Social anxiety disorder (DSM-IV 300.23), also known as social anxiety or social phobia is a diagnosis within psychiatry and other mental health professions referring to excessive social anxiety (anxiety in social situations) causing considerable distress and impaired ability to function in at least some areas of daily life. The diagnosis can be of a specific disorder (when only some particular situations are feared) or a generalized disorder. Generalized social anxiety disorder typically involves a persistent, intense, and chronic fear of being judged by others and of potentially being embarrassed or humiliated by one's own actions. These fears can be triggered by perceived or actual scrutiny by others. While the fear of social interaction may be recognized by the person as excessive or unreasonable, considerable difficulty can be encountered overcoming it. Approximately 13.3 percent of the general population may meet criteria for social anxiety disorder at some point in their lifetime, according to the highest survey estimate, with the male to female ratio being 1:1.5.
Physical symptoms often accompanying social anxiety disorder include excessive blushing, sweating (hyperhidrosis), trembling, palpitations, nausea, and stammering and in some extreme cases sialorrhea. Panic attacks may also occur under intense fear and discomfort. An early diagnosis may help in minimizing the symptoms and the development of additional problems such as depression. Some sufferers may use alcohol or other drugs to reduce fears and inhibitions at social events. It is very common for sufferers of social phobia to self-medicate in this fashion, especially if they are undiagnosed and/or untreated. This can lead to alcoholism or other kinds of substance abuse.
A person with the disorder may be treated with psychotherapy, medication, or both. Research has shown cognitive behavior therapy, whether individually or in a group, to be effective in treating social phobia. The cognitive and behavioral components seek to change thought patterns and physical reactions to anxiety-inducing situations. Prescribed medications include several classes of antidepressants: selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs). Other commonly used medications include beta-blockers and benzodiazepines, as well as newer antidepressants such as mirtazapine. A herb called kava has also attracted attention as a possible treatment, although safety concerns exist, especially given the unregulated nature of herbs in the United States.
Attention given to social anxiety disorder has significantly increased in the United States since 1999 with the approval and marketing of drugs for its treatment.
History
Literary descriptions of shyness can be traced back to the days of Hippocrates around 400 B.C. Hippocrates described someone who 'through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him'.
Charles Darwin wrote about the physiology and social context of blushing and shyness. The first mention of a psychiatric term, social phobia ("phobie des situations sociales"), was made in the early 1900s. Psychologists used the term "social neurosis" to describe extremely shy patients in the 1930s. After extensive work by Joseph Wolpe on systematic desensitization, research in phobias and their treatment grew. The idea that social phobia was a separate entity from other phobias came from the British psychiatrist Isaac Marks, in the 1960s. This was accepted by the American Psychiatric Association and was first officially included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. The definition of the phobia was revised in 1989 to allow comorbidity with avoidant personality disorder, and introduced generalized social phobia. Social phobia had been largely ignored prior to 1985.
After a call to action by psychiatrist Michael Liebowitz and clinical psychologist Richard Heimberg, there was an increase in attention to and research on the disorder. The DSM-IV gave social phobia the alternative name Social Anxiety Disorder. Research on the psychology and sociology of everyday social anxiety continued. Cognitive Behavioural models and therapies were developed for social anxiety disorder. In the 1990s, paroxetine became the first prescription drug in the U.S. approved to treat social anxiety disorder, with others following.
Social phobia in many cases can be an extremely debilitating disorder, especially because one who struggles with it often suffers alone.
Diagnostic Criteria
According to the DSM-IV-TR, to be diagnosed with Social Phobia all these criteria (A-H) must be met:
A. A marked and persistent fear of one or more social 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 social or performance situation almost invariably provokes an immediate anxiety response. This response may take the form of a situationally bound or situationally people 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 their fear is excessive or unreasonable. Note : In children, this feature may be absent.
D. The social or performance situation is avoided, although it is sometimes endured with dread (intense anxiety or distress).
E. The avoidance, anxious anticipation of, or distress in, the feared social or performance situation interferes significantly with the person's normal routine, occupational (academic) functioning, social life, or if the person is markedly distressed 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 or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder, 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 or the avoidance in Criterion D, 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).
Specify if :
Generalized : if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder).Symptoms
Cognitive aspects
In cognitive models of Social Anxiety Disorder, social phobics experience dread over how they will be presented to others. They may be overly self-conscious, pay high self-attention after the activity, or have high performance standards for themselves. According to the social psychology theory of self-presentation, a sufferer attempts to create a well-mannered impression on others but believes he or she is unable to do so. Many times, prior to the potentially anxiety-provoking social situation, sufferers may deliberately go over what could go wrong and how to deal with each unexpected case. After the event, they may have the perception they performed unsatisfactorily. Consequently, they will review anything that may have possibly been abnormal or embarrassing. These thoughts do not just terminate soon after the encounter, but may extend for weeks or longer. Those with social phobia tend to interpret neutral or ambiguous conversations with a negative outlook and many studies suggest that socially anxious individuals remember more negative memories than those less distressed.
An example of an instance may be that of an employee presenting to his co-workers. During the presentation, the person may stutter a word, upon which he or she may worry that other people significantly noticed and think that their perceptions of him or her as a presenter have been tarnished. This cognitive thought propels further anxiety which compounds with further stuttering, sweating, and, potentially, a panic attack.
Behavioral aspects
Social anxiety disorder is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that he or she may do something or act in a way that will be humiliating or embarrassing. It exceeds normal "shyness" as it leads to excessive social avoidance and substantial social or occupational impairment. Feared activities may include almost any type of social interaction, especially small groups, dating, parties, talking to strangers, restaurants, etc. Possible physical symptoms include "mind going blank", fast heartbeat, blushing, stomach ache, nausea and gagging. Cognitive distortions are a hallmark, and learned about in CBT (
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