Social phobia (Social Anxiety Disorder)

Social phobia is the most common type of anxiety disorder. It affects about 13% of the population in the USA at some time of their life. It is the third most common mental health problem in the United States.

People who have social phobia are anxious when under scrutiny by others. This occurs, for example during various social activities such as when when public speaking, talking to others at social functions, meeting new people. It may also occur when performing activities in front of others. Examples include eating a meal or writing a cheque in front of other people. It is interesting that when alone these activities do not provoke anxiety. Using the telephone also causes anxiety to many with social phobia.

These situations are seen as unpleasant and painful by those with social phobia because they fear humiliation. They expect to be judged shamefully.

Everyone feels uncomfortable or nervous from time to time, especially in new situations. For example, if you’ve been experiencing social fears for less than six months, you may not have social phobia. A short-term fear of socializing may be a temporary reaction to a new stress such as moving to a new neighbourhood or getting a new job. However, you may have social phobia if you experience the following symptoms for a prolonged period:

  • You fear situations with unfamiliar people or ones where you may be observed or evaluated in some way.
  • When forced into an uncomfortable social situation, your anxiety increases powerfully. For example, if you fear public speaking, your voice shakes and your knees tremble the moment that you start your speech.
  • You realize that your fear is greater than the situation really warrants. For example, if you fear meeting new people, logically you know nothing horrible will happen, but tidal waves of adrenaline and fearful anticipation course through your veins.
  • You avoid fearful situations as much as you can or endure them only with great distress.

Social phobia was as we understand it today was first described in 1966. Since then it has been extensively studied by psychologists. It is thought that social phobics want to create a certain impression on others but doubt their ability to do so. Psychologists have concluded that those with social phobia do not actually lack social skills.

Well known  performers who have suffered from social phobia include Laurence Olivier, Donny Osmond, Barbara Streisand, and Kim Bassinger.

Some facts about social phobia:

Social phobia usually begins during the mid teens but may start in early childhood.

Most people are socially anxious at some time especially during adolescence, but not many develop social phobia. To develop social phobia one must be biologically and psychologically vulnerable to anxious apprehension. There is a genetic contribution to social phobia.

Some psychologists prefer the term social anxiety disorder to social phobia

Shyness seems to be closely related to social phobia. Another possible precursor is behavioural inhibition-children who are fearful timid and wary when in contact with unknown people and new surroundings.

Numerous studies have shown a connection between behavioural inhibition in childhood and social anxiety during adolescence.

The most frequent co-morbid  disorder is depression.

It has been suggested that the fear of being watched is an exaggeration of the normal human sensitivity to eyes.

Self-focused attention impairs performance in people with social phobia, possibly because self-focus detracts resources from optimal task performance.

Humans are sensitive to anger, criticism or other forms of social disapproval. As a result of evolutionary forces.

There is a high overlap between social phobia and avoidant personality disorder (APD).

Once established social phobia can persist for many years, if not indefinitely, in the absence of any treatment.

Treatment of Social Phobia

 

Pharmacological Treatments for Social Phobia

The most common drug treatments for treating social phobia include: Monoamine oxidase inhibitors (MAOIs), Selective serotonin reuptake inhibitors (SSRIs), benzodiazepines, tricyclic and other antidepressants and beta blockers.

Mono amine oxidase inhibitors (MAOI’s)

MAOI’s antidepressant drugs are effective in treating social phobia, but their use is limited by their side effect profile and the dietary restrictions required when taking them.

Selective Serotonin Reuptake Inhibitors (SSRI’s)

The SSRI’s are antidepressants which have been found to be effective in treating anxiety.The first SSRI to receive FDA approval as a treatment for social phobia was paroxetine in 1999. There are now 3 SSRIs approved by the FDA for the treatment of social anxiety: paroxetine, sertraline and fluvoxamine. Studies have shown that other SSRI’s such as fluoxetine are also effective in treating social phobia. These drugs are now the treatment of choice if medication is required for social phobia

Benzodiazepines

Only 2 benzodiazepines have been tested under double-blind conditions. These are clonazepam and alprazolam. Clonazepam was effective in treating 78% of patients compared to 20% taking a placebo. Alprazolam was only effective in 38% of patients compared with phenelzine (a MAOI) which worked in 69% of patients.
The problem with benzodiazeines is the risk of physical dependence and a high rate of relapse when the drugs are discontinued. Clonazepam is easier to discontinue possibly because it has a longer half-life. In addition benzodiazepines are contra-indicated in patients who drink alcohol to reduce their social anxiety, because of the synergistic effect of these drugs with alcohol.

Tricyclic Antidepressants

These drugs have been less well researched. There is some data for the use of imipramine and clomipramine to treat social phobia but these drugs had a poor response rate eg with imipramine, only 20% of patients responded to the drug.

Beta-Blockers

These drugs have been widely used since the 1970’s for treating performance anxiety. They are commonly taken by musicians to treat stage fright, often  being obtained without a prescription. Clinical double-blind studies have not shown a significant benefit with beta-blockers however, when compared to placebo.

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