Social anxiety disorder

**Social phobias**
ICD-10	F40.1
ICD-9	300.23
OMIM	{{{OMIM}}}
DiseasesDB	{{{DiseasesDB}}}
MedlinePlus	{{{MedlinePlus}}}
eMedicine	{{{eMedicineSubj}}}/{{{eMedicineTopic}}}
MeSH	{{{MeshNumber}}}

Social anxiety is an intense feeling of fear, apprehension or worry regarding any or all social situations or public events. It is sometimes known as social phobia and, less commonly, social trauma. In psychiatry, it is diagnosed as social anxiety disorder, a form of anxiety disorder. According to United States epidemiological data, it is currently the third largest mental health care problem in the world. The disorder is treatable with medical and therapeutic treatments available. ^[1]

Overview

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. (p.241) 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). state.edu/spdsm-iv.htm 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. (Crozier, p.18) As a result, social phobics tend to limit or remove themselves from situations where they maybe 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. (Crozier, p.242).

Psychiatrists 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(Crozier, p.12). 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 similarities and differences 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 avoid or 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, has more apparent functional impairment, and 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. (Crozier, p.10) There are some that argue that shyness is mistakenly treated with medication intended for social phobia, effectively labeling the personality trait a mental illness. [2].

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 principle difference between the two is that the social phobia deals with anxiety in a social setting, while generalized anxiety disorder is extreme anxiety of any kind, whether it is work or school.

Symptomatology

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 to oneself 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 social anxious situation, sufferers may deliberate over what could go wrong and how to deal with each unexpected case. People with social phobia often review comprehensively what they perceive to be wrong. These thoughts do not just terminate soon after the encounter, but may last weeks or more. This is complemented by the perception that they performed unsatisfactorily. [3] [4]

Sufferers tend to interpret neutral or ambiguous conversations with a negative outlook. Although still inconclusive, some studies suggest that socially anxious individuals remember more negative memories than those less distressed.

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 cross arms to avoid recognizable shaking. [5]

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. [6] Adults may also weep, as well as experience excessive sweating, nausea, and palpitations as a result of the fight-or-flight response. Blushing is commonly exhibited by individuals suffering from social phobia. [7]

Prevalence

When prevalence estimates were based on the examination of psychiatric clinic samples, social anxiety\ disorder was thought to be a relatively rare disorder. The opposite was instead true; social anxiety was common but many were afraid to seek psychiatric help, leading to an understatement of the problem. [8] Prevalence rates vary widely because of its vague diagnostic criteria and its overlapping symptoms with other disorders. There has been some debate on how the studies are conducted and whether the illness truly impairs the respondents as laid out in the official criteria. Psychologist Dr. Ray Crozier argues, "it is difficult to ascertain whether the person being interviewed adheres to the DSM-III-R criteria or whether they are merely exhibiting poor social skills or shyness." (Crozier, p.4).

The National Comorbidity Survey of over 8,000 American correspondents in 1994 revealed a 12-month and lifetime prevalence rate of 7.9% and 13.3% making it the third most prevalent psychiatric disorder after depression and alcohol dependence and the most and the most apparent of the anxiety disorders. [9] According to U.S. epidemiological data from the National Institute of Mental Health, social phobia affects 5.3 million adult Americans in any given year. Cross-cultural studies have reached similar prevalence rates with the most conservative rates at 5% (Crozier, p.3). [10] However, recent estimates vary within 2% and 7% of the U.S. adult population. [www.surgeongeneral.gov/library/mentalhealth/pdfs/c4.pdf]

Onset of social phobia typically occurs between 11 and 19 years of age. Onset after age 25 is rare. [11]. Slightly more females than males have social phobia, although men are more likely to seek help. The prevalence of social phobia appears to be increasing among white, married, and well-educated individuals. [12] As a group, those with generalized social phobia are less likely to graduate from high school and are more likely to rely on government financial assistance or have poverty-level salaries. [13]. Surveys carried out in 2002 show the youth of England, Scotland, and Wales have a prevalence rate of .4%, 1.8%, and .6%, respectively. [14] The prevalence of self- reported social anxiety for Nova Scotians older than 14 years was 4.2% in June 2004 with women (4.6%) reporting more than men (3.8%). [15] In Australia, social phobia is the 5th and 8th leading disease or illness for 15-24 year olds as of 2003. [16]

Comorbidity

There is a high degree of comorbidity with other psychiatric disorders. Social phobia is highly comorbid with low self-esteem and major depression, due to lack of personal relationships and long periods of isolation. To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to substance abuse. About one-fifth of patients with social anxiety disorder also suffer from alcohol dependence. [17] The most common complementary psychiatric condition that may be associated with social anxiety is depression. In a sample of 14,263 people, of the 2.4% of persons diagnosed with social phobia, 16.6% also met the criteria for major depression. (Crozier, p.358-9). Besides depression, the most common disorders diagnosed in patients with social phobia are panic disorder (33%); generalized anxiety disorder (19%); PTSD (36%); substance abuse disorder (18%); and attempted suicide (23%). encyclopedia/social-phobia In one study of social anxiety disorder patients who developed comorbid alcoholism, panic disorder or depression, social anxiety disorder preceded the onset of alcoholism, panic disorder & depression in 75%, 61% & 90% of patients, respectively. Avoidant personality disorder has also been correlated with social phobia. (Crozier, p.361) Because of its close relationship and overlapping symptoms with other illnesses, treating social phobics may help understand underlying connection in other psychiatric disorders. [18]

Etiology

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Scientists have yet to pinpoint the exact causes of social phobia. Studies suggest the disorder is familial; however these findings do not differentiate between environmental and genetic factors. Preliminary studies suggest that both biological and psychological factors contribute to the disorder. ^[19]

Genetic and family factors

It has been shown that there is a two to three fold greater risk of having social phobia if a first-degree relative also has the disorder. If parents themselves are socially anxious their children might acquire social fears and avoidance through processes of modeling. Consequently, the child's exposure to social events and conversations may be limited preventing the child to experience and develop better social skills. These psychologists suggest people with social phobia may acquire their fear from observing the behavior and consequences of others, a process called observational learning. A previous negative social experience can be a trigger to social phobia.^[20] ^[21]

Some scientists think social phobia is related to an imbalance of the brain chemical serotonin. Sociability is also closely tied to dopamine neurotransmission. Low D2 receptor binding is found in people with social anxiety. [22] Researchers supported by the National Institute of Mental Health (NIMH) recently identified the site of a gene in mice that affects learned fearfulness, suggesting that social anxiety disorder is inherited.

Treatment

Up to 80 percent of those treated for social phobia say they've gotten their anxiety under control, according to the Anxiety Disorders Association of America. Perhaps the most important clinical point to emerge from studies of comorbid social anxiety disorder is the necessity for early diagnosis and treatment. Social anxiety disorder remains under-recognized in primary care practice, with patients presenting for treatment only after the onset of complications such as major depression or substance use disorders. [23]

Effective treatments for each of the anxiety disorders have been developed through research. In general, two types of treatment are available for an anxiety disorder—medication and specific types of therapy. Both approaches can be effective for most disorders. Arguably the two main specific treatments are the use of anti-depressants and cognitive-behavioral therapy. Many times, being treated with both medication and psychotherapy is most effective.

Medications

Some of the newest antidepressants that treat social anxiety disorder are called selective serotonin reuptake inhibitors, or SSRIs. These medications act in the brain on a chemical messenger called serotonin. SSRIs tend to have fewer side effects than older antidepressants. People do sometimes report feeling side-effects from the drug when first taken or when a dose is increased. Paxil, which was the first drug formally approved by the U.S. to treat social phobia in 2002 and ran with the slogan "Imagine being allergic to people", is the most well-known SSRI drug. However fluoxetine, sertraline, fluvoxamine, and citalopram are also commonly prescribed for social phobia.

Another option is the use of highly-potent benzodiazepines which generally relieve symptoms quickly with few side effects. Because people can develop an addiction to them, benzodiazepines are generally prescribed for short periods of time so as to avoid dependence on the drug.

Psychotherapy

Research has shown that a form of psychotherapy that is effective for several anxiety disorders, particularly panic disorder and social phobia, is cognitive-behavioral therapy (CBT) (Burns, 1999). It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. A person with social phobia might be helped to overcome the belief that others are continually watching and harshly judging him or her. The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is exposure, in which people confront the things they fear in a sensitive manner. This is done with support and guidance when the therapist feels the patient is ready and only with the permission of the patient and at the pace the patient wishes.

Cognitive-behavior therapy for social phobia also includes anxiety management training, such as teaching people techniques such as deep breathing to control their levels of anxiety.

History

Although, literary descriptions of shyness can be traced back to the days of Hippocrates around 400 B.C., the first mention of psychiatric term, social phobia ("phobie des situations sociales"), was made in the early 1900s. Pertinently, psychologists used the term "social neurosis" to describe extremely shy patients in the 1930s. After extensive work by Joseph Wolpe on systematic desensitization, research in phobias and their treatment grew. The idea that social phobia belonged was a separate entity from other phobias came from the British psychiatrist, Isaac Marks in the 1960s. This was accepted by the American Psychiatric Association and was first officially included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. The definition of the illness was revised in 1989 to allow comorbidity between avoidant personality disorder and social phobia and introduced generalized social phobia. [24]

References

^ Social Phobia/Social Anxiety Association. What is Social Phobia? Found at http://www.socialphobia.org/whatis.html
^ Kids Health website. Mental health disorders: Social phobia http://kidshealth.org/teen/your_mind/mental_health/social_phobia.html
^ Surgeon General government website. Anxiety disorders. Found at http://www.surgeongeneral.gov/library/mentalhealth/chapter4/sec2.html
^ National Institute of Mental Health. Phobia facts Found at http://www.nimh.nih.gov/publicat/phobiafacts.cfm
^ Food and Drug Administration Home Page. Social Phobia's Traumas and Treatments by Tamar Nordenberg. Found at http://www.fda.gov/fdac/features/1999/699_phobia.html
^ Alcohol Research & Health. Social anxiety disorder and alcohol use by Sarah W. Book, Carrie L. Randall. Found at http://www.findarticles.com/p/articles/mi_m0CXH/is_2_26/ai_95148615
^ National Center for Health and Wellness. Causes of Social Anxiety Disorder. Found at http://www.social-anxiety-disorder-resources.com/causes-of-social-anxiety-disorder.html
^ Athealth.com. Social phobia. Found at http://www.athealth.com/Consumer/disorders/SocialPhobia.html

Literature

American Psychiatric Association (2000). "Anxiety disorders". In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp. 450–456. Washington, D.C.: American Psychiatric Association.
Belzer, K. D.; McKee, M. B.; Liebowitz, M. R. (2005). "Social Anxiety Disorder: Current Perspectives on Diagnosis and Treatment". Primary Psychiatry, 12(11):40-53. [25]
Bruch, M. A. (1989). "Familial and developmental antecedents of social phobia: Issues and findings". Clinical Psychology Review, 9: 37-47.
Crozier, W. Ray; Alden, Lynn E. International Handbook of Social Anxiety: Concepts, Research, and Interventions Relating to the Self and Shyness. New York John Wiley & Sons, Ltd. (UK), 2001. ISBN 0471491292.
Burns, David D. Feeling Good: The New Mood Therapy. Revised Edition. Avon, 1999. ISBN 0-38-081033-6
Hales, R. E.; Yudofsky, S. C., eds. (2003). "Social phobia". Textbook of Clinical Psychiatry, 4th ed., pp. 572–580. Washington, D.C.: American Psychiatric Publishing.
Okano K. (1994). Shame and social phobia: a transcultural viewpoint. Bull Menninger Clin, 58(3): 323-38.
Samson, A. (2002). "Psychiatric Conceptions of "Social Phobia": A Comparative Perspective". Swiss Journal of Sociology, 28(3): 505-527.
Stein, M. B.; Kean, Y. M. (2000). "Disability and quality of life in social phobia: Epidemiologic findings". American Journal of Psychiatry, 157(1): 1606–1613.
Van Ameringen, M. A., et al. (2001). "Sertraline treatment of generalized social phobia: A 20-week, double-blind, placebo-controlled study". American Journal of Psychiatry, 158(2): 275–281.
Wagstaff, A. J., et al. (2002). "Spotlight on paroxetine in psychiatric disorders in adults". Drugs, 62(4): 655–703.

External links

UK Social Anxiety Site
National Institute of Mental Health - What is social anxiety, signs, and treatment
Social Phobia/Social Anxiety Association
UK Phobics-society - Information and personal experiences
Anxiety Disorders Association of America
Social Phobia -From Epidemiology to Brain Function - Dissertation by Tomas Furmark from Uppsala University.
Social anxiety disorder
The Social Anxiety Institute
Comprehensive list of articles pertaining to social anxiety
Social Anxiety Research Clinic New York State Psychatric Institute

Online support groups

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