Social Anxiety Disorder and Substance Use: Signs Families Should Know and Treatment Options

Written by the medical team at Day One Rehabilitation Center, Nakhon Nayok, Thailand · Medically reviewed by Dr. Pichayut Kasemphakdeephong (Psychiatrist)

Being quiet, shy, or preferring to be alone does not mean someone has social anxiety disorder. Some people simply have a personality that dislikes social events, yet can still study, work, talk with others, and do what’s necessary in life without much distress.

Social anxiety disorder is different, because a person with this condition tends to fear being watched, judged, criticized, or doing something embarrassing in front of others. Some fear that others will notice them blushing, their hands trembling, stumbling over words, or looking nervous. These fears can lead to avoiding public speaking, meetings, job interviews, meeting new people, dating, or even ordinary activities that have to be done in front of others.

The problem becomes more complicated when the person discovers that alcohol or certain substances make them feel temporarily relaxed and braver. What began as drinking only at social events can gradually turn into a feeling of “I can’t talk to people without drinking” or “I need to use something first to feel confident,” creating a cycle between fear, avoidance, and reliance on the substance.

Treatment should therefore not focus only on stopping the substance, but must also understand what fear the person is trying to cope with by using it, and help them gradually return to living, studying, working, and building relationships without needing to rely on a substance for confidence.

What Are the Symptoms of Social Anxiety Disorder, and How Is It Different From Shyness?

Social anxiety disorder is a form of anxiety disorder in which the primary fear relates to situations where one might be observed or judged by others. A person with this condition may not fear “people” directly, but rather fears making a mistake, saying something wrong, appearing nervous, or being viewed negatively.

Examples of symptoms include:

• Fear of speaking in front of a large group of people

• Intense anxiety when meeting or talking with unfamiliar people

• Not daring to speak up in meetings or in class

• Fear of job interviews or presentations

• Fear of phone calls or talking with people one isn’t close to

• Fear of eating, writing, or doing certain activities while being watched

• Worrying about blushing, trembling hands, sweating, or stumbling over words

• A racing heart, nausea, breathlessness, or feeling physically tense when entering a situation

• Worrying for days in advance before having to meet people or attend an event

• After talking with others, replaying the conversation and worrying about whether one said something wrong

• Avoiding social events, meetings, classes, or activities that involve meeting people

• Missing out on opportunities in school, work, or relationships because of fear

• Needing to drink alcohol or use a substance before feeling brave enough to socialize

A shy person may feel nervous meeting someone new, but as the situation unfolds, they can adapt and do what they need to do. Someone with social anxiety disorder, on the other hand, may be so afraid that they avoid important things in their life, or endure the situation with significant distress.

On the other hand, someone who prefers being alone does not necessarily have social anxiety disorder, as long as they are content with their lifestyle and are not avoiding social situations out of fear of being judged. The term “social anxiety” should not be used simply because someone is quiet or dislikes social gatherings.

Why Might Someone With Social Anxiety Disorder Use Alcohol or Substances to Feel Braver?

The relationship between social anxiety disorder and substance use often begins with a reason that feels easy to understand: “it makes me less afraid” or “after drinking, I don’t overthink as much.”

For example, someone might feel very anxious before a party because they’re afraid they won’t have anything to talk about with anyone, so they drink alcohol beforehand. After drinking, they feel more relaxed, braver about talking, and less anxious. This experience creates the belief that alcohol helps them socialize.

The next time there’s an event, the person drinks again, and a cycle gradually develops:

“Before meeting people I’m afraid I’ll say something wrong, so I drink to feel braver. Once I get through the situation, I believe it’s because of the alcohol that I managed it, and the next time I’ll be even less confident about socializing without drinking.”

Some people may start drinking before a date, before a party, before meeting a client, or before going to entertainment venues. What began as use on certain occasions can gradually increase in frequency or amount as social situations increase.

The key problem is that the person may never get the chance to learn that, even while feeling nervous, they can still talk with others and get through the situation without using a substance. Confidence gradually becomes tied to alcohol or the substance instead of coming from their own experience.

Besides alcohol, some people may use cannabis, anti-anxiety medication, or other substances to try to reduce nervousness. But the effects of substances differ from person to person — some substances can actually cause a racing heart, anxiety, fear, or reduced behavioral control, and using certain anti-anxiety medications without proper medical supervision can lead to dependence.

Substances should therefore not be used as a self-directed treatment for social anxiety disorder, even if in the short term the substance seems to reduce the fear.

How Does Social Anxiety Disorder Together With Addiction Affect Life?

The impact of social anxiety disorder is not limited to disliking social gatherings. Once fear begins to drive a person’s decisions, they may choose their studies, their job, or avoid important opportunities simply to avoid being in a situation where they might be judged by others.

Some people are capable at their jobs but don’t dare apply for a new position because they fear the interview. Some don’t dare ask their teacher a question even when they don’t understand the lesson. Some don’t speak up in meetings even when they have a useful opinion, while others want relationships but don’t dare start a conversation with someone new.

If substance use is also involved, problems can increase, such as:

• Needing to drink or use a substance before socializing

• Starting to feel unable to talk to others without the substance

• Increasing the amount of drinking to feel as relaxed as before

• Avoiding an event or activity if unable to use the substance

• Choosing to socialize only with groups where drinking or substance use occurs

• Problems arising from behavior while intoxicated

• Feeling anxious or guilty afterward about what one said or did

• Impact on school or work

• Problems in relationships with family or a partner

• Declining confidence in one’s own abilities

• Starting to use the substance even in situations that didn’t previously require it

A cycle can develop that begins with fear of socializing, leads to using a substance for courage, and when negative consequences from the substance occur, the person may feel more embarrassed or anxious, leading them to avoid people even more and return to relying on the substance again the next time they need to socialize.

Treatment that focuses only on the substance use without addressing the underlying fear may allow the person to stop using for a while, but when they return to the same situations — a party, a meeting, or meeting someone new — the urge to use may return.

How Is Social Anxiety Disorder Treated When It Occurs Together With Addiction?

Treatment should assess both the social fear and the pattern of substance use. It is not always necessary to choose “treat social anxiety disorder first” or “treat the addiction first” — instead, both problems should be planned for and addressed together, in a connected way.

Assessing Whether Social Anxiety Disorder or Substance Use Came First

The care team will ask when the fear of social situations began, how the person was able to socialize before starting to use the substance, what reason led to first using it, and what situations currently feel like they require the substance.

It’s also necessary to consider whether the anxiety truly stems from social anxiety disorder or is related to the substance’s effects or withdrawal, because stimulants, cannabis, alcohol, and other psychoactive substances can all change a person’s level of anxiety.

Some people may have other co-occurring conditions, such as depression, panic disorder, anxiety disorder, or ADHD, which should be assessed together.

Cognitive Behavioral Therapy to Address the Thoughts That Keep the Fear Alive

Cognitive behavioral therapy is a key approach to treating social anxiety disorder. It helps the person in treatment see the automatic thoughts that arise in various situations, such as:

“If I say something wrong, everyone will think I’m strange.”

“If my hands shake, other people will definitely notice.”

“Without alcohol, I won’t be able to talk to anyone.”

The person then gradually examines how closely these thoughts match what actually happens, and practices viewing the situation in a more balanced way.

Another important part is gradually practicing facing feared situations in order of difficulty — for example, starting with a brief conversation with someone unfamiliar before progressing to speaking in a group, in a meeting, or in more difficult situations.

The goal is not to make the anxiety disappear completely before taking action, but to help the person learn that even while feeling nervous, they can still stay in the situation and do what they want to do.

During therapy, the person may need to gradually reduce behaviors used to feel safe — such as needing to drink before talking to people, having a friend speak for them, avoiding eye contact at all times, or rehearsing every sentence in their head to the point of not being able to listen to the person in front of them — because these behaviors can keep alive the belief that “without something to help me, I can’t cope.”

Treating Addiction Alongside Social Fear

For someone with a substance-use problem, therapy must help identify which situations trigger cravings — such as a party, a date, meeting a client, being with a group of friends, loneliness, or a feeling of not belonging.

A specific coping plan can then be made — such as how to attend an event without using a substance, how to respond when someone offers a drink, how to leave a situation if cravings become strong, and who to ask for help.

For someone who does not yet see substance use as a problem, motivational conversation can help them explore what the substance helps with in the short term, and how it is changing their life in the long term — without needing to start from blame or forcing them to accept that they have an addiction.

Using Medication for Social Anxiety Disorder When Indicated

Social anxiety disorder can be treated with medication in some cases. A psychiatrist will consider the severity of symptoms, the impact on the person’s life, any co-occurring conditions, treatment history, and patterns of substance use.

Certain classes of medication used to treat anxiety take time to work and should be taken continuously according to the doctor’s plan — not taken only before socializing with the expectation that anxiety will disappear immediately.

For someone with a history of substance use, medication choice requires special caution, because certain anti-anxiety medications can lead to dependence if used inappropriately. Medication should never be bought and taken independently, borrowed from someone else, increased in dose, or stopped without consulting a doctor.

How Should Families Help Someone With Social Anxiety Disorder Who Uses Substances?

Social fear can be hard to understand for someone who has never experienced it, so families may unintentionally say things like “just go talk to people,” “no one is paying that much attention to you,” “you’re just overthinking it,” or “go out and meet people often and it’ll go away eventually.”

Even said with good intentions, these comments can make the person feel their fear isn’t understood.

At the same time, families should not help the person avoid every situation — for example, always making phone calls for them, always speaking on their behalf, or letting them avoid all important activities entirely, because continuous avoidance can keep the fear alive.

What helps more is asking questions to understand, such as, “When you have to be around a lot of people, what part worries you most?” or “Before going out to meet friends, what does having a drink help with in that moment?”

If it becomes clear that the person needs to rely on alcohol or a substance to socialize, it can help to reflect what’s been observed without blame, such as, “Lately we’ve noticed you need to drink almost every time before going out to meet people — we’re worried it’s becoming something you can’t do without.”

Inviting the person into treatment doesn’t need to start with the words “alcoholic” or “social anxiety disorder.” If they’re not yet ready to accept this, it may help to start from a problem they themselves want to solve — such as wanting to do well in a job interview, wanting to speak up in meetings, or wanting friends or a relationship without needing to drink first.

Families should not force the person into their most feared situation right away to “prove there’s nothing to be afraid of.” Appropriate exposure practice should be gradual, so the person gains a real experience that they can actually cope.

Outpatient or Residential Treatment: Which Is Right for Social Anxiety Disorder With Substance Use?

Most people with social anxiety disorder do not need residential treatment. If there is no complex addiction, no emergency, and the person can attend follow-up treatment, outpatient care is usually a suitable starting point.

Anyone with a fear of socializing, who avoids school or work, or who has started using alcohol or substances to feel braver, can start with an outpatient assessment at Piti Clinic, our mental-health clinic on Pradiphat Road, Saphan Khwai, Bangkok, to assess symptoms, patterns of avoidance, substance use, and any co-occurring mental-health conditions.

If the person is not yet ready for an assessment, families can come in for a consultation first, to help understand the problem and plan how to talk with the person without adding pressure.

In cases of clear addiction, an inability to stop using in the same environment, repeated relapse, needing to use the substance regularly to socialize or manage emotions, or multiple co-occurring psychiatric conditions, residential treatment may be the more suitable option.

Treating Social Anxiety Disorder and Addiction Together at Day One Rehabilitation Center

For someone with social anxiety disorder together with addiction, the goal of treatment should not be simply to stop alcohol or substance use, but must also help the person understand why socializing became something that required a substance to get through.

At Day One Rehabilitation Center, residential treatment is suitable for someone with clear co-occurring addiction who needs an environment that reduces access to substances in the early stage. The care team can assess psychiatric symptoms, substance use, sleep, relationships, and the triggers that lead back to substance use.

Individual therapy helps the person in treatment explore their own thoughts and fears, while group therapy provides a space to practice communication, listen to others, and gradually build confidence in being with other people within a structured environment.

A psychiatrist can consider medication when indicated, as well as assess any co-occurring conditions such as depression, anxiety disorder, panic disorder, or sleep problems.

For addiction, treatment helps identify triggers, practice managing cravings, and prepare a plan for real situations after leaving the center — such as returning to work, meeting friends, socializing, or being offered a drink or a substance again.

The goal is not to turn a shy person into someone who loves socializing, but to help the person in treatment live according to what they themselves want, without fear dictating every decision, and without needing to rely on a substance to feel confident enough.

Frequently Asked Questions About Social Anxiety Disorder and Substance Use

What’s the difference between shyness and social anxiety disorder?

Shyness is a common trait and does not need to be a disorder. Social anxiety disorder involves such intense fear of being watched or judged that it causes real distress, leads to avoidance, and clearly affects school, work, relationships, and life opportunities.

Does disliking socializing mean someone has social anxiety disorder?

Not always. Some people enjoy spending time alone and don’t feel distressed by it. What matters is the reason for avoiding social situations. If someone avoids them out of fear of being judged or embarrassed, and that fear is disrupting their life, they should be assessed.

Why does drinking alcohol make someone feel braver about talking to people?

Alcohol can create temporary relaxation and reduce inhibition, so some people feel braver or less anxious. But this effect does not treat the underlying cause of social anxiety disorder, and using alcohol as a tool every time one socializes can lead to a drinking problem.

Does drinking only in social situations count as alcohol addiction?

This cannot be judged from the situation alone. What matters is the amount, frequency, ability to control it, cravings, impact, and whether the person feels they need to drink. If someone starts thinking, “I can’t socialize without drinking,” both the social anxiety and the drinking pattern should be assessed.

Is occasionally using alcohol to reduce nervousness a problem?

Using alcohol to cope with fear can teach the brain that social situations require alcohol to get through. If this pattern repeats, confidence in socializing without a substance can decline, and the risk of a drinking problem can increase.

Can social anxiety disorder be treated?

Social anxiety disorder can be treated and its symptoms managed. Cognitive behavioral therapy, along with gradually and appropriately practicing feared situations, is a key approach, and some people may also receive medication as assessed by a psychiatrist.

Should someone with social anxiety be forced to go out and meet people often to get over their fear?

They should not be forced to face their most difficult situation right away. Appropriate practice should be gradual and goal-directed, so the person learns that they can cope with their anxiety, rather than having an experience that reinforces the fear even more.

Can social anxiety disorder be treated with medication?

Yes, in some cases. A psychiatrist will consider the severity of symptoms and each person’s individual factors. Anyone with a history of substance use should tell their doctor, because certain classes of anti-anxiety medication carry a risk of dependence and may not be suitable for some patients.

For someone with social anxiety disorder and addiction, which should be treated first?

In many cases, both problems should be treated at the same time, because fear can be a trigger for substance use, and substance use can make anxiety and life problems more complicated. Treatment should therefore address both the underlying reason for relying on the substance and the effects of using it.

Does social anxiety disorder require residential treatment?

Not for everyone. Someone with social anxiety disorder without complex addiction can start outpatient treatment at Piti Clinic. If there is clear co-occurring addiction, an inability to stop using in the same environment, repeated relapse, or multiple co-occurring psychiatric conditions, residential treatment at Day One Rehabilitation Center may be worth considering.

Social Anxiety Disorder Does Not Have to Be Solved by Avoidance or Substance Use

Someone with social anxiety disorder is not weak, does not lack social skills, and does not need to change themselves into someone who loves socializing. The real problem is when the fear of being watched or judged begins to limit what the person wants to do in life.

Drinking alcohol or using a substance to build courage may seem to make situations easier to get through at first, but if a person has to keep relying on it repeatedly, confidence can gradually become tied to the substance, creating a cycle that makes both the social anxiety and the substance use harder to treat.

Treatment helps the person in treatment gradually understand the thoughts behind their fear, practice facing situations appropriately, build confidence through real experience, and learn to manage anxiety without using a substance as their main tool.

If someone in the family starts avoiding school, work, or meeting people, or needs to drink or use a substance every time before socializing, seeking an assessment while the problem is not yet severe can help clarify both the mental-health issue and the substance use, and allow for a treatment approach suited to that person.