Social Phobia

Social phobia (also referred to as social anxiety disorder) is one of the more common anxiety disorders, affecting between 3-7% of the adult population. It involves fear of embarrassment or humiliation in situations where you are exposed to the scrutiny of others or must perform (for example, speaking up at a meeting, going to a party, a job interview, or giving a report at work or school), This fear is much stronger than the normal anxiety most non-phobic people experience in social or performance situations. Usually it's so strong that it causes you to avoid the situation altogether, although some people with social phobia endure social situations, albeit with considerable anxiety. Typically, your concern is that you will say or do something that will cause others to judge you as being anxious, weak, "crazy," or stupid. Also, you may be afraid that other people will see your physical symptoms of anxiety, such as trembling, sweating or blushing, and judge you harshly for them. Your concern is generally out of proportion to the situation, and you recognize that it's excessive (children with social phobia, however, do not recognize that their fear is excessive).

The most common social phobia is fear of public speaking. In fact, this is the most common of all phobias and affects performers, speakers, people whose jobs require them to make presentations, and students who have to speak before their class. Public speaking phobia affects a large percentage of the population and is equally prevalent among men and women.

Other common social phobias include

• Fear of blushing in public
• Fear of choking on or spilling food while eating in public
• Fear of being watched at work
• Fear of using public toilets
• Fear of writing or signing documents in the presence of others
• Fear of crowds
• Fear of examinations

Sometimes social phobia is less specific and involves a generalized fear of any social or group situation where you feel that you might be watched or evaluated. When your fear is of a wide range of social situations (for example, initiating conversations, participating in small groups, speaking to authority figures, dating, attending parties, and so on), the condition is referred to as generalized social phobia.

While social anxieties are common, you would be given a formal diagnosis of social phobia only if your avoidance interferes with work, social activities, or important relationships, and/or it causes you considerable distress. As with agoraphobia, panic attacks can accompany social phobia, although your panic is related more to being embarrassed or humiliated than to being confined or trapped. Also the panic arises only in connection with a specific type of social or performance situation.

Social phobias tend to develop earlier than agoraphobia and can begin in late childhood or adolescence. They often develop in shy children around the time they are faced with increased peer pressure at school. Typically these phobias persist (without treatment) through adolescence and young adulthood, but have a tendency to decrease in severity later in life.

All of the following interventions are part of the current treatment for social phobia.

Relaxation Training
Abdominal breathing and deep muscle relaxation techniques are practiced on a regular basis to assuage physical symptoms of anxiety.

Cognitive Therapy
Fearful thoughts that tend to perpetuate social phobias are identified, challenged, and replaced with more realistic thoughts. For example, the thought "I'll make a fool of myself if I speak up" would be replaced with the idea "It's okay if I'm a bit awkward at first when I speak up—most people won't be bothered."

Exposure
Exposure involves gradually and incrementally facing the social or performance situation you're phobic about. You might do this first in imagery and then in real life. For example, if you're phobic of public speaking, you might start out giving a one-minute talk to a friend and then gradually increase, through many steps, both the duration of what you say and the number of people to whom you speak. Or, if you have difficulty speaking up in groups, you'd gradually increase both the length and degree of self-disclosure of remarks made in a group setting. After each exposure, you'd review and challenge any unrealistic thinking that caused anxiety.

Two factors may complicate exposure for social phobia. One is that, in some cases, it's difficult to develop a truly incremental hierarchy of exposures for a particular social or performance situation. You can rehearse a job interview or a piano recital with a significant other or friends, but there is a jump from those levels of exposure to the real-life performance situation. In these cases, you would need to work on relieving worry and anticipatory anxiety in advance of the real-life performance situation. See the section of this site on Generalized Anxiety Disorder for more information on dealing with worry. Another issue is that you may have to enter into a particular phobic situation, such as a meeting at work or a group interaction at school, before you are ready to do so in terms of your gradual exposure process in therapy.

While the treatment for social phobia can be done on an individual basis, group therapy is the ideal treatment approach. This allows direct exposure to the situation and stimuli that evoke anxiety in the first place.

Staying on Task
Persons with social phobia tend to focus a lot on how they are doing or try to gauge other people's reactions while speaking/performing in a social situation. Treatment includes training in attention to focus only on the task at hand, whether conversing with a boss, speaking up in class, or presenting information to a group.

Medication
SSRI medications such as Zoloft, Luvox, Celexa or Lexapro, or low doses of benzodiazepine tranquilizers such as Xanax or Klonopin may be used as an adjunct to the cognitive and exposure-based treatments described above.

Social Skills Training
In some cases, learning basic social skills such as smiling and making eye contact, maintaining a conversation, self-disclosure, and active listening are part of the treatment for social phobia.

Assertiveness Training
Training in assertiveness, the ability to ask directly for what you want or to say "No" to what you don't want, is often included in the treatment for social anxiety disorders.