Social phobia (Social Anxiety Disorder)

Is a fear of one or more social situations where there might be unfamiliar people or judgment by others.  Typically people with social phobia worry that they will embarrass themselves in such a situation, either by showing symptoms of anxiety (e.g., blushing, sweating) or by otherwise acting in a way that will be humiliating to them.  The lifetime prevalence of social phobia is 1 in 8, and it is twice as common for women than for men.  The typical onset of symptoms is in the early teenage years, though sometimes is diagnosed in childhood.  Severe cases of the disorder can be extremely debilitating (i.e., few friends, unable to attain goals).

In addition to the aforementioned fear of social situations, people with social phobia experience intense anxiety in these situations, and often avoid them when possible.  Although people with social phobia are aware that their fears are unreasonable, the anxiety experienced in social situations or worrying about social situations causes impairment in functioning (e.g., relationships, occupation).

There are a number of factors that are thought to contribute to social phobia, but the specific cause is unknown.  There is likely a genetic role, as many people with social phobia also have relatives with the diagnosis.  Often previous experience(s) with embarrassment or humiliation in social settings contributes to fear of future embarrassment.  It is also thought that negative automatic thoughts in situations (e.g., “I’m going to sound stupid when I try to talk about this topic”), as well as extremely high standards (e.g., “I should not be anxious”).  Although it has long been thought that people with social phobia lack social skills, recent theory has challenged this, posing that people with social phobia are actually more attentive to social cues, and thus more sensitive to unskilful behaviour.

What treatments are available?

1.Medication: There are a variety of anti-anxiety medications available for people with social phobia.  One problem with medication is that anxiety symptoms often recur when the medication is stopped; for this reason many think psychotherapy is the treatment of choice.

2.Cognitive-Behavioural Therapy (CBT) is a widely used treatment for people with social phobia.  Based on the cognitive model, anxiety is reinforced and maintained by negative thoughts and avoidance of situations.  Thus, common interventions include changing thoughts and behaviour.

Given the propensity for negative automatic thoughts, CBT therapists help clients with social phobia test some of the assumptions that underlie these thoughts.  Clients might engage in observation of others’ behaviour, behavioural experiments about others’ reactions to anxiety behaviour (e.g., exercising before going to a part to test the impact of sweating in a social situation), and developing alternative explanations to others’ behaviour (e.g., “John must not have seen me,” rather than “John must not like me” when friend does not make eye contact on the street).

Another common CBT intervention used with clients with social phobia is exposure.  Using exposure techniques, the therapist introduces the client to the situations the client fears, first in the therapy room (i.e., imaginal or in-session role play exposure) and then in the uncomfortable social situation (i.e., in vivo exposure).  The therapist supplies the client with tools for these situations (with social skills training and relaxation training), and does not push the client to do anything the client is not ready and willing to do.  After repeatedly experiencing feared situations, clients realize that their fears rarely (if ever) come true, and anxiety related to these situations is reduced.  Clients that have gone through CBT for social phobia report that they feel less anxious, and are able to approach rather than avoid social situations.

3.Acceptance and Commitment Therapy (ACT) is a new therapy that has been applied to clients with social phobia.  ACT focuses not on reducing symptoms, but on accepting symptoms and moving in the direction of things that the client values.  In an ACT model, the problem is not the symptoms, but the way in which individuals respond to those symptoms.  In treatment for social phobia, ACT focuses on avoidance (of both feelings of anxiety and external situations) that in turn keeps the client from obtaining goals and acting in line with his or her values.  Although individuals are often able to reduce anxiety through both internal and external processes, in the case of social phobia it is virtually impossible to move toward values when so focused on avoidance of unpleasant experiences.

ACT interventions include discussion of control and the alternative of willingness and acceptance.  Through use of metaphors, therapists help clients to see what their true values are and how they can more effectively move in that direction with their lives, along with any negative emotions and experiences.  Many of the aforementioned CBT techniques can be used in the ACT intervention as well, but rather than helping client to approach avoided situations to reduce anxiety, the ACT therapist helps the client to approach only situations that are consistent with their desired values rather than all feared situations.