6.104: Social Phobia

DSM-IV-TR Criteria

• A. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. NOTE: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.

• B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. NOTE: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
• C.The person recognizes that the fear is excessive or unreasonable. NOTE: In children, this feature may be absent.
• D. The feared social or performance situations are avoided or else endured with intense anxiety or distress.
• E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
• F. In individuals under age 18 years, the duration is at least 6 months.
• G. The fear or avoidance is not due to the direct psychological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder).
• H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa.

In addition, the DSM-IV has the “Generalized” specifier, where the person’s fear includes almost all social situations.

Associated Features

Also known as Social Anxiety Disorder, persons with SP are often hypersensitive to criticism, greatly fear negative evaluation, have increased perceptions of rejection, difficulty being assertive, and low self-esteem or feelings of inferiority. Test taking can be difficult for individuals with social phobia due to their fear of indirect evaluation by others. Observable signs of anxiety (poor eye contact, making sounds like “uh” and “um” during speech) are often present in individuals with this disorder. Attending school or work may also be difficult for people with social phobia and they tend to underachieve in these areas.

Comorbidity within persons diagnosed with SP is very high, over 80% in clinical settings. In adults, the most commonly diagnosed comorbids are major depression, dysthymia, panic disorder, GAD, specific phobias, and alcohol use disorders. In children, high rates of oppositional defiant disorder, conduct disorder, and ADHD are both present (all of which are unique among the anxiety disorders). SP most often develops prior to other comorbid problems, but relationship with substance use disorders is more uncertain. Some studies have found substance use causing SP, while others have found the reverse. Avoidant Personality Disorder (AVPD), which involves severe restriction and avoidance of situations in which one feels that they would be judged, shows high overlap with SP, with over 40% of people with SP also meeting criteria for AVPD. It is generally more severe than SP, and some researchers claim it is just an extreme variant of SP. Other research, though, shows that there are several distinctions between the two, and that it may be more related to schizophrenia spectrum disorders.

The impact of SP is wide-ranging, both in youth and adults. It is a common reason for school refusal in youth, and the only internalizing disorder highly associated with dropping out of school early. In adults, we find reduced workplace productivity and higher unemployment rates in those with SP. Reduced health-related QoL are also found. Other problematic areas are the high rates of being single or divorced, a wide range of reported sexual dysfunctions, smaller social networks and less social support, and a lowered amount of positive psychological experiences. Persons with Sp are also at a greater risk for suicide than general population.

Child vs. Adult Presentations

SP is the anxiety disorder where the highest percentage of cases begin in childhood, with reliable and valid cases being seen as early as age six. Children are likely to show symptoms such as crying or throwing tantrums, freezing up, and staying close to a familiar person. They also can show inhibited social interactions, even up to the point of selective mutism, and may seem highly timid and uninvolved in group activities. As seen with college-aged adults, children show signs of underachievement in school settings compared to their academic and intellectual potential. Unlike adults, many children may be unable to identify the nature of their anxiety and often do not have the option of avoiding feared situations, as they are forced into them by adults.

Gender and Cultural Differences in Presentation

Community based and epidemiological studies find that SP is slightly more represented in females (13.0% lifetime) than in males (11.1%). In most clinical and treatment-seeking samples, though, the majority of clients are males. The most commonly avoided or anxiety-provoking situations are different for males and females. For men, eating in restaurants and writing in public are seen more frequently, while in women using public restrooms and speaking in public are more represented.

In the U.S., higher rates of SP are seen among those of lower socioeconomic status, as well as persons with lower levels of education. While Native Americans are at a higher risk than Caucasians for development of SP, other minority groups show lower rates. Interestingly, people living in urban areas in both the U.S. and abroad show lower levels of SP.

Cross-country comparisons show much higher rates in the U.S. (7.1% for 1-year rates) compared to non-Western nations, such as Japan (0.8%), South Korea (0.2%), urban China (0.2%), Mexico (1.7%), South Africa (1.9%). Even compared to Europe (1.1-2.3%) and Australia (1.3%), U.S. rates are much higher. When comparing Western and Asian populations, there appears to be a distinctive division between what is causing the social anxiety: fear of embarrassing self (Western) versus fear of offending others (Eastern). The culturally bound disorder of taijin kyofusho (TKS; translated as “fear of interpersonal relations) seen in Japan and Korea seems to exemplify this division. In TKS, people show similar avoidance patterns as SP, but do so because they fear doing something to offend another person (rather than embarrassing themselves, which is what is seen in SP). Also distinct from most cases of SP is what the individual fears they will do or present, such as having an unpleasant body odor or that they will stare at another person’s crotch or chest. These features, however, have been observed in Western samples.

Epidemiology

Best evidence indicates that, in the U.S., the lifetime prevalence rate of SP for adults is 12.1%, with a 12-month prevalence rate of 7.1%. Prevalence decreases with age, from a 12-month rate of 9.1% among 18-29 year olds to 3.1% in those 60 years and above. Rates in children are relatively high due to the early onset of this disorder, with an under-18 prevalence of 6.8%. Over 50% of adults self-report retrospectively that they began having problems in childhood, and almost 80% report development of the disorder by age 20. Lower-level, non-clinical levels of SP are common, with one study showing that 20% of participants reported excessive fear of public speaking and performance, but only about 2% appeared to experience enough impairment or distress to warrant a diagnosis of SP. In the general population, most individuals with SP fear public speaking, where less than half fear speaking to strangers or meeting new people.

Etiology

As with all the other anxiety disorders, there has been significant progress in understanding the biological, psychological, and social causes of SP over the last several decades. Biologically, multiple gene variants and neurotransmitters seem to play a role in social anxiety, with no one “true” pathway to the disorder. There is only modest heritability seen in SP, less so than for OCD, but the research is still attempting to unravel if this is due to genetic linkage or shared environmental factors. What is likely is that genetics and other pre- and peri-natal biological influences are responsible for the development of a behaviorally inhibited temperament, which then places an individual at a greatly increased risk for developing SP later in life. This risk factor (behavioral inhibition) then interacts with certain types of social environments to cause someone to become social anxious. For instance, studies have found that the family environments of people diagnosed with SP tend to be more overprotective and less affectionate than is typical. Their families also tend place a very high emphasis on other people’s opinions and demonstrate a distinct lack of family sociability.

Cognitive-behavioral models emphasize the psychological and learning factors that assist in developing SP. The CBT model focuses on the role of negative self and situation interpretation and avoidance. When a person with SP encounters a social situation, such as having to speak in front of an audience, this activates certain negative assumptions about themselves (“I’m no good at this, I will look foolish, no one is interested in hearing what I say”). That then causes them to perceive the situation as dangerous, not physically but socially. This activates the sympathetic nervous system, causing the outward, observable manifestations of anxiety (e.g., sweating, increased heart rate, dry mouth, feeling flushed) and at the same time making them more focused inward on themselves. In turn, this provides evidence for them that they actually are socially awkward, as anxiety often inhibits performance and thus causes what was feared to come true (in this case, verbal blocking, not making eye contact, looking nervous). This will feed back into negative evaluations of themselves and lead to escape and avoidance behaviors, which will cause a reduction in anxiety, negatively reinforcing those behaviors. This will also cause the person to feel that their negative cognitions concerning social situations are accurate, making them want to avoid such things in the future.

Empirically Supported Treatments

Only half of persons with SP ever seek treatment of any kind, and for those who do seek treatment, the average amount of time between onset of problems and seeking help is between 15-20 years. This is particularly sad due to the fact that both pharmacological and psychotherapeutic interventions are quite effective for this disorder. While combining the two does not appear to show benefit over either alone, the effect sizes are quite large for both medications (1.5) and cognitive-behavioral therapy (1.8). While medications tend to decrease symptoms more quickly than CBT, the effects of CBT are slightly greater and outlast medication significantly.

The first line medical treatments for SP are the SSRIs, with the exception of fluoxetine, and the SNRIs. In particular, escitalopram and paroxetine appear to show the highest response rates (54-71% and 55-72%, respectively). Both classes are well-tolerated and have similar effect sizes compared to placebos. While the MAOIs and benzodiazepines can both be effective at lowering symptoms, they have more dangerous side effect profiles, and both carry a risk of addiction. Recently, research has also examined the use of D-cycloserine (a glutaminergic agent), but not as a standalone treatment. Instead, it appears that it may be useful as an adjunct to CBT incorporating EX/RP, increasing it’s effectiveness.

Treatment for SP is longer and involves more components than for specific phobias, as the feared situations tend to be more diffuse and more anxiety-based. Gains or even improvements are seen from 6-12 months post treatment, and there are low drop-out rates (10-20%) during treatment. Both group and individual formats both show large improvement rates, but individual is higher. Given the problems with access to trained therapists, though, researchers have also examined the use of minimal contact therapies that rely heavily on self-guided exposures. One study found that bibliotherapy plus only three hours of non-therapy contact with a therapist clinically improved 40% of clients with SP. Those with severe symptoms, however, did not improve much, so this may be good option for persons with mild to moderate SP.

Six components are used in CBT addressing social anxiety: psychoeducation, applied relaxation, social skills training, imaginal and in-vivo exposure, video feedback, and cognitive restructuring. The education component helps the client to better understand the nature of social anxiety and orient them to treatment. In applied relaxation, the therapist trains clients in the use of relaxation methods such diaphragmatic breathing and progressive muscle relaxation and then has the person use them while in social situations. Social skills training focuses on improving use of verbal and nonverbal behaviors in conversations and other social situations. Video feedback involves taping the person doing a task (often public speaking) and then playing it back to them to help show them they are not acting as awkward as they believed during the task. The use of exposures appears to be the most important aspect of the treatment, as studies comparing the full CBT package to EX/RP alone have shown similar effect sizes.

Likewise, applied relaxation techniques are not effective by themselves, and the same seems to be true of social skills training. Video feedback can be seen as a kind of exposure, which leaves only one other component that may play an active role in change. Cognitive restructuring is often used to help prepare for engaging in the exposures. Exposures can thus be seen as the “test” of if automatic negative thoughts are correct or incorrect. So, as the key component, exposures must be done in a very controlled manner, taking care to catch and not allow subtle avoidance or distractor behaviors and instead and focus on the situation at hand. Dichotomizing the components of EX/RP and cognitive restructuring, though, may be misleading. Observation of expert therapists treating people with SP often mix the two, rather than strictly using one or the other. As such, SP treatment is a prime example of the CBT model of behavior causing changes in thoughts, but thoughts also causing changes in behavior.

Proposed DSM-5 Revisions

The first change is the name of the disorder. In the DSM-IV, it is referred to as “Social Phobia (Social Anxiety Disorder)” while in the DSM-5 it is proposed to be renamed “Social Anxiety Disorder (Social Phobia).” This is due to the fact that the disorder appears to be one not of fear, but of anxiety. Persons with SP do not overtly and actively avoid all social interaction (which is pervasive in society) as someone with a phobia would, but instead endure such situations with marked distress and discomfort. Another significant change is the addition of two more specifiers to the current Generalized one: Performance Only and Selective Mutism. This is less supported by the research data, though, particularly the “Performance Only” subtype.

Key References

Abramowtiz, J.S., Moore, E.L., Braddock, A.E., & Harrington, D.L. (2009). Self-help cognitive–behavioral therapy with minimal therapist contact for social phobia: A controlled trial. Journal of Behavior Therapy & Experimental Psychiatry, 40, 98-105.

Bogels, S.M., Alden, L., Beidel, D., Clark, L.A., Pine, D.S. et al. (2010). Social anxiety disorder: Questions and answers for the DSM-V. Depression and Anxiety, 27, 168-189.

Kashdan, T. (2007). Social anxiety spectrum and diminished positive experiences: Theoretical synthesis and meta-analysis. Clinical Psychology Review, 27, 348-365.

Morris, E.P., Stewart, S.H., & Ham, L.S. (2005). The relationship between social anxiety and alcohol use disorders: A critical review. Clinical Psychology Review, 25, 734-760.

Stein, M.B., & Stein, D.J. (2008). Social anxiety disorder. Lancent, 371, 1115-1125.

Zimmerman, M., Dalrymple, K., Chelminski, I., Young, D., & Galione, J. N. (2010). Recognition of irrationality of fear and the diagnosis of social anxiety disorder and specific phobia in adults: Implications for criteria revision in DSM-5. Depression and Anxiety, 27(11), 1044-1049.

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