Social Anxiety Disorder and Social Phobia

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Authors Andrew M. Jacobs, Psy.D.

Anxiety Treatment and Research Centre, St. Joseph's Healthcare, Hamilton, Ontario, Canada



Martin M. Antony, Ph.D., ABPP

Department of Psychology, Ryerson University, Toronto, Ontario, Canada

Social anxiety is a feeling of discomfort, fear, or worry that is centered on our interactions with other people and involves a concern with being judged negatively, evaluated, or looked down upon by others. While it can often happen during the social exchange itself, it may also pop up in anticipation of a social occasion, or afterward when we review our performance in a given situation.

Quick Definitions Shyness, social anxiety, social phobia...these terms are often used interchangeably, although their meanings are often quite different and can lead to confusion and misunderstanding. The following definitions are provided to clarify how each term is used in this article. Anxiety is a feeling of uneasiness, apprehension, and/or dread about a real or imagined future event. It is tied to a sense that these unpleasant events are at least partially unpredictable and uncontrollable, and therefore accompanied by an uncomfortable level of uncertainty. Shyness is a feeling of timidity, apprehension, or discomfort in at least some social situations. This term is often used to describe a personality disposition or temporary event, and less frequently in reference to a mental health concern. Social anxiety is a feeling of uneasiness, dread, or apprehension about social interaction and presentation. Frequently, the primary concern fueling social anxiety is a concern that one will be (or is being) judged negatively by other people, regardless of whether this is actually the case. The experience of occasional, mild social anxiety is quite common, as is the experience of anxiety in general. Social anxiety can range from a relatively benign, infrequent level of severity to being a major hindrance in everyday life. Social Anxiety Disorder or Social Phobia are mental health diagnoses used to describe a level of social anxiety that is so distressing, excessive, and/or pervasive that it is significantly interfering with an individual's quality of life. The feared or avoided situations in Social Phobia can be very narrow and specific, or may extend to the majority of one's interactions with others.



What is Social Anxiety?

Because social anxiety can often seem unwieldy or even overwhelming to understand as a single concept, it is often helpful to view it in terms of three separate components that are interrelated and can strengthen one another, leading to a cycle of anxiety:

Anxious sensations in our bodies, such as:

Blushing

Sweating

Racing heart

Shaking or tremor

Dry mouth

Shortness of breath

Feeling faint

Anxious thoughts about ourselves, others, and the situation:

"Everyone is staring at me."

"They'll think I'm a loser."

"I don't belong here."

"I won't have anything to say."

"People will see how nervous I am."

"They won't want to talk to me again."

"I will keep looking more and more foolish."

Anxious behaviors, which can be triggered by anxiety, but can also make the anxiety worse over the long term:

Avoiding entering social situations

Leaving situations

Only entering "safe" places or with "safe" people

Using mobile phones, MP3 players, or other devices to avoid being in conversations

Apologizing excessively

Asking for reassurance from others

Preparing excessively (memorizing what to say, extreme grooming)

Trying to direct people's attention away from one's performance (e.g., by making jokes, dressing in a particular way, etc.)

Watching for signs that people are judging us

Social anxiety can emerge in a wide range of situations - essentially, whenever we are in contact with other people or believe we may become a focus of others' attention (Antony & Swinson, 2008). While the possibilities are infinite, the following list outlines some of the more common situations in which people experience social anxiety:

Interpersonal situations - our anxiety is triggered by our interactions with others.

Going on a date

Starting a conversation with a stranger

Asking for directions

Starting a conversation

Keeping a conversation going

Attending a party

Being interviewed for a job

Holding eye contact

Performance situations - our anxiety is triggered by potentially or actually being the focus of attention.

Public speaking

Public singing

Eating at a restaurant alone

Dropping something in a public place

Spilling a drink

Reading in front of others

Voicing an opinion during a class or meeting

Is Social Anxiety Always a Bad Thing?

No! Anxiety is a normal and healthy part of being human. It mobilizes our bodies and minds to take action in dangerous or unhealthy situations. Without anxiety, we would probably not be alive - it is what tells us to get out of the way of the bus heading right toward us or to get that 3-week-old cough looked at. Social anxiety is no different. Social anxiety helps us to remain sensitive to the feelings and needs of others, which is a core foundation of cooperation and building relationships. Even strong social anxiety can occasionally be useful; for that job interview, we'll likely do better if we're extra careful in choosing our words and our outfits.

When Does Social Anxiety Become a Problem?

Social anxiety becomes a problem only when it is so severe that it is excessive or outside the "norm," and when it causes major problems in our overall functioning and quality of life. When our social anxiety leads us to consistently avoid social situations, to be very distressed when exposed to them, to have excessive fears of being negatively judged by others, or to miss out on things that we otherwise strongly want or need to do, mental health professionals may consider a diagnosis of Social Phobia (also known as Social Anxiety Disorder) (American Psychiatric Association, 2000).

There are two subtypes of Social Phobia:

Generalized: In Generalized Social Phobia, a person fears judgment in, and avoids, most social situations.

In Generalized Social Phobia, a person fears judgment in, and avoids, most social situations. Non-generalized: In Non-generalized Social Phobia, a person is normally not excessively anxious unless they are in particular types of social situations (such as public speaking)

Do I have Social Phobia?

Maybe...or maybe not. If you find that your social anxiety is above and beyond what you would consider "normal" or appropriate and it significantly interferes with your quality of life, you may have Social Phobia. However, because social anxiety is something many of us experience from time to time, it is critical not to self-diagnose. If you think you have Social Phobia and would like this assessed, your best bet would be to consult with a mental health professional about your concerns.

What Causes Social Anxiety and Social Phobia?

In a sense, social anxiety and Social Phobia are probably caused by the same factors that are responsible for any strong human emotional experience: our genetic makeup, biological factors, and the culmination of learning experiences throughout our lives (Antony & Swinson, 2008). It is virtually impossible to single out one factor that "causes" social anxiety; rather, it is more likely to be a combination of contributing causes that come together in the right place, at the right time. Below we discuss three factors that are believed to play a role: Our genes, our brains, and our life experiences.

Our Genes: Ongoing research on the genetic foundations of physical and mental health suggests that a tendency toward anxiety, and social phobia in particular, has a moderate level of "heritability" - in other words, if your parents have Social Phobia or another anxiety disorder, you are somewhat more likely to have an anxiety disorder yourself, because of genes inherited from your parents.

Our Brains: Medications that are used to treat social phobia affect levels of neurotransmitters in the brain (neurotransmitters are chemical messengers that transmit signals from one brain cell to the next). However, the verdict is still out on whether differences in these chemicals can cause social phobia. Similarly, several studies (such as that of Blair et al., 2008) have found that certain areas of the brain, such as a small, almond-shaped area called the amygdala, can be more active in individuals with social phobia.

Our Life Experiences: Experiences in our life, and our reactions to them, can also contribute to the development of Social Phobia. If we repeatedly are put in situations where we are made to feel different, to fear the judgment of other people, or are somehow singled out in a negative way, we can understandably develop beliefs about ourselves and the world that are more consistent with social anxiety. As these experiences continue, we may also begin to selectively pay attention only to those parts of our environment that reinforce our negative beliefs - for example, a public speaker may focus on the two people in her audience who appear bored, while she may hardly notice the 38 others who are watching and nodding with great interest. As these beliefs and attention "filters" get strengthened, the tendency toward acting, feeling, and thinking in a socially anxious way becomes more automatic. After a while, these beliefs can also lead us to make unhelpful assumptions in otherwise neutral situations. If a person glances at us on the sidewalk, we may automatically assume that he thinks we look strange or have an odd walk. We might not even consider the possibility that he appreciated our making way for him to get past, or that he simply likes to make eye contact with everyone he encounters. Naturally, if we believe most social situations are going to go poorly or create a great deal of discomfort, we are going to avoid them. The catch here is that while we are successful in temporarily escaping our unpleasant feelings of anxiety, we also confirm our beliefs that we are unable to handle social situations. At the same time, we miss chances to find out that our negative assumptions may not always be correct. As another illustration, a person who enjoys singing but fears the judgment of others will never find out he has an excellent voice if he continually avoids singing in public. Avoiding more and more situations for fear of evaluation will strengthen our negative biases and beliefs and prevent us from going into an increasing number of situations where we might otherwise want or need to go. As this pattern starts to interfere with our overall functioning, the warning signs of Social Phobia can become more apparent.

How Common is Social Phobia?

Quite common. While the exact prevalence of Social Phobia remains to be determined, a recent survey of approximately 9,000 Americans suggested that approximately 12% of the general public will experience social anxiety to a clinically significant, diagnosable degree at some point during their lives (Kessler, Berglund, Demler, Jin, & Walters, 2005).

What Types of Professionals Can Assess and Treat Social Anxiety?

Psychologists

Psychologists have completed doctoral training (usually indicated by a Ph.D. or Psy.D.) in both the research and clinical service delivery aspects of mental health, and have met the licensure requirements of their state or province. In addition to studying the applied, treatment-oriented aspects of disorders such as Social Phobia, psychologists also complete a great deal of study on our basic psychological makeup, including factors in emotional development, theories of personality, family functioning, and social influences on mental health. This background and preparation of psychologists makes them especially well suited to provide thorough assessment and psychotherapy services for individuals with Social Phobia. Because they do not usually have medical training, psychologists are not able to prescribe medications (although in a few states, psychologists with additional training in pharmacology are able to do so).

Psychiatrists

Psychiatrists are physicians who have completed specialty training in mental health after completing their MD (Doctor of Medicine) or DO (Doctor of Osteopathy) degrees. Because of their medical background, psychiatrists are often especially skilled at considering the physical aspects of anxiety disorders and prescribing appropriate medication treatments where needed. While psychiatric training programs often focus on psychopharmacology (treatment using psychiatric drugs), many also have training in providing psychotherapy (including cognitive-behavioral therapy).

Clinical Social Workers

Clinical social workers have completed graduate (usually MSW - Master of Social Work) training in mental health. While clinical social workers can provide psychotherapy and some assessments, many also have particular knowledge and skill in helping individuals from a social and community perspective - for example, connecting clients with needed social assistance programs or working with families in need of help.

Other Professionals

Other professionals may also be able to help you in coping with Social Phobia. These individuals can include your general practice physician, professional counselors, psychiatric nurses and nurse practitioners, and members of the clergy. As with any professional (including psychologists, psychiatrists, and clinical social workers), it is important to assess whether the practitioner is experienced in treating anxiety problems using evidence based approaches - especially cognitive-behavioral treatments and medications, each of which are discussed in the next section.

What Sorts of Treatments are Available for Social Anxiety?

Although there are dozens of treatments that have been claimed to be useful for anxiety-based problems, only a small number of these have actually been found to be effective in systematic scientific studies based on individuals suffering with Social Phobia. These include medication treatments, cognitive-behavioral therapy, and combinations of these approaches.

Medications

Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs are currently among the most popular medications used in treating Social Phobia. They have been demonstrated as effective in several studies, and they have relatively few major side effects. Commonly used SSRIs are listed below. Although most of these have been found to be effective treatments for social phobia, only two are officially approved by the US Food and Drug Administration (FDA) for the treatment of social phobia (paroxetine, sertraline).

Citalopram (Celexa)

Escitalopram (Lexapro, Cipralex)

Fluoxetine (Prozac)

Fluvoxamine (Luvox)

Paroxetine (Paxil)

Sertraline (Zoloft)

Serotonin and Norepinephrine Reuptake Inhibitors (SNRIs): SNRIs act on two brain chemicals, rather than just serotonin like the SSRIs. They are often used for Social Phobia in a similar way to the SSRI medications. Two SNRIs (listed below) are currently on the market, though only venlafaxine-XR has been studied as a treatment for Social Phobia.

Duloxetine (Cymbalta)

Venlafaxine-XR (Effexor-XR)

Benzodiazepines: Benzodiazepines are very effective at lowering anxiety levels quickly, which led to their being very commonly used for several decades. However, they also have a number of significant side effects and can be addictive. Because of this, SSRI medications are now more commonly used for long-term management; however, benzodiazepines may still be appropriate, particularly for short term use. This category includes several familiar medications, though clonazapam and alprazolam are the two that have been studied most in the treatment of Social Phobia. Benzodiazepines that are often used to treat anxiety problems include:

Alprazolam (Xanax)

Clonazepam (Klonopin, Rivotril)

Diazepam (Valium)

Lorazepam (Ativan)

Beta-Blockers: Beta-blocker medications such as propanolol (Inderal) can be used to lower the physical symptoms of social anxiety, such as shaking, sweating, and racing heart. Because of this, they are commonly used for anxiety in performance situations such as public speaking or performing music. They do not usually have significant effects on anxious thoughts or anxious behaviors. Nor are they an effective treatment for generalized Social Phobia.

Monoamine Oxidase Inhibitors (MAOIs): MAOIs are another type of medication that is occasionally used to treat Social Phobia. One MAOI in particular, phenelzine (Nardil), has shown strong effectiveness in treating the disorder. Unfortunately, the MAOI medications also have a number of significant side effects and require a strict diet that eliminates several common foods to avoid life-threatening reactions. As a result, MAOIs are relatively uncommon as a treatment for Social Phobia.

Cognitive-Behavioral Therapy

The most effective psychological treatment for Social Phobia currently available is called cognitive behavioral therapy, or CBT. Numerous research trials have demonstrated a clear advantage for CBT, and the treatment is now widely accepted as a first choice treatment for Social Phobia. While the specific ways in which CBT for Social Phobia can be administered may vary somewhat between therapists, a number of features distinguish this approach from other commonly used psychotherapies:

CBT is collaborative - the client and therapist work together as a team. The therapist does not simply tell you what to do or think. Together, you and your therapist develop strategies for overcoming anxiety.

- the client and therapist work together as a team. The therapist does not simply tell you what to do or think. Together, you and your therapist develop strategies for overcoming anxiety. CBT includes a focus on developing new skills . You will learn several strategies for counteracting Social Phobia.

. You will learn several strategies for counteracting Social Phobia. CBT is brief and time-limited . You and the therapist will set specific goals and remain focused on these goals throughout treatment, which generally lasts 12 to 16 sessions. The ultimate aim is to assist you in becoming your own "therapist."

and . You and the therapist will set specific goals and remain focused on these goals throughout treatment, which generally lasts 12 to 16 sessions. The ultimate aim is to assist you in becoming your own "therapist." CBT is focused on the present . While a CBT therapist is likely to agree that the roots of Social Phobia may be due, in part, to experiences during childhood, the emphasis of treatment is on uncovering the current cognitive and behavioral patterns that are maintaining symptoms and on making changes in your present life.

. While a CBT therapist is likely to agree that the roots of Social Phobia may be due, in part, to experiences during childhood, the emphasis of treatment is on uncovering the cognitive and behavioral patterns that are maintaining symptoms and on making changes in your present life. CBT is structured . Each session, as well as the overall course of treatment, has specific objectives and agendas that you develop in cooperation with your therapist.

. Each session, as well as the overall course of treatment, has specific objectives and agendas that you develop in cooperation with your therapist. CBT emphasizes between-session exercises (often referred to as homework ) that you complete on your own. These tasks are planned with your therapist and are intended to provide you with actual, "real-life" experience working with new ways of thinking and behaving.

) that you complete on your own. These tasks are planned with your therapist and are intended to provide you with actual, "real-life" experience working with new ways of thinking and behaving. CBT is research-based. The strategies used in CBT to address symptoms of Social Phobia have been subjected to numerous clinical studies and have been shown to be effective.

Cognitive behavioral treatment draws on a number of therapeutic strategies when addressing Social Phobia. While the specific approaches used may vary based on your symptoms, your therapist, and the setting in which you are being treated, CBT for Social Phobia often includes many of the following components:

Psychoeducation: Perhaps one of the most difficult aspects of coping with Social Phobia is simply understanding what it is, where it came from, why it's so hard to change, and how it keeps coming back with a vengeance. Psychoeducation involves you and your therapist working together to develop a better way to understand your Social Phobia, and subsequently, how to work with it.

Cognitive Restructuring: As discussed earlier, individuals with Social Phobia frequently hold negative beliefs about themselves and others, which often show up as unhelpful thoughts in social situations. Cognitive restructuring is an important component of CBT, and it involves working with your therapist to identify these thoughts and look for patterns within them. As you become skilled at noticing these thoughts, you then develop strategies for gaining flexibility in your thinking and considering more helpful ways of looking at your experiences.

In Vivo Exposure: In vivo (real life) exposure is another core element of CBT for Social Phobia. You and the therapist identify situations that you avoid because of Social Phobia, and then gradually enter these situations while accepting your anxiety and allowing it to naturally dissipate. While this step probably sounds quite intimidating, it is important to know that exposure is done at a very gradual, planned pace, and that your therapist will support you throughout the process. Many clients report exposure practices as being among the most useful elements in their treatment.

Interoceptive Exposure: Some individuals with Social Phobia are fearful not only of social situations, but also of the anxious physical sensations (such as blushing, shaking, sweating, etc.) that can accompany them. Interoceptive exposure practices deliberately bring about these sensations through such activities as wearing a warm sweater to induce sweating in social situations. Just as exposure to feared situations leads to reductions in situational fear, exposure to feared sensations will lead to a reduction in anxiety over experiencing these feelings in social situations.

Social Skills Training: In the midst of a tense social situation, many people with Social Phobia fear that they do not have the necessary social skills to successfully navigate the exchange. While this may be due to negative self-talk and self-consciousness (rather than an actual lack of skill), many people find it helpful to discuss such topics as carrying on conversations, being assertive, and effective listening. Social skills training provides a chance to work on these areas in therapy.

Can I Do Anything About My Social Anxiety On My Own?

Yes! As mentioned earlier, learning to become your own therapist is one of the primary goals of CBT. While it is often most helpful to work through these strategies with the help of a psychotherapist, many people are able to achieve significant gains using self-guided therapy manuals. One such book, The Shyness and Social Anxiety Workbook: Proven Step-by-Step Techniques for Overcoming Your Fear by Martin M. Antony, Ph.D., and Richard Swinson, M.D., has recently been demonstrated to be an effective treatment for individuals with mild to moderate Social Phobia (Abramowitz, Moore, Braddock, & Harrington, 2009). This and other CBT-based books are designed to teach people evidence-based cognitive and behavioral strategies for making gains on their own. Examples of recommended readings are provided below.

Where Else Can I Find Help and Resources for Social Phobia?

The following professional associations have comprehensive websites that provide information, resources, and contact information that may assist your efforts in working with Social Phobia. Some also provide referrals to professionals who can work with this problem.

Academy of Cognitive Therapy (http://www.academyofct.org)

American Psychological Association (http://www.apa.org)

Anxiety Disorders Association of America (http://www.adaa.org)

Anxiety Disorders Association of Canada (http://www.anxietycanada.ca)

Association for Behavioral and Cognitive Therapies (http://www.abct.org)

Canadian Psychological Association (http://www.cpa.ca)

Recommended Readings for Consumers

Recommended Readings for Professionals

Recommended Videos

About the Authors

Andrew M. Jacobs, Psy.D.

Dr. Jacobs is a psychologist in the Anxiety Treatment and Research Centre at St. Joseph's Healthcare in Hamilton, Ontario, Canada. His professional interests focus on interpersonal and motivational factors in cognitive behavioral therapy for anxiety and mood disorders, cultural minority considerations in psychotherapy, and the dissemination of empirically-based psychological knowledge to the general public.

Martin M. Antony, Ph.D., ABPP

Dr. Antony is Professor and Director of Graduate Training in the Department of Psychology at Ryerson University in Toronto, Ontario, Canada. He is also President-Elect of the Canadian Psychological Association. He has published more than 25 books and over 150 scientific articles and book chapters, mostly on the topics of anxiety disorders and cognitive behavioral treatment. His website can be found at www.martinantony.com.

References

Abramowitz, 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 and Experimental Psychiatry, 40, 98-105.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., Text Revision). Washington, DC: Author.

Antony, M. M., & Swinson, R. P. (2008). The shyness and social anxiety workbook: Proven, step-by-step techniques for overcoming your fear (2nd ed.). Oakland, CA: New Harbinger Publications.

Blair, K., Shaywitz, J., Smith, B. W., Rhodes, R., Geraci, M. R. N., Jones, M., et al. (2008). Response to emotional expressions in generalized social phobia and generalized anxiety disorder: Evidence for separate disorders. American Journal of Psychiatry, 165, 1193-1202.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.