Social phobia
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{{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 – 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]]