Blushing and social anxiety, how the two are connected

Social anxiety disorder is the fear of situations where other people might judge you. Not shyness, which most people have a little of, but a fear strong enough to make you avoid the situations or get through them braced, and to cost you things: conversations you did not start, jobs you did not apply for, a room you left early.

For a long time blushing sat beside that diagnosis rather than inside it. That changed in 2013. The fifth edition of the diagnostic manual psychiatrists use, the DSM, names blushing as a hallmark physiological response of social anxiety disorder. A researcher who wanted to know how strong the link really is could therefore no longer treat it as a footnote.

What the meta analysis found

In 2015 Nikolić, Colonnesi, de Vente, Drummond and Bögels pooled every study that had measured both blushing and social anxiety, and ran three separate meta analyses, one for each way of measuring a blush.

The first was self perceived blushing: how much people say they blush. Here the link with social anxiety was strong. The second was physiological blushing, the actual change in blood flow in the face, measured with instruments. Here the link was small. The third was observed blushing, what other people could see. Medium.

Read those three together and the shape of the connection appears. Socially anxious people believe they blush more than less anxious people do, and they overestimate how intense their own blushing is. The skin is involved, but only a little. Most of the connection runs through attention and belief.

That is not a way of saying it is in your head. Attention and belief are exactly what a treatment can reach, and the skin is what surgery reaches, and the meta analysis is one more reason to try the first before the second.

The people who fear only the blush

A French team led by Pelissolo asked a different question in 2012: is fear of blushing its own thing, or just social anxiety wearing a particular face.

They compared three groups of patients who all met the criteria for social anxiety disorder. 142 whose only social fear was blushing, most of them referred by a surgery department after asking for an operation on the nerve that drives the blush. 97 who feared blushing and other things too. And 190 who had social anxiety with no fear of blushing at all.

The pure blushing group looked different from both of the others. Their problem had started later in life. They had fewer other disorders alongside it. They were less behaviourally inhibited as a temperament, and their self esteem was higher. And yet their social anxiety and the damage it did to their lives were high, as high as anyone's.

The authors concluded that fear of blushing deserves its own place in the social anxiety spectrum, either as a subtype or as a social anxiety that grew out of the blushing rather than the other way round. In plain terms: you can be an otherwise confident, otherwise unafraid person whose entire problem is what your face does. That is a real diagnosis, it is common, and it is the one most people reading this page have.

Which comes first

For the pure group the order is probably blush first, fear second. A face that colours easily, a few moments where it was noticed, and then a fear of the next time, which turns attention inward, which makes the next time more likely to be noticed by the one person watching for it, which is you.

The beliefs that hold the loop in place have been measured too. People who fear blushing overestimate both how likely they are to blush and how much it will cost them when they do. They associate blushing with social cost automatically, before they have had time to think. And they hold themselves to stricter social rules than other people hold them to.

The last belief is the one the evidence most clearly contradicts. In a 2011 study, people who blushed after letting someone down were trusted more afterwards than people who did not blush. A blush reads as a conscience. The person watching you go red is, on average, not thinking what you think they are thinking.

What this changes about treatment

The family of treatment is the same in both directions, which is the useful part. The British guideline for social anxiety disorder recommends individual cognitive behavioural therapy built for social anxiety as the first thing to offer, and if someone prefers medication, an SSRI antidepressant. Beta blockers do not appear in its recommendations.

For fear of blushing specifically there is a version of that therapy developed for the problem: task concentration training, which trains attention outward in graded steps. In a randomised trial of sixty five patients it was superior to applied relaxation at one year on fear of showing bodily symptoms, and in a German group trial of eighty two patients both it and cognitive therapy beat a waiting list, with remission between 69 and 73 per cent among completers at six months.

So if your social anxiety is broad, and the blush is one symptom among several, treating the social anxiety is the route and the blush usually comes along. If your fear is the pure kind Pelissolo described, the blushing specific approaches are the ones built for you, and nothing about a higher self esteem or a later start makes them work less well.

Either way, the target is the fear. In the one trial that measured the skin directly while treating the fear, the fear fell substantially and the measured blushing did not change. That sounds like a failure until you notice that the people were no longer afraid. The blush was never the problem. The bracing was.

The thing worth taking away

Blushing and social anxiety overlap mostly in what you believe about the blush, not in the blush itself. The people whose only fear is blushing are a recognised group, with their own profile, and they are not less anxious for being otherwise confident. And the treatments with evidence behind them work on the belief and the attention, which is the part that was doing the damage.

If any of that is you, the page on this site about erythrophobia goes through the mechanism and the studies in more detail, and the daily videos are the same material in a form you can watch on the bus.