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Social Phobia : More Than Shyness

More than half of Americans consider themselves shy, but most shy persons would be shocked to know what goes on in the mind of an individual with social phobia.

Sometimes defined as the extreme end of the shyness spectrum, social phobia is severe enough to cause significant distress, underachievement and underemployment–often becoming entangled with other problems such as depression, anxiety or chemical dependency.

Mary declined a major promotion because she knew it would mean leading small group meetings. Rick took all the course work for a Ph.D. but dropped out of the program because he feared having to take a comprehensive oral examination. Jason stopped shopping in certain stores because he knew he might run into acquaintances there and did not want to have to conduct an informal conversation with them.

Social phobia is characterized by persistent avoidance of certain situations because of a fear of appearing foolish or incompetent. Embarrassed to come forward, social phobia patients often go untreated, but it’s believed that social phobia is the third most common mental problem after depression and substance abuse, affecting at least 13 percent of Americans at some time during their lives.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) recognizes two types. In its least serious form, social phobia involves a fear of a specific situation such as speaking in public, performing before an audience, taking examinations or carrying on small talk in social settings. Many cases of impotence are linked at least in part to performance anxiety.

Other examples of what professionals call circumscribed or discrete social phobia include those who are unable to eat in a restaurant, use a public rest room or write while someone is watching. One woman avoided left turns for fear of incurring the impatience of drivers behind her.

The second type, known as generalized social phobia, is usually more disabling because it involves anxiety about a wider range of situations. A person with generalized social phobia feels extremely vulnerable to being embarrassed or rejected by others. Fearing he will say something that sounds foolish, he says nothing or tries to avoid any social situation where he is likely to be scrutinized or judged by others.

The degree of avoidance varies widely––from clamming up when asked a question in class to efforts to avoid any kind of social gathering outside of close family or friends who are unlikely to be judgmental.

The direct eye contact that is often important to getting a job or making a sale is difficult for the person with social phobia. Fearing his gaze would be misinterpreted, Norman often looked away when talking to others––leading to exactly the misinterpretation he was trying to avoid. Like many persons with social phobia, he was particularly anxious about the prospect of speaking to anyone in a position of authority. As a result, he deliberately avoided his boss...and all others who might influence his chance for a promotion or a good recommendation.

In most cases, social phobia can be traced back to childhood, but it can start at any age. Children with social phobia tend to avoid birthday parties, athletic teams, sometimes even school itself. They are almost always solitary and often depressed. Many adolescents who use alcohol and drugs say these substances give them courage at social gatherings.

Shyness apparently has a strong genetic component. But it can also develop as a result of a traumatic social experience, such as being exposed to ridicule in front of a group or having one’s mind go blank while giving a speech. Some children develop symptoms from observing others, such as parents, in social situations.

Long-term studies, following individuals over a 25- to 30-year period, have found that traits of shyness or social inhibition persist. Men who were shy as children were slower to marry, become fathers and establish themselves in an occupation. Women who were shy were less likely to attend college or work outside the home.

Many persons outgrow shyness or learn to overcome it. However, without treatment, a person with social phobia is likely to become increasingly demoralized and isolated, feeling the effects of the disorder in virtually every area of life. About 69 percent develop another mental disorder such as depression, anxiety or chemical dependency.

For simple performance anxiety, musicians, actors and speakers frequently use beta blockers, which can be taken on an as needed basis and have the effect of calming the nerves and steadying the hands. Beta blockers generally are not effective, however, for generalized social phobia.

Psychotherapy for generalized social phobia usually takes a cognitive/behavioral approach, frequently in a group context. While some patients may need to gain personal insights or better social skills, most are handicapped by negative self perceptions.

Patients are taught to challenge their automatic thoughts by asking: “How would another person view this situation?” Or “What is the worst that could happen if I go to the party?” Through role playing during therapy sessions and assigned homework, the patient works on escaping from the cycle of fear and avoidance. Several controlled studies have confirmed the effectiveness of cognitive-behavioral group therapy, even after five years of follow up.

Medication is the other widely used treatment, either on its own or in conjunction with cognitive-behavioral therapy. Paroxetine (Paxil), a selective serotonin reuptake inhibitor (SSRI), was the first medication approved for the treatment of social phobia. Other medications that have been used to treat social phobia include SSRIs such as fluvoxamine, fluoxetine and sertraline; monoamine oxidase (MAO) inhibitors such as phenelzine, tranylcypromine; and high-potency benzodiazepines such as clonazepam.

The biggest challenge is identifying persons with social phobia and getting them to seek treatment. Most are embarrassed to bring their problems into the open and have resigned themselves to the idea that “this is the way I am.”

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Last modified: Tuesday, April 22, 2014

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