Social anxiety disorder
Encyclopedia
Social anxiety disorder (SAD or SAnD) (DSM-IV
300.23), also known as social phobia, is an anxiety disorder
characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life. The diagnosis of social anxiety disorder 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, chronic
fear of being judged by others and of being embarrassed or humiliated by one's own actions. These fears can be triggered by perceived or actual scrutiny from others. While the fear of social interaction may be recognized by the person as excessive or unreasonable, overcoming it can be quite difficult. Physical symptoms often accompanying social anxiety disorder include excessive blushing
, sweating
(hyperhidrosis
), trembling
, palpitations, nausea
, and stammering often accompanied with rapid speech. Panic attack
s may also occur under intense fear and discomfort. An early diagnosis
may help minimize the symptoms and the development of additional problems, such as depression
. Some sufferers may use alcohol
or other drug
s to reduce fears and inhibitions at social events. It is common for sufferers of social phobia to self-medicate
in this fashion, especially if they are undiagnosed, untreated, or both; this can lead to alcoholism, eating disorders or other kinds of substance abuse.
Standardized rating scales such as Social Phobia Inventory
can be used for screening social anxiety disorder and measuring severity of social phobia. 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 anxiety-inducing situations. Attention given to social anxiety disorder has significantly increased in the United States
since 1999 with the approval and marketing of drugs for its treatment. Prescribed medications include several classes of antidepressant
s: selective serotonin reuptake inhibitor
s (SSRIs) such as Zoloft, Prozac, and Paxil; serotonin-norepinephrine reuptake inhibitor
s (SNRIs); and monoamine oxidase inhibitors (MAOIs). Other commonly used medications include beta blocker
s and benzodiazepine
s, as well as newer antidepressants, such as mirtazapine
. Kava-kava has also attracted attention as a possible treatment, although safety concerns exist.
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."
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. 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 attention to and research on the disorder. The DSM-IV gave social phobia the alternative name social anxiety disorder. Research on the psychology and sociology of everyday social anxiety continued. Cognitive Behavioural models and therapies were developed for social anxiety disorder. In the 1990s, paroxetine
became the first prescription drug in the U.S. approved to treat social anxiety disorder, with others following.
Social phobia in many cases can be an extremely debilitating disorder, especially because one who struggles with it often suffers alone.
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 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 deliberately go 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 many 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 their perceptions of him or her as a presenter have been tarnished. This cognitive thought propels further anxiety which compounds with further stuttering, sweating, and, potentially, a panic attack.
and gagging. Cognitive distortions are a hallmark, and learned about in CBT (cognitive-behavioral therapy). Thoughts are often self-defeating and inaccurate.
According to psychologist B.F. Skinner, phobias are controlled by escape
and 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). Major avoidance behaviors could include an almost pathological/compulsive lying behavior in order to preserve self-image and avoid judgement in front of others. 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 anxiety.
as well as experiencing excessive sweat
ing, nausea
, difficulty breathing, shaking
, and palpitation
s as a result of the fight-or-flight response. The walk disturbance (where a person is so worried about how they walk that they may lose balance) may appear, especially when passing a group of people. Blushing
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 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 rate 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. 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. However, other estimates vary within 2 percent and 7 percent of the U.S. adult population.
The mean onset of social phobia is 10 to 13 years. Onset after age 25 is rare and is typically preceded by panic disorder or major depression. Social anxiety disorder occurs in females nearly twice as often as males, and 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 0.4 percent, 1.8 percent, and 0.6 percent, respectively. The prevalence of self-reported social anxiety for Nova Scotians older than 14 years was 4.2 percent in June 2004 with women (4.6 percent) reporting more than men (3.8 percent). 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. Because of the difficulty in separating social phobia from poor social skills or shyness, some studies have a large range of prevalence. The table also shows higher prevalence in Brazil.
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 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
. 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 disorder
(18 percent), and attempted suicide
(23 percent). In one study of social anxiety disorder among 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. 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
. Some researchers believe they share an underlying cyclothymic-anxious-sensitive disposition. In addition, studies show that more socially phobic patients treated with anti-depressant medication develop hypomania
than non-phobic controls. 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.
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 causes
. Studies suggest that genetics can play a part in combination with environmental factors.
Generally, social anxiety begins at a specific point in an individual's life. This will develop over time as the person struggles to recover. Eventually mild social awkwardness can start to show symptoms of social anxiety or phobia. Probably the most common example is when a person is either abused emotionally or physically by peers or parental figures at a young age. The person will tend to relate the past experiences with what is going on at the moment he or she experiences anxiety. To avoid this they create subconscious fail safes such as thinking through what they say or do excessively or trying to balance out perceived mistakes by being either excessively good or bad.
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. 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. Studies suggest that parents of those with social anxiety disorder tend to be more 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 insecure (anxious-ambivalent) attachment with their mother as infants were twice as likely to develop anxiety disorders by late adolescence, 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.
or humiliating social event appears to be associated with the onset or worsening of the disorder; 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. 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 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. Socially phobic children appear less likely to receive positive reactions from peers and anxious or inhibited children may isolate themselves.
or access employment or education, and shame
. 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 emphasize the importance of others' 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. Purely demographic variables may also play a role – for example there are possibly lower rates of social anxiety disorder in Mediterranean
countries and higher rates in Scandinavia
n countries, and it has been hypothesized 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 while others have. 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'. An interpersonal or media emphasis on 'normal' or 'attractive' personal characteristics has also been argued to fuel 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
originally wrote about the evolutionary basis of shyness and blushing, and modern evolutionary psychology
and psychiatry also addresses social phobia in this context. It has been hypothesized 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-behavioral models and therapies Another evolutionary explanation, applicable to social situation with strangers, is that in an ancestral environment characterized by small bands in which all individuals where known to one another, it was usually very dangerous to be confronted by a large group of staring, non-kin, unknown, and not smiling strangers.
initially helps social phobia, excessive alcohol misuse can worsen social phobia symptoms and can cause panic disorder to develop or worsen during alcohol intoxication and especially during alcohol withdrawal syndrome
. This effect is not unique to alcohol but can also occur with long term use of drugs which have a similar mechanism of action to alcohol such as the benzodiazepines which are sometimes prescribed as tranquillisers.
Benzodiazepines possess anti-anxiety properties and can be useful for the short-term treatment of severe anxiety. Like the anticonvulsants, they tend to be mild and well tolerated, although habit forming C(IV). Benzodiazepines are usually administered orally for the treatment of anxiety; however, occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attack
s.
The World Council of Anxiety does not recommend benzodiazepines for the long term treatment of anxiety due to a range of problems associated with long term use of benzodiazepines including tolerance, psychomotor impairment, cognitive and memory impairments, physical dependence
and a benzodiazepine withdrawal syndrome
upon discontinuation of benzodiazepines. Despite increasing focus on the use of antidepressants and other agents for the treatment of anxiety, benzodiazepines have remained a mainstay of anxiolytic pharmacotherapy due to their robust efficacy, rapid onset of therapeutic effect, and generally favorable side effect profile. Treatment patterns for psychotropic drugs appear to have remained stable over the past decade, with benzodiazepines being the most commonly used medication for panic disorder.
Approximately half of patients attending mental health services for conditions including anxiety disorders such as panic disorder
or social phobia are the result of alcohol
or benzodiazepine dependence
. Sometimes anxiety pre-existed alcohol
or benzodiazepine dependence but the alcohol or benzodiazepine dependence act to keep the anxiety disorders going and often progressively making them worse. Many people who are addicted to alcohol or prescribed benzodiazepines when it is explained to them they have a choice between ongoing ill mental health or quitting and recovering from their symptoms decide on quitting alcohol and/or their benzodiazepines. It was noted that every individual has an individual sensitivity level to alcohol or sedative hypnotic drugs and what one person can tolerate without ill health another will suffer very ill health and that even moderate drinking can cause rebound anxiety syndromes and sleep disorders. A person who is suffering the toxic effects of alcohol or benzodiazepines will not benefit from other therapies or medications as they do not address the root cause of the symptoms. Symptoms may temporarily worsen however, during alcohol withdrawal or benzodiazepine withdrawal.
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 behaviors' (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 Behavioral Therapy for social anxiety disorder, which has been shown to have efficacy.
neurotransmission
. Misuse of stimulants like amphetamines to increase self-confidence and improve social performance is common. In a recent study a direct relation between social status of volunteers and binding affinity of dopamine D2/3 receptors in the striatum
was found.
Other research shows that the binding affinity of dopamine D2 receptors in the striatum of social anxiety sufferers is lower than controls.
Some other researches show an abnormality in dopamine transporter
density in the striatum of social anxiety sufferers.
However, some researchers do not replicate previous findings of evidence of dopamine abnormality in social anxiety disorder.
Studies have shown high prevalence of social anxiety in Parkinson's disease and schizophrenia. In a recent study, social phobia was diagnosed in 50% of Parkinson's disease
patients. Other researchers have found social phobia symptoms in patients treated with dopamine antagonists like haloperidol, emphasizing the role of dopamine neurotransmission in social anxiety disorder.
Also, concentration problems, mental and physical fatigue, Anhedonia
and decreased self-confidence are seen in those with social anxiety disorder.
. A recent study report increased Serotonin
transporter binding in psychotropic medication-naive patients with generalized social anxiety disorder.
Although there are not many evidences of abnormality in Serotonin
neurotransmission, the limited efficacy of medications which affect serotonin levels may indicate the role of this pathway. Paroxetine
and Sertraline
are two SSRIs that have been confirmed by FDA to treat social anxiety disorder. Some researchers believe that SSRIs decrease activity of Amygdala
.
There is also increasing focus on other candidate transmitters, e.g. Norepinephrine and Glutamate, which may be over-active in social anxiety disorder, and the inhibitory transmitter GABA-which is subsequently lacking.
which is related to fear cognition and emotional learning. 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. 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.
practice, with patients often presenting for treatment only after the onset of complications
such as clinical depression
or substance abuse disorders.
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.
, 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. However, it is not clear whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations.
Additionally, a recent study has suggested that interpersonal therapy, a form of psychotherapy primarily used to treat depression, may also be effective in the treatment of social phobia.
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 U.S. or Seroxat in the UK. Compared to older forms of medication, there is less 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 clinically meaningful improvement in 55 percent of patients with generalized social anxiety disorder, compared with 23.9 percent of those taking placebo. An October 2004 study yielded similar results. Patients were treated with either fluoxetine
, psychotherapy, fluoxetine and psychotherapy, placebo and psychotherapy, or 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.
General 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. In late 2004 much media attention was given to a proposed link between SSRI use and suicidality [a term that encompasses suicidal ideation and attempts at suicide as well as suicide]. For this reason, [although evidential causality between SSRI use and actual suicide has not been demonstrated] 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. 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.
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 dietary
restrictions required, high toxicity 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. A newer type of this medication, 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 such as alprazolam
and clonazepam
are an alternative to SSRIs. These drugs are often used for short-term relief of severe, disabling anxiety. Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is some concern over the development of drug tolerance, dependency and misuse. It has been recommended that benzodiazepines are only considered for individuals who fail to respond to safer medications. Benzodiazepines augment the action of GABA
, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours.
The novel antidepressant mirtazapine
has been proven effective in treatment of social anxiety disorder. This is especially significant due to mirtazapine's fast onset and lack of many unpleasant side-effects associated with SSRIs (particularly, sexual dysfunction
).
In Japan, the serotonin-norepinephrine reuptake inhibitor
(SNRI), Milnacipran
is used in the treatment of Taijin kyofusho
a Japanese variant of social anxiety disorder.
Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure. 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. 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. It has been shown that administering a small dose acutely 1 hour before exposure therapy
can facilitate extinction learning that occurs during therapy.
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
300.23), also known as social phobia, is an anxiety disorder
Anxiety disorder
Anxiety disorder is a blanket term covering several different forms of abnormal and pathological fear and anxiety. Conditions now considered anxiety disorders only came under the aegis of psychiatry at the end of the 19th century. Gelder, Mayou & Geddes explains that anxiety disorders are...
characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life. The diagnosis of social anxiety disorder 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, chronic
Chronic (medicine)
A chronic disease is a disease or other human health condition that is persistent or long-lasting in nature. The term chronic is usually applied when the course of the disease lasts for more than three months. Common chronic diseases include asthma, cancer, diabetes and HIV/AIDS.In medicine, the...
fear of being judged by others and of being embarrassed or humiliated by one's own actions. These fears can be triggered by perceived or actual scrutiny from others. While the fear of social interaction may be recognized by the person as excessive or unreasonable, overcoming it can be quite difficult. Physical symptoms often accompanying social anxiety disorder include excessive blushing
Blushing
Blushing refers to the involuntary reddening of a person's face due to embarrassment or emotional stress, though it has been known to come from being lovestruck, or from some kind of romantic stimulation. It is thought that blushing is the result of an overactive sympathetic nervous system...
, sweating
Sweating
Perspiration is the production of a fluid consisting primarily of water as well as various dissolved solids , that is excreted by the sweat glands in the skin of mammals...
(hyperhidrosis
Hyperhidrosis
Hyperhidrosis is the condition characterized by abnormally increased perspiration, in excess of that required for regulation of body temperature.-Classification:Hyperhidrosis can either be generalized or localized to specific parts of the body...
), trembling
Tremor
A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving to-and-fro movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, face, head, vocal folds, trunk, and legs. Most tremors occur in the...
, palpitations, nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...
, and stammering often accompanied with rapid speech. Panic attack
Panic attack
Panic attacks are periods of intense fear or apprehension that are of sudden onset and of relatively brief duration. Panic attacks usually begin abruptly, reach a peak within 10 minutes, and subside over the next several hours...
s may also occur under intense fear and discomfort. An early diagnosis
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
may help minimize the symptoms and the development of additional problems, such as depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
. Some sufferers may use alcohol
Alcohol
In chemistry, an alcohol is an organic compound in which the hydroxy functional group is bound to a carbon atom. In particular, this carbon center should be saturated, having single bonds to three other atoms....
or other drug
Drug
A drug, broadly speaking, is any substance that, when absorbed into the body of a living organism, alters normal bodily function. There is no single, precise definition, as there are different meanings in drug control law, government regulations, medicine, and colloquial usage.In pharmacology, a...
s to reduce fears and inhibitions at social events. It is common for sufferers of social phobia to self-medicate
Self-medication
Self-medication is a term used to describe the use of drugs or other self-soothing forms of behavior to treat untreated and often undiagnosed mental distress, stress and anxiety, including mental illnesses and/or psychological trauma...
in this fashion, especially if they are undiagnosed, untreated, or both; this can lead to alcoholism, eating disorders or other kinds of substance abuse.
Standardized rating scales such as Social Phobia Inventory
Social Phobia Inventory
Social Phobia Inventory abbreviated as is a questionnaire developed by the department of Psychiatry and Behavioral Sciences of Duke University for screening and measuring severity of social anxiety disorder. This self-reported assessment scale consists of 17 items, which cover the main spectrum of...
can be used for screening social anxiety disorder and measuring severity of social phobia. A person with the disorder may be treated with psychotherapy
Psychotherapy
Psychotherapy is a general term referring to any form of therapeutic interaction or treatment contracted between a trained professional and a client or patient; family, couple or group...
, 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 anxiety-inducing situations. Attention given to social anxiety disorder has significantly increased in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...
since 1999 with the approval and marketing of drugs for its treatment. Prescribed medications include several classes of antidepressant
Antidepressant
An antidepressant is a psychiatric medication used to alleviate mood disorders, such as major depression and dysthymia and anxiety disorders such as social anxiety disorder. According to Gelder, Mayou &*Geddes people with a depressive illness will experience a therapeutic effect to their mood;...
s: selective serotonin reuptake inhibitor
Selective serotonin reuptake inhibitor
Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. The efficacy of SSRIs is disputed...
s (SSRIs) such as Zoloft, Prozac, and Paxil; serotonin-norepinephrine reuptake inhibitor
Serotonin-norepinephrine reuptake inhibitor
Serotonin–norepinephrine reuptake inhibitors are a class of antidepressant drugs used in the treatment of major depression and other mood disorders...
s (SNRIs); and monoamine oxidase inhibitors (MAOIs). Other commonly used medications include beta blocker
Beta blocker
Beta blockers or beta-adrenergic blocking agents, beta-adrenergic antagonists, beta-adrenoreceptor antagonists or beta antagonists, are a class of drugs used for various indications. They are particularly for the management of cardiac arrhythmias, cardioprotection after myocardial infarction ,...
s and benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
s, as well as newer antidepressants, such as mirtazapine
Mirtazapine
Mirtazapine is a tetracyclic antidepressant used primarily in the treatment of depression. It is also sometimes used as a hypnotic, antiemetic, and appetite stimulant, and for the treatment of anxiety, among other indications...
. Kava-kava has also attracted attention as a possible treatment, although safety concerns exist.
History
Literary descriptions of shyness can be traced back to the days of HippocratesHippocrates
Hippocrates of Cos or Hippokrates of Kos was an ancient Greek physician of the Age of Pericles , and is considered one of the most outstanding figures in the history of medicine...
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."
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
Joseph Wolpe
Joseph Wolpe was born on April 20, 1915, in Johannesburg, South Africa, and died on December 4, 1997, from lung cancer. He is one of the most influential figures in behavior therapy....
on systematic desensitization
Systematic desensitization
Systematic desensitization is a type of behavioral therapy used in the field of psychology to help effectively overcome phobias and other anxiety disorders. More specifically, it is a type of Pavlovian therapy / classical conditioning therapy developed by a South African psychiatrist, Joseph Wolpe...
, 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
Isaac Marks
Isaac Meyer Marks was born in Cape Town, South Africa. He trained in medicine there, qualifying in 1956. His training as a psychiatrist began in 1960 at the University of London and was completed in 1963...
, in the 1960s. This was accepted by the American Psychiatric Association
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
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
Avoidant personality disorder
Avoidant personality disorder is a personality disorder recognized in the Diagnostic and Statistical Manual of Mental Disorders handbook in a person characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of...
, and introduced generalized social phobia. Social phobia had been largely ignored prior to 1985.
After a call to action by psychiatrist Michael Liebowitz
Michael Liebowitz
Dr. Michael R. Liebowitz is a Columbia University psychiatrist and founder of the Anxiety Disorders Clinic, the first of its kind, at the New York State Psychiatric Institute. In 1985, he researched and highlighted an underrecognized status of Social Anxiety Disorder . This led to subsequent...
and clinical psychologist Richard Heimberg
Richard Heimberg
Dr. Richard Heimberg is a researcher, psychotherapist, and current professor at Temple University.-Early life:Dr. Heimberg graduated magna cum laude from the University of Tennessee in 1972, earning a Bachelor of Science degree in psychology...
, there was an increase in attention to and research on the disorder. The DSM-IV gave social phobia the alternative name social anxiety disorder. Research on the psychology and sociology of everyday social anxiety continued. Cognitive Behavioural models and therapies were developed for social anxiety disorder. In the 1990s, paroxetine
Paroxetine
Paroxetine is an SSRI antidepressant. Marketing of the drug began in 1992 by the pharmaceutical company SmithKline Beecham, now GlaxoSmithKline...
became the first prescription drug in the U.S. approved to treat social anxiety disorder, with others following.
Social phobia in many cases can be an extremely debilitating disorder, especially because one who struggles with it often suffers alone.
Cognitive aspects
In cognitive modelCognitive model
A cognitive model is an approximation to animal cognitive processes for the purposes of comprehension and prediction. Cognitive models can be developed within or without a cognitive architecture, though the two are not always easily distinguishable.In contrast to cognitive architectures, cognitive...
s of social anxiety disorder, social phobics experience dread
Angst
Angst is an English, German, Danish, Norwegian and Dutch word for fear or anxiety . It is used in English to describe an intense feeling of apprehension, anxiety or inner turmoil...
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
Social psychology
Social psychology is the scientific study of how people's thoughts, feelings, and behaviors are influenced by the actual, imagined, or implied presence of others. By this definition, scientific refers to the empirical method of investigation. The terms thoughts, feelings, and behaviors include all...
theory of self-presentation
Impression management
In sociology and social psychology, impression management is a goal-directed conscious or unconscious process in which people attempt to influence the perceptions of other people about a person, object or event; they do so by regulating and controlling information in social interaction...
, 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 deliberately go over what could go wrong and how to deal with each unexpected case. After the event, they may have the perception
Perception
Perception is the process of attaining awareness or understanding of the environment by organizing and interpreting sensory information. All perception involves signals in the nervous system, which in turn result from physical stimulation of the sense organs...
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 many 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 their perceptions of him or her as a presenter have been tarnished. This cognitive thought propels further anxiety which compounds with further stuttering, sweating, and, potentially, a 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. Possible physical symptoms include "mind going blank", fast heartbeat, difficulty breathing, blushing, stomach ache, nauseaNausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...
and gagging. Cognitive distortions are a hallmark, and learned about in CBT (cognitive-behavioral therapy). Thoughts are often self-defeating and inaccurate.
According to psychologist B.F. Skinner, phobias are controlled by escape
Escape response
Escape response, escape reaction, or escape behaviour is a possible reaction in response to stimuli indicative of danger, in particular, it initiates an escape motion of an animal...
and avoidance behaviors
Avoidance response
An avoidance response is a form of escape behavior present in animals in which the subject evades an aversive event. This can be due to anxiety or a frightening situation. Avoidance response is a response that is not necessarily conditioned before being exposed to in the stressful or fearful...
. 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). Major avoidance behaviors could include an almost pathological/compulsive lying behavior in order to preserve self-image and avoid judgement in front of others. Minor avoidance behaviors are exposed when a person avoids eye contact
Eye contact
Eye contact is a meeting of the eyes between two individuals.In human beings, eye contact is a form of nonverbal communication and is thought to have a large influence on social behavior. Coined in the early to mid-1960s, the term has come in the West to often define the act as a meaningful and...
and crosses arms to avoid recognizable shaking
Tremor
A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving to-and-fro movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, face, head, vocal folds, trunk, and legs. Most tremors occur in the...
. A fight-or-flight response
Fight-or-flight response
The fight-or-flight response was first described by Walter Bradford Cannon....
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. In adults, it may be tearsTears
Tears are secretions that clean and lubricate the eyes. Lacrimation or lachrymation is the production or shedding of tears....
as well as experiencing excessive sweat
SWEAT
SWEAT is an OLN/TSN show hosted by Julie Zwillich that aired in 2003-2004.Each of the 13 half-hour episodes of SWEAT features a different outdoor sport: kayaking, mountain biking, ice hockey, beach volleyball, soccer, windsurfing, rowing, Ultimate, triathlon, wakeboarding, snowboarding, telemark...
ing, nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...
, difficulty breathing, shaking
Tremor
A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving to-and-fro movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, face, head, vocal folds, trunk, and legs. Most tremors occur in the...
, and palpitation
Palpitation
A palpitation is an abnormality of heartbeat that causes a conscious awareness of its beating, whether it is too slow, too fast, irregular, or at its normal frequency. The word may also refer to this sensation itself...
s as a result of the fight-or-flight response. The walk disturbance (where a person is so worried about how they walk that they may lose balance) may appear, especially when passing a group of people. Blushing
Blushing
Blushing refers to the involuntary reddening of a person's face due to embarrassment or emotional stress, though it has been known to come from being lovestruck, or from some kind of romantic stimulation. It is thought that blushing is the result of an overactive sympathetic nervous system...
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
Brain
The brain is the center of the nervous system in all vertebrate and most invertebrate animals—only a few primitive invertebrates such as sponges, jellyfish, sea squirts and starfishes do not have one. It is located in the head, usually close to primary sensory apparatus such as vision, hearing,...
called the amygdala
Amygdala
The ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.-...
, part of the limbic system
Limbic system
The limbic system is a set of brain structures including the hippocampus, amygdala, anterior thalamic nuclei, septum, limbic cortex and fornix, which seemingly support a variety of functions including emotion, behavior, long term memory, and olfaction. The term "limbic" comes from the Latin...
, 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
Correlation
In statistics, dependence refers to any statistical relationship between two random variables or two sets of data. Correlation refers to any of a broad class of statistical relationships involving dependence....
with the increased response in the amygdala.
Prevalence
| Country | Prevalence |
|---|---|
| United States | 2–7% |
| England | 0.4% (children) |
| Scotland | 1.8% (children) |
| Wales | 0.6% (children) |
| Australia | 1–2.7% |
| Brazil | 4.7–7.9% |
When prevalence
Prevalence
In epidemiology, the prevalence of a health-related state in a statistical population is defined as the total number of cases of the risk factor in the population at a given time, or the total number of cases in the population, divided by the number of individuals in the population...
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 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
Social skills
A social skill is any skill facilitating interaction and communication with others. Social rules and relations are created, communicated, and changed in verbal and nonverbal ways. The process of learning such skills is called socialization...
or shyness."
The National Comorbidity Survey of over 8,000 American correspondents in 1994 revealed a 12-month and lifetime prevalence rate 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. According to U.S. epidemiological data from the National Institute of Mental Health
National Institute of Mental Health
The National Institute of Mental Health is one of 27 institutes and centers that make up the National Institutes of 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. However, other estimates vary within 2 percent and 7 percent of the U.S. adult population.
The mean onset of social phobia is 10 to 13 years. Onset after age 25 is rare and is typically preceded by panic disorder or major depression. Social anxiety disorder occurs in females nearly twice as often as males, and 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
England
England is a country that is part of the United Kingdom. It shares land borders with Scotland to the north and Wales to the west; the Irish Sea is to the north west, the Celtic Sea to the south west, with the North Sea to the east and the English Channel to the south separating it from continental...
, Scotland
Scotland
Scotland is a country that is part of the United Kingdom. Occupying the northern third of the island of Great Britain, it shares a border with England to the south and is bounded by the North Sea to the east, the Atlantic Ocean to the north and west, and the North Channel and Irish Sea to the...
, and Wales
Wales
Wales is a country that is part of the United Kingdom and the island of Great Britain, bordered by England to its east and the Atlantic Ocean and Irish Sea to its west. It has a population of three million, and a total area of 20,779 km²...
have a prevalence rate of 0.4 percent, 1.8 percent, and 0.6 percent, respectively. The prevalence of self-reported social anxiety for Nova Scotians older than 14 years was 4.2 percent in June 2004 with women (4.6 percent) reporting more than men (3.8 percent). In Australia
Australia
Australia , officially the Commonwealth of Australia, is a country in the Southern Hemisphere comprising the mainland of the Australian continent, the island of Tasmania, and numerous smaller islands in the Indian and Pacific Oceans. It is the world's sixth-largest country by total area...
, social phobia is the 8th and 5th leading disease or illness for males and females between 15–24 years of age as of 2003. Because of the difficulty in separating social phobia from poor social skills or shyness, some studies have a large range of prevalence. The table also shows higher prevalence in Brazil.
Comorbidity
There is a high degree of comorbidityComorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...
with other psychiatric disorders. Social phobia often occurs alongside low self-esteem
Self-esteem
Self-esteem is a term in psychology to reflect a person's overall evaluation or appraisal of his or her own worth. Self-esteem encompasses beliefs and emotions such as triumph, despair, pride and shame: some would distinguish how 'the self-concept is what we think about the self; self-esteem, the...
and clinical depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
, 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
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
. It is estimated that one-fifth of patients with social anxiety disorder also suffer from alcohol dependence. 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
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
. Besides depression, the most common disorders diagnosed in patients with social phobia are panic disorder
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
(33 percent), generalized anxiety disorder (19 percent), post-traumatic stress disorder
Post-traumatic stress disorder
Posttraumaticstress disorder is a severe anxiety disorder that can develop after exposure to any event that results in psychological trauma. This event may involve the threat of death to oneself or to someone else, or to one's own or someone else's physical, sexual, or psychological integrity,...
(36 percent), substance abuse disorder
Substance abuse
A substance-related disorder is an umbrella term used to describe several different conditions associated with several different substances .A substance related disorder is a condition in which an individual uses or abuses a...
(18 percent), and attempted suicide
Suicide
Suicide is the act of intentionally causing one's own death. Suicide is often committed out of despair or attributed to some underlying mental disorder, such as depression, bipolar disorder, schizophrenia, alcoholism, or drug abuse...
(23 percent). In one study of social anxiety disorder among 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
Avoidant personality disorder
Avoidant personality disorder is a personality disorder recognized in the Diagnostic and Statistical Manual of Mental Disorders handbook in a person characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of...
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.
There is research indicating that social anxiety disorder is often correlated with bipolar disorder
Bipolar disorder
Bipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
. Some researchers believe they share an underlying cyclothymic-anxious-sensitive disposition. In addition, studies show that more socially phobic patients treated with anti-depressant medication develop hypomania
Hypomania
Hypomania is a mood state characterized by persistent and pervasive elevated or irritable mood, as well as thoughts and behaviors that are consistent with such a mood state...
than non-phobic controls. 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
ResearchResearch
Research can be defined as the scientific search for knowledge, or as any systematic investigation, to establish novel facts, solve new or existing problems, prove new ideas, or develop new theories, usually using a scientific method...
into the causes of social anxiety and social phobia is wide-ranging, encompassing multiple perspectives from neuroscience
Neuroscience
Neuroscience is the scientific study of the nervous system. Traditionally, neuroscience has been seen as a branch of biology. However, it is currently an interdisciplinary science that collaborates with other fields such as chemistry, computer science, engineering, linguistics, mathematics,...
to sociology
Sociology
Sociology is the study of society. It is a social science—a term with which it is sometimes synonymous—which uses various methods of empirical investigation and critical analysis to develop a body of knowledge about human social activity...
. Scientists have yet to pinpoint the exact causes
Etiology
Etiology is the study of causation, or origination. The word is derived from the Greek , aitiologia, "giving a reason for" ....
. Studies suggest that genetics can play a part in combination with environmental factors.
Generally, social anxiety begins at a specific point in an individual's life. This will develop over time as the person struggles to recover. Eventually mild social awkwardness can start to show symptoms of social anxiety or phobia. Probably the most common example is when a person is either abused emotionally or physically by peers or parental figures at a young age. The person will tend to relate the past experiences with what is going on at the moment he or she experiences anxiety. To avoid this they create subconscious fail safes such as thinking through what they say or do excessively or trying to balance out perceived mistakes by being either excessively good or bad.
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 geneticsGenetics
Genetics , a discipline of biology, is the science of genes, heredity, and variation in living organisms....
and/or due to children acquiring social fears and avoidance through processes of observational learning
Observational learning
Observational learning is a type of learning that occurs as a function of observing, retaining and replicating novel behavior executed by others...
or parental psychosocial
Psychosocial
For a concept to be psychosocial means it relates to one's psychological development in, and interaction with, a social environment. The individual needs not be fully aware of this relationship with his or her environment. It was first commonly used by psychologist Erik Erikson in his stages of...
education. Studies of identical twins brought up (via adoption
Adoption
Adoption is a process whereby a person assumes the parenting for another and, in so doing, permanently transfers all rights and responsibilities from the original parent or parents...
) 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. 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. Studies suggest that parents of those with social anxiety disorder tend to be more socially isolated
Solitude
Solitude is a state of seclusion or isolation, i.e., lack of contact with people. It may stem from bad relationships, deliberate choice, infectious disease, mental disorders, neurological disorders or circumstances of employment or situation .Short-term solitude is often valued as a time when one...
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 insecure (anxious-ambivalent) attachment with their mother as infants were twice as likely to develop anxiety disorders by late adolescence, 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.
Social experiences
A previous negative social experience can be a trigger to social phobia, perhaps particularly for individuals high in 'interpersonal sensitivity'. For around half of those diagnosed with social anxiety disorder, a specific traumaticPsychological trauma
Psychological trauma is a type of damage to the psyche that occurs as a result of a traumatic event...
or humiliating social event appears to be associated with the onset or worsening of the disorder; this kind of event appears to be particularly related to specific (performance) social phobia
Specific social phobia
Mental health professionals often distinguish between generalized social phobia and specific social phobia. People with generalized social phobia have great distress in a wide range of social situations. Those with specific social phobia may experience anxiety only in a few situations...
, 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. 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 or childhood bullying or harassment
Harassment
Harassment covers a wide range of behaviors of an offensive nature. It is commonly understood as behaviour intended to disturb or upset, and it is characteristically repetitive. In the legal sense, it is intentional behaviour which is found threatening or disturbing...
(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. Socially phobic children appear less likely to receive positive reactions from peers and anxious or inhibited children may isolate themselves.
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 relationshipsInterpersonal relationship
An interpersonal relationship is an association between two or more people that may range from fleeting to enduring. This association may be based on limerence, love, solidarity, regular business interactions, or some other type of social commitment. Interpersonal relationships are formed in the...
or access employment or education, and shame
Shame
Shame is, variously, an affect, emotion, cognition, state, or condition. The roots of the word shame are thought to derive from an older word meaning to cover; as such, covering oneself, literally or figuratively, is a natural expression of shame....
. 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 emphasize the importance of others' 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
China
Chinese civilization may refer to:* China for more general discussion of the country.* Chinese culture* Greater China, the transnational community of ethnic Chinese.* History of China* Sinosphere, the area historically affected by Chinese culture...
, research has indicated that shy-inhibited children are more accepted than their peers
Peers
Peers is a surname, and may refer to:* Donald Peers* Edgar Allison Peers, an English academician* Gavin Peers* Kerry Peers* Michael Peers* Teddy Peers , Welsh international footballer...
and more likely to be considered for leadership and considered competent, in contrast to the findings in Western countries. Purely demographic variables may also play a role – for example there are possibly lower rates of social anxiety disorder in Mediterranean
Mediterranean Basin
In biogeography, the Mediterranean Basin refers to the lands around the Mediterranean Sea that have a Mediterranean climate, with mild, rainy winters and hot, dry summers, which supports characteristic Mediterranean forests, woodlands, and scrub vegetation...
countries and higher rates in Scandinavia
Scandinavia
Scandinavia is a cultural, historical and ethno-linguistic region in northern Europe that includes the three kingdoms of Denmark, Norway and Sweden, characterized by their common ethno-cultural heritage and language. Modern Norway and Sweden proper are situated on the Scandinavian Peninsula,...
n countries, and it has been hypothesized 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
Confidence
Confidence is generally described as a state of being certain either that a hypothesis or prediction is correct or that a chosen course of action is the best or most effective. Self-confidence is having confidence in oneself. Arrogance or hubris in this comparison, is having unmerited...
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 while others have. 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
Middle class
The middle class is any class of people in the middle of a societal hierarchy. In Weberian socio-economic terms, the middle class is the broad group of people in contemporary society who fall socio-economically between the working class and upper class....
es'. An interpersonal or media emphasis on 'normal' or 'attractive' personal characteristics has also been argued to fuel perfectionism
Perfectionism (psychology)
Perfectionism, in psychology, is a belief that a state of completeness and flawlessness can and should be attained. In its pathological form, perfectionism is a belief that work or output that is anything less than perfect is unacceptable...
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
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 DarwinCharles Darwin
Charles Robert Darwin FRS was an English naturalist. He established that all species of life have descended over time from common ancestry, and proposed the scientific theory that this branching pattern of evolution resulted from a process that he called natural selection.He published his theory...
originally wrote about the evolutionary basis of shyness and blushing, and modern evolutionary psychology
Evolutionary psychology
Evolutionary psychology is an approach in the social and natural sciences that examines psychological traits such as memory, perception, and language from a modern evolutionary perspective. It seeks to identify which human psychological traits are evolved adaptations, that is, the functional...
and psychiatry also addresses social phobia in this context. It has been hypothesized 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-behavioral models and therapies Another evolutionary explanation, applicable to social situation with strangers, is that in an ancestral environment characterized by small bands in which all individuals where known to one another, it was usually very dangerous to be confronted by a large group of staring, non-kin, unknown, and not smiling strangers.
Substance induced
While alcoholEthanol
Ethanol, also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a psychoactive drug and one of the oldest recreational drugs. Best known as the type of alcohol found in alcoholic beverages, it is also used in thermometers, as a...
initially helps social phobia, excessive alcohol misuse can worsen social phobia symptoms and can cause panic disorder to develop or worsen during alcohol intoxication and especially during alcohol withdrawal syndrome
Alcohol withdrawal syndrome
-Protracted withdrawal:A protracted alcohol withdrawal syndrome occurs in many alcoholics where withdrawal symptoms continue beyond the acute withdrawal stage but usually at a subacute level of intensity and gradually decreasing with severity over time. This syndrome is also sometimes referred to...
. This effect is not unique to alcohol but can also occur with long term use of drugs which have a similar mechanism of action to alcohol such as the benzodiazepines which are sometimes prescribed as tranquillisers.
Benzodiazepines possess anti-anxiety properties and can be useful for the short-term treatment of severe anxiety. Like the anticonvulsants, they tend to be mild and well tolerated, although habit forming C(IV). Benzodiazepines are usually administered orally for the treatment of anxiety; however, occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attack
Panic attack
Panic attacks are periods of intense fear or apprehension that are of sudden onset and of relatively brief duration. Panic attacks usually begin abruptly, reach a peak within 10 minutes, and subside over the next several hours...
s.
The World Council of Anxiety does not recommend benzodiazepines for the long term treatment of anxiety due to a range of problems associated with long term use of benzodiazepines including tolerance, psychomotor impairment, cognitive and memory impairments, physical dependence
Physical dependence
Physical dependence refers to a state resulting from chronic use of a drug that has produced tolerance and where negative physical symptoms of withdrawal result from abrupt discontinuation or dosage reduction...
and a benzodiazepine withdrawal syndrome
Benzodiazepine withdrawal syndrome
Benzodiazepine withdrawal syndrome—often abbreviated to benzo withdrawal—is the cluster of symptoms which appear when a person who has taken benzodiazepines long term and has developed benzodiazepine dependence stops taking benzodiazepine drug or during dosage reductions...
upon discontinuation of benzodiazepines. Despite increasing focus on the use of antidepressants and other agents for the treatment of anxiety, benzodiazepines have remained a mainstay of anxiolytic pharmacotherapy due to their robust efficacy, rapid onset of therapeutic effect, and generally favorable side effect profile. Treatment patterns for psychotropic drugs appear to have remained stable over the past decade, with benzodiazepines being the most commonly used medication for panic disorder.
Approximately half of patients attending mental health services for conditions including anxiety disorders such as panic disorder
Panic disorder
Panic disorder is an anxiety disorder characterized by recurring severe panic attacks. It may also include significant behavioral change lasting at least a month and of ongoing worry about the implications or concern about having other attacks. The latter are called anticipatory attacks...
or social phobia are the result of alcohol
Ethanol
Ethanol, also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a psychoactive drug and one of the oldest recreational drugs. Best known as the type of alcohol found in alcoholic beverages, it is also used in thermometers, as a...
or benzodiazepine dependence
Benzodiazepine dependence
Benzodiazepine dependence or benzodiazepine addiction is a condition during which a person is dependent on benzodiazepine drugs. Dependence can be either a psychological dependence, physical dependence, or a combination of the two...
. Sometimes anxiety pre-existed alcohol
Ethanol
Ethanol, also called ethyl alcohol, pure alcohol, grain alcohol, or drinking alcohol, is a volatile, flammable, colorless liquid. It is a psychoactive drug and one of the oldest recreational drugs. Best known as the type of alcohol found in alcoholic beverages, it is also used in thermometers, as a...
or benzodiazepine dependence but the alcohol or benzodiazepine dependence act to keep the anxiety disorders going and often progressively making them worse. Many people who are addicted to alcohol or prescribed benzodiazepines when it is explained to them they have a choice between ongoing ill mental health or quitting and recovering from their symptoms decide on quitting alcohol and/or their benzodiazepines. It was noted that every individual has an individual sensitivity level to alcohol or sedative hypnotic drugs and what one person can tolerate without ill health another will suffer very ill health and that even moderate drinking can cause rebound anxiety syndromes and sleep disorders. A person who is suffering the toxic effects of alcohol or benzodiazepines will not benefit from other therapies or medications as they do not address the root cause of the symptoms. Symptoms may temporarily worsen however, during alcohol withdrawal or benzodiazepine withdrawal.
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. One line of work has focused more specifically on the key role of self-presentational concerns. 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. A similar model emphasizes 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 anticipationAnticipation (emotion)
Anticipation, or being enthusiastic, is an emotion involving pleasure, excitement, and sometimes anxiety in considering some expected or longed-for good event.-As defence mechanism:...
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 behaviors' (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 Behavioral Therapy for social anxiety disorder, which has been shown to have efficacy.
Neural mechanisms
There are many studies investigating neural bases of social anxiety disorder. Although the exact neural mechanisms have not been found yet, there is evidence relating social anxiety disorder to imbalance in some neurochemicals and hyperactivity in some of brain areas.Dopamine
Sociability is closely tied to dopamineDopamine
Dopamine is a catecholamine neurotransmitter present in a wide variety of animals, including both vertebrates and invertebrates. In the brain, this substituted phenethylamine functions as a neurotransmitter, activating the five known types of dopamine receptors—D1, D2, D3, D4, and D5—and their...
neurotransmission
Neurotransmitter
Neurotransmitters are endogenous chemicals that transmit signals from a neuron to a target cell across a synapse. Neurotransmitters are packaged into synaptic vesicles clustered beneath the membrane on the presynaptic side of a synapse, and are released into the synaptic cleft, where they bind to...
. Misuse of stimulants like amphetamines to increase self-confidence and improve social performance is common. In a recent study a direct relation between social status of volunteers and binding affinity of dopamine D2/3 receptors in the striatum
Striatum
The striatum, also known as the neostriatum or striate nucleus, is a subcortical part of the forebrain. It is the major input station of the basal ganglia system. The striatum, in turn, gets input from the cerebral cortex...
was found.
Other research shows that the binding affinity of dopamine D2 receptors in the striatum of social anxiety sufferers is lower than controls.
Some other researches show an abnormality in dopamine transporter
Dopamine transporter
The dopamine transporter is a membrane-spanning protein that pumps the neurotransmitter dopamine out of the synapse back into cytosol, from which other transporters sequester DA and NE into vesicles for later storage and release...
density in the striatum of social anxiety sufferers.
However, some researchers do not replicate previous findings of evidence of dopamine abnormality in social anxiety disorder.
Studies have shown high prevalence of social anxiety in Parkinson's disease and schizophrenia. In a recent study, social phobia was diagnosed in 50% of Parkinson's disease
Parkinson's disease
Parkinson's disease is a degenerative disorder of the central nervous system...
patients. Other researchers have found social phobia symptoms in patients treated with dopamine antagonists like haloperidol, emphasizing the role of dopamine neurotransmission in social anxiety disorder.
Also, concentration problems, mental and physical fatigue, Anhedonia
Anhedonia
In psychology and psychiatry, anhedonia is defined as the inability to experience pleasure from activities usually found enjoyable, e.g. hobbies, exercise, social interaction or sexual activity....
and decreased self-confidence are seen in those with social anxiety disorder.
Other neurotransmitters
Some scientists hypothesize that social phobia is related to an imbalance of the brain chemical serotoninSerotonin
Serotonin or 5-hydroxytryptamine is a monoamine neurotransmitter. Biochemically derived from tryptophan, serotonin is primarily found in the gastrointestinal tract, platelets, and in the central nervous system of animals including humans...
. A recent study report increased Serotonin
Serotonin
Serotonin or 5-hydroxytryptamine is a monoamine neurotransmitter. Biochemically derived from tryptophan, serotonin is primarily found in the gastrointestinal tract, platelets, and in the central nervous system of animals including humans...
transporter binding in psychotropic medication-naive patients with generalized social anxiety disorder.
Although there are not many evidences of abnormality in Serotonin
Serotonin
Serotonin or 5-hydroxytryptamine is a monoamine neurotransmitter. Biochemically derived from tryptophan, serotonin is primarily found in the gastrointestinal tract, platelets, and in the central nervous system of animals including humans...
neurotransmission, the limited efficacy of medications which affect serotonin levels may indicate the role of this pathway. Paroxetine
Paroxetine
Paroxetine is an SSRI antidepressant. Marketing of the drug began in 1992 by the pharmaceutical company SmithKline Beecham, now GlaxoSmithKline...
and Sertraline
Sertraline
Sertraline hydrochloride is an antidepressant of the selective serotonin reuptake inhibitor class. It was introduced to the market by Pfizer in 1991. Sertraline is primarily used to treat major depression in adult outpatients as well as obsessive–compulsive, panic, and social anxiety disorders in...
are two SSRIs that have been confirmed by FDA to treat social anxiety disorder. Some researchers believe that SSRIs decrease activity of Amygdala
Amygdala
The ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.-...
.
There is also increasing focus on other candidate transmitters, e.g. Norepinephrine and Glutamate, which may be over-active in social anxiety disorder, and the inhibitory transmitter GABA-which is subsequently lacking.
Brain areas
The amygdala is part of the limbic systemLimbic system
The limbic system is a set of brain structures including the hippocampus, amygdala, anterior thalamic nuclei, septum, limbic cortex and fornix, which seemingly support a variety of functions including emotion, behavior, long term memory, and olfaction. The term "limbic" comes from the Latin...
which is related to fear cognition and emotional learning. Individuals with social anxiety disorder have been found to have a hypersensitive amygdala
Amygdala
The ' are almond-shaped groups of nuclei located deep within the medial temporal lobes of the brain in complex vertebrates, including humans. Shown in research to perform a primary role in the processing and memory of emotional reactions, the amygdalae are considered part of the limbic system.-...
, 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. Recent research has also indicated that another area of the brain, the anterior cingulate cortex
Anterior cingulate cortex
The anterior cingulate cortex is the frontal part of the cingulate cortex, that resembles a "collar" form around the corpus callosum, the fibrous bundle that relays neural signals between the right and left cerebral hemispheres of the brain...
, 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.
Treatment
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 carePrimary care
Primary care is the term for the health services by providers who act as the principal point of consultation for patients within a health care system...
practice, with patients often presenting for treatment only after the onset of complications
Complication (medicine)
Complication, in medicine, is an unfavorable evolution of a disease, a health condition or a medical treatment. The disease can become worse in its severity or show a higher number of signs, symptoms or new pathological changes, become widespread throughout the body or affect other organ systems. A...
such as clinical depression
Clinical depression
Major depressive disorder is a mental disorder characterized by an all-encompassing low mood accompanied by low self-esteem, and by loss of interest or pleasure in normally enjoyable activities...
or substance abuse disorders.
Research has provided evidence for the efficacy
Efficacy
Efficacy is the capacity to produce an effect. It has different specific meanings in different fields. In medicine, it is the ability of an intervention or drug to reproduce a desired effect in expert hands and under ideal circumstances.- Healthcare :...
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.
Psychotherapy
Research has shown that cognitive behavioral therapy (CBT) can be highly effective for several anxiety disorders, particularly specific phobias, panic disorder and social anxiety disorder. CBT, as its name suggests, has two main components, cognitive and behavioral. In cases of social anxiety, the cognitive component can help the patient question how they can be so sure that others are continually watching and harshly judging them. The behavioral component seeks to change people's reactions to anxiety-provoking situations. As such it serves as a logical extension of cognitive therapy, whereby people are shown proof in the real world that their dysfunctional thought processes are unrealistic. A key element of this component was gradual exposure, in which the patient was confronted by the things they fear in a structured, sensitive manner. Gradual exposure is an inherently unpleasant technique; and had high drop out rates. Ideally it involves exposure to a feared social situation that is anxiety provoking but bearable, for as long as possible, two to three times a week. Often, a hierarchy of feared steps is constructed and the patient is exposed each step sequentially. Now modern CBT treatments have been enhanced by focussing treatment on cognitive process, e.g., behavioral experiment with attentional focus, video feedback experiments, addressing fears of negative evaluation, identifying and removing safety seeking behaviors, etc. The aim is to learn from acting differently and observing reactions. This is intended to be done with support and guidance, and when the therapist and patient feel they are ready. Cognitive-behavioral therapy for social phobia for few patients now includes anxiety management training, which may include techniques such as deep breathing and muscle relaxation exercises, which may be practiced 'in-situ'. These early interventions, for some, can be useful but for most can become safety seeking behaviors (and thus unhelpful) so need to be suggested in a considered case conceptualization (i.e., individualized understanding of the cognitive and behavioral factors that are maintaining the problem). CBT can also be conducted partly in group sessionsGroup therapy
Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group...
, 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. However, it is not clear whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations.
Additionally, a recent study has suggested that interpersonal therapy, a form of psychotherapy primarily used to treat depression, may also be effective in the treatment of social phobia.
SSRIs
Selective serotonin reuptake inhibitorSelective serotonin reuptake inhibitor
Selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitor are a class of compounds typically used as antidepressants in the treatment of depression, anxiety disorders, and some personality disorders. The efficacy of SSRIs is disputed...
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
Food and Drug Administration
The Food and Drug Administration is an agency of the United States Department of Health and Human Services, one of the United States federal executive departments...
was paroxetine
Paroxetine
Paroxetine is an SSRI antidepressant. Marketing of the drug began in 1992 by the pharmaceutical company SmithKline Beecham, now GlaxoSmithKline...
, sold as Paxil in the U.S. or Seroxat in the UK. Compared to older forms of medication, there is less risk of tolerability and drug dependency. However, their efficacy
Efficacy
Efficacy is the capacity to produce an effect. It has different specific meanings in different fields. In medicine, it is the ability of an intervention or drug to reproduce a desired effect in expert hands and under ideal circumstances.- Healthcare :...
and increased suicide risk has been subject to controversy.
In a 1995 double-blind
Double-blind
A blind or blinded experiment is a scientific experiment where some of the people involved are prevented from knowing certain information that might lead to conscious or subconscious bias on their part, invalidating the results....
, placebo
Placebo
A placebo is a simulated or otherwise medically ineffectual treatment for a disease or other medical condition intended to deceive the recipient...
-controlled trial, the SSRI paroxetine was shown to result in clinically meaningful improvement in 55 percent of patients with generalized social anxiety disorder, compared with 23.9 percent of those taking placebo. An October 2004 study yielded similar results. Patients were treated with either fluoxetine
Fluoxetine
Fluoxetine is an antidepressant of the selective serotonin reuptake inhibitor class. It is manufactured and marketed by Eli Lilly and Company...
, psychotherapy, fluoxetine and psychotherapy, placebo and psychotherapy, or 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.
General side-effects
Adverse effect (medicine)
In medicine, an adverse effect is a harmful and undesired effect resulting from a medication or other intervention such as surgery.An adverse effect may be termed a "side effect", when judged to be secondary to a main or therapeutic effect. If it results from an unsuitable or incorrect dosage or...
are common during the first weeks while the body adjusts to the drug. Symptoms may include headache
Headache
A headache or cephalalgia is pain anywhere in the region of the head or neck. It can be a symptom of a number of different conditions of the head and neck. The brain tissue itself is not sensitive to pain because it lacks pain receptors. Rather, the pain is caused by disturbance of the...
s, nausea
Nausea
Nausea , is a sensation of unease and discomfort in the upper stomach with an involuntary urge to vomit. It often, but not always, precedes vomiting...
, insomnia
Insomnia
Insomnia is most often defined by an individual's report of sleeping difficulties. While the term is sometimes used in sleep literature to describe a disorder demonstrated by polysomnographic evidence of disturbed sleep, insomnia is often defined as a positive response to either of two questions:...
and changes in sexual behavior. Treatment safety during pregnancy has not been established. In late 2004 much media attention was given to a proposed link between SSRI use and suicidality [a term that encompasses suicidal ideation and attempts at suicide as well as suicide]. For this reason, [although evidential causality between SSRI use and actual suicide has not been demonstrated] 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. 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 used, 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
Monoamine oxidase inhibitor
Monoamine oxidase inhibitors are a class of antidepressant drugs prescribed for the treatment of depression. They are particularly effective in treating atypical depression....
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 dietary
Diet (nutrition)
In nutrition, diet is the sum of food consumed by a person or other organism. Dietary habits are the habitual decisions an individual or culture makes when choosing what foods to eat. With the word diet, it is often implied the use of specific intake of nutrition for health or weight-management...
restrictions required, high toxicity 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. A newer type of this medication, Reversible inhibitors of monoamine oxidase subtype A
Rima
Rima, also known as Rima the Jungle Girl, is the fictional heroine of W. H. Hudson's 1904 novel Green Mansions: A Romance of the Tropical Forest. In 1974, she was adapted into a comic book character and featured in the short-lived monthly series Rima the Jungle Girl, published by DC Comics...
(RIMAs) inhibit the MAO enzyme
Enzyme
Enzymes are proteins that catalyze chemical reactions. In enzymatic reactions, the molecules at the beginning of the process, called substrates, are converted into different molecules, called products. Almost all chemical reactions in a biological cell need enzymes in order to occur at rates...
only temporarily, improving the adverse-effect profile but possibly reducing their efficacy.
Benzodiazepine
Benzodiazepine
A benzodiazepine is a psychoactive drug whose core chemical structure is the fusion of a benzene ring and a diazepine ring...
s such as alprazolam
Alprazolam
Alprazolam is a short-acting anxiolytic of the benzodiazepine class of psychoactive drugs. Alprazolam, like other benzodiazepines, binds to specific sites on the GABAA gamma-amino-butyric acid receptor...
and clonazepam
Clonazepam
Clonazepamis a benzodiazepine drug having anxiolytic, anticonvulsant, muscle relaxant, and hypnotic properties. It is marketed by Roche under the trade name Klonopin in the United States and Rivotril in Australia, Brazil, Canada and Europe...
are an alternative to SSRIs. These drugs are often used for short-term relief of severe, disabling anxiety. Although benzodiazepines are still sometimes prescribed for long-term everyday use in some countries, there is some concern over the development of drug tolerance, dependency and misuse. It has been recommended that benzodiazepines are only considered for individuals who fail to respond to safer medications. Benzodiazepines augment the action of GABA
Gabâ
Gabâ or gabaa, for the people in many parts of the Philippines), is the concept of a non-human and non-divine, imminent retribution. A sort of negative karma, it is generally seen as an evil effect on a person because of their wrongdoings or transgressions...
, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours.
The novel antidepressant mirtazapine
Mirtazapine
Mirtazapine is a tetracyclic antidepressant used primarily in the treatment of depression. It is also sometimes used as a hypnotic, antiemetic, and appetite stimulant, and for the treatment of anxiety, among other indications...
has been proven effective in treatment of social anxiety disorder. This is especially significant due to mirtazapine's fast onset and lack of many unpleasant side-effects associated with SSRIs (particularly, sexual dysfunction
Sexual dysfunction
Sexual dysfunction or sexual malfunction refers to a difficulty experienced by an individual or a couple during any stage of a normal sexual activity, including desire, arousal or orgasm....
).
In Japan, the serotonin-norepinephrine reuptake inhibitor
Serotonin-norepinephrine reuptake inhibitor
Serotonin–norepinephrine reuptake inhibitors are a class of antidepressant drugs used in the treatment of major depression and other mood disorders...
(SNRI), Milnacipran
Milnacipran
Milnacipran is a serotonin–norepinephrine reuptake inhibitor used in the clinical treatment of fibromyalgia...
is used in the treatment of Taijin kyofusho
Taijin kyofusho
Taijin kyofusho , is a Japanese culture-specific syndrome. The term taijin kyofusho literally means the disorder of fear of interpersonal relations . Dr...
a Japanese variant of social anxiety disorder.
Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure. 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. DCS is an old antibiotic
Antibiotic
An antibacterial is a compound or substance that kills or slows down the growth of bacteria.The term is often used synonymously with the term antibiotic; today, however, with increased knowledge of the causative agents of various infectious diseases, antibiotic has come to denote a broader range of...
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. It has been shown that administering a small dose acutely 1 hour before exposure therapy
Exposure therapy
Exposure therapy is a technique in behavior therapy intended to treat anxiety disorders and involves the exposure to the feared object or context without any danger in order to overcome their anxiety. Procedurally it is similar to the fear extinction paradigm in rodent work...
can facilitate extinction learning that occurs during therapy.
Social Phobia In Adults
Adults who had a stuttering problem when they were younger will have a higher level of Social Anxiety Disorder and independent speech problems. This is a lifelong disorder. It does not go away in a few weeks or months, it stays with the person for their life. Negative impact can have a role in social phobia e.g. verbal abuse by parents when they were younger. Social Phobia is hard to live with because you think people are always staring at you, making fun of you, you have a hard time talking in front of people because you think they are judging you constantly. When the person is under that kind of pressure it does affect their speech and they will stutter.[A positive relationship between social phobia and lack of close relationship with an adult, not being first born (in males only), marital conflict in the family of origin, parental history of mental disorder, moving more than three times as a child, juvenile justice and child welfare involvement, running away from home, childhood physical and sexual abuse, failing a grade, requirement of special education before age 9 and dropping out of high school.] Marteinsdottir, I., Svensson, A., Svedberg, M., Anderberg, U., & von Knorring, L. (2007). The role of life events in social phobia. Nordic Journal of Psychiatry, 61(3), 207-212. doi:10.1080/08039480701352546.[ Genetic influences might, however, leave some individuals more vulnerable to negative life events than others]. Marteinsdottir, I., Svensson, A., Svedberg, M., Anderberg, U., & von Knorring, L. (2007). The role of life events in social phobia. Nordic Journal of Psychiatry, 61(3), 207-212. doi:10.1080/08039480701352546See also
- AgoraphobiaAgoraphobiaAgoraphobia is an anxiety disorder defined as a morbid fear of having a panic attack or panic-like symptoms in a situation from which it is perceived to be difficult to escape. These situations can include, but are not limited to, wide-open spaces, crowds, or uncontrolled social conditions...
- AnxietyAnxietyAnxiety is a psychological and physiological state characterized by somatic, emotional, cognitive, and behavioral components. The root meaning of the word anxiety is 'to vex or trouble'; in either presence or absence of psychological stress, anxiety can create feelings of fear, worry, uneasiness,...
- Anxiety Disorders Association of AmericaAnxiety Disorders Association of AmericaThe Anxiety Disorders Association of America is the only U.S. nonprofit organization solely dedicated to increasing awareness and improving the diagnosis, treatment, and cure of anxiety disorders in children and adults. The Anxiety Disorders Association of America is the leader in education,...
- Avoidant personality disorderAvoidant personality disorderAvoidant personality disorder is a personality disorder recognized in the Diagnostic and Statistical Manual of Mental Disorders handbook in a person characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of...
- FearFearFear is a distressing negative sensation induced by a perceived threat. It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of danger...
- Generalized anxiety disorder
- HikikomoriHikikomoriis a Japanese term to refer to the phenomenon of reclusive people who have chosen to withdraw from social life, often seeking extreme degrees of isolation and confinement because of various personal and social factors in their lives...
- HypervigilanceHypervigilanceHypervigilance is an enhanced state of sensory sensitivity accompanied by an exaggerated intensity of behaviors whose purpose is to detect threats. Hypervigilance is also accompanied by a state of increased anxiety which can cause exhaustion. Other symptoms include: abnormally increased arousal, a...
- HypoglycemiaHypoglycemiaHypoglycemia or hypoglycæmia is the medical term for a state produced by a lower than normal level of blood glucose. The term literally means "under-sweet blood"...
- Introversion and extroversion
- Liebowitz social anxiety scaleLiebowitz social anxiety scaleThe Liebowitz Social Anxiety Scale is a questionnaire by psychologist and researcher, Michael Liebowitz, whose objective is to assess the range of social interaction and performance situations which patients with social anxiety disorder may fear. It is commonly used to study outcomes in clinical...
(LSAS) - Love-shynessLove-shyness- The Definition Of Love-shyness:Love-shyness is a specific type of severe chronic shyness that impairs or prevents intimate relationships. It implies a degree of inhibition and reticence with potential partners that is sufficiently severe to preclude participation in courtship, marriage and family...
- Major depressive disorder
- Mean world syndromeMean World Syndrome"Mean world syndrome" is a term coined by George Gerbner to describe a phenomenon whereby violence-related content of mass media makes viewers believe that the world is more dangerous than it actually is. Mean world syndrome is one of the main conclusions of cultivation theory...
- Mindfulness (psychology)Mindfulness (psychology)Modern clinical psychology and psychiatry since the 1970s have developed a number of therapeutic applications based on the concept of mindfulness in Buddhist meditation.-Definitions:...
- Paranoid personality disorderParanoid personality disorderParanoid personality disorder is a psychiatric diagnosis characterized by paranoia and a pervasive, long-standing suspiciousness and generalized mistrust of others....
- Schizoid personality disorderSchizoid personality disorderSchizoid personality disorder is a personality disorder characterized by a lack of interest in social relationships, a tendency towards a solitary lifestyle, secretiveness, emotional coldness, and sometimes apathy, with a simultaneous rich, elaborate, and exclusively internal fantasy world...
- Schizotypal personality disorderSchizotypal personality disorderSchizotypal personality disorder, or simply schizotypal disorder, is a personality disorder that is characterized by a need for social isolation, anxiety in social situations, odd behavior and thinking, and often unconventional beliefs.-Genetic:...
- ShynessShynessIn humans, shyness is a social psychology term used to describe the feeling of apprehension, lack of comfort, or awkwardness experienced when a person is in proximity to, approaching, or being approached by other people, especially in new situations or with unfamiliar people...
- Selective mutismSelective mutismSelective mutism is an anxiety disorder in which a person, most often a child, who is normally capable of speech is unable to speak in given situations, or to specific people...
- Social anxietySocial anxietySocial anxiety is anxiety about social situations, interactions with others, and being evaluated or scrutinized by other people...
- Social phobiaSocial phobiaSocial phobia may refer to any of the following conditions:* Social anxiety disorder – a diagnosis referring to clinically excessive social anxiety...
- Social controlSocial controlSocial control refers generally to societal and political mechanisms or processes that regulate individual and group behavior, leading to conformity and compliance to the rules of a given society, state, or social group. Many mechanisms of social control are cross-cultural, if only in the control...
- Social rejectionSocial rejectionSocial rejection occurs when an individual is deliberately excluded from a social relationship or social interaction. The topic includes both interpersonal rejection and romantic rejection. A person can be rejected on an individual basis or by an entire group of people...
- Taijin kyofushoTaijin kyofushoTaijin kyofusho , is a Japanese culture-specific syndrome. The term taijin kyofusho literally means the disorder of fear of interpersonal relations . Dr...
- Telephone phobiaTelephone phobiaTelephone phobia is reluctance or fear of making or taking phone calls, literally, "fear of telephone"...
- Timidness
Further reading
Marteinsdottir, I., Svensson, A., Svedberg, M., Anderberg, U., & von Knorring, L. (2007). The role of life events in social phobia. Nordic Journal of Psychiatry, 61(3), 207-212. doi:10.1080/08039480701352546- 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.
- Berent, Jonathan, with Amy Lemley (1993). Beyond Shyness: How to Conquer Social Anxieties. New York: Simon & Shuster. ISBN 0-671-74137-3.
- Burns, D. D.David D. BurnsDavid D. Burns is an adjunct professor emeritus in the Department of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine and the author of the best-selling book Feeling Good: The New Mood Therapy. Burns popularized cognitive behavioral therapy when his book became a...
(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.