is an experience of fear, apprehension or worry regarding social situations and being evaluated by others. People vary in how often they experience anxiety in this way or in which kinds of situations. Anxiety about public speaking or interviews is common.
(SAD), previously referred to clinically as social phobia, is a
Psychiatric Anxiety Disorder involving overwhelming
Anxiety and excessive
Self-conscious ness in everyday social situations. People experiencing social anxiety often have a persistent, intense, and chronic fear of being watched and judged by others and being embarrassed or humiliated by their own actions. Their fear may be so severe that it significantly impairs their work, school, social life, and other activities. While many people experiencing social anxiety recognize that their fear of being around people may be excessive or unreasonable, they confront considerable difficulty overcoming it. This differs from
Shyness , in that the person is functionally debilitated and avoids such anxiety provoking situations by all means.
Social anxiety can be limited to only one type of situation—such as a fear of speaking in formal or informal situations, or
Eating , or writing in front of others—or, in its most severe form, may be so broad that a person experiences
Symptom s almost anytime they are around other people. Many people have the specific fear of
Public Speaking , called
Glossophobia .
Statistic s on the number of people diagnosed with the disorder vary widely due to its close relation with other illnesses, such as
Avoidant Personality Disorder and
Depression .
Physical symptoms often accompany social anxiety, and include
Blushing , profuse sweating, trembling,
Nausea , and
Stammer ing.
Panic Attack s may also occur under intense fear and discomfort. An early
Diagnosis helps in minimizing the symptoms and having other mental illnesses such as depression. Sufferers may also use alcohol to reduce fears and inhibitions at social events.
A person with the disorder may be treated with therapy, medication, or both. Research has shown
Cognitive Behavior Therapy , whether individually or in a group, to be effective in treating social phobics. The
Cognitive and
Behavioral components seek to change thinking patterns and physical reactions to anxious situations.
Prescribed Medication consists of a class of
Antidepressant s called
Selective Serotonin Reuptake Inhibitor s (SSRIs). Such treatment has a high response rate, low risk of dependancy but has been criticized for its adverse side-effects and possible increase in suicide risk.
Attention given to social anxiety disorder has significantly increased since 1999 with the approval of drugs for its treatment. Marketing campaigns by pharmaceutical companies may be largely responsible for driving this.
According to the
Diagnostic And Statistical Manual Of Mental Disorders , social
Phobia 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. For one to be social phobic, exposure to the feared situation must provoke
Anxiety and the person must recognize this anxiety is irrational (although this may be absent in children). If another disorder is present, the social phobic fear is unrelated to it. For instance, if a person has a history of panic attacks, having a panic attack must not be the sufferer's fear. Sufferers are typically more self-conscious and self-attentive than others. As a result, social phobics tend to limit or remove themselves from situations where they may be subject to evaluation. Sufferers often recognize their fear is excessive or irrational, yet can't seem to break out of the cycle. As such, the diagnosis of social phobia is made only when the fear leads to avoiding occupational functions, social activities, or relationships with others.
Psychiatrists often distinguish between generalized and specific social anxiety disorders. People with generalized social anxiety have great distress with most or all social situations. A famous study by
Stanford University established that distress was more likely when social encounters were unfamiliar, involved power or status differences, difference in gender, or the presence of a group of people. Those with specific social phobias may experience anxiety only in a few situations. For example the most common specific phobia is
Glossophobia , the fear of public speaking or performance, also known as "stage fright". Other examples of specific social phobias include fears of writing in public (
Scriptophobia ) and using public restrooms (
Paruresis ).
There is much debate concerning the relationship between social phobia and s in social situations, heightened
Physiological reactivity, a tendency to avoid social situations, and deficits in social skills. Negative cognitions include fear of negative evaluation,
Self-conscious ness, devaluation of social skills, self-deprecating thoughts, and self-blaming attributions for social difficulties. Social phobia is distinct from shyness in that it has a lower prevalence in the population, follows a more chronic course, is more functionally debilitating, and has a later age of onset. There are problems with these kinds of comparisons. It may be that the differences between them are quantitative rather than qualitative. There are some that argue that shyness is mistakenly treated with
Medication intended for social phobia, effectively labeling the
Personality Trait a mental illness.
Social phobia should not be confused with
Panic Disorder . Sufferers of panic disorder are convinced that their panic comes from some dire physical cause, and often go to the hospital or call for an ambulance during or after their attacks. Social phobics may experience a panic attack when triggered, but they are aware that it is extreme anxiety they are experiencing, and that the cause is an irrational fear. Few social phobics would willingly go to a hospital in that instance because they fear rejection and judgment by authority figures (such as the medical staff). The general form of social anxiety is sometimes incorrectly called
Generalized Anxiety Disorder . The principal difference between the two is that the social phobia deals with anxiety in a social setting, while generalized anxiety disorder is extreme anxiety for any situation (work, school, et al.), not necessarily one involving other people.
In cognitive models of social anxiety, 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 oneself. According to the social psychology theory,
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.
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. Those with social phobia tend to interpret neutral or ambiguous conversations with a negative outlook and although still inconclusive, some studies suggest that socially anxious individuals remember more negative memories than those less distressed. 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.
According to renowned psychologist
Burrhus Skinner , phobias are controlled by
Escape and
Avoidance Behavior s. 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 shaking. A
Fight-or-flight Response is then triggered in such events. Preventing these automatic responses is at the core of treatment for social phobia.
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,
Crying , clinging to parents, and shutting themselves out. Adults may weep, as well as experience excessive
Sweat ing,
Nausea ,
Shaking , and
Palpitation s as a result of the fight-or-flight response.
Blush ing is commonly exhibited by individuals suffering from social phobia. 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.
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. 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."
The
National Comorbidity Survey of over 8,000 American correspondents in 1994 revealed a 12-month and lifetime prevalence rates of 7.9% and 13.3% making it the third most prevalent psychiatric disorder after depression and alcohol dependence and the most apparent of the anxiety disorders. 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. Recent studies suggest the lifetime prevalence number may be as high as 15 million people or 6.8% of the American population. Cross-cultural studies have reached prevalence rates with the conservative rates at 5% of the population. However, other estimates vary within 2% and 7% of the U.S. adult population.
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 twice as often as males, although men are more likely to seek help. 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. Surveys carried out in 2002 show the youth of
England ,
Scotland , and
Wales have a prevalence rate of .4%, 1.8%, and .6%, respectively. The prevalence of self-reported social anxiety for Nova Scotians older than 14 years was 4.2% in June 2004 with women (4.6%) reporting more than men (3.8%). 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.
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. The most common complementary psychiatric condition is depression. In a sample of 14,263 people, of the 2.4% of persons diagnosed with social phobia, 16.6% also met the criteria for
Major Depression . Besides depression, the most common disorders diagnosed in patients with social phobia are
Panic Disorder (33%),
Generalized Anxiety Disorder (19%),
Post-traumatic Stress Disorder (36%),
Substance Abuse Disorder (18%), and attempted
Suicide (23%). 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%, 61%, and 90% of patients, respectively.
Avoidant Personality Disorder is also highly correlated with social phobia. Because of its close relationship and overlapping symptoms with other illnesses, treating social phobics may help understand underlying connection in other psychiatric disorders.
Scientists have yet to pinpoint the exact
Causes of social phobia. Studies suggest the disorder is familial; however these findings do not differentiate between environmental and
Genetic factors. Preliminary studies suggest that both biological and psychological factors contribute to the disorder.
It has been shown that there is a two to three fold greater risk of having social phobia if a first-degree relative also has the disorder. If parents themselves are socially anxious, their children might acquire social fears and avoidance through processes of modeling. Consequently, the child's exposure to social events and conversations may be limited, preventing the child from gaining the experience needed to develop better social skills. These psychologists suggest people with social phobia may acquire their fear from observing the behavior and consequences of others, a process called
Observational Learning . A previous negative social experience can be a trigger to social phobia.
Some scientists hypothesize that social phobia is related to an imbalance of the brain chemical
Serotonin . Sociability is also closely tied to
Dopamine Neurotransmission . Low D2 receptor binding is found in people with social anxiety. Researchers supported by the National Institute of Mental Health (NIMH) recently identified the site of a gene in mice that affects learned fearfulness, suggesting that social anxiety disorder is inherited.
Arguably the most important clinical point to emerge from studies of comorbid social anxiety disorder is the necessity for early diagnosis and treatment. Social anxiety disorder remains underrecognized in primary care practice, with patients presenting for treatment only after the onset of complications such as major depression or substance use disorders. Up to 80 percent of those treated for social phobia say they've gotten their anxiety under control, according to the
Anxiety Disorders Association Of America . Improvement is lower for those with more severe social phobia and with comorbid disorders, such as avoidant personality disorder and depression. 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 supported by the
NIMH has shown that there are two effective forms of treatment available for social phobia (and anxiety disorders): certain medications and a specific form of short-term psychotherapy called cognitive-behavioral therapy (CBT), the central component being gradual exposure therapy. Medications include antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as drugs known as high-potency benzodiazepenes.
Selective Serotonin Reuptake Inhibitor s (SSRIs), a class of antidepressants, are considered the first choice by doctors in defusing fears associated with social phobia and related anxiety disorders. These drugs are designed to elevate the level of the neurotransmitter serotonin. The first drug formally approved by the
Food And Drug Administration was
Paroxetine , sold as
Paxil . Compared to older forms of medication, there is little risk of tolerability and drug dependency. 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% of patients with generalized social anxiety disorder, compared with 23.9% of those taking placebo. 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% 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.
General . 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. Recent studies have shown no increase in rates of suicide. These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder.
Although SSRIs are often the first choice for treatment, other prescription drugs are also commonly issued.
Benzodiazepine s are a more
Potent alternative to SSRIs. The drug is often used for short-term relief of severe, disabling anxiety. Although benzodiazepines are prescribed for long-term use, there is much concern over the development of
Drug Tolerance ,
Dependency and
Recreational Abuse . Benzodiazepines, such as
Xanax augment the action of
GABA , the major inhibitory neurotransmitter in the brain; effects may begin to appear within days or hours.
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 by researchers such as
Michael Liebowitz . Irreversible MAOIs, most notably phenlzine, has been more efficacious than benzodiazepines in the short-term (8-12 weeks). Relapse is common, which may result in long-term usage. Because of the
Diet ary restrictions required, high
Toxic ity in overdose, and incompatibilities with other drugs, its usefulness as a treatment for social phobics is limited.
Reversible Inhibitors Of Monoamine Oxidase Subtype A (RIMAs) also inhibit
Monoamine Oxidase . In contrast with MAOIs, reversibility means that they can inhibit the
Enzyme only temporarily. Because their action is short-lived and selective, they have a better
Safety Profile than the older MAOI drugs. A special diet does not need to be strictly adhered to.
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 shaking of anxiety and can be taken before a public performance.
Research has shown that a form of psychotherapy that is effective for several anxiety disorders, particularly panic disorder and social phobia, is
Cognitive-behavioral Therapy (CBT) (Burns, 1999). It has two components. The cognitive component helps people change thinking patterns that keep them from overcoming their fears. A person with social phobia might be helped to overcome the belief 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. A key element of this component is gradual exposure, in which people confront the things they fear in a structured, sensitive manner. This is done with support and guidance when the therapist feels the patient is ready and only with the permission of the patient and at the pace the patient wishes. Cognitive-behavior therapy for social phobia also includes anxiety management training, such as teaching people techniques such as deep breathing to control their levels of anxiety.
Cognitive Behavioral Group Therapy (CBGT), founded upon research done by
Richard Heimberg , is a similar psychotherapeutic approach. It is generally held for 12 weekly sessions which run for two or three hours. A range of 4-10 patients and two therapists are involved in sharing individual experiences, participating in simulated exposures, and completing homework assignments in the goal of replacing irrational and automatic negative thoughts in social situations. A sample homework assignment might include reading a book or initiating a conversation with an acquaintance. Even in CBGT, sufferers are treated individually. Each person is exposed to different levels of anxious situations, depending on the severity of their illness.
These two types of cognitive behavior therapy have proven effective in reducing anxiety among social phobics. A 1998 study by
Heimberg and
Michael Liebowitz and a 2004 experiment showed the efficacy of CBGT.
(pictured), as well as
Richard Heimberg are prominent researchers on social phobia.]]
Although literary descriptions of shyness can be traced back to the days of
Hippocrates around 400 B.C., the first mention of 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 illness was revised in 1989 to allow comorbidity between avoidant personality disorder and social phobia and introduced generalized social phobia. Social phobia had been largely ignored prior to 1985. After a call to action by psychiatrist
Michael Liebowitz ,
Richard Heimberg and the founding of the
Anxiety Disorders Clinic , psychologists began conducting more research about the disorder. In the 1990s,
Paroxetine became the first prescription drug approved to treat social anxiety disorder. Two more drugs have since been approved by the FDA (
Sertraline and
Venlafaxine ). Notable public figures with social phobia include
NFL football player
Ricky Williams and American entertainment personality
Donny Osmond .
Social Anxiety Disorder is frequently mentioned in association with criticisms that pharmaceutical companies attempt to market ordinary life experiences as "diseases" requiring a "cure", with a profit motive. Since the approval of
Paxil in 1999 the disorder has been subject to extensive marketing campaigns. Major concerns are that people are receiving unnecessary treatment (which can do more harm than good), and that side affects are not properly mentioned.
{Link without Title}
Given the blurry lines between shyness and social anxiety disorder, there is concern that people may start taking drugs to cure ordinary shyness. Also of concern is the inordinate level of attention being given towards drug treatments at the expense of behavioral and cognitive therapy.
This also could be diagnosed in accordance with OCD, as many of those with OCD have trouble dealing with social situations. Lack of public awareness of Social Anxiety Disorder may cause many to believe that people suffering from this disorder are just self-conscious and shy, two ordinary personality traits.
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