Social phobia 48750 226126550 2008-07-16T22:52:56Z Ronz 7862 /* External links */ spam {{DiseaseDisorder infobox | Name = Social phobias | ICD10 = {{ICD10|F|40|1|f|40}}, {{ICD10|F|93|2|f|90}} | ICD9 = {{ICD9|300.23}} | }} {{Disputed|date=June 2008}} '''Social phobia''' (DSM-IV 300.23), also known as '''social anxiety disorder''' (DSM-IV 300.23) is a diagnosis within [[psychiatry]] and other [[mental health professions]] referring to excessive [[social anxiety]] (anxiety in social situations) {{Fact|date=April 2008}} causing abnormally considerable distress and impaired ability to function in at least some areas of daily life. The diagnosis can be of a ''specific'' [[disorder]] (when only some particular situations are feared) or a ''generalized'' disorder. Generalized social anxiety disorder typically involves a persistent, intense, and [[chronic (medicine)|chronic]] fear of being judged by others and of potentially being [[embarrassed]] or [[humiliated]] by one's own actions. These fears can be triggered by perceived or actual scrutiny by others. While the fear of social interaction may be recognized by the person as excessive or unreasonable, considerable difficulty can be encountered overcoming it. Approximately 13.3 percent of the general population may meet criteria for social anxiety disorder at some point in their lifetime, according to the highest survey estimate, with the male to female ratio being 1:1.5.<ref>p. 29-30. [http://scholar.google.com/url?sa=U&q=http://books.google.com/books%3Fhl%3Den%26lr%3D%26id%3DrXrekuSy2bsC%26oi%3Dfnd%26pg%3DRA2-PA1%26sig%3D9qpn9ZQfXmwVAdBQQ7X38iSsLYs%26dq%3D%2522Heimberg%2522%2B%2522Social%2BPhobia:%2BDiagnosis,%2BAssessment,%2Band%2BTreatment%2522%2B Social Phobia: Diagnosis, Assessment, and Treatment]. Richard G. Heimberg. Guilford Press</ref> Physical symptoms often accompanying social anxiety disorder include excessive [[blushing]], [[sweating]] ([[hyperhidrosis]]), [[tremor|trembling]], [[palpitations]], [[nausea]], and [[stutter|stammering]]. [[Panic attack]]s may also occur under intense fear and discomfort. An early [[diagnosis]] may help in minimizing the symptoms and the development of additional problems such as [[clinical depression|depression]]. Some sufferers may use [[alcohol]] or other [[drug]]s to reduce fears and inhibitions at social events. It is very common for sufferers of social phobia to self-medicate in this fashion, especially if they are undiagnosed and/or untreated. This sort of self-medicating behavior is usually always counter productive to the sufferer, as many illicit drugs and alcohol are depressants and only make the problem worse.{{Fact|date=June 2008}} Specific prescription medications have a far better success rate at treating social phobia than self-medication. A person with the disorder may be treated with [[psychotherapy]], medication, or both. Research has shown [[cognitive behavior therapy]], whether individually or in a group, to be effective in treating social phobia. The cognitive and behavioral components seek to change thought patterns and physical reactions to anxious situations. [[Prescription drugs|Prescribed medications]] include two classes of [[antidepressant]]s: [[selective serotonin reuptake inhibitor]]s (SSRIs) and [[serotonin-norepinephrine reuptake inhibitor]]s (SNRIs). Attention given to social anxiety disorder has significantly increased in the [[US]] since 1999 with the approval and marketing of drugs for its treatment. ==Symptoms== ===Cognitive aspects=== In [[cognitive model]]s of Social Anxiety Disorder, social phobics experience [[dread]] over how they will be presented to others. They may be overly [[self-conscious]], pay high self-attention after the activity, or have high performance standards for themselves. According to the [[social psychology]] theory of [[impression management|self-presentation]], a sufferer attempts to create a well-mannered impression on others but believes he or she is unable to do so. Many times, prior to the potentially anxiety-provoking social situation, sufferers may deliberate over what could go wrong and how to deal with each unexpected case. <!--example--> After the event, they may have the [[perception]] they performed unsatisfactorily. Consequently, they will review anything that may have possibly been abnormal or embarrassing. These thoughts do not just terminate soon after the encounter, but may extend for weeks or longer.<ref name="fears">Shyness & Social Anxiety Treatment Australia [http://www.socialanxietyassist.com.au/common_fears.shtml Social Phobia]</ref> Those with social phobia tend to interpret neutral or [[ambiguous]] conversations with a negative outlook and many studies suggest that socially anxious individuals remember more negative memories than those less distressed.<ref name="furmark">Furmark, Thomas. [http://www.diva-portal.org/diva/getDocument?urn_nbn_se_uu_diva-546-1__fulltext.pdf Social Phobia - From Epidemiology to Brain Function]. Retrieved February 21, 2006.</ref> An example of an instance may be that of an employee presenting to his co-workers. During the presentation, the person may [[stutter]] a word upon which he or she may worry that other people significantly noticed and think that he or she is a terrible presenter. This cognitive thought propels further anxiety which may lead to further stuttering, sweating and a possible panic attack. ===Behavioral aspects=== Social anxiety disorder is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that he or she may do something or act in a way that will be humiliating or embarrassing. It exceeds normal "shyness" as it leads to excessive social avoidance and substantial social or occupational impairment. Feared activities may include almost any type of social interaction, especially small groups, [[dating]], parties, talking to strangers, restaurants, etc. Physical symptoms include "mind going blank", fast heartbeat, blushing, [[stomach ache]]. Cognitive distortions are a hallmark, and learned about in CBT (cognitive-behavioral therapy). Thoughts are often self-defeating and inaccurate. The groundless fear of the [[telephone]] is typical, both calling somebody and answering the phone. It may appear early in childhood. According to psychologist [[B.F. Skinner]], [[phobias]] are controlled by [[escape response|escape]] and [[avoidance response|avoidance behaviors]]. For instance, a student may leave the room when talking in front of the class (escape) and refrain from doing verbal presentations because of the previously encountered anxiety attack (avoid). Minor avoidance behaviors are exposed when a person avoids [[eye contact]] and crosses arms to avoid recognizable [[Tremor|shaking]].<ref name="furmark" /> A [[fight-or-flight response]] is then triggered in such events. Preventing these automatic responses is at the core of treatment for social anxiety. ===Physiological aspects=== Physiological effects, similar to those in other anxiety disorders, are present in social phobics. Faced with an uncomfortable situation, children with social anxiety may display [[tantrum]]s, [[weeping]], clinging to parents, and shutting themselves out.<ref name="physiology">eNotes. [http://health.enotes.com/mental-disorders-encyclopedia/social-phobia#Causes%20and%20symptoms Social phobia - Causes]. Retrieved February 22, 2006.</ref> In adults, it may be [[tears]] as well as experiencing excessive [[sweat]]ing, [[nausea]], [[tremor|shaking]], and [[palpitation]]s as a result of the fight-or-flight response. The walk disturbance may appear, especially when passing a group of people. [[Blush]]ing is commonly exhibited by individuals suffering from social phobia.<ref name="furmark"/> These visible symptoms further reinforce the anxiety in the presence of others. A 2006 study found that the area of the [[brain]] called the [[amygdala]], part of the [[limbic system]], is [[hyperactive]] when patients are shown threatening faces or confronted with frightening situations. They found that patients with more severe social phobia showed a [[correlation]] with the increased response in the amygdala.<ref>[http://www.sciencedaily.com/releases/2006/01/060118205940.htm Studying Brain Activity Could Aid Diagnosis Of Social Phobia]. Monash University. January 19, 2006.</ref> ==Prevalence== {| class="wikitable" align="right" |- !align="left"|Country !align="left"|Prevalence |- |align="left"|United States |align="center"|2-7%[http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c4.pdf] |- |align="left"|England |align="center"|0.4% (children)[http://www.statistics.gov.uk/downloads/theme_health/Mentalhealth_Scotland.pdf] |- |align="left"|Scotland |align="center"|1.8% (children)[http://www.statistics.gov.uk/downloads/theme_health/Mentalhealth_Scotland.pdf] |- |align="left"|Wales |align="center"|0.6% (children)[http://www.statistics.gov.uk/downloads/theme_health/Mentalhealth_Scotland.pdf] |- |align="left"|Australia |align="center"|1-2.7%[http://journals.cambridge.org/action/displayAbstract?fromPage=online&aid=150763] |- |align="left"|Brazil |align="center"|4.7-7.9%[http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=16224610&dopt=Abstract] |} When [[prevalence]] estimates were based on the examination of [[psychiatric]] clinic samples, social anxiety disorder was thought to be a relatively rare disorder. The opposite was instead true; social anxiety was common but many were afraid to seek psychiatric help, leading to an understatement of the problem.<ref name="furmark" /> Prevalence rates vary widely because of its vague diagnostic criteria and its overlapping symptoms with other disorders. There has been some debate on how the studies are conducted and whether the illness truly impairs the respondents as laid out in the official criteria. Psychologist [[Dr. Ray Crozier]] argues, "it is difficult to ascertain whether the person being interviewed adheres to the DSM-III-R criteria or whether they are merely exhibiting poor [[social skills]] or shyness."<ref name="crozier-socialskills">Crozier, page 4.</ref> The [[National Comorbidity Study|National Comorbidity Survey]] of over 8,000 American correspondents in 1994 revealed a 12-month and lifetime prevalence rates of 7.9 percent and 13.3 percent making it the third most prevalent psychiatric disorder after depression and alcohol dependence and the most apparent of the anxiety disorders.<ref>[http://www.findarticles.com/p/articles/mi_m3225/is_8_60/ai_58266993 Social Anxiety Disorder: A Common, Underrecognized Mental Disorder]. American Family Physician. Nov 15, 1999.</ref> According to U.S. [[epidemiological]] data from the [[National Institute of Mental Health]], social phobia affects 5.3 million adult Americans in any given year. Cross-cultural studies have reached prevalence rates with the conservative rates at 5 percent of the population.<ref name="crozier-prevalence">Crozier, page 3.</ref><ref name="prevalence">Stein, Murray B., Gorman, Jack M. ''[http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=ref&cmd=prlinks&id=11394188 Unmasking social anxiety disorder]'' February, 2001. Retrieved February 22, 2006.</ref> However, other estimates vary within 2 percent and 7 percent of the U.S. adult population.<ref name="surg-gen-prevalence">Surgeon General [http://www.surgeongeneral.gov/library/mentalhealth/pdfs/c4.pdf Adults and Mental Health] 1999. Retrieved February 22, 2006.</ref> Onset of social phobia typically occurs between 11 and 19 years of age. Onset after age 25 is rare. Social anxiety disorder occurs in females nearly twice as often as males, although men are more likely to seek help.<ref name="nimh-facts">National Institute of Mental Health. [http://www.nimh.nih.gov/publicat/phobiafacts.cfm Facts About Social Phobia]. 1999. Retrieved February 22, 2006.</ref> The prevalence of social phobia appears to be increasing among white, married, and well-educated individuals. As a group, those with generalized social phobia are less likely to graduate from high school and are more likely to rely on government financial assistance or have poverty-level salaries.<ref name="fda-demographics">Nordenberg, Tamar. ''FDA Consumer''. U.S. Food and Drug Administration. [http://www.fda.gov/fdac/features/1999/699_phobia.html Social Phobia's Traumas and Treatments]. November-December 1999. Retrieved February 23, 2006.</ref> Surveys carried out in 2002 show the youth of [[England]], [[Scotland]], and [[Wales]] have a prevalence rate of 0.4 percent, 1.8 percent, and 0.6 percent, respectively.<ref name="europe-prevalence">National Statistics. [http://www.statistics.gov.uk/downloads/theme_health/Mentalhealth_Scotland.pdf The mental health of young people looked after by local authorities in Scotland]. 2002-2003. Retrieved February 23, 2006.</ref> The prevalence of self-reported social anxiety for [[Nova Scotian]]s older than 14 years was 4.2 percent in June 2004 with women (4.6 percent) reporting more than men (3.8 percent).<ref name="sa-nova-scotia">Nova Scotia Department of Health. [http://www.gov.ns.ca/heal/downloads/CCHS_SocialAnxiety.pdf Social Anxiety in Nova Scotia]. June 2004. Retrieved February 23, 2006.</ref> In [[Australia]], social phobia is the 8th and 5th leading disease or illness for males and females between 15-24 years of age as of 2003.<ref name="sa-australia">Senate Select Committee on Mental Health. [http://www.aph.gov.au/senate/committee/mentalhealth_ctte/submissions/sub109.pdf Mental Health]. 2003. Retrieved February 23, 2006.</ref> Because of the difficulty in separating social phobia from poor social skills or shyness, some studies have a large range of prevalence.<ref>{{web cite|url=http://www.springerlink.com/content/9pkp3ephnqe6l486/|title=Social phobia in the general population: prevalence and sociodemographic profile (Sweden)|author=Thomas Furmark|date=1999-09-01|accessdate=2007-03-28}}</ref> The table also shows higher prevalence in Brazil. ==Comorbidity== There is a high degree of [[comorbidity]] with other psychiatric disorders. Social phobia often occurs alongside low [[self-esteem]] and [[clinical depression]], due to lack of personal relationships and long periods of isolation from avoiding social situations. To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to [[substance abuse]]. It is estimated that one-fifth of patients with social anxiety disorder also suffer from alcohol dependence.<ref name="sa-alcohol">Alcohol Research and Health. Sarah W. Book, Carrie L. Randall. [http://www.findarticles.com/p/articles/mi_m0CXH/is_2_26/ai_95148615 ''Social anxiety disorder and alcohol use'']. Retrieved February 24, 2006.</ref> The most common complementary psychiatric condition is unipolar depression. In a sample of 14,263 people, of the 2.4 percent of persons diagnosed with social phobia, 16.6 percent also met the criteria for [[clinical depression]].<ref name="crozier-comorbidity">Crozier, page 358-9.</ref> Besides depression, the most common disorders diagnosed in patients with social phobia are [[panic disorder]] (33 percent), [[generalized anxiety disorder]] (19 percent), [[post-traumatic stress disorder]] (36 percent), [[substance abuse|substance abuse disorder]] (18 percent), and attempted [[suicide]] (23 percent).<ref name="comorbidity">eNotes. [http://health.enotes.com/mental-disorders-encyclopedia/social-phobia Social phobia] Retrieved February 23, 2006.</ref> In one study of social anxiety disorder patients who developed comorbid alcoholism, panic disorder or depression, social anxiety disorder preceded the onset of alcoholism, panic disorder and depression in 75 percent, 61 percent, and 90 percent of patients, respectively. [[Avoidant personality disorder]] is also highly correlated with social phobia.<ref name="crozier-correlation">Crozier, page 361.</ref> Because of its close relationship and overlapping symptoms with other illnesses, treating social phobics may help understand underlying connection in other psychiatric disorders. There is research indicating that social anxiety disorder is often correlated with [[bipolar disorder]] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Retrieve&dopt=AbstractPlus&list_uids=16630705&query_hl=5&itool=pubmed_docsum]. Some researchers believe they share an underlying cyclothymic-anxious-sensitive disposition. [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=12462857&dopt=Abstract] In addition, studies show that more socially phobic patients treated with anti-depressant medication develop [[hypomania]] than non-phobic controls[http://www.biopsychiatry.com/bipolsp.htm] [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15820266&dopt=Abstract], although this can be seen as the medication creating a new problem, and also has this adverse effect in a proportion of those without social phobia. ==Causes and perspectives== [[Research]] into the causes of social anxiety and social phobia is wide-ranging, encompassing multiple perspectives from [[neuroscience]] to [[sociology]]. Scientists have yet to pinpoint the exact [[etiology|causes]]. Studies suggest that genetics can play a part in combination with environmental factors. ===Genetic and family factors=== It has been shown that there is a two to threefold greater risk of having social phobia if a first-degree relative also has the disorder. This could be due to [[genetics]] and/or due to children acquiring social fears and avoidance through processes of [[observational learning]] or parental [[psychosocial]] education. Studies of [[identical twins]] brought up (via [[adoption]]) in different families have indicated that, if one twin developed social anxiety disorder, then the other was between 30 percent and 50 percent more likely than average to also develop the disorder.<ref>{{cite journal |author=Kendler K, Karkowski L, Prescott C |title=Fears and phobias: reliability and heritability |journal=Psychol Med |volume=29 |issue=3 |pages=539–53 |year=1999 |pmid=10405076 | doi = 10.1017/S0033291799008429 <!--Retrieved from CrossRef by DOI bot--> }}</ref> To some extent this 'heritability' may not be specific - for example, studies have found that if a parent has any kind of anxiety disorder or clinical depression, then a child is somewhat more likely to develop an anxiety disorder or social phobia.<ref>Merikangas, S. Avenevoli, L. Dierker and C. Grillon (1999) Vulnerability factors among children at risk for anxiety disorders. ''Biol Psychiatry'' 46 1523-1535</ref> Studies suggest that parents of those with social anxiety disorder tend to be more [[solitude|socially isolated]] themselves (Bruch and Heimberg, 1994; Caster et al, 1999), and shyness in adoptive parents is significantly correlated with shyness in adopted children (Daniels and Plomin, 1985); Adolescents who were rated as having an [[Emotional insecurity|insecure]] (anxious-ambivalent) attachment with their mother as infants were twice as likely to develop anxiety disorders by late adolescence,<ref>Warren S, Huston L, Egeland B, Sroufe L (1997) Child and adolescent anxiety disorders and early attachment. J Am Acad Child Adolesc Psychiatry 36:637-644.</ref> including social phobia. A related line of research has investigated 'behavioural inhibition' in infants &ndash; early signs of an inhibited and introspective or fearful nature. Studies have shown that around 10-15 percent of individuals show this early temperament, which appears to be partly due to genetics. Some continue to show this trait in to adolescence and adulthood, and appear to be more likely to develop social anxiety disorder.<ref>Schwartz C, Snidman N, Kagan J (1999) Adolescent social anxiety as an outcome of inhibited temperament in childhood. J Am Acad Child Adolesc Psychiatry 38:1008-1015</ref> ===Social experiences=== A previous negative social experience can be a trigger to social phobia.<ref name="sa-causes">National Center for Health and Wellness.[http://www.social-anxiety-disorder-resources.com/causes-of-social-anxiety-disorder.html Causes of Social Anxiety Disorder]. Retrieved February 24, 2006.</ref><ref name="sa-causes2">Athealth.com.[http://www.athealth.com/Consumer/disorders/SocialPhobia.html Social phobia]. 1999. Retrieved February 24, 2006.</ref> perhaps particularly for individuals high in '[[interpersonal]] sensitivity'. For around half of those diagnosed with social anxiety disorder, a specific [[Psychological trauma|traumatic]] or humiliating social event appears to be associated with the onset or worsening of the disorder;<ref>Mineka S, Zinbarg R (1995) [[Classical conditioning|Conditioning]] and ethological models of social phobia. In: Heimberg R, Liebowitz M, Hope D, Schneier F, editors. Social Phobia: Diagnosis, Assessment, and Treatment. New York: The Guilford Press, 134-162</ref> this kind of event appears to be particularly related to specific (performance) social phobia, for example regarding public speaking (Stemberg ''et al.'', 1995). As well as direct experiences, observing or hearing about the socially negative experiences of others (e.g. a faux pas committed by someone), or verbal warnings of social problems and dangers, may also make the development of a social anxiety disorder more likely.<ref>Beidel, D.C., & Turner, S.M. (1998). Shy children, phobic adults: The nature and treatment of social phobia. American Psychological Association Books.</ref> Social anxiety disorder may be caused by the longer-term effects of not fitting in, or being [[bullied]], rejected or ignored (Beidel and Turner, 1998). Shy adolescents or [[avoidant]] adults have emphasised unpleasant experiences with peers<ref>Ishiyama F (1984) Shyness: Anxious social sensitivity and self-isolating tendency. Adolescence 19:903-911</ref> or childhood bullying or [[harassment]] (Gilmartin, 1987). In one study, popularity was found to be negatively correlated with social anxiety, and children who were neglected by their peers reported higher social anxiety and fear of negative evaluation than other categories of children.<ref>La Greca A, Dandes S, Wick P, Shaw K, Stone W (1988):Development of the social anxiety scale for children: Reliability and concurrent validity. J Clin Child Psychol 17:84-91</ref> Socially phobic children appear less likely to receive positive reactions from peers<ref>Spence SH, Donovan C, Brechman-Toussaint M (1999) Social skills, social outcomes, and cognitive features of childhood social phobia. J Abnorm Psychol 108:211-221.</ref> and anxious or inhibited children may isolate themselves.<ref>Rubin K, Mills R (1988) The many faces of social isolation in childhood. J Consult Clin Psychol 56:916-924.</ref> ===Social/cultural influences=== [[Cultural]] factors that have been related to social anxiety disorder include a society's attitude towards shyness and avoidance, affecting ability to form [[relationships]] or access employment or education. One study found that the effects of parenting are different depending on the culture - American children appear more likely to develop social anxiety disorder if their parents emphasise the importance of other's opinions and use [[shame]] as a disciplinary strategy (Leung ''et al.'', 1994), but this association was not found for Chinese/Chinese-American children. In [[China]], research has indicated that shy-inhibited children are more accepted than their [[peers]] and more likely to be considered for leadership and considered competent, in contrast to the findings in Western countries.<ref>Xinyin, C. Rubin, KH, Boshu, L. (1995). Social and school adjustment of shy and [[aggressive]] children in China. Development and Psychopathology, 7, 337-349</ref> Purely [[demographic]] variables may also play a role - for example there are possibly lower rates of social anxiety disorder in [[Mediterranean Basin|Mediterranean]] countries and higher rates in [[Scandinavia]]n countries, and it has been hypothesised that hot weather and high-density may reduce avoidance and increase interpersonal contact. Problems in developing social skills, or 'social effectiveness', may be a cause of some social anxiety disorder, through either inability or lack of [[confidence]] to interact socially and gain positive reactions and acceptance from others. The studies have been mixed, however, with some studies not finding significant problems in social skills<ref>Rapee, RM, & Lim, L. (1992). Discrepancy between self- and observer ratings of performance in social phobia. Journal of Abnormal Psychology, 101, 728-731</ref> while others have.<ref>{{cite journal |author=Stopa L, Clark D |title=Cognitive processes in social phobia |journal=Behav Res Ther |volume=31 |issue=3 |pages=255–67 |year=1993 |pmid=8476400 | doi = 10.1016/0005-7967(93)90024-O <!--Retrieved from CrossRef by DOI bot--> }}</ref> What does seem clear is that the socially anxious perceive their own social skills to be low. It may be that the increasing need for sophisticated social skills in forming relationships or careers, and an emphasis on assertiveness and competitiveness, is making social anxiety problems more common, at least among the '[[middle class]]es'.<ref>Heimberg R.G., Stein M.B. Hirirpi E.V.A. and Kessler R.C. (2000), Trends in the prevalence of social phobia in the United States: A synthetic cohort analysis of changes over four decades. European Psychiatry 15 pp. 29-37</ref> An interpersonal or media emphasis on 'normal' or 'attractive' personal characteristics has also been argued to fuel [[Perfectionism (psychology)|perfectionism]] and feelings of inferiority or insecurity regarding negative evaluation from others. The need for social acceptance or social standing has been elaborated in other lines of research relating to social anxiety<ref>{{cite journal |author=Baumeister R, Leary M |title=The need to belong: desire for interpersonal attachments as a fundamental human motivation |journal=Psychol Bull |volume=117 |issue=3 |pages=497–529 |year=1995 |pmid=7777651 | doi = 10.1037/0033-2909.117.3.497 <!--Retrieved from CrossRef by DOI bot--> }}</ref> ===Evolutionary context=== A long-accepted evolutionary explanation of anxiety is that it reflects an in-built 'fight or flight' system, which errs on the side of safety. One line of research suggests that specific dispositions to monitor and react to social threats may have evolved, reflecting the vital and complex importance of social living and social rank in human ancestral environments. [[Charles Darwin]] originally wrote about the evolutionary basis of shyness and blushing, and modern [[evolutionary psychology]] and psychiatry also addresses social phobia in this context.<ref>Gilbert, P. (2001). Evolution and social anxiety - The role of attraction, social competition, and social hierarchies. Psychiatric Clinics of North America</ref> It has been hypothesised that in modern day society these evolved tendencies can become more inappropriately activated and result in some of the cognitive 'distortions' or 'irrationalities' identified in cognitive-behavioural models and therapies<ref>Gilbert, P. (1998). The evolved basis and adaptive functions of cognitive distortions. British Journal of Medical Psychology, 71, 447-463.</ref> ===Neurochemical and neurocognitive influences=== Some scientists hypothesize that social phobia is related to an imbalance of the brain chemical [[serotonin]]. A recent study report increased [[Serotonin]] and [[Dopamine]] transporter binding in psychotropic medication-naive patients with Generalized Social Anxiety Disorder.<ref>{{Cite journal | author = van der Wee et al. | title = Increased Serotonin and Dopamine Transporter Binding in Psychotropic Medication–Naïve Patients with Generalized Social Anxiety Disorder Shown by 123I-β-(4-Iodophenyl)-Tropane SPECT | journal = The Journal of Nuclear Medecine | year = 2008 | month = May | volume = 49 | issue = 5 | pages = 757–763 | pmid = 18413401 | url = http://www.ncbi.nlm.nih.gov/pubmed/18413401?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum | doi = 10.2967/jnumed.107.045518 | doi_brokendate = 2008-06-25 }}</ref> [[Sociability]] is also closely tied to [[dopamine]] [[neurotransmitter|neurotransmission]]. Low D2 receptor binding is found in people with social anxiety.<ref name="d2-receptor">Murray B. Stein, MD; Jack M. Gorman, MD. ''Journal of Psychiatry & Neuroscience'' Volume 26. [http://www.cma.ca/multimedia/staticContent/HTML/N0/l2/jpn/vol-26/issue-3/pdf/pg185.pdf Unmasking social anxiety disorder] 2001. Retrieved March 1, 2006.</ref> The efficacy of medications which affect serotonin and dopamine levels also indicates the role of these pathways. There is also increasing focus on other candidate transmitters, e.g. Norepinephrine, which may be over-active in social anxiety disorder, and the inhibitory transmitter GABA. Individuals with social anxiety disorder have been found to have a hypersensitive [[amygdala]], for example in relation to social threat cues (e.g. someone might be evaluating you negatively), angry or hostile faces, and while just waiting to give a speech.<ref>Davidson, Marshall, Tomarkenc & Henriquesa (2000) While a phobic waits: regional brain electrical and autonomic activity in social phobics during anticipation of public speaking. Biological Psychiatry, 47(2), 85-95</ref> Recent research has also indicated that another area of the brain, the '[[Anterior cingulate cortex]]', which was already known to be involved in the experience of physical pain, also appears to be involved in the experience of 'social pain', for example perceiving group exclusion.<ref>Eisenberger, N.I., Lieberman, M.D. & Williams, K.D. (2003). Does rejection hurt? An fMRI study of social exclusion. Science, 302: 290-292</reF> ===Psychological factors=== Research has indicated the role of 'core' or 'unconditional' negative beliefs (e.g. I am inept) and 'conditional' beliefs nearer to the surface (e.g. If I show myself, I will be rejected). They are thought to develop based on personality and adverse experiences and to be activated when the person feels under threat.<ref>Beck AT, Emery G, Greenberg RL (1985) Anxiety Disorders and Phobias: A Cognitive Perspective. New York: Basic Books.</ref> One line of work has focused more specifically on the key role of self-presentational concerns.<ref>Leary, M.R., & Kowalski, R.M. (1995) Social Anxiety. London: Guildford Press</ref><ref>Leary, M.R., Kowalski, R.M, Campbell, C.D. (1988). Self-presentational concerns and social anxiety: the role of generalised impression expectancies. Journal of Research in Personality, 22, 308-321.</ref> The resulting anxiety states are seen as interfering with social performance and the ability to concentrate on interaction, which in turn creates more social problems, which strengthens the negative [[schema]]. Also highlighted has been a high focus on and worry about anxiety symptoms themselves and how they might appear to others.<ref>Clark, D. M., & Wells, A. (1995). A cognitive model of social phobia. In. R. G. Heimberg, M. R. Liebowitz, D. A. Hope, & F. R. Schneier (Eds.), Social phobia: Diagnosis, assessment, and treatment (pg 41-68). Guilford Press: New York.</ref> A similar model<ref>Rapee, R.M., & Heimberg, R.G. 1997 A cognitive-behavioral model of anxiety in social phobia, Behaviour Research and Therapy, 35, pp. 741-756</ref> emphasises the development of a distorted mental representation of their self and over-estimates of the likelihood and consequences of negative evaluation, and of the performance standards that others have. Such cognitive-behavioral models consider the role of negatively-biased memories of the past and the processes of rumination after an event, and fearful [[anticipation (emotion)|anticipation]] before it. Studies have also highlighted the role of subtle avoidance and defensive factors, and shown how attempts to avoid feared negative evaluations or use 'safety behaviours' (Clark & Wells, 1995) can make social interaction more difficult and the anxiety worse in the long run. This work has been influential in the development of Cognitive Behavioural Therapy for social anxiety disorder, which has been shown to have efficacy. ==Treatment== Arguably the most important clinical point to emerge from studies of social anxiety disorder is the benefit of early diagnosis and treatment. Social anxiety disorder remains under-recognized in [[primary care]] practice, with patients often presenting for treatment only after the onset of [[complication (medicine)|complications]] such as [[clinical depression]] or substance abuse disorders. The patients who achieve full resolution are usually far fewer; there are still many who, after receiving treatment, are unable to function in the long-term without anxiety symptoms. Research has provided evidence for the [[efficacy]] of two forms of treatment available for social phobia: certain medications and a specific form of short-term psychotherapy called [[Cognitive-behavioral therapy]] (CBT), the central component being gradual exposure therapy. ===Pharmacological treatments=== ====SSRIs==== [[Selective serotonin reuptake inhibitor]]s (SSRIs), a class of antidepressants, are considered by many to be the first choice medication for generalised social phobia. These drugs elevate the level of the neurotransmitter serotonin, among other effects. The first drug formally approved by the [[Food and Drug Administration]] was [[paroxetine]], sold as [[Paxil]] in the US or [[Seroxat]] in the UK. Compared to older forms of medication, there is less risk of tolerability and drug dependency.<ref>{{cite book|coauthors=Stuart Montgomery, Hans Den Boer|title=SSRIs in Depression and Anxiety|ISBN=0-4708-4136-2|pages=109-111|publisher=John Wiley and Sons}}</ref> However, their [[efficacy]] and increased suicide risk has been subject to controversy. In a 1995 [[double-blind]], [[placebo]]-controlled trial, the SSRI paroxetine was shown to result in [[clinical]]ly meaningful improvement in 55 percent of patients with generalized social anxiety disorder, compared with 23.9 percent of those taking placebo.<ref name="ssri-1995-study">Murray B. Stein, MD; Michael R. Liebowitz, MD; R. Bruce Lydiard, PhD, MD; Cornelius D. Pitts, RPh; William Bushnell, MS; Ivan Gergel, MD. [http://jama.ama-assn.org/cgi/content/full/280/8/708?ijkey=90c9882018a7891117a7107e8775afc75d52cf52 Paroxetine Treatment of Generalized Social Phobia (Social Anxiety Disorder)] April 1995 - February 1996. Retrieved February 24, 2006.</ref> An October 2004 study yielded similar results. Patients were treated with either [[fluoxetine]], psychotherapy, fluoxetine and psychotherapy, placebo and psychotherapy, and a placebo. The first four sets saw improvement in 50.8 to 54.2 percent of the patients. Of those assigned to receive only a placebo, 31.7 percent achieved a rating of 1 or 2 on the [[Clinical Global Impression-Improvement]] scale. Those who sought both therapy and medication did not see a boost in improvement.<ref name="ssri-2004-study">Jonathan R. T. Davidson, MD; Edna B. Foa, PhD;Jonathan D. Huppert, PhD; Francis J. Keefe, PhD; Martin E. Franklin, PhD; Jill S. Compton, PhD; Ning Zhao, PhD; Kathryn M. Connor, MD; Thomas R.Lynch, PhD; Kishore M. Gadde, MD [http://archpsyc.ama-assn.org/cgi/content/abstract/61/10/1005 Fluoxetine, Comprehensive Cognitive Behavioral Therapy, and Placebo in Generalized Social Phobia] October 2004. Retrieved February 24, 2006.</ref> General [[Adverse effect (medicine)|side-effects]] are common during the first weeks while the body adjusts to the drug. Symptoms may include [[headache]]s, [[nausea]], [[insomnia]] and changes in sexual behavior. Treatment safety during pregnancy has not been established.<ref>{{cite web|url=http://www.emedicine.com/med/topic3121.htm| publisher=eMedicine|title=Social Phobia| first=Kiki D| last= Chang| accessdate=2006-05-14|year=March 28, 2006}}</ref> In late 2004 much media attention was given to a proposed link between SSRI use and [[teenage suicide|juvenile suicide]]. For this reason, the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor.<ref name="fda-warning">Federal Drug and Administration. [http://www.fda.gov/cder/drug/antidepressants/PI_template.pdf Class Suicidality Labeling Language for Antidepressants]. 2004. Retrieved February 24, 2006.</ref> Recent studies have shown no increase in rates of suicide.<ref name="ssri-suicide">Group Health Cooperative. [http://www.ghc.org/news/news.jhtml?reposid=/common/news/news/20051223-suicide.html Study refutes link between suicide risk, antidepressants] January 1, 2006. Retrieved February 24, 2006.</ref> These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder. However, it should be noted that due to the nature of the conditions, those taking SSRIs for social phobias are far less likely to have suicidal ideation than those with depression. ====Other drugs==== Although SSRIs are often the first choice for treatment, other prescription drugs are also commonly issued, sometimes only if SSRIs fail to produce any clinically significant improvement. In 1985, before the introduction of SSRIs, anti-depressants such as [[monoamine oxidase inhibitor]]s (MAOIs) were frequently used in the treatment of social anxiety. Their efficacy appears to be comparable or sometimes superior to SSRIs or Benzodiazepines. However, because of the [[Diet (nutrition)|dietary]] restrictions required, high [[toxic]]ity in overdose, and incompatibilities with other drugs, its usefulness as a treatment for social phobics is now limited. Some argue for their continued use, however, or that a special diet does not need to be strictly adhered to.<ref name="crozier-maoi">Crozier, page. 475-477.</ref> A newer type of this medication, [[RIMA|Reversible inhibitors of monoamine oxidase subtype A]] (RIMAs) inhibit the MAO [[enzyme]] only temporarily, improving the adverse-effect profile but possibly reducing their efficacy. [[Benzodiazepine]]s are a short-acting and more [[potent]] alternative to SSRIs. The drug is often used for short-term relief of severe, disabling anxiety. [[Alprazolam]] and [[clonazepam]] are usual benzodiazepines for social fear. Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is much concern over the development of [[drug tolerance]], [[chemical dependency|dependency]] and [[Recreational drug use|recreational abuse]]. Benzodiazepines augment the action of [[GABA]], the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours. Some people with a form of social phobia called performance phobia have been helped by [[beta-blocker]]s, which are more commonly used to control high blood pressure. Taken in low doses, they control the physical manifestation of anxiety and can be taken before a public performance. A novel treatment approach has recently been developed as a result of translational research. It has been shown that a combination of acute dosing of d-cycloserine (DCS) with exposure therapy facilitates the effects of exposure therapy of social phobia (Hofmann, Meuret, Smits, et al., 2006). DCS is an old antibiotic medication used for treating tuberculosis and does not have any anxiolytic properties per se. However, it acts as an agonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor site, which is important for learning and memory (Hofmann, Pollack, & Otto, 2006). It has been shown that administering a small dose acutely 1 hour before exposure therapy can facilitate extinction learning that occurs during therapy. ===Psychotherapy=== Research has shown that a form of [[psychotherapy]] that is effective for several anxiety disorders, particularly panic disorder and social phobia<ref name="cbt">Jonathan R. T. Davidson, MD; Edna B. Foa, PhD; ''et al.'' [http://archpsyc.ama-assn.org/cgi/content/abstract/61/10/1005 Fluoxetine, Comprehensive Cognitive Behavioral Therapy, and Placebo in Generalized Social Phobia] 1998. Retrieved March 1, 2006.</ref> is [[cognitive-behavioral therapy]] (CBT). It has two main components. The cognitive component helps people become aware of and to change thinking patterns that keep them from overcoming their fears. A person with social phobia might be helped to question how they can be so sure that others are continually watching and harshly judging him or her. The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. It also serves as a logical extension of cognitive therapy where people are shown proof in the real world that their dysfunctional thought processes are unrealistic. A key element of this component is gradual exposure, in which people confront the things they fear in a structured, sensitive manner. Gradual exposure is an inherently unpleasant technique. It involves four components, duration, frequency, graded and focused. Ideally the person should be exposed to a feared social situation that is anxiety provoking but bearable (graded) for as long as possible (duration), two to three times a day (frequency), and the person must endure the anxiety until it declines (focused). A hierarchy of feared steps is constructed and the patient is exposed to each step. The aim is also to learn from acting differently and observing reactions (behavioral 'experiments'). This is intended to be done with support and guidance when the therapist and patient feel they are ready. Cognitive-behavior therapy for social phobia also includes anxiety management training, which may include techniques such as deep breathing and muscle relaxation exercises, which may be practiced '[[in-situ]]'. CBT may also be conducted partly in group sessions (Cognitive behavioral [[group therapy]]), facilitating the sharing of experiences, a sense of acceptance by others and undertaking behavioral challenges in a trusted environment (Heimberg). Some studies have suggested social skills training can help with social anxiety<ref>Mersch ''et al.'', 1991</ref>. Whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations, does not seem to be clear<ref>Stravynski & Amado, 2001</ref>. Interpersonal Therapy has been shown to have efficacy for depression and a small study of the therapy in the treatment of social phobia suggests it may also work with social phobia<ref>Lipsitz et al, 1999</ref>. ==History== Literary descriptions of shyness can be traced back to the days of [[Hippocrates]] around 400 B.C. Hippocrates described someone who 'through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. 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'. Charles Darwin wrote about the physiology and social context of blushing and shyness. The first mention of a psychiatric term, social phobia ("phobie des situations sociales"), was made in the early 1900s. Psychologists used the term "[[social neurosis]]" to describe extremely shy patients in the 1930s. After extensive work by [[Joseph Wolpe]] on [[systematic desensitization]], research in phobias and their treatment grew. The idea that social phobia was a separate entity from other phobias came from the British psychiatrist, [[Isaac Marks]] in the 1960s. This was accepted by the [[American Psychiatric Association]] and was first officially included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. The definition of the phobia was revised in 1989 to allow comorbidity with [[avoidant personality disorder]], and introduced generalized social phobia. <ref name="furmark" /> Social phobia had been largely ignored prior to 1985. After a call to action by psychiatrist [[Michael Liebowitz]] and [[clinical psychologist]] [[Richard Heimberg]], there was an increase in research and attention on the disorder. The DSM-IV gave social phobia the alternative name Social Anxiety Disorder. Research in to the psychology and sociology of everyday social anxiety continued. Cognitive Behavioural models and therapies were developed for social anxiety disorder. In the 1990s<!-- when exactly? -->, [[paroxetine]] became the first prescription drug in the US approved to treat social anxiety disorder, with others following. ==Criticisms== Some argue that inherent problems with society such as a competitive culture, power imbalances, lack of care and poor social education in families cause social anxiety; they feel the diagnostic boundaries have been stretched too far and that clinical and media work is promoting the idea that any problems with shyness or social worries are a pathological medical condition requiring medical treatment. Some see this as being driven by [[pharmaceutical companies]], either by direct advertising to the public or their financial influence on psychiatry.<ref>{{cite journal| title=Disorders Made to Order| first=Brendan I.| last=Koerner| month=July/August| year=2002 | journal=Mother Jones| url=http://www.motherjones.com/news/feature/2002/07/disorders.html| accessdate=2006-05-14}}</ref> This view can be associated with, but is not exclusive to, [[anti-psychiatry]]. ==See also== {| style="background-color: transparent; width: {{{width|100%}}}" | width="50%" align="{{{align|left}}}" valign="{{{valign|top}}}" | * [[Agoraphobia]] * [[Anxiety]] * [[Anxiety Disorders Association of America]] * [[Asperger syndrome]] * [[Avoidant personality disorder]] * [[Fear]] * [[Generalized anxiety disorder]] * [[Hikikomori]] * [[Hypervigilance]] * [[Hypoglycemia]] * [[Introversion and extroversion]] * [[Liebowitz social anxiety scale]] (LSAS) | width="50%" align="{{{align|left}}}" valign="{{{valign|top}}}" | * [[Love-shyness]] * [[Major depressive disorder]] * [[Mean world syndrome]] * [[mindfulness]] * [[Paranoid personality disorder]] * [[Schizoid personality disorder]] * [[Schizotypal personality disorder]] * [[Selective mutism]] * [[Social anxiety]] * [[Social control]] * [[Social rejection]] * [[Taijin kyofusho]] * [[Timidness]] |} ==References== {{reflist|2}} ==Further reading== * American Psychiatric Association. (2000). Anxiety disorders. In ''Diagnostic and statistical manual of mental disorders'' (4th ed., text rev., pp. 450–456). Washington, D.C.: American Psychiatric Association. * Belzer, K. D., McKee, M. B., & Liebowitz, M. R. (2005). [http://www.primarypsychiatry.com/aspx/articledetail.aspx?articleid=247 Social Anxiety Disorder: Current Perspectives on Diagnosis and Treatment]. ''Primary Psychiatry, 12''(11), 40–53. * Bruch, M. A. (1989). Familial and developmental antecedents of social phobia: Issues and findings. ''Clinical Psychology Review, 9'', 37-47. * [[David D. Burns|Burns, D. D.]] (1999). ''Feeling good: The new mood therapy'' (Rev. ed.). New York: Avon. ISBN 0-380-81033-6. * Crozier, W. R., & Alden, L. E. (2001). ''International Handbook of Social Anxiety: Concepts, Research, and Interventions Relating to the Self and Shyness''. New York: John Wiley & Sons, Ltd. ISBN 0-471-49129-2. * Hales, R. E., & Yudofsky, S. C. (Eds.). (2003). Social phobia. In ''Textbook of Clinical Psychiatry'' (4th ed., pp. 572–580). Washington, D.C.: American Psychiatric Publishing. * Hofmann, S. G., Meuret, A. E., Smits, J. A. J., Simon, N. M., Pollack, M. H., Eisenmenger, K., Shiekh, M., & Otto, M. W. (2006). Augmentation of exposure therapy for social anxiety disorder with d-cycloserine. ''Archives of General Psychiatry, 63'', 298-304. * Hofmann, S. G., Pollack, M. H. & Otto, M. O. (2006). Augmentation treatment of psychotherapy for anxiety disorders with d-cycloserine. ''CNS Drug Reviews, 12'', 208–217. * Okano, K. (1994). Shame and social phobia: A transcultural viewpoint. ''Bulletin of the Menninger Clinic, 58''(3), 323–38. * Samson, A. (2002). Psychiatric conceptions of "social phobia": A comparative perspective. ''Swiss Journal of Sociology, 28''(3), 505–527. * Stein, M. B., & Kean, Y. M. (2000). Disability and quality of life in social phobia: Epidemiologic findings. ''American Journal of Psychiatry, 157'', 1606–1613. * Van Ameringen, M. A., et al. (2001). Sertraline treatment of generalized social phobia: A 20-week, double-blind, placebo-controlled study. ''American Journal of Psychiatry, 158''(2), 275–281. * Wagstaff, A. J., et al. (2002). "Spotlight on paroxetine in psychiatric disorders in adults". ''Drugs, 62'', 655–703. * Garcia-Lopez et al. (2006). Efficacy of three CBGT treatments: A 5-year follow-up. Journal of Anxiety Disorders, ==External links== {{Spoken Wikipedia|social_anxiety.ogg|2006-06-27}} * [http://dmoz.org/Health/Mental_Health/Disorders/Anxiety/Social_Anxiety/ Social Anxiety at the Open Directory Project] * [http://www.adaa.org/ Anxiety Disorders Association of America] - Help for people with anxiety disorders, including social anxiety disorder {{Mental and behavioural disorders}} [[Category:Anxiety disorders]] [[Category:Phobias]] [[cs:Sociální fobie]] [[da:Socialfobi]] [[de:Soziale Phobie]] [[es:Fobia social]] [[fr:Phobie sociale]] [[it:Fobia sociale]] [[he:חרדה חברתית]] [[lt:Sociofobija]] [[nl:Sociale fobie]] [[ja:社会恐怖]] [[no:Sosial angst]] [[pl:Fobia społeczna]] [[pt:Fobia social]] [[ru:Социофобия]] [[sr:Социјална фобија]] [[fi:Sosiaalisten tilanteiden pelko]] [[sv:Social fobi]] [[tr:Sosyal fobi]] [[yi:סאציעלע פאביע]] [[zh:社交恐懼症]]