8/12/2019 15. Social Phobia and Specific Phobias

1/3

8/12/2019 15. Social Phobia and Specific Phobias

2/3

Social Phobia and SpecificPhobias 84. What is social phobia?Social pho bia is a form of phobia-distinct from specific phobias-in which an individual hasan excessive and persistent fear of a given social situation where they might b e exposed to thescrutiny of o thers. Th e exposure to, or anticipation of, the feared situation causes a marked anxiety

response, and the individual either avoids those situations or endu res them with significant discom-fort. The person usually recognizes that the fear is excessive. Avoidance attempts and/or the anxietydisrupts social or occupational functioning.When there is only on e situation that is feared, the person is considered to have a specific socialphobia. The most well-known specific social phobia is perform ance anxiety-the fea r of publicspeaking. When more than one situation is feared, it is called generalized social phobia.People withgeneralized social phob ia tend to be more disabled, as almost all social settings and interpersonal con-tacts elicit anxiety and avoidance. Someone with a specific social phob ia may be ab le to structure hisor her life in such a way as to avoid or limit exposure to the particular situation that causes anxiety.The most comm on fears seen in social phobia include speaking before a group or being the centerof attention, eating in public, writing in pu blic, and using public lavatories. For many people, the fear ofscrutiny and anx iety is the result of a physical condition such as a tremor, Tourettes syndrom e, scarring,obesity, or physical deformity. In these situations, however, the individual is not considered to havesocial phobia (as his or her assessmen t of being negatively scrutinized by o thers may w ell be accurate).5 How common a problem is social phobia?Social phobia is now known to be on e of the mo st comm on psychiatric disorders in the generalpopu lation. Epidem iologic researchers have found that there is a 13.3 lifetime prevalence of socialphobia, with a higher prevalence existing in women (15.5 ) than in men (1 1.1 ). Unfortunately, i tis estimated that only 2 of the people with so cial phobia actually seek treatment fo r it . Manypeop le end up stru cturing their lives to avoid whatever situation triggers their anxiety. Th is may

work for s om e people with specific social phobias, but for those individuals with generalized socialphobia, their ability to lead a full life often is significantly impaired.Alcohol comm only is utilized in an attempt to d ecrease the anxiety and allow the individual totolerate the feared social situation. In approximately 85 of the people with both social phobia andalcohol abuse, the social phobia precedes the alco hol problem.6. What are the cognitive processes involved in social phobia?People with social phobia tend to overestimate their own symptoms of anxiety-for instance, ifthey are feeling anxious and flushed, they m ay assume that they are beet red. They also misinterpretthe responses of others in negative w ays. They overestimate the degree to which other peop le are

paying attention to them , and the likelihood that they w ill be embarrassed o r rejected. Finally, theytend to overemphasize any perceived or actual failures, while discounting their achievements andpositive feedb ack.7. What other conditions might be confused with social phobia?The differential diagnosis for social phobia includes agoraphobia, panic disorder, generalizedanxiety disorder, depression, body d ysmorphic disorder, avoidant or schizoid personality disorders,and nonpathological shyness.8. Can medications help in social phobia?

Absolutely. For individuals with specific social phobia, such as perform ance anxiety, P blockers (e.g., propranolol) can be beneficial. These drugs target the physiologic symptoms of anxiety(such as increased heart rate) rather than the em otional experience. T his ends up having an indirecteffect on the cognitive com ponent of the anxiety-as the physiolog ic feedback to the cognitiveaspect of the anxiety is blocked. Benzodiazepines(e.g., alprazolam, lorazepam, clonazepam) alsoare effective in these individuals and can be used on an as-needed basis. For those peop le with gen-eralized social phobia, both monoamine oxidase inhibitors (e.g., phenelzine, tranylcypramine) andserotonin specific reuptake inhibitors (e.g., paroxetine, sertraline, fluoxetine) can be effective

8/12/2019 15. Social Phobia and Specific Phobias

3/3

82 Gen eralized Anxiety Disordertreatments. The use of these antide press ants also has the benefit of treating comorbid depressionwhen it occurs.Other medications that are showing som e promise in treating social phobia include venlafax-ine (which inhibi ts the reuptake of both serotonin and norepinephrine) and gabapentin (whichworks at the GABA receptor co m ple x). Tricyclic antidepressants, however, have not been shownto be efficacious.9. Are there other types of treatment for social phobia?An im portant form of treatment for social phobia is cognitive behavioral therapy (CBT). Thistype of therapy involves cognitive restructuring by helping the individual with social phobia identifyhis or her cognitive distortions and challenge the accuracy of their perceptions. They also learn howto decrease their physiolog ic response of anxiety with various techn iques including deep-breathingand progressive muscle relaxation. Graded e xposure to the feared situation also is employed as theylearn to tolerate increasingly greater exposure to the feared situation. Eventually, the anxious re-sponse is extinguished.

Group CBT also is helpful in the treatment of social phobia. This form of treatment includessocial skills training and role-playing, and allows individuals to get direct, immediate feedback ontheir perceptions of how othe rs view them.BIBLIOGRAPHY

1 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed.Washington, DC, American Psychiatric Association, 1994.2. Goisman RM, Allsworth J Rog ers MP, et al: Simple phobia as a com orbid anxiety disorder. Depress Anxiety7(3):105-112, 1998.3. Heimberg RG, Juster HR: Treatment of social phobia in cognitive-behavioral groups. J Clin PsychiatryS5(Suppl):3846, 1994.4 Jefferson JW: Socia l phob ia: pharm acolog ic treatment overview. J Clin Psychiatry 56(Suppl 5): 18-24,199s.

5 Keck PE , McElroy SL New uses for antidepressants: Social phobia. J Clin Psychiatry 58(Suppl 14):32-38,1997.6. Kessler RC, M cGonagle KA, Zhoa S et al: Lifetime and 12-month prevalence of DSM-111-R psychiatric disor-ders in the U nited States: Results from the National Co morbidity Survey. Arch Gen Psychiatry51 :8-19, 1994.7. Schneier FR, Johnson J, Hornig CD , et al: Social phobia: Comorbidity and morbidity in an epidemiologicsample. Arch Gen Psychiatry 49:282-288, 1992.

16. GENERALIZED ANXIETY DISOR DERRobert D Davies, M . D . , and Leslie Winter, M . D

1. What is generalized anxiety disorder?Anxiety and worry are commo nly exp erienced responses to the stress of day-to-day life. We allworry at times about various aspects of our lives-particularly the unknown o r novel. Th is is ab-solutely normal. However, when worry and anxiety are the predominate approach to life, it is notnormal. People with generalized anxiety disorder (G AD ) experience excessive levels of anxietyand w orry most of the time and have great difficulty controlling their worry. Th e excessive level ofanxiety they experience causes significant distress and often impairs their ability to function in var-ious areas of their life (such as socially or occupationally). Many people with GA D become p reoc-cup ied with the physical sym ptom s associated with anxiety (such as gastrointestinal distress andfatigu e) and worry a bou t their health. Th is worry may lead them to repeatedly seek out medicalevaluations and reassurance. Thus, GA D typically is seen in primary care settings rather than i nmental health settings.