Social anxiety disorder
Social anxiety disorder | |
---|---|
Other names | Social phobia |
Benzodiazapines
Gabapentin | |
Frequency | 7.1%[3] |
Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by sentiments of fear and anxiety in social situations, causing considerable distress and impairing ability to function in at least some aspects of daily life.[4]: 15 These fears can be triggered by perceived or actual scrutiny from others. Individuals with social anxiety disorder fear negative evaluations from other people.
Physical symptoms often include excessive
The first line of treatment for social anxiety disorder is
History
Literary descriptions of shyness can be traced back to the days of Hippocrates around 400 B.C. 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."[14]
The first mention of the psychiatric term "social phobia" (phobie des situations sociales) was made in the early 1900s.[15] 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. The definition of the phobia was revised in 1989 to allow comorbidity with avoidant personality disorder and introduced generalized social phobia.[16] Social phobia had been largely ignored prior to 1985.[17]
After a call to action by psychiatrist
Signs and symptoms
The 10th version of the
Cognitive aspects
In
Behavioural 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.[19] Feared activities may include almost any type of social interaction, especially small groups, dating, parties, talking to strangers, restaurants, interviews, etc.
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.[20] 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.[20]
According to psychologist
Physiological aspects
Physiological effects, similar to those in other anxiety disorders, are present in social phobias.
Social aspects
People with SAD avoid situations that most people consider normal. They may have a hard time understanding how others can handle these situations so easily. 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.[medical citation needed] SAD can also lead to low self-esteem, negative thoughts, major depressive disorder, sensitivity to criticism, and poor social skills that do not improve.[24] People with SAD experience anxiety in a variety of social situations, from important, meaningful encounters, to everyday trivial ones. These people may feel more nervous in job interviews, dates, interactions with authority, or at work.[25]
Problematic digital media use
In April 2018, the International Journal of Environmental Research and Public Health published a systematic review of 24 studies researching associations between internet gaming disorder (IGD) and various psychopathologies that found a 92% correlation between IGD and anxiety and a 75% correlation between IGD and social anxiety.[26] In August 2018, Wiley Stress & Health published a meta-analysis of 39 studies comprising 21,736 subjects that found a small-to-medium association between smartphone use and anxiety.[27]
In December 2018, Frontiers in Psychiatry published a systematic review of 9 studies published after 2014 investigating associations between problematic SNS use and comorbid psychiatric disorders that found a positive association between problematic SNS use and anxiety.[28] In March 2019, the International Journal of Adolescence and Youth published a systematic review of 13 studies comprising 21,231 adolescent subjects aged 13 to 18 years that found that social media screen time, both active and passive social media use, the amount of personal information uploaded, and social media addictive behaviors all correlated with anxiety.[29] In February 2020, Psychiatry Research published a systematic review and meta-analysis of 14 studies that found positive associations between problematic smartphone use and anxiety and positive associations between higher levels of problematic smartphone use and elevated risk of anxiety,[30] while Frontiers in Psychology published a systematic review of 10 studies of adolescent or young adult subjects in China that concluded that the research reviewed mostly established an association between social networks use disorder and anxiety among Chinese adolescents and young adults.[31]
In April 2020, BMC Public Health published a systematic review of 70 cross-sectional and longitudinal studies investigating moderating factors for associations for screen-based sedentary behaviors and anxiety symptoms among youth that found that while screen types was the most consistent factor, the body of evidence for anxiety symptoms was more limited than for depression symptoms.[32] In October 2020, the Journal of Behavioral Addictions published a systematic review and meta-analysis of 40 studies with 33,650 post-secondary student subjects that found a weak-to-moderate positive association between mobile phone addiction and anxiety.[33] In November 2020, Child and Adolescent Mental Health published a systematic review of research published between January 2005 and March 2019 on associations between SNS use and anxiety symptoms in subjects between ages of 5 to 18 years that found that increased SNS screen time or frequency of SNS use and higher levels of investment (i.e. personal information added to SNS accounts) were significantly associated with higher levels of anxiety symptoms.[34]
In January 2021, Frontiers in Psychiatry published a systematic review of 44 studies investigating social media use and development of psychiatric disorders in childhood and adolescence that concluded that the research reviewed established a direct association between levels of anxiety, social media addiction behaviors, and nomophobia, longitudinal associations between social media use and increased anxiety, that fear of missing out and nomophobia are associated with severity of Facebook usage, and suggested that fear of missing out may trigger social media addiction and that nomophobia appears to mediate social media addiction.[35] In March 2021, Computers in Human Behavior Reports published a systematic review of 52 studies published before May 2020 that found that social anxiety was associated with problematic social media use and that socially anxious persons used social media to seek social support possibly to compensate for a lack of offline social support.[36] In June 2021, Clinical Psychology Review published a systematic review of 35 longitudinal studies published before August 2020 that found that evidence for longitudinal associations between screen time and anxiety was lacking.[37] In August 2021, a meta-analysis was presented at the 2021 International Conference on Intelligent Medicine and Health of articles published before January 2011 that found evidence for a negative impact of social media on anxiety.[38]
In January 2022, The European Journal of Psychology Applied to Legal Context published a meta-analysis of 13 cross-sectional studies comprising 7,348 subjects that found a statistically significant correlation between cybervictimization and anxiety with a moderate-to-large effect size.[39] In March 2022, JAMA Psychiatry published a systematic review and meta-analysis of 87 studies with 159,425 subjects 12 years of age or younger that found a small but statistically significant correlation between screen time and anxiety in children,[40] while Adolescent Psychiatry published a systematic review of research published from June 2010 through June 2020 studying associations between social media use and anxiety among adolescent subjects aged 13 to 18 years that established that 78.3% of studies reviewed reported positive associations between social media use and anxiety.[41] In April 2022, researchers in the Department of Communication at Stanford University performed a meta-analysis of 226 studies comprising 275,728 subjects that found a small but positive association between social media use and anxiety,[42] while JMIR Mental Health published a systematic review and meta-analysis of 18 studies comprising 9,269 adolescent and young adult subjects that found a moderate but statistically significant association between problematic social media use and anxiety.[43]
In May 2022, Computers in Human Behavior published a meta-analysis of 82 studies comprising 48,880 subjects that found a significant positive association between social anxiety and mobile phone addiction.[44] In August 2022, the International Journal of Environmental Research and Public Health published a systematic review and meta-analysis of 16 studies comprising 8,077 subjects that established a significant association between binge-watching and anxiety.[45] In November 2022, Cyberpsychology, Behavior, and Social Networking published a systematic review of 1,747 articles on problematic social media use that found a strong bidirectional relationship between social media use and anxiety.[46] In March 2023, the Journal of Public Health published a meta-analysis of 27 studies published after 2014 comprising 120,895 subjects that found a moderate and robust association between problematic smartphone use and anxiety.[47] In July 2023, MDPI Healthcare published a systematic review and meta-analysis of 16 studies that established correlation coefficients of 0.31 and 0.39 between nomophobia and anxiety and nomophobia and smartphone addiction respectively.[48]
In September 2023, Frontiers in Public Health published a systematic review and meta-analysis of 37 studies comprising 36,013 subjects aged 14 to 24 years that found a positive and statistically significant association between problematic internet use and social anxiety,[49] while BJPsych Open published a systematic review of 140 studies published from 2000 through 2020 found that social media use for more than 3 hours per day and passive browsing was associated with increased anxiety.[50] In January 2024, the Journal of Computer-Mediated Communication published a meta-analysis of 141 studies comprising 145,394 subjects that found that active social media use was associated with greater symptoms of anxiety and passive social media use was associated with greater symptoms of social anxiety.[51] In February 2024, Addictive Behaviors published a systematic review and meta-analysis of 53 studies comprising 59,928 subjects that found that problematic social media use and social anxiety are highly and positively correlated,[52] while The Egyptian Journal of Neurology, Psychiatry and Neurosurgery published a systematic review of 15 studies researching associations between problematic social media use and anxiety in subjects from the Middle East and North Africa (including 4 studies with subjects exclusively between the ages of 12 and 19 years) that established that most studies found a significant association.[53]Comorbidity
SAD shows a high degree of
Anxiety disorders other than SAD are also very common in patients with SAD, in particular generalized anxiety disorder.[59][60] Avoidant personality disorder is likewise highly correlated with SAD, with comorbidity rates ranging from 25% to 89%.[55][61][62]
To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to
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.[67] 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.[68]
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
Growing up with overprotective and hypercritical parents has also been associated with social anxiety disorder.
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.[76]
Social experiences
A previous negative social experience can be a trigger to social phobia,
Cultural influences
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[90] while others have.[91] What does seem clear is that the socially anxious perceive their own social skills to be low.[92] 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'.[93] 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.[94]
Substance-induced
While
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.[97] 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.[98] 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.[99]
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.[100] Symptoms may temporarily worsen however, during alcohol withdrawal or benzodiazepine withdrawal.[100]
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.[101] 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").[102]
A secondary factor is
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"[106] can make social interaction more difficult and the anxiety worse in the long run.[102] This work has been influential in the development of cognitive behavioral therapy for social anxiety disorder, which has been shown to have efficacy.
Mechanisms
There are many studies investigating neural bases of social anxiety disorder.[108][109] Although the exact neural mechanisms have not been found yet, there is evidence relating social anxiety disorder to imbalance in some neurochemicals and hyperactivity in some brain areas.
Neurotransmitters
Sociability is closely tied to dopaminergic neurotransmission.[110] In a 2011 study, a direct relation between social status of volunteers and binding affinity of dopamine D2/3 receptors in the striatum was found.[111] Other research shows that the binding affinity of dopamine D2 receptors in the striatum of people with social anxiety is lower than in controls.[112] Some other research shows an abnormality in dopamine transporter density in the striatum of those with social anxiety.[113][114] However, some researchers have been unable to replicate previous findings of evidence of dopamine abnormality in social anxiety disorder.[115] Studies have shown high prevalence of social anxiety in Parkinson's disease and schizophrenia. In a recent study, social phobia was diagnosed in 50% of Parkinson's disease patients.[116] Other researchers have found social phobia symptoms in patients treated with dopamine antagonists like haloperidol, emphasizing the role of dopamine neurotransmission in social anxiety disorder.[117]
Some evidence points to the possibility that social anxiety disorder involves reduced serotonin receptor binding.[118] A recent study reports increased serotonin transporter binding in psychotropic medication-naive patients with generalized social anxiety disorder.[113] Although there is little evidence of abnormality in serotonin neurotransmission, the limited efficacy of medications which affect serotonin levels may indicate the role of this pathway. Paroxetine, sertraline and fluvoxamine are three SSRIs that have been approved by the FDA to treat social anxiety disorder. Some researchers believe that SSRIs decrease the activity of the amygdala.[108] There is also increasing focus on other candidate transmitters, e.g. norepinephrine and glutamate, which may be over-active in social anxiety disorder, and the inhibitory transmitter GABA, which may be under-active in the thalamus.[108][119]
Brain areas
The amygdala is part of the limbic system which is related to fear cognition and emotional learning. Individuals with social anxiety disorder have been found to have a hypersensitive amygdala; for example in relation to social threat cues (e.g. perceived negative evaluation by another person), angry or hostile faces, and while waiting to give a speech.[120] Recent research has also indicated that another area of the brain, the anterior cingulate cortex, which was already known to be involved in the experience of physical pain, also appears to be involved in the experience of 'social pain',[121] for example perceiving group exclusion.[122] Recent research also highlighted the potent role of the prefrontal cortex, especially its dorsolateral part, in the maintenance of cognitive biases involved in SAD.[123] A 2007 meta-analysis also found that individuals with social anxiety had hyperactivation in the amygdala and insula areas which are frequently associated with fear and negative emotional processing.[124]
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 micturition. Symptoms may progress to panic attacks.[8]
Standardized rating scales such as the
DSM-5 Diagnosis
DSM-5 defines Social Anxiety Disorder as a marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others.[130]
DSM-5 Diagnostic Criteria with Diagnostic Features:
- Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech). Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.
- The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection or offend others). When exposed to such social situations, the individual fears that they will be negatively evaluated. The individual is concerned that they will be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable. The individual fears that they will act or appear in a certain way or show anxiety symptoms, such as blushing, trembling, sweating, stumbling over one's words, or staring, that will be negatively evaluated by others.
- The social situations almost always provoke fear or anxiety. Thus, an individual who becomes anxious only occasionally in the social situation(s) would not be diagnosed with social anxiety disorder. Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
- The social situations are avoided. Alternatively, the situations are endured with intense fear or anxiety.
- The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context. The fear or anxiety is judged to be out of proportion to the actual risk of being negatively evaluated or to the consequences of such negative evaluation. Sometimes, the anxiety may not be judged to be excessive, because it is related to an actual danger (e.g., being bullied or tormented by others). However, individuals with social anxiety disorder often overestimate the negative consequences of social situations, and thus the judgment of being out of proportion is made by the clinician.
- The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more. This duration threshold helps distinguish the disorder from transient social fears that are common, particularly among children and in the community. However, the duration criterion should be used as a general guide, with allowance for some degree of flexibility.
- The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The fear, anxiety, and avoidance must interfere significantly with the individual's normal routine, occupational or academic functioning, or social activities or relationships, or must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. For example, an individual who is afraid to speak in public would not receive a diagnosis of social anxiety disorder if this activity is not routinely encountered on the job or in classroom work, and if the individual is not significantly distressed about it. However, if the individual avoids, or is passed over for, the job or education they really want because of social anxiety symptoms, criterion is met.
- The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., an addictive substance, a medication) or another medical condition.
- The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorphic disorder, or autism spectrum disorder.
- If another medical condition (e.g., Parkinson disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
If the fear is restricted to speaking or performing in public it is performance only social anxiety disorder.
Differential diagnosis
The DSM-IV criteria stated that an individual cannot receive a diagnosis of social anxiety disorder if their symptoms are better accounted for by one of the
Because of its close relationship and overlapping symptoms, treating people with social phobia may help understand the underlying connections to other mental disorders. Social anxiety disorder is often linked to
Prevention
Prevention of
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 only in those who are not interested in therapy.[4]: 191 [9] According to research studies, combining the use of CBT with escitalopram (a type of SSRI) in contrast to using CBT with a placebo reduced anticipatory speech-state anxiety and increased reductions of social anxiety symptoms, revealing the potential of combining various treatment methods.[138] Self-help based on principles of CBT is a second-line treatment.[4]: 191 [139][140]
There is some emerging evidence for the use of
Some studies have suggested social skills training (SST) can help with social anxiety.[143][144] Examples of social skills focused on during SST for social anxiety disorder include: initiating conversations, establishing friendships, interacting with members of the preferred sex, constructing a speech and assertiveness skills.[145] 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.[146]
There is some evidence that expressive therapies (e.g. painting, drawing or musical therapy) can be effective for treating social anxiety disorder in certain contexts. A 2019 study, for example, found that art therapy produced an "increase in subjective quality of life (both with large effects) and an improvement in accessibility of emotion regulation strategies" in adult women with anxiety.[147] Both VAGA and the American Art Therapy Association run specific workshops for social anxiety disorder.
Furthermore, error-related brain activity varies in accordance to factors that affect the motivational significance of behavioural performance, such as social contexts and personality traits, suggesting that understanding how individuals appraise the relevance of incentives in a given context is crucial for designing interventions to ameliorate or prevent maladaptive patterns of performance evaluation, particularly with regards to social anxiety disorder and substance abuse.[148]
Given the evidence that social anxiety disorder may predict subsequent development of other psychiatric disorders such as depression, early diagnosis and treatment is important.
Medications
SSRIs
Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are the first choice of medication for generalized social phobia but a second-line treatment.[4]: 191 Compared to older forms of medication, there is less risk of tolerability and drug dependency associated with SSRIs.[152]
Paroxetine and paroxetine CR, sertraline, escitalopram, venlafaxine XR and fluvoxamine CR (Luvox CR) are all approved for SAD and are all effective for it, especially paroxetine.[10] All SSRIs are somewhat effective for social anxiety except fluoxetine which was equivalent to placebo in all clinical trials.[153] Paroxetine was able to change personality and significantly increase extraversion.[154][155]
In a 1995
Citalopram also appears to be effective.[159]
General
In addition, studies show that more socially phobic patients treated with anti-depressant medication develop hypomania than non-phobic controls. The hypomania can be seen as the medication creating a new problem.[163][164]
Other drugs
Other prescription drugs are also used, if other methods are not effective. Before the introduction of SSRIs,
Certain anticonvulsant drugs such as gabapentin and pregabalin are effective in social anxiety disorder and may be a possible treatment alternative to benzodiazepines.[169][170][171][172] However there is concern regarding their off-label use due to the lack of strong scientific evidence for their efficacy and their proven side effects.[173]
Some people with a form of social phobia called performance phobia have been helped by
A novel treatment approach has recently been developed as a result of translational research. It has been shown that a combination of acute dosing of
Epidemiology
Country | Prevalence |
---|---|
United States | 2–7%[186] |
England | 0.4% (children)[187] |
Scotland | 1.8% (children)[187] |
Wales | 0.6%
(children)[187] |
Australia | 1–2.7%[188] |
Brazil | 4.7–7.9%[189] |
India | 12.8% (adolescents)[190] |
Iran | 0.8%[191] |
Israel | 4.5%[192] |
Nigeria | 9.4% (university students)[193] |
Sweden | 15.6% (university students)[194] |
Turkey | 9.6% (university students)[195] |
Poland | 7–9% (2002)[196] |
Taiwan | 7% children (2002~2008) |
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.[198] 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.[199]
When
The
The mean onset of social phobia is 10 to 13 years.
Terminology
It has also been referred to as anthropophobia,[211][212] meaning "fear of humans", from Greek: άνθρωπος, ánthropos, "human" and φόβος, phóbos, "fear". Other names have included interpersonal relation phobia.[211] A specific Japanese cultural form is known as taijin kyofusho.[177] There is also another cultural form of social phobia, Aymat zibur,[213] in the Ultra-Orthodox Jewish community which is mostly rooted in a fear of embarrassment in the performance of religious duties.
See also
- Avoidant Personality Disorder
- Alexithymia
- Agoraphobia
- Asociality
- Highly sensitive person
- Impostor syndrome
- Obsessive-compulsive disorder
- Scopophobia
- Selective mutism
- Social inhibition
- Social rejection
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Further reading
- Belzer, K. D.; McKee, M. B.; Liebowitz, M. R. (2005). "Social Anxiety Disorder: Current Perspectives on Diagnosis and Treatment". Primary Psychiatry. 12 (11): 40–53. Archived from the original on 2012-05-12. Retrieved 2006-06-21.
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- Berent, Jonathan; Lemley, Amy (1993). Beyond shyness: how to conquer social anxieties. New York, NY: Simon & Schuster. ISBN 0-671-74137-3.
- Boyle, Louise E. (2018). "The (un)habitual geographies of Social Anxiety Disorder". Social Science & Medicine. 231: 31–37. S2CID 1509802.
- Bruch, M. A. (1989). "Familial and developmental antecedents of social phobia: Issues and findings". Clinical Psychology Review. 9: 37–47. ISSN 0272-7358.
- ISBN 0-380-81033-6.
- Crozier, W. R., & Alden, L. E. (2001). International Handbook of Social Anxiety: Concepts, Research, and Interventions Relating to the Self and Shyness. New York: John Wiley & Sons, Ltd. ISBN 0-471-49129-2.
- Hales, R. E., & Yudofsky, S. C. (Eds.). (2003). Social phobia. In Textbook of Clinical Psychiatry (4th ed., pp. 572–580). Washington, D.C.: American Psychiatric Publishing.
- Marteinsdottir I.; Svensson A.; Svedberg M.; Anderberg U.; von Knorring L. (2007). "The role of life events in social phobia". Nordic Journal of Psychiatry. 61 (3): 207–212. S2CID 11620169.