Social Phobia

DSM-IV-TR 300.23
(Social Anxiety Disorder)

Carolyn Miller
Deanna Lee
CPsy 427: Standardized Tests
&Measures
Examples
 A student won’t attend her university classes on the first day because she
knows that in some classes the professor will instruct them to go around the
room and introduce themselves. Just thinking about sitting there, waiting to
introduce herself to a roomful of strangers who will be staring at her makes her
feel nauseous…..The anxiety is just too much to bear -- so she skips the first
day of class to avoid the possibility of having to introduce herself in public.

 To the person with social anxiety, going to a job interview is pure

torture…..You’ll look funny, you’ll be hesitant, maybe you’ll even blush, and you
won’t be able to find the right words to answer all the questions. It is especially
frustrating because you know you could do the job well if you could just get
past this terrifying and intimidating interview.

 A man hates to go to work because a meeting is scheduled the next day…. Just
the thought of speaking in front of co-workers raises his anxiety. Sometimes he
can’t sleep the night before because of the anticipatory anxiety that builds up.
Finally, the meeting is over. A big wave of relief spills over him as he begins to
relax. But the memory of the meeting is still uppermost in his mind. He is
convinced he made a fool of himself and that everyone in the room saw how
afraid he was when he spoke and how stupid he acted in their presence.
The Third Largest Mental Health
Problem in the US
 The fear of social situations that involve interactions
with other people which can automatically bring
about feelings of self-consciousness, judgment,
evaluation, and criticism.
 Social Phobia is much more common now then past
estimates have led us to believe. It is believed to
affect 15 million Americans in any given year.
 As a result of social anxiety many may suffer from
depression.
 Those with social anxiety may abuse alcohol or
drugs to reduce fear in social settings.
Emotional Distress
 Being introduced to others people
 Being teased or criticized
 Being the center of attention
 Being watched while doing something
 Meting people in authority
 Most social encounters, particularly with
strangers
 Making small talk at parties
 Going around the room in a circle and having
to say something
Physiological Manifestations
 Intense fear
 Racing heart
 Turning red or blushing
 Dry throat and mouth
 Trembling
 Swallowing with difficulty
 Muscle twitches
 Gastrointestinal discomfort
Features and Perceptions
 People with social anxiety will  People with social
often feel:
 Hypersensitivity to criticism
anxiety can often be
 Negative evaluation
viewed as:
 Rejection  Quiet
 Difficulty being assertive  Shy
 Low self-esteem
 Inferiority
 Introverted
 Fear that everyone's attention is  Backward
focused on them  Withdrawn
 Fear that they will make mistakes
and everyone will notice  inhibited
 Feeling that everyone else is more  Unfriendly
capable in the same situation
 Fear that they are being judged by  Nervous
others  Aloof
 Fear that they will embarrass or
humiliate themselves in front of  Disinterested
others
 DSM-IV DIAGNOSTIC CRITERIA
 A. A marked and persistent fear of one or more social and 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 predisoposed Panic Attack. Note: In children, the anxiety may be expressed by crying, tantrums, freezing, or
shrinking from social situations with unfamiliar people.

 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 situation 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.
Features of Social Phobia
 They will typically avoid these feared situations.
 Less commonly, the person will force themselves to endure the social
or performance situation, but experiences it with intense anxiety.
 Marked anticipatory anxiety may also occur far in advance of an
upcoming event. Sometimes worrying for weeks before attending a
social event.
 Fears of embarrassment in social situations are common, but the
degree of distress or impairment must be extreme to warrant
diagnosis.
 The fear or avoidance must interfere significantly with the person’s
normal routine, occupational or academic functions, or social
activities and relationships.
 Shy people do not experience the same intense anxiety as people
with social anxiety disorder. In addition, shy people do not avoid
social situations to the extreme that people with social anxiety
disorder do.
Culture & Gender
 Clinical presentation and resulting impairment may differ across
cultures depending on social demands.

 It was found that the effects of parenting may play a part in social
anxiety- American children appear more likely to develop social
anxiety disorder if their parents emphasize the importance of other's
opinions and use shame as a disciplinary strategy

 In certain cultures (e.g., Japan & Korea), individuals may develop

persistent and excessive fears of giving offense to others in social
situations, instead of being embarrassed.

 These fears may take the form of extreme anxiety that blushing, eye-
to-eye contact, or one’s body odor will be offensive to others.

 Studies have show social phobia to be 2x’s more common in women.

Age
 In children crying, tantrums, freezing, clinging or staying
close to a familiar person, and inhibited interactions to
the point of mutism may be present. Younger children
may appear excessively timid, shrink from contact of
others, or refuse to participate in group play.
 Unlike adults they do not have much option in avoiding
feared situations and may be unable to identify the
nature of their anxiety.
 Impairments may take the form of failure to achieve an
expected level of functioning rather then a decline from
an optimal level of performance.
 However in adolescents there may be a notable decline
in social and academic performance as with the adult
population.
Social Phobia Onset
 Typically has an onset in the mid-teens. Sometimes
emerging out of a childhood history of social
inhibition or shyness.
 There have been some reports of onsets in early
childhood.
 May abruptly follow a stressful or humiliating
experience.
 Duration is frequently lifelong.
 Severity may fluctuate with life stressors and
demands.
 More common to those who have parents
diagnosed with the disorder.
Anticipating Social Situation
Differential Diagnosis
 Panic Disorder
 Agoraphobia
 Separation Anxiety Disorder
 Specific Phobia
 Pervasive Developmental Disorder
 Schizoid Personality Disorder
 Avoidant Personality Disorder
 Anxiety Disorder not otherwise specified
Tests and Measures of SAD
 Interview/Assessment
 Self-rating scales
 Social Phobia Inventory (SPIN)
 Mini SPIN
 http://socialanxiety.factsforhealth.org/have/
 Beck Anxiety Inventory
 Clinician Diagnosis
 Treatment Options

 Medication Therapy
 Behavior Therapy
 Cognitive-Behavior Therapy
 Combination Therapy
Medication Therapy
 Can decrease the frequency and intensity of anxiety
and avoidance behavior for individuals with social
anxiety disorder
 Research indicates that about 70% of SAD patients
achieve gains from medication therapy
 Advantages
 Minimal effort
 Relieve symptoms more quickly than therapy
 Disadvantages
 Side effects
 Gains from medication may fade when meds are stopped
 Medications Used for
Treatment
 There are 5 categories of medication used
for treatment, currently there are only three
types of medication approved by the FDA
 SSRI - selective serotonin reuptake inhibitor
 Paroxetine (Paxil) – 1st med to receive FDA
approval
 Sertraline (Zoloft)
 SNRI – serotonin-norepinephrine reuptake
inhibitor
 Venlafaxine (Effexor)
5 Categories of Medication
 SSRI – selective seretonin reuptake
inhibitor
 SNRI – serotonin norepinephrine
reuptake inhibitor
 Benzodiazepines
 MAOIs – monoamine oxidase
inhibitors
 Gabapentine
 Behavior Therapy
 Provides patients with a method for controlling anxiety
in social situation, for decreasing anticipatory anxiety,
and for reducing the use of avoidance as a maladaptive
coping tactic
 Advantages
 Free of side effects
 Results are long-lasting
 Disadvantages
 Requires a significant amount of time and effort
 Must be willing to face avoided situation and endure increase in
anxiety before decrease
 Experienced behavior therapists not always available
 Behavior therapy does not work for everyone
 How does Behavior Therapy
work?
 A structured set of techniques that a patient
learns to employ whenever anxiety, panic,
discomfort, dysfunction or avoidance arises.
Focuses on specific steps a patient can take
to reduce anxiety and keep it from returning.
 Exposure – patients are asked to face the
thing they fear
 Must learn to stop using avoidance as a way of
coping with any anxiety that occurs
 Cognitive - Behavior Therapy
 It is a way to talk about how you think about yourself,
the world, and other people
 How what you do effects your thoughts and feelings
 CBT can help you to change how you think ("Cognitive")
and what you do ("Behavior)".
 A Situation - a problem, event or difficult situation
From this can follow:
 Thoughts
 Emotions
 Physical feelings
 Actions
 Each of these areas can affect the others. How you think about a
problem can affect how you feel physically and emotionally. It can
also alter what you do about it.
How CBT Works
 With the therapist, you break each problem down into its
separate parts. therapist may ask you to keep a diary. This
will help you to identify your individual patterns of thoughts,
emotions, bodily feelings and actions.
 Together you will look at your thoughts, feelings and
behaviors to work out:
- if they are unrealistic or unhelpful
- how they affect each other, and you.
 Therapist will then help you to work out how to change
unhelpful thoughts and behaviors.
 After you have identified what you can change, your therapist
will recommend "homework" - you practice these changes in
your everyday life.
 Question a self-critical or upsetting thought and replace it with a
positive (and more realistic) one that you have developed in CBT
 CBT
 http://www.youtube.com/watch?v=hL0
ZSzyYl5o
 Combination Therapy
 Combine medication with behavior
therapy or CBT
 May be the most effective treatment
for social anxiety disorder
 Some choose to begin with medication
before starting therapy, others want to
start with therapy and add medication
if needed.
 Famous People
 Many famous people suffer from social anxiety disorder,
including:
 Jerry Seinfeld,
 Kim Basinger,
 Donny Osmond,
 Barbara Streisand,
 Sir Laurence Olivier,
 Susie O’Neill,
 Rebecca Gibney,
 Gary MacDonald, and
 Simon Palomares.
 As performers, many of these stars have learned to deal
effectively with their social anxiety disorder.
 (http://www.socialanxietyblog.com/m=200507)
 (
http://www.socialanxietyassist.com.au/famous_people.shtml
)
 References
American psychiatric association: Diagnostic and statistical ,manual of mental disorders(4 th
ed.tr.).(2000). Washington, DC, American Psychiatric Association
Clip http://www.youtube.com/watch?v=hL0ZSzyYl5o&mode=related&search
Department of Health (2001). Treatment choice in psychological therapies and counselling.
London: HMSO.
Famous People. Used to describe social anxiety of celebrities and possible therapy used.
http://www.socialanxietyassist.com.au/famous_people.shtml
Hofmann, S. G., & Moscovitch, D. A., (2006). When ambiguity hurts:Social standards moderate
self-appraisals in generalized social phobia. Behaviour Research and Therapy: In Press.
Miller, Gary. (2005). Social Anxiety Holds You Back. Examples of Famous people with SAD
http://www.socialanxietyblog.com/?m=200507
Royal College of Psychiatrists, Cognitive Behavioural Therapy (2005)
http://www.rcpsych.ac.uk/mentalhealthinformation/cognitivebehaviouraltherapy
Social Anxiety Disorder. SPIN Inventory, Dr. Jonathan Davidson (1999). Therapy Options:
Medicine and Behavior therapy http://socialanxiety.factsforhealth.org/help/
Social Anxiety Institute. What is the difference between social anxiety and panic disorder?
Retrieved March 17, 2007, from http://socialanxietyinstitute.org
Social Phobia/ Social Anxiety Association. Fact Sheet. Retrieved March 17, 2007, from
http://www.socialphobia.org
The Social Anxiety Network. Examples of social anxiety disorder. Retrieved March 17, 2007,
from http://www.social-anxiety-network.com