Social Phobia Diagnosis

  • Diagnosis

    Social phobia is a common psychiatric disorder. People with social phobia have an intense fear of performance or social situations where they may be judged, embarrassed, or humiliated Table 01. Feeling shy or anxious when meeting new people or speaking in front of a group of strangers can cause anxiety in just about anyone at one time or another. Unlike shyness or stage fright, however, social phobia causes intense anxiety and distress that increases to the point of causing impairment. Even though social phobics are aware that these responses are excessive and unreasonable, they will avoid feared situations. If a particular situation is unavoidable, they will approach it with anxious anticipation that can start weeks before the actual event.

    Table 1.  Situations That Lead to Social Phobia Symptoms

    Being introduced to unfamiliar people
    Speaking/performing in public
    Speaking with people in important positions
    Eating/writing while being observed in public
    Using a public lavatory
    Using the telephone
    Initiating a conversation or small talk
    Asking questions in groups
    Refusing unreasonable requests
    Attending social gatherings
    Dating
    Receiving visitors

    There are two subtypes of social phobia: nongeneralized, in which you may fear only one or two situations (usually performance-related), and generalized, in which you fear three or more situations. If you have nongeneralized social phobia, you will be most fearful of situations that require performing in front of others. This category includes such things as public speaking, acting, or writing in public.

    Generalized social phobia is more severe and disabling than nongeneralized social phobia, and tends to run in families. Generalized social phobics fear multiple situations, including many of the same situations that are feared by nongeneralized social phobics.

    With social phobia, fears can persist even when stressful situations are avoided. If left untreated, social phobia can progress to the point where it interferes with academic achievement, employment success, income, and personal relationships.

    While experts are unsure about the exact causes of social phobia, certain biological imbalances appear to cause symptoms. Social phobia has long gone unrecognized as a major illness, thus delaying serious research into its cause. Various theories have been raised, most of them pointing to the importance of key biological imbalances in the body.

    For example, in most people a fearful situation will trigger a chemical "fight or flight" response that wanes as the person adjusts to the situation. In people with social phobia, however, the fight or flight response does not naturally diminish, but rather mounts to the point where it causes total impairment.

    An imbalance in the brain chemical serotonin may also play a role in social phobia. Serotonin is involved in modulating mood, emotions, sleep, and appetite, and is involved in the transmission of impulses between nerve cells. It is believed that people with social phobia may possess receptors that are extra-sensitive to serotonin, which then leads to fluctuations in nerve impulses.

    In feared social or performance situations, social phobia can produce symptoms of anxiety, including heart palpitations, trembling, sweating, tense muscles, and a sinking feeling in the stomach Table 02. An important reason why social phobia often goes unrecognized is that social phobics and many doctors alike dismiss social phobia as a form of exaggerated shyness. It's also easy to blame impaired daily functioning on anything but social phobia. However, there are some very distinct and important differences between social phobia and simple shyness.

    Social phobia is often mistaken for other anxiety disorders, including panic disorder and agoraphobia (fear of going outside the home) Table 03. One way to distinguish social phobia from other anxiety disorders is to examine the thoughts behind the fears. People with social phobia are afraid that they will be negatively judged, embarrassed, or humiliated in social situations; people with panic disorder fear having an unexpected panic attack in any situation—not just social situations. People with agoraphobia dread leaving a safe environment for fear that they will have an anxiety attack in a situation where they can't escape, or where familiar people are not present.

    Table 2.  Symptoms of Social Phobia

    Heart palpitations
    Trembling
    Sweating
    Tense muscles
    Sinking feeling or butterflies in the stomach
    Dry mouth
    Hot or cold sinking sensation
    Blushing
    Increased urge to urinate or defecate
    Shortness of breath
    Headache/pressure in the head

    Table 3.  Symptoms of Social Phobia as Compared to Other Disorders

    Disorder Key characteristics
    Social phobia Excessive fear of being negatively judged, embarrassed, or humiliated in social/performance situations
    Anxiety symptoms increase throughout a feared situation and become disabling
    Able to leave the house so long as assured not to run into others
    Knows that fears are unreasonable and would seek the company of others if anxiety was absent
    Shyness/performance anxiety Uneasiness about social or performance situations that quickly lessens/disappears as the situation is encountered
    Fears are not disabling
    Panic disorder Fear that unexpected anxiety attack will occur at any time
    Not limited to social situations
    Having familiar people around is comforting
    Agoraphobia Fear of leaving safe environments in case an anxiety attack occurs in a situation from which there is no escape
    Comforted by familiar faces
    Schizoid personality disorder Total lack of interest in interacting with others
    Depression Desire to withdraw from social situations as a result of depression
    Socialization is normal when not depressed.
    Feelings of inadequacy
    Body dysmorphic disorder Preoccupation with an imagined physical defect or a slight physical abnormality that leads to feelings of distress, interferes with daily functioning

    Social phobia usually begins in childhood, but symptoms start to emerge around the middle to late teenage years. Symptoms that emerge before age 11 often predict more severe disease and poorer recovery. Social phobia is the third most common psychiatric disorder in the U.S. (following substance abuse and depression), affecting roughly 8% of the population each year.

    Although social phobia may begin in childhood, its symptoms don't usually begin to emerge or peak until adolescence. Usually social phobia will worsen around age 15. This worsening may result from an especially humiliating experience, or may simply occur over time.

    Because social phobia begins in childhood, family environment appears to play a role. Feeling safe and secure is important to children. When their world is disrupted by experiences they can't control or predict, certain fears can develop. Studies suggest that people whose parents were verbally abusive to one another may be at a higher risk for social phobia than the general population. Sexual abuse by a relative before the age of 12 can also increase the risk for social phobia in women.

    Having a close relative (i.e., mother, father, sister, brother) with social phobia increases your risk for social phobia. Additionally, there's evidence that identical twins (which develop from a single egg) will have similar fears of doing things in front of others, whereas fraternal twins, developing from two different eggs, will not.

    To determine if you have social phobia, your doctor will ask about major milestones throughout your childhood, and about your relationship with your family.

    How a person handles major life transitions can provide important clues about early experiences. Be prepared to answer questions about how well you got along with your parents, as well as how well they got along with each other. You may also be asked to reveal information about any physical or sexual abuse that might have occurred, or information about dating experiences and relationships with peers.

    Your employment history and social history (current relationships and living arrangements) are also crucial to diagnosis. Work productivity and income can be significantly affected by social phobia. Productivity is reduced in about a third of people with social phobia when compared with people with recurring medical illnesses (due to absenteeism, being late for work, and poor work performance). In addition, about 20% of people in the U.S. with social phobia are on welfare or disability.

    People with social phobia are less likely to marry and more likely to divorce than people in the general population. Although most social phobics admit to feeling isolated and lonely, they often find that social contacts are difficult to maintain, and may become the source of stress rather than comfort.

    Your doctor may ask questions about any type of psychiatric illnesses that runs in your family. Social phobia may be hereditary. It also commonly leads to other psychiatric illnesses, especially when not treated promptly and aggressively. What's more, people with social phobia tend to seek care for symptoms of other disorders rather than for their social phobia.

    Sometimes conditions such as Parkinson's, eating disorders, and stuttering can cause social phobia—like symptoms. Your doctor will take a full medical history and conduct a thorough physical exam to rule out any underlying conditions. Certain medical conditions can cause a person to fear belittlement in social or performance situations. That's why your doctor will want to rule out the possibility that your symptoms are caused by an illness completely unrelated to social phobia.

    He or she will also want to conduct a physical exam to ensure that there isn't a neurological reason (such as a brain tumor, seizure disorder, eye problem, etc.) for your symptoms.

    Based on the results of your history and physical exam, your doctor may order specific laboratory tests to detect or rule out conditions similar to, or which occur in addition to, social phobia. There are some very general blood tests that help your doctor determine possible reasons for your symptoms, and others that assist with pinpointing specific anxiety disorders. Your doctor will select the best tests based on the information you provide and the findings of the histories.

    If your doctor suspects social phobia, he may ask you to complete a questionnaire designed to help confirm diagnosis, determine your type of social phobia, and develop an effective treatment program. Questionnaires are screening tools that focus on identifying key behaviors and symptoms that confirm that you have social phobia.

    Early treatment can help to prevent other conditions (e.g., depression, drug and alcohol abuse) from occurring in tandem with social phobia. Because social phobia often precedes other psychiatric disorders by a year or more, it's important to see your doctor if you suspect that you have social phobia symptoms. Early diagnosis and aggressive treatment may help to decrease the likelihood that your condition will worsen and cause total impairment. It may also head off other serious conditions before they become full-blown.

  • Prevention and Screening

    If your doctor suspects social phobia, he may ask you to complete a questionnaire designed to help confirm diagnosis, determine your type of social phobia, and develop an effective treatment program. Questionnaires are screening tools that focus on identifying key behaviors and symptoms that confirm that you have social phobia.

    Early treatment can help to prevent other conditions (e.g., depression, drug and alcohol abuse) from occurring in tandem with social phobia. Because social phobia often precedes other psychiatric disorders by a year or more, it's important to see your doctor if you suspect that you have social phobia symptoms. Early diagnosis and aggressive treatment may help to decrease the likelihood that your condition will worsen and cause total impairment. It may also head off other serious conditions before they become full-blown.

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