Understanding Social Anxiety

social anxiety, anxiety and addiction, co-occurring mental health disorders, social anxiety and alcohol, social anxiety and drugs

Anxiety disorders are the most frequently diagnosed mental health conditions in the United States. About 18 percent of adults are diagnosed with anxiety in the U.S. each year. Next to specific phobias, social anxiety is the most common anxiety disorder in America, affecting 7 percent of the general population. What makes this condition so common, and how does it affect the people who have it?

What Is Social Anxiety Disorder?

Social anxiety disorder (SAD) is more than just being shy or uncomfortable in certain social situations. It is a disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM) that is defined by a specific set of associated symptoms. To be diagnosed with this condition, a person must have persistent fears of one or more social situations that involve exposure to unfamiliar people or possible social scrutiny. In addition, they must meet the following criteria:

  • Exposure to feared circumstances must provoke significant anxiety nearly every time.
  • The person either has to avoid these situations or endure them with intense distress.
  • The avoidance, anxiety, or distress must cause significant functional impairments.
  • These anxious reactions must be persistent, lasting six months or more.
  • The person must recognize that their fear is unreasonable or excessive.

What makes social anxiety different from shyness is the level of distress and impairment it causes. People with severe social anxiety might become completely socially isolated, refusing to even leave their homes. The condition can worsen to the point they are at risk of harm due to not being able to go outside to buy food or other necessities. Even in less extreme cases, SAD can prevent people from succeeding in school or at work and drive the development of any number of secondary conditions, including comorbid depression and substance use disorders.

Social Anxiety Disorder and Addiction

Research shows that having an anxiety disorder significantly increases the likelihood a person will develop a substance use disorder. As many as 20 percent of people who are in treatment for a substance use disorder have a comorbid anxiety disorder, and anxiety disorders precede the development of co-occurring substance use disorders nearly two thirds of the time.

There are many reasons for this connection. Many frequently abused substances counteract anxiety and lower social inhibition, providing people with SAD and other anxiety disorders temporary relief from their fears. In turn, this allows them to engage in social situations that would otherwise be too overwhelming. This social facilitation effect often leads to addiction.

When people feel like substance use is the only way to overcome their anxiety, they turn to it not just for relief from distress, but for reasons they see as practical. Substance use can become the means to getting themselves out of the door to a job interview or even a stressful, socially demanding job. Of course, this is practical only to a point—escalating substance use nearly always has a negative impact on work and relationships.

Another common reason that people with SAD often develop a co-occurring substance use disorder is the loneliness that comes with the condition. People with social anxiety want to socialize and be liked, but are so afraid of rejection, judgment, or humiliation that they avoid social situations. As a result, they can end up spending most of their time alone. Alcohol is well known for its ability to temporarily relieve loneliness, and most other substances can have this effect, too. Using substances to alleviate loneliness can lead to a vicious cycle in which people escalate their substance use and end up even more isolated.

Treatment for Social Anxiety Disorder

There are many behavioral changes people with social anxiety disorder can make to alleviate their symptoms. Aerobic exercise, yoga, meditation, and walks in nature can all lower anxiety levels, as can dietary changes like reducing sugar and caffeine intake. However, for people with severe social anxiety, professional psychiatric help is usually required. The two main ways that mental health professionals treat anxiety are medication and therapy.

Medications for Social Anxiety Disorder

Many medications have been developed for the treatment of anxiety, including sedatives and benzodiazepines. These are four of the most commonly prescribed benzodiazepines:

  • Alprazolam (Xanax)
  • Clonazepam (Klonopin)
  • Lorazepam (Ativan)
  • Diazepam (Valium)

These medications are well-known for their powerful sedative effect and are often requested by name. Unfortunately, they are also commonly abused and contraindicated for people with co-occurring substance use disorders. This can be discouraging for people with dually diagnosed disorders who genuinely want to recover from their anxiety. They can feel like the road to relief has been closed off to them.

It can help to understand that none of these medications cure anxiety. Though they can be an effective part of an anti-anxiety regimen, they only tamp down the symptoms of anxiety for a relatively short period of time. For many people, other medications actually work better for general improvement of the condition.

Selective serotonin reuptake inhibitors (SSRI) were originally developed in the 1980s for the treatment of depression. Since then, they have also been found to effectively treat anxiety disorders. These are five of the SSRIs most commonly used to treat anxiety:

  • Paroxetine (Paxil)
  • Citalopram (Celexa)
  • Escitalopram (Lexapro)
  • Sertraline (Zoloft)
  • Fluoxetine (Prozac)

These are all longer-acting than benzodiazepines and affect brain functioning more holistically. Other medications prescribed for anxiety include anticonvulsant medications like gabapentin (Neurontin) and pregabalin (Lyrica). Serotonin and norepinephrine reuptake inhibitors (SNRIs) like duloxetine (Cymbalta) and venlafaxine (Effexor), work in a similar way as SSRIs but are more effective for some people.

Therapy for Social Anxiety Disorder

Medication can help improve symptoms, but it does not address the underlying causes of social anxiety disorder. While differences in brain structure and function cause some people to have an anxious temperament, putting them at increased risk for anxiety disorders, there are usually also environmental or historic causes. These may include traumatic past events or the words or actions of parents, authority figures, and peers in childhood. Therapy can help get to the roots of these causes and promote lasting recovery.

Two common therapeutic interventions for social anxiety are cognitive behavioral therapy (CBT) and exposure therapy. A therapist who practices CBT helps people with SAD identify the cognitive distortions and irrational beliefs that drive their social anxiety, then learn new ways to think about themselves and their social potential. Therapists who practice CBT also help clients develop social skills to improve their confidence and ability to handle the social situations that make them anxious.

In exposure therapy, a therapist helps a person gradually confront their fears. Often, a clinician who utilizes this technique begins with having a person simply imagine being in the situation that makes them anxious. They may eventually start assigning “homework” in which a client engages in activities that make them feel mildly anxious, slowly progressing to facing the things that frighten them most.

An alternative to either of these approaches is acceptance and commitment therapy (ACT). It is a modified form of CBT replaces “correcting thoughts” with “accepting thoughts.” This method still focuses on promoting insight into the ways that thinking causes or intensifies psychiatric symptoms. However, instead of trying to change these thoughts, a person engaging in ACT learns to stop struggling with them and how to act independently from them.


Social anxiety disorder is a severe anxiety disorder that affects millions of Americans every year. It can arise from differences in temperament and brain function but is usually triggered by life experiences that made people feel humiliated or socially rejected. A common approach to treatment is to use medications, often SSRIs, to control symptoms and to use therapy to address and change the painful thinking and beliefs that maintain the disorder. People with social anxiety frequently turn to substances for help in overcoming their anxiety, but with the right treatment, they can recover from both anxiety and addiction.

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