Sections

Social Phobia

Overview

Practice Essentials

Signs and symptoms

Individuals with social phobia typically experience symptoms resembling panic during a social encounter. These situations may include speaking in public, using public restrooms, eating with other people, or engaging in social contact in general.

Persons with this disorder fear being humiliated or embarrassed in social and/or performance situations by their actions and may become intensely anxious, with an increased heart rate, diaphoresis, and other signs of autonomic arousal. These physical symptoms may cause additional anxiety, often leading to a conditioned fear response that reinforces their anxiety in public situations.^[1]

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) criteria for social phobia are as follows:^[3]

Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. In children, the anxiety must occur in peer settings and not just during interactions with adults.
The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated.
The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent.
The social situations almost always provoke fear or anxiety. In children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
The social situations are avoided or endured with intense fear or anxiety.
The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.
The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.
The fear, anxiety, or avoidance cause clinically significant distress or impairment in social, occupationals, or other important areas of functioning.
The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance or another medical condition.
The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder.
If another medical condition is present, the fear, anxiety, or avoidance is clearly unrelated or is excessive.

Management

A combination of pharmacotherapy and psychotherapy is usually indicated for persons with social phobia.

Antidepressants including selective serotonin reuptake inhibitors (SSRIs; citalopram [Celexa], escitalopram [Lexapro], fluvoxamine [Luvox], paroxetine [Paxil], fluoxetine [Prozac], sertraline [Zoloft]) and venlafaxine (Effexor)) are commonly prescribed to treat the symptoms of social phobia and generally result in remission of symptoms after 4 weeks of treatment.

Cognitive restructuring can be combined with in vivo exposure, performance feedback, and attention retraining and/or combined with nonspecific stress management or computer-based cognitive behavior therapy (CBT).^[4] Cognitive therapy has evidence-based efficacy.^{[5, 6]}

Background

Social phobia, also called social anxiety disorder, is the third most common mental health disorder after depression and substance abuse, affecting as many as 10 million Americans. Social phobia is an anxiety disorder involving intense distress in response to public situations.^{[1, 2]}Individuals with social phobia typically experience symptoms resembling panic during a social encounter. These situations may include speaking in public, using public restrooms, eating with other people, or engaging in social contact in general.

The onset of social phobia may or may not be abrupt, often manifesting after a stressor or humiliating social experience in an individual with a childhood history of excessive shyness or social inhibition. Social phobia is considered a disorder if it is severe enough to adversely affect social or occupational functioning.^[7]Individuals with true social phobia go to great lengths to avoid social situations, usually to their own detriment. The fear of embarrassment is egodystonic, thus persons with social phobia are distressed by their symptoms.^[8]

Pathophysiology

The pathophysiology of social phobia is evolving as a result of research into brain connectivity and function and recent hypotheses regarding cognition.

A functional connectivity study of 174 subjects, 78 of whom had social anxiety disorder, examined whether emotion regulation can be a transdiagnostic measure. Results showed that effectual regulation in the context of negative stimuli consisted of engagement of the Prefrontal Cortex (PFC) along with reduced amygdala reactivity, and greater symptom severity correlated with less engagement of the Dorsal Anterior Cingulate Cortex (DACC) and less functional connectivity between the amygdala and ventrolateral prefrontal cortex.^[9]

Cognitive theories helpful in the understanding of the etiology of social phobia include the "Clark and Wells cognitive model of social phobia," which hypothesizes that self-focused attention, negative observer-perspective images of oneself, and safety behaviors maintain anxiety in subjects with social phobia and that this anxiety associates with observer-perspective imagery and safety-seeking behavior in adolescence; however, even though adolescents with clinical social phobia may report frequent negative self-focused thoughts, this may not be a clear associated symptom. However, such negative cognitions focused on self do not associate to self-reported social anxiety.^[10]

Theories have also arisen looking at the efficacy of pharmacologic agents used to treat social phobia. Thus, serotonergic functioning might be involved, as serotonergic reuptake inhibitors help alleviate symptoms. Similarly, some researchers believe in an adrenergic etiology because of the success of propranolol therapy. Neurocircuitry involving the amygdala, a structure involved in fear, may be involved, as studies have found an exaggerated reactivity of the amygdala to aversive social stimuli in social anxiety.^{[11, 12]}

Implications for treatment include the importance of not advancing treatment too quickly and triggering severe anxiety and early cessation of treatment; to enhance the ability to tolerate low levels of anxiety, the presence of a caregivier who is able to model adaptive functioning is desirable as an initial approach.^[13]

Very low weight (600–1250 g) premature babies may also be at higher risk for later development of social anxiety disorder, possibly owing to abnormalities in the uncinate fasciculus, the major white matter tract connecting the frontal cortex to the amygdala, and other limbic temporal regions.^[14]

One multisite study looked at whether treatment response was associated with specific genetic loci. Although treatment response was not assoicated with specific genetic loci, FKBP5, GR polymorphisms, or pretreatment percentage DNA methylation, the change in FKBP5 DNA methylation was nominally associated with treatment response as persons who demonstrated the greatest reduction in severity decreased in percentage DNA methylation during treatment compared with persons with one or more FKBP5 risk alleles who had little or no decrease or an increase in percentage of DNA methylation and did not show robust treatment response.^[15]

Frequency

In the United States, 9% of youth experience social phobia at some point in their lifetime—a slightly lower rate than the 12.1% rate observed among US adults in the National Comorbidity Survey (NCS)-Replication study. This social phobia was associated with marked levels of impairment and persistence. However, adolescents did not have significant associations, when compared with adults, between social phobia and mood or alcohol use disorders, after controlling for comorbid disorders; this suggests these relationships may be due, in part, to other psychopathology.

The US NCS-Adolescent Supplement is the first study of social phobia in adolescents with a large community-based sample and was done from 2001–2004.^[16] This study of 10,123 adolescents aged 13–18 years in the continental United States had a very good overall response rate of 83.3% of parents/parental surrogates, who responded to a self-administered questionnaire. Additional scales of excellent quality were used, such as the modified version of the World Health Organization Composite International Diagnostic Interview (CIDI) Version 3.0 and the Sheehan Disability Scale, to determine the impact of the disorder on the adolescents’ general functioning.

The study used the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for social phobia and found no sex differences in incidence; data were statistically very reliable (P = .001-.01) that 4.8% of all adolescents, representing more than half (55.8%) of all adolescents with social phobia, had fear of most social situations — generalized social phobia (7 or more of the 12 types of social fears)—as follows:

Meeting new people their own age
Talking to people in authority (eg, coaches, other adults they do not know very well)
Being with a group of people their own age (eg, at a party, in the lunchroom at school)
Going into a room that already has people in it
Talking with people they do not know very well
Going out with/dating someone they are interested in
Any other situation in which they could be the center of attention or something embarrassing might happen (eg, working/doing homework while someone watches; writing/eating/drinking while someone watches; speaking in class when a teacher asks a question/when a teacher calls on them; acting/performing/giving a talk in front of a group of people; taking an important test/examination or interviewing for a job, although they are well prepared)

A smaller percentage (3.8%) of all adolescents, representing 44.2% of all those adolescents with social phobia, had nongeneralized type of social phobia—fewer than 7 types of fears.

A very much smaller percentage of all adolescents (0.7%) had performance social phobia, representing only 0.8% of all adolescents with social phobia. This is perhaps due to the fact that public speaking and performance fears may only become clinically significant with the greater opportunity for avoidance that characterizes adulthood, as youth are required, because of school, to participate in such situations. Thus, they have more occasions for exposure resulting in performance anxiety, habituation, and lower prevalence rates than occur in adults, who are able to avoid such situations.

Disability from social phobia of the generalized type was moderate to severe and highly persistent; 87.03% of adolescents experienced at least 7 fears for 4 days of the previous calendar year, and there was a high comorbidity with social phobia. About one third to one fifth of adolescents with generalized social phobia had another disorder, most often anxiety due to agoraphobia (27%), followed by panic disorder (20.5%), separation anxiety disorder (18.1%), posttraumatic stress disorder (17.1%), and specific phobia (12.8%).

Lifetime incidence of comorbid oppositional defiant disorder occurred in a significant number of adolescents, more so in those with generalized social phobia (12.5% compared with adolescents who had the nongeneralized type of social phobia). That group had lower rates of comorbid disorders, and there was a statistically significant rate (P = .05) of significant comorbid drug-use disorders in 13% of those with generalized social phobia, as compared with only 7.2% of those with nongeneralized social phobia.

A unique pattern was found — an association between generalized social phobia with agoraphobia and panic disorder. Nongeneralized social phobia had an association with posttraumatic stress disorder and a unique negative association with alcohol use disorders. Although overall 18.6% of adolescents with social phobia presented with a lifetime mood disorder, adjusted odds ratios indicated that these associations were primarily due to other anxiety or behavior disorder.

The lifetime prevalence of social phobia is estimated at 7%–12%.^[7]Some community samples of adolescents show an incidence of 1.6%.^{[1, 2]}

Social phobia often goes undiagnosed in patients with other coexisting acute psychiatric conditions such as depression or suicidality but should not be overlooked, as it can contribute to a lack of symptom remission. In some situations, social phobia may be the root cause of depressive or suicidal symptoms.^{[8, 17]}

Mortality/Morbidity

Social phobia is often comorbid with other anxiety disorders; in one study, 60% of children with social phobia had another disorder (generally an anxiety disorder); 10% had generalized anxiety disorder, attention deficit/hyperactivity disorder (ADHD), or specific phobia. In other studies, children with social phobia were found to have comorbid separation anxiety disorder (in younger children), as well as selective mutism. Social phobia often leads to extreme social isolation in children and can be accompanied by selective mutism and/or can be a precursor to depression.

Intermitten explosive disorder (IED) can co-occur with social phobia. Data from the National Comorbidity Survey Replication and Adolescent Supplement Study indicated lifetime presence of an anxiety disorder increased the rate of IED by almost 3-fold (7.8% in adolescents without anxiety compared with 22.9% in adolescents with anxiety).^[18]

In adults with social phobia, academic and occupational functioning may be affected; often, people with social phobia have significant trouble forming relationships with others.^[12]

Social phobia can also be comorbid with autistic spectrum disorder. Longstanding social phobia increases the lifetime risk of depression later in adulthood, potentially leading to an increased risk of substance abuse, including alcoholism. This thereby confers a higher risk for cardiovascular morbidity and mortality.^{[19, 7, 20, 21]}

A severe form of social phobia and avoidant personality disorder, Hikikomori has been associated with adverse cardiovascular consequences including hypertension and has been found in many cultures, not exclusively in Japan but also found in Hong Kong, China, India, South Korea, Spain and the United States.^[22]

Race

Social phobia occurs in many cultures. Persons of Asian descent in North America may not receive treatment as early in the course of the disorder as persons of European descent. In addition, persons of Asian descent have significant cultural differences involving emotional responses in social interactions compared with persons of other cultures.^{[23, 24]}

Sex

In the general population, more females than males develop social phobia, with a female-to-male ratio of 1.5–2:1; however, in clinical samples, cases involving males are more prevalent. The reasons for this prevalence are unknown.^[25]

Age

Social phobia typically manifests in middle childhood, at approximately age 10 years. Adolescents (aged 11–12 y) with social phobia may avoid age-appropriate social activities, such as attending parties and dating. Symptoms of social phobia in younger children include crying, temper tantrums, fidgeting, somatic complaints, and avoidance and withdrawal from social situations. Untreated childhood social phobia typically continues into adulthood.^{[1, 19]}

Interpersonal stressors/trauma exposure

A recent study suggests that interpersonal stressors, including the particularly detrimental stressors of peer victimization and familial emotional maltreatment, may predict the later development of social anxiety symptoms in adolescents who have more immediate depressogenic reactions after stress.^[26]

Prognosis

Mild social phobia is associated with a good prognosis and may have a benign course. Severe avoidance behavior and substance abuse are often associated witha guarded prognosis.

Symptoms of social phobia in younger children include crying, temper tantrums, fidgeting, somatic complaints, and avoidance and withdrawal from social situations.^[1]The median delay from onset to seeking treatment can be as long as 28 years.^[17]Untreated childhood social phobia typically continues into adulthood and thus can potentially cause significant duration of impairment and interfere with normal development.^[19]

Social anxiety can occur in the presence of autism and can have a poorer prognosis, especially if major depression develops in adulthood.^[27]

Patient Education

Naturalistic research looked at functional MRI activity in anxious children and adolescents who requested that their caregiver accompany them in the scanner room compared with those without their caregiver present. Results indicate that activity in the hypothalamus, ventromedial, and ventrolateral prefrontal cortex were significantly reduced in anxious children and adolescents who requested that their caregiver accompany them in the scanner room compared to those without their caregiver present. Mean activity in these regions in anxious children and adolescents with their caregiver in the scanner room was comparable to that of healthy controls. This suggests links between social contact and neural mechanisms of emotional reactivity, and that the presence of caregivers may lessen the increase in anxiety associated with stressful stimuli.^[13]

Approaches to prevention of social phobia in school children include universal emotional health interventions using computer programs such as FRIENDS or Coping Cat to decrease anxiety symptoms and to improve self-eseteem, which may be helpful as long as the interventions specifically target social phobia.^{[28, 29, 30, 31, 32, 33]}

The folllowing organizations may prove beneficial to patients and their families:

Anxiety and Depression Association of America - a nonprofit organization dedicated to informing the public about anxiety disorders and their treatment with an excellent scientific advisory board and updated resources for stakeholders and therapists
American Academy of Child and Adolescent Psychiatry
Social Anxiety Association
National Institute of Mental Health
American Psychological Association
Association for Behavioral and Cognitive Therapies - has a directory of mainly psychologist providers and offers information and workshops and annual conferences in the United States and abroad
Selective Mutism Group/Childhood Anxiety Network - a nonprofit group with a goal of increasing awareness of selective mutism and related childhood anxiety disorders
The Child Anxiety Network - a Boston University-affiliated website that provides online resources for parents, children, and professionals and a directory of providers, primarily psychologists, experienced in working with children and anxiety disorders; offers workshops for a fee
VirtualClinic - online support groups
CRUfAD Schools - resources for schools
The Patient Health Questionnaire (PHQ-9) - resources for diagnosis and treatment

Patient and family education are important for helping resolve symptoms and preventing relapses. Family support may be helpful in behavioral desensitization techniques and in decreasing the social isolation of the patient. Patients and families should be educated regarding the nature, prognosis, and treatment of the disorder.

Clinical Presentation

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