is the fear that in certain social situations, one will be criticized or
judged negatively. The individual feels a great deal of anxiety,
humiliation, embarrassment or even panic in social settings. One can have
either specific or generalized social phobia. The most common specific
social phobia is the fear of speaking in public. Individuals with
generalized social phobia are anxious in almost all interpersonal
situations. If the individual is going to be judged or graded on his
performance in a public situation, the fear is greatly increased.
Many people get
a minor case of the “jitters” before performing in public. For some,
this mild anxiety actually enhances their performance. However, this
anxious reaction is massively exaggerated in the individual with social
phobia. While mild normal anxiety can actually enhance performance,
excessive anxiety can severely impair performance.
episode may be associated with some or all of the symptoms of a panic
attack. These might include sweaty palms, palpitations, rapid breathing,
tremulousness and a sense of impending doom. Some individuals,
particularly those with generalized social phobia may have chronic anxiety
symptoms. Individuals with social phobia may turn down accelerated classes
and after school activities because of their fears that these situations
will lead to increased public scrutiny.
with a specific social phobia feels anxious during the feared social
situation and also when anticipating it. Some individuals may deal with
their fear by arranging their lives so that they do not have to be in the
feared situation. If the individual is successful at this, he or she does
not appear to be impaired. Types of discrete social phobia may include:
of public speaking—by far the most common. This seems to have a more
benign course and outcome.
of interacting socially at informal gatherings (making small talk at a
of eating or drinking in public
of writing in public
of using public washrooms (bashful bladder) Some students may only
urinate or defecate at home.
with generalized social phobia are characterized as extremely shy. They
often wish that they could be more socially active, but their anxiety
prevents this. They often have insight into their difficulties. They often
report that they have been shy most of their lives. They are sensitive to
even minor perceived social rejection. Because they become so social
isolated, they have greater academic, work and social impairment. They may
crystallize into an avoidant personality disorder.
is the third most common psychiatric disorder. (Depression—17.1%
Alcoholism—14.1% Social phobia—13.3%. (Kessler et al 1994.) Onset is
usually in childhood or adolescence. It tends to become chronic. It is
often associated with depression, substance abuse and other anxiety
disorders. The individual usually seeks treatment for one of the other
disorders. Individuals with SP alone are less likely to seek treatment
than people with no psychiatric disorder (Schneier et al 1992) Social
phobia is vastly under-diagnosed. It is not as likely to be noticed in a
classroom setting because these children are often quiet and generally do
not manifest behavior problems. Children with SP often show up with
physical complaints such as headaches and stomach aches. Parents may not
noticed the anxiety if it is specific to situations outside the home.
Additionally, since anxiety disorders often run in families, the parents
may see the behavior as normal because they are the same way themselves.
On the other hand, if the parent has some insight into his of her own
childhood anxieties, he or she may bring the child into treatment so that
the child will not have to experience the pain the parent experienced as a
There is the most evidence for cognitive-behavioral psychotherapy. Since
the child or adolescent is more dependent on his parents than an adult,
the parents should have some adjunctive family therapy.
and group therapy are useful. The basic premise is that faulty assumptions
contribute to the anxiety. The therapist helps the individual identify
these thoughts and restructure them
out automatic thoughts: “If I sound nervous when I present my paper,
my teacher and classmates will ridicule me.” The patient then
identifies his physiological and verbal responses to the thoughts.
Finally he identifies the mood associated with the thoughts.
beliefs that underlie automatic thoughts:
reasoning: “If I am nervous, then I must be performing
All or nothing: Absolute
statements that do not admit any partial success of gray areas. “I
am a failure unless I make an A.”
One unfortunate event becomes evidence that nothing will go well.
thoughts: Insisting that an unchangeable reality must change in
order for one to succeed.
Drawing unwarranted conclusions: Making connections between ideas that have no
Taking a relatively small negative event to illogically drastic
Believing that an event has special negative relationship to oneself.
(“The whole group got a bad grade because my hands trembled during
my part of the presentation”.) Selective negative focus: Only seeing
the negative parts of an event and negating any positive ones.
negative beliefs: Once the patient and therapist have identified and
characterized the negative thoughts, the therapist should help the
patient examine the lack of data supporting the beliefs and look for
other explanations of what the patient sees.
Create a hierarchy of feared situations and start to allow one to
experience them. One starts with situations that only elicit a little
anxiety and then gradually move up to more intense experiences. This must
be done in reality, not just as visualization in the office.
This can be a powerful modality for individuals with social phobia. A
patient may need to use individual therapy to prepare for group therapy.
In the group patients can encourage each other and can try out new
behaviors within the safety of the group. They can get immediate feedback
that may refute their fears. Patients should not be forced to participate
more actively than they wish.
have shown that some of the SSRI medications can be helpful in the
treatment of SP. Paroxetine (Paxil) sertraline (Zoloft) have been approved
by the FDA for treatment of SP. Other medications that may be useful
include ß blockers (propranolol, atenolol) Benzodiazepines (lorazepam,
clonazepam) buspirone, and the MAO inhibitors (Parnate, Nardil.)
MAO Inhibitors are only rarely used in children and adolescents
because one must go on dietary restrictions while taking them. SSRI and
other antidepressant medications are going to now have special
cautionary statements about the potential activation of suicidal
thoughts. However the SSRI medications are still useful if monitored
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