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- See also: Social Anxiety
Social phobias: Definition
Social phobia (DSM-IV 300.23), also known as social anxiety disorder (DSM-IV 300.23) is a diagnosis within psychiatry and other mental health professions referring to excessive social anxiety (anxiety in social situations)  causing abnormally considerable distress and impaired ability to function in at least some areas of daily life. The diagnosis can be of a specific disorder (when only some particular situations are feared) or a generalized disorder. Generalized social anxiety disorder typically involves a persistent, intense, and chronic fear of being judged by others and of potentially being embarrassed or humiliated by one's own actions. These fears can be triggered by perceived or actual scrutiny by others. While the fear of social interaction may be recognized by the person as excessive or unreasonable, considerable difficulty can be encountered overcoming it. Approximately 13.3 percent of the general population may meet criteria for social anxiety disorder at some point in their lifetime, according to the highest survey estimate, with the male to female ratio being 1:1.5.
Physical symptoms often accompanying social anxiety disorder include excessive blushing, sweating (hyperhidrosis), trembling, palpitations, nausea, and stammering. Panic attacks may also occur under intense fear and discomfort. An early diagnosis may help in minimizing the symptoms and the development of additional problems such as depression. Some sufferers may use alcohol or other drugs to reduce fears and inhibitions at social events. It is very common for sufferers of social phobia to self-medicate in this fashion, especially if they are undiagnosed and/or untreated. This can lead to alcoholism or other kind of substance abuse.
A person with the disorder may be treated with psychotherapy, medication, or both. Research has shown cognitive behavior therapy, whether individually or in a group, to be effective in treating social phobia. The cognitive and behavioral components seek to change thought patterns and physical reactions to anxious situations. Prescribed medications include two classes of antidepressants: selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). Attention given to social anxiety disorder has significantly increased in the US since 1999 with the approval and marketing of drugs for its treatment.
- 1 Symptoms
- 2 Related articles
- 3 Causes and perspectives
- 4 Treatment
- 5 History
- 6 Criticisms
- 7 See also
- 8 References
- 9 Further reading
- 10 External links
In cognitive models of Social Anxiety Disorder, 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 themselves. According to the social psychology theory of 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 many 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.
Social anxiety disorder 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. It exceeds normal "shyness" as it leads to excessive social avoidance and substantial social or occupational impairment. Feared activities may include almost any type of social interaction, especially small groups, dating, parties, talking to strangers, restaurants, etc. Physical symptoms include "mind going blank", fast heartbeat, blushing, stomach ache. Cognitive distortions are a hallmark, and learned about in CBT (cognitive-behavioral therapy). Thoughts are often self-defeating and inaccurate.
The groundless fear of making telephone calls is typical, both answering and picking up, due to conversing's social nature.[How to reference and link to summary or text] It may appear early in childhood.
According to psychologist B.F. 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 anxiety.
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, weeping, clinging to parents, and shutting themselves out. In adults, it may be tears as well as experiencing excessive sweating, nausea, shaking, and palpitations as a result of the fight-or-flight response. The walk disturbance may appear, especially when passing a group of people. 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.
- Main article: Social phobia - Diagnosis
- Main article: Social phobia - Biological factors
- Main article: Social phobia - Genetic factors
- Main article: Social phobia - Environmental factors
- Main article: Social phobia - Children
- Main article: Social phobia - Developmental factors
- Main article: Social phobia - Cognitive features
- Main article: Social phobia - Theoretical approaches
- Main article: Social phobia - Course of the condition
- Main article: Social phobia - Epidemiology.
- Main article: Social phobia - Risk factors.
- Main article: Social phobia - Etiology.
- Main article: Social phobia - Service planning and care pathways
- Main article: Social phobia - Assessment.
- Main article: Social phobia - Comorbidity.
- Main article: Social phobia - Treatment.
- Main article: Social phobia - Relapse prevention
- Main article: Social phobia - Prognosis.
- Main article: Social phobia - Suicide
- Main article: Social phobia - Service user page.
- Main article: Social phobia - Carer page.
Onset of social phobia typically occurs between 11 and 19 years of age. Onset after age 25 is rare. Social anxiety disorder occurs in females nearly twice as often as males, although men are more likely to seek help. The prevalence of social phobia appears to be increasing among white, married, and well-educated individuals. 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. Surveys carried out in 2002 show the youth of England, Scotland, and Wales have a prevalence rate of 0.4 percent, 1.8 percent, and 0.6 percent, respectively. The prevalence of self-reported social anxiety for Nova Scotians older than 14 years was 4.2 percent in June 2004 with women (4.6 percent) reporting more than men (3.8 percent). In Australia, social phobia is the 8th and 5th leading disease or illness for males and females between 15-24 years of age as of 2003. Because of the difficulty in separating social phobia from poor social skills or shyness, some studies have a large range of prevalence. The table also shows higher prevalence in Brazil.
Causes and perspectives
Research into the causes of social anxiety and social phobia is wide-ranging, encompassing multiple perspectives from neuroscience to sociology. Scientists have yet to pinpoint the exact causes. Studies suggest that genetics can play a part in combination with environmental factors.
Genetic and family factors
It has been shown that there is a two to threefold greater risk of having social phobia if a first-degree relative also has the disorder. This could be due to genetics and/or due to children acquiring social fears and avoidance through processes of observational learning or parental psychosocial education. Studies of identical twins brought up (via adoption) in different families have indicated that, if one twin developed social anxiety disorder, then the other was between 30 percent and 50 percent more likely than average to also develop the disorder. To some extent this 'heritability' may not be specific - for example, studies have found that if a parent has any kind of anxiety disorder or clinical depression, then a child is somewhat more likely to develop an anxiety disorder or social phobia. Studies suggest that parents of those with social anxiety disorder tend to be more socially isolated themselves (Bruch and Heimberg, 1994; Caster et al, 1999), and shyness in adoptive parents is significantly correlated with shyness in adopted children (Daniels and Plomin, 1985);
Adolescents who were rated as having an insecure (anxious-ambivalent) attachment with their mother as infants were twice as likely to develop anxiety disorders by late adolescence, including social phobia.
A related line of research has investigated 'behavioural inhibition' in infants – early signs of an inhibited and introspective or fearful nature. Studies have shown that around 10-15 percent of individuals show this early temperament, which appears to be partly due to genetics. Some continue to show this trait in to adolescence and adulthood, and appear to be more likely to develop social anxiety disorder.
A previous negative social experience can be a trigger to social phobia. perhaps particularly for individuals high in 'interpersonal sensitivity'. For around half of those diagnosed with social anxiety disorder, a specific traumatic or humiliating social event appears to be associated with the onset or worsening of the disorder; this kind of event appears to be particularly related to specific (performance) social phobia, for example regarding public speaking (Stemberg et al., 1995). As well as direct experiences, observing or hearing about the socially negative experiences of others (e.g. a faux pas committed by someone), or verbal warnings of social problems and dangers, may also make the development of a social anxiety disorder more likely. Social anxiety disorder may be caused by the longer-term effects of not fitting in, or being bullied, rejected or ignored (Beidel and Turner, 1998). Shy adolescents or avoidant adults have emphasised unpleasant experiences with peers or childhood bullying or harassment (Gilmartin, 1987). In one study, popularity was found to be negatively correlated with social anxiety, and children who were neglected by their peers reported higher social anxiety and fear of negative evaluation than other categories of children. Socially phobic children appear less likely to receive positive reactions from peers and anxious or inhibited children may isolate themselves.
Cultural factors that have been related to social anxiety disorder include a society's attitude towards shyness and avoidance, affecting ability to form relationships or access employment or education. One study found that the effects of parenting are different depending on the culture - American children appear more likely to develop social anxiety disorder if their parents emphasize the importance of other's opinions and use shame as a disciplinary strategy (Leung et al., 1994), but this association was not found for Chinese/Chinese-American children. In China, research has indicated that shy-inhibited children are more accepted than their peers and more likely to be considered for leadership and considered competent, in contrast to the findings in Western countries. Purely demographic variables may also play a role - for example there are possibly lower rates of social anxiety disorder in Mediterranean countries and higher rates in Scandinavian countries, and it has been hypothesised that hot weather and high-density may reduce avoidance and increase interpersonal contact.
Problems in developing social skills, or 'social effectiveness', may be a cause of some social anxiety disorder, through either inability or lack of confidence to interact socially and gain positive reactions and acceptance from others. The studies have been mixed, however, with some studies not finding significant problems in social skills while others have. What does seem clear is that the socially anxious perceive their own social skills to be low. It may be that the increasing need for sophisticated social skills in forming relationships or careers, and an emphasis on assertiveness and competitiveness, is making social anxiety problems more common, at least among the 'middle classes'. An interpersonal or media emphasis on 'normal' or 'attractive' personal characteristics has also been argued to fuel perfectionism and feelings of inferiority or insecurity regarding negative evaluation from others. The need for social acceptance or social standing has been elaborated in other lines of research relating to social anxiety
A long-accepted evolutionary explanation of anxiety is that it reflects an in-built 'fight or flight' system, which errs on the side of safety. One line of research suggests that specific dispositions to monitor and react to social threats may have evolved, reflecting the vital and complex importance of social living and social rank in human ancestral environments. Charles Darwin originally wrote about the evolutionary basis of shyness and blushing, and modern evolutionary psychology and psychiatry also addresses social phobia in this context. It has been hypothesised that in modern day society these evolved tendencies can become more inappropriately activated and result in some of the cognitive 'distortions' or 'irrationalities' identified in cognitive-behavioural models and therapies
Neurochemical and neurocognitive influences
Some scientists hypothesize that social phobia is related to an imbalance of the brain chemical serotonin. A recent study report increased Serotonin and Dopamine transporter binding in psychotropic medication-naive patients with Generalized Social Anxiety Disorder. Sociability is also closely tied to dopamine neurotransmission. Low D2 receptor binding is found in people with social anxiety. The efficacy of medications which affect serotonin and dopamine levels also indicates the role of these pathways. There is also increasing focus on other candidate transmitters, e.g. Norepinephrine, which may be over-active in social anxiety disorder, and the inhibitory transmitter GABA.
Individuals with social anxiety disorder have been found to have a hypersensitive amygdala, for example in relation to social threat cues (e.g. someone might be evaluating you negatively), angry or hostile faces, and while just waiting to give a speech. Recent research has also indicated that another area of the brain, the 'Anterior cingulate cortex', which was already known to be involved in the experience of physical pain, also appears to be involved in the experience of 'social pain', for example perceiving group exclusion.
Research has indicated the role of 'core' or 'unconditional' negative beliefs (e.g. I am inept) and 'conditional' beliefs nearer to the surface (e.g. If I show myself, I will be rejected). They are thought to develop based on personality and adverse experiences and to be activated when the person feels under threat. One line of work has focused more specifically on the key role of self-presentational concerns. The resulting anxiety states are seen as interfering with social performance and the ability to concentrate on interaction, which in turn creates more social problems, which strengthens the negative schema. Also highlighted has been a high focus on and worry about anxiety symptoms themselves and how they might appear to others. A similar model emphasises the development of a distorted mental representation of their self and over-estimates of the likelihood and consequences of negative evaluation, and of the performance standards that others have. Such cognitive-behavioral models consider the role of negatively-biased memories of the past and the processes of rumination after an event, and fearful anticipation before it. Studies have also highlighted the role of subtle avoidance and defensive factors, and shown how attempts to avoid feared negative evaluations or use 'safety behaviours' (Clark & Wells, 1995) can make social interaction more difficult and the anxiety worse in the long run. This work has been influential in the development of Cognitive Behavioural Therapy for social anxiety disorder, which has been shown to have efficacy.
Arguably the most important clinical point to emerge from studies of social anxiety disorder is the benefit of early diagnosis and treatment. Social anxiety disorder remains under-recognized in primary care practice, with patients often presenting for treatment only after the onset of complications such as clinical depression or substance abuse disorders.
Research has provided evidence for the efficacy of two forms of treatment available for social phobia: certain medications and a specific form of short-term psychotherapy called Cognitive-behavioral therapy (CBT), the central component being gradual exposure therapy.
Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are considered by many to be the first choice medication for generalised social phobia. These drugs elevate the level of the neurotransmitter serotonin, among other effects. The first drug formally approved by the Food and Drug Administration was paroxetine, sold as Paxil in the US or Seroxat in the UK. Compared to older forms of medication, there is less risk of tolerability and drug dependency. However, their efficacy and increased suicide risk has been subject to controversy.
In a 1995 double-blind, placebo-controlled trial, the SSRI paroxetine was shown to result in clinically meaningful improvement in 55 percent of patients with generalized social anxiety disorder, compared with 23.9 percent of those taking placebo. An October 2004 study yielded similar results. Patients were treated with either fluoxetine, psychotherapy, fluoxetine and psychotherapy, placebo and psychotherapy, and a placebo. The first four sets saw improvement in 50.8 to 54.2 percent of the patients. Of those assigned to receive only a placebo, 31.7 percent achieved a rating of 1 or 2 on the Clinical Global Impression-Improvement scale. Those who sought both therapy and medication did not see a boost in improvement.
General side-effects are common during the first weeks while the body adjusts to the drug. Symptoms may include headaches, nausea, insomnia and changes in sexual behavior. Treatment safety during pregnancy has not been established. In late 2004 much media attention was given to a proposed link between SSRI use and juvenile suicide. For this reason, the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor. Recent studies have shown no increase in rates of suicide. These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder. However, it should be noted that due to the nature of the conditions, those taking SSRIs for social phobias are far less likely to have suicidal ideation than those with depression.
Although SSRIs are often the first choice for treatment, other prescription drugs are also commonly issued, sometimes only if SSRIs fail to produce any clinically significant improvement.
In 1985, before the introduction of SSRIs, anti-depressants such as monoamine oxidase inhibitors (MAOIs) were frequently used in the treatment of social anxiety. Their efficacy appears to be comparable or sometimes superior to SSRIs or Benzodiazepines. However, because of the dietary restrictions required, high toxicity in overdose, and incompatibilities with other drugs, its usefulness as a treatment for social phobics is now limited. Some argue for their continued use, however, or that a special diet does not need to be strictly adhered to. A newer type of this medication, Reversible inhibitors of monoamine oxidase subtype A (RIMAs) inhibit the MAO enzyme only temporarily, improving the adverse-effect profile but possibly reducing their efficacy.
Benzodiazepines are a short-acting and more potent alternative to SSRIs. The drug is often used for short-term relief of severe, disabling anxiety. Alprazolam and clonazepam are usual benzodiazepines for social fear. Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is much concern over the development of drug tolerance, dependency and recreational abuse. Benzodiazepines augment the action of GABA, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours.
Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure. Taken in low doses, they control the physical manifestation of anxiety and can be taken before a public performance.
A novel treatment approach has recently been developed as a result of translational research. It has been shown that a combination of acute dosing of d-cycloserine (DCS) with exposure therapy facilitates the effects of exposure therapy of social phobia (Hofmann, Meuret, Smits, et al., 2006). DCS is an old antibiotic medication used for treating tuberculosis and does not have any anxiolytic properties per se. However, it acts as an agonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor site, which is important for learning and memory (Hofmann, Pollack, & Otto, 2006). It has been shown that administering a small dose acutely 1 hour before exposure therapy can facilitate extinction learning that occurs during therapy.
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). It has two main components. The cognitive component helps people become aware of and to change thinking patterns that keep them from overcoming their fears. A person with social phobia might be helped to question how they can be so sure 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. It also serves as a logical extension of cognitive therapy where people are shown proof in the real world that their dysfunctional thought processes are unrealistic. A key element of this component is gradual exposure, in which people confront the things they fear in a structured, sensitive manner. Gradual exposure is an inherently unpleasant technique. It involves four components, duration, frequency, graded and focused. Ideally the person should be exposed to a feared social situation that is anxiety provoking but bearable (graded) for as long as possible (duration), two to three times a day (frequency), and the person must endure the anxiety until it declines (focused). A hierarchy of feared steps is constructed and the patient is exposed to each step. The aim is also to learn from acting differently and observing reactions (behavioral 'experiments'). This is intended to be done with support and guidance when the therapist and patient feel they are ready. Cognitive-behavior therapy for social phobia also includes anxiety management training, which may include techniques such as deep breathing and muscle relaxation exercises, which may be practiced 'in-situ'. CBT may also be conducted partly in group sessions (Cognitive behavioral group therapy), facilitating the sharing of experiences, a sense of acceptance by others and undertaking behavioral challenges in a trusted environment (Heimberg).
Some studies have suggested social skills training can help with social anxiety. Whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations, does not seem to be clear.
Interpersonal Therapy has been shown to have efficacy for depression and a small study of the therapy in the treatment of social phobia suggests it may also work with social phobia.
Literary descriptions of shyness can be traced back to the days of Hippocrates around 400 B.C. Hippocrates described someone who 'through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him'.
Charles Darwin wrote about the physiology and social context of blushing and shyness. The first mention of a psychiatric term, social phobia ("phobie des situations sociales"), was made in the early 1900s. 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 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 phobia was revised in 1989 to allow comorbidity with avoidant personality disorder, and introduced generalized social phobia.  Social phobia had been largely ignored prior to 1985. After a call to action by psychiatrist Michael Liebowitz and clinical psychologist Richard Heimberg, there was an increase in research and attention on the disorder. The DSM-IV gave social phobia the alternative name Social Anxiety Disorder. Research in to the psychology and sociology of everyday social anxiety continued. Cognitive Behavioural models and therapies were developed for social anxiety disorder. In the 1990s, paroxetine became the first prescription drug in the US approved to treat social anxiety disorder, with others following.
A contemporary example of social anxiety disorder in literature can be found in New York City-based author Tao Lin's story-collection Bed in which a 20-something woman suffering from loneliness lays in her room listening to tapes her father bought her designed to cure, or help cure, social anxiety disorder.
Some argue that inherent problems with society such as a competitive culture, power imbalances, lack of care and poor social education in families cause social anxiety; they feel the diagnostic boundaries have been stretched too far and that clinical and media work is promoting the idea that any problems with shyness or social worries are a pathological medical condition requiring medical treatment. Some see this as being driven by pharmaceutical companies, either by direct advertising to the public or their financial influence on psychiatry. This view can be associated with anti-psychiatry.
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