Social anxiety disorder (social phobia)

[David Baxter PhD]

Social anxiety disorder (social phobia)
Mayo Clinic
Aug. 28, 2009

It's normal to feel nervous in some social situations. Going on a date or giving a presentation may give you that feeling of having butterflies in your stomach, for instance. This isn't social anxiety disorder.

In social anxiety disorder, everyday interactions cause extreme fear and self-consciousness. It may become impossible for you to eat with acquaintances or write a check in public, let alone go to a party with lots of strangers. If your life is disrupted by this kind of fear, you may have social anxiety disorder.

If you or a loved one has social anxiety disorder, take heart. Effective treatment — often with cognitive behavioral therapy, medication and positive coping skills — can improve the symptoms of social anxiety disorder and open up new opportunities.

Symptoms
Social anxiety disorder is a chronic mental health condition that causes an irrational anxiety or fear of activities or situations in which you believe that others are watching you or judging you. You also fear that you'll embarrass or humiliate yourself.

Social anxiety disorder can have emotional, behavioral and physical signs and symptoms.

Emotional and behavioral signs and symptoms of social anxiety disorder include:

• Intense fear of being in situations in which you don't know people
• Fear of situations in which you may be judged
• Worrying about embarrassing or humiliating yourself
• Fear that others will notice that you look anxious
• Anxiety that disrupts your daily routine, work, school or other activities
• Avoiding doing things or speaking to people out of fear of embarrassment
• Avoiding situations where you might be the center of attention

Physical signs and symptoms of social anxiety disorder include:

• Blushing
• Profuse sweating
• Trembling or shaking
• Nausea
• Stomach upset
• Difficulty talking
• Shaky voice
• Muscle tension
• Confusion
• Palpitations
• Diarrhea
• Cold, clammy hands
• Difficulty making eye contact

You may also be affected by:

• Low self-esteem
• Trouble being assertive
• Negative self-talk
• Hypersensitivity to criticism
• Poor social skills

Worrying about having symptoms
When you have social anxiety disorder, you realize that your anxiety or fear is out of proportion to the situation. Yet you're so worried about developing social anxiety disorder symptoms that you avoid situations that may trigger them. And indeed, just worrying about having any symptoms can cause them or make them worse.

When to see a doctor
If your fears or anxieties don't really bother you, you may not need treatment. For instance, you may not like making speeches but you do so anyway without being overwhelmed by anxiety.

What sets social anxiety disorder apart from everyday nervousness is that its symptoms are much more severe and last much longer. If social anxiety disorder disrupts your life, causes you distress and affects your daily activities, call your doctor.

Common, everyday experiences that may be difficult to endure when you have social anxiety disorder include:

• Using a public restroom or telephone
• Returning items to a store
• Interacting with strangers
• Writing in front of others
• Making eye contact
• Entering a room in which people are already seated
• Ordering food in a restaurant
• Being introduced to strangers
• Initiating conversations

Social anxiety disorder symptoms can change over time. They may flare up if you're facing a lot of stress or demands. Or if you completely avoid situations that would usually make you anxious, you may not have symptoms. Although avoidance may allow you to feel better in the short term, your anxiety is likely to persist over the long term if you don't get treatment.

Causes
Like many other mental health conditions, social anxiety disorder likely arises from a complex interaction of environment and genes. Researchers continue to study possible causes, including:

• Genes. Researchers are seeking specific genes that play a role in anxiety and fear. Social anxiety disorder seems to run in families. But evidence suggests that the hereditary component of this condition is due at least in part to anxious behavior learned from other family members.
• Biochemistry. Researchers are exploring the idea that natural chemicals in your body may play a role in social anxiety disorder. For instance, an imbalance in the brain chemical serotonin (ser-oh-TOE-nin) could be a factor. Serotonin, a neurotransmitter, helps regulate mood and emotions, among other things. People with social anxiety disorder may be extra-sensitive to the effects of serotonin.
• Fear responses. Some research suggests that a structure in the brain called the amygdala (uh-MIG-duh-luh) may play a role in controlling the fear response. People who have an overactive amygdala may have a heightened fear response, causing increased anxiety in social situations.

Risk factors
Social anxiety disorder is one of the most common of all mental disorders. Between 3 and 13 percent of people in Western countries experience social anxiety disorder at some point in their lives. Social anxiety disorder usually begins in the early to midteens, although it can sometimes begin earlier in childhood or in adulthood.

A number of factors can increase the risk of developing social anxiety disorder, including:

• Your sex. Women are more likely to have social anxiety disorder.
• Family history. Some research indicates that you're more likely to develop social anxiety disorder if your biological parents or siblings have the condition.
• Environment. Some experts theorize that social anxiety disorder is a learned behavior. That is, you may develop the condition after witnessing the anxious behavior of others. In addition, there may be an association between social anxiety disorder and parents who are more controlling or protective of their children.
• Negative experiences. Children who experience teasing, bullying, rejection, ridicule or humiliation may be more prone to social anxiety disorder. In addition, other negative events in life, such as family conflict or sexual abuse, may be associated with social anxiety disorder.
• Temperament. Children who are shy, timid, withdrawn or restrained when facing new situations or people may be at greater risk.
• New social or work demands. Meeting new people, giving a speech in public or making an important work presentation may trigger social anxiety disorder symptoms for the first time. These symptoms usually have their roots in adolescence, however.

Complications
Left untreated, social anxiety disorder can be debilitating. Your anxieties may run your life. They can interfere with work, school, relationships or enjoyment of life. You may be considered an "underachiever," when in reality it's your fears holding you back from excelling. In severe cases, you may drop out of school, quit work or lose friendships.

Social anxiety disorder can also lead to other health problems, such as:

• Substance abuse
• Excessive drinking
• Depression
• Suicide

What to expect from your doctor
A doctor or mental health provider who sees you for possible social anxiety disorder may ask:

• Does fear of embarrassment cause you to avoid doing things or speaking to people?
• Do you avoid activities in which you are the center of attention?
• Would you say that being embarrassed or looking stupid is among your worst fears?
• When did you first notice these symptoms?
• When are your symptoms most likely to occur?
• Does anything seem to make your symptoms better or worse?
• How are your symptoms affecting your life, including your work and personal relationships?
• Do you ever have symptoms when you're not being observed by others?
• Have any of your close relatives had similar symptoms?
• Have you been diagnosed with any medical conditions?
• Have you been treated for other psychiatric symptoms or mental illness in the past? If yes, what type of therapy was most beneficial?
• Have you ever thought about harming yourself or others?
• Do you drink alcohol or use illicit drugs? If so, how often?

Tests and diagnosis
When you decide to seek treatment for symptoms of possible social anxiety disorder, you may have both a physical and psychological evaluation. The physical exam can determine if there may be any physical causes triggering your symptoms.

There's no laboratory test to diagnose social anxiety disorder, however. Your doctor or mental health provider will ask you to describe your signs and symptoms, how often they occur and in what situations. He or she may review a list of situations to see if they make you anxious or have you fill out psychological questionnaires or self-assessments to help pinpoint a diagnosis.

To be diagnosed with social anxiety disorder, a person must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

Criteria for social anxiety disorder to be diagnosed include:

• A persistent fear of social situations in which you believe you may be scrutinized or act in a way that's embarrassing or humiliating
• These social situations cause you a great deal of anxiety
• You recognize that your anxiety level is excessive or out of proportion for the situation
• You avoid anxiety-producing social situations
• Your anxiety or distress interferes with your daily living

Treatments and drugs
Social anxiety disorder typically persists for life, often waxing and waning. But don't lose hope. Treatment can help you control symptoms and become more confident and relaxed in social situations.

The two most effective types of treatment are medications and a form of psychotherapy called cognitive behavioral therapy. These two approaches are often used in combination.

Psychotherapy
Cognitive behavioral therapy improves symptoms in up to 75 percent of people with social anxiety disorder. This type of therapy is based on the idea that your own thoughts — not other people or situations — determine how you behave or react. Even if an unwanted situation won't change — you still have to give a presentation to management, for instance — you can change the way you think and behave in a positive way. In therapy, you learn how to recognize and change negative thoughts about yourself.

Cognitive behavioral therapy may also include exposure therapy. In this type of therapy, you gradually work up to facing the situations you fear most. This allows you to become better skilled at coping with these anxiety-inducing situations and to develop the confidence to face them. You may also participate in skills training or role-playing to practice your social skills and gain comfort and confidence relating to others. Relaxation or stress management techniques may be included in your treatment plan.

First choices in medications
Several types of medications are used to treat social anxiety disorder. However, selective serotonin reuptake inhibitors (SSRIs) are generally considered the safest and most effective treatment for persistent symptoms of social anxiety. SSRIs your doctor may prescribe include:

• Paroxetine (Paxil, Paxil CR)
• Sertraline (Zoloft)
• Fluvoxamine (Luvox, Luvox CR)
• Fluoxetine (Prozac, Sarafem, others)

The serotonin and norepinephrine reuptake inhibitors (SNRI) drug venlafaxine (Effexor, Effexor XR) also may be used as a first-line therapy for social anxiety disorder.

To reduce the risk of side effects, your doctor will start you at a low dose of medication and gradually increase your prescription to a full dose. It may take up to three months of treatment for your symptoms to noticeably improve.

Other medication options
Your doctor or mental health provider may also prescribe other medications for symptoms of social anxiety, including:

• Other antidepressants. You may have to try several different antidepressants to find which one is the most effective and has the fewest unpleasant side effects.
• Anti-anxiety medications. A type of anti-anxiety medication called benzodiazepines (ben-zo-di-AZ-uh-penes) may reduce your level of anxiety. Although they often work quickly, they can be habit-forming. Because of that, they're often prescribed for only short-term use. They may also be sedating.
• Beta blockers. These medications work by blocking the stimulating effect of epinephrine (adrenaline). They may reduce heart rate, blood pressure, pounding of the heart, and shaking voice and limbs. Because of that, they may work best when used infrequently to control symptoms for a particular situation, such as giving a speech. They're not recommended for general treatment of social anxiety disorder.

Stick with it
Don't give up if treatment doesn't work quickly. You can continue to make strides in therapy over several weeks or months. And remember that finding the right medication for your situation can take some trial and error.

For some people, the symptoms of social anxiety disorder may fade over time, and medication can be discontinued. Others may need to take medication for years to prevent a relapse.

Lifestyle and home remedies
Although social anxiety disorder generally requires help from a medical expert or qualified psychotherapist, you can try some self-help techniques to handle situations likely to trigger social anxiety disorder symptoms.

First, assess your fears to identify what situations cause the most anxiety. Then gradually practice these activities until they cause you less anxiety. You may need to begin with small steps in situations that aren't overwhelming.

Situations to practice may include:

• Eating with a close relative, friend or acquaintance in a public setting.
• Making eye contact and returning greetings from others, or being the first to say hello.
• Giving someone a compliment.
• Asking a retail clerk to help you find an item.
• Getting directions from a stranger.
• Showing an interest in others. Ask about their homes, children, grandchildren, hobbies or travels, for instance.
• Calling a friend to make plans.

At first being social when you are feeling anxious is challenging. As difficult or painful as it may seem initially, don't avoid situations that trigger your symptoms. By regularly facing these kinds of situations, you'll continue to build and reinforce your coping skills.

The following techniques can help you begin to face situations that make you nervous. Practicing these techniques regularly can help you manage or reduce your anxiety.

• Prepare for conversation. For instance, read the newspaper to identify an interesting story you can talk about.
• Focus on personal qualities you like about yourself.
• Practice relaxation exercises.
• Adopt stress management techniques.
• Set realistic goals.
• Pay attention to how often the embarrassing situations you're afraid of actually take place. You may notice that the scenarios you fear usually don't come to pass.
• When embarrassing situations do happen, remind yourself that your feelings will pass, and you can handle them until they do.

In addition, be sure to keep your medical or therapy appointments, take medications as directed, and talk to your doctor about any changes in your condition.

Coping and support
Coping with social anxiety disorder can be challenging. Having social anxiety disorder can make it difficult for you to go to work or school, to interact with other people, or even to visit the doctor. But maintaining connections and building relationships are key ways to help cope with any mental disorder.

Over time, treatment can help you feel more comfortable, relaxed and confident in the presence of others. In the meantime, don't use alcohol or illicit drugs to try to get through an event or situation that makes you anxious.

Some positive coping methods include:

• Reaching out to people with whom you feel comfortable
• Joining a support group
• Engaging in pleasurable activities, such as exercise or hobbies, when you feel anxious
• Getting enough sleep
• Eating a well-balanced diet

Over time, doing this can help control your symptoms and prevent a relapse. Remind yourself that you can get through anxious moments, that your anxiety is short-lived, and that the negative consequences you worry about so much rarely come to pass.

Symptoms References

• Social phobia (social anxiety disorder). In: Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. 4th ed. Arlington, Va.: American Psychiatric Association; 2000. PsychiatryOnline - Home
• Hollander E, et al. Social phobia (social anxiety disorder). In: Hales RE, et al., eds. The American Psychiatric Publishing Textbook of Psychiatry. 5th ed. Arlington, Va.: American Psychiatric Association; 2008. PsychiatryOnline - Home
• Bruce TJ, et al. Social anxiety disorder. UpToDate Inc.
• Phobic disorders. The Merck Manual for Healthcare Professionals. Phobic Disorders: Anxiety Disorders: Merck Manual Professional
• Social phobia (social anxiety disorder). National Institute of Mental Health. NIMH ? Social Phobia (Social Anxiety Disorder)
• Feldman MD, et al. Phobias. In: Ferri FF. Ferri's Clinical Advisor 2009. St. Louis, Mo.: Mosby; 2008: MD Consult -- Start Session Cookie Error
• Abramowitz JS. Self-help cognitive-behavioral therapy with minimal therapist contact for social phobia: A controlled trial. Journal of Behavior Therapy and Experimental Psychiatry. 2009;40:98.
• Ebell MH. Diagnosis of anxiety disorders in primary care. American Family Physician. 2008;78:501.
• Whiteside SP (expert opinion). Mayo Clinic, Rochester, Minn. June 17, 2009.

 

[Daniel E.]

CBT and Social Anxiety Disorder
By Arlin Cuncic
About.com
November 3, 2008

Social Anxiety Disorder (SAD) is commonly treated with Cognitive-Behavioral Therapy (CBT), a form of therapy that first became popular in the 1980s and 1990s for treating anxiety disorders. Research has shown that CBT is one of the few forms of therapy that reliably helps in overcoming clinical anxiety disorders.

CBT is not one set method but rather a combination of various techniques that depend on the disorder being treated. For example, CBT for treating depression will be different from CBT for treating SAD or other anxiety disorders. Because there are so many different techniques, it is important that your therapist is experienced in using CBT for treating SAD, and knows which particular techniques are most effective for this disorder.

Goals of CBT for Social Anxiety Disorder
One of the central goals of CBT is to identify irrational beliefs and thought patterns and replace them with more realistic views. As part of the therapy process, you will work on a number of problem areas including:

• misperceptions you may have about your abilities and self-worth
• guilt, embarrassment, or anger over past situations
• how to be more assertive
• tackling perfectionism and being more realistic
• dealing with procrastination related to social anxiety

Your CBT therapy sessions may feel somewhat like a student-teacher relationship. The therapist will take the role of a teacher, outlining concepts and helping you on a path of self-discovery and change. You will also be assigned homework assignments that are key to making progress.

Cognitive Methods
CBT consists of a number of techniques, many of which focus on problematic thinking. Cognitive methods help lessen anxiety in interpersonal relationships and groups, and give the person with SAD a feeling of control over their anxiety in social situations. The ultimate goal of cognitive therapy is to change your underlying core beliefs (also known as your “schemas”) which influence how you interpret your environment. A change in your core beliefs will lead to long-lasting improvement of your anxiety symptoms.

One of the central problems targeted by CBT are automatic negative thoughts, also known as cognitive distortions. People with SAD have developed automatic negative ways of thinking that are misaligned with reality, increase anxiety, and lessen your ability to cope. These thoughts occur instantly when you think about an anxiety-provoking situation. For example, if you have a fear of public speaking, just thinking about the situation will elicit thoughts of embarrassment and fear of failure. The goal of CBT is to replace these cognitive distortions with more realistic views.

As a person suffering from SAD, at some point in your life someone has probably told you to just “think positive”. Unfortunately, the problem is not that simple to solve –- if it were, you likely would have overcome your anxiety long ago. Because your brain has become hardwired over time to think negatively and have anxious thoughts, it needs to be gradually trained to think in a new way. Just telling yourself “I will be less anxious next time” doesn’t work because this is an irrational statement, given your current way of thinking.

Changing negative automatic thinking in the long term requires practice and repetition, every day for several months. At first you might be asked simply to catch negative automatic thoughts and make them rationally neutral. As this becomes easier, you would work your way up to thoughts that are more realistic. Only then does it become automatic and habitual.

Over time, your memory processes will be affected and the neural pathways in your brain will be altered. You will begin to think, act and feel differently, but it will take persistence, practice, and patience for progress to be made. At first, this is a conscious process but as it is practiced and repeated it becomes automatic.

Behavioral Methods
One of the most commonly used behavioral techniques to treat SAD is exposure training, also known as systematic desensitization. Exposure training involves gradually exposing yourself to anxiety-provoking situations so that over time they elicit less fear.

Exposure training for SAD has to be a very gradual process. People may have told you to “toughen up and face your fears;" unfortunately this is extremely bad advice. People with social anxiety are already forced to face what they fear on a daily basis. Exposure that is not structured in a gradual step-by-step process does more damage than good. It will make your anxiety worse, keep you locked in a vicious cycle, and eventually lead to doubt and depression.

With your therapist, you will gradually expose yourself to feared situations so that over time they no longer elicit fear. At first, you may practice “in vivo” exposure, such as imagining giving a speech or practicing a job interview through role playing. Once the practiced or imagined situation becomes easier, you would move to the situation in the real world. If exposure training moves too fast or the situations are too demanding too soon, it will backfire.

Keys for Success
Research has shown that there are several keys for success when it comes to CBT and SAD. The likelihood that CBT will help you depends largely on your expectations about success, your willingness to complete homework assignments, and your ability to confront uncomfortable thoughts. People who are willing to work hard and believe that CBT will help them are more likely to improve. Although this form of therapy is intensive and requires active participation by the person with SAD, the improvement shown tends to be long-lasting and well worth the effort invested.

Sources:
Anxiety Treatment and Resource Centre, Hamilton, Ontario, Canada. Social Anxiety Disorder. 5 September 2007.
Beck, J.S. (1995). Cognitive Therapy: Basics and Beyond. Guilford Press.
Social Anxiety Institute, Phoenix, Arizona. What is Comprehensive Cognitive-Behavioral Therapy? 5 September 2007.

 

[Thoraxe]

holy crap i didnt realize that there was so much wrong with me i looked at the thread by David and i looked at the symptoms because it intrigued me and i experience all of these i cant even use the public restroom here at school because i get anxious