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Social anxiety

2007 Schools Wikipedia Selection. Related subjects: Health and medicine

   CAPTION: Social phobias
   Classifications and external resources

   ICD- 10 F40.1
   ICD- 9  300.23

   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 disorder, also referred to clinically as social phobia,
   is a psychiatric anxiety disorder involving overwhelming anxiety and
   excessive self-consciousness in everyday social situations. People
   experiencing social anxiety often have a persistent, intense, and
   chronic fear of being watched and judged by others and being
   embarrassed or humiliated by their own actions. Often the triggering
   social stimulus is a perceived or actual scrutiny by others. Their fear
   may be so severe that it significantly impairs their work, school,
   social life, and other activities. While many people experiencing
   social anxiety recognize that their fear of being around people may be
   excessive or unreasonable, they encounter considerable difficulty
   overcoming it. This differs from shyness, in that the person is
   functionally debilitated and avoids such anxiety provoking situations.
   At the same time, a person with social anxiety may only feel the fear
   during certain situations. For example, an actor or singer may feel
   fine on stage, but afraid of social situations in everyday life.

   Social anxiety is often part of only a certain situation—such as a fear
   of speaking in formal or informal situations, or eating, or writing in
   front of others—or, in its most severe form, may be so broad that a
   person experiences symptoms almost anytime they are around other
   people. Many people have the specific fear of public speaking, called
   glossophobia. In this case, the fear is of doing or saying something
   which may cause embarrassment. Approximately 13.3% of the general
   population will experience social phobia at some point in their
   lifetime according to the highest estimate; with the male to female
   ratio being 1.4:1.0, respectively. Physical symptoms often accompany
   social anxiety, and include blushing, profuse sweating, trembling,
   nausea, and stammering. Panic attacks may also occur under intense fear
   and discomfort. An early diagnosis helps 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 behaviour therapy,
   whether individually or in a group, to be effective in treating social
   phobia. The cognitive and behavioural components seek to change
   thinking patterns and physical reactions to anxious situations.
   Prescribed medication includes a class of antidepressants called
   selective serotonin reuptake inhibitors (SSRIs).

   Attention given to social anxiety disorder has significantly increased
   since 1999 with the approval and marketing of drugs for its treatment.

Overview

   According to the Diagnostic and Statistical Manual of Mental Disorders,
   social phobia is a persistent fear of one or more situations in which
   the person is exposed to possible scrutiny by others and fears that he
   or she may do something or act in a way that will be humiliating or
   embarrassing. For one to be social phobic, exposure to the feared
   situation must provoke anxiety and the person must recognize this
   anxiety is irrational (although this may be absent in children). If
   another disorder is present, the social phobic fear is unrelated to it.
   For instance, if a person has a history of panic attacks, having a
   panic attack must not be the sufferer's fear. Sufferers are typically
   more self-conscious and self-attentive than others. As a result, social
   phobics tend to limit or remove themselves from situations where they
   may be subject to evaluation. Sufferers often recognize their fear is
   excessive or irrational, yet can't seem to break out of the cycle. As
   such, the diagnosis of social phobia is made only when the fear leads
   to avoiding occupational functions, social activities, or relationships
   with others.

   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.

   Social phobia should not be confused with panic disorder. Sufferers of
   panic disorder are convinced that their panic comes from some dire
   physical cause, and often go to the hospital or call for an ambulance
   during or after their attacks. Social phobics may experience a panic
   attack when triggered, but they are aware that it is extreme anxiety
   they are experiencing, and that the cause is an irrational fear. Few
   social phobics would willingly go to a hospital in that instance
   because they fear rejection and judgment by authority figures (such as
   the medical staff). The general form of social anxiety is sometimes
   incorrectly called generalized anxiety disorder. The principal
   difference between the two is that the social phobia deals with anxiety
   in a social setting, while generalized anxiety disorder is extreme
   anxiety for any situation (work, school, et al.), not necessarily one
   involving other people.

Symptoms

Cognitive aspects

   In cognitive models of social anxiety, social phobics experience dread
   over how they will be presented to others. They may be overly
   self-conscious, pay high self-attention after the activity, or have
   high performance standards for 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.

Behavioural 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 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. 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 phobia.

Physiological aspects

   Physiological effects, similar to those in other anxiety disorders, are
   present in social phobics. Faced with an uncomfortable situation,
   children with social anxiety may display 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.

Prevalence

   When prevalence estimates were based on the examination of psychiatric
   clinic samples, social anxiety disorder was thought to be a relatively
   rare disorder. The opposite was instead true; social anxiety was common
   but many were afraid to seek psychiatric help, leading to an
   understatement of the problem. Prevalence rates vary widely because of
   its vague diagnostic criteria and its overlapping symptoms with other
   disorders. There has been some debate on how the studies are conducted
   and whether the illness truly impairs the respondents as laid out in
   the official criteria. Psychologist Dr. Ray Crozier argues, "it is
   difficult to ascertain whether the person being interviewed adheres to
   the DSM-III-R criteria or whether they are merely exhibiting poor
   social skills or shyness."

   The National Comorbidity Survey of over 8,000 American correspondents
   in 1994 revealed a 12-month and lifetime prevalence rates of 7.9% and
   13.3% making it the third most prevalent psychiatric disorder after
   depression and alcohol dependence and the most apparent of the anxiety
   disorders. According to U.S. epidemiological data from the National
   Institute of Mental Health, social phobia affects 5.3 million adult
   Americans in any given year. Recent studies suggest the lifetime
   prevalence number may be as high as 15 million people or 6.8% of the
   American population. Cross-cultural studies have reached prevalence
   rates with the conservative rates at 5% of the population. However,
   other estimates vary within 2% and 7% of the U.S. adult population.

   Onset of social phobia typically occurs between 11 and 19 years of age.
   Onset after age 25 is rare. Social anxiety disorder occurs in females
   twice as often as males, although men are more likely to seek help. The
   prevalence of social phobia appears to be increasing among white,
   married, and well-educated individuals. As a group, those with
   generalized social phobia are less likely to graduate from high school
   and are more likely to rely on government financial assistance or have
   poverty-level salaries. Surveys carried out in 2002 show the youth of
   England, Scotland, and Wales have a prevalence rate of .4%, 1.8%, and
   .6%, respectively. The prevalence of self-reported social anxiety for
   Nova Scotians older than 14 years was 4.2% in June 2004 with women
   (4.6%) reporting more than men (3.8%). In Australia, social phobia is
   the 8th and 5th leading disease or illness for males and females
   between 15-24 years of age as of 2003.

Comorbidity

   There is a high degree of comorbidity with other psychiatric disorders.
   Social phobia often occurs alongside low self-esteem and clinical
   depression, due to lack of personal relationships and long periods of
   isolation from avoiding social situations. To try to reduce their
   anxiety and alleviate depression, people with social phobia may use
   alcohol or other drugs, which can lead to substance abuse. It is
   estimated that one-fifth of patients with social anxiety disorder also
   suffer from alcohol dependence. The most common complementary
   psychiatric condition is depression. In a sample of 14,263 people, of
   the 2.4% of persons diagnosed with social phobia, 16.6% also met the
   criteria for major depression. Besides depression, the most common
   disorders diagnosed in patients with social phobia are panic disorder
   (33%), generalized anxiety disorder (19%), post-traumatic stress
   disorder (36%), substance abuse disorder (18%), and attempted suicide
   (23%). In one study of social anxiety disorder patients who developed
   comorbid alcoholism, panic disorder or depression, social anxiety
   disorder preceded the onset of alcoholism, panic disorder and
   depression in 75%, 61%, and 90% of patients, respectively. Avoidant
   personality disorder is also highly correlated with social phobia.
   Because of its close relationship and overlapping symptoms with other
   illnesses, treating social phobics may help understand underlying
   connection in other psychiatric disorders.

   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 a proportion of socially phobic patients treated with
   anti-depressant medication develop hypomania ., although this can be
   seen as the medication creating a new problem, and also has this
   adverse effect in a proportion of those without social phobia.

Causes and perspectives

   Research into the causes of social anxiety and social phobia is
   wide-ranging, encompassing multiple perspectives from neuroscience to
   sociology. Scientists have yet to pinpoint the exact causes. Studies
   suggest that genetics plays a part in combination with environmental
   factors.

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);

   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 (Warren et al, 1997), including
   social phobia (SAD)

   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% 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 their disorder (Mineka &
   Zinbarg, 1995); this kind of event appears to be particularly related
   to specific performance SA, for example 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
   emphasised 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).

Sociocultural influences

   Cultural factors that have been related to social anxiety disorder
   include a societies attitude towards shyness and avoidance, impacting
   ability to form relationships or access employment or education. 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 hypothesised that hot
   weather and high-density may reduce avoidance and increase
   interpersonal contact. There appear to be differences between more
   'western' and more 'eastern' cultures. One study has suggested that the
   effects of parenting are different depending on the culture - American
   children appear more likely to develop social anxiety disorder if their
   parents emphasise the importance of other's opinions and use shame as a
   disciplinary strategy (Leung et al., 1994), but this association was
   not found for Chinese/Chinese-American children.

   Problems in developing 'social skills' 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).

Evolutionary context

   A long-accepted evolutionary explanation of anxiety is that it reflects
   an in-built 'fight or flight' system, which errs on the side of safety.
   One line of research suggests that specific dispositions to monitor and
   react to social threats may have evolved, reflecting the vital and
   complex importance of social living and social rank in human ancestral
   environments. Charles Darwin originally wrote about the evolutionary
   basis of shyness and blushing, and modern evolutionary psychology and
   psychiatry also addresses social phobia in this context. It has been
   hypothesised that in modern day society these evolved tendencies can
   become more inappropriately activated and result in some of the
   cognitive 'distortions' or 'irrationalities' identified in
   cognitive-behavioural models and therapies (Gilbert, 1998).

Neurochemical and neurocognitive influences

   Some scientists hypothesize that social phobia is related to an
   imbalance of the brain chemical serotonin. Sociability is also closely
   tied to dopamine neurotransmission. Low D2 receptor binding is found in
   people with social anxiety.. 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. Noradrenalin, 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

   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 worriy about anxiety symptoms themselves and
   how they might appear to others (Clark & Wells, 1995). A similar model
   (Heimberg & Rapee, 1997) emphasises the development of a distorted
   mental representation of their self and over-estimates of the
   likelihood and consequences of negative evaluation, and of the
   performance standards that others have. Such cognitive-behavioural
   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 behaviours' (Clark & Wells, 1995) can make
   social interaction more difficult and the anxiety worse in the long
   run. This work has been influential in the development of Cognitive
   Behavioural Therapy for social anxiety disorder, which has been shown
   to have efficacy.

Treatment

   Arguably the most important clinical point to emerge from studies of
   social anxiety disorder is the benefit of early diagnosis and
   treatment. Social anxiety disorder remains underrecognized in primary
   care practice, with patients often presenting for treatment only after
   the onset of complications such as major depression or substance use
   disorders. Improvement is lower for those with more severe social
   phobia and with comorbid disorders, such as avoidant personality
   disorder and depression. The patients who achieve full resolution are
   usually far fewer; there are still many who, after receiving treatment,
   are unable to function in the long-term without anxiety symptoms.

   Research 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-behavioural
   therapy (CBT), the central component being gradual exposure therapy.

Pharmacological treatments

SSRIs

   Selective serotonin reuptake inhibitors (SSRIs), a class of
   antidepressants, are considered by many to be the first choice
   medication for generalised social phobia. These drugs elevate the level
   of the neurotransmitter serotonin, among other effects. The first drug
   formally approved by the Food and Drug Administration was paroxetine,
   sold as Paxil in the US. 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% of
   patients with generalized social anxiety disorder, compared with 23.9%
   of those taking placebo. An October 2004 study yielded similar results.
   Patients were treated with either fluoxetine, psychotherapy, fluoxetine
   and psychotherapy, placebo and psychotherapy, and a placebo. The first
   four sets saw improvement in 50.8 to 54.2% of the patients. Of those
   assigned to receive only a placebo, 31.7 percent achieved a rating of 1
   or 2 on the Clinical Global Impression-Improvement scale. Those who
   sought both therapy and medication did not see a boost in improvement.

   General side-effects are common during the first weeks while the body
   adjusts to the drug. Symptoms may include headaches, nausea, insomnia
   and changes in sexual behaviour. Treatment safety during pregnancy has
   not been established. In late 2004 much media attention was given to a
   proposed link between SSRI use and juvenile suicide. For this reason,
   the use of SSRIs in pediatric cases of depression is now recognized by
   the Food and Drug Administration as warranting a cautionary statement
   to the parents of children who may be prescribed SSRIs by a family
   doctor. 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 commonly issued, sometimes only if SSRIs
   fail to produce any clinically significant improvement.

   In 1985, before the introduction of SSRIs, anti-depressants such as
   monoamine oxidase inhibitors (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.

   Benzodiazepines are a short-acting and more potent alternative to
   SSRIs. The drug is often used for short-term relief of severe,
   disabling anxiety. Although benzodiazepines are still sometimes
   prescribed for long-term use in some countries, there is much concern
   over the development of drug tolerance, dependency and recreational
   abuse. Benzodiazepines augment the action of GABA, the major inhibitory
   neurotransmitter in the brain; effects usually begin to appear within
   minutes or hours.

   Some people with a form of social phobia called performance phobia have
   been helped by beta-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.

Psychotherapy

   Research has shown that a form of psychotherapy that is effective for
   several anxiety disorders, particularly panic disorder and social
   phobia is cognitive-behavioural therapy (CBT). It has two main
   components. The cognitive component helps people become aware of and to
   change thinking patterns that keep them from overcoming their fears. A
   person with social phobia might be helped to question how they can be
   so sure that others are continually watching and harshly judging him or
   her. The behavioral component of CBT seeks to change people's reactions
   to anxiety-provoking situations. A key element of this component is
   gradual exposure, in which people confront the things they fear in a
   structured, sensitive manner. The aim is also to learn from acting
   differently and observing reactions (behavioural 'experiments'). This
   is intended to be done with support and guidance when the therapist and
   patient feel they are ready. Cognitive-behaviour therapy for social
   phobia also includes anxiety management training, which may include
   techniques such as deep breathing and muscle relaxation exercises,
   which may be practiced ' in-situ'. CBT may also be conducted partly in
   group sesssions (Cognitive behavioral group therapy), facilitating the
   sharing of experiences, a sense of acceptance by others and undertaking
   behavioural challenges in a trusted environment (Heimberg).

   Some studies have suggested social skills training can help with social
   anxiety (Mersch et al., 1991). Whether specific social skills
   techniques and training are required, rather than just support with
   general social functioning and exposure to social situations, does not
   seem to be clear (Stravynski & Amado, 2001).

   Interpersonal Therapy has been shown to have efficacy for depression
   and a small study of the therapy in the treatment of social phobia
   suggests it may also work with social phobia (Lipsitz et al, 1999).

History

   Michael Liebowitz (pictured), as well as Richard Heimberg, are
   prominent researchers on social phobia.
   Enlarge
   Michael Liebowitz (pictured), as well as Richard Heimberg, are
   prominent researchers on social phobia.

   Literary descriptions of shyness can be traced back to the days of
   Hippocrates around 400 B.C. Charles Darwin wrote about the physiology
   and social context of blushing and shyness. The first mention of a
   psychiatric term, social phobia ("phobie des situations sociales"), was
   made in the early 1900s. Psychologists used the term " social neurosis"
   to describe extremely shy patients in the 1930s. After extensive work
   by Joseph Wolpe on systematic desensitization, research in phobias and
   their treatment grew. The idea that social phobia was a separate entity
   from other phobias came from the British psychiatrist, Isaac Marks in
   the 1960s. This was accepted by the American Psychiatric Association
   and was first officially included in the third edition of the
   Diagnostic and Statistical Manual of Mental Disorders. The definition
   of the phobia was revised in 1989 to allow comorbidity with avoidant
   personality disorder, and introduced generalized social phobia. 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 in increase in research and attention on the
   disorder. The DSM-IV gave social phobia the alternative name Social
   Anxiety Disorder. Research in to the psychology and sociology of
   everyday social anxiety continued. Cognitive Behavioural models and
   therapies were developed for social anxiety disorder. In the 1990s,
   paroxetine became the first prescription drug in the US approved to
   treat social anxiety disorder, with others following.

Criticisms

   Many professionals and sufferers continue to criticise a perceived
   underdiagnosis and undertreatment of Social Anxiety Disorder and
   associated disability, and that not enough is being done to overcome
   the barriers faced by this group (e.g. Olfson et al., 2000)

   By contrast, others are critical that the diagnostic boundaries have
   been stretched too far and that clinical and media work is promoting
   the idea that any problems with shyness or social worries are a
   pathological medical condition requiring medical treatment. Some see
   this as being driven by pharmaceutical companies, either by direct
   advertising to the public or their financial influence on psychiatry.
   This view can be associated with, but is not exclusive to,
   anti-psychiatry.

   Some argue that problems with social anxiety in individuals can be seen
   as indicating problems with society - for example a competitive
   culture, power imbalances, lack of care or social education in families
   and communities - and are critical of focusing disorder and treatment
   only on individuals.

Literature

     * American Psychiatric Association (2000). "Anxiety disorders". In
       Diagnostic and Statistical Manual of Mental Disorders, 4th ed.,
       text rev., pp. 450–456. Washington, D.C.: American Psychiatric
       Association.
     * Belzer, K. D.; McKee, M. B.; Liebowitz, M. R. (2005). "Social
       Anxiety Disorder: Current Perspectives on Diagnosis and Treatment".
       Primary Psychiatry, 12(11):40-53.
     * Bruch, M. A. (1989). "Familial and developmental antecedents of
       social phobia: Issues and findings". Clinical Psychology Review, 9:
       37-47.
     * Crozier, W. Ray; Alden, Lynn E. International Handbook of Social
       Anxiety: Concepts, Research, and Interventions Relating to the Self
       and Shyness. New York John Wiley & Sons, Ltd. (UK), 2001. ISBN
       0-471-49129-2.
     * Burns, David D. Feeling Good: The New Mood Therapy. Revised
       Edition. Avon, 1999. ISBN 0-380-81033-6
     * Hales, R. E.; Yudofsky, S. C., eds. (2003). "Social phobia".
       Textbook of Clinical Psychiatry, 4th ed., pp. 572–580. Washington,
       D.C.: American Psychiatric Publishing.
     * Okano K. (1994). Shame and social phobia: a transcultural
       viewpoint. Bull Menninger Clin, 58(3): 323-38.
     * Samson, A. (2002). "Psychiatric Conceptions of "Social Phobia": A
       Comparative Perspective". Swiss Journal of Sociology, 28(3):
       505-527.
     * Stein, M. B.; Kean, Y. M. (2000). "Disability and quality of life
       in social phobia: Epidemiologic findings". American Journal of
       Psychiatry, 157(1): 1606–1613.
     * Van Ameringen, M. A., et al. (2001). "Sertraline treatment of
       generalized social phobia: A 20-week, double-blind,
       placebo-controlled study". American Journal of Psychiatry, 158(2):
       275–281.
     * Wagstaff, A. J., et al. (2002). "Spotlight on paroxetine in
       psychiatric disorders in adults". Drugs, 62(4): 655–703.

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