Social Anxiety Disorder

The patient who has structured their entire life around avoiding social situations may no longer appear anxious — because they've eliminated every trigger. Look for: remote work by choice, declining promotions, no close friendships, app-based ordering, self-checkout only, letting calls go to voicemail. The absence of visible anxiety doesn't mean the absence of an anxiety disorder.

Alcohol misuse is a common complication of social anxiety disorder. The patient who "needs a few drinks to be social" may be describing treatment for an undiagnosed anxiety disorder. Ask specifically: "Do you drink more in social situations? Would you be able to attend the same events without drinking?" Alcohol reduces social anxiety acutely but worsens it chronically.

Social anxiety in adolescents frequently presents as school refusal with somatic complaints — stomachaches, headaches, nausea before school. The child is often worked up for separation anxiety, school phobia, or oppositional behavior before someone asks what specifically about school terrifies them. Key distinguishing feature: the child is talkative and engaged at home but shuts down in social or school settings.

Chronic social isolation from untreated social anxiety eventually produces depression. The patient presents for depression because that's what they feel by the time they seek help. The social anxiety that drove the isolation is invisible because the avoidance is complete. Ask depressed, isolated patients: "Would you want more social connection if it didn't feel so uncomfortable?"

Social anxiety has a prominent physiological signature — palpitations, trembling, blushing, nausea, sweating. Some patients present to cardiology, gastroenterology, or primary care for these symptoms. The diagnosis is missed because the social context of the symptoms isn't explored. Always ask about situational triggers for somatic anxiety symptoms.