Social phobia is a psychiatric disorder in which social functioning deteriorates due to avoidance of various social situations after experiencing social anxiety in which people seem embarrassed or stupid in front of others. People with social phobia have an excessive fear of embarrassment in a variety of social situations. For example, when talking in front of a large number of people, when urinating in a public toilet, and when asking for a meeting with the opposite sex, they experience severe anxiety.
People with social phobia develop severe anxiety when they are exposed to or expected to be exposed to the situation they fear. Some patients may develop anxiety symptoms in the form of a panic attack.
Patients make constant efforts to avoid situations that cause anxiety, which leads to deterioration in social functioning.
Depression is common, and it is estimated that about one-third of patients with social phobia have depression. Molar abuse problems, such as alcohol abuse, are also common.
Social phobia, like other mental health problems, is thought to arise through complex interactions between environmental and genetic factors. The causative factors currently being studied are as follows.
Currently, researchers are looking for genes that play a key role in anxiety and fear. Although social phobia tends to occur within the same family, it is not yet clear whether this is due to genetic factors or learning anxiety behaviors from other family members.
An imbalance of neurotransmitters such as serotonin is being studied as the cause. Serotonin is responsible for regulating emotions and mood, and it is speculated that patients with social phobia have abnormally sensitive neurotransmission systems.
Some studies have reported that a brain area called the amygdala is involved in the fear response. From this, it was inferred that people with hypersensitive amygdala may have exaggerated fear responses that cause social anxiety.
According to the diagnostic criteria of the Diagnostic Statistical Manual of Mental Disorders (DSM-IV-TR) of the American Psychiatric Association, social phobia must satisfy all of the following criteria.
- A. A marked and persistent fear of one or more social or performance situations in which the person 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.
- Note: In children, there must be 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.
- B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack.
- Note: In children, the anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
- C. The person recognizes that the fear is excessive or unreasonable.
- Note: In children, this feature may be absent.
- D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
- E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
- F. In individuals under age 18 years, the duration is at least 6 months.
- G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder).
- H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it (e.g., the fear is not of stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa).
- Specify if: Generalized: if the fears include most social situations (also consider the additional diagnosis of avoidant personality disorder)
Depressive disorder should be differentiated through psychiatric counseling. In the case of depressive disorder, various depressive symptoms exist simultaneously in addition to social avoidance. It is also necessary to differentiate it from personality disorder. Some personality problems lack the need for socialization rather than the fear of socialization.
It is common to combine psychotherapy with medication.
SSRIs or SNRIs are mainly used for the treatment of general social phobia. For example, if a patient starts taking paroxetine orally at 20 mg per day, the response can be confirmed after 6 weeks, and the dose can be increased to a maximum of 60 mg per day. Venlafaxine can be started at 37.5 mg per day and increased to 75 to 225 mg per day. These drugs begin to take effect after 6 weeks and reach their maximum effect at 12 to 16 weeks. In addition, treatment should be continued for at least 6 to 12 weeks.
For social phobias associated with specific situations or behaviors, benzodiazepines or beta-blockers may be used. In other words, take clonazepam 0.25 to 1.0 mg or lorazepam 0.5 to 2 mg 30 to 60 minutes before the symptom-causing activity. Another option is to take 20-60 mg of propranol 30-60 minutes before the anxiety-provoking event.
Psychotherapy is based on cognitive behavioral therapy. It consists of psychological education, cognitive reconstruction training, and situational exposure practice. In particular, cognitive reconstruction training recognizes negative and maladaptive beliefs and automated thoughts, observes the association between anxious emotions and automated thoughts, and examines errors in logic. The therapist then constructs rational alternatives to these beliefs and thoughts.
Progress and complications
Social phobia usually begins in adolescence. It tends to develop into a chronic disease and can negatively affect an individual’s life for a considerable period of time. In particular, it has a negative impact on social functioning, such as academic or work life.
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