Social anxiety – An NHS self help guide
The written version of this guide was Highly Commended at the British Medical Association Patient Information Awards 2018.
“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 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 affects both men and women. Most of us feel shy or anxious in social situations at some point. This can be much more serious for some people, however, who find that their relationships, career and life in general can be deeply affected by their problem.
Do I suffer from social anxiety?
In order to check whether you may be suffering from social anxiety make a note of any of the following 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:
- Heart racing and pounding.
- Chest feeling tight or painful.
- Tingling or numbness in toes and fingers.
- Stomach churning or butterflies.
- Dry mouth.
- Having to go to the toilet.
- Feeling jumpy or restless.
- Tense muscles.
- Breathing changes.
- Dizziness and feeling light headed.
What you feel/think
- You feel a strong sense of fear in social situations that won’t go away.
- You know that the fear is too much or unreasonable.
- You think you may act in a way that will be embarrassing in front of others.
- You believe that others are judging and thinking badly of you.
- You tell yourself “I must not look anxious”.
- You believe “If I get it wrong people won’t like me” or “If I show I’m nervous people will think I’m stupid”
- You think “I will make a fool of myself” or “I will look stupid”.
- You think “I’m boring” or “I’m strange”.
- You have a negative picture of yourself in your mind, which is how you fear other people see you, this may be flustered, foolish, uninteresting, weak, timid etc.
- Before you go into social situations you think that things will go badly.
- After you’ve been in a social situation you think “that was awful”, “I looked so stupid”, etc. You may go over these thoughts again and again.
What you do
- Sometimes you go into social situations that you find difficult but find this very distressing and become very anxious.
- You avoid going into social situations that you find difficult, even if this is inconvenient to you. For example, going out to buy sandwiches rather than having to go into the busy staff canteen.
- You avoid talking on the telephone sometimes not even answering it.
- You do things to help yourself when you can’t relax in social situations, such as: drinking a lot of alcohol; smoking more than usual; rehearsing what you are going to say; offering to help in social situations so that you can keep busy; sitting hiding in a corner; planning your exit; checking out the toilets and visiting frequently; avoiding eye contact; talking too much or too little.
If you recognise most of these thoughts, feelings and behaviours then you may have social anxiety.
What is 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 that they are being watched closely and that they want to come across well. At the same time they may fear that they are not as good as other people and are not ‘up to the mark’. They suffer symptoms of anxiety such as tension, rapid heartbeat and light-headedness when they are in social situations. They may blush or stammer or be unable to speak.
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 getting up and 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. 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 great inconvenience, loss of social life or even career prospects. 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 behaviours’ can include things like: not looking people in the eye so as not to draw attention to themselves, sitting on the outside of a group; staying close to someone they know; hiding visible signs of anxiety (such as wearing a jacket to avoid sweating or make-up to hide blushing); finding a task to look busy; asking lots of questions to keep focus on the other person or saying very little; using alcohol or recreational drugs; wearing sunglasses or a hat. The list is endless. You may recognise some of these in yourself and we will look at this more closely later. People may fear that they cannot control their anxiety in these social situations and that they will make a bad impression on others.
In summary – People who experience social anxiety fear that other people will think badly of them and often believe that they are not as good as others. This makes social situations very difficult or impossible with anxiety affecting the body, thoughts and behaviour.
What causes social anxiety?
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 have a huge effect 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. 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 generalised anxiety. As well as people diagnosed with autism or attention deficit hyperactivity disorder (ADHD). 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.
What keeps social anxiety going?
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:
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.
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 behaviours’ that stop them learning that they are doing fine. For example, not making eye contact.
As well as lots of negative thoughts about themselves, the person with social anxiety often holds an unpleasant image in their mind of how they look to others. When mixing with others the anxiety tends to make them focus on themselves more. They think of this image, feel anxious and believe that they look terrible to others. They rarely look to see how the other person is really responding to them. They make negative guesses about what the other person is thinking and therefore never challenge their negative, unpleasant image of themselves.
‘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 know I will go bright red when I speak”, “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.
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 too).
With all these negative thoughts going on before, during and after social situations, the feared symptoms unfortunately will almost always happen, for example, blushing, shaking, sweating, mind going blank. Therefore strengthening beliefs and increasing fear for future situations. 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.
In summary – social anxiety is linked to low self-esteem and continues because people hold long-term beliefs that they are ‘no good in social situations’. Although unlikely to be true, these beliefs are never challenged because of avoidance, ‘safety behaviours’ and self focusing when faced with social situations. A vicious cycle can develop which keeps the anxiety going.
How can I help myself to overcome social anxiety?
There are a number of ways you can begin to help yourself overcome social anxiety.
The approaches we suggest are:
- Understanding social anxiety;
- Understanding and reducing negative thoughts, beliefs and images;
- Reducing how much you focus on yourself;
- Becoming more comfortable with uncertainty;Tackling avoidance and safety behaviours;
- Tackling the physical symptoms of social anxiety;
- 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).
Understanding social anxiety
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 an actual 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 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.
How can I reduce my negative thoughts, beliefs and images?
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.
Negative automatic thought
“I don’t know what to say – people will think that I’m stupid”.
An image of self as small mousy creature.
Negative automatic thought
Everyone will look at me when I walk in and I will shake”.
An image of self shaking like a leaf and others smirking.
Negative automatic thought
“I will stammer and not find my words”.
An image of self flushed and sweating, look of pity on faces of others.
Negative automatic thought
“I sounded really pathetic when I asked a question”.
An image of self with high squeaky voice, others looking strong and calm.
It may help to think of 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?
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.
Am I fortune-telling? e.g. “I’m going to have an awful time, everyone will be laughing at me”.
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”.
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”.
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 think of two columns – one for your anxious thoughts and the other for a fairer more balanced thought.
I am trembling all over and my voice is shaky, people must think I am really odd.”
People would not have thought I was odd, and probably didn’t even notice me trembling. People always say I look and sound confident. I just expect people to be negative about me when there really isn’t any evidence”.
I just gabbled away all the time, I must look like an idiot.
No-one seemed bothered by this. People came over to talk, I can’t be that bad.
Write down some of your thoughts now and then 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.
How can I stop focusing on myself?
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.
Become more comfortable with uncertainty
We know that social anxiety can be triggered by feelings of uncertainty. People who have social anxiety would prefer to have 100% certainty about what will happen in social situations. When they are not 100% sure of something, they are likely to be more anxious about it, even when there is nothing to fear. It is helpful for anxious people to try to become more comfortable with and accept uncertainty as part of life. If you are a worrier then it is most likely that you are trying to achieve 100% certainty. But as 100% certainty is not often possible you have probably noticed this is not very successful. To become more comfortable with uncertainty try and change your behaviour to act ‘as if’ you are comfortable with it. For example try to reduce your tendency to ‘over plan’. Try to be more spontaneous. Let go of control of some events and allow others to plan things for you. It’s hard at first but will help you to reduce worry.
Try out some of these ideas if you can and see if they work for you.
How can I change my own behaviour?
Changing what you do is probably the most helpful way to overcome social anxiety. We have already talked of how avoidance and safety 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 behaviours.
- Not going to places where you will meet people.
- Asking other people to do things for you so you can avoid having to meet people.
- Avoiding talking to people you know.
- Not looking people in the eye.
- Saying little or letting someone else do the talking.
- Planning what to say or rehearsing words before speaking.
- Gripping objects tightly.
- Going to a safe place/corners.
- Looking away.
- Keeping very busy.
- Speaking quickly.
- Not speaking about self.
- Looking for a safe person to stick with
All of these types of avoidance and safety 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 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 avoided this by using safety 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.
John’s 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 when in a group, and not monitor his own symptoms and thoughts.
Step 6 – his most difficult – is to say more and speak slower in a group.
John will begin with step 1 (meeting a friend and going into the club) and gradually work towards step 6 (saying more and speaking more slowly in a group). He will gradually reduce his safety behaviours and make sure not to take on new ones!
Try this for yourself. Make up your own anxiety ladder.
How can I reduce my physical symptoms?
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 can 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.
To begin with, choose a time of day when you feel most relaxed. You can do this exercise sitting or standing with your eyes open or closed. Concentrate on your breathing for a few minutes, breathing slowly and calmly in through your nose and out through your lips. Place one hand on your chest and one on your stomach. Imagine you are filling a bottle from the bottom up, so the hand on your stomach moves first then your hand on your chest. You are filling and emptying your lungs with each breath. It may help to count in-two-three and out-two-three. Once you have mastered the controlled breathing try saying to yourself ‘calm’ as you breathe in and ‘relax’ as you breathe out. Controlled breathing can be used any time and anywhere to switch off the body’s stress response.
Deep muscle relaxation
It is helpful to listen to these instructions a few times first and eventually learn them by heart. Start off by sitting or lying somewhere warm and comfortable, where you won’t be disturbed. This relaxation exercise takes you through different muscle groups in the body, teaching you first to tense, then relax. Don’t tense your muscles too tightly. It should not be uncomfortable or painful. Each time you relax a group of muscles notice how they feel when they are relaxed. Don’t try too much to relax but just let go of the tension. Allow your muscles to relax as much as you can. Think about the difference in the way they feel when they are tense compared to when they are relaxed.
It is useful to stick to the same order, as you work through the muscle groups:
Breathing – Close your eyes and concentrate on your breathing for a few minutes, breathing slowly and calmly in two-three and out two-three. Say the word ‘calm’ to yourself as you breathe in and ‘relax’ as you breathe out.
Hands – Start with your hands. Clench one fist first and notice the tension in your hand and forearm. Hold it and study the tension for a minute…and then relax. You might feel a slight tingling; this is the relaxation beginning to develop.
Arms – Bend your elbows and tense your arms. Feel the tension especially in your upper arms. Remember, do this for a few seconds and then relax.
Neck – Press your head back and roll it gently from side to side. Feel how the tension moves. Then bring your head forward into a comfortable position.
Face – There are several muscles here, but it is enough to think about your forehead and jaw. First lower your eyebrows in a frown. Relax your forehead. You can also raise your eyebrows, and then relax. Now, clench your jaw, notice the difference when you relax.
Shoulders – This is where we hold a lot of tension. Shrug your shoulders up – then relax them. Notice the tension ease away as you drop your shoulders down. Circle your shoulders slowly and let go of any remaining tension.
Chest – Take a deep breath, hold it for a few seconds, notice the tension, then relax. Let your breathing return to normal.
Stomach –Tense your stomach muscles as tightly as you can and relax.
Buttocks – Squeeze your buttocks together and relax.
Legs – Straighten your legs and bend your feet towards your face then relax.
Feet – Point your toes to the floor, hold it for a few seconds, then wiggle your toes. Imagine you are letting go of the last bit of tension through your feet.
You may find it helpful to get a friend to listen to the instructions with you. There are also many free relaxation resources online or to buy. We have suggested some free resources in the written version of this guide.
To make best use of relaxation you need to:
- Practice daily.
- Start to use relaxation in everyday situations.
- Learn to relax without having to tense your muscles first, just focus on the muscles and let the tension go.
- Use some relaxation techniques to help in difficult situations, e.g. breathing slowly, dropping your shoulders.
- Practice in public situations (on the bus, in a queue etc).
- Use the deep, slow breathing, with the word calm to instantly relax where ever you are.
- Slow down.
- Don’t try too hard, just let it happen.
This is a different approach to managing stress. The goal of mindful breathing is calm, non-judging awareness, allowing thoughts and feelings to come and go without getting caught up in them. The aim is to concentrate only on the present moment, not the past and not the future. Much of our stress is linked to thoughts and feelings about the past and the future, so just being in the here and now can be very helpful. Follow these instructions:
- Sit comfortably, with your eyes closed or lowered and your back straight.
- Bring your attention to your breathing.
- Observe the natural rhythm of your breathing. Every time you breathe in, notice what it feels like. Where do you feel the breath? How does it feel? Each time you breathe out, notice your lungs deflate. Notice the sensations as your lungs fill and empty. Breathe in through your nose and out through your lips.
- Thoughts will come into your mind, and that’s okay, because that’s just what the mind does. You don’t need to dwell on them though. Just notice the thoughts, then bring your attention back to your breathing.
- You may notice sounds, physical feelings, and emotions, but again, just bring your attention back to your breathing.
- Don’t follow those thoughts or feelings, don’t judge yourself for having them, or analyse them in any way. It’s okay for the thoughts to be there. Just notice those thoughts, and let them drift on by bringing your attention back to your breathing.
Thoughts will enter your awareness, and your attention will follow them. No matter how many times this happens, just keep bringing your attention back to your breathing. The more you can practice this exercise the better you will get at being in the present moment. You can then start to be mindful in everyday situations, bringing your full focus of attention to whatever you are doing. Be it washing the dishes, having a shower or being out for a walk.
There are many useful websites with further information about mindfulness which are listed in the written version of this guide.
We know that people with social anxiety tend to focus on threatening information about social situations. This tends to increase anxiety. Studies have shown that it can be helpful to attend away from threatening information or thoughts.
If you take your mind off your symptoms you will find that the symptoms often disappear. Try to look around you. Study things in detail, registration numbers, what sort of shoes people are wearing, conversations.
Whilst controlled breathing, relaxation, mindful breathing and distraction techniques can help reduce anxiety, it is vitally important to realise that anxiety is not harmful or dangerous. Even if we did not use these techniques, nothing awful would happen. Anxiety cannot harm us, but it can be uncomfortable. These techniques can help reduce this discomfort.
You may have to accept a certain level of social anxiety, many people have some social anxiety. By focusing on identifying and getting on with your goals for life, based on values that are important to you social anxiety may become less troublesome in time.
Take things one step at a time
You will need to practise 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.
Summary – coping with social anxiety.
Understand all the parts of your anxiety, the physical symptoms, the thoughts and beliefs and your safety and avoidance behaviours.
Reduce negative thoughts by looking for and challenging unhelpful thinking. Use balanced thoughts to get a fairer picture of yourself. Do not spend time on self-critical review after social events.
Reduce self focus – try not to monitor your own physical symptoms and thoughts. Look to what is going on around you.
Reduce avoidance and safety behaviours by gradually facing situations you fear whilst reducing safety behaviours.
Tackle the physical symptoms of social anxiety using relaxation and other methods described.
Where can I get further help?
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.
A list of useful contacts, books and references are available in the written version of this guide.
Written by Dr Lesley Maunder and Lorna Cameron, Consultant Clinical Psychologists.
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.