Social anxiety

2007 Schools Wikipedia Selection. Related subjects: Health and medicine

Social phobias
Classifications and external resources

ICD- 10	F40.1
ICD- 9	300.23

Social anxiety is an experience of fear, apprehension or worry regarding social situations and being evaluated by others. People vary in how often they experience anxiety in this way or in which kinds of situations. Anxiety about public speaking, performance, or interviews is common.

Social anxiety disorder, also referred to clinically as social phobia, is a psychiatric anxiety disorder involving overwhelming anxiety and excessive self-consciousness in everyday social situations. People experiencing social anxiety often have a persistent, intense, and chronic fear of being watched and judged by others and being embarrassed or humiliated by their own actions. Often the triggering social stimulus is a perceived or actual scrutiny by others. Their fear may be so severe that it significantly impairs their work, school, social life, and other activities. While many people experiencing social anxiety recognize that their fear of being around people may be excessive or unreasonable, they encounter considerable difficulty overcoming it. This differs from shyness, in that the person is functionally debilitated and avoids such anxiety provoking situations. At the same time, a person with social anxiety may only feel the fear during certain situations. For example, an actor or singer may feel fine on stage, but afraid of social situations in everyday life.

Social anxiety is often part of only a certain situation—such as a fear of speaking in formal or informal situations, or eating, or writing in front of others—or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people. Many people have the specific fear of public speaking, called glossophobia. In this case, the fear is of doing or saying something which may cause embarrassment. Approximately 13.3% of the general population will experience social phobia at some point in their lifetime according to the highest estimate; with the male to female ratio being 1.4:1.0, respectively. Physical symptoms often accompany social anxiety, and include blushing, profuse sweating, trembling, nausea, and stammering. Panic attacks may also occur under intense fear and discomfort. An early diagnosis helps in minimizing the symptoms and the development of additional problems such as depression. Some sufferers may use alcohol or drugs to reduce fears and inhibitions at social events.

A person with the disorder may be treated with psychotherapy, medication, or both. Research has shown cognitive behaviour therapy, whether individually or in a group, to be effective in treating social phobia. The cognitive and behavioural components seek to change thinking patterns and physical reactions to anxious situations. Prescribed medication includes a class of antidepressants called selective serotonin reuptake inhibitors (SSRIs).

Attention given to social anxiety disorder has significantly increased since 1999 with the approval and marketing of drugs for its treatment.

Overview

According to the Diagnostic and Statistical Manual of Mental Disorders, social phobia is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that he or she may do something or act in a way that will be humiliating or embarrassing. For one to be social phobic, exposure to the feared situation must provoke anxiety and the person must recognize this anxiety is irrational (although this may be absent in children). If another disorder is present, the social phobic fear is unrelated to it. For instance, if a person has a history of panic attacks, having a panic attack must not be the sufferer's fear. Sufferers are typically more self-conscious and self-attentive than others. As a result, social phobics tend to limit or remove themselves from situations where they may be subject to evaluation. Sufferers often recognize their fear is excessive or irrational, yet can't seem to break out of the cycle. As such, the diagnosis of social phobia is made only when the fear leads to avoiding occupational functions, social activities, or relationships with others.

Mental health professionals often distinguish between generalized and specific social anxiety disorders. People with generalized social anxiety have great distress with most or all social situations. A famous study by Stanford University established that distress was more likely when social encounters were unfamiliar, involved power or status differences, difference in gender, or the presence of a group of people. Those with specific social phobias may experience anxiety only in a few situations. For example the most common specific phobia is glossophobia, the fear of public speaking or performance, also known as "stage fright". Other examples of specific social phobias include fears of writing in public ( scriptophobia) and using public restrooms ( paruresis).

There is much debate concerning the relationship between social phobia and shyness. Shyness is not a criterion for social anxiety disorder. People with social anxiety disorder may be quite comfortable with certain people or many people, but still feel intense anxiety in specific social situations. Child psychologist Samuel Turner provides a summary between shyness and social phobia. Both share several features: negative cognitions in social situations, heightened physiological reactivity, a tendency to avoid social situations, and deficits in social skills. Negative cognitions include fear of negative evaluation, self-consciousness, devaluation of social skills, self-deprecating thoughts, and self-blaming attributions for social difficulties. Social phobia is distinct from shyness in that it has a lower prevalence in the population, follows a more chronic course, is more functionally debilitating, and has a later age of onset. There are problems with these kinds of comparisons. It may be that the differences between them are quantitative rather than qualitative. There are some that argue that shyness is mistakenly treated with medication intended for social phobia, effectively labeling the personality trait a mental illness.

Social phobia should not be confused with panic disorder. Sufferers of panic disorder are convinced that their panic comes from some dire physical cause, and often go to the hospital or call for an ambulance during or after their attacks. Social phobics may experience a panic attack when triggered, but they are aware that it is extreme anxiety they are experiencing, and that the cause is an irrational fear. Few social phobics would willingly go to a hospital in that instance because they fear rejection and judgment by authority figures (such as the medical staff). The general form of social anxiety is sometimes incorrectly called generalized anxiety disorder. The principal difference between the two is that the social phobia deals with anxiety in a social setting, while generalized anxiety disorder is extreme anxiety for any situation (work, school, et al.), not necessarily one involving other people.

Symptoms

Cognitive aspects

In cognitive models of social anxiety, social phobics experience dread over how they will be presented to others. They may be overly self-conscious, pay high self-attention after the activity, or have high performance standards for themselves. According to the social psychology theory of self-presentation, a sufferer attempts to create a well-mannered impression on others but believes he or she is unable to do so. Many times, prior to the potentially anxiety-provoking social situation, sufferers may deliberate over what could go wrong and how to deal with each unexpected case. After the event, they may have the perception they performed unsatisfactorily. Consequently, they will review anything that may have possibly been abnormal or embarrassing. These thoughts do not just terminate soon after the encounter, but may extend for weeks or longer. Those with social phobia tend to interpret neutral or ambiguous conversations with a negative outlook and although still inconclusive, some studies suggest that socially anxious individuals remember more negative memories than those less distressed. An example of an instance may be that of an employee presenting to his co-workers. During the presentation, the person may stutter a word upon which he or she may worry that other people significantly noticed and think that he or she is a terrible presenter. This cognitive thought propels further anxiety which may lead to further stuttering, sweating and a possible panic attack.

Behavioural aspects

Social Anxiety Disorder is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that he or she may do something or act in a way that will be humiliating or embarrassing. It exceeds normal "shyness" as it leads to excessive social avoidance and substantial social or occupational impairment. Feared activities may include most any type of social interaction, especially small groups, dating, parties, talking to strangers, restaurants, etc. Physical symptoms include "mind going blank", fast heartbeat, blushing, stomach ache. Cognitive distortions are a hallmark, and learned about in CBT. Thoughts are often self-defeating and inaccurate. According to renowned psychologist B.F. Skinner, phobias are controlled by escape and avoidance behaviors. For instance, a student may leave the room when talking in front of the class (escape) and refrain from doing verbal presentations because of the previously encountered anxiety attack (avoid). Minor avoidance behaviors are exposed when a person avoids eye contact and crosses arms to avoid recognizable shaking. A fight-or-flight response is then triggered in such events. Preventing these automatic responses is at the core of treatment for social phobia.

Physiological aspects

Physiological effects, similar to those in other anxiety disorders, are present in social phobics. Faced with an uncomfortable situation, children with social anxiety may display tantrums, crying, clinging to parents, and shutting themselves out. Adults may weep, as well as experience excessive sweating, nausea, shaking, and palpitations as a result of the fight-or-flight response. Blushing is commonly exhibited by individuals suffering from social phobia. These visible symptoms further reinforce the anxiety in the presence of others. A 2006 study found that the area of the brain called the amygdala, part of the limbic system, is hyperactive when patients are shown threatening faces or confronted with frightening situations. They found that patients with more severe social phobia showed a correlation with the increased response in the amygdala.

Prevalence

When prevalence estimates were based on the examination of psychiatric clinic samples, social anxiety disorder was thought to be a relatively rare disorder. The opposite was instead true; social anxiety was common but many were afraid to seek psychiatric help, leading to an understatement of the problem. Prevalence rates vary widely because of its vague diagnostic criteria and its overlapping symptoms with other disorders. There has been some debate on how the studies are conducted and whether the illness truly impairs the respondents as laid out in the official criteria. Psychologist Dr. Ray Crozier argues, "it is difficult to ascertain whether the person being interviewed adheres to the DSM-III-R criteria or whether they are merely exhibiting poor social skills or shyness."

The National Comorbidity Survey of over 8,000 American correspondents in 1994 revealed a 12-month and lifetime prevalence rates of 7.9% and 13.3% making it the third most prevalent psychiatric disorder after depression and alcohol dependence and the most apparent of the anxiety disorders. According to U.S. epidemiological data from the National Institute of Mental Health, social phobia affects 5.3 million adult Americans in any given year. Recent studies suggest the lifetime prevalence number may be as high as 15 million people or 6.8% of the American population. Cross-cultural studies have reached prevalence rates with the conservative rates at 5% of the population. However, other estimates vary within 2% and 7% of the U.S. adult population.

Onset of social phobia typically occurs between 11 and 19 years of age. Onset after age 25 is rare. Social anxiety disorder occurs in females twice as often as males, although men are more likely to seek help. The prevalence of social phobia appears to be increasing among white, married, and well-educated individuals. As a group, those with generalized social phobia are less likely to graduate from high school and are more likely to rely on government financial assistance or have poverty-level salaries. Surveys carried out in 2002 show the youth of England, Scotland, and Wales have a prevalence rate of .4%, 1.8%, and .6%, respectively. The prevalence of self-reported social anxiety for Nova Scotians older than 14 years was 4.2% in June 2004 with women (4.6%) reporting more than men (3.8%). In Australia, social phobia is the 8th and 5th leading disease or illness for males and females between 15-24 years of age as of 2003.

Comorbidity

There is a high degree of comorbidity with other psychiatric disorders. Social phobia often occurs alongside low self-esteem and clinical depression, due to lack of personal relationships and long periods of isolation from avoiding social situations. To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to substance abuse. It is estimated that one-fifth of patients with social anxiety disorder also suffer from alcohol dependence. The most common complementary psychiatric condition is depression. In a sample of 14,263 people, of the 2.4% of persons diagnosed with social phobia, 16.6% also met the criteria for major depression. Besides depression, the most common disorders diagnosed in patients with social phobia are panic disorder (33%), generalized anxiety disorder (19%), post-traumatic stress disorder (36%), substance abuse disorder (18%), and attempted suicide (23%). In one study of social anxiety disorder patients who developed comorbid alcoholism, panic disorder or depression, social anxiety disorder preceded the onset of alcoholism, panic disorder and depression in 75%, 61%, and 90% of patients, respectively. Avoidant personality disorder is also highly correlated with social phobia. Because of its close relationship and overlapping symptoms with other illnesses, treating social phobics may help understand underlying connection in other psychiatric disorders.

There is research indicating that social anxiety disorder is often correlated with bipolar disorder . Some researchers believe they share an underlying cyclothymic-anxious-sensitive disposition. In addition, studies show that a proportion of socially phobic patients treated with anti-depressant medication develop hypomania ., although this can be seen as the medication creating a new problem, and also has this adverse effect in a proportion of those without social phobia.

Causes and perspectives

Research into the causes of social anxiety and social phobia is wide-ranging, encompassing multiple perspectives from neuroscience to sociology. Scientists have yet to pinpoint the exact causes. Studies suggest that genetics plays a part in combination with environmental factors.

Genetic and family factors

It has been shown that there is a two to three fold greater risk of having social phobia if a first-degree relative also has the disorder. This could be due to genetics and/or due to children acquiring social fears and avoidance through processes of observational learning or parental psychosocial education. Studies of identical twins brought up (via adoption) in different families have indicated that, if one twin developed social anxiety disorder, then the other was between 30% and 50% more likely than average to also develop the disorder (Kendler et al., 1999). To some extent this 'heritability' may not be specific - for example, studies have found that if a parent has any kind of anxiety disorder or clinical depression, then a child is somewhat more likely to develop an anxiety disorder or social phobia (Merikangas et al., 1999). Studies suggest that parents of those with social anxiety disorder tend to be more socially isolated themselves (Bruch and Heimberg, 1994; Caster et al, 1999), and shyness in adoptive parents is significantly correlated with shyness in adopted children (Daniels and Plomin, 1985);

Adolescents who were rated as having an insecure (anxious-ambivalent) attachment with their mother as infants were twice as likely to develop anxiety disorders by late adolescence (Warren et al, 1997), including social phobia (SAD)

A related line of research has investigated 'behavioural inhibition' in infants - early signs of an inhibited and introspective or fearful nature. Studies have shown that around 10-15% of individuals show this early temperament, which appears to be partly due to genetics. Some continue to show this trait in to adolescence and adulthood, and appear to be more likely to develop social anxiety disorder (Schwartz et al., 1999)

Social Experiences

A previous negative social experience can be a trigger to social phobia. , perhaps particularly for individuals high in 'interpersonal sensitivity'. For around half of those diagnosed with social anxiety disorder, a specific traumatic or humiliating social event appears to be associated with the onset or worsening of their disorder (Mineka & Zinbarg, 1995); this kind of event appears to be particularly related to specific performance SA, for example public speaking (Stemberg et al., 1995). As well as direct experiences, observing or hearing about the socially negative experiences of others (e.g. a faux pas committed by someone), or verbal warnings of social problems and dangers may also make the development of a social anxiety disorder more likely (Beidel & Turner, 1998). Social anxiety disorder may be caused by the longer-term effects of not fitting in, or being bullied, rejected or ignored (Beidel and Turner, 1998). Shy adolescents or avoidant adults have emphasised unpleasant experiences with peers (Ishiyama, 1984) or childhood bullying or harassment (Gilmartin, 1987). In one study, popularity was found to be negatively correlated with social anxiety, and children who were neglected by their peers reported higher social anxiety and fear of negative evaluation than other categories of children (La Greca et al, 1988). Socially phobic children appear less likely to receive positive reactions from peers (Spence et al, 1999) and anxious or inhibited children may isolate themselves (Rubin and Mills 1988).

Sociocultural influences

Cultural factors that have been related to social anxiety disorder include a societies attitude towards shyness and avoidance, impacting ability to form relationships or access employment or education. In China, research has indicated that shy-inhibited children are more accepted than their peers and more likely to be considered for leadership and considered competent, in contrast to the findings in Western countries (Xinyin, Rubin & Boshu, 1995). Purely demographic variables may also play a role - for example there are possibly lower rates of social anxiety disorder in Mediterranean countries and higher rates in Scandinavian countries, and it has been hypothesised that hot weather and high-density may reduce avoidance and increase interpersonal contact. There appear to be differences between more 'western' and more 'eastern' cultures. One study has suggested that the effects of parenting are different depending on the culture - American children appear more likely to develop social anxiety disorder if their parents emphasise the importance of other's opinions and use shame as a disciplinary strategy (Leung et al., 1994), but this association was not found for Chinese/Chinese-American children.

Problems in developing 'social skills' may be a cause of some social anxiety disorder, through either inability or lack of confidence to interact socially and gain positive reactions and acceptance from others. The studies have been mixed, however, with some studies not finding significant problems in social skills (Rapee & Lim, 1992) while others have (Stopa & Clark, 1993). What does seem clear is that the socially anxious perceive their own social skills to be low. It may be that the increasing need for sophisticated social skills in forming relationships or careers, and an emphasis on assertiveness and competitiveness, is making social anxiety problems more common, at least among the 'middle classes' (Heimberg et al., 2000). An interpersonal or media emphasis on 'normal' or 'attractive' personal characteristics has also been argued to fuel perfectionism and feelings of inferiority or insecurity regarding negative evaluation from others. The need for social acceptance or social standing has been elaborated in other lines of research relating to social anxiety (e.g. Baumeister & Leary).

Evolutionary context

A long-accepted evolutionary explanation of anxiety is that it reflects an in-built 'fight or flight' system, which errs on the side of safety. One line of research suggests that specific dispositions to monitor and react to social threats may have evolved, reflecting the vital and complex importance of social living and social rank in human ancestral environments. Charles Darwin originally wrote about the evolutionary basis of shyness and blushing, and modern evolutionary psychology and psychiatry also addresses social phobia in this context. It has been hypothesised that in modern day society these evolved tendencies can become more inappropriately activated and result in some of the cognitive 'distortions' or 'irrationalities' identified in cognitive-behavioural models and therapies (Gilbert, 1998).

Neurochemical and neurocognitive influences

Some scientists hypothesize that social phobia is related to an imbalance of the brain chemical serotonin. Sociability is also closely tied to dopamine neurotransmission. Low D2 receptor binding is found in people with social anxiety.. The efficacy of medications which affect Serotonin and Dopamine levels also indicates the role of these pathways. There is also increasing focus on other candidate transmitters, e.g. Noradrenalin, which may be over-active in social anxiety disorder, and the inhibitory transmitter GABA.

Individuals with social anxiety disorder have been found to have a hypersensitive amygdala, for example in relation to social threat cues (e.g. someone might be evaluating you negatively), angry or hostile faces, and while just waiting to give a speech (Davidson, 2000). Recent research has also indicated that another area of the brain, the 'Anterior Cingulate Cortex', which was already known to be involved in the experience of physical pain, also appears to be involved in the experience of 'social pain', for example perceiving group exclusion (Eisenberger et al 2003).

Psychological factors

Research has indicated the role of 'core' or 'unconditional' negative beliefs (e.g. I am inept) and 'conditional' beliefs nearer to the surface (e.g. If I show myself, I will be rejected). They are thought to develop based on personality and adverse experiences and to be activated when the person feels under threat (Beck & Emery, 1986). One line of work has focused more specifically on the key role of self-presentational concerns (e.g. Leary, 1995). The resulting anxiety states are seen as interfering with social performance and the ability to concentrate on interaction, which in turn creates more social problems, which strengthens the negative schema. Also highlighted has been a high focus on and worriy about anxiety symptoms themselves and how they might appear to others (Clark & Wells, 1995). A similar model (Heimberg & Rapee, 1997) emphasises the development of a distorted mental representation of their self and over-estimates of the likelihood and consequences of negative evaluation, and of the performance standards that others have. Such cognitive-behavioural models consider the role of negatively-biased memories of the past and the processes of rumination after an event, and fearful anticipation before it. Studies have also highlighted the role of subtle avoidance and defensive factors, and shown how attempts to avoid feared negative evaluations or use 'safety behaviours' (Clark & Wells, 1995) can make social interaction more difficult and the anxiety worse in the long run. This work has been influential in the development of Cognitive Behavioural Therapy for social anxiety disorder, which has been shown to have efficacy.

Treatment

Arguably the most important clinical point to emerge from studies of social anxiety disorder is the benefit of early diagnosis and treatment. Social anxiety disorder remains underrecognized in primary care practice, with patients often presenting for treatment only after the onset of complications such as major depression or substance use disorders. Improvement is lower for those with more severe social phobia and with comorbid disorders, such as avoidant personality disorder and depression. The patients who achieve full resolution are usually far fewer; there are still many who, after receiving treatment, are unable to function in the long-term without anxiety symptoms.

Research has provided evidence for the efficacy of two forms of treatment available for social phobia: certain medications and a specific form of short-term psychotherapy called cognitive-behavioural therapy (CBT), the central component being gradual exposure therapy.

Pharmacological treatments

SSRIs

Selective serotonin reuptake inhibitors (SSRIs), a class of antidepressants, are considered by many to be the first choice medication for generalised social phobia. These drugs elevate the level of the neurotransmitter serotonin, among other effects. The first drug formally approved by the Food and Drug Administration was paroxetine, sold as Paxil in the US. Compared to older forms of medication, there is less risk of tolerability and drug dependency. However, their efficacy and increased suicide risk has been subject to controversy.

In a 1995 double-blind, placebo-controlled trial, the SSRI paroxetine was shown to result in clinically meaningful improvement in 55% of patients with generalized social anxiety disorder, compared with 23.9% of those taking placebo. An October 2004 study yielded similar results. Patients were treated with either fluoxetine, psychotherapy, fluoxetine and psychotherapy, placebo and psychotherapy, and a placebo. The first four sets saw improvement in 50.8 to 54.2% of the patients. Of those assigned to receive only a placebo, 31.7 percent achieved a rating of 1 or 2 on the Clinical Global Impression-Improvement scale. Those who sought both therapy and medication did not see a boost in improvement.

General side-effects are common during the first weeks while the body adjusts to the drug. Symptoms may include headaches, nausea, insomnia and changes in sexual behaviour. Treatment safety during pregnancy has not been established. In late 2004 much media attention was given to a proposed link between SSRI use and juvenile suicide. For this reason, the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor. Recent studies have shown no increase in rates of suicide. These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder. However, it should be noted that due to the nature of the conditions, those taking SSRIs for social phobias are far less likely to have suicidal ideation than those with depression.

Other drugs

Although SSRIs are often the first choice for treatment, other prescription drugs are also commonly issued, sometimes only if SSRIs fail to produce any clinically significant improvement.

In 1985, before the introduction of SSRIs, anti-depressants such as monoamine oxidase inhibitors (MAOIs) were frequently used in the treatment of social anxiety. Their efficacy appears to be comparable or sometimes superior to SSRIs or Benzodiazepines. However, because of the dietary restrictions required, high toxicity in overdose, and incompatibilities with other drugs, its usefulness as a treatment for social phobics is now limited. Some argue for their continued use, however, or that a special diet does not need to be strictly adhered to. A newer type of this medication, Reversible inhibitors of monoamine oxidase subtype A (RIMAs) inhibit the MAO enzyme only temporarily, improving the adverse-effect profile but possibly reducing their efficacy.

Benzodiazepines are a short-acting and more potent alternative to SSRIs. The drug is often used for short-term relief of severe, disabling anxiety. Although benzodiazepines are still sometimes prescribed for long-term use in some countries, there is much concern over the development of drug tolerance, dependency and recreational abuse. Benzodiazepines augment the action of GABA, the major inhibitory neurotransmitter in the brain; effects usually begin to appear within minutes or hours.

Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure. Taken in low doses, they control the physical manifestation of anxiety and can be taken before a public performance.

Psychotherapy

Research has shown that a form of psychotherapy that is effective for several anxiety disorders, particularly panic disorder and social phobia is cognitive-behavioural therapy (CBT). It has two main components. The cognitive component helps people become aware of and to change thinking patterns that keep them from overcoming their fears. A person with social phobia might be helped to question how they can be so sure that others are continually watching and harshly judging him or her. The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. A key element of this component is gradual exposure, in which people confront the things they fear in a structured, sensitive manner. The aim is also to learn from acting differently and observing reactions (behavioural 'experiments'). This is intended to be done with support and guidance when the therapist and patient feel they are ready. Cognitive-behaviour therapy for social phobia also includes anxiety management training, which may include techniques such as deep breathing and muscle relaxation exercises, which may be practiced ' in-situ'. CBT may also be conducted partly in group sesssions (Cognitive behavioral group therapy), facilitating the sharing of experiences, a sense of acceptance by others and undertaking behavioural challenges in a trusted environment (Heimberg).

Some studies have suggested social skills training can help with social anxiety (Mersch et al., 1991). Whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations, does not seem to be clear (Stravynski & Amado, 2001).

Interpersonal Therapy has been shown to have efficacy for depression and a small study of the therapy in the treatment of social phobia suggests it may also work with social phobia (Lipsitz et al, 1999).

History

Literary descriptions of shyness can be traced back to the days of Hippocrates around 400 B.C. Charles Darwin wrote about the physiology and social context of blushing and shyness. The first mention of a psychiatric term, social phobia ("phobie des situations sociales"), was made in the early 1900s. Psychologists used the term " social neurosis" to describe extremely shy patients in the 1930s. After extensive work by Joseph Wolpe on systematic desensitization, research in phobias and their treatment grew. The idea that social phobia was a separate entity from other phobias came from the British psychiatrist, Isaac Marks in the 1960s. This was accepted by the American Psychiatric Association and was first officially included in the third edition of the Diagnostic and Statistical Manual of Mental Disorders. The definition of the phobia was revised in 1989 to allow comorbidity with avoidant personality disorder, and introduced generalized social phobia. Social phobia had been largely ignored prior to 1985. After a call to action by psychiatrist Michael Liebowitz and clinical psychologist Richard Heimberg, there was in increase in research and attention on the disorder. The DSM-IV gave social phobia the alternative name Social Anxiety Disorder. Research in to the psychology and sociology of everyday social anxiety continued. Cognitive Behavioural models and therapies were developed for social anxiety disorder. In the 1990s, paroxetine became the first prescription drug in the US approved to treat social anxiety disorder, with others following.

Criticisms

Many professionals and sufferers continue to criticise a perceived underdiagnosis and undertreatment of Social Anxiety Disorder and associated disability, and that not enough is being done to overcome the barriers faced by this group (e.g. Olfson et al., 2000)

By contrast, others are critical that the diagnostic boundaries have been stretched too far and that clinical and media work is promoting the idea that any problems with shyness or social worries are a pathological medical condition requiring medical treatment. Some see this as being driven by pharmaceutical companies, either by direct advertising to the public or their financial influence on psychiatry. This view can be associated with, but is not exclusive to, anti-psychiatry.

Some argue that problems with social anxiety in individuals can be seen as indicating problems with society - for example a competitive culture, power imbalances, lack of care or social education in families and communities - and are critical of focusing disorder and treatment only on individuals.

Literature

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