Fri, 9am - 6pm.
• National Debtline
  Tel: 0808 808 4000
  www.nationaldebtline.org
  Help for anyone in debt or concerned they may fall into debt.
• NHS Talking Therapies
  www.nhs.uk/mental-health/talking-therapies-medicine-treatments/talking-therapies-and-counselling/nhs-talking-therapies/
  Provides details on how to access local talking therapies services
• Relate
  www.relate.org.uk
  Help with marital or relationship problems. 
• Rethink
  Advice service: 0808 810 0525
  Email: advice@rethink.org
  www.rethink.org
  Provides information and a helpline for anyone affected by mental health problems.
• Samaritans
  Tel: 116 123
  www.samaritans.org
  Email: jo@samaritans.org
  Post: Freepost SAMARITANS LETTERS
  Confidential support for anyone in a crisis.
• Social Anxiety UK
  www.social-anxiety.org.uk
  Email: contact@social-anxiety.org.uk
  Information on social anxiety disorder and tips for living with the condition.  No helpline available.
• Triumph over Phobia
  Tel: 01225 571 740
  Email: info@topuk.org
  www.topuk.org
  Provides national network of self help groups for people with phobias or OCD. 

• Complete self help for your nerves
  Claire Weekes
  HarperCollins 2008
  Guide for everything you need to know to keep relaxed through everyday life. Offers comprehensive insight and advice into coping with nervous stress.
• Feeling good: the new mood therapy
  David Burns
  HarperCollins 2005
  A drug-free guide to curing anxiety, guilt, pessimism, procrastination, low self-esteem, and other depressive disorders.
• Feel the fear and do it anyway: how to turn your fear and indecision into confidence and action
  Susan Jeffers
  Vermilion 2012
  Will give you the insight and tools to vastly improve your ability to handle any given situation. 
• Living with fear (2nd revised edition)
  Isaac Marks
  McGraw-Hill 2005
  This self-help guide gives practical advice to people who are suffering from phobias, panic, obsessions, rituals or traumatic distress.
• Overcoming social anxiety and shyness: a self-help guide using cognitive behavioural techniques
  Gillian Butler
  Robinson 2016
  Outlines the nature of shyness, the symptoms and possible causes and explains how to deal with upsetting thoughts, overcome avoidance and manage symptoms of anxiety through relaxation, distraction and panic management.
• The mindfulness and acceptance workbook for social anxiety and shyness: using acceptance and commitment therapy to free yourself from fear and reclaim your life
  Jan E. Fleming MD, Nancy L. Kocovski PhD, Zindel V. Segal  PhD
  New Harbinger 2013
  A step by step programme to help you: understand social anxiety in a new way, stop avoiding social situations, speak in public and start participating fully in the life you want.
• We're all mad here: the no-nonsense guide to living with social anxiety
  Claire Eastham
  Jessica Kingsley 2017
  No-nonsense guide to surviving social anxiety.

For young people:

• The shyness and social anxiety workbook for teens: CBT and ACT skills to help you build social confidence
  Jennifer Shannon
  New Harbinger 2012
  This workbook for teens offers worksheets and comic-style illustrated scenarios that help teen readers identify their values and practice evidence-based skills from cognitive behavioural therapy (CBT) and acceptance and commitment therapy (ACT) for overcoming shyness and social anxiety.

• www.franticworld.com – Mindfulness: Finding Peace in a Frantic World – Free meditations and mindfulness resources.
• www.headspace.com – A free taster of mindfulness, with an opt-in to buy further sessions.
• www.freemindfulness.org – A collection of free to download meditations.

• www.cntw.nhs.uk/relaxation
• www.wellbeing-glasgow.org.uk/relaxation

A full list of references is available on request by emailing pic@cntw.nhs.uk
 

Share your thoughts with other people and let them know what you think of this guide.

Written by Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists

Many thanks to Dr Kevin Meares, Consultant Clinical Psychologist, Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, who has contributed to the review of this guide.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust has developed this resource with the support of NHS healthcare staff, service users and local voluntary sector groups.

Published by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust

2024 Copyright PIC/100/0324 March 2024 V5

Review date 2027