Social Phobia and Shyness

Social phobia

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.

 

An anxious

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.

 

The individual

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:

  • Fear

    of public speaking—by far the most common. This seems to have a more

    benign course and outcome.

  • Fear

    of interacting socially at informal gatherings (making small talk at a

    party)

  • Fear

    of eating or drinking in public

  • Fear

    of writing in public

  • Fear

    of using public washrooms (bashful bladder) Some students may only

    urinate or defecate at home.

 

Individuals

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.

 

Social phobia

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

child.

 

Treatment: 

Psychotherapy:

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.

 

Both individual

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

  • Identifying

    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.

  • Irrational

    beliefs that underlie automatic thoughts: 

    Emotional

    reasoning: “If I am nervous, then I must be performing

    terribly.”  

    All or nothing: Absolute

    statements that do not admit any partial success of gray areas. “I

    am a failure unless I make an A.” 

    Overgeneralization:

    One unfortunate event becomes evidence that nothing will go well. 

    Should

    thoughts: Insisting that an unchangeable reality must change in

    order for one to succeed. 

    Drawing unwarranted conclusions: Making connections between ideas that have no

    logical connection. 

    Catastrophizing:

    Taking a relatively small negative event to illogically drastic

    hypothetical conclusions. 

    Personalization:

    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.

  • Challenge

    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.

Exposure:

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.

 

Group therapy:

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.

 

Medication

Treatment: 

Recent studies

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

carefully.  

References: 

Kessler R.C.

McGonagle, K.A. Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen,

H.U., and Kendler, K.S.(1994) Lifetime and 12-month prevalence of

DSM-III-R psychiatric disorders in the United States. Results from the

National Comorbidity Survey. Archives of General Psychiatry, 51,

8-19. 

Kessler, R.C.,

Stein, M.B., Berglund, P. (1998) Social Phobia Subtypes in the National

Comorbidity Survey. American Journal of Psychiatry, 155:5. 

Murray, B.,

Chartier, M.J., Hazen, A.L., Kozak, M.V.Tancer, M.E., Lander, S., Furer,

P., Chutbaty, D., Walker, J.R.  A

Direct Interview Family Study of Generalized Social Phobia. American

Journal of Psychiatry, (1998) 155: 1. 

Pollack, M.H.,

Otto, M.W.Sabatino, S., Majcher, D., Worthington, J.J. McArdle, E.T.,

Rosenbaum, J.F. Relationship of Childhood Anxiety to Adult Panic Disorder:

Correlates and Influence on Course. American Journal of Psychiatry. 153:

3.  

Schneier, F.R.,

Johnson, J., Hornig, C.., Liebowitz, M.R. and Weissman, M.M. (1992) Social

Phobia: Comorbidity and morbidity in a epidemiologic sample. Archives

of General Psychiatry, 49, 282-288.


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