Introduction

Social anxiety is a chronic psychiatric condition characterized by marked fear or anxiety in situations where individuals may be observed or evaluated by others. Common manifestations include fear of public speaking, interacting with unfamiliar people, participating in group discussions, eating or writing in public, avoidance of social situations, excessive self-consciousness, anticipatory anxiety, blushing, trembling, sweating, palpitations, and impaired academic, occupational, and social functioning [1,2]. It typically manifests during adolescence and can lead to significant impairment in academic, occupational, and social functioning [2]. The lifetime prevalence of social anxiety in the general population has been estimated to range from 3% to 13%, whereas studies from India have reported substantially lower prevalence estimates in the general population. Community-based studies from India have reported prevalence estimates of approximately 2-5%, considerably lower than estimates reported in Western countries [3].

Contemporary neuropsychological models suggest that social anxiety arises from interactions between cognitive biases, altered emotional processing, self-efficacy, personality characteristics, and neural circuits involved in threat detection and emotion regulation. Individuals with social anxiety often demonstrate heightened sensitivity to perceived social threats, exaggerated amygdala responses to negative social cues, reduced confidence in their social abilities (self-efficacy), and greater levels of neuroticism and insecure personality traits. Social anxiety also shows considerable comorbidity with depression, generalized anxiety disorder, substance use disorders, and avoidant personality disorder, suggesting overlapping psychological and neurobiological mechanisms [2,4,5-8].

However, specific populations such as medical students are at increased risk due to academic stress, competitive environments, and frequent evaluation [9]. Among medical students, the prevalence is considerably higher than in the general population. A recent systematic review reported that approximately one-third of medical students worldwide experience clinically significant social anxiety symptoms, with prevalence varying according to screening instrument, diagnostic threshold, and geographical region [9]. Medical education exposes students to multiple psychological stressors, including a demanding curriculum, frequent written and practical examinations, bedside clinical assessments, oral viva examinations, competition for academic achievement, transition to patient care responsibilities, fear of making mistakes, and continuous evaluation by faculty and peers. These stressors may increase vulnerability to anxiety disorders, particularly social anxiety [9,10,11].

Self-esteem refers to an individual’s overall evaluation of personal worth and has an important role in emotional regulation, resilience, coping behavior, and psychological well-being [10]. Self-esteem plays a vital role in emotional regulation and resilience. According to the self-presentational model proposed by Schlenker and Leary, individuals with low self-esteem often perceive themselves as socially inadequate and doubt their ability to create favorable impressions on others [4]. These negative self-beliefs increase fear of criticism and rejection, resulting in heightened self-focused attention during social interactions. This excessive self-monitoring promotes anticipatory anxiety, avoidance of feared situations, and maintenance of social anxiety symptoms through negative reinforcement. Consequently, low self-esteem may both predispose individuals to social anxiety and perpetuate existing symptoms [4]. Individuals with healthy self-esteem generally demonstrate greater confidence, adaptive coping strategies, and resilience when confronted with stressful situations. Conversely, low self-esteem has consistently been associated with depression, anxiety disorders, impaired interpersonal functioning, reduced academic confidence, and poorer quality of life [4,10]. Self-efficacy and personality security may further influence this relationship by affecting confidence during social interactions and the ability to regulate emotional responses [4,7,8].

Despite its importance, limited studies have explored the relationship between self-esteem and social anxiety disorder among Indian medical students. Understanding this relationship is important for developing targeted interventions. This study aims to assess the prevalence of social anxiety disorder and low self-esteem among medical students and to evaluate their association with gender and age of onset.