Family doctor

What is Social Phobia? How do I know I have Social Phobia?

Social Phobia or Social Phobia/Anxiety is defined as:

a) A marked or persistent fear of one or more social or performance situations in which the sufferer is exposed to unfamiliar people or possible scrutiny by others. The individual fears that they may act in a way that may lead to humiliation or embarrassment.

b) Exposure to the feared situation almost invariably provokes anxiety that may take the form of a situationally bound or predisposed panic attack.

c) The person recognises the fear as excessive or unreasonable.

d) Feared situations are avoided or else are endured with anxiety or distress.

e) The Social Phobia must significantly interfere with the person's routine, occupational activities and/or social functioning. (The Diagnostic and Statistical Manual of Mental Disorders-IV 1994 criteria for Social Phobia).

The central feature of this disorder is an underlying fear of being negatively evaluated or judged by others. Most patients with social phobia fear or avoid more than one situation by either totally avoiding situations or only partially avoiding them by minimising eye contact, verbal communication or their physical presence. Anticipatory anxiety is very common, and can occur well in advance of exposure and is often as distressing or intense as the anxiety/panic experienced in the feared situation. Being in a feared social setting triggers anxiety and including situationally bound panic attacks.

The most common physical symptoms in response to the feared situation are heart palpitations, trembling, sweating, tense muscles, a sinking feeling in the stomach, dry mouth, hot or cold feelings, blushing and headaches.

Situations most commonly feared by individuals with Social Phobia include:

• Being introduced
• Meeting people in authority
• Using the telephone when others are around or in a crowded place
• Receiving visitors
• Being watched doing something
• Being teased or criticised
• Eating at home with family
• Eating or speaking in public
• Writing in front of others
• Using public toilets or transport
• Being in social situations where they may say or do foolish things
• Being in situations where they may blush or appear anxious
• Shopping centres/ malls/ department stores
• Standing in lines or queues

Social phobia for many patients is a chronic and disabling condition with many other problems occurring concurrently that increase the likelihood of failure to achieve one's full personal, social and occupational potential.

Differential diagnosis:

To help make a diagnosis of social phobia it must be shown that the situations avoided are limited to those involving the fear of scrutiny and humiliation and the panic attacks are specific to the feared social situation.

Epidemiology

Social phobia has been reported to exist in all cultures, although cultural factors may influence recognition of this disorder. Some studies considered a six month prevalence rate of social phobia at 0.9 - 1.7% of men and 1.5 - 2.6% of women. Community based studies indicate a lifetime prevalence of social phobia ranging from 3 - 13 percent. The rates vary according to the threshold used to determine the distress and impairment on one's life.

Social Phobia is most common amongst young people 18 to 29 years of age, those with less education, single, and those from a lower socio-economic status group.

Although epidemiological samples indicate a greater prevalence of social phobia amongst women, clinical samples of people seeking treatment include an equal or greater proportion of men. Patients who present for treatment report an early onset and chronic cause of this disorder. The average age of onset is in the mid to late teens but many patients report a much earlier onset. Different studies have found the average ages of presentation to helping services to be between 30 and 41 years of age. The average duration from onset to presentation is about 12 years. Most people with social phobia are not treated for this illness, unfortunately leaving them to cope with this chronic disorder which tends to fluctuate over time.

The onset of social phobia may follow a stressful or humiliating experience or may affect a person with a history of social inhibition or shyness. Due to the high degree of co-morbidity with social phobia as seen below, there are certainly common symptoms between a number of anxiety disorders and related disorders.

Patients presenting with social phobia are more likely to present with the following problems:

Illness/conditon	Social Phobia Group	Control Group
Agoraphobia	19.2 percent	7.8 percent
Alcohol abuse	23.6 percent	8.6 percent
Depression	44.2 percent	24.5 percent

There is also evidence indicating social anxiety commonly co-exist with eating disorders.

Etiology

Etiological theories of social anxiety generally see this current problem encompassing biological and cognitive behavioural domains. There are multiple determinants affecting the development of social phobia, however, family and twin studies have indicated there is an inherited vulnerability to anxiety in general. There is evidence for some specific genetic risk factors in social phobia.

Sub-types of Social Phobia:

Three types of social phobia have been recognised in the literature: the most debilitating is the generalised sub-type: where the individual avoids and/or experiences anxiety/panic in several public performance and/or social interaction situations. Sufferers of the generalised sub-type may have deficits in social skills, self esteem and assertiveness. Occupational social and educational functioning is, for most, significantly impaired. Those who have specific sub-type avoid only one or few social situations and there's limited impact on life functioning. Sub-threshold sub-type has recently been identified and defining feature is the occurrence of one or more symptoms of social phobia in limited situations but the absence of significant avoidance behaviour.

Somatic and Phobic symptoms:

No difference has been reported in the somatic symptoms between the sub-types of social phobia. Over 70% report palpitations, trembling and sweating, and 60% report tense muscles, a sinking feeling in the abdomen and dry mouth. Other symptoms less frequently reported are feeling hot and cold, and pressure in the head and headaches. Co-morbid depression and dysthymia (low mood) are also common; 35% of a sample with social phobia reported a lifetime history of depression, while many reported transient episodes of depression. A link between social phobia and alcohol abuse has been well documented, alcohol being the most common non-medical means of coping. Co-morbid personality disorders often increase the severity of social phobia. Between 24 and 84% of those with social phobia may receive the diagnosis of avoidant personality disorder. The critical features are a pattern of pervasive social inhibitions, feelings of inadequacy and hypersensitivity to criticism and negative evaluation.

Shyness and Social Phobia:

Does shyness equate with a diagnosis of social phobia? The question remains unanswered for want of an adequate definition of shyness; to differentiate between the two the extent of social fears needs to be established. Those who are shy, fearfulness is generalised: those with social phobia avoid specific social situations.

Treatment options:

The course of social phobia if untreated is a chronic unremitting illness with spontaneous remission being rare. Data from epidemiological clinical population show the mean duration to be 19 and 21 years respectively. Collectively, studies suggest social phobia strikes at an early age, many being unable to recall when they did not experience social anxiety. For those with generalised social anxiety, age of onset is earlier than those with specific social phobia.

Treatment for Social Phobia:

Although social phobia is debilitating and interferes with one's life chances, most people avoid or delay treatment until years after the onset of social phobia. Most people with social phobia are not receiving treatment.

Historically, supportive counselling, analytic psychotherapy and the use of tricyclic anti-depressants and benzodiazepines have been used in the treatment of social phobia. Studies now show these therapies are with little or no effect. Today, social phobia has specific pharmacotherapy and psychotherapy: both therapeutic modalities are effective alone or when used simultaneously.

Pharmacotherapy:

The main classes of drugs that have been applied to the treatment of social phobia include: Anxiolytics: benzodiazapines class, Beta blockers, and some anti-depressants noted for anti-phobic anti-panic actions such as monoamine oxidase inhibitors (MAOI's) and selective serotonin reuptake inhibitors (SSRI's). Historically the monoamine oxidase inhibitors, phenelzine (Nardil) and tranylcypromine (Parnate) have been the first choice of drug treatment. Reversible Inhibitors of Monoamine-A (RIMA's) such as moclobemide (Aurorix), are similarly efficacious with social phobia.

Advantages occur in the use of moclobemide over the monoamine oxidase inhibitors: toxicity is lower, tolerability higher and no tyramine-restricted diet is required. Studies have shown the efficacy of SSRI's in social phobia: sertraline, fluvoxamine, fluoxetine, paroxetine and citalopram have been shown to be effective in the treatment in social phobia.

Doctors faced with a patient who meets the diagnostic criteria for social phobia can be offered the following guidelines:

For the patient with social phobia, "cognitive behavioural therapy" alone or in combination with medication is effective. Patients with generalised social phobia SSRI's RIMA'S, MOAI's are useful. A patient should be told that the role of medication is to alleviate their social or performance anxiety in social situations. Increasing exposure to such situations is therefore crucial to overcoming their condition. For the patient with specific performance anxiety, cognitive behavioural group or individual psychotherapies are the most sensible initial approaches.

Medication treatment for Social Phobia and co-morbid conditions:

Social phobia and depression = RIMA, MAOI, SSRI.

Social Phobia and alcohol abuse = RIMA, SSRI.

Social Phobia and Obsessive Compulsive Disorder = SSRI, Clomipramine, MAOI‚Äö RIMA.

Social Phobia and Panic Disorders/Agoraphobia = RIMA, MAOI, Clonazapam, SSRI.

Cognitive Behavioural Treatment of Social Phobia:

Recognition that cognitive processes modulate and maintain social phobia have seen the development of cognitive therapy. It is the reduction in the fear of negative evaluation by others, learnt in cognitive therapy, that is crucial in recovery when associated with exposure therapy.

The rational for cognitive behavioural therapy is to encourage sufferers to confront negative beliefs such as thinking failure is inevitable in social situations - the thought to be at the root of their social phobia. One of the main goals of cognitive behavioural therapy is to encourage patients to confront their anxieties.

Group therapy sessions are particularly useful in the treatment of social phobia. Cognitive Behavioural Group Therapy (CBGT), has been the most thoroughly studied. In a typical CBGT treatment programme a group of about six to eight patients will receive therapy from two co-therapists every week for about three months. Within the group therapy sessions, patients are exposed to anxiety provoking social situations, during and after which patients are taught cognitive restructuring procedure. These therapeutic procedures are followed up by homework exercises carried out by the patients during their own daily activity. A variety of other cognitive and behavioural approaches to treatment of social phobia have been studied. The most promising include social skills training, assertiveness training, relaxation techniques, in-vivo exposure as well as other cognitive techniques.

Self-help treatments:

Leading researchers have compared Cognitive Behavioural Group Therapy with Educational Supportive Group Psychotherapy (ESGP) and found that patients given CBGT were significantly less impaired than those on ESGP only. CBGT patients reported less anxiety during a behavioural test carried out immediately after the treatment course finished and six months later.

Summary:

Social phobia is a common illness, historically under recognised and inappropriately treated. It is an illness for which the economic and social impact for the sufferer and society has been ignored. Historically, social phobia has been seen as a chronic illness that profoundly affects the sufferer's life chances.

Social phobia is today a treatable illness. Specific pharmacological and cognitive behavioural therapies have been developed, that when used alone or simultaneously, are efficacious in reducing social anxiety and avoidance behaviour. Until recently those with social phobia suffered in silence while they waited to be asked "are there situations in which you fear humiliation and embarrassment?".

Prognosis:

The likely outcome for untreated social anxiety is poor, however with appropriate treatment including either or combined Cognitive Behavioural Therapy and pharmacotherapy, outcome or illness improvement is extremely good.

Other sources of information/support:

Your doctor or psychologist should be able to advise you on treatment and local support groups.