Social phobia is defined by DSM-IV-TR as an anxiety disorder characterized by a strong and persistent fear of social or performance situations in which the patient might feel embarrassment or humiliation. Generalized social phobia refers to a fear of most social interactions combined with fear of most performance situations, such as speaking in public or eating in a restaurant. Persons who are afraid of only one type of performance situation or afraid of only a few rather than most social situations may be described as having nongeneralized, circumscribed, or specific social phobia.
Social phobia, which is also known as social anxiety disorder, is a serious mental health problem in the United States. In any given year, social phobia affects 3.7% of the American population between the ages of 18 and 54, or about 5.3 million people. It is the third most common psychiatric condition after depression and alcoholism. Patients diagnosed with social phobia have the highest risk of alcohol abuse of all patients with anxiety disorders; in addition, they suffer from worse impairment than patients with major medical illnesses, including congestive heart failure and diabetes.
Social phobia varies in its development and initial presentation. In some young people, the disorder grows out of a long-term history of shyness or social inhibition. In others, social phobia becomes apparent following a move to a new school or similar developmental challenge. In adults, circumscribed social phobia may be associated with a change of occupation or job promotion, the most common example being the emergence of the disorder with regard to public speaking in a person whose previous jobs did not require them to make presentations or speeches in front of others. The onset of social phobia may be insidious, which means that it gets worse by slow degrees. About half of all patients, however, experience a sudden onset of social phobia following a particularly humiliating or frightening experience. For example, in one British case study the patient's social phobia developed abruptly after her father's sudden death. The patient had had an argument with him one morning and he was killed in an accident later in the day. The onset of social phobia almost always occurs in childhood or the midteens; onset after age 25 is unusual. The disorder is often a lifelong problem, although its severity may diminish in adult life.
Adults and adolescents with social phobia, as well as many children with the disorder, have sufficient insight to recognize that their fears are excessive or unwarranted. This factor often adds to their distress and feelings of inferiority.
Social phobia is of major concern to society as a whole for two reasons. One reason is the disorder's very high rate of comorbidity with such other mental health problems as major depression and substance abuse. In comparison with patients diagnosed with other anxiety disorders, patients with social phobia have higher averages of concurrent anxiety disorders (1.21 versus 0.45); comorbid depression or other disorders (2.05 versus1.19); and lifetime disorders (3.11 versus 2.05). The most common comorbid disorders diagnosed in patients with social phobia are major depression (43%); panic disorder (33%); generalized anxiety disorder (19%); PTSD (36%); alcohol or substance abuse disorder (18%); and attempted suicide (23%).
The second reason is the loss to the larger society of the gifts and talents that these patients possess. Social phobia can have a devastating effect on young people's intellectual life and choice of career, causing them to abandon their educations, stay stuck in dead-end jobs, refuse promotions involving travel or relocation, and make similar self-defeating choices because of their fear of classroom participation, job interviews, and other social interactions in educational and workplace settings. One sample of patients diagnosed with social phobia found that almost half had failed to finish high school; 70% were in the bottom two quartiles of socioeconomic status (SES); and 22% were on welfare. In addition to their academic and employment-related difficulties, people with social phobia have limited or nonexistent social support networks. They are less likely to marry and start families of their own because of their fear of interpersonal relationships. Many continue to live at home with their parents even as adults, or remain in unfulfilling relationships.
Causes and symptoms
The causes of social phobia appear to be a combination of physical and environmental factors.
NEUROBIOLOGICAL FACTORS. There is some evidence as of 2002 that social phobia can be inherited. A group of researchers at Yale has identified a genetic locus on human chromosome 3 that is linked to agoraphobia and two genetic loci on chromosomes 1 and 11q linked to panic disorder. Because social phobia shares some traits with panic disorder, it is likely that there are also genes that govern a person's susceptibility to social phobia. In addition, researchers at the National Institute of Mental Health (NIMH) have identified a gene in mice that appears to govern fearfulness.
Positron emission tomography (PET) scans of patients diagnosed with social phobia indicate that blood flow is increased in a region of the brain (the amygdala) associated with fear responses when the patients are asked to speak in public. In contrast, PET scans of control subjects without social phobia show that blood flow during the public speaking exercise is increased in the cerebral cortex, an area of the brain associated with thinking and evaluation rather than emotional arousal. The researchers have concluded that patients with social phobia have a different neurochemical response to certain social situations or challenges that activates the limbic system rather than the cerebral cortex.
TEMPERAMENT. A number of researchers have pointed to inborn temperament (natural predisposition) as a broad vulnerability factor in the development of anxiety and mood disorders, including social phobia. More specifically, children who manifest what is known as behavioral inhibition in early infancy are at increased risk for developing more than one anxiety disorder in adult life, particularly if the inhibition remains over time. Behavioral inhibition refers to a group of behaviors that are displayed when the child is confronted with a new situation or unfamiliar people. These behaviors include moving around, crying, and general irritability, followed by withdrawing, seeking comfort from a familiar person, and stopping what one is doing when one notices the new person or situation. Children of depressed or anxious parents are more likely to develop behavioral inhibition. One study of preadolescent children diagnosed with social phobia reported that many of these children had been identified as behaviorally inhibited in early childhood.
PSYCHOSOCIAL FACTORS. The development of social phobia is also influenced by parent-child interactions in a patient's family of origin. Several studies have found that the children of parents with major depression, whether or not it is comorbid with panic disorder, are at increased risk of developing social phobia. Children of parents with major depression and comorbid panic disorder are at increased risk of developing more than one anxiety disorder. A family pattern of social phobia, however, is stronger for the generalized than for the specific or circumscribed subtype.
It is highly likely that the children of depressed parents may acquire certain attitudes and behaviors from their parents that make them more susceptible to developing social phobia. One study of children with social phobia found that their cognitive assessment of ambiguous situations was strongly negative, not only with regard to the dangerousness of the situation but also in terms of their ability to cope with it. In other words, these children tend to overestimate the threats and dangers in life and to underestimate their strength, intelligence, and other resources for coping. This process of learning from observing the behavior of one's parents or other adults is called social modeling .
Still another psychosocial factor related to the development of social phobia in children and adolescents is the general disintegration in the social fabric of the developed countries since World War II. A number of social theorists as well as physicians and therapists have noted that children are exposed more frequently to both real-life and media depictions of aggressive behavior and abrasive language than earlier generations. Children also learn about frightening or unpleasant social realities at earlier and earlier ages. The increased rate of social phobia and school refusal among adolescent girls has been linked to the greater crudity of teasing from boys in junior high and high school. The American Association of University Women released a study in 1998 that reported that 70% of girls experience verbal sexual harassment in high school and 50%, unwanted sexual touching. In addition, the fortress mentality reflected in the architecture of high-rise apartment buildings and gated communities for those who can afford them also sends children the message that other people are to be feared. While trends in the larger society may not directly cause social phobia (or other mental disorders), they are nonetheless important indirect influences.
The symptoms of social phobia are somewhat different in children and adults, in that the early onset of social phobia typically means that children with the disorder fail to achieve at their predicted level, whereas adults and adolescents show declines from previously achieved levels of functioning.
SYMPTOMS IN CHILDREN. Symptoms of social phobia in children frequently include tantrums, crying, "freezing," clinging to parents or other familiar people, and inhibiting interactions to the point of refusing to talk to others (mutism).
SYMPTOMS IN ADULTS. The symptoms of social phobia in adults include a range of physical signs of anxiety as well as attitudes and behaviors.
- blushing, sweating, nausea, diarrhea, dry mouth, tremors, and other physical indications of anxiety
- difficulties with self-assertion
- extreme sensitivity to criticism, rejection, or negative evaluations
- intense preoccupation with the reactions and responses of others
- heightened fears of being embarrassed or humiliated
- avoidance of the feared situation(s) and anticipatory anxiety
In adults, there is often a "vicious circle" quality to the symptoms, in that the anxiety and symptoms lead to actual or perceived poor performances, which in turn increase the anxiety and avoidance. A common example is performance anxiety related to musical instruments; the person who is afraid of having to play the piano in a
Not all adults with social phobia appear shy or outwardly nervous to other people. Some adults are able to force themselves to attend social events, give public presentations, or interact with others by self-medicating with alcohol or limiting the time period of their interactions. These strategies, however, prevent the underlying fears and disabilities from being addressed.
The prevalence of social phobia in the general United States population is difficult to evaluate because researchers differ in their estimation of the threshold of "significant interference" with the person's occupational or educational functioning. In addition, different studies have focused on different subtypes of social phobia. One study found that about 20% of the adults surveyed reported high levels of anxiety related to public speaking or other types of public performance, but only 2% indicated sufficient distress to meet the diagnostic criteria of social phobia. Because of these differences in measurement, epidemiological and community-based studies give figures for a lifetime prevalence of social phobia that fall between 3% and 13%.
The types of situations associated with social phobia are different in the general population as contrasted with clinical populations. Surveys of adults in the general population indicate that most people diagnosed with social phobia are afraid of public speaking; only 45% report being afraid of meeting new people or having to talk to strangers. Fears related to eating, drinking, or writing in public, or using a public restroom, are much less common in this group of patients. By contrast, people being treated for social phobia in outpatient clinics are more likely to be afraid of a range of social situations rather than just one. Social phobia accounts for 10%–20% of the anxiety disorders diagnosed in patients in outpatient clinics, but it is rarely the reason for hospitalizing a patient.
The same difference between general and clinical populations affects the sex ratios given for social phobia. Community-based studies suggest that social phobia is more common in women, but in most samples of clinical patients, the sex ratio is either 1:1 or males are in the majority. A study of social phobia in prepubertal children found that girls were more likely to verbalize anxiety than boys, but the researchers who observed the children interact with adults and with one another did not observe any behavioral differences between boys and girls. The researchers concluded that the apparently higher rates of social phobia in women may simply reflect women's greater openness about their feelings.
With regard to race, the same study found no statistically significant difference in the incidence of social phobia between Caucasian and African American children. This finding was consistent with a 1995 study that failed to find differences based on race in lists of children's top 10 fears. Further research, however, is necessary in order to determine whether social phobia has different symptom patterns or rates of development in different racial or ethnic groups.
The demographics of social phobia in young children are particularly difficult to determine because of changes in diagnostic categories and criteria in successive editions of DSM. Social phobia was introduced as a diagnostic category in DSM-III , which was published in 1980. Neither DSM-III nor its 1987 revision restricted social phobia to adults, but the disorder was rarely diagnosed in children—most likely because DSM-III and DSM-III-R listed two diagnoses for children, overanxious disorder and avoidant disorder of childhood, whose symptoms overlapped with those of social phobia. Statistics based on DSM-III-R 's criteria for social phobia placed the prevalence of the disorder in children in the general population at about 1%. The revisions of the diagnostic criteria in DSM-IV , however, have led to an apparent dramatic increase in the prevalence of social phobia in children. One study done in 1997 reported that 18% of the children in a clinical sample met DSM-III-R criteria for social phobia, but that 40% of the children in the same sample had social phobia according to DSM-IV criteria.
The diagnosis of social phobia is usually made on the basis of the patient's history and reported symptoms. The doctor may also decide to administer diagnostic questionnaires intended to rule out other phobias, other anxiety disorders, and major depression. In diagnosing a child, the doctor will usually ask the child's parents, teachers, or others who know the child well for their observations.
Children and adolescents
A doctor who is evaluating a child for social phobia must take into account that children do not have the freedom that adults usually have to avoid the situations that frighten them. As a result, they may not be able to explain why they are anxious. It is important to evaluate the child's capacity for social relationships with people that he or she knows; and to assess his or her interactions with peers for indications of social phobia, not only his or her behavior around adults.
A semi-structured interview that a doctor can use to assess social phobia in children is the Anxiety Disorders Interview Schedule for Children, or ADIS-C. A newer clinician-administered test is the Liebowitz Social Anxiety Scale for Children and Adolescents, or LSAS-CA. Self-report inventories for children include the Child Depression Inventory , or CDI, and the Social Phobia and Anxiety Inventory for Children, or SPAI-C. Parents can be asked to complete the Child Behavior Checklist (CBL), and teachers may be given the Teacher's Report Form (TRF).
Diagnostic instruments for assessing social phobia in adults are more problematic. Some general screeners that are used in primary care settings, such as the Structured Clinical Interview for DSM-IV-Screen (SCID-Screen), do include questions related to social phobia but can take as long as 25 minutes to administer. Others, such as the Primary Care Evaluation of Mental Disorders, or Prime-MD, are not specific for social phobia. Instruments designed to measure social phobia by itself, such as the Fear of Negative Evaluation Scale and the Social Avoidance and Distress Scale, are lengthy and generally more useful for monitoring the progress of therapy. Another clinician-administered interview for social phobia in adults, the Liebowitz Social Anxiety Scale (LSAS), is not yet in widespread use.
Many physicians, however, have found that the addition of a few selected questions to a general screener for mental disorders is helpful in detecting social phobia. One study found that giving patients three specific statements with yes/no answers detected 89% of cases of social phobia:
- Being embarrassed or looking stupid are among my worst fears.
- Fear of embarrassment causes me to avoid doing things or speaking to people.
- I avoid activities in which I am the center of attention.
As of 2002 there are no laboratory tests or brain imaging techniques that can help to diagnose social phobia in adults.
Social phobia responds well to proper treatment; however, patients with social phobia have a distinctive set of barriers to treatment. Unlike persons with some other types of mental disorders, they are unlikely to deny that they have a problem. What researchers have found is that in comparison to persons suffering from other disorders, persons with social phobia are significantly more likely to say that financial problems, uncertainty over where to go for help, and fear of what others might think prevent them from seeking treatment. The researchers concluded that providing better information about community services as well as easing the psychological and financial burdens of patients with social phobia would significantly improve their chances of recovery. Left untreated, social phobia can become a chronic, disabling disorder that increases the patient's risk of suicide.
About 53% of patients diagnosed with social phobia are treated with medications. Drug treatment has proven beneficial to patients with this disorder; however, no one type of medication appears to be clearly superior to others. Selection of a medication depends on the subtype of the patient's social phobia; the presence of other mental disorders; and the patient's occupation and personal preferences.
Specific medications that are used to treat social phobia include:
- Benzodiazepine tranquilizers. These are often prescribed for patients who need immediate relief from anxiety. They have two major drawbacks, however; they are habit-forming, and they are unsuitable for patients with comorbid alcohol or substance abuse disorders. Benzodiazepines are, however, sometimes prescribed for patients who have a low risk for substance abuse and have not responded to other medications.
- Monoamine oxidase inhibitors (MAOIs). About twothirds of patients with social phobia show significant improvement when treated with these drugs. MAOIs, however, have the disadvantage of requiring patients to stick to a low-tyramine diet that excludes many popular foods, and requiring them to avoid many over-thecounter cold and cough preparations.
- Selective serotonin reuptake inhibitors (SSRIs). About 50%–75% of patients with social phobia benefit from treatment with SSRIs. The SSRIs appear to work best in patients with comorbid major depression or panic disorder. Sertraline (Zoloft) has been recommended for patients with generalized social phobia.
- Newer drugs. A recent placebo-controlled study indicates that gabapentin (Neurontin) shows promise as a treatment for social phobia.
- Beta blockers . These medications, which include propranolol (Inderal), are given to patients with mild to moderate circumscribed performance anxiety. The patient takes the medication on an as-needed basis rather than a standing dosage. Beta-blockers do not appear to be helpful for patients with generalized social phobia.
The type of psychotherapy most commonly recommended for treatment of social phobia is cognitive-behavioral therapy (CBT). Mild to moderate cases of social phobia often show considerable improvement with CBT alone; patients with more severe social phobia benefit from a combination of CBT and an appropriate medication. Cognitive-behavioral treatment of adults diagnosed with social phobia usually combines exposure therapy with cognitive restructuring techniques. In exposure therapy, the patient is exposed to small "doses" of the feared situation that are gradually lengthened in time. The chief drawback to exposure therapy for social phobia is that some feared situations are easier to replicate for purposes of treatment than others. Patients who are afraid of public speaking or musical performance can practice performing in front of any group of people that can be collected to help; but it is not so easy to arrange exposure sessions for a patient who is afraid of interactions with a specific teacher, employer, or supervisor. The other aspect of CBT that is used in treating social phobia in adults is cognitive restructuring. This approach challenges the patient to reconsider and then replace the biased cognitions that have led him or her to overestimate the dangers in social situations and to underestimate his or her own resources for coping with them.
Several trial programs of CBT group therapy have been used with adolescents with social phobia. One pilot program situated the group meetings in the school rather than in a clinic, on the grounds that most of the fears of adolescents with social phobia revolve around school activities. Another CBT group for adolescents was conducted in a clinical setting. Both programs included social skills training alongside exposure therapy and cognitive restructuring, and both were reported to be moderately successful at one-year follow-up.
Other approaches that have been used to treat social phobia include family therapy and relaxation techniques.
The prognosis for recovery from social phobia is good, given early diagnosis and appropriate treatment. The prognosis for persons with untreated social phobia, however, is poor. In most cases, these individuals become long-term underachievers, at high risk for alcoholism, major depression, and suicide.
Given that some of the factors implicated in social phobia are neurobiological or genetic, the best preventive strategy as of 2002 is early identification of children with behavioral inhibition and developing techniques for assisting their social development.
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Rebecca J. Frey, Ph.D.