Social Phobia: Overview

Disorders defines social anxiety disorder as a marked and persistent fear of social or performance situations in which embarrassment may occur (DSM). Exposure to these situations provokes an immediate anxiety response such as a panic attack (DSM). In order to be diagnosed, fear or avoidance of these situations must interfere significantly with the person’s normal routines, occupational or academic functioning, social activities or relationships, or a person must experience marked distress about having the phobia (DSM).

In 400 B. C. , Hippocrates described a young man that displayed the symptoms of a social anxiety disorder. “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” (Burton 2009). Throughout the 20th century, psychiatrists described extremely shy patients as having social phobia and social neurosis. British psychiatrists Isaac Marks and Michael Gelder proposed that social phobias be considered a distinct category separate from other simple phobias (Hope, Heimberg, Juster, & Turk 2005).

In 1980, the third edition of the Diagnostic and Statistical Manual of Mental Disorders introduced social phobia as an official psychiatric diagnosis. Social phobia was described as a fear of performance situations, but did not include fears of informal situations such as casual conversations or social situations. Patients with broad fears were likely to be diagnosed with avoidant personality disorder, which could not be diagnosed in conjunction with social phobia.

In 1985, psychiatrist Michael Liebowitz and psychologist Richard Heimberg initiated a call to action for research on social phobia (Weiner, Freedheim, Freedheim, Reynolds, Miller, Gallagher, Nelson, Gallagher, Nelson, Gallagher, & Nelson 2003). Due to the lack of research on social anxiety disorder, the disorder came to be known by many as the “neglected anxiety disorder” (Weiner, Freedheim, Freedheim, Reynolds, Miller, Gallagher, Nelson, Gallagher, Nelson, Gallagher, & Nelson 2003).

In 1987, the DSM-III-R introduces changes in some of the diagnostic criteria. To diagnosis social anxiety disorder the symptoms must cause “interference or marked distress” rather than simply “significant distress. ” It also became possible to diagnose social phobia and avoidant personality disorder in the same patient (Weiner, Freedheim, Freedheim, Reynolds, Miller, Gallagher, Nelson, Gallagher, Nelson, Gallagher, & Nelson 2003).

In 1994, the DSM-IV was released, and the disorder was defined as a “marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others” (Weiner, Freedheim, Freedheim, Reynolds, Miller, Gallagher, Nelson, Gallagher, Nelson, Gallagher, & Nelson 2003). The etiology of social anxiety disorder is largely attributed to genetics, and environmental factors. Family studies of individuals with social anxiety disorder show a higher incidence of the disorder than that found in the general population, and a twin study found a concordance rate of 15. % in dizygotes and a 24. 4% concordance in monozygotes (Kedler, Neale, Kessler, Heath & Eaves 1992. ).

Of course, there is very little evidence that the genetic factors attributed to social anxiety disorder extend beyond the link between environmental factors since there is very little evidence of neurobiological factors. Other than the fact that selective serotonin reuptake inhibitors (SSRIs) are effective treatments for social anxiety disorder, there is little evidence to implicate dysfunction of the serotonergic system (Jefferson 2001. . The lack of empirical data identifying neurobiological factors in causing the onset of social anxiety disorder is best stated in a quote by Dr. Murray B. Stein, a Professor of Psychiatry and Family & Preventive Medicine at the University of California San Diego, “It is clear that we have a long way to go before we can speak with authority about the ‘neurobiology of social phobia’” (Stein 1998. ) Therefore, environmental factors remain the most referred to etiological agent in the onset of social anxiety disorder.

Parenting traits such as over control, lack of warmth or rejection, and overprotection are known to be associated with the etiology of social anxiety disorder (Brooks, & Schmidt 2008). Some individuals with social anxiety disorder associate its onset with a specific social event or interaction that was particularly embarrassing or humiliating. Such a circumstance could be considered an adverse conditioning stimulus (Jefferson 2001). There is further evidence that poor results from quality of life assessments can be attributed to social anxiety disorder.

Individuals with major depressive disorder, obsessive-compulsive disorder (OCD), panic disorder, and social anxiety disorder have substantially poorer quality of life than community comparison cohorts. In many cases, the quality-of-life impairments associated with these anxiety disorders are equal to or greater than those seen with other chronic medical disorders (Rapaport, Clary, Fayyad, & Endicott 2005). Social anxiety disorder is a common disorder. The lifetime prevalence of SAD is somewhere between 7% and 13% in Western countries (Furmark 2002).

Furthermore, epidemiological studies have demonstrated that social anxiety disorder is the most widespread of all the anxiety disorders, and the third most common psychiatric disorder after major depression and alcohol abuse (Brooks, & Schmidt 2008). Therapy and medication are the most common treatments for social anxiety disorder. Cognitive behavioral therapy is the most utilized form of psychotherapy, and has been found to be successful in seventy-five percent of patients (“Social anxiety disorder,” 2009).

This type of therapy focuses on reminding the patient that it is their own thoughts, not other people or situations, that determine how they behave or react (“Social anxiety disorder,” 2009). In therapy, the patient is taught how to recognize and change the negative thoughts they have about themselves (“Social anxiety disorder,” 2009). Exposure therapy is also a common form of treatment for social anxiety disorder. In this type of therapy, the patient is gradually exposed to situations that they fear most (“Social anxiety disorder,” 2009).

Exposure therapy enables the patient to learn coping techniques, and develop the courage to face them (“Social anxiety disorder,” 2009). The patient is also exposed to role-playing with emphasis on developing the skills to cope with different social situations in a “safe” environment (“Social anxiety disorder,” 2009). There are several medications used to treat social anxiety disorder. These medications are typically serotonin reuptake inhibitors including Paxil, Zoloft, and Prozac (“Social anxiety disorder,” 2009).

A serotonin norepinephrine reuptake inhibitor (SNRI) drug such as Venlafaxine may also be used as a first-line therapy for social anxiety disorder (“Social anxiety disorder,” 2009). Typically, the patient begins with a low dosage, and is gradually increased to a full dosage, to minimize side effects (“Social anxiety disorder,” 2009). It may take up to three months of treatment before the patient begins to have noticeable improvement of symptoms (“Social anxiety disorder,” 2009). Social anxiety disorder remains a largely misunderstood, and under researched, disorder.

Momentum through increased clinical research, in depth understanding through treatment, and stricter guidelines for proper diagnosis are positive indications that Psychology has recognized the debilitating effects of social anxiety disorder on patients. In time, clinicians will be better prepared to treat patients suffering from this disorder, and will improve the lives of patients.

References

1. Brooks, C. A. , & Schmidt, L. A. (2008). Social anxiety disorder: a review of environmental risk factors. Neuropsychiatr Disease and Treatment, 4(1), Retrieved from http://www. ncbi. nlm. ih. gov/pmc/articles/PMC2515922/
2. Burton, Robert. (2009). The Anatomy of melancholy. Charlottesville, VA: The University of Virginia. Furmark T. (2002). Social phobia: overview of community surveys, Acta Psychiatrica Scandinavica, 105, Retrieved from http://www. ncbi. nlm. nih. gov/pubmed/11939957
3. Hope, Debra, Heimberg, Richard, Juster, Harlan, & Turk, Cynthia. (2005). Managing social anxiety. New York, NY: Oxford Univ Pr.
4. Jefferson, J. W. (2001). Physicians postgraduate press, inc.. Primary Care Companion to the Journal of Clinical Psychiatry, 3(1), Retrieved from http://www. cbi. nlm. nih. gov/pmc/articles/PMC181152/
5. Kedler, K. S. , Neale, M. C. , Kessler, R. C. , Heath, A. C. , and Eaves, L. J. (1992) The genetic epidemiology of phobias in women: the interrelationship of agoraphobia, social phobia, situational phobia, and simple phobia. Arch. Gen. Psychiatry.
6. Rapaport, M. H. , Clary, C, Fayyad, R, & Endicott, J. (2005). Quality-of-life impairment in depressive and anxiety disorders. American Journal of Psychiatry, 162(6), Retrieved from http://www. ncbi. nlm. nih. gov/pubmed/9861470
7. Social anxiety disorder (social phobia). (2009). Mayoclinic. com. Retrieved (2010, April 25), Retrieved from http://www. mayoclinic. com/health/social-anxiety-disorder/DS00595/DSECTION=treatments%2Dand%2Ddrugs
8. Stein, M. B. (1998). Neurobiological perspectives on social phobia: from affiliation to zoology. Biological Psychiatry, 44(12), Retrieved from http://www. ncbi. nlm. nih. gov/pubmed/9861470
9. Weiner, Irving, Freedheim, Donald, Freedheim, Donald, Reynolds, William, Miller, Gloria, Gallagher, Michela, Nelson, Randy, Gallagher, Michela, Nelson, Randy, Gallagher, Michela, & Nelson, Randy. (2003). Handbook of psychology. Hoboken, NJ: John Wiley & Sons Inc.