ICD: Social phobias

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 : Definition

Social anxiety is an experience of fear, apprehension or worry regarding social situations and being evaluated by others. People vary in how often they experience anxiety in this way or in which kinds of situations. Anxiety about public speaking, performance, or interviews is common.

Social anxiety disorder (SAD), also referred to clinically as social phobia, is a psychiatric anxiety disorder involving overwhelming anxiety and excessive self-consciousness in everyday social situations. People experiencing social anxiety often have a persistent, intense, and chronic fear of being watched and judged by others and being embarrassed or humiliated by their own actions. Their fear may be so severe that it significantly impairs their work, school, social life, and other activities. While many people experiencing social anxiety recognize that their fear of being around people may be excessive or unreasonable, they confront considerable difficulty overcoming it. This differs from shyness, in that the person is functionally debilitated and avoids such anxiety provoking situations by all means. At the same time, a person with social anxiety may only feel the fear of the disorder during certain situations. For example, an actor or singer may feel fine on stage, but afraid of social situations in everyday life.

Social anxiety is often part of only a certain situation—such as a fear of speaking in formal or informal situations, or eating, or writing in front of others—or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people. Many people have the specific fear of public speaking, called glossophobia. In this case, the fear is not actually of public speaking, however; a fear of doing or saying something, which may cause embarrassment. Approximately 13.3% of the general population will experience social phobia at some point in their lifetime; with the male to female ratio being 1.4:1.0, respectively. Physical symptoms often accompany social anxiety, and include blushing, profuse sweating, trembling, nausea, and stammering. Panic attacks may also occur under intense fear and discomfort. An early diagnosis helps in minimizing the symptoms and having other mental illnesses such as depression. Sufferers may also use alcohol to reduce fears and inhibitions at social events.

 : Description According to the Diagnostic and Statistical Manual of Mental Disorders, social phobia is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that he or she may do something or act in a way that will be humiliating or embarrassing. For one to be social phobic, exposure to the feared situation must provoke anxiety and the person must recognize this anxiety is irrational (although this may be absent in children). If another disorder is present, the social phobic fear is unrelated to it. For instance, if a person has a history of panic attacks, having a panic attack must not be the sufferer's fear. Sufferers are typically more self-conscious and self-attentive than others. As a result, social phobics tend to limit or remove themselves from situations where they may be subject to evaluation. Sufferers often recognize their fear is excessive or irrational, yet can't seem to break out of the cycle. As such, the diagnosis of social phobia is made only when the fear leads to avoiding occupational functions, social activities, or relationships with others.

Mental health professionals often distinguish between generalized and specific social anxiety disorders. People with generalized social anxiety have great distress with most or all social situations. A famous study by Stanford University established that distress was more likely when social encounters were unfamiliar, involved power or status differences, difference in gender, or the presence of a group of people. Those with specific social phobias may experience anxiety only in a few situations. For example the most common specific phobia is glossophobia, the fear of public speaking or performance, also known as "stage fright". Other examples of specific social phobias include fears of writing in public (scriptophobia) and using public restrooms (paruresis).

There is much debate concerning the relationship between social phobia and shyness. Shyness is not a criterion for social anxiety disorder. People with social anxiety disorder may be quite comfortable with certain people or many people, but still feel intense anxiety in specific social situations. Child psychologist Samuel Turner provides a summary between shyness and social phobia. Both share several features: negative cognitions in social situations, heightened physiological reactivity, a tendency to avoid social situations, and deficits in social skills. Negative cognitions include fear of negative evaluation, self-consciousness, devaluation of social skills, self-deprecating thoughts, and self-blaming attributions for social difficulties. Social phobia is distinct from shyness in that it has a lower prevalence in the population, follows a more chronic course, is more functionally debilitating, and has a later age of onset. There are problems with these kinds of comparisons. It may be that the differences between them are quantitative rather than qualitative. There are some that argue that shyness is mistakenly treated with medication intended for social phobia, effectively labeling the personality trait a mental illness.

Social phobia should not be confused with panic disorder. Sufferers of panic disorder are convinced that their panic comes from some dire physical cause, and often go to the hospital or call for an ambulance during or after their attacks. Social phobics may experience a panic attack when triggered, but they are aware that it is extreme anxiety they are experiencing, and that the cause is an irrational fear. Few social phobics would willingly go to a hospital in that instance because they fear rejection and judgment by authority figures (such as the medical staff). The general form of social anxiety is sometimes incorrectly called generalized anxiety disorder. The principal difference between the two is that the social phobia deals with anxiety in a social setting, while generalized anxiety disorder is extreme anxiety for any situation (work, school, et al.), not necessarily one involving other people.

Cognitive aspects
In cognitive models of social anxiety, social phobics experience dread over how they will be presented to others. They may be overly self-conscious, pay high self-attention after the activity, or have high performance standards for oneself. According to the social psychology theory, self-presentation, a sufferer attempts to create a well-mannered impression on others but believes he or she is unable to do so. Many times, prior to the potentially anxiety-provoking social situation, sufferers may deliberate over what could go wrong and how to deal with each unexpected case. After the event, they may have the perception they performed unsatisfactorily. Consequently, they will review anything that may have possibly been abnormal or embarrassing. These thoughts do not just terminate soon after the encounter, but may extend for weeks or longer. Those with social phobia tend to interpret neutral or ambiguous conversations with a negative outlook and although still inconclusive, some studies suggest that socially anxious individuals remember more negative memories than those less distressed. An example of an instance may be that of an employee presenting to his co-workers. During the presentation, the person may stutter a word upon which he or she may worry that other people significantly noticed and think that he or she is a terrible presenter. This cognitive thought propels further anxiety which may lead to further stuttering, sweating and a possible panic attack.

Behavioral aspects
According to renowned psychologist Burrhus Skinner, phobias are controlled by escape and avoidance behaviors. For instance, a student may leave the room when talking in front of the class (escape) and refrain from doing verbal presentations because of the previously encountered anxiety attack (avoid). Minor avoidance behaviors are exposed when a person avoids eye contact and crosses arms to avoid recognizable shaking. A fight-or-flight response is then triggered in such events. Preventing these automatic responses is at the core of treatment for social phobia.

Physiological aspects
Physiological effects, similar to those in other anxiety disorders, are present in social phobics. Faced with an uncomfortable situation, children with social anxiety may display tantrums, crying, clinging to parents, and shutting themselves out. Adults may weep, as well as experience excessive sweating, nausea, shaking, and palpitations as a result of the fight-or-flight response. Blushing is commonly exhibited by individuals suffering from social phobia. These visible symptoms further reinforce the anxiety in the presence of others. A 2006 study found that the area of the brain called the amygdala, part of the limbic system is hyperactive when patients are shown threatening faces or confronted with frightening situations. They found that patients with more severe social phobia showed a correlation with the increased response in the amygdala.

 Social phobias: History of the disorder
 * historical sources
 * famous clinicans

 Social phobias: Epidemiology
 * Social phobias: incidence
 * Social phobias: prevalence
 * Social phobias: morbidity
 * Social phobias: mortality
 * Social phobias: racial distribution
 * Social phobias: age distribution
 * Social phobias: sex distribution

 Social phobias: Risk factors
 * Social phobias: known evidence of risk factors
 * Social phobias: theories of possible risk factors

 Social phobias: Etiology
 * Social phobias: known evidence of causes
 * Social phobias: theories of possible causes

 Social phobias: Diagnosis & evaluation
 * Social phobias: psychological tests
 * Social phobias: differential diagnosis
 * Social phobias: evaluation protocols

 Social phobias: Treatment A person with the disorder may be treated with therapy, medication, or both. Research has shown cognitive behavior therapy, whether individually or in a group, to be effective in treating social phobics. The cognitive and behavioral components seek to change thinking patterns and physical reactions to anxious situations. This may be done through a technique called role playing. Prescribed medication consists of a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs). Such treatment has a high response rate, low risk of dependancy but has been criticized for its adverse side-effects and possible increase in suicide risk.

Attention given to social anxiety disorder has significantly increased since 1999 with the approval of drugs for its treatment. Marketing campaigns by pharmaceutical companies may be largely responsible for driving this.


 * outcome studies
 * Social phobias: treatment protocols
 * Social phobias: treatment considerations
 * Social phobias: evidenced based treatment
 * Social phobias: theory based treatment
 * Social phobias: team working considerations
 * Social phobias: followup

 Social phobias: For people with this difficulty
 * Social phobias: user:how to get help
 * Social phobias: user:self help materials
 * Social phobias: user:useful reading
 * Social phobias: user:useful websites

 Social phobias: For their carers
 * Social phobias: carer:how to get help
 * Social phobias:carer:useful reading
 * Social phobias: carer:useful websites

 Social phobias: For the practitioner
 * Social phobias: practitioner:further reading
 * Social phobias: practioner:useful websites

 Social phobias: Anonymous fictional case studies for training