Social Phobia
and Anxiety Introduction
Social Phobia !!! Anxiety !!! Everybody
knows what it’s like to feel anxious -- the butterflies in your
stomach before a first date, the tension you feel when your boss
is angry, and the way your heart pounds if you're in danger. Anxiety
rouses you to action. It gears you up to face a threatening situation.
It makes you study harder for that exam, and keeps you on your
toes when you're making a speech.
In general, it helps
you cope. But if you have an anxiety disorder, this normally
helpful emotion can do just the opposite
-- it can keep you from coping and can disrupt your daily life.
You want to reduce, relief, stop, and cure the problem ! There
are several types of anxiety disorders, each with their
own distinct features.
  Today, much more is known about the causes
and treatment of this mental health problem. We know
that there are biological and psychological components to every
anxiety disorder and that the best form of treatment is a combination of cognitive-behavioral
psychotherapy interventions.
Depending upon the severity of the anxiety,
medication is used in combination with psychotherapy. Contrary
to many popular misconceptions about anxiety disorders
today, it is not a purely biochemical or medical disorder.
There are as many potential causes of
anxiety disorders as there are people who suffer from them.
Family history and genetics play a part in the greater likelihood
of someone getting an anxiety disorder in their lifetime.
Increased stress and inadequate coping mechanisms to deal
with that stress may also contribute to anxiety.
Anxiety symptoms can result from such a variety of factors
including having had a traumatic experience, having to face major
decisions in a one's life, or having developed a more fearful
perspective on life. Anxiety caused by medications or substance
or alcohol abuse is not typically recognized as an anxiety
disorder.
Many people still carry the misperception
that anxiety disorders are a character flaw, a problem
that happens because you are weak. They say, "Pull yourself
up by your own bootstraps!" and "You just have a case
of the nerves." Wishing the symptoms away does not work -- but there are
treatments that can help.
Anxiety disorders and panic attacks are not signs
of a character flaw. Most importantly, feeling anxious is not
your fault. It is a serious mood disorder, which affects a person's
ability to function in every day activities. It affects one's
work, one's family, and one's social life.
Anxiety and Social
Phobia and Anxiety
What is Anxiety?
 Anxiety is an unpleasant complex combination
of emotions that includes fear, apprehension and worry,
and is often accompanied by physical sensations such as heart
palpitations, nausea, chest pain and/or shortness of breath, and
feelings of inner nervousness.
Anxiety is often described as having
cognitive, somatic, emotional, and behavioral components (Seligman,
Walker & Rosenhan, 2001). The cognitive component entails
expectation of a diffuse and uncertain danger. Somatically the
body prepares the organism to deal with threat (known as an emergency
reaction): blood pressure and heart rate are increased, sweating
is increased, blood flow to the major muscle groups is increased,
and immune and digestive system functions are inhibited.
Externally, somatic signs of anxiety
may include pale skin, sweating, trembling, and pupillary dilation.
Emotionally, anxiety causes a sense of dread or panic and physically
causes nausea, and chills. Behaviorally, both voluntary and involuntary
behaviors may arise directed at escaping or avoiding the source
of anxiety.
These behaviors are frequent and often
maladaptive, being most extreme in anxiety disorders. However,
anxiety is not always pathological or maladaptive: it is a common
emotion along with fear,
anger, sadness, and happiness, and it has a very important function
in relation to survival. Anxiety can be some what of a mental
illness.
Neural circuitry involving the amygdala and hippocampus is
thought to underlie anxiety (Rosen & Schulkin, 1998). When
confronted with unpleasant and potentially harmful stimuli such
as foul odors or tastes, PET-scans show increased blood flow in
the amygdala. In these studies, the participants also reported
moderate anxiety.
This might indicate that anxiety is a protective mechanism
designed to prevent the organism from engaging in potentially
harmful behaviors.
Anxiety disorder and
Social Phobia and Anxiety
What is an anxiety disorder?
Anxiety disorder
is a cover-all term covering several different forms of abnormal,
pathological anxiety, fears, phobias and nervous conditions that may come on
suddenly or gradually over a period of several years, and may
impair or prevent the pursuing of normal daily routines.
Anxiety and fear
are ubiquitous emotions. The terms anxiety and fear have specific scientific meanings, but
common usage has made them interchangeable. For example, a phobia
is a kind of anxiety that is also defined in the Diagnostic and
Statistical Manual of Mental Disorders, 4th edition (DSM-IV-TR)
as a "persistent or irrational fear."
Fear is defined as an
emotional and physiological response to a recognized external
threat (e.g. a runaway car or an impending crash in an airplane).
Anxiety is an unpleasant emotional state, the sources
of which are less readily identified. It is frequently accompanied
by physiological symptoms that may lead to fatigue or even exhaustion. Because
fear of recognized threats
causes similar unpleasant mental and physical changes, patients
use the terms fear and anxiety interchangeably. Thus, there
is little need to strive to differentiate anxiety from fear.
However, distinguishing among different anxiety disorders
is important, since accurate diagnosis is more likely to result
in effective treatment and a better
prognosis.
Diagnosis of Anxiety Disorder
A good assessment is essential for the initial diagnosis of an
anxiety disorder, preferably using a standardized interview
or questionnaire procedure alongside expert evaluation and the
views of the persons themselves.
There
should be a medical examination in order to identify possible
medical conditions that can cause the symptoms
of anxiety. A family
history of anxiety disorders is suggestive of the possibility
of an anxiety disorder.
Types of Anxiety disorders
Overview -Types of Anxiety Disorders
Panic Disorder - Unpredictable
attacks of anxiety that are accompanied by physiological manifestations.
People with this disorder often undergo medical evaluations for
symptoms related to heart attacks or other medical conditions
before the diagnosis of panic disorder is made. Attacks may last
from minutes to hours.
An affected person often lives in fear
of another attack and may be reluctant to be alone or far from
medical assistance. Panic attacks can occur at any time,
even during sleep. An attack generally peaks within 10 minutes,
but some symptoms may last much longer.
Agoraphobia - An abnormal
fear of being helpless
in an embarrassing or inescapable situation that is characterized
especially by the avoidance of open or public places. It may occur
alone, or may accompany panic disorder. People with this disorder
may become house bound for years, with resulting impairment of
social and interpersonal relationships.
Specific Phobias -
Persistent fear of objects
or situations. When these situations or objects appear, they can
produce immediate and severe symptoms
of anxiety.
Social anxiety disorder - A persistent irrational fear
of situations in which the person may be closely watched and judged
by others, as in public speaking, eating, or using public facilities.
A person then becomes fearful of social or performance situations in which they
may be subject to the scrutiny of others.
Post Traumatic Stress Disorder (PTSD) - Post-traumatic stress disorder is a psychiatric
illness that can occur following a traumatic event, in which there
is the threat of injury or death to you or someone else.
Obsessive Compulsive Disorder (Obsessive-compulsive disorder (OCD)) - The person suffering from Obsessive-compulsive disorder (OCD) uses ritualistic
and repeated behaviors to rid themselves of obsessive thoughts
and anxieties. Recent data show that 2-3% of people, or about
7 million Americans, suffer from this disorder.
Generalized Anxiety disorder (General Anxiety Disorder) – This is a common condition. The disorder is characterized
by excessive anxiety and worry that is out of proportion to the impact
of the event or circumstance that is the focus of the worry.
Persons with General Anxiety Disorder may eventually experience other mental disorders,
such as panic disorder or major depressive disorder.
General Anxiety disorder
Definition of General Anxiety Disorder
 General anxiety disorder or generalized anxiety
disorder (General Anxiety Disorder) is an anxiety disorder that is characterized
by excessive and uncontrollable worry
about everyday things.
The frequency, intensity, and duration of the worry
are disproportionate to the actual source of worry,
and such worry often
interferes with daily functioning. It affects approximately 5%
of the total population, yet is more prevalent in women and much
more prevalent in youth, where 12% to 20% are affected (Achenbach,
Howell, McConaughy & Stranger, 1995).
People with General Anxiety Disorder often have a variety of symptoms such as tension, skittishness, restlessness, hyperactivity,
worrying, fear,
and rumination. These symptoms must be consistent, persisting at least every other
day and persist for at least 6 months (DSM-IV; American Psychiatric
Association, 1994, as cited in Heimberg, 2004).
General Anxiety Disorder sufferers often worry
excessively over things such as their job, their finances, and
the health of themselves and their family. However, General Anxiety Disorder sufferers
can also worry over
more minor matters such as deadlines for appointments, keeping
the house clean, and whether or not their workspace is properly
organized.
Causes of General Anxiety Disorder
Only
about 30% of the causes of General Anxiety Disorder are inherited, yet certain traits
cause people to become more prone to obtaining it. People with
general nervousness, depression, inability to tolerate frustration,
and feelings of being inhibited are more likely to be shown in
General Anxiety Disorder patients.
People with General Anxiety Disorder tend to have more conflicts with
others and are very hard on themselves, they also tend to avoid
common situations for fear
of worry and anxiety
(Leahy, 2000 as cited in Hemiberg, 2004, pg 270). In youth General Anxiety Disorder
often leads to lower levels of social supports, academic underachievement,
underemployment, substance use and high probability of obtaining
other psychiatric disorders (Velting, Setzer, & Albano, 2004 as cited in Gosch, 2006, pg 247).
General Anxiety Disorder differs from other anxiety disorders in the sense that there
is no clear stimulus that elicits anxiety or was associated with
how it began. It also lacks the clear avoidance and escape behaviors
of phobias and unlike panic attacks associated with most
disorders, General Anxiety Disorder stays fairly moderate in its anxiety levels (Deffenbacher
and Suinn, 1987, pg 332).
Diagnosis Criteria for General Anxiety
Disorder
1. Excessive anxiety
and worry (apprehensive
expectation), occurring more days than not for at least six months,
about a number of events or activities (such as work or school
performance).
2. The person finds it difficult to control the worry.
 3. The anxiety and worry
are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only
one item is required in children:
restlessness or feeling keyed up or on edge, being
easily fatigued, difficulty
concentrating or the mind going blank, irritability, muscle tension,
and sleep disturbance.
4. the anxiety or worry
is not about having a panic attack (as in panic disorder),
being embarrassed in public (as in social phobia), being contaminated
(as in obsessive-compulsive disorder), being away from home or
close relatives (as in separation anxiety disorder), gaining
weight (as in anorexia nervosa), having multiple physical complaints
(as in somatization disorder), or having a serious illness (as
in hypochondriasis), and the anxiety and worry
do no occur exclusively during posttraumatic stress disorder.
5. The
anxiety, worry, or physical symptoms cause clinically
significant distress or impairment in social, occupational, or other
important areas of functioning.
6. The
disturbance is not due to the direct physiological effects of
a substance (e.g., a drug of abuse, a medication) or a
general medical condition (e.g., hyperthyroidism) and does not
occur exclusively during a mood disorder, a psychotic disorder,
or a pervasive developmental disorder.
Panic Disorder
Definition of Panic Disorder
 Panic disorder (also known as cardiac neurosis or
neurosis cordis) is a mental condition that causes the sufferer
to experience sporadic panic attacks.
Panic disorder sufferers usually have a series of
intense episodes of extreme anxiety, known as panic attacks.
A panic event may be triggered by an especially stressful situation,
or it may occur for no particular reason. These events usually
last for several minutes. Some individuals deal with these events
on a regular basis—sometimes daily or weekly.
Because
of the constant fear
of having another panic attack, individuals with panic
disorder are often extremely uncomfortable in social situations.
As a result, as many as 35% of all individuals with panic disorder
also have agoraphobia.
 It typically strikes in young adulthood; roughly
half of all people who have panic disorder develop the condition
before age 24, though some sources say that the majority of young
people affected for the first time are between the ages of 25
and 30. Women are twice as likely as men to develop panic disorder.
Panic disorder can continue for months or years,
depending on how and when treatment is sought.
If left untreated, it may worsen to the point where the person's
life is seriously affected by panic attacks and by attempts
to avoid or conceal them. In fact, many people have had problems
with friends and family or lost jobs while struggling to cope
with panic disorder. It does not usually go away unless the person
receives treatments designed specifically to help
people with panic disorder.
For people who seek active treatment early in development,
the majority of symptoms can disappear within a few weeks, with no permanent
negative effects once treatment is completed.
Panic disorder has been found to run in families,
and this may mean that inheritance plays a strong role in determining
who will get it. However, many people who have no family history
of the disorder develop it. Other biological factors, stressful life events,
environment, and thinking in a way that exaggerates relatively
normal bodily reactions are also believed to play a role in the
onset of panic disorder.
Often
the first attacks are triggered by physical illnesses, major stress,
or certain medications. People who tend to take on excessive
responsibilities may develop a tendency to suffer panic attacks.
Post-traumatic stress disorder (PTSD) patients also show a much higher rate of panic disorder than
the general population. The exact causes of panic disorder are
unknown at this point.
Studies in animals and humans have focused on pinpointing
the specific brain areas involved in anxiety disorders
such as panic disorder. Fear,
an emotion that evolved to deal with danger, causes an automatic,
rapid protective response that occurs without the need for conscious
thought.
It has been found that the body's fear
response is coordinated by a small but complicated structure deep
inside the brain called the amygdala. Eating disorders have also
been linked to have caused panic attacks in several people.
Some mood disorders can cause panic disorder. In addition to clinical
depression, bipolar disorder
can cause panic disorder in some people.
Stimulants
are a rather common cause for panic attacks. An excess
of common stimulants such as caffeine and nicotine often can induce
panic attacks in less experienced users. Chemicals, including
carbon monoxide, in tobacco smoke can also trigger panic attacks
in certain people. Some people's response to small amounts of
carbon monoxide is to panic. Not surprisingly, the attacks stop
or get much less severe after they quit the cause, such as smoking.
Diagnosis Criteria of Panic Disorder
1. Recurrent unexpected
panic attacks (discrete episode of
intense sympathetic symptoms, symptoms peak within 10
minutes, four or more symptoms from those listed
below).
2. Panic attack symptoms: pounding heart,
chest pains, lightheadedness or dizziness, nausea or stomach problems,
flushes or chills, shortness of breath or a feeling of smothering
or choking, Tingling or numbing, shaking or trembling, terror,
fear of dying, and
sweating.
3. Persistent
worry about future
attacks or consequences.
4. No identified
anxiety secondary
cause.
Agoraphobia
Definition of Agoraphobia
 Agoraphobia is an anxiety disorder which
primarily consists of the fear
of experiencing a difficult or embarrassing situation from which
the sufferer cannot escape.
Agoraphobics may experience severe panic attacks
in situations where they feel trapped, insecure, out of control, or too far from their
personal comfort zone. In severe cases, an agoraphobic may be
confined not only to their home, but to one or two rooms, and
they may even become bed-bound, or a recluse.
Agoraphobics are often extremely sensitized to their
own bodily sensations, subconsciously over-reacting to perfectly
normal events. For example, the exertion involved in climbing
a flight of stairs may trigger a full-blown panic attack,
because it increases the heartbeat and breathing rate, which the
agoraphobic interprets as the start of a panic attack instead
of a normal fluctuation.
 The word agoraphobia is an English adoption of the
Greek words agora (αγορά) and phobos
(φόβος), literally translated as "a
fear of the marketplace".
This translation is the reason for the common misconception
that agoraphobia is a fear of open spaces. This is not exactly the
case, since agoraphobics are not afraid of open spaces themselves,
but of having panic attacks as a result of being in certain
locations.
Another misconception is that agoraphobia is a fear of "crowded spaces". Once again,
an agoraphobic does not fear people: he or she rather fears an embarrassing/dangerous situation with no escape.
Some people with agoraphobia are comfortable seeing visitors,
but only in a defined space they feel in control of.
Such people may live for years without leaving their
homes, while happily seeing visitors and working, as long as they
can stay within their safety zones. Most people who present to
mental health specialists develop agoraphobia after the onset
of panic disorder (American Psychiatric Association, 1998). Agoraphobia
is best understood as an adverse behavioral outcome of repeated
panic attacks and the subsequent worry,
preoccupation, and avoidance.
Agoraphobia can be successfully treated in many
cases through a very gradual process of graduated exposure therapy
combined with cognitive therapy and sometimes anti-anxiety or
antidepressant medications. Anti-anxiety medications
include benzodiazepines such as alprazolam.
Anti-depressant medications which are used
to treat anxiety disorders are mainly in the SSRI (selective serotonin reuptake inhibitor) class
such as sertraline, paroxetine and fluoxetine. Treatment options for
agoraphobia and panic disorder are similar.
Diagnosis Criteria of Agoraphobia
 1. Anxiety about being in places or situations from
which escape might be difficult (or embarrassing) or in which
help may not be available
in the event of having an unexpected or situationally predisposed
panic attack or panic-like symptoms.
Agoraphobic fears typically involved
characteristic clusters of situations that include being outside
the home alone; being in a crowd or standing in a line; being
on a bridge; and traveling in a bus, train or automobile.
2.
The situations are avoided (e.g., travel is restricted) or else
are endured with marked distress or anxiety about having a Panic attack or
panic-like symptoms, or require
the presence of a companion.
3.
The disturbance is not due to the direct physiological effects
of a substance (e.g., a drug of abuse, a medication) or
a general medical condition.
4. The
anxiety or phobic avoidance is not better accounted for by another
mental disorder, such as Social Phobia (e.g., avoidance limited
to social situations because of fear of embarrassment), Specific Phobia (e.g.,
avoidance limited to single situation like elevators), Obsessive-Compulsive
Disorder (e.g., avoidance of dirt in someone with an obsession
about contamination), Posttraumatic Stress Disorder (e.g.,
avoidance of stimuli associated with a severe stressor),
or Separation anxiety disorder (e.g., avoidance of leaving
home or relatives).
Phobia
Definition of Phobia
 A phobia (from the Greek φόβος
"fear"), is a strong, persistent fear
of situations, objects, activities, or persons. The main symptom
of this disorder is the excessive, unreasonable desire to avoid
the feared subject.
When the fear is beyond one's control, or if the fear
is interfering with daily life, then a diagnosis under one of
the anxiety disorders can be made. Phobias (in the clinical
meaning of the term) are the most common form of anxiety disorders.
An American study by the National Institute of Mental
Health (NIMH) found that between 8.7% and 18.1% of Americans suffer
from phobias. Broken down by age and gender, the study found that
phobias were the most common mental illness among women in all
age groups and the second most common illness among men older
than 25.
It is generally accepted that phobias arise from
a combination of external events and internal predispositions.
Some phobias such as arachnophobia (fear of spiders) and ophidiphobia (fear
of snakes) however, may arise more easily due to an evolutionary
trait that conditioned humans to fear certain creatures that could cause them
harm.
In a famous experiment, Martin Seligman used classical
conditioning to establish phobias of snakes and flowers. The results
of the experiment showed that it took far fewer shocks to create
an adverse response to a picture of a snake than to a picture
of a flower, leading to the conclusion that certain objects may
have a genetic predisposition to being associated with fear.
Many specific phobias can be traced back to a specific
triggering event, usually a traumatic experience at an early age.
Social phobias and agoraphobia have more complex causes that are
not entirely known at this time. It is believed that heredity,
genetics, and brain chemistry combine with life-experiences to
play a major role in the development of anxiety disorders
and phobias.
Diagnosis Criteria of Phobia
1. The person experiences excessive or irrational
fear of a specific object
or situation.
2. Exposure to the object or situation causes an
immediate anxiety response or a panic attack.
3. The person knows that the fear is excessive and irrational.
4. The object or situation is endured with distress or avoided.
5.
Avoidance, anticipatory anxiety, or distress during exposure
to the feared object or situation interferes with
the person's ability to function in normal daily activities. The
person may have distress about having the phobia.
l 
Most Common Phobias
More than ten percent (10%) of the population in the United States has some form of phobia. It is the
most common mental disorder in the United States. The following is a list of the most
common phobias
- Achluophobia
- fear of being
in darkness
- Acrophobia
- fear of heights
- Aquaphobia
– fear of water
or drowning
- Agoraphobia
- fear of open
spaces or fear of leaving home
- Arachnophobia
– fear of spiders
- Claustrophobia
- fear of being
in closed spaces
- Demophobia
- fear of being
in crowded places
- Mysophobia
- fear of germs
or dirt
- Social
phobia - fear of being
around unfamiliar people in social situations
·
 Xenophobia - fear
of strangers
Social Anxiety (or Social Phobia)
Definition of Social Anxiety (or Social
Phobia)
Social anxiety is an experience of fear,
apprehension or worry regarding social situations and being
evaluated by others. People vary in how often they experience
anxiety in this way or in which kinds of situations.
Anxiety about public speaking, performance, or interviews
is common. Social anxiety can be related to shyness. The experience
is commonly described as having physiological components (e.g.
sweating, blushing), cognitive/perceptual components (e.g. belief
that one may be judged negatively; looking for signs of disapproval)
and behavioral components (e.g. avoiding a situation).
Social anxiety disorder, also known as social phobia, is a diagnosis within psychiatry and
other mental health professions referring to excessive long-lasting
social anxiety causing relatively extreme distress and impaired
ability to function in at least some areas of daily life.
The
diagnosis can be of a 'specific' disorder (when only some particular
situations are feared)
or a generalized disorder. Generalized social anxiety disorder typically involves
a persistent, intense, and chronic fear of being judged by others and of potentially
being embarrassed or humiliated by their own actions.
These
fears can be triggered by perceived or actual scrutiny
by others. While the fear of social interaction may be recognized
by the person as excessive or unreasonable, considerable difficulty
can be encountered overcoming it. Approximately 13.3% of the general
population may meet criteria for social
anxiety disorder at some point in their lifetime, according
to the highest survey estimate, with the male to female ratio
being 1:1.5 respectively.
Physical symptoms often accompanying social
anxiety disorder include excessive blushing, sweating
(hyperhidrosis), trembling, nausea, and stammering. Panic attacks
may also occur under intense fear and discomfort. An early diagnosis may
help in minimizing the
symptoms and the development of additional problems such
as depression. Some sufferers
may use alcohol or drugs to reduce fears and inhibitions at social events.
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 thinking patterns and physical reactions to anxious
situations.
 According to the Diagnostic and Statistical Manual
of Mental Disorders, social phobia is a persistent fear
of one or more situations in which the person is exposed to possible
scrutiny by others and fears that he or she may do something or act in a way
that will be humiliating or embarrassing.
For one to be social phobic, exposure to the feared situation must provoke anxiety and
the person must recognize this anxiety as irrational (although
this may be absent in children).
If another disorder is present, the social phobic fear
is unrelated to it. For instance, if a person has a history of
panic attacks, having a panic attack must not be
the sufferer's fear.
Sufferers are typically more self-conscious and
self-attentive than others. As a result, social phobics tend to
limit or remove themselves from situations where they may be subject
to evaluation. Sufferers often recognize their fear
is excessive or irrational, yet can't seem to break out of the
cycle. As such, the diagnosis of social phobia is made only when
the fear leads to avoiding
occupational functions, social activities, or relationships with
others.
Mental health professionals often distinguish between
generalized and specific social anxiety disorders. People with generalized
social anxiety have great distress with most or
all social situations. A famous study by Stanford University established that distress was more likely
when social encounters were unfamiliar, involved power or status
differences, difference in gender, or the presence of a group
of people.
Those
with specific social phobias may experience anxiety only in a
few situations. For example the most common specific phobia is
glossophobia, the fear
of public speaking or performance, also known as "stage fright".
Other examples of specific social phobias include fears of writing in public (scriptophobia) and using
public restrooms (paruresis). There is much debate concerning
the relationship between social phobia and shyness. Shyness is
not a criterion for social anxiety
disorder. People with social
anxiety disorder may be quite comfortable with certain
people or many people, but still feel intense anxiety in specific
social situations. Child
psychologist Samuel Turner provides a summary between shyness
and social phobia. Both share several features: negative cognitions
in social situations, heightened physiological reactivity, a tendency
to avoid social situations, and deficits in social skills.
Negative cognitions include fear
of negative evaluation, self-consciousness, devaluation
of social skills, self-deprecating thoughts, and self-blaming
attributions for social difficulties. Social phobia is distinct
from shyness in that it has a lower prevalence in the population,
follows a more chronic course, is more functionally debilitating,
and has a later age of onset.
There are problems with these kinds of comparisons.
It may be that the differences between them are quantitative rather
than qualitative. There are some that argue that shyness is mistakenly
treated with medication intended for social phobia, effectively
labeling the personality trait a mental illness.
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|
Social phobia should not be confused with panic
disorder. Sufferers of panic disorder are convinced that their
panic comes from some dire physical cause, and often go to the
hospital or call for an ambulance during or after their attacks.
Social phobics may experience a panic attack when triggered,
but they are aware that it is extreme anxiety they are experiencing,
and that the cause is an irrational fear.
Few social phobics would willingly go to a hospital
in that instance because they fear
rejection and judgment by authority figures (such as the medical
staff). The principal difference between the two is that the social
phobia deals with anxiety in a social setting, while generalized
anxiety disorder is extreme anxiety for any situation (work,
school, et al.), not necessarily one involving other people.
Cognitive Aspects of Social Anxiety
(or Social Phobia)
 In cognitive models 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 deliberate over what could go wrong and how to deal with each
unexpected case.
After the event, they may have the perception they
performed unsatisfactorily. Consequently, they will review anything
that may have possibly been abnormal or embarrassing. These thoughts
do not just terminate soon after the encounter, but may extend
for weeks or longer.
Those with social phobia tend to interpret neutral
or ambiguous conversations with a negative outlook and although
still inconclusive, some studies suggest that socially anxious
individuals remember more negative memories than those less distressed. An example of an instance may be that of an
employee presenting to his co-workers.
During the presentation, the person may stutter
a word upon which he or she may worry
that other people significantly noticed and think that he or she
is a terrible presenter. This cognitive thought propels further
anxiety which may lead to further stuttering, sweating and a possible
panic attack.
Behavioral
Aspects of Social Anxiety (or Social Phobia)
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 most any type of social interaction, especially
small groups, dating, parties, talking to strangers, restaurants,
etc. Physical symptoms include "mind going blank", fast heartbeat,
blushing, stomach ache. Cognitive distortions are a hallmark,
and learned about in CBT (cognitive-behavioral therapy).
Thoughts are often self-defeating and inaccurate.
According
to renowned 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).
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
Psychological Aspects of Social Anxiety
(or Social Phobia)
Physiological effects, similar to those in other
anxiety disorders, are present in social phobics. Faced
with an uncomfortable situation, children
with social anxiety may display tantrums, crying, clinging to
parents, and shutting themselves out. Adults may weep, as well
as experience excessive sweating, nausea, shaking, and palpitations
as a result of the fight-or-flight response.
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 Dr. Ray Crozier
argues, "it is difficult to ascertain whether the person
being interviewed adheres to the DSM-III-R criteria or whether they are merely exhibiting
poor social skills or shyness." There is research indicating
that social anxiety disorder
is often correlated with bipolar disorder.
Causes and Perspectives of Social Anxiety
(or Social Phobia):
 Genetic and family factors—It has been shown that there is a two to three
fold greater risk of having social phobia if a first-degree relative
also has the disorder.
This could be due to genetics and/or due to children
acquiring social fears and avoidance through processes of observational
learning or parental psychosocial education. Studies of identical
twins brought up (via adoption) in different families have indicated
that, if one twin developed social anxiety disorder, then the other was
between 30% and 50% more likely than average to also develop the
disorder (Kendler et al., 1999).
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
(Merikangas et al., 1999). 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).
A related line of research has investigated 'behavioral
inhibition' in infants – early signs of an inhibited and introspective
or fearful nature. Studies have shown that around 10-15% 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 (Schwartz et al., 1999)
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 traumatic or humiliating social event appears to be
associated with the onset or worsening of the disorder (Mineka
& Zinbarg, 1995); 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 (Beidel & Turner,
1998). 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 emphasized
unpleasant experiences with peers (Ishiyama, 1984) 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 (La Greca et al, 1988). Socially
phobic children appear
less likely to receive positive reactions from peers (Spence et
al, 1999) and anxious or inhibited children may isolate themselves (Rubin and
Mills 1988).
 Social/cultural influences—Cultural factors that have been related to social
anxiety disorder include a society's attitude towards
shyness and avoidance, impacting ability to form relationships
or access employment or education.
One study found that the effects of parenting are
different depending on the culture - American children appear more likely to develop social
anxiety disorder if their parents emphasize the importance
of other's opinions and use shame as a disciplinary strategy (Leung
et al., 1994), but this association was not found for Chinese/Chinese-American
children.
In China, research has indicated that shy-inhibited children
are more accepted than their peers and more likely to be considered
for leadership and considered competent, in contrast to the findings
in Western countries (Xinyin, Rubin & Boshu, 1995). 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 Scandinavian 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
(Rapee & Lim, 1992) while others have (Stopa & Clark,
1993).
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 classes' (Heimberg et al., 2000).
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 (e.g. Baumeister & Leary).
Neurochemical and neurocognitive influences on Social
Anxiety (or Social Phobia)—Some scientists hypothesize that social phobia
is related to an imbalance of the brain chemical serotonin.
Sociability is also closely tied to dopamine neurotransmission.
The efficacy of medications which affect serotonin and
dopamine levels also indicates the role of these pathways. There
is also increasing focus on other candidate transmitters, e.g.
Norepinephrine, which may be over-active in social anxiety disorder, and the inhibitory
transmitter GABA.
Individuals with social anxiety disorder have been found to
have a hypersensitive amygdala, for example in relation to social
threat cues (e.g. someone might be evaluating you negatively),
angry or hostile faces, and while just waiting to give a speech
(Davidson, 2000).
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 (Eisenberger et al 2003).
Psychological factors of Social Anxiety (or Social
Phobia) —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 (Beck & Emery, 1986). One line of work has focused
more specifically on the key role of self-presentational concerns
(e.g. Leary, 1995). 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
(Clark & Wells, 1995). A similar model (Heimberg & Rapee,
1997) 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 anticipation before it. Studies have also highlighted
the role of subtle avoidance and defensive factors, and shown
how attempts to avoid feared negative evaluations or use 'safety
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. |
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Diagnosis Criteria of Social Anxiety (or Social Phobia)
Definition of Obsessive-compulsive disorder (OCD)
Definition
Diagnosis
Criteria
Is
it Normal?