Social Anxiety Disorder (Social Phobia)
Are you shy? Do you feel anxious in social situations? Then you might be suffering from what is called Social Anxiety Disorder. Most of us do not like to be embarrassed in front of others or being rejected by other people. Social Anxiety Disorder (also referred to as social phobia) involves the fear of social situations, including situations that involve scrutiny or contact with strangers.
The term social anxiety disorder is distinctly different from specific phobia, which is the intense and persistent fear of an object or situation. Persons with social anxiety disorder are fearful of embarrassing themselves in social situations (i.e., social gatherings, oral presentations, meeting new people). They may have specific fears about performing specific activities such as eating or speaking in front of others, or they may experience a vague, nonspecific fear of “embarrassing oneself.” In either case, the fear in social anxiety disorder is of the embarrassment that may occur in the situation, not of the situation itself.
One of the most common social fears is that of public speaking. In one of the study nearly half of college students identify themselves as "shy" and say they get nervous on meeting new people or encountering unfamiliar social situations.
People with social anxiety disorder become so anxious in social situations and are so afraid of being rejected, judged, or humiliated in public that they are preoccupied with worries about such events to the point that their lives may become focused on avoiding social encounters. In most cultures, it is easier to avoid snakes or spiders than it is to avoid social situations.
In social situations, people with social anxiety disorder may tremble and perspire, feel confused and dizzy, have heart palpitations, and eventually have a full panic attack. They feel others view their nervousness and judge them as inarticulate, weak, stupid, or crazy. People with social anxiety disorder may avoid eating or drinking in public, for fear that they will make noise while they are eating, drop food, or otherwise embarrass themselves. They may avoid writing in public, for they are afraid that others will see their hands tremble. Especially men with social anxiety disorder often avoid urinating in public washrooms.
In short Social phobia is shyness taken to an extreme. People with a social phobia, have an intense fear of being scrutinized by others and avoid potentially embarrassing social situations.
EPIDEMIOLOGY
Various studies have reported a lifetime prevalence ranging from 3 to 13 percent for social anxiety disorder. According to Kessler et al., 2005 and Ruscio et al., 2008; approximately 12 percent of the population meets the diagnostic criteria for social phobia at some point in their lives. The 6-month prevalence is about 2 to 3 per 100 persons. In epidemiological studies, females are affected more often than males (about 60 percent of sufferers are women), and it typically begins during adolescence or early adulthood (Bruce et al., 2005; Ruscio et al., 2008). The peak age of onset for social anxiety disorder is in the teens, although onset is common as young as 5 years of age and as old as 35 years.
Social phobia is more common among women. Nearly two-thirds of people with social phobia suffer from one or more additional anxiety disorders at some point in their lives, and about 50 percent also suffer from a depressive disorder at the same time (Kessler, et al., 2005; Ruscio et al., 2008).
Approximately one-third abuse alcohol to reduce their anxiety and help them face the situations they fear (Magee et al., 1996).
Moreover, because of their distress and avoidance of social situations, people with social phobia, on average, have lower employment rates and lower socioeconomic status, and approximately one-third have severe impairment in one or more domains of their life (Ruscio et al., 2008).
COMORBIDITY
Persons with social anxiety disorder may have a history of other anxiety disorders, mood disorders, substance-related disorders, and bulimia nervosa.
Chronic social isolation during a social anxiety disorder may result in major depressive disorder. Comorbidity with depression is high among older adults.
Substances may be used as self-medication for social fears, but the symptoms of substance intoxication or withdrawal, such as trembling, may also be a source of (further) social fear.
Social anxiety disorder is frequently comorbid with bipolar disorder or body dysmorphic disorder. The more generalized form of social anxiety disorder is often comorbid with avoidant personality disorder. In children, comorbidities with high-functioning autism and selective mutism are common.
DEVELOPMENT AND COURSE
Onset of social anxiety disorder may follow a stressful or humiliating experience (e.g., being bullied, vomiting during a public speech), or it may be insidious, developing slowly. First onset in adulthood is relatively rare and is more likely to occur after a stressful or humiliating event or after life changes that require new social roles (e.g., marrying someone from a different social class, receiving a job promotion). Social anxiety disorder may diminish after an individual with fear of dating marries and may re-emerge after divorce.
Adolescents endorse a broader pattern of fear and avoidance, including of dating, compared with younger children.
Older adults express social anxiety at lower levels but across a broader range of situations, whereas younger adults express higher levels of social anxiety for specific situations. In older adults, social anxiety may concern disability due to declining sensory functioning (hearing, vision) or embarrassment about one's appearance (e.g., tremor as a symptom of Parkinson's disease) or functioning due to medical conditions, incontinence, or cognitive impairment (e.g., forgetting people's names). In the community approximately 30% of individuals with social anxiety disorder experience remission of symptoms within one year, and about 50% experience remission within a few years. For approximately 60% of individuals without a specific treatment for social anxiety disorder, the course takes several years or longer. Detection of social anxiety disorder in older adults may be challenging because of several factors, including a focus on somatic symptoms, comorbid medical illness, limited insight, changes to social environment or roles that may obscure impairment in social functioning, or silence about describing psychological distress.
RISK AND PROGNOSTIC FACTORS
Risk and prognostic factors for Social Anxiety Disorder are:
1. Temperamental: - Underlying traits that predispose individuals to social anxiety disorder include behavioural inhibition and fear of negative evaluation. Several studies have reported that children have a trait characterized by a consistent pattern of behavioural inhibition. This trait was particularly common in the children of parents who are affected with panic disorder, and it may develop into severe shyness as the children grow older.
2. Environmental: - There is no causative role of increased rates of childhood maltreatment or other early-onset psychosocial adversity in the development of social anxiety disorder. However, childhood maltreatment and adversity are risk factors for social anxiety disorder.
3. Genetic and physiological: - Traits predisposing individuals to social anxiety disorder, such as behavioural inhibition, are strongly genetically influenced. The genetic influence is subject to gene-environment interaction; that is, children with high behavioural inhibition are more susceptible to environmental influences, such as socially anxious modeling by parents. Also, social anxiety disorder is heritable with first-degree relatives having a two to six times greater chance of having social anxiety disorder, and liability to the disorder involves the interplay of disorder-specific (e.g., fear of negative evaluation) and nonspecific (e.g., neuroticism) genetic factors.
FUNCTIONAL CONSEQUENCES OF SOCIAL ANXIETY DISORDER
Social anxiety disorder is associated with elevated rates of school dropout and with decreased well-being, employment, workplace productivity, socioeconomic status, and quality of life.
Social anxiety disorder is also associated with being single, unmarried, or divorced and with not having children, particularly among men.
In older adults, there may be impairment in care giving duties and volunteer activities. Social anxiety disorder also impedes leisure activities.
Despite the extent of distress and social impairment associated with social anxiety disorder, only about half of individuals with the disorder in Western societies ever seek treatment, and they tend to do so only after 15-20 years of experiencing symptoms. Not being employed is a strong predictor for the persistence of social anxiety disorder.
DIAGNOSIS AND CLINICAL FEATURES
The Clinician should recognize that at least some degree of social anxiety or self-consciousness is common in the general population.
Community studies suggest that roughly one-third of all persons consider themselves to be far more anxious than other people in social situations. Moreover, such concerns may appear particularly heightened during certain developmental stages, such as adolescence, or after life transitions, such as marriage or occupation changes, associated with new demands for social interaction. Such anxiety only becomes social anxiety disorder when the anxiety either prevents an individual from participating in desired activities or causes marked distress during such activities.
DSM-5 also includes a performance only diagnostic specifier for persons who have extreme social phobia explicitly about speaking or performing in public.
Diagnostic criteria for Social Anxiety Disorder according to DSM-5 are:
A. Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g., having a conversation, meeting unfamiliar people), being observed (e.g., eating or drinking), and performing in front of others (e.g., giving a speech).
Note: In children, the anxiety must occur in peer settings and not just during interactions with adults.
B. The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing: will lead to rejection or offend others).
C. The social situations almost always provoke fear or anxiety.
Note: In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
D. The social situations are avoided or endured with intense fear or anxiety.
E. The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the socio-cultural context.
F. The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
G. The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
H. The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
I. The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as panic disorder, body dysmorhic disorder, or autism spectrum disorder.
J. If another medical condition (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.
Specify if:
1. Performance only: If the fear is restricted to speaking or performing in public.
Specifiers
Individuals with the performance only type of social anxiety disorder have performance fears that are typically most impairing in their professional lives (e.g., musicians, dancers, performers, athletes) or in roles that require regular public speaking. Performance fears may also manifest in work, school, or academic settings in which regular public presentations are required. Individuals with performance only social anxiety disorder do not fear or avoid nonperformance social situations.
DIAGNOSTIC FEATURES IN DETAIL DESCRIPTION
The essential feature of social anxiety disorder is a marked, or intense, fear or anxiety of social situations in which the individual may be scrutinized by others. In children the fear or anxiety must occur in peer settings and not just during interactions with adults (Criterion A). When exposed to such social situations, the individual fears that he or she will be negatively evaluated. The individual is concerned that he or she will be judged as anxious, weak, crazy, stupid, boring, intimidating, dirty, or unlikable.
The individual fears that he or she will act or appear in a certain way or show anxiety symptoms, such as blushing, trembling, sweating, stumbling over one's words, or staring, that will be negatively evaluated by others (Criterion B). Some individuals fear offending others or being rejected as a result. Fear of offending others, for example, by a gaze or by showing anxiety symptoms, may be the predominant fear in individuals from cultures with strong collectivistic orientations. An individual with fear of trembling of the hands may avoid drinking, eating, writing, or pointing in public; an individual with fear of sweating may avoid shaking hands or eating spicy foods; and an individual with fear of blushing may avoid public performance, bright lights, or discussion about intimate topics. Some individuals fear and avoid urinating in public restrooms when other individuals are present (i.e., paruresis, or"shy bladder syndrome").
The social situations almost always provoke fear or anxiety (Criterion C). Thus, an individual who becomes anxious only occasionally in the social situation(s) would not be diagnosed with social anxiety disorder. However, the degree and type of fear and anxiety may vary (e.g., anticipatory anxiety, a panic attack) across different occasions. The anticipatory anxiety may occur sometimes far in advance of upcoming situations (e.g., worrying every day for weeks before attending a social event, repeating a speech for days in advance). In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, or shrinking in social situations. The individual will often avoid the feared social situations.
Alternatively, the situations are endured with intense fear or anxiety (Criterion D). Avoidance can be extensive (e.g., not going to parties, refusing school) or subtle (e.g., over preparing the text of a speech, diverting attention to others, limiting eye contact). The fear or anxiety is judged to be out of proportion to the actual risk of being negatively evaluated or to the consequences of such negative evaluation (Criterion E). Sometimes, the anxiety may not be judged to be excessive, because it is related to an actual danger (e.g., being bullied or tormented by others). However, individuals with social anxiety disorder often over estimate the negative consequences of social situations, and thus the judgment of being out of proportion is made by the clinician. The individual's socio-cultural context needs to be taken into account when this judgment is being made. For example, in certain cultures, behaviour that might otherwise appear socially anxious may be considered appropriate in social situations (e.g., might be a sign of respect).
The duration of the disturbance is typically at least 6 months (Criterion F). This duration threshold helps distinguish the disorder from transient social fears that are common, particularly among children and in the community. However, the duration criterion should be used as a general guide, with allowance for some degree of flexibility. The fear, anxiety, and avoidance must interfere significantly with the individual's normal routine, occupational or academic functioning, or social activities or relationships, or must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion G). For example, an individual who is afraid to speak in public would not receive a diagnosis of social anxiety disorder if this activity is not routinely encountered on the job or in classroom work, and if the individual is not significantly distressed about it. However, if the individual avoids, or is passed over for, the job or education he or she really wants because of social anxiety symptoms. (Criterion G is met).
ASSOCIATED FEATURES SUPPORTING DIAGNOSIS:
Individuals with social anxiety disorder may be inadequately assertive or excessively submissive or, less commonly, highly controlling of the conversation. They may show overly rigid body posture or inadequate eye contact, or speak with an overly soft voice. These individuals may be shy or withdrawn, and they may be less open in conversations and disclose little about themselves. They may seek employment in jobs that do not require social contact, although this is not the case for individuals with social anxiety disorder, performance only. They may live at home longer. Men may be delayed in marrying and having a family, whereas women who would want to work outside the home may live a life as homemaker and mother. Self-medication with substances is common (e.g., drinking before going to a party). Social anxiety among older adults may also include exacerbation of symptoms of medical illnesses, such as increased tremor or tachycardia. Blushing is a hallmark physical response of social anxiety disorder.
DIFFERENTIAL DIAGNOSIS
Social anxiety disorder needs to be differentiated from appropriate fear and normal shyness, respectively. Differential diagnostic considerations for social anxiety disorder are agoraphobia, panic disorder, avoidant personality disorder, major depressive disorder, and schizoid personality disorder.
A patient with agoraphobia is often comforted by the presence of another person in an anxiety-provoking situation, but a patient with social anxiety disorder is made more anxious by the presence of other people. Whereas breathlessness, dizziness, a sense of suffocation, and a fear of dying are common in panic disorder and agoraphobia, the symptoms associated with social anxiety disorder usually involve blushing, muscle twitching, and anxiety about scrutiny. Differentiation between social anxiety disorder and avoidant personality disorder can be difficult and can require extensive interviews and psychiatric histories.The avoidance of social situations can often be a symptom in depression, but a psychiatric interview with the patient is likely to elicit a broad constellation of depressive symptoms. In patients with schizoid personality disorder, the lack of interest in socializing, not the fear of socializing, leads to the avoidant social behaviour.
TREATMENT
Both psychotherapy and pharmacotherapy are useful in treating social anxiety disorder. Some studies indicate that the use of both pharmacotherapy and psychotherapy produces better results than either therapy alone, although the finding may not be applicable to all situations and patients.
1. PSYCHOTHERAPY: Psychotherapy for social anxiety disorder usually involves a combination of behavioural and cognitive methods, including cognitive retraining, desensitization, rehearsal during sessions, and a range of homework assignments. Cognitive, behavioural, and exposure techniques are also useful in performance situations. A number of meta-analyses have found that CBT is an effective treatment for social anxiety disorder and is just as effective as antidepressants in reducing symptoms over the course of therapy. Even it is much more effective in preventing relapse following therapy (Rodebaugh et al., 2004; Heimberg, 2002). Mindfulness-based interventions also can prove helpful for people with social anxiety disorder (Goldin & Gross, 2009). These interventions teach individuals to be less judgmental about their own thoughts and reactions and more focused on, and relaxed in, the present moment.
2. PHARMACOTHERAPY: Effective drugs for the treatment of social anxiety disorder include:
(1) SSRIs,
(2) The benzodiazepines,
(3) Venlafaxine (Effexor), and
(4) Buspirone (BuSpar).
Most clinicians consider SSRIs the first-line treatment choice for patients with more generalized forms of social anxiety disorder. The benzodiazepines alprazolam (Xanax) and clonazepam(Klonopin) are also efficacious in social anxiety disorder. Buspirone has shown additive effects when used to augment treatment with SSRIs. The treatment of social anxiety disorder associated with performance situations frequently involves the use of β-adrenergic receptor antagonists shortly before exposure to a phobic stimulus.
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References :
· Bruce, S. E., Yonkers, K. A., Otto, M. W., Eisen, J. L., Weisberg, R. B., Pagano, M., et al. (2005). Influence of psychiatric comorbidity on recovery and recurrence in generalized anxiety disorder, social phobia, and panic disorder: A 12-year prospective study. Am. J. Psychiat, 162(6), 1179–87.
· Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
· Goldin, P. R., Manber, T., Hakimi, S., Canli, T., & Gross, J. J. (2009). Neural bases of social anxiety disorder: Emotional reactivity and cognitive regulation during social and physical threat. Arch. Gen. Psychiat., 66(2), 170–80. doi: 10.1001/ archgenpsychiatry.2008.525
· Heimberg, R. G. (2002). Cognitive-behavioral therapy for social nxiety disorder: Current status and future directions. Biol. Psychiat., 51, 101–8.
· James N. Butcher, Susan Mineka and Jill M. Hooley (2013) in Abnormal Psychology by Pearson Education, Inc.
· KAPLAN & SADOCK S Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry eleventh edition ISBN 978-1-60913-971-1
· Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005b). Lifetime prevalence and age of onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiat., 62, 593–602.
· Magee et al., 1996 Magee, W. J., Eaton, W. W., Wittchen, H., McGonagle, K. A., & Kessler, R. C. (1996). Agoraphobia, simple phobia, and social phobia in the National Comorbidity Survey. Arch. Gen. Psychiat., 53, 159–68.
· Rodebaugh et al., 2004 Rodebaugh, T. L., Holaway, R. M., & Heimberg, R. G. (2004). The treatment of social anxiety disorder. Clinical Psychology Review, 24, 883-908.
· Ruscio et al., 2008 Ruscio, A. M., Brown, T. A., Chiu, W. T., Sareen, J.,Stein, M. B., & Kessler, R. C. (2008). Social fears and social phobia in the USA: Results from the National Comorbidity Survey Replication. Psychol. Med., 38(1), 15–28. doi: 10.1017/ s0033291707001699
· Susan Nolen-Hoeksema (2014) ABNORMAL PSYCHOLOGY, SIXTH EDITION .Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121.
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