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Date: 03/03/22- 14/03/22

Author Name: Udita Singh

Qualifications: B.A.(Hons), M.A. Applied Psychology (Specialisation in Clinical Psychology)

Designation: Consultant Psychologist, ACRO Mental Health Services.

Word count: 3,218 words

Reading time: 28 mins

Reviewed by: Aishwarya Krishna Priya, Sareem Athar and Mariyam Mohammed.

“Anxiety does not empty tomorrow of its sorrows, but only empties today of its strength.” - Charles Spurgeon (1)

What is social anxiety?

Social anxiety disorder is a type of anxiety disorder marked by a profound fear in social situations, causing severe distress and impaired ability to function in some parts of daily life (2,3). It is also known as social phobia, and it is one of the most common mental disorders (4).It can be so severe that the simplest interactions such as ordering at a restaurant, making eye contact, going to school or the office, dating, using a public restroom, eating in front of others, or answering calls can cause panic (5). This can lead to avoidance that can disrupt daily life and affect daily routine, school, work and the ability to develop a close relationship with people outside of the family (6). People with a social anxiety disorder may know that their fears are illogical and unreasonable, but they feel helpless to defeat them (7).

Let’s say it’s your first day at your new job (8). Maybe you are nervous, or jittery. You want to make a good impression (9,10). Those feelings are quite normal and may help you be more alert and careful (11). But after a few weeks, once you are used to the job, and you know your coworkers, that nervousness usually diminishes (12). But, for some people that initial anxiety is high, and it stays high over time (13). For those people, the fear of being judged negatively by new people might be so daunting that it affects their ability to do their job well (14). Even the idea of having to be somewhere where they may be scrutinised by others might make them not want the job in the first place. This describes social anxiety disorder (15,16).

Do you find it hard to socialise with other people? Do you feel overwhelmed at the thought of going to a social event? Are you extremely afraid of being judged by others? Are you very self-conscious in everyday social situations? Do you avoid meeting new people? These are all trademark signs of social anxiety (17,18).

It is the second most commonly diagnosed anxiety disorder following specific phobias (19). Furthermore, it can be very easy to confuse social anxiety with shyness since they share many of the same characteristics (20). While shyness is a personality trait, social anxiety is a mental illness. Social anxiety disorder can cause significant disruption of a person’s daily life (21,22).

How is social anxiety disorder diagnosed?

Social anxiety disorder is a disorder that involves fear, anxiety, and sometimes panic when social situations occur (23,24). So, the first criterion to diagnose the disorder is anxiety or fear in social situations where there is a possibility of exposure to scrutiny (25). This is one of the key characteristics of a social anxiety disorder (26). The emphasis is really on these social situations or on that somebody is afraid of being negatively evaluated by others (27).

The second criterion is the fear of acting in a way that will result in a negative evaluation (28). Somebody could be afraid that they might humiliate or embarrass themselves and this takes on a lot of different forms in terms of what specifically a person is worried will happen and what types of social situations can trigger that (29). This is not only related to public speaking but it can be all different types of public performance (30).

The next criterion is that social situations almost always result in anxiety or fear (31). If there is an individual who occasionally has an intense anxiety reaction to different social situations, they may not qualify for a diagnosis (32,33).

People with social anxiety make sure that social situations are avoided or they are endured with intense fear or anxiety (34). The next criterion is that the anxiety and fear are out of proportion to the actual threat (35). It is not unusual that individuals are worried or have anxiety about situations that are threatening (36). Most of the time, that reaction is out of proportion to what is going on, meaning, there may be some threat present, but it does not rise to the level that matches the anxiety, fear, or panic that we observe (37).

The next criterion is that the disturbance lasts longer than six months (38). It is quite persistent. Also, it must lead to clinically significant distress in social, occupational, and other areas (39). So there are instances where people have a social anxiety disorder but it only relates to performing (40):it could be work performance, public speaking, etc (41).

How prevalent is it?

Since it is one of the most common anxiety disorders, a social anxiety disorder can be found in around 7 to 13% of the population (42). It has been found that at least 1 in 8 people suffer or get diagnosed with social anxiety disorder in the course of their life (43,44). With regard to gender, it has been noted that there is no such difference in the occurrence according to gender; for both males and females, it occurs at a similar rate (45).

What is it like living with social anxiety?

Depending on the intensity of it, it can be pretty mild, and just lead to anxiety at parties, anxiety about speaking in front of groups, etc (46). But for some people, it leads to avoidance and it could be quite problematic if the person is unwilling to go out and socialise if they are unable to turn their camera on in a Zoom call, if they are unable to make or maintain friendships, then it can not only be debilitating, but it can also lead to other disorders like depressive disorders because of a lack of connection, a lack of positive reinforcement by getting out there and experiencing what life has to offer (47). So, it can be quite challenging (48, 49).

How does social anxiety differ from other anxiety disorders?

All anxiety disorders are maintained by “experiential avoidance” (50). So if there is anxiety, and the person is letting that anxiety control their behaviour, and lead them to avoid whatever situation they are fearful of, then that same process plays out (51). In social anxiety, what the person is avoiding has to do with socialising (52). The feared stimulus is a social environment or situation (53).

What are its symptoms?

1. You are always self-conscious: One aspect of social anxiety is the extreme fear of being judged (54,55). If you have social anxiety, you will constantly worry about the way you look or act and what others think of you (56). Your greatest fear is embarrassing yourself in front of others (57). A shy person, on the other hand, will only worry about being judged in certain situations, like in public speaking or when meeting someone new (58).

2. Your anxiety feels out of hand: there are times when it is normal to feel shy or nervous around other people, for example when you move to a new school or college or have to perform in front of an audience (59). But social anxiety is irrational and unwarranted (60). You may feel distressed about things as simple as making eye contact with someone, using public transportation or eating in front of other people (61).The fear is always there…(62).

3. It interferes with your performance: have you ever called in sick to work when your anxiety became too overwhelming? Or have you kept quiet when you were having trouble in class? Social anxiety can impact your performance in many ways (63,64). With the constant fear of people’s judgement, you may even be afraid to do well to avoid drawing attention (65). You don’t pitch ideas in meetings, raise your hand in class, or join clubs because of how much anxiety it creates (66).

4. It affects your relationships: While it is hard to make friends when you are shy, it can feel almost impossible when you have social anxiety (67). For a shy person, it is usually about breaking the ice and going through the initial awkwardness of meeting each other (68). But having social anxiety can complicate your relationships (69,70). You feel tense and uneasy around people, no matter how close you are or how long you have known them (71).

5. It does not go away with familiarity: it is normal to feel shy at the beginning of a new relationship, but as you get to know each other, the tension will start to subside (72). This is not the case if you have social anxiety (73). Instead, you always experience fear, distress, and embarrassment whenever you are around other people(74). It doesn’t matter if it is your parents, siblings, or your best friend; you always feel uneasy and stressed unless you are alone (75).

6. You overanalyse everything: Social anxiety can make you obsess over your social interactions, body language, and tone of voice; to see if they mean what they are saying or not (77).

7. You avoid social situations: Are you often absent or very late to social gatherings? It is a serious matter if your social anxiety leads you to avoid social situations altogether (78,79). You decline invitations, refuse to speak in front of others, and would rather sit in the corner to avoid being noticed and mingle with anyone else (80).

8.You have physical symptoms: do you feel nausea, dizziness or chest palpitations when you are in social situations? (81) Just like most anxiety disorders, social anxiety is often accompanied by physical symptoms (82). Some common ones are sweaty palms, shortness of breath, lightheadedness and trembling (83). While these are also the same signs of someone having a panic attack, you will be able to tell the difference if you only show these symptoms when anticipating or being out in a social setting (84,85).

What are the signs and symptoms shown by a child who has a social anxiety disorder?

Children who have social anxiety may be uncomfortable or awkward with peers, they might have difficulty joining group activities and they might protest against becoming a part of group activities (86). They may also have trouble with separation from their caregiver or parents in the morning (87).They may have trouble warming up in a group, so they may have difficulty joining a playgroup of kids (88). It may take the influence of teachers or other adults to draw them towards the playgroups and help them interact with other kids (89).

What are the causes?

The exact cause of the disorder is unknown (90). Several pathways can lead to the development of social anxiety disorder (91). Current literature also points out that it is likely that an individual suffering from it has been affected by a combination of these factors (92). But this is not the case for everyone (93).Even though researchers have not been able to associate specific genes with social anxiety, data points towards familial links (94). The children of socially anxious parents are more likely to suffer from it than the children of non-socially anxious people (95). Thus, it tends to run in families, and therefore, it can be concluded that there seems to be a moderate genetic component to it (96).

One way through which our genes influence our reactions to certain stimuli is temperament (97).When thinking of temperament, we usually picture uncontrollable outbursts of anger. But in the case of social anxiety disorder, it is a different type of temperament playing a causal role for many people (98). In comparison to most individuals who can engage with new people and situations more or less easily, this subgroup displays rather precautious and avoidant behaviour and tends to react with increased sensitivity when faced with unfamiliar stimuli (100,101).

There is an increased risk of developing the disorder for people who exhibit a stable childhood temperament of behavioural inhibition (102). Another factor that influences the development of social anxiety is the attachment style of a person (103). In a famous study conducted by Mary Ainsworth, a young child and her primary caregiver were brought to a lab, and they were separated for a short period of time, and they have reunited again (104,105). Of special interest is the behaviour of the child in this process (106). A securely attached child will display distress on separation from his or her mother but calms down relatively easily when reunited with her (107,108).

While about 60% of people account for this group, three types of insecure attachment styles have been observed: the insecure ambivalent style, the anxious-avoidant type, and the disorganized type (109). An insecure attachment style has been found to increase the chances of developing social anxiety disorder (110,111).

Many people suffering from the disorder report having been raised by parents that are overprotective, controlling, insensitive, rejecting, and emotionally distant (112). Therefore, a controlling and rejecting parenting style is believed to be another predisposition for the development of social anxiety (113). Parents of people suffering from the disorder may also overemphasize the opinions of others, socially isolate their offspring when they are children or use shame as a disciplinary procedure (114). Many people suffering from social anxiety can recall an experience that seemed to cause the onset of the disorder in their lives or which worsened their symptoms drastically, such as struggling when reading out loud in front of the class and being laughed at as a result (115). In a survey conducted in 1985, 58% of people suffering from social anxiety reported a traumatic experience being responsible for the outbreak of their problem (116). Therefore, it could be concluded that direct conditioning through traumatic experiences accounts for another possible cause (117).

Experiments with non-human primates have demonstrated the powerful impact of observational learning of fear responses, which leads to speculations about the causation of social fears by observing another human being experiencing a traumatic social event; especially for individuals who have socially anxious parents, this might be a relevant cause. (118,119).

Another way children can acquire a fearful attitude from their parents is by observation and interpretation of their parents’ verbal and non-verbal behaviour (120). It has been speculated that this also accounts for socially fearful behaviour as children witness their parents being anxious around others or avoiding certain social situations (121). Thus, the child learns to be socially anxious by “information transfer” (122,123).

Negative life events and stressors, especially in childhood, also seem to be able to set the stage for the development of social anxiety disorder (124). These include moving various times during childhood, being sexually abused, separation or divorce of parents, child illness, psychopathology of a parent, and family conflict (125). The disorder seems to be associated with poor social performance, although many people suffering from social anxiety do not seem to lack social skills (126).

A vicious cycle was proposed, in which the sufferers show poor social performance, which results in negative social experiences (127). These experiences lead to more anxiety, which in turn leads to avoidance of social situations (128). By avoiding social situations, they are less likely to gain better social skills, which reinitiates the cycle by letting them perform poorly in future social interactions (129,130).

How does culture play a role in developing social anxiety?

While in Western countries, such as Germany, France, and the United States, being socially reserved and shy is seen as a negative personality trait (131). In East Asian countries such as Japan and China, people show much more positive attitudes towards these features (132). This of course, not only causes big differences in the suffering the disorder provokes, but also leads to less prevalence in East Asian countries and higher prevalence in Western culture where the disorder has a more negative impact on the quality of life (133).

What happens in the brain when someone is socially anxious?

When social anxiety happens, the brain starts to get hardwired to expect the worst of every situation, which leads to more negative views of others and very low self-esteem (134).

The amygdala is often associated with social anxiety (135). It is the brain’s primary fear-processing centre (136).This means that if you are feeling afraid of something, your amygdala is probably the reason. It also actively reacts to facial expressions (137).

Hippocampus is a structure that is associated with memory. It provides context to situations based on similar experiences that have happened in the past (138).

The prefrontal cortex is a structure located in the frontal lobe and includes three different sections: a control centre for decision making and attention, one section for emotional responses, and the other for social behaviour. The prefrontal cortex allows us to think and behave rationally (139).

These brain structures look very different in people with social anxiety disorder. The amygdala grows in density and experiences more activity and blood flow in people with social anxiety (140). Contrary to this, the hippocampus experiences a decrease in density and activity. The activity in the prefrontal cortex is dramatically reduced in the brain in someone with social anxiety (141).

When someone without social anxiety sees an angry face, their amygdala will recognize that they need to be cautious, but people with social anxiety will experience an out-of-proportion negative reaction, not only with angry faces but with neutral ones as well (142). Remember, that the hippocampus uses context from the past to evaluate situations (143). Individuals with social anxiety have more trouble putting social situations into context. They will be less able to remember positive encounters with others and more likely to remember unpleasant ones. Because of this, the pattern of feeling scared about social encounters will continue (144).

The prefrontal cortex of socially anxious individuals has more difficulty deciding whether a particular social situation should or should not be feared, and instead, perceives all situations as threats if they are in the social context (145). This leads to a heightened level of fear and avoidance (146,147)

What can be done?

Various psychological treatments can be adapted to treat social anxiety disorder (148). These include cognitive behavioural therapy (CBT) and CBT focuses on working on the clients’ various beliefs that contribute to them developing social anxiety (149). Along with beliefs, cognitive behavioural therapists also work on clients’ past situations or events that have contributed to them developing social anxiety over the years (150,151).

Furthermore, pharmacological treatments could also be chosen such as prescribing SSRIs (selective serotonin reuptake inhibitors) (152). But when it comes to having social anxiety related to specific performance tasks like public speaking, then different medications could be prescribed by a psychiatrist (153).But more or less, psychotherapy like CBT can help clients to deal with the psychological aspects that result in the development of social anxiety. (154,155).

To summarise, social anxiety is the fear of being humiliated, embarrassed, or rejected, in some kind of a social situation, whether it is on the phone, on a zoom call, or in person with other people (156). Everybody experiences social anxiety to some degree, but social anxiety disorder occurs when there is some kind of intense impairment or distress that occurs in these scenarios(157). Various factors could contribute to the development of social anxiety such as genetics, environmental factors, attachment style of the child, temperament, cultural differences, etc (158,159). With the help of talk therapy such as CBT and medications, social anxiety can be effectively treated (160).

If you or anyone you know are showing signs and symptoms of having social anxiety, please do not hesitate and contact a mental health professional to seek professional help to combat social anxiety. Remember…you are not alone!

Audio-visual credits:

  1. Photo by Priscilla Du Preez on Unsplash

  2. Photo by Alexander Krivitskiy on Unsplash

  3. Photo by Baptista Ime James on Unsplash

  4. Photo by Will Kell on Unsplash

  5. Photo by Wes Hicks on Unsplash

  6. Photo by Compare Fibre on Unsplash

  7. Photo by Steven Lasry on Unsplash

  8. Photo by Mika Baumeister on Unsplash

  9. Photo by Wan San Yip on Unsplash

  10. Photo by Kevin Lee on Unsplash

  11. Photo by Ryan Fields on Unsplash

  12. Photo by Sarah Medina on Unsplash

  13. Photo by Jordan Whitt on Unsplash

  14. Photo by Kelli McClintock on Unsplash

  15. Photo by Lynda Hinton on Unsplash


1. Parade. 101 Anxiety Quotes to Help You Get Through and Lift Your Spirits [Internet]. Parade: Entertainment, Recipes, Health, Life, Holidays. 2020. Available from:

2. Mayo Clinic. Social anxiety disorder (social phobia) - Symptoms and causes [Internet]. Mayo Clinic. Mayo Clinic; 2017. Available from:

3. Social Anxiety Disorder [Internet]. Anxiety Canada. Available from:

4. Coping Strategies That Actually Make Anxiety Worse [Internet]. Verywell Mind. 2019. Available from:

5. Social Anxiety Disorder: Causes, Symptoms & Diagnosis [Internet]. Healthline. 2012. Available from:

6. How Can I Manage My Social Anxiety at Work? [Internet]. Verywell Mind. [cited 2022 Mar 12]. Available from: people

7. Social Anxiety Disorder | Anxiety and Depression Association of America, ADAA [Internet]. Available from: anxiety%20disorder%20 affects%20 approximately

8. The Surprising Similarities Between Shyness and Social Anxiety [Internet]. Verywell Mind. 2019. Available from:

9. Shaw G. Is social anxiety disorder (SAD) -- also called social phobia -- just another name for being really shy? [Internet]. WebMD. Available from:

10. Digital Communications Division (DCD). What are the five major types of anxiety disorders? [Internet]. 2015. Available from:

11. Social Phobia - Psychiatric Disorders [Internet]. MSD Manual Professional Edition. [cited 2022 Mar 12]. Available from:

12. OsórioF de L, CrippaJAS, Hallak JEC, Loureiro SR. Social Anxiety Disorder, Fear of Public Speaking, and the use of Assessment Instruments [Internet]. IntechOpen; 2011 [cited 2022 Mar 12]. Available from:

13. Melinda. [Internet]. 2019. Available from:

14. Substance Abuse and Mental Health Services Administration. Table 16, DSM-IV to DSM-5 Social Phobia/Social Anxiety Disorder Comparison [Internet]. Substance Abuse and Mental Health Services Administration (US); 2016. Available from:

15. Social Anxiety Disorder (Social Phobia) DSM-5 300.23 (F40.10) - Therapedia [Internet]. 2014. Available from:

16. Social Anxiety Disorder Symptoms and Progression [Internet]. Verywell Mind. 2019. Available from:

17. What is Social Anxiety Disorder? [Internet]. Anxiety Canada. Available from:

18. Prevalence of Social Anxiety Disorder (Social Phobia) [Internet]. Andrew Kukes Foundation for Social Anxiety. Available from:

19. How Anxiety Affects Men and Women Differently [Internet]. Available from:

20. High-Functioning Social Anxiety [Internet]. Bridges to Recovery. [cited 2022 Mar 12]. Available from: symptoms%20of%20some%20 with

21. What is it like to live with Social Anxiety? | Social Anxiety Institute [Internet]. [cited 2022 Mar 12]. Available from: socially%20 anxious%20 person%20can

22. This is What it’s Like to Have Social Anxiety [Internet]. Healthline. 2017. Available from:

23. How GAD and Social Anxiety Disorder Differ [Internet]. Verywell Mind. Available from:

24. National Institute of Mental Health. NIMH» Social Anxiety Disorder: More than Just Shyness [Internet]. 2021. Available from:

25. Social Phobia (for Teens) - KidsHealth [Internet]. 2018. Available from:

26. Social anxiety disorder: More than just shyness. (n.d.). Retrieved March 3, 2023, from National Institute of Mental Health (NIMH) website:

27. Better Health Channel. Social phobia [Internet]. 2012. Available from:

28. What It’s Like to Be an Employee With Social Anxiety Disorder [Internet]. Verywell Mind.Available from:

29. Social Anxiety and Relationships [Internet]. Bridges to Recovery. Available from:

3‌0. Dr. Jay Saul [Internet]. Available from:

31. NHS. Social anxiety (social phobia) [Internet]. 2021. Available from:

32. Anxiety and Depression Association of America. Social Anxiety Disorder | Anxiety and Depression Association of America, ADAA [Internet]. 2000. Available from:

33. Social Anxiety In Kids: Help Them Cope With Symptoms [Internet]. - Mental Health Treatment Resource Since 1996. 2021 [cited 2022 Mar 13]. Available from: anxiety%20disorder

34. Understanding the Causes of Social Anxiety Disorder [Internet]. Verywell Mind. 2019. Available from:

35. Beyond Blue. What causes anxiety [Internet]. beyondblue; 2019. Available from:

36. McCarty K. The relationship between attachment and social anxiety, focusing on self-esteem and locus of control as possible mediators. uhrahertsacuk [Internet]. 2005; Available from: anxiety%20 may%20be%20 conceptualised

37. The link between social anxiety disorder and attachment theory [Internet]. Camino Recovery Spain. 2021. Available from:

38. Brumariu LE, Kerns KA. Mother–child attachment and social anxiety symptoms in middle childhood. Journal of Applied Developmental Psychology [Internet]. 2008 Sep;29(5):393–402. Available from:

39. Parenting Styles and Social Anxiety among Adolescents - ProQuest [Internet]. [cited 2022 Mar 14]. Available from:

40. National Collaborating Centre for Mental Health (UK). (2013). Social anxiety disorder. British Psychological Society

41. Eslinger, P. J., Anders, S., Ballarini, T., Boutros, S., Krach, S., Mayer, A. V., Moll, J., Newton, T. L., Schroeter, M. L., de Oliveira-Souza, R., Raber, J., Sullivan, G. B., Swain, J. E., Lowe, L., & Zahn, R. (2021). The neuroscience of social feelings: mechanisms of adaptive social functioning. Neuroscience and Biobehavioral Reviews, 128, 592–620.

42. Percy, R., Creswell, C., Garner, M., O’Brien, D., & Murray, L. (2016). Parents’ verbal communication and childhood anxiety: A systematic review. Clinical Child and Family Psychology Review, 19(1), 55–75.

43. Olson, C. M. (2021). Familial factors in the development of social anxiety disorder. Journal of Psychosocial Nursing and Mental Health Services, 59(7), 23–34.

44. Garcia, K. M., Carlton, C. N., & Richey, J. A. (2021). Parenting characteristics among adults with social anxiety and their influence on social anxiety development in children: A brief integrative review. Frontiers in Psychiatry, 12, 614318.

45. Okawa, S., Arai, H., Sasagawa, S., Ishikawa, S.-I., Norberg, M. M., Schmidt, N. B., Kwon, J.-H., Rapee, R. M., & Shimizu, E. (2021). A cross-cultural comparison of the bivalent fear of evaluation model for social anxiety. Journal of Behavioral and Cognitive Therapy, 31(3), 205–213.

46. Mobbs, D., Adolphs, R., Fanselow, M. S., Barrett, L. F., LeDoux, J. E., Ressler, K., Tye, K. M., & Neuroscience, N. (By Dean Mobbs, Ralph Adolphs, Michael S. Fanselow, Lisa Feldman Barrett, Joseph E. LeDoux, Kerry Ressler, Kay M. Tye, Nature Neuroscience   October 10 2019). On the nature of fear.ScientificAmerican.

47. Tyng, C. M., Amin, H. U., Saad, M. N. M., & Malik, A. S. (2017). The influences of emotion on learning and memory. Frontiers in Psychology, 8, 1454.

48. Choy, O., Raine, A., & Hamilton, R. H. (2018). Stimulation of the prefrontal cortex reduces intentions to commit aggression: A randomised, double-blind, placebo-controlled, stratified, parallel-group trial. The Journal of Neuroscience: The Official Journal of the Society for Neuroscience, 38(29), 6505–6512.

49. Freitas-Ferrari, M. C., Hallak, J. E. C., Trzesniak, C., Filho, A. S., Machado-de-Sousa, J. P., Chagas, M. H. N., Nardi, A. E., & Crippa, J. A. S. (2010). Neuroimaging in social anxiety disorder: A systematic review of the literature. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 34(4), 565–580.

50. Kikutani, M. (2018). Influence of social anxiety on recognition memory for happy and angry faces: Comparison between own- and other-race faces. Quarterly Journal of Experimental Psychology (2006), 71(4), 870–878.

51. LaMarco, N. (2022, September 6). How social anxiety affects the brain. Retrieved March 3, 2023, from Psych Central website:

52. Fenn, K., & Byrne, M. (2013). The key principles of cognitive behavioural therapy. InnovAiT Education and Inspiration for General Practice, 6(9), 579–585. doi:10.1177/1755738012471029

53. Shaywitz, J. (2011). Medication treatments for social anxiety disorder. Focus (American Psychiatric Publishing), 9(3), 273–277. doi:10.1176/foc.9.3.foc273

54. Muzina, D. J., & El-Sayegh, S. (2001). Recognizing and treating social anxiety disorder. Cleveland Clinic Journal of Medicine, 68(7), 649–657. doi:10.3949/ccjm.68.7.649

55. Stein MB, Stein DJ. Social anxiety disorder. Lancet [Internet]. 2008;371(9618):1115–25. Available from:

56. Turk CL, Heimberg RG, Magee L. Social anxiety disorder. Clinical handbook of psychological disorders: A step-by-step treatment manual, 4th ed [Internet]. 2008;4:123–63. Available from:

57. Rodebaugh TL, Holaway RM, Heimberg RG. The treatment of social anxiety disorder. Clin Psychol Rev [Internet]. 2004;24(7):883–908. Available from:

58. Morrison AS, Heimberg RG. Social anxiety and social anxiety disorder. Annu Rev Clin Psychol [Internet]. 2013;9(1):249–74. Available from:

59. Mennin DS, Fresco DM, Heimberg RG, Schneier FR, Davies SO, Liebowitz MR. Screening for social anxiety disorder in the clinical setting: using the Liebowitz Social Anxiety Scale. J Anxiety Disord [Internet]. 2002;16(6):661–73. Available from:

60. Rytwinski NK, Fresco DM, Heimberg RG, Coles ME, Liebowitz MR, Cissell et al. Screening for social anxiety disorder with the self-report version of the Liebowitz Social Anxiety Scale. Depress Anxiety [Internet]. 2009;26(1):34–8. Available from:

61. Turk CL, Heimberg RG, Luterek JA, Mennin DS, Fresco DM. Emotion dysregulation in generalised anxiety disorder: A comparison with social anxiety disorder. Cognit Ther Res [Internet]. 2005;29(1):89–106. Available from:

62. Hofmann SG. Cognitive factors that maintain social anxiety disorder: a comprehensive model and its treatment implications. Cogn Behav Ther [Internet]. 2007;36(4):193–209. Available from:

63. Aderka IM, Hofmann SG, Nickerson A, Hermesh H, Gilboa-Schechtman E, Marom S. Functional impairment in social anxiety disorder. J Anxiety Disord [Internet]. 2012;26(3):393–400. Available from:

64. Weinstock LS. Gender differences in the presentation and management of social anxiety disorder. J Clin Psychiatry [Internet]. 1999 [cited 2023 May 12];60 Suppl 9:9–13. Available from:

65. Spence SH, Rapee RM. The ethiology of social anxiety disorder: An evidence-based model. Behav Res Ther [Internet]. 2016;86:50–67. Available from:

66. Katzelnick DJ, Kobak KA, DeLeire T, Henk HJ, Greist JH, Davidson JR, et al. Impact of generalised social anxiety disorder in managed care. Am J Psychiatry [Internet]. 2001;158(12):1999–2007. Available from:

67. Heimberg RG, Brozovich FA, Rapee RM. A cognitive-behavioural model of social anxiety disorder. In: Hofmann SG, DiBartolo PM, editors. Social Anxiety. San Diego, CA: Elsevier; 2014. p. 705–28.

68. Mathew SJ, Coplan JD, Gorman JM. Neurobiological mechanisms of social anxiety disorder. Am J Psychiatry [Internet]. 2001;158(10):1558–67. Available from:

69. Kashdan TB, Herbert JD. Clin Child Fam Psychol Rev [Internet]. 2001;4(1):37–61. Available from:

70. Keller MB. The lifelong course of social anxiety disorder: a clinical perspective. Acta Psychiatr Scand Suppl [Internet]. 2003;(417):85–94. Available from:

71. ADAA. Social Anxiety Disorder. February 13,2018 Available at:

72. [cited 2023 May 13]. Available from:

73. How to be less shy (it’s easier than you think!) [Internet]. Healthline. 2021 [cited 2023 May 13]. Available from:

74. Rodriguez C. Overcoming social anxiety and shyness: 8 tips to start [Internet]. Psych Central. 2015 [cited 2023 May 13]. Available from:

75. Melinda Smith MA, Segal J. Social anxiety disorder - [cited 2023 May 13]; Available from:

76. Dawn Potter P. Need help overcoming social anxiety? 6 tips from an expert [Internet]. Cleveland Clinic. 2021 [cited 2023 May 13]. Available from:

77. Types of social anxiety [Internet]. Conquer Social Anxiety. 2019 [cited 2023 May 13]. Available from:

78. National Collaborating Centre for Mental Health (UK). Social anxiety disorder. Leicester, England: British Psychological Society; 2013.

79. [cited 2023 May 13]. Available from:

80. [cited 2023 May 13]. Available from:

81. Physician AG. Social anxiety disorder (social phobia)- causes, symptoms and treatment [Internet]. Apollo Hospitals Blog. Apollo; 2021 [cited 2023 May 13]. Available from:

82. Overview | Social anxiety disorder: recognition, assessment and treatment | Guidance | NICE. [cited 2023 May 13]; Available from:

83. Social anxiety in children [Internet]. Raising Children Network. 2022 [cited 2023 May 13]. Available from:

84. Bennington-Castro J, Gillihan's. What is social anxiety disorder? Symptoms, causes, diagnosis, treatment, and prevention [Internet]. [cited 2023 May 13]. Available from:

85. Social anxiety disorder (social phobia). In: Integrative CBT for Anxiety Disorders. Chichester, UK: John Wiley & Sons, Ltd; 2015. p. 54–78.

86. [cited 2023 May 13]. Available from:

87. Cuncic A. Signs that you may have social anxiety disorder [Internet]. Verywell Mind. 2018 [cited 2023 May 13]. Available from:

88. [cited 2023 May 13]. Available from:

89. Social phobia [Internet]. [cited 2023 May 13]. Available from:

90. Walter HJ, Bukstein OG, Abright AR, Keable H, Ramtekkar U, Ripperger-Suhler J, et al. Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry [Internet]. 2020 [cited 2023 May 13];59(10):1107–24. Available from:

91. Anxiety disorders [Internet]. National Institute of Mental Health (NIMH). [cited 2023 May 13]. Available from:

92. Hofmann SG, Gutner CA, Fang A. Social Anxiety Disorder ☆. In: Reference Module in Neuroscience and Biobehavioral Psychology. Elsevier; 2017.

93. Healthdirect Australia. Social anxiety disorder. 2022 [cited 2023 May 13]; Available from:

94. Bögels SM, Zigterman D. J Abnorm Child Psychol [Internet]. 2000;28(2):205–11. Available from:

95. Stein DJ, Ipser JC, Balkom AJ. Pharmacotherapy for social phobia. Cochrane Database Syst Rev [Internet]. 2004 [cited 2023 May 13];(4):CD001206. Available from:

96. Mennin DS, McLaughlin KA, Flanagan TJ. Emotion regulation deficits in generalised anxiety disorder, social anxiety disorder, and their co-occurrence. J Anxiety Disord [Internet]. 2009;23(7):866–71. Available from:

97. Blanco C, Schneier FR, Schmidt A, Blanco-Jerez C-R, Marshall RD, Sánchez-Lacay A, et al. Pharmacological treatment of social anxiety disorder: a meta-analysis: Research Article: Meta-Analysis of Social Anxiety Disorder. Depress Anxiety [Internet]. 2003;18(1):29–40. Available from:

98. Moutier CY, Stein MB. The history, epidemiology, and differential diagnosis of social anxiety disorder. J Clin Psychiatry [Internet]. 1999 [cited 2023 May 13];60 Suppl 9:4–8. Available from:

99. Schmidt NB, Richey JA, Buckner JD, Timpano KR. Attention training for generalised social anxiety disorder. J Abnorm Psychol [Internet]. 2009;118(1):5–14. Available from:

100. Aarturk C, Cuijpers P, van Straten A, de Graaf R. Psychological treatment of social anxiety disorder: a meta-analysis. Psychol Med [Internet]. 2009 [cited 2023 May 13];39(2):241–54. Available from:

101. Social anxiety disorder: More than just shyness [Internet]. National Institute of Mental Health (NIMH). [cited 2023 May 13]. Available from:

102. Elizabeth J, King N, Ollendick TH, Gullone E, Tonge B, Watson S, et al. Social anxiety disorder in children and youth: A research update on aetiological factors. Couns Psychol Q [Internet]. 2006;19(2):151–63. Available from:

103. Keles B, McCrae N, Grealish A. A systematic review: the influence of social media on depression, anxiety and psychological distress in adolescents. Int J Adolesc Youth [Internet]. 2020;25(1):79–93. Available from:

104. Rozga A, Hesse E, Main M, Duschinsky R, Beckwith L, Sigman M. A short-term longitudinal study of correlates and sequelae of attachment security in autism. Attach Hum Dev [Internet]. 2018;20(2):160–80. Available from:

105. Rozga A, Hesse E, Main M, Duschinsky R, Beckwith L, Sigman M. A short-term longitudinal study of correlates and sequelae of attachment security in autism. Attach Hum Dev [Internet]. 2018;20(2):160–80. Available from:

106. Quaye AA, Coyne I, Söderbäck M, Hallström IK. Children’s active participation in decision-making processes during hospitalisation: An observational study. J Clin Nurs [Internet]. 2019 [cited 2023 Jun 6];28(23–24):4525–37. Available from:

107. Riggs SA. Childhood emotional abuse and the attachment system across the life cycle: What theory and research tell us. J Aggress Maltreat Trauma [Internet]. 2010;19(1):5–51. Available from:

108. Riggs SA. Childhood emotional abuse and the attachment system across the life cycle: What theory and research tell us. J Aggress Maltreat Trauma [Internet]. 2010;19(1):5–51. Available from:

109. Schmidt FMD, Fiorini G, da Costa AA, Brenner EB, Bittencourt LZ, Ramires VRR. Association of attachment and reflective function with baseline symptoms in child and adolescent psychodynamic psychotherapy. J Infant Child Adolesc Psychother [Internet]. 2022;21(3):239–51. Available from:

110. Newman L, Sivaratnam C, Komiti A. Attachment and early brain development – neuroprotective interventions in infant–caregiver therapy. Transl Dev Psychiatry [Internet]. 2015;3(1):28647. Available from:

111. Newman L, Sivaratnam C, Komiti A. Attachment and early brain development – neuroprotective interventions in infant–caregiver therapy. Transl Dev Psychiatry [Internet]. 2015;3(1):28647. Available from:

112. Sahithya BR, Manohari SM, Vijaya R. Parenting styles and its impact on children – a cross cultural review with a focus on India. Ment Health Relig Cult [Internet]. 2019;22(4):357–83. Available from:

113. Yaffe Y. A narrative review of the relationship between parenting and anxiety disorders in children and adolescents. Int J Adolesc Youth [Internet]. 2021;26(1):449–59. Available from:

114. Bessell S. Rethinking child poverty. J Human Dev Capabil [Internet]. 2022;23(4):539–61. Available from:

115. 11th international congress on psychopharmacology & 7th international symposium on child and adolescent psychopharmacology. Psyc. Clin Psychopharmacol [Internet]. 2019;29(sup1):129–263. Available from:

116. Hyman S. Fear and anxiety: The science of mental health [Internet]. 1st Edition. Hyman SE, editor. London, England: Routledge; 2013 [cited 2023 Jun 6]. Available from:*1x1jcja*_ga*ODgwNTAwMjgwLjE2ODU5NDkyNDg.*_ga_0HYE8YG0M6*MTY4NjA3MTcwOS40LjEuMTY4NjA3MjY1OS4wLjAuMA..

117. Overall JE, Tonidandel S. The case for use of simple difference scores to test the significance of differences in mean rates of change in controlled repeated measurements designs. Multivariate Behav Res [Internet]. 2010;45(5):806–27. Available from:

118. Kirsch P. Oxytocin in the socioemotional brain: implications for psychiatric disorders. Dialogues Clin Neurosci [Internet]. 2015;17(4):463–76. Available from:

119. Kirsch P. Oxytocin in the socioemotional brain: implications for psychiatric disorders. Dialogues Clin Neurosci [Internet]. 2015;17(4):463–76. Available from:

120. Darling-Hammond L, Flook L, Cook-Harvey C, Barron B, Osher D. Implications for educational practice of the science of learning and development. Appl Dev Sci [Internet]. 2020;24(2):97–140. Available from:

121. 5. Poster presentations. Eur J Psychotraumatol [Internet]. 2011;2(1):7235. Available from:

122. Aktar E, Majdandžić M, De Vente W, Bögels SM. Parental expressions of anxiety and child temperament in toddlerhood jointly predict preschoolers’ avoidance of novelty. J Clin Child Adolesc Psychol [Internet]. 2018;47(sup1):S421–34. Available from:

123. Aktar E, Majdandžić M, De Vente W, Bögels SM. Parental expressions of anxiety and child temperament in toddlerhood jointly predict preschoolers’ avoidance of novelty. J Clin Child Adolesc Psychol [Internet]. 2018;47(sup1):S421–34. Available from:

124. Muldoon OT, Haslam SA, Haslam C, Cruwys T, Kearns M, Jetten J. The social psychology of responses to trauma: social identity pathways associated with divergent traumatic responses. Eur Rev Soc Psychol [Internet]. 2019;30(1):311–48. Available from:

125. Jacobs J, Agho K, Stevens G, Raphael B. Do childhood adversities cluster in predictable ways? A systematic review. Vulnerable Child Youth Stud [Internet]. 2012;7(2):103–15. Available from:

126. Chen J, van den Bos E, Karch JD, Westenberg PM. Social anxiety is related to reduced face gaze during a naturalistic social interaction. Anxiety Stress Coping [Internet]. 2023;36(4):460–74. Available from:

127. Konishi M, Shishikura K, Nakaaki S, Komatsu S-I, Mimura M. Remembering and forgetting: directed forgetting effect in obsessive-compulsive disorder. Neuropsychiatr Dis Treat [Internet]. 2011 [cited 2023 Jun 6];7:365–72. Available from:

128. Nikolić M. Social emotions and social cognition in the development of social anxiety disorder. Eur J Dev Psychol [Internet]. 2020;17(5):649–63. Available from:

129. Schall J, Wallace TL, Chhuon V. ‘Fitting in’ in high school: how adolescent belonging is influenced by locus of control beliefs. Int J Adolesc Youth [Internet]. 2016;21(4):462–75. Available from:

130. Schall J, Wallace TL, Chhuon V. ‘Fitting in’ in high school: how adolescent belonging is influenced by locus of control beliefs. Int J Adolesc Youth [Internet]. 2016;21(4):462–75. Available from:

131. Scuzzarello S. Practising privilege. How settling in Thailand enables older Western migrants to enact privilege over local people. J Ethn Migr Stud [Internet]. 2020;46(8):1606–28. Available from:

132. Sonoda S. Asian views of China in the age of China’s rise: interpreting the results of pew survey and Asian student survey in chronological and comparative perspectives, 2002-2019. J Contemp East Asia Stud [Internet]. 2021;10(2):262–79. Available from:

133. MacGregor B, Allaire C, Bedaiwy MA, Yong PJ, Bougie O. Disease burden of dysmenorrhea: Impact on life course potential. Int J Womens Health [Internet]. 2023 [cited 2023 Jun 6];15:499–509. Available from:*1pjz7u*_ga*ODgwNTAwMjgwLjE2ODU5NDkyNDg.*_ga_0HYE8YG0M6*MTY4NjA4MjYzNy41LjEuMTY4NjA4MzcyNi4wLjAuMA..&_ga=2.206887889.395441562.1685949248-880500280.1685949248.

134. Hofmann SG. Cognitive Factors that Maintain Social Anxiety Disorder: a Comprehensive Model and its Treatment Implications. Cognitive Behaviour Therapy [Internet]. 2007 Dec;36(4):193–209. Available from:

135. La Greca AM, Harrison HM. Adolescent Peer Relations, Friendships, and Romantic Relationships: Do They Predict Social Anxiety and Depression? Journal of Clinical Child & Adolescent Psychology. 2005 Feb;34(1):49–61.

136. De Castella K, Goldin P, Jazaieri H, Ziv M, Heimberg RG, Gross JJ. Emotion beliefs in social anxiety disorder: Associations with stress, anxiety, and well-being. Australian Journal of Psychology. 2014 Mar 27;66(2):139–48.

137. Enez Darcin A, Kose S, Noyan CO, Nurmedov S, Yılmaz O, Dilbaz N. Smartphone addiction and its relationship with social anxiety and loneliness. Behaviour & Information Technology. 2016 Apr 7;35(7):520–5.

138. Werner KH, Jazaieri H, Goldin PR, Ziv M, Heimberg RG, Gross JJ. Self-compassion and social anxiety disorder. Anxiety, Stress & Coping. 2012 Sep;25(5):543–58.

139. Snir A, Moskow DM, Hofmann SG. When is it appropriate to treat children with social anxiety, pharmacologically? Expert Opinion on Pharmacotherapy. 2021 Jun 30;22(18):2423–6.

140. Farmer AS, Kashdan TB. Social Anxiety and Emotion Regulation in Daily Life: Spillover Effects on Positive and Negative Social Events. Cognitive Behaviour Therapy. 2012 Mar 20;41(2):152–62.

141. La Greca AM, Stone WL. Social Anxiety Scale for Children-Revised: Factor Structure and Concurrent Validity. Journal of Clinical Child Psychology. 1993 Mar;22(1):17–27.

142. Coyle S, Malecki CK. The Association Between Social Anxiety and Perceived Frequency and Value of Classmate and Close Friend Social Support. School Psychology Review. 2018 Sep;47(3):209–25.

143. Mansell W, Clark DM, Ehlers A, Chen YP. Social Anxiety and Attention away from Emotional Faces. Cognition & Emotion. 1999 Oct;13(6):673–90.

144. Culotta CM, Goldstein SE. Adolescents’ Aggressive and Prosocial Behavior: Associations With Jealousy and Social Anxiety. The Journal of Genetic Psychology. 2008 Mar 1;169(1):21–33.

145. La Greca AM, Dandes SK, Wick P, Shaw K, Stone WL. Development of the Social Anxiety Scale for Children: Reliability and Concurrent Validity. Journal of Clinical Child Psychology. 1988 Mar;17(1):84–91.

146. McLean CP, Miller NA, Hope DA. Mediating Social Anxiety and Disordered Eating: The Role of Expressive Suppression. Eating Disorders. 2007 Jan;15(1):41–54.

147. Eres R, Lim MH, Lanham S, Jillard C, Bates G. Loneliness and emotion regulation: implications of having social anxiety disorder. Australian Journal of Psychology. 2021 Jan 2;73(1):46–56.

148. Weeks JW. Replication and Extension of a Hierarchical Model of Social Anxiety and Depression: Fear of Positive Evaluation as a Key Unique Factor in Social Anxiety. Cognitive Behaviour Therapy. 2014 Dec 20;44(2):103–16.

149. Elliott R, Shahar B. Emotion-focused therapy for social anxiety (EFT-SA). Person-Centered & Experiential Psychotherapies. 2017 Apr 3;16(2):140–58.

150. Khakpoor S, Saed O, Shahsavar A. The concept of “Anxiety sensitivity” in social anxiety disorder presentations, symptomatology, and treatment: A theoretical perspective. Booth RW, editor. Cogent Psychology. 2019 May 22;6(1)

151. Telman LGE, Van Steensel FJA, Verveen AJC, Bögels SM, Maric M. Modular CBT for Youth Social Anxiety Disorder: A Case Series Examining Initial Effectiveness. Evidence-Based Practice in Child and Adolescent Mental Health. 2020 Feb 20;1–12.

152. Acquah EO, Topalli PZ, Wilson ML, Junttila N, Niemi PM. Adolescent loneliness and social anxiety as predictors of bullying victimisation. International Journal of Adolescence and Youth. 2015 Sep 14;21(3):320–31.

153. Cooper R, Doehrmann O, Fang A, Gerlach AL, Hoijtink HJA, Hofmann SG. Relationship between social anxiety and perceived trustworthiness. Anxiety, Stress, & Coping. 2013 Sep 16;27(2):190–201.

154. Kaminer D, Stein DJ. Social anxiety disorder. The World Journal of Biological Psychiatry. 2003 Jan;4(3):103–10.

155. Rodebaugh TL, Fernandez KC, Levinson CA. Testing the Effects of Social Anxiety Disorder on Friendship Quality Across Gender and Ethnicity. Cognitive behaviour therapy [Internet]. 2012 [cited 2021 Sep 2];41(2). Available from:

156. Tillfors M, Van Zalk N, Boersma K, Anniko M. Longitudinal links between adolescent social anxiety and depressive symptoms: stressful experiences at home, in school and with peers. Nordic Psychology. 2023 Mar 15;1–20.

157. Cox SL, Chen J. Perfectionism: A contributor to social anxiety and its cognitive processes. Australian Journal of Psychology. 2014 Nov 19;67(4):231–40.

158. Anderson ER, Veed GJ, Inderbitzen-Nolan HM, Hansen DJ. An Evaluation of the Applicability of the Tripartite Constructs to Social Anxiety in Adolescents. Journal of Clinical Child & Adolescent Psychology. 2010 Feb 26;39(2):195–207.