Social Phobia 

  • Author: Bettina E Bernstein, DO; Chief Editor: Eduardo Dunayevich, MD   more...
 
Updated: Sep 14, 2011
 

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.

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]

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.[3] That is, individuals with true social phobia go to great lengths to avoid social situations, usually to their own detriment. The fear of embarrassment is egodystonic, and persons with social phobia are distressed by their symptoms.

The median delay from onset to seeking treatment can be as long as 28 years.[4, 5]

Case presentation

The chief complaint of a 9-year-old boy is, "No one likes me or wants to play with me, and I hate it when the teacher asks me to read aloud." He has difficulties with functioning at school, his teacher reports that he rarely raises his hand to be called on, and his mother reports that he has frequent stomachaches, especially the night before he is supposed to take standardized tests. At home, he seems content to play his clarinet by himself, and he tells the clinician that he dreads concerts because he is expected to play in front of others.

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Pathophysiology

The pathophysiology of social phobia is unclear. However, theories have arisen based on 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.[6, 7]

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.[8]

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-esteem, which may be helpful as long as the interventions specifically target social phobia.[9, 10, 11, 12, 13, 14]

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Epidemiology

Frequency

United States

Nine percent of youth in the United States 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.[15] . 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 new Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) proposed 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.

International

The lifetime prevalence of social phobia is estimated at 7%-12%.[3] 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.[4, 5]

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.

In adults with social phobia, academic and occupational functioning may be affected; often, people with social phobia have significant trouble forming relationships with others.[7]

Social phobia is also commonly 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.[16, 3, 17, 18]

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.[19, 20]

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.[21]

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, 16]

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Contributor Information and Disclosures
Author

Bettina E Bernstein, DO  Clinical Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Outpatient Consultant, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia; Court Appointed Evaluator, Family Court of Philadelphia; Psychiatric Consultant, Intercommunity Action, Inc, Easttown Tredyffrin School District

Bettina E Bernstein, DO is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry and American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mohammed A Memon, MD  Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry, Spartanburg Regional Medical Center

Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric Psychiatry, American Medical Association, and American Psychiatric Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Harold H Harsch, MD  Program Director of Geropsychiatry, Department of Geriatrics/Gerontology, Associate Professor, Department of Psychiatry and Department of Medicine, Froedtert Hospital, Medical College of Wisconsin

Harold H Harsch, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: lilly Honoraria Speaking and teaching; Forest Labs None None; Pfizer Grant/research funds Speaking and teaching; Northstar None None; Novartis Grant/research funds research; Pfizer Honoraria Speaking and teaching; Sunovion Speaking and teaching; Otsuke Grant/research funds reseach; GlaxoSmithKline Grant/research funds research; Merck Honoraria Speaking and teaching

Chief Editor

Eduardo Dunayevich, MD  Adjunct Assistant Professor, Department of Psychiatry, University of Cincinnati; Clinical Research Physician, Neuroscience, Lilly Research Laboratories

Eduardo Dunayevich, MD is a member of the following medical societies: American Psychiatric Association

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous coauthor, Kiki D Chang, MD, to the development and writing of this article.

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