Social phobia (Social Anxiety Disorder)

Social phobia is one of the anxiety disorders. Patients with social phobia obviously and persistently feel anxious or frightened in one or many social situations. They also have negative thoughts on themselves, others as well as social interactions. They always feel being judged in social situations. At the same time, they feel worried and are self-conscious of their anxious symptoms being discovered, leading others to have a poor impression on them or even causing humiliation to themselves. They may also feel that everyone demands highly of the people around, and will judge an individual by his/her social performance.

In social situations, patients with social phobia may remain silent to avoid attention. When facing others, they may easily blush or tremble. Gradually, they try to stay away from social situations. They are, however, different from the eccentric in that they indeed do not like behaving that way. They also know that their anxiety is excessive yet they simply cannot control themselves. Finally, they can only choose to escape as their resolution.

The onset of social phobia is often at teenage, but it may also have early onset in childhood or later in adulthood.

The following factors may cause one to be more prone to social phobia:

• Shyness, timidity and withdrawal; encountering various embarrassing social situations at teenage together with the lack of social confidence may gradually develop to become social phobia.
• Having unpleasant or frightening experiences in social situations can more likely lead to fear in similar situations.
• The chance of having social phobia is higher if any family member has it.
• Children being over-protected or controlled by parents, and those often being laughed at, bullied or refused are more likely to have social phobia.

Similar to other emotional disorders, social phobia is developed by many factors, including physiological and environmental ones such as:

Social phobia is somehow related to heredity, but further research is required to verify if it is indeed linked with hereditary genes. On the other hand, some researchers stated that the behaviour of social phobia may be the result of mimicking some family members.

Neurotransmitters in the brain

Scientists have found that social phobia has a close relationship with the imbalance of the brain's neurotransmitters, e.g., the neurotransmitters may be especially sensitive to serotonin which is responsible for monitoring and regulating emotions. Also, patients with social phobia may have less dopamine, which is another kind of neurotransmitter in the brain, than normal. All these may render the patients more susceptible to social phobia.

Over-reactive fear responses

A structure in the brain called amygdala plays a role in monitoring and regulating fear responses. Some studies regarded that patients with social phobia have an over-reactive amygdala, leading to their heightened fear responses and easily becoming panic in social situations.

 Patients with social phobia may display the following emotional and physical symptoms:

Emotional Symptoms

• Extremely frightened when being together with strangers
• Fear of social situations in which he/she would be evaluated
• Worry of humiliating himself/herself or making a scene
• Fear of being found anxious
• Such anxious emotions have already affected one's daily life and work
• Fear of talking or working with others, because of the worry that he/she may be making a fool of himself/herself
• Avoid situations in which he/she may catch attention

Physical symptoms

• Blushing
• Profuse sweating
• Trembling or shaking, shaky voice
• Nausea
• Difficulty in speech
• Stomach upset
• Cold hands and feet
• Palpitations

If symptoms persist and worsen, as well as affecting daily life, one should seek for the doctor's assistance.

  The doctor will conduct a body check to exclude the possibilities of getting other diseases. He/She will also have a detailed talk as well as an assessment on the prospective patient to further understand the patient's emotional state. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), by the American Psychiatric Association, the diagnostic criteria for social phobia include:

• Obvious and persistent fear of one or more social situations in which one believes that he/she may act inappropriately (or manifest anxiety symptoms), leading to embarrassment or humiliation.
• One would almost definitely develop anxiety when being in a social situation he/she is afraid of.
• The patient recognizes that his/her anxiety is excessive or unreasonable.
• The patient will avoid anxiety-provoking social situations, or try his/her best to endure anxiety or distress.
• The patient's withdrawal, anticipated anxiety, or the uneasiness when being in such a social situation will severely affect his/her normal daily life, work (or study), social activities or social relations, which will by all means cause distress.
• The above situations are not caused by medications or other diseases.

The doctor will assess the patient's conditions and recommend medications or psychotherapy, or both.

1. Medications

To cure social phobia, the most frequently used medication is selective serotonin reuptake inhibitors (SSRI), and serotonin and norepinephrine reuptake inhibitors (SNRI). Both can help serotonin and norepinephrine to resume balance, thus improving the symptoms and curing social phobia with less side effects.

i) Selective serotonin reuptake inhibitors (SSRI)
The commonly used SSRI are Paroxetine, Sertraline, Fluvoxamine, etc. These may cause short-term nausea, insomnia, fatigue, etc. but when the medical effects begin, the side effects will gradually lessen or disappear.

ii) Serotonin and norepinephrine reuptake inhibitors (SNRI)
One example is Venlafaxine. Its effects are quicker than those of SSRI. At the early use of medications, side effects such as dizziness, headache, nausea, insomnia, etc. may occur, but they will lessen or disappear after the patient has adapted to it.

iii) Benzodiazepine
This type of anti-anxiety medication may reduce the patient’s level of anxiety in a short time, but it is habit-forming with significant long-term side effects. It is, therefore, prescribed only for short-term use.

iv) Beta blockers
These medications help the patients in a particular situation such as giving a speech through reducing heart pounding, blood pressure, shaky voice and trembling limbs. These medications, however, would not help treat social phobia.

2. Psychotherapy

Cognitive behavioural therapy is the commonly employed method of psychotherapy so far. The clinical psychologist will first develop a mutual trust with the patient. Through interview, analysis and various skills deployed, the clinical psychologist helps the patient correct certain mistakes in thinking, thus enabling one to change his/her escaping behaviour and to reduce his/her level of anxiety. During the therapy, the patient follows the schedule agreed upon between him/her and the clinical psychologist. The patient is taught to practice how to gradually face the situations he/she is afraid of and to improve his/her managing skills, thus enabling him/her to recover the confidence in dealing with these situations.

The clinical psychologist will also advise the patient on some social interaction skills and relaxation management, in the hope of improving his/her performance in social situations, thereby strengthening his/her confidence.

If left untreated, social phobia will affect the patient's work, study and interpersonal relations, causing one to lack further confidence, to feel lonely and may then give up study or work, etc.

Social phobia can also lead to the following problems:

• Drug abuse
• Excessive drinking
• Depression
• Suicide

To cure social phobia, no matter it is medications or psychotherapy that is adopted, a longer time is needed. The patient should persist in receiving treatment and getting follow-up checks as well as not giving up in the middle of the treatment. On the other hand, the patient can also consider the following suggestions which are helpful to an early recovery:

• Reaching out to people with whom you feel comfortable
• Do more relaxation exercises
• Drink less beverage containing caffeine
• Keep doing exercises and take a well-balanced diet
• Get enough sleep
• Quit alcoholic drinks and do not abuse drugs