Social phobia

Social phobia

DiseaseDisorder infobox
Name = Social phobias
ICD10 = ICD10|F|40|1|f|40, ICD10|F|93|2|f|90
ICD9 = ICD9|300.23

Social phobia (DSM-IV 300.23), also known as social anxiety disorder [ [ Webmd. Mental Health: Social Anxiety Disorder] ] (DSM-IV 300.23) is adiagnosis within psychiatry and other mental health professions referring to excessive social anxiety (anxiety in social situations) [ [ Webmd. Mental Health: Social Anxiety Disorder] ] causing abnormally considerable distress andimpaired ability to function in at least some areas of daily life. Thediagnosis can be of a "specific" disorder (when only some particularsituations are feared) or a "generalized" disorder. Generalized socialanxiety disorder typically involves a persistent, intense, and chronicfear of being judged by others and of potentially being embarrassed or
humiliated by one's own actions. These fears can be triggered byperceivedor actual scrutiny by others. While the fear of social interaction may berecognized by the person as excessive or unreasonable, considerabledifficulty can be encountered overcoming it. Approximately 13.3 percent of thegeneral population may meet criteria for social anxiety disorder at somepoint in their lifetime, according to the highest survey estimate, withthe male to female ratio being 1:1.5. [p. 29-30. [,%2BAssessment,%2Band%2BTreatment%2522%2B Social Phobia: Diagnosis, Assessment, and Treatment] . Richard G.Heimberg.Guilford Press]

Physical symptoms often accompanying social anxiety disorder includeexcessive blushing, sweating (hyperhidrosis),
trembling, palpitations, nausea, and stammering.
Panic attacks may also occur under intense fear and discomfort. Anearly diagnosis may help in minimizing the symptoms and thedevelopment of additional problems such as depression. Some sufferers mayuse alcohol or other drugs to reduce fears and inhibitions atsocial 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 socialphobia. The cognitive and behavioral components seek tochange thought patterns and physical reactions toanxious situations. Prescribed medicationsincludetwo classes of antidepressants: selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors(SNRIs). Attention given to social anxiety disorder has significantlyincreased in the US since 1999 with the approval and marketing of drugs for itstreatment.


Cognitive aspects

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 highperformance standards for themselves. According to the social psychologytheory of self-presentation, a suffererattemptsto create a well-mannered impression on others but believes he or she isunable to do so. Many times, prior to the potentially anxiety-provokingsocial situation, sufferers may deliberate over what could go wrong andhow to deal with each unexpected case. After the event, they may have the perception they performedunsatisfactorily. Consequently, they will review anything that may havepossibly been abnormal or embarrassing. These thoughts do not justterminate soon after the encounter, but may extend for weeks orlonger.Shyness & Social Anxiety Treatment Australia [ Social Phobia] ] Those with social phobia tend to interpret neutral or
ambiguous conversations with a negative outlook and many studies suggest that socially anxious individualsremember more negative memories than those less distressed.Furmark, Thomas. [ Social Phobia - From Epidemiology to Brain Function] . Retrieved February21, 2006.] An example of an instance may be that of an employeepresenting to his co-workers. During the presentation, the person may
stutter a word upon which he or she may worry that other peoplesignificantly noticed and think that he or she is a terrible presenter.This cognitive thought propels further anxiety which may lead to furtherstuttering, sweating and a possible panic attack.

Behavioral aspects

Social anxiety disorder is a persistent fear of one or more situations inwhich the person is exposed to possible scrutiny by others and fears thathe or she may do something or act in a way that will be humiliating orembarrassing. It exceeds normal "shyness" as it leads to excessivesocial 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", fastheartbeat, blushing, stomach ache. Cognitive distortions are a hallmark,and learned about in CBT (cognitive-behavioral therapy). Thoughts areoften self-defeating and inaccurate.

The groundless fear of the telephone is typical, both callingsomebody and answering the phone. It may appear early in childhood.

According to psychologist B.F. Skinner, phobias are controlled by
escape and avoidancebehaviors.For instance, a student may leave the room when talking in front of theclass (escape) and refrain from doing verbal presentations because of thepreviously encountered anxiety attack (avoid). Minor avoidance behaviorsare exposed when a person avoids eye contact and crosses arms to avoidrecognizable shaking. A fight-or-flight responseis then triggered in such events. Preventing these automatic responses isat the core of treatment for social anxiety.

Physiological aspects

Physiological effects, similar to those in other anxiety disorders, arepresent in social phobics. Faced with an uncomfortable situation,childrenwith social anxiety may display tantrums, weeping, clingingto parents, and shutting themselves out.eNotes. [ Social phobia - Causes] . Retrieved February 22, 2006.] In adults, itmay be tears as well as experiencing excessive
sweating, nausea, shaking, and palpitations as aresult of the fight-or-flight response. The walkdisturbance may appear,especially when passing a group of people. Blushing is commonlyexhibited by individuals suffering from social phobia. These visible symptoms further reinforce the anxiety in the presenceofothers. A 2006 study found that the area of the brain called the
amygdala, part of the limbic system, is hyperactive whenpatients are shown threatening faces or confronted with frighteningsituations. They found that patients with more severe social phobiashoweda correlation with the increased response in theamygdala. [ [ Studying Brain Activity Could Aid Diagnosis Of Social Phobia] . MonashUniversity. January 19, 2006.]


When prevalence estimates were based on the examination of psychiatricclinic samples, social anxiety disorder was thought to be a relativelyrare disorder. The opposite was instead true; social anxiety was commonbut many were afraid to seek psychiatric help, leading to anunderstatement of the problem. Prevalence ratesvarywidely because of its vague diagnostic criteria and its overlappingsymptoms with other disorders. There has been some debate on how thestudies are conducted and whether the illness truly impairs therespondents as laid out in the official criteria. Psychologist Dr. Ray Crozier argues, "it is difficult to ascertain whether the person beinginterviewed adheres to the DSM-III-R criteria or whether they are merelyexhibiting poor social skills or shyness."Crozier, page 4.]

The National Comorbidity Survey of over8,000 American correspondents in 1994 revealed a 12-month and lifetimeprevalence rates of 7.9 percent and 13.3 percent making it the third most prevalentpsychiatric disorder after depression and alcohol dependence and the mostapparent of the anxietydisorders. [ [ Social Anxiety Disorder: A Common, Underrecognized Mental Disorder] .American Family Physician. Nov 15, 1999.] 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 prevalence rates with theconservativerates at 5 percent of the population.Crozier,page3.] cite journal |author=Stein MB, Gorman JM |title=Unmasking social anxiety disorder |journal=J Psychiatry Neurosci |volume=26 |issue=3 |pages=185–9 |year=2001 |month=May |pmid=11394188 |pmc=1408304 |doi= |url=] However, other estimates vary within 2 percent and 7 percent of population.Surgeon General [ Adults and Mental Health] 1999. Retrieved February 22, 2006.]

Onset of social phobia typically occurs between 11 and 19 years of age.Onset after age 25 is rare. Social anxiety disorder occurs in femalesnearly twice as often as males, although men are more likely to seekhelp.National Institute of Mental Health. [ Facts About Social Phobia] . 1999. Retrieved February 22, 2006.] The prevalence ofsocialphobia appears to be increasing among white, married, and well-educatedindividuals. As a group, those with generalized social phobia are lesslikely to graduate from high school and are more likely to rely ongovernment financial assistance or have poverty-level salaries.Nordenberg, Tamar. "FDA Consumer". U.S. FoodandDrug Administration. [ Social Phobia's Traumas and Treatments] . November-December 1999.RetrievedFebruary 23, 2006.] 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.NationalStatistics. [ The mental health of young people looked after by local authorities in Scotland] . 2002-2003. Retrieved February 23, 2006.] The prevalenceofself-reported social anxiety for Nova Scotians older than 14 years was4.2 percentin June 2004 with women (4.6 percent) reporting more than men (3.8 percent).Nova Scotia Department of Health. [ Social Anxiety in Nova Scotia] . June 2004. Retrieved February 23, 2006.] In
Australia, social phobia is the 8th and 5th leading disease or illnessformales and females between 15-24 years of age as of 2003.Senate Select Committee on Mental Health. [ Mental Health] . 2003. Retrieved February 23, 2006.] Because of thedifficulty in separating social phobia from poor social skills orshyness,some studies have a large range of prevalence. [web cite|url=|title=Social phobia in the general population: prevalence and sociodemographic profile (Sweden)|author=Thomas Furmark|date=1999-09-01|accessdate=2007-03-28] The table also shows higher prevalence in Brazil.


There is a high degree of comorbidity with other psychiatricdisorders. Social phobia often occurs alongside low self-esteem and
clinical depression, due to lack of personal relationships and longperiods of isolation from avoiding social situations. To try to reducetheir anxiety and alleviate depression, people with social phobia may usealcohol or other drugs, which can lead to substance abuse. It isestimated that one-fifth of patients with social anxiety disorder alsosuffer from alcohol dependence.Alcohol ResearchandHealth. Sarah W. Book, Carrie L. Randall. [ "Social anxiety disorder and alcohol use"] . Retrieved February 24, 2006.] The most common complementary psychiatric condition isunipolar depression. In a sample of 14,263 people, of the 2.4 percent of personsdiagnosed with social phobia, 16.6 percent also met the criteria for
clinical depression.Crozier, page 358-9.] Besides depression,the most common disorders diagnosed in patients with social phobia are
panic disorder (33 percent), generalized anxiety disorder (19 percent),
post-traumatic stress disorder (36 percent), substanceabuse disorder (18 percent), and attempted suicide (23 percent).eNotes. [ Social phobia] Retrieved February 23, 2006.] In one study of socialanxiety disorder patients who developed comorbid alcoholism, panicdisorder or depression, social anxiety disorder preceded the onset ofalcoholism, panic disorder and depression in 75 percent, 61 percent, and 90 percent ofpatients, respectively. Avoidant personality disorder is also highlycorrelated with social phobia.Crozier,page 361.] Because of its close relationship and overlappingsymptomswith other illnesses, treating social phobics may help understandunderlying connection in other psychiatric disorders.

There is research indicating that social anxiety disorder is often correlated with bipolar disorder [cite journal |author=Pini S, Maser JD, Dell'Osso L, "et al" |title=Social anxiety disorder comorbidity in patients with bipolar disorder: a clinical replication |journal=J Anxiety Disord |volume=20 |issue=8 |pages=1148–57 |year=2006 |pmid=16630705 |doi=10.1016/j.janxdis.2006.03.006 |url=] .Some researchers believe they share an underlying cyclothymic-anxious-sensitive disposition. [cite journal |author=Perugi G, Akiskal HS |title=The soft bipolar spectrum redefined: focus on the cyclothymic, anxious-sensitive, impulse-dyscontrol, and binge-eating connection in bipolar II and related conditions |journal=Psychiatr. Clin. North Am. |volume=25 |issue=4 |pages=713–37 |year=2002 |month=Dec |pmid=12462857 |doi= |url=] In addition, studies show that more socially phobic patients treated with anti-depressant medication develop hypomania than non-phobic controls [] [cite journal |author=Valença AM, Nardi AE, Nascimento I, "et al" |title=Do social anxiety disorder patients belong to a bipolar spectrum subgroup? |journal=J Affect Disord |volume=86 |issue=1 |pages=11–8 |year=2005 |month=May |pmid=15820266 |doi=10.1016/j.jad.2004.12.007 |url=] , although this can be seen as the medication creating a new problem, and also has this adverse effect in a proportion of those without social phobia.

Causes and perspectives

Research into the causes of social anxiety and social phobia iswide-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 withenvironmental factors.

Genetic and family factors

It has been shown that there is a two to threefold greater risk ofhavingsocial phobia if a first-degree relative also has the disorder. Thiscouldbe due to genetics and/or due to children acquiring social fears andavoidance 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 twindevelopedsocial anxiety disorder, then the other was between 30 percent and 50 percent morelikelythan average to also develop the disorder. [cite journal
author=Kendler K, Karkowski L, Prescott C |title=Fears and phobias:reliability and heritability |journal=Psychol Med |volume=29 |issue=3
pages=539–53 |year=1999 |pmid=10405076 | doi = 10.1017/S0033291799008429
] To some extent this'heritability' may not be specific - for example, studies have found thatif a parent has any kind of anxiety disorder or clinical depression, thena child is somewhat more likely to develop an anxiety disorder or socialphobia. [Merikangas, S. Avenevoli, L. Dierker and C. Grillon (1999)Vulnerability factors among children at risk for anxiety disorders."Biol Psychiatry" 46 1523-1535] Studies suggest that parentsofthose with social anxiety disorder tend to be more socially isolatedthemselves (Bruch and Heimberg, 1994; Caster et al, 1999), and shyness inadoptive parents is significantly correlated with shyness in adoptedchildren (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 developanxiety disorders by late adolescence, [Warren S, Huston L, Egeland B,Sroufe L (1997) Child and adolescent anxiety disorders and earlyattachment. J Am Acad Child Adolesc Psychiatry 36:637-644.] including social phobia.

A related line of research has investigated 'behavioural inhibition' ininfants – early signs of an inhibited and introspective or fearfulnature. Studies have shown that around 10-15 percent of individuals show thisearly temperament, which appears to be partly due to genetics. Somecontinue to show this trait in to adolescence and adulthood, and appeartobe more likely to develop social anxiety disorder. [Schwartz C, SnidmanN, Kagan J (1999) Adolescent social anxiety as an outcome of inhibitedtemperament in childhood. J Am Acad Child Adolesc Psychiatry38:1008-1015]

ocial experiences

A previous negative social experience can be a trigger to socialphobia.National Center for Health and Wellness. [ Causes of Social Anxiety Disorder] . Retrieved February 24, 2006.] [ Social phobia] . 1999. Retrieved February 24, 2006.] perhaps particularlyfor individuals high in 'interpersonal sensitivity'. For around half ofthose diagnosed with social anxiety disorder, a specific traumatic orhumiliating social event appears to be associated with the onset orworsening of the disorder; [Mineka S, Zinbarg R (1995) Conditioning andethological models of social phobia. In: Heimberg R, Liebowitz M, Hope D,Schneier F, editors. Social Phobia: Diagnosis, Assessment, and Treatment.

New York: The Guilford Press, 134-162] this kind of event appearstobe particularly related to specific (performance) social phobia, forexample regarding public speaking (Stemberg "et al.", 1995). As well asdirect experiences, observing or hearing about the socially negativeexperiences of others (e.g. a faux pas committed by someone), or verbalwarnings of social problems and dangers, may also make the development ofa social anxiety disorder more likely. [Beidel, D.C., & Turner, S.M.(1998). Shy children, phobic adults: The nature and treatment of socialphobia. American Psychological Association Books.] Social anxietydisorder may be caused by the longer-term effects of not fitting in, orbeing bullied, rejected or ignored (Beidel and Turner, 1998). Shyadolescents or avoidant adults have emphasised unpleasant experienceswithpeers [Ishiyama F (1984) Shyness: Anxious social sensitivity andself-isolating tendency. Adolescence 19:903-911] or childhoodbullying or harassment (Gilmartin, 1987). In one study, popularity wasfound to be negatively correlated with social anxiety, and children whowere neglected by their peers reported higher social anxiety and fear ofnegative evaluation than other categories of children. [La Greca A,Dandes S, Wick P, Shaw K, Stone W (1988):Development of the socialanxietyscale for children: Reliability and concurrent validity. J Clin ChildPsychol 17:84-91] Socially phobic children appear less likely toreceive positive reactions from peers [cite journal |author=Spence SH, Donovan C, Brechman-Toussaint M |title=Social skills, social outcomes, and cognitive features of childhood social phobia |journal=J Abnorm Psychol |volume=108 |issue=2 |pages=211–21 |year=1999 |month=May |pmid=10369031 |doi= |url=] and anxious or inhibited children may isolate themselves. [cite journal |author=Rubin KH, Mills RS |title=The many faces of social isolation in childhood |journal=J Consult Clin Psychol |volume=56 |issue=6 |pages=916–24 |year=1988 |month=Dec |pmid=3204203 |doi= |url=]

ocial/cultural influences

Cultural factors that have been related to social anxiety disorderincludea society's attitude towards shyness and avoidance, affecting ability toform relationships or access employment or education. One study foundthatthe effects of parenting are different depending on the culture -Americanchildren appear more likely to develop social anxiety disorder if theirparents emphasize the importance of other's opinions and use shame as adisciplinary strategy (Leung "et al.", 1994), but this association wasnot found for Chinese/Chinese-American children. In China, research hasindicated that shy-inhibited children are more accepted than their peersand more likely to be considered for leadership and considered competent,in contrast to the findings in Western countries. [Xinyin, C. Rubin,KH,Boshu, L. (1995). Social and school adjustment of shy and aggressivechildren in China. Development and Psychopathology, 7, 337-349] Purely demographic variables may also play a role - for example there arepossibly lower rates of social anxiety disorder in Mediterraneancountries and higher rates in Scandinavian countries, and it has been hypothesisedthat hot weather and high-density may reduce avoidance and increaseinterpersonal contact.

Problems in developing social skills, or 'social effectiveness', may be acause of some social anxiety disorder, through either inability or lackof
confidence to interact socially and gain positive reactions andacceptancefrom others. The studies have been mixed, however, with some studies notfinding significant problems in social skills [cite journal |author=Rapee RM, Lim L |title=Discrepancy between self- and observer ratings of performance in social phobics |journal=J Abnorm Psychol |volume=101 |issue=4 |pages=728–31 |year=1992 |month=Nov |pmid=1430614 |doi= |url=] whileothers have. [cite journal |author=Stopa L, Clark D |title=Cognitiveprocesses in social phobia |journal=Behav Res Ther |volume=31 |issue=3
pages=255–67 |year=1993 |pmid=8476400 | doi = 10.1016/0005-7967(93)90024-O
] What does seem clear isthat the socially anxious perceive their own social skills to be low. Itmay be that the increasing need for sophisticated social skills informingrelationships or careers, and an emphasis on assertiveness andcompetitiveness, is making social anxiety problems more common, at leastamong the 'middle classes'. [cite journal |author=Heimberg RG, Stein MB, Hiripi E, Kessler RC |title=Trends in the prevalence of social phobia in the United States: a synthetic cohort analysis of changes over four decades |journal=Eur. Psychiatry |volume=15 |issue=1 |pages=29–37 |year=2000 |month=Feb |pmid=10713800 |doi= |url=] An interpersonal or mediaemphasison 'normal' or 'attractive' personal characteristics has also been arguedto fuel perfectionism and feelings of inferiority or insecurity regardingnegative evaluation from others. The need for social acceptance or socialstanding has been elaborated in other lines of research relating tosocialanxiety [cite journal |author=Baumeister R, Leary M |title=The needtobelong: desire for interpersonal attachments as a fundamental humanmotivation |journal=Psychol Bull |volume=117 |issue=3 |pages=497–529
year=1995 |pmid=7777651 | doi = 10.1037/0033-2909.117.3.497

Evolutionary context

A long-accepted evolutionary explanation of anxiety is that it reflectsanin-built 'fight or flight' system, which errs on the side of safety. Oneline of research suggests that specific dispositions to monitor and reactto social threats may have evolved, reflecting the vital and compleximportance of social living and social rank in human ancestralenvironments. Charles Darwin originally wrote about the evolutionarybasis of shyness and blushing, and modern evolutionary psychology andpsychiatry also addresses social phobia in this context. [cite journal |author=Gilbert P |title=Evolution and social anxiety. The role of attraction, social competition, and social hierarchies |journal=Psychiatr. Clin. North Am. |volume=24 |issue=4 |pages=723–51 |year=2001 |month=Dec |pmid=11723630 |doi= |url=] It has been hypothesised that in modern day society theseevolved tendencies can become more inappropriately activated and resultinsome of the cognitive 'distortions' or 'irrationalities' identified incognitive-behavioural models and therapies [cite journal |author=Gilbert P |title=The evolved basis and adaptive functions of cognitive distortions |journal=Br J Med Psychol |volume=71 ( Pt 4) |issue= |pages=447–63 |year=1998 |month=Dec |pmid=9875955 |doi= |url=]

Neurochemical and neurocognitive influences

Some scientists hypothesize that social phobia is related to an imbalanceof the brain chemical serotonin. A recent study report increased Serotonin and Dopamine transporter binding in psychotropic medication-naive patients with Generalized Social Anxiety Disorder. [Cite journal
author = van der Wee et al.
title = Increased Serotonin and Dopamine Transporter Binding in Psychotropic Medication–Naïve Patients with Generalized Social Anxiety Disorder Shown by 123I-β-(4-Iodophenyl)-Tropane SPECT
journal = The Journal of Nuclear Medicine
year = 2008
month = May
volume = 49
issue = 5
pages = 757–63
pmid = 18413401
doi = 10.2967/jnumed.107.045518
doi_brokendate = 2008-06-25
] Sociability is also closely tiedto dopamine neurotransmission. Low D2 receptorbinding is found in people with social anxiety.Murray B. Stein, MD; Jack M. Gorman, MD. "Journal ofPsychiatry & Neuroscience" Volume 26. [ Unmasking social anxiety disorder] 2001. Retrieved March 1, 2006.] The efficacy of medications which affect serotonin and dopamine levelsalso indicates the role of these pathways. There is also increasing focuson other candidate transmitters, e.g. Norepinephrine, which may beover-active in social anxiety disorder, and the inhibitory transmitterGABA.

Individuals with social anxiety disorder have been found to have ahypersensitive amygdala, for example in relation to social threatcues(e.g. someone might be evaluating you negatively), angry or hostilefaces,and while just waiting to give a speech. [cite journal |author=Davidson RJ, Marshall JR, Tomarken AJ, Henriques JB |title=While a phobic waits: regional brain electrical and autonomic activity in social phobics during anticipation of public speaking |journal=Biol. Psychiatry |volume=47 |issue=2 |pages=85–95 |year=2000 |month=Jan |pmid=10664824 |doi= |url=] Recent research hasalso indicated that another area of the brain, the 'Anterior cingulate cortex', which was already known to be involved in the experience ofphysical pain, also appears to be involved in the experience of 'socialpain', for example perceiving group exclusion. [cite journal |author=Eisenberger NI, Lieberman MD, Williams KD |title=Does rejection hurt? An FMRI study of social exclusion |journal=Science (journal) |volume=302 |issue=5643 |pages=290–2 |year=2003 |month=Oct |pmid=14551436 |doi=10.1126/science.1089134 |url=]

Psychological factors

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 developbased on personality and adverse experiences and to be activated when theperson feels under threat. [Beck AT, Emery G, Greenberg RL (1985)Anxiety Disorders and Phobias: A Cognitive Perspective. New York: BasicBooks.] One line of work has focused more specifically on the keyrole of self-presentational concerns. [Leary, M.R., & Kowalski, R.M.(1995) Social Anxiety. London: Guildford Press] [Leary, M.R.,Kowalski, R.M, Campbell, C.D. (1988). Self-presentational concerns andsocial anxiety: the role of generalised impression expectancies. Journalof Research in Personality, 22, 308-321.] The resulting anxietystates are seen as interfering with social performance and the ability toconcentrate on interaction, which in turn creates more social problems,which strengthens the negative schema. Also highlighted has been a highfocus on and worry about anxiety symptoms themselves and how they mightappear to others. [Clark, D. M., & Wells, A. (1995). A cognitive modelof social phobia. In. R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F.R.Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pg41-68). Guilford Press: New York.] A similar model [cite journal |author=Rapee RM, Heimberg RG |title=A cognitive-behavioral model of anxiety in social phobia |journal=Behav Res Ther |volume=35 |issue=8 |pages=741–56 |year=1997 |month=Aug |pmid=9256517 |doi= |url=] emphasisesthe development of a distorted mental representation of their self andover-estimates of the likelihood and consequences of negative evaluation,and of the performance standards that others have. Suchcognitive-behavioral models consider the role of negatively-biasedmemories of the past and the processes of rumination after an event, andfearful anticipation before it. Studies have also highlighted the role ofsubtle avoidance and defensive factors, and shown how attempts to avoidfeared negative evaluations or use 'safety behaviours' (Clark & Wells,1995) can make social interaction more difficult and the anxiety worse inthe long run. This work has been influential in the development ofCognitive Behavioural Therapy for social anxiety disorder, which has beenshown to have efficacy.


Arguably the most important clinical point to emerge from studies ofsocial 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 treatmentavailable for social phobia: certain medications and a specific form ofshort-term psychotherapy called Cognitive-behavioral therapy (CBT), thecentral component being gradual exposure therapy.

Pharmacological treatments


Selective serotonin reuptake inhibitors (SSRIs), a class ofantidepressants, are considered by many to be the first choice medicationfor generalised social phobia. These drugs elevate the level of theneurotransmitter serotonin, among other effects. The first drug formallyapproved by the Food and Drug Administration was paroxetine, soldas Paxil in the US or Seroxat in the UK. Compared to older forms of medication, there isless risk of tolerability and drug dependency. [cite book|coauthors=Stuart Montgomery, Hans Den Boer|title=SSRIs in Depression and Anxiety|ISBN=0-4708-4136-2|pages=109-111|publisher=John Wiley and Sons] However, their efficacy and increased suicide risk hasbeen subject to controversy.

In a 1995 double-blind, placebo-controlled trial, the SSRIparoxetine was shown to result in clinically meaningful improvementin55 percent of patients with generalized social anxiety disorder, compared with23.9 percent of those taking placebo.cite journal |author=Stein MB, Liebowitz MR, Lydiard RB, Pitts CD, Bushnell W, Gergel I |title=Paroxetine treatment of generalized social phobia (social anxiety disorder): a randomized controlled trial |journal=JAMA |volume=280 |issue=8 |pages=708–13 |year=1998 |month=Aug |pmid=9728642 |doi= |url= ] An October 2004 study yielded similar results. Patients were treated witheither fluoxetine, psychotherapy, fluoxetine and psychotherapy,placebo and psychotherapy, and a placebo. The first four sets sawimprovement in 50.8 to 54.2 percent of the patients. Of those assigned toreceiveonly a placebo, 31.7 percent achieved a rating of 1 or 2 on the
Clinical Global Impression-Improvement scale. Those who sought both therapy andmedication did not see a boost in improvement.cite journal |author=Davidson JR, Foa EB, Huppert JD, "et al" |title=Fluoxetine, comprehensive cognitive behavioral therapy, and placebo in generalized social phobia |journal=Arch. Gen. Psychiatry |volume=61 |issue=10 |pages=1005–13 |year=2004 |month=Oct |pmid=15466674 |doi=10.1001/archpsyc.61.10.1005 |url=]

General side-effects are common during thefirst 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. [eMedicine|med|3121|Social Phobia] In late 2004 much media attention was giventoa proposed link between SSRI use and juvenilesuicide.For this reason, the use of SSRIs in pediatric cases of depression is nowrecognized by the Food and Drug Administration as warranting a cautionarystatement to the parents of children who may be prescribed SSRIs by afamily doctor.Federal Drug and Administration. [ Class Suicidality Labeling Language for Antidepressants] . 2004. Retrieved February 24, 2006.] Recent studies have shown no increase in ratesof suicide.Group Health Cooperative. [ Study refutes link between suicide risk, antidepressants] January 1, 2006. Retrieved February 24, 2006.] 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 suicidalideation than those with depression.

Other drugs

Although SSRIs are often the first choice for treatment, otherprescription drugs are also commonly issued, sometimes only if SSRIs failto produce any clinically significant improvement.

In 1985, before the introduction of SSRIs, anti-depressants such as
monoamine oxidase inhibitors (MAOIs) were frequently used in thetreatment of social anxiety. Their efficacy appears to be comparable orsometimes superior to SSRIs or Benzodiazepines. However, because of the
dietary restrictions required, high toxicity inoverdose, and incompatibilities with other drugs, its usefulness as atreatment for social phobics is now limited. Some argue for theircontinued use, however, or that a special diet does not need to bestrictly adhered to.Crozier, page.475-477.] A newer type of this medication, Reversible inhibitors ofmonoamineoxidase subtype A (RIMAs) inhibit the MAO enzyme only temporarily,improving the adverse-effect profile but possibly reducing theirefficacy.

Benzodiazepines are a short-acting and more potent alternative to SSRIs. The drug is often used forshort-term relief of severe, disabling anxiety. Alprazolam and clonazepam are usual benzodiazepines for social fear. Although benzodiazepinesare still sometimes prescribed for long-term everyday use in some countries, thereis much concern over the development of drug tolerance, dependency and recreational abuse.Benzodiazepines augment the action of GABA, the major inhibitoryneurotransmitter in the brain; effects usually begin to appear withinminutes or hours.

Some people with a form of social phobia called performance phobia havebeen helped by beta-blockers, which are more commonly used to controlhigh blood pressure. Taken in low doses, they control the physicalmanifestation of anxiety and can be taken before a public performance.

A novel treatment approach has recently been developed as a result oftranslational research. It has been shown that a combination of acutedosing of d-cycloserine (DCS) with exposure therapy facilitates theeffectsof exposure therapy of social phobia (Hofmann, Meuret, Smits, et al.,2006). DCS is an old antibiotic medication used for treating tuberculosisand does not have any anxiolytic properties per se. However, it acts asanagonist 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 hourbefore exposure therapy can facilitate extinction learning that occursduring therapy.


Research has shown that a form of psychotherapy that is effective for several anxiety disorders, particularly panic disorder and social phobiaJonathan R. T. Davidson, MD; Edna B. Foa, PhD; "etal." [ Fluoxetine, Comprehensive Cognitive Behavioral Therapy, and Placebo in Generalized Social Phobia] 1998. Retrieved March 1, 2006.] 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 [Mersch "et al.", 1991] . 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 [Stravynski & Amado, 2001] .

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 [Lipsitz et al, 1999] .


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 physiologyand social context of blushing and shyness. The first mention of apsychiatric term, social phobia ("phobie des situations sociales"), wasmade 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 phobiasand their treatment grew. The idea that social phobia was a separateentity 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 ofthe Diagnostic and Statistical Manual of Mental Disorders. The definitionof 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 inresearch and attention on the disorder. The DSM-IV gave social phobia thealternative name Social Anxiety Disorder. Research in to the psychologyand sociology of everyday social anxiety continued. Cognitive Behaviouralmodels and therapies were developed for social anxiety disorder. In the1990s , paroxetine became the first prescriptiondrug in the US approved to treat social anxiety disorder, with othersfollowing.


Some argue that inherent problems with society such as a competitiveculture, power imbalances, lack of care and poor social education in families cause social anxiety; they feel the diagnostic boundaries have beenstretched too far and that clinical and media work is promoting the ideathat any problems with shyness or social worries are a pathologicalmedical condition requiring medical treatment. Some see this as beingdriven by pharmaceutical companies, either by direct advertising tothe public or their financial influence on psychiatry. [cite journal
title=Disorders Made to Order| first=Brendan I.| last=Koerner
month=July/August| year=2002 | journal=Mother Jones
] This view can be associated with anti-psychiatry.

ee also


Further reading

* 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.
* Berent, Jonathan, with Amy Lemley (1993). "Beyond Shyness: How to Conquer Social Anxieties". New York: Simon & Shuster. ISBN 0-671-74137-3.
* Bruch, M. A. (1989). Familial and developmental antecedents of social phobia: Issues and findings. "Clinical Psychology Review, 9", 37-47.
* Burns, D. D. (1999). "Feeling good: The new mood therapy" (Rev. ed.). New York: Avon. ISBN 0-380-81033-6.
* Crozier, W. R., & Alden, L. E. (2001). "International Handbook of Social Anxiety: Concepts, Research, and Interventions Relating to the Self and Shyness". New York: John Wiley & Sons, Ltd. ISBN 0-471-49129-2.
* Hales, R. E., & Yudofsky, S. C. (Eds.). (2003). Social phobia. In "Textbook of Clinical Psychiatry" (4th ed., pp. 572–580). Washington, D.C.: American Psychiatric Publishing.
* Samson, A. (2002). Psychiatric conceptions of "social phobia": A comparative perspective. "Swiss Journal of Sociology, 28"(3), 505–527.

External links

* [ Social Anxiety at the Open Directory Project]
* [ Anxiety Disorders Association of America] - Help for people with anxiety disorders, including social anxiety disorder

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