Social Phobia

This is a lightly edited reprint of a brief paper I submitted to a graduate course several years ago.  The information is still current.  I am adding it to my blog to assist anyone
suffering from Social Phobia to better understand their problem and the treatments available for it.

A friend who is an accomplished speaker once admitted to an audience that he had a problem that regularly caused him embarrassment and discomfort.  He had a fear of ordering from a menu in a restaurant when he was with a group of people.  He didn’t have any problem ordering from a menu when he was alone.  He wasn’t bothered by the waiter or waitress.  It was his fear of what the people with him at the table might think of his food choices and manner of ordering.  He regularly managed the problem by waiting until someone else ordered, and then saying, “I’ll have the same, please.”

This man suffers from a social phobia.  He is distressed by the fear of what others might think about his performance in a social situation.  “Social phobia, also called social anxiety disorder, is diagnosed when people become overwhelmingly anxious and excessively self-conscious in everyday social situations” (NIMH, 2009).  Social phobia is a strong fear of being judged by others, and becomes a disorder when it interferes with everyday life (NIMH, 2008).

Social phobia is one type of phobia.  Phobias are a subset of anxiety disorders.  Although at least 275 types of phobias have been identified, the DSM-IV-TR only lists three:  agoraphobia, specific phobia, and social phobia (Maxmen, Ward, & Kilgus, 2009). About fifteen million American adults suffer from social phobia (Kessler, et.al., 2005). The lifetime prevalence is between three percent and thirteen percent of the American adult
population (Ingersol and Burns, 2001).  Social phobia affects men and women equally (Bourdon, et. al., 1998).  People suffering social phobia may experience physical symptoms such as blushing, heavy sweating, trembling, nausea, and difficulty walking (NIMH, 2008).

Social phobia can be treated with medication and/or therapy.  Drugs that have efficacy for treating social phobias include escitalopram, fluvoxamine, paroxetine, sertraline, and venlafaxine (Hansen, et. al., 2008).  In addition to antidepressants, anti-anxiety
medications and beta blockers are also useful (NIMH, 2008).  The most common therapies for social phobia are social skills training (SST), relaxation techniques, exposure-based methods, and multicomponent cognitive-behavioral treatments (Barlow, Esler, and
Vitali, 1998).

The DSM IV (Diagnostic and Statistics Manual, fourth edition) defines social phobia as a marked or persistent fear of social situations where embarrassment may occur (APA, 2000, p. 450).

Diagnostic Criteria for Social Phobia (APA, 2000, p. 456):

A. A marked or 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 are 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 physiological 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.

“Essential in the treatment of phobias is exposing patients to the feared object or situation for an uninterrupted period of time” (Maxmen, Ward, & Kilgus, 2009, p. 396).  The objective of therapy is to motivate and enable the client to immerse self in the feared social situation and experience a sense of control over self, both emotional and behavioral.  The medications prescribed are to enable the person to endure the physical and emotional reactions to their fear.  The counselor helps the person to find healthier ways of thinking about the feared situations, as well as to discover and practice successful ways of acting in the situation.

Cognitive-behavioral therapy (CBT) has been shown to be effective with anxiety disorders, including social phobia (NIMH, 2009).  An example of a treatment method for social phobia using CBT is to lead the client through the thought process of imagining their feared situation occurring.  The feared outcome is explored.  The client is asked to imagine being one of the other social interactors.  The question is posed, “How would you feel if you witnessed someone else experiencing what you fear?”  After the client becomes adept at imagining self failing in the social situation and the consequences being less than feared, the person is led to actively engage in a similar situation with trusted people and intentionally fail.  The outcome is reported back to the therapist.  From that point, the person is encouraged to fail again and survive the experience.  Eventually, the person is able to perform ably despite their continued fear of the situation.

At this time, a cure for social phobia is not available.  But social phobia ceases to be a disorder when the person learns to continue their life in normal ways despite their fear.

If my friend referred to at the beginning of this article were to seek therapy, the following outcome might occur.  The person could describe the fear in detail to the therapist.  All
aspects of the possible outcomes of ordering from a menu in a public restaurant in the midst of peers would be explored.  The client would visualize their worst fear occurring, and then explore the most likely results.  The client would be led to imagine self as an observer of this failure, and describe in detail the feelings concerning the person experiencing the social embarrassment.  The client might be asked to recall the most embarrassing event that occurred concerning the social fear.  Then, the client and the therapist together would design an experiment with safe people (such as close friends or
trusted family members).  The client would intentionally fail during the ordering process in a restaurant in the way most feared.  After the failure, the client would pay close attention to the behavior of the people around.  This experience would be described in detail to the counselor, after the fact.  Then the client would be challenged to again intentionally fail during the ordering process, but with a group of people considered less safe.  Again, the client would be instructed to observe the reactions of these people to the social failure.  After lowering the fear of failure, the final sessions of counseling would center on success strategies for ordering in a variety of public situations.  The client
would be sent forth to succeed and report back to the therapist.  Associated methods of treatment might also include relaxation techniques and visualizing success.  The client would still have the fear, but it would be manageable and not limiting to normal life.

Social phobia is a common problem in American society.  Between three and thirteen percent of the population will find their life limited by the phobia at some point.  There is no cure at present, but there are effective therapies that allow the sufferers to regain control of their life.

References

APA, (2000).  Diagnostic and Statistical Manual of Mental Disorders IV-TR.  Washington:   American Psychiatric Association.

Barlow, D. H., Esler, J. L., & Vitali, A. E.  (1998).  Psychosocial treatments for panic disorders,   phobias, and generalized anxiety disorder.  In P. E. Nathan and J. M. Gorman, Ed.s. A   guide to treatments that work, 288-318. New York: Oxford.

Bourdon, K. H., Boyd, J. H., Rae, D. S., et.al. (1998).  Gender differences in phobias:  Results of  the ECA community survey.  Journal of Anxiety Disorders, 2, 227-241.  [Referenced in NIMH, 2009, Anxiety disorders, p. 10.].

Hansen, R. A., Gaynes, B. N., Gartlehner, G., Moore, C. G., Tiwari, R., & Lohr, K. N.
(2008).    Efficacy and tolerability of second-generation antidepressants in
social anxiety disorder.  International Clinical Psychopharmacology, 23 (3), 170-9.

Ingersol, R. E., & Burns, L. (2001).  Prevalence of adult disorders.  In E. R. Welfel & R. E. Ingersol, Ed.s, The Mental Health Desk Reference, 3-10.  New   York:  Wiley.

Kessler, R. C., Chiu, W. T., Demler, O., & Walters, E. E.  (2005).  Prevalence, severity, and comorbidity of twelve month DSM-IV disorders in the National Comorbidity Survey Replication (NCS-R).  Archives of General Psychiatry, 62 (6), 617-627.

Maxmen, J. S., Ward, N. G., & Kilgus, M.  (2009).  Essential psychopathology and its
treatment  
(3rd ed.).  New   York:  Norton.

NIMH.  (2008).  Social phobia:  (Social anxiety disorder).  National Institute of Mental Health,    United States Department of Health and Human Services, NIH publication No. 08-4678.

NIMH.  (2009). Anxiety disorders.  National Institute of Mental Health, United States      Department of Health and Human Services, NIH publication No. 09-3879.

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