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anxiety disorder

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Social phobias

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Social anxiety refers to feelings of fear, apprehension or worry about social situations and being evaluated by others. In psychiatry or psychology, recurrent disabling social anxiety can be diagnosed as social anxiety disorder, a form of anxiety disorder, also known as social phobia. According to some United States epidemiological data, it may be the third largest mental health care problem in the world, although other surveys suggest somewhat lower figures. A number of psychosocial approaches (e.g. cognitive behavioral techniques) and some medications appear to have efficacy in improving the disorder^[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.^[2] 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.^[3] 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.^[4]

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. ^[5] 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.^[6] There are some that argue that shyness is mistakenly treated with medication intended for social phobia, effectively labeling the personality trait a mental illness.^[7]

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 for any situation (work, school, et al.), not necessarily one involving other people.

Symptoms

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 for weeks or longer. This is complemented by the perception that they performed unsatisfactorily.^[8] 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.^[9]

Behavioral aspects

According to renowned 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 cross arms to avoid recognizable shaking.^[10] A fight-or-flight response is then triggered in such events. Stopping these automatic responses is a difficult problem facing social phobics.

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.^[11] 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.^[12] 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.^[13]

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.^[14] 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."^[15]

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 apparent of the anxiety disorders.^[16] 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. Recent studies suggest the lifetime prevalence number may be as high as 15 million people or 6.8% of the American population.^[17] Cross-cultural studies have reached prevalence rates with the conservative rates at 5% of the population.^[18][19] However, other estimates vary within 2% and 7% of the U.S. adult population. ^[20]

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 twice as often than males, although men are more likely to seek help.^[21] 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.^[22] Surveys carried out in 2002 show the youth of England, Scotland, and Wales have a prevalence rate of .4%, 1.8%, and .6%, respectively.^[23] 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%).^[24] 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.^[25]

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.^[26] 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.^[27] Besides depression, the most common disorders diagnosed in patients with social phobia are panic disorder (33%), generalized anxiety disorder (19%), post-traumatic stress disorder (36%), substance abuse disorder (18%), and attempted suicide (23%).^[28] 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 and depression in 75%, 61%, and 90% of patients, respectively. Avoidant personality disorder has also been correlated with social phobia.^[29] Because of its close relationship and overlapping symptoms with other illnesses, treating social phobics may help understand underlying connection in other psychiatric disorders.

Causes and perspectives

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. ^[30]

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.^{[31] [32]}

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.^[33] 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

Arguably 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 underrecognized in primary care practice, with patients presenting for treatment only after the onset of complications such as major depression or substance use disorders. 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. Improvement is lower for those with more severe social phobia and with comorbid disorders, such as avoidant personality disorder and depression. Other studies present the percentage of resolution from 50-70%.^[34] The patients who achieve full resolution are far lower than the above figures; there are still many who, after receiving treatment, are unable to function in the long-term without anxiety symptoms.

Research supported by NIMH has shown that there are two effective forms of treatment available for social phobia (and anxiety disorders): certain medications and a specific form of short-term psychotherapy called cognitive-behavioral therapy (CBT), the central component being exposure therapy. Medications include antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as drugs known as high-potency benzodiazepenes. A person can help alleviate anxiety by getting plenty of sleep, exercise, and having a balanced diet.

Pharmacological treatments

SSRIs

Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressant, are considered the first choice in defusing fears associated with social phobia and related anxiety disorders. These drugs are designed to elevate the level of the neurotransmitter serotonin. The first drug formally approved by the Food and Drug Administration was paroxetine, sold as Paxil. Compared to older forms of medication, there is little risk of tolerability and drug dependency. 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% of patients with generalized social anxiety disorder, compared with 23.9% of those taking placebo.^[35] 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% 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.^[36]

General side-effects are common during the first weeks while the body adapts to the drug. Symptoms may include headaches, nausea, insomnia, changes in sexual behavior. Pediatric and pregnancy studies have been largely inconclusive.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.^[37] Recent studies have shown no increase in rates of suicide.^[38] These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder.

Other drugs

Although SSRIs are often the first choice for treatment, other prescription drugs are also commonly issued.

Benzodiazepines are a more potent alternative to SSRIs. The drug is often used for short-term relief of severe, disabling anxiety. Although, benzodiazepines are prescribed for long-term use, there is much concern over the development of drug tolerance, dependency and recreational abuse. Benzodiazepines, such as Xanax augment the action of GABA, the major inhibitory neurotransmitter in the brain; effects may begin to appear within days or hours.^[39]

In 1985, before the introduction of SSRIs, anti-depressants such as, monoamine oxidase inhibitors (MAOIs), were frequently used in the treatment of social anxiety by researchers such as Michael Liebowitz. Irreversible MAOIs, most notably phenlzine, has been more efficacious than benzodiazepines in the short-term (8-12 weeks). Relapse is common, which may result in long-term usage. Because of the dietary restrictions, high toxicity in overdose, incompatibilities with other drugs have been limited its usefulness as a treatment for social phobics. Reversible inhibitors of monoamine oxidase subtype A (RIMAs) also inhibit monoamine oxidase. In contrast with MAOIs, reversibility means that they can inhibit the enzyme for a time only temporary. Because their action is short-lived and selective, they have a better safety profile than the older MAOI drugs. A special diet does not need to be strictly adhered to.^[40]

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 shaking of anxiety and can be taken before a public performance.

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.

Cognitive behavioral group therapy (CBGT), founded upon research done by Richard Heimberg, is a similar psychotherapeutic approach. It is generally held for 12 weekly sessions which run for two or three hours. A range of 4-10 patients and two therapists are involved in sharing individual experiences, participating in simulated exposures, and completing homework assignments in the goal of replacing irrational and automatic negative thoughts in social situations. A sample homework assignment might include reading a book or initiating a conversation with an acquaintance. Even in CBGT, sufferers are treated individually. Each person is exposed to different levels of anxious situations, depending on the severity of their illness.

These two types of cognitive behavior therapy have proven effective in reducing anxiety among social phobics. A 1998 study by Heimberg and Michael Liebowitz and a 2004 experiment showed the efficacy of CBGT.^[41][42]

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. 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. ^[43] Social phobia had been largely ignored prior to 1985. After a call to action by psychiatrist Michael Liebowitz, Richard Heimberg and the founding of the Anxiety Disorders Clinic, psychologists began conducting more research about the disorder. In the 1990s , paroxetine became the first prescription drug approved to treat social anxiety disorder. Two more drugs have since been approved by the FDA (sertraline and venlafaxine). Notable public figures with social phobia include NFl football player, Ricky Williams and American entertainment personality Donny Osmond.

Criticisms

Social Anxiety Disorder is frequently mentioned in association with criticisms that pharmaceutical companies attempt to market ordinary life experiences as "diseases" requiring a "cure", with a profit motive. Since the approval of Paxil in 1999 the disorder has been subject to extensive marketing campaigns. Major concerns are that people are receiving unnecessary treatment (which can do more harm than good), and that side affects are not properly mentioned. [44]

See also

• Agoraphobia
• Avoidant personality disorder
• Generalized anxiety disorder
• Introversion and extroversion
• Love-shyness
• Schizoid personality disorder
• Schizotypal personality disorder
• Selective mutism
• Shyness
• Social rejection
• Taijin kyofusho

References

1. ^  Social Phobia/Social Anxiety Association. What is Social Phobia?. Retrieved February 21, 2006.
2. ^  Diagnostic and Statistical Manual of Mental Disorders IV-TR. Social Phobia. Retrieved February 21, 2006.
3. ^  Crozier, W. Ray; Alden, Lynn E. International Handbook of Social Anxiety: Concepts, Research, and Interventions Relating to the Self and Shyness. page 18. New York John Wiley & Sons, Ltd. (UK), 2001. ISBN 0471491292.
4. ^  Crozier, page 242.
5. ^  Crozier, page 12.
6. ^  Crozier, page 10.
7. ^  Cable News Network (CNN). Anxiety disorder -- a problem beyond simple shyness. April 6, 2000. Retrieved February 21, 2006.
8. ^  Shyness & Social Anxiety Treatment Australia Social Phobia
9. ^  Furmark, Thomas. Social Phobia - From Epidemiology to Brain Function. Retrieved February 21, 2006.
10. ^  eNotes. Social phobia - Causes. Retrieved February 22, 2006.
11. ^  Crozier, page 4.
12. ^  Crozier, page 3.
13. ^  Stein, Murray B., Gorman, Jack M. Unmasking social anxiety disorder' February, 2001. Retrieved February 22, 2006.
14. ^  Surgeon General Adults and Mental Health 1999. Retrieved February 22, 2006.
15. ^  National Institute of Mental Health. Facts About Social Phobia. 1999. Retrieved February 22, 2006.
16. ^  Nordenberg, Tamar. FDA Consumer. U.S. Food and Drug Administration. Social Phobia's Traumas and Treatments. November-December 1999. Retrieved February 23, 2006.
17. ^  National Statistics. The mental health of young people looked after by local authorities in Scotland. 2002-2003. Retrieved February 23, 2006.
18. ^  Nova Scotia Department of Health. Social Anxiety in Nova Scotia. June 2004. Retrieved February 23, 2006.
19. ^  Senate Select Committee on Mental Health. Mental Health. 2003. Retrieved February 23, 2006.
20. ^  Book, Sarah W., Randall, Carrie L. Alcohol Research & Health. Social anxiety disorder and alcohol use. Early 2002. Retrieved February 23, 2006.
21. ^  Crozier, page 358-9.
22. ^  eNotes. Social phobia Retrieved February 23, 2006.
23. ^  Crozier, page 361.
24. ^  Kids Health website. Mental health disorders: Social phobia. Retrieved February 24, 2006.
25. ^  Surgeon General. Anxiety disorders. Retrieved February 24, 2006.
26. ^  National Institute of Mental Health. Phobia facts. Retrieved February 24, 2006.
27. ^  Food and Drug Administration Home Page. Tamar Nordenberg. Social Phobia's Traumas and Treatments. Retrieved February 24, 2006.
28. ^  Alcohol Research and Health. Sarah W. Book, Carrie L. Randall. Social anxiety disorder and alcohol use. Retrieved February 24, 2006.
29. ^  National Center for Health and Wellness. Causes of Social Anxiety Disorder. Retrieved February 24, 2006.
30. ^  Athealth.com. Social phobia. 1999. Retrieved February 24, 2006.
31. ^  Murray B. Stein, MD; Jack M. Gorman, MD. Journal of Psychiatry & Neuroscience Volume 26. Unmasking social anxiety disorder 2001. Retrieved March 1, 2006.
32. ^  Chang, Kiki D. Stanford University. eMedicine. Social Phobia. August 15, 2004. Retrieved February 24, 2006.
33. ^  Murray B. Stein, MD; Michael R. Liebowitz, MD; R. Bruce Lydiard, PhD, MD; Cornelius D. Pitts, RPh; William Bushnell, MS; Ivan Gergel, MD. Paroxetine Treatment of Generalized Social Phobia (Social Anxiety Disorder) April 1995 - February 1996. Retrieved February 24, 2006.
34. ^  Jonathan R. T. Davidson, MD; Edna B. Foa, PhD; Jonathan D. Huppert, PhD; Francis J. Keefe, PhD; Martin E. Franklin, PhD; Jill S. Compton, PhD; Ning Zhao, PhD; Kathryn M. Connor, MD; Thomas R. Lynch, PhD; Kishore M. Gadde, MD Fluoxetine, Comprehensive Cognitive Behavioral Therapy, and Placebo in Generalized Social Phobia October 2004. Retrieved February 24, 2006.
35. ^  Federal Drug and Administration. Class Suicidality Labeling Language for Antidepressants. 2004. Retrieved February 24, 2006.
36. {{note|ssri-suicide]} Group Health Cooperative. Study refutes link between suicide risk, antidepressants January 1, 2006. Retrieved February 24, 2006.
37. ^  Crozier, page. 478-80.
38. ^  Crozier, page. 475-477.
39. ^  Jonathan R. T. Davidson, MD; Edna B. Foa, PhD; et al. Fluoxetine, Comprehensive Cognitive Behavioral Therapy, and Placebo in Generalized Social Phobia 1998. Retrieved March 1, 2006.
40. ^  Richard G. Heimberg, PhD; Michael R. Liebowitz, MD. et al. Cognitive Behavioral Group Therapy vs Phenelzine Therapy for Social Phobia

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. [45]
• 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

There are numerous online resources on the topic of social anxiety; including research organisations, healthcare professionals, support groups and discussion forums. See the following:

• Social Anxiety at the Open Directory Project

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