Social Phobia (Social Anxiety Disorder) — The Dana Guide


by Murray B. Stein

March, 2007

sections include: searching for a causediagnosis and treatment 

Social phobia, or social anxiety disorder, is often mistaken for ordinary shyness. In fact, many people who have this disorder think of themselves as shy, but they are also painfully aware that their shyness is more severe than most people’s and that it interferes with their quality of life. Unfortunately, most people with social phobia fail to seek treatment because they do not recognize it as a treatable condition, and perhaps because they are so reticent about calling attention to themselves.

Individuals with social phobia are typically timid, quiet in groups, and uncomfortable being the center of attention. Accordingly, they avoid speaking in public, expressing opinions, or even socializing with peers. Many people with social phobia lack self-esteem, find it difficult to interact with people in authority, and cannot speak or perform in front of even small groups.

People with social phobia fear and avoid social situations because they believe that they will do or say something to embarrass themselves. For example, they may avoid signing checks in the supermarket for fear that their hands will shake and observers will discover that they are anxious. People with social phobia also tend to process neutral social information in ways that reflect negatively on themselves. For example, when talking with a new acquaintance, a social phobia sufferer might think, “Was that a yawn? She thinks I’m boring!” These negative thoughts lead to even more anxiety in social situations, and even to avoiding those situations. When an individual is unable to avoid or easily escape from a frightening social situation, he or she may experience an anxiety attack similar to those that occur in panic disorder.

We use the term generalized social anxiety disorder when a person’s social phobia interferes with a wide range of social situations. It is this generalized form that is most pervasive and accounts for most cases seen by psychiatric and general medical practitioners, although most people with social anxiety disorder never seek care for this condition. Approximately 5 percent to 10 percent of the general population has some form of social phobia, about a third of which is of the more pervasive, generalized type.

Social anxiety disorder begins early in life and often becomes manifest in childhood. About 50 percent of people with the disorder report that it began before their adolescence, many recalling that they “have always been this way.” Others report the onset during or shortly after adolescence. As an early-onset disorder, social anxiety disorder is frequently complicated over time by the occurrence of other conditions, most prominent among them being major depression, alcoholism and, more rarely, other substance abuse disorders.

Social phobia can result in tremendous disability and impairment in a person’s life. It is a disorder of lost opportunities. People with the illness make major life choices in order to accommodate it. For example, an individual with social anxiety disorder may drop out of school early due to fear of speaking in front of groups, or search for jobs that allow workers to avoid interacting with others. People suffering from social phobia often do not date at all, and many become lonely and isolated. If and when they eventually seek treatment, people with generalized social anxiety disorder report tremendous dissatisfaction with their lives.

Searching for a Cause

As with other psychiatric conditions, the causes of social phobia disorder remain obscure. It might seem reasonable to expect that childhood adversities or developmental experiences would confer an increased risk for the disorder, but studies have not yet shown this pattern. The disorder has a hereditary component, particularly in its generalized form; the risk to first-degree relatives (parents, siblings, or offspring) is five to ten times that of the general population. This finding, of course, does not distinguish the family environment in which a person grows up from his or her genetic inheritance of risk, but researchers are trying to isolate those factors.

Researchers are currently testing several biological models of social phobia; one of the most promising is the theory that the disorder involves dysfunction in the brain’s systems to regulate dopamine. In support of this possibility, two separate studies using a form of computed tomography (CT) scan called single-photon-emission computed tomography (SPECT) have found that people with generalized social phobia show a significantly lower count of molecules binding to the dopamine transporter, and to the dopamine D2 receptor in their brains, compared with healthy subjects. Additional imaging studies, looking at functioning within neural circuits believed to mediate fear and anxiety (for example, the amygdala and related structures), point to possible alterations in functioning of these neural systems in social phobia.

Diagnosis and Treatment

We now know that social phobia is a treatable disorder, and that several pharmacotherapeutic choices are available to the physician. Treatment with medication for a year or more is usually recommended, but optimal duration of treatment is currently being studied. We also know that many people benefit from cognitive behavioral therapy directed at changing their views about themselves and their expectations for social interactions, in concert with gradual exposure to and practice in the social situations they fear.

Although the efficacy of the monoamine oxidase inhibitors (for example, phenelzine) in the treatment of social phobia has been confirmed, their unfavorable side effects and the need for a special, low-tyramine diet have relegated them to second- or third-line status.

High-potency benzodiazepines (such as clonazepam) are efficacious for social phobia, although their potential for abuse remains of some concern and may limit their use by some practitioners. Beta-adrenergic blockers (such as propranolol and atenolol), although of some use in the treatment of isolated performance anxiety, are probably of no benefit in the treatment of generalized social anxiety disorder. This information still needs to reach some physicians, many of whom equate social phobia with public-speaking anxiety and accordingly prescribe beta-blockers because of their familiarity with this class of drugs. Similarly, buspirone, another medication frequently used to treat anxiety in primary care settings, has been shown to be inefficacious in the treatment of social anxiety disorder.

Recently the effectiveness of selective serotonin reuptake inhibitors (SSRIs) for social phobia has been confirmed in large clinical trials. Currently, newer pharmacotherapies are being tested, and researchers are exploring the possibility of combining pharmacotherapy and cognitive behavioral therapy.  

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