eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Social Phobia

Author: Bettina E Bernstein, DO, Assistant Professor, Department of Psychiatry, Philadelphia College of Osteopathic Medicine; Private Practice at the Wynnewood House; Consultant, Child Guidance Resource Centers, Early Elementary Education Program, Clinical Affiliate, Department of Child and Adolescent Psychiatry, Children's Hospital of Philadelphia
Contributor Information and Disclosures

Updated: Oct 26, 2009

Introduction

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.

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}

Frequency

United States

According to the US National Comorbidity Survey from 1994, social phobia is the third most common psychiatric disorder in the United States. More recent studies (2002) have estimated that the prevalence of pediatric social phobia ranges from 5%-10%, with an average of 7%. The prevalence of social phobia appears to be increasing among white, married, and well-educated individuals.^15,16

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.^15,3,17,18

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.^1,15

Clinical

History

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria for social phobia are as follows:

• The person has a marked and persistent fear of one or more social or performance situations in which he or she is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. Children must show evidence of the capacity for age-appropriate social relationships with familiar people, and the anxiety must occur in peer settings, not just in interactions with adults.
• Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. In children, the anxiety may be expressed as crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
• The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent.
• The feared social or performance situations are avoided or are endured with intense anxiety or distress.
• The avoidance, anxious anticipation, or distress in the feared social or performance situation interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships; alternatively, the patient has marked distress about having the phobia.
• In individuals younger than 18 years, the duration is at least 6 months.
• The fear or avoidance is not due to the direct physiological effects of a substance (eg, drug of abuse, medication) or a general medical condition and is not better accounted for by another mental disorder (eg, panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, pervasive developmental disorder, schizoid personality disorder).
• If a general medical condition or another mental disorder is present, the fear in one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others is unrelated to it; for example, the fear is not of stuttering, trembling in persons with Parkinson disease, or exhibiting abnormal eating behavior in persons with anorexia nervosa or bulimia nervosa.
• The phobia is specified as generalized if the fears include most social situations; also consider the additional diagnosis of avoidant personality disorder.
• Associated features include depressed mood; somatic/sexual dysfunction; addiction; and anxious, fearful, or dependent personality.
• Social phobia typically manifests in middle childhood, at approximately age 10 years. Adolescents (age 11-12 y) 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.

Physical

A thorough Mental Status Examination should be included, with the following areas specifically assessed:

• General appearance: The patient may be noticeably uncomfortable or anxious in the office. The patient may be hesitant or have difficulty speaking. However, in one-on-one situations, the patient may not demonstrate significant social anxiety. Individuals observed to be silent or mute should undergo screening for selective mutism with the selective mutism questionnaire or other appropriate checklists that gather information from the child and other sources of information (eg, from parents or teachers).²²
• Because elevated cortisol levels may worsen symptoms of social phobia, the history and cursory observation of the patient's habitus should include ruling in or out conditions that cause elevated cortisol levels (intrinsic or extrinsic).²³
• Mood/affect: Because depression is commonly comorbid with social phobia, the patient may report depressed or anxious mood and may appear to have a depressed or anxious affect.
• Speech: The patient may speak softly and with hesitancy.
• Thought processes: Thought processes in individuals with social phobia are usually in the "normal" range. Their thought processes are usually appropriately goal-directed and syntonic without morbid preoccupation or impairment of reality.
• Perception: Auditory or visual hallucinations are not elements of social phobia; however, schizophrenia or acute stress disorder may be comorbid with social phobia.²⁴
• Thought content: The patient may be preoccupied with what others are thinking about him or her. Delusions are not present, but preoccupation with the scrutiny of others may approach delusional levels. True paranoia or fixed delusions are not consistent with social phobia and are more suggestive of schizophrenia.²⁴
• Cognition: Cognition is normal.
• Suicidal/homicidal ideation: This is not common with social phobia per se, but the social isolation associated with social phobia can lead to despair, depression, and suicidal ideation. Thus, it is important to screen for depression, especially in the presence of obsessive thinking accompanied by compulsive behaviors.^25,26

Causes

Genetic factors may contribute to social phobia. Pedigree analyses suggest that first-degree relatives of probands with social phobia are 3 times more likely to have social phobia than controls. However, specific genes have not been isolated. An inhibited temperament in childhood has been linked with the development of social phobia in adolescence. The brain dysfunction in social phobia may result from increased activation of neural circuitry to fearful faces, specifically in the amygdala.^25,26

A cross-cultural perspective is essential, as individuals of some cultures (Japanese, Korean) may have a persistent and excessive fear of offending others in social situations, called taijin kyofusho. Specifically, the individual fears that his or her body odor, eye-to-eye contact, or blushing could be offensive to others.²⁷

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