Social Phobia

For 5.3 million Americans, an impending social engagement or performance situation brings fear that prompts avoidance or otherwise interferes with functioning. Social phobia typically begins before adulthood and is best treated with cognitive-behavioral therapy, with or without medications.

Definition

Social phobia, also called Social Anxiety Disorder, is an anxiety disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. People with social phobia have a persistent, intense, and chronic fear of being watched and judged by others and of being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work, school, or other activities. While many people with social phobia recognize that their fear of being around people may be excessive or unreasonable, they are unable to overcome it. They often worry for days or weeks in advance of a dreaded situation. In addition, they often experience low self-esteem and depression.

Social phobia can be limited to only one type of situation -- such as a fear of speaking in formal or informal situations, or eating or drinking in front of others -- or, in its most severe form, a person experiences symptoms whenever they are around other people. If left untreated, social phobia can have severe consequences. For example, it may keep people from going to work or school on some days. Many with this illness are afraid of being with people other than family members. As a result, they may have a hard time making and keeping friends.

Physical symptoms often accompany the intense anxiety of social phobia and include blushing, profuse sweating, trembling, and other symptoms of anxiety, including difficulty talking and nausea or other stomach discomfort. These visible symptoms heighten the fear of disapproval, and the symptoms themselves can become an additional focus of fear. Fear of symptoms can create a vicious cycle: as people with social phobia worry about experiencing the symptoms, the greater their chances of developing the symptoms.

Social phobia often runs in families and may be accompanied by depression or other anxiety disorders, such as panic disorder and obsessive-compulsive disorder. Some people with social phobia self medicate themselves with alcohol or other drugs, which can lead to addiction.

Prevalence of Social Phobia

About 3.7% of the U.S. population -- approximately 5.3 million Americans -- is affected by social phobia. Social phobia occurs in women twice as often as in men, although a higher proportion of men seek help for this disorder. The disorder typically begins in childhood or early adolescence and rarely develops after age 25.

Symptoms

A diagnosis of social phobia is made only if his avoidance, fear or anxious anticipation of a social or performance situation interferes with daily routine, occupational functioning, social life or if he is markedly distressed by having the phobia. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV-TR(tm)) provides the following criteria for diagnosing social phobia. Please note: guidelines are provided for information only; they cannot substitute a visit to a doctor or mental health practitioner.

  • Fear of one or more social or performance situations if the person is exposed to unfamiliar people. And the individual fears that she will behave in a manner that causes embarrassment
  • Exposure to social situations causes intense anxiety
  • The level of anxiety is recognized by the individual as excessive
  • The feared situation must be avoided, or endured with anxiety and distress
  • The avoidance, anxious anticipation, or distress interferes significantly with the person's social, academic or occupational functioning

Causes

While research to define the causes of social phobia is ongoing, some investigations implicate a small structure in the brain called the amygdala in the symptoms of social phobia. The amygdala is believed to be a central site in the brain that controls fear responses.

  • Animal studies also suggest that social phobia can be inherited. In fact, researchers supported by the National Institute of Mental Health (NIMH) identified the site of a gene in mice that affects learned fearfulness.
  • One line of research is investigating a biochemical basis for the disorder. Scientists are exploring the idea that heightened sensitivity to disapproval may be physiologically or hormonally based.
  • Other researchers are investigating the environment's influence on the development of social phobia. People with social phobia may acquire their fear from observing the behavior and consequences of others, a process called observational learning or social modeling.

Treatments

Fortunately, most anxiety disorders can be treated successfully by a trained health or mental health care professional.

Research has shown that there are two main forms of effective treatment for social phobia: short-term psychotherapy called cognitive-behavioral therapy, and certain medications.  Cognitive-Behavioral and Behavioral Therapy

Cognitive-behavioral therapy (CBT) is a form of psychotherapy that is very effective in treating social phobia. It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. For example, a person with social phobia might be helped to overcome the belief that others are continually watching and harshly judging him. The behavioral component of CBT seeks to help people become more comfortable with the situations that frighten them.

A key element of this component is exposure, in which people confront the things they fear. The exposure process generally involves three stages. First, a person is introduced to the feared situation. The second step is to increase the risk for disapproval in that situation so a person can build confidence that she can handle rejection or criticism. The third step involves teaching a person techniques for coping with disapproval. In this stage, one is asked to imagine his worst fear and is encouraged to develop constructive responses to his fear and perceived disapproval.

These stages are often accompanied by anxiety management training -- for example, teaching people techniques such as deep breathing to control their anxiety. If this is all done carefully, with support from the therapist, it may be possible to defuse the anxiety associated with feared situations.

If you undergo CBT or behavioral therapy, exposure will be carried out only when you are ready; it will be done gradually and only with your permission. You will work with the therapist to determine how much you can handle and at what pace you can proceed.

A major aim of CBT and behavioral therapy is to reduce anxiety by eliminating beliefs or behaviors that help to maintain the anxiety disorder. For example, avoidance of a feared object or situation prevents a person from learning that it is harmless.

CBT and behavioral therapy have no adverse side effects other than the temporary discomfort of increased anxiety, but the therapist must be well trained in the techniques of the treatment  for it to work as desired. During treatment, the therapist will likely assign homework -- specific problems that the patient will need to work on between sessions.

CBT or behavioral therapy generally lasts about 12 weeks. It may be conducted in a group, provided the people in the group have sufficiently similar problems. Supportive therapy such as group therapy, or couples or family therapy to educate significant others about the disorder, is also helpful. Sometimes people with social phobia also benefit from social skills training. Individuals suffering from social phobia should seek out a provider who is competent in cognitive and behavioral therapies.

Medications

Proper and effective medications may also play a role in treatment, along with psychotherapy. Medications include antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as drugs known as high-potency benzodiazepenes. Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high-blood pressure.

It is important to understand that treatments for social phobia do not work instantly, and that no one plan works well for all patients. Treatment must be tailored to one's needs. A therapist and a patient should work together to determine which treatment plan will be most effective and to assess whether the treatment plan seems to be on track. Adjustments to the plan are sometimes necessary, since patients respond differently to treatment. Overall, the prospects for long-term recovery for most individuals who seek appropriate professional help are good.

Sources

  • Diagnostic and Statistical Manual of Mental Disorders; Fourth Edition
  • National Institute of Mental Health
Last reviewed 11/24/2014