Social phobia

The term "phobia" means an irrational fear of certain objects, circumstances, or situations. Phobias are classified according to the nature of the objects or situations that cause fear. The DSM-IV identifies three types of phobias: agoraphobia, closely related to panic disorder, specific phobias, and social phobia, or sociophobia.

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Pathogenesis

Compared to panic disorder, the pathogenesis of social phobia is much less studied. The bulk of research is devoted to the search for biological markers of panic disorder in patients with social phobia. These studies have revealed close relationships between panic disorder and social phobia both in individual patients and at the level of their families.

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Biological markers of panic disorder

In a number of biological parameters, patients with social phobia occupy an intermediate position between patients with panic disorder and mentally healthy individuals. Thus, patients with social phobia have a more intense anxiety reaction to carbon dioxide inhalation than healthy individuals, but less intense than patients with panic disorder. Patients with social phobia also have a smoothing of the growth hormone secretion curve when administering clonidine, but in terms of the severity of this phenomenon, they also occupy an intermediate position between healthy individuals and patients with panic disorder. Although autonomic theories predict increased cardiac reactivity in response to social stimuli, preliminary research results indicate the opposite - patients with social phobia have a decreased cardiac reactivity when exposed to social stimuli. The results of neuroendocrine tests indicate dysfunction of the serotonergic system in social phobia; However, further studies are needed to compare these rates in healthy individuals, patients with panic disorder, social phobia, and major depression.

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Specific changes in social phobia

Genealogical and long-term prospective studies indicate a peculiar type of transmission of social phobia, which can be linked to the uniqueness of the disease itself. Indeed, social phobia has the earliest onset of all anxiety disorders, in most cases appearing in adolescence.

Childhood Temperament and Social Phobia

There is reliable data on the connection between anxiety disorders and reserved behavior in an unfamiliar situation. In a new situation, especially in the presence of other people, children with a special type of temperament become quiet. These children hesitate for a long time to talk to a stranger, do not take part in group games, their facial expressions are constrained - all this resembles the manifestations of social phobia. Research shows that reserved behavior has strong genetic roots, although it is also influenced by external factors. It is assumed that reserved behavior is the result of an abnormally low threshold of amygdala excitation, but there is only indirect evidence for this assumption. Apparently, the connection between reserved behavior and social phobia is not so unambiguous. There is evidence that reserved behavior is more closely associated with panic disorder than with social phobia. Nevertheless, data on the connection between reserved behavior in early childhood and adolescent social phobia continues to accumulate.

Functional asymmetry of the brain

It is assumed that the asymmetry of the functions of the frontal lobes is associated with behavioral characteristics. When the frontal lobe of the right hemisphere dominates, a person in a stressful situation (including a social situation) more often chooses a passive behavior strategy, whereas with increased activity of the left frontal lobe, a person chooses an active coping strategy. In children with restrained behavior, the dominance of the right frontal lobe is revealed, which predetermines the choice of a passive strategy. The main limitation of this theory is its lack of specificity - it is applicable not only to social phobia, but rather explains the predisposition to a wide range of anxiety and affective disorders.

Stages

Social phobia usually manifests itself in adolescence and young adulthood. The generalized form tends to be chronic, although, as with other anxiety disorders, there is insufficient data on this subject from prospective epidemiological studies. Both retrospective epidemiological and prospective clinical studies show that social phobia can have an extremely negative impact on various areas of the patient's life for many years - study, work, social development.

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Diagnostics social phobia

• A marked or persistent fear of being in one or more social situations that involve the presence of unfamiliar people or the possibility of attracting attention from others. The patient fears that he or she will reveal the fear or will act in such a way that he or she will be embarrassed or humiliated. Note: Children should have age-appropriate development of social relationships with familiar people, and the anxiety should occur with peers as well as adults.
• When the patient finds himself in a social situation that frightens him, he almost always experiences anxiety, which can take the form of a situational or conditionally situational (situationally predisposed) panic attack. Note: in children, when communicating with strangers, anxiety can be expressed in crying, outbursts of irritation, freezing, or stiffness.
• The patient understands that his fears are excessive and irrational. Note: this symptom is absent in children.
• The patient tries to avoid situations of communication or public speaking that cause him fear, or tries to overcome intense anxiety and discomfort.
• Avoidance, anxious anticipation or discomfort in situations of communication or performance that frighten the patient significantly complicate his daily life, work, study, social activity, relationships with other people, or the very fact of having a phobia causes severe anxiety.
• In people under 18 years of age, symptoms must persist for at least 6 months.
• The fear and avoidance are not caused by a direct physiological effect of exogenous substances (including addictive drugs or medications) or a general medical condition and are not better explained by the presence of another mental disorder (panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, pervasive developmental disorder, or schizoid personality disorder).
• In the presence of a general illness or other mental disorder, the fear qualified by criterion A is not related to them (for example, the fear is not caused by stuttering, tremors in Parkinson's disease, or fears of discovering pathological eating habits in anorexia nervosa or bulimia).

If fear occurs in most social situations, then a generalized type of social phobia is diagnosed (social phobia can be accompanied by a phobic personality disorder)

Diagnosis of social phobia requires the presence of intense anxiety, which may take the form of a situational panic attack in a situation where the patient is forced to communicate, perform certain actions in public, and may find themselves in the center of attention or in an awkward position. Fear may arise only in specific situations (for example, when having to write, eat, or speak in the presence of others) or be of a more vague general nature in the form of fears of being embarrassed in front of someone. DSM-IV identifies a special generalized type of social phobia in which the patient experiences fear of most social situations. Such individuals are afraid to communicate in a wide variety of situations, take part in social events, and are afraid to come into contact with authorities. Diagnosis of social phobia requires that the fear either hinders the patient's life or causes severe discomfort; it is also necessary for the patient to recognize the excessiveness and irrationality of their fears and either avoid social situations or overcome their discomfort with difficulty.

Many people experience some degree of anxiety or awkwardness when in public, but this does not meet the criteria for social phobia. Sociological research shows that more than a third of the population believes that they experience more anxiety in social situations than other people. However, such anxiety is a sign of social phobia only if it interferes with the implementation of planned actions or causes significant discomfort when performing them. In people with more specific forms of social phobia, fear is associated only with certain social situations. For example, fear of public speaking can be so pronounced that it makes it difficult to perform professional duties - this is one of the most common variants of specific social phobia.

Like all anxiety disorders, social phobia is often combined with other anxiety and affective disorders. The most attention is drawn to the connection between social phobia and panic disorder and major depression. A connection between social phobia and drug addiction and obedience disorder in children has also been noted.

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Differential diagnosis

Sufferers may experience symptoms of social phobia in a variety of circumstances. One very common scenario is that the sufferer is unable to cope with work or social environments because they are unable to complete certain tasks or chores. Another scenario, less common for social phobia, is that the sufferer feels a strong need to have friends or family but is unable to overcome social isolation.

Since social isolation can be caused by various mental illnesses, diagnosing social phobia in such cases is quite difficult. Particularly difficult is the differential diagnosis of social phobia and agoraphobia, since both disorders are associated with fear of crowded situations. The key difference is in the direction of fear. Patients with social phobia are afraid of making contact with people, patients with agoraphobia are afraid not of communicating with people, but are afraid of finding themselves in a situation from which it is difficult to escape. Moreover, in some situations, patients with agoraphobia feel calmer in the presence of other people if they, due to the nature of the place of stay, are not able to prevent them from getting out of there. Whereas with social phobia, patients avoid any communication.

Difficulties also arise in the differential diagnosis of social phobia with social isolation caused by major depression or early manifestations of psychosis. In this case, two circumstances should be kept in mind. Firstly, social isolation in social phobia is caused by anxiety and fear associated with social situations, while patients with depression or developing psychosis withdraw into themselves for other reasons. Secondly, in social phobia, the symptoms are limited to fear associated with social situations, while in other disorders, social isolation is accompanied by other psychopathological manifestations that are not characteristic of social phobia.

Unlike panic disorder, social phobia rarely requires differential diagnosis with somatogenic anxiety disorders. Secondary anxiety disorders usually arise against the background of pronounced somatic symptoms and are not associated with specific social situations. However, as in the diagnosis of panic disorder, a detailed anamnesis and a thorough physical examination are necessary in patients with manifestations of social phobia.

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