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Social Phobia

By Seema Mansoor Ali Pirani

The Social Phobia (also known as social anxiety disorder) is a fear in a situation, when an individual has been scrutiny by others while doing some actions. According to Valente (2002) “Social phobia involves a persistent and irrational fear of social interactions and evokes a compelling wish to avoid those situations. It may markedly compromise both quality of life and psychosocial function” (p. 67). Various literatures define the Social Phobia as commonly occurring anxiety disorder usually correlate with serious role impairment. A literature defines Social Phobia as “a condition marked by extreme manifest fear and/or avoidance of situations that involve possible scrutiny by others” (Stein, Tougrud, and Walker, 2000, p. 1046). Phobia can be caused due to animals, activities and social situations, it is basically a fear, everyone have fear about things i.e. heights and spider. An individual who comes across from a danger becomes fearful but with phobias, these fears are difficult to deal with and disproportionate.

Phobias are of different categories. First, agoraphobia in which person become fearful because he/she is alone in the place or situation and the escape is difficult. In addition, this person is unable to go in crowded areas and some time they unable to go out of their house. Secondly, an individual affected with social phobia could not perform any activity in presence of other public. This phobia is a psychiatric problem. According to American Psychiatric Association (1994) define social phobia as “a marked and persistent fear of social or performance situations in which embarrassment may occur” (p. 411). The person with the social phobia expose in a social environment becomes anxious in the form of situationally bound or situationally predispose with a panic attack. Moreover, this person must acquaint that the attack is unreasonable. Beside that, the person also becomes distress which leads to poor concentration in his/her routine. Social Phobia mainly more affect on children but it has been affecting all group of ages. Davis and Ollendick (2005) declare that “it is estimated that over 350,000 children and adolescents in the United States have clinically significant specific phobia at any one point of time” (p. 144). Along with that the prevalence rate is more in female than in male. Hofmann (2000) cites that “resent data from National Comorbidity Survey indicate that social phobia is the third most common mental disorder, with a life time prevalence of 13.3” (Kessler et al 1994).

The features of social phobia are very much similar with other mental disorder due to that it was difficult to identify and provide treatment. But now for the diagnostic purpose of social phobia in children, the American Psychiatric Association (1994) has identified four provisions which incorporate and emphasize the difference in development in child with adult. First, the child maintains the social relationship with the familiar people and their anxiety occurs in peer context, not only with adult one. Secondly, if the child presents in the social gathering of unfamiliar people, they become anxious by showing with crying, crabbiness, glacial and attenuation. Third, the child becomes unaware of their fear in social gathering as their cognitive and perceptual skill is not developed fully. Fourth, the child should show the symptom for minimum of 6 month. Therefore, it is easy to diagnose the Social Phobia from other mental disorders. After the definition of social phobia it is essential to know about the factors which lead to this problem, its subtypes, comorbids and treatments.

There are many factors which lead to social anxiety and social phobia. From the age of 6 month to 3 years, children experience anxiety because of separation from their parents name as separation anxiety. Self consciousness is the primary prerequisite of social phobia. The Velting and Albano (2001) cited that “the abilities to see oneself as a social object and to experience embarrassment may emerge around age 4 or 5 (Buss et al 1979), while the abilities to take others’ perspectives and then to anticipate and feel clear concern over negative evaluation from others probably do not fully develop until around 8 year of age” (Asendorpf, 1989; Crozier and Burnham, 1990; Bennett and Gillingham, 1991.,). Furthermore, during the childhood and adolescence period the child can come across with the normal anxiety but some time these anxieties may lead to social phobia. The Velting and Albano (2001) cited that “social phobia is though to evolve from normal anxiety that is magnified by the social demands of preadolescence” (Amies et al 1983).

Beside that, one of the factors of social phobia is genetic. If social phobia occurs in parents then there is a high chance of running this in their offspring. Velting and Albano (2001) cited that “having more than one parent with an anxiety disorder significantly increases the risk of social phobia in children” (Merikangas et al 1999). Moreover, these phobias are not only occurs in twins but also the prevalence of this is more common in first-degree relatives. Velting and Albano (2001) cited that “upon interviewing the large sample of anxiety disordered, normal control adults and the relatives of two groups, found a moderate familial aggregation of social phobia, with a significant two-fold risk increase in the first- degree relatives of the social phobia proband” (Fyer et al 1995).

Furthermore, temperamental can play an imperative role in the development of social phobia because of behavioral inhibition. According to Velting and Albano (2001) “behavioral inhibition refers to a temperamental style that is characterized by reluctance to interact and withdraw from the unfamiliar settings, people or object”. If these inhibitions arise in early childhood then it escort to social anxiety and social phobia. Moreover, if the behavioral inhibitions occur, the infant become bad-tempered, toddlers, bashfulness and nervousness and school age children become cautiousness, reserve and coyness.

Beside that, environmental factors related to family are also a leading cause of Social Phobia in children and adolescence. Studies have shown that the anxious parents’ children are more prone to get anxiety disorder and their treatment may be difficult. Velting and Albano (2001) cited that “a resent treatment study found that anxious children with at least one anxious parent had poorer outcomes after a course of cognitive behavioral treatment than the children who had no anxious parents” (Cobham et al 1998). Moreover, the parenting style, controllable and restricted environments and get less affection from their parent may escort children and adolescence to become social phobic. Velting and Albano (2001) cited that “in one early study in this area, a group of adult social phobic recalled their parents as being more controlling/overprotecting and as expressing less affection than did normal controls” (Parker, 1979).

Social Phobia is been recognized since 1980 but the type are introduced when third edition of Diagnostic and Statistical Manual of Mental Disorder was published. Social Phobia has two subtypes; first is generalize in which the individual’s anxiousness envelop most situation. Hook and Valentiner (2002) cited that “generalized social phobia is characterized by a pervasive pattern of social fear and its thought to be more incapacitating form of social phobia” (American Psychiatric Association, 1984). The other is specific social phobia in which individual become fearful in a specific circumstance, for example eating or speaking infront of others. Hook and Valentiner (2002) cited that “specific social phobia is defined as the fear of the limited number of social situations and individuals with this may fear only one social situation” (Schneier et al, 1992). In comparison with specific social phobia, generalize social phobic individuals have difficulties to manage their school, work and house hold responsibilities; have fear of getting negative evaluation and social anxiety. In addition, generalize phobic individuals are on the high risk or vulnerable to get other diseases like anxiety disorder, dysthymia, eating disorder, depression and suicidal behaviors. Velting and Albano (2001) cited that “as they age, generalized socially phobic adolescents are at an increased risk of developing comorbid disorders” (Hofmann et al, 1999). Along with that, it has been conformed from the studies that the children and adolescent both can fall in generalized category. Velting and Albano (2001) cited that “it has been hypothesized that, rather than remaining specific to one or two situations, social fear in children tend to generalize and become part of phenomenological expression of anxiety characteristic of generalize social phobia or over anxious disorder” (Albano et al 1995). Beside that Velting and Albano (2001) cited that one of the study done on 33 socially phobic adolescences by Hofmann et al (1999) and they categorized the fear situation in to 4 domains; Formal speaking; Informal speaking; Observation by others and; Assertion. They identify that “about half (45.5%) of adolescences have these four domains and they fall in the category of generalize” (p.133). Along with that another study which also shows that there is no significant differences between generalize and specific social phobia. This study done on 176 socially phobic individual by Weinshenker et al (1996-1997) and they found “no statistically significant differences between the two subtypes on age of onset, current comorbidities, treatment- seeking behaviors, health, functioning in social roles and adverse childhood events. The one difference suggestive of a qualitative difference between groups was a greater reported fear of public speaking in the nongeneralized group”.

Children and adolescence with social phobia have a terror of communication, ingestion, writing and performing arts infront of the group. Along with that they face trouble in initiating and lengthen the conversation in the parties and with the higher authorities. Because of that they have a negative impact on their activities. In addition, if individual have a high level of social anxiety they are less acknowledged and supported by other and also they are less romantic toward their associates. Besides that, socially anxious girls are become more compromise and they hardly share their feeling with their peer. Adding to that, the individual with the specific social phobia have difficulty in speaking because of increase heart rate infront of people as compare to generalized social phobia.

If the social phobia is not interrupting the life style then it is normal and no treatment is required but if it have a negative impact on social activities then treatment in needed. Velting and Albano (2001) cited that “problematic social anxiety is that which exceeds expected developmental levels resulting in significant distress and impairment at home, school and in social contexts”(Albano et al,1996., Kazdin and Wiesz, 1998). One of the treatments of social phobia is Cognitive Behavioral Treatment. According to Velting and Albano (2001) Cognitive Behavioral Treatment has four domains; first is Psychoeducation which gives the correct information regarding anxiety and fear stimuli, somatic management techniques target autonomic arousal and related physiological responses; second is skill training in which they identify the maladapted thought and teaching realistic, coping focused thinking; third is exposed method in which the individual is exposed to a systematic and control stimuli or situation; and last is relapse prevention in which long term treatment is provided. Moreover, many studies have done on this treatment and they find it effective as it reduce the symptoms of cognitive and behavior from the patients. Furthermore, Velting and Albano (2001) cited that one of the studies done by Kendall et al in 1997 on 94 children age 9-13 found that 50% of them have experiences reduction in the disease after the treatment with cognitive behavior.

Before 1980 the symptom of social anxiety and phobia was treated in psychotherapy because it was thinking that these symptoms were normal personality behavior or shyness. But, now a day there are the medications to treat the symptom of social phobia in adult. These are Monoamine Oxidase Inhibitors (MAOIs); Selective Serotonin Reuptake Inhibitors (SSRIs); and Benzodiazepine Clonazepam. Besides that, Beta-blocker is also useful for adult but it is not for pediatric and ineffective for generalized social phobia. Along with that, the first line of drug is SSRIs with Paroetine because of less dietary restrictions and side effects. Another drug is Fluxotine use in the treatment of social phobia. Velting and Albano (2001) cited that two studies done on Fluxotine, one by Barmaher et al in 1994 on 21 children (ages 11-17) and second by Manassis and Brabely in 1994 with the age between 5-11 years with the diagnosis of social phobia. They identified that children showed measure improvement after 6-8 week of treatment. In addition, Velting and Albano (2001) cited that The National Institute of Mental Health recognized the Research Unit in Pediatric Pharmacology to observe the effect of medication used in social phobia. The institute did a research on 128 children with the usage of Fluvoxamine drug for 8 weeks and they identified that 76% of children responded with the decrease in the anxiety level (Vitilio, member of Research Units in Pediatric Pharmacology, 2000).
To conclude, the Social Phobia is a psychiatric disorder in which person unable to perform activities infront of others. Beside that, it comprises of three factors which includes temperamental, genetic and environmental/family. Next to, social phobia has two subtypes; first is generalized; and second is specific. Furthermore, there are two different modes of treatments, one is Cognitive Behavior Therapy and second is pharmacological. So, I would recommend that the treatment should be started from Cognitive Behavior Therapy and not directly jumps towards the medications because of its side effects. Along with that, as a nurse it is necessary to give awareness to person about social phobia and its consequences. So, if any body is affliction from this disease can obtain benefit from the treatment soon.