Introduction

Social Anxiety Disorder (SAD), also commonly referred to as Social Phobia, is a condition characterised by an intense, irrational and persistent fear of being scrutinised or evaluated by others. Those who suffer from SAD anticipate humiliation or ridicule in social situations and, in order to avoid it, isolate themselves from society. As opposed to individuals experiencing anxiety which is transient and does not significantly interfere with their functioning, those who frequently experience high levels of social anxiety and either extreme distress or avoidance of social/performance situations may warrant the diagnosis of social anxiety disorder SAD, also known as social phobia. The research into the cognitive, behavioural, interpersonal and physiological aspects of social anxiety has increased dramatically over the last 20 years. Several theoretical models have been proposed which led to increased understanding among clinicians of the nature and maintaining factors of social anxiety disorder. Well-validated assessment tools and procedures including self-report, interview and behavioural methods, are now available.  Finally, despite the chronic course and high degree of impairment seen in social anxiety disorder, several treatments have been found to be effective in clinical and community studies.

Diagnostic criteria for SAD

The disorder was not officially recognised as a diagnostic entity until the publication of the third edition of the Diagnostic and Statistical Manual of Mental Disorder. Among main criteria of SAD from the Fourth Edition of the Diagnostic and Statistical Manual of Mental Disorders are:

• the individual experiences excessive and persistent fear of one or more social or performance situations,
• the individual experiences feelings of anxiety, fear, or panic immediately upon encountering the feared social situation,
• the person recognises that the fear is excessive, unreasonable, or out of proportion to the actual risk in the situation,
• the individual tends to avoid the feared social situation, or if he or she doesn’t avoid, the situation is endured with intense anxiety or discomfort,
• the individual’s fear, anxiety, or avoidance causes significant distress (i.e., it bothers the person that he or she has the fear) or significant interference in the person’s day to day life. For example, the fear may make it difficult for the person to perform important tasks at work, meet new friends, attend classes, or interact with others,
• other criteria include the age of onset in children, exclusions if anxiety is triggered by a medical condition, drug or a substance(e.g., cocaine use, caffeine),

Based on symptomathology, there is a distinction made between SAD generalised type if the person fears most social situations, and non-generalised subtype, whereby anxiety occurs in specific social situations only.

Clinical features

Even though SAD was once considered rarely incapacitating, it is now known, due to its secondary complications as a severely disabling disorder leading to an egodystonic social isolation, unstable employment record, poor achievement and often financial dependence for the patients. The onset of SAD generally occurs early in childhood or in adolescence, between five and 20 years. However, social anxiety disorder can be diagnosed in children as young as eight years of age. Recovery is less likely if the condition started in early childhood. The course of SAD is that of a chronic, unremitting lifelong disease.

The clinical symptoms of social anxiety disorder can be conceptualised as revolving around three core levels: cognition, physiological symptoms, and behavioural responses:

Cognitions:

• exaggeration the impact of social blunders and rumination about them afterwards,
• an unrealistic tendency to experience others as critical or disapproving, associated with hypersensitivity to rejection or criticism,
• overestimates of risks in social situations,
• underestimates of ability to cope with feared situations,
• low assertiveness at least in phobic situations and low self-esteem,
• mind going blank,
• difficulty speaking,
• depersonalisation,
• derealisation,
• loss of concentration.

Physiological symptoms:

• blushing,
• tachycardia / palpitations,
• chest pain,
• sweating,
• trembling,
• muscle tension,
• dry throat,
• gastrointestinal distress (nausea, diarrhoea),
• dizziness,
• feeling faint,
• numbness,
• tingling,
• difficulty breathing,
• chills,
• hot flashes.

Behavioural Responses:

• panic attacks,
• avoidance of social situations,
• avoidance of eye contact,
• submissive behaviour, hesitancy, passivity,
• keeping opinions private/talking to familiar people only/stuttering or mumbling words, talking very quietly or loudly,
• only going to familiar places/leaving social situations ASAP,
• overly helpful or agreeable, agreeing with majority,
• fidgeting, biting nails,
• dressing plainly.

Causes

Current theories consider the development of SAD to be due to a combination of genetic and environmental factors. Individuals suffering from SAD are born with a biological disposition to low threshold for physiological arousal or propensity for fear conditioning.  Relatives of people who suffer from generalised form of SAD are ten times more likely to have the disorder then members of the general population. Also, first-degree relatives who meet criteria for SAD are 2-3 times more likely to have the disorder. Another family study reported significant increased risk for SAD in the first-degree relatives of social phobics.

Environmental experiences that have been found to predict increased likelihood of SAD include separation from or death of parents, marital discord, family violence, over-protectiveness, criticism, stressful life events, sexual and physical abuse and bullying by peers. Recurrent images of the self in SAD can be linked to upsetting memories of being teased or bullied.

Considering the complexity of risk factors in SAD (biological, psychological and environmental), a diathesis-stress model appears to best explain the development of SAD. The greater the underlying genetic vulnerability toward a particular disorder (diathesis), the less stress needed to trigger associated problem behaviours (stress). In the last ten years, a number of scientific studies have hypothesised such a model for SAD.

Assessment

Tremendous progress has been made in the last 20 years in the assessment of social anxiety disorder. A range of strategies and instruments has been developed, ranging from quick diagnostic screening instruments to extended assessments of anxiety and avoidance across situations. These include client self-report scales and questionnaires, clinician-administered questionnaires and diagnostic interviews, and behavioural assessment.

Among the advantages of self-report scales and questionnaires are their highly structured way of gathering information, and the fact that most are rigorously tested and offer sound reliability and validity. Additionally, they serve as an opportunity to be used as baseline with which to assess treatment effects. Also, potentially, they reduce anxiety for interviewee by writing rather than having to speak.

Among main disadvantages is the fact that assessment of individuals occurs at a single moment in time, although many ask to answer across a period of time (e.g. over last two weeks).

Clinical interview have several functions, including establishing a differential diagnosis, learning about the aetiology and course of the disorder, learning about the patient’s family history, and deciding upon a treatment plan that is likely to be effective.

Clinical Observation is used to gain information about individual’s symptoms in trigger situations. It can be performed by means of direct observation, behavioural tests, and self report diaries.

Clinical observation allows assessor to gather information on anxiety issues at time of anxious arousal, offers a baseline for future testing. Also, during direct observation, assessor can look for any avoidance or safety behaviours that the individual may not be aware of.

However, self-report measures rely on individual’s awareness and honesty. Direct observation can be costly in terms of time. Also, presence of assessor may act as a safety behaviour itself.

Treatment

Treatments with demonstrated efficacy for SAD include pharmacotherapy, cognitive-behaviour therapy and psycho-pharmacotherapy, a combination of pharmacotherapy and psychological interventions. According to National Institute for Clinical Excellence (NICE) guidelines, it has been recommended that interventions for adults with social anxiety disorder should include offering individual cognitive behavioural therapy (CBT) specifically developed for social anxiety disorder and based on the Clark and Wells model or the Heimberg model and/or offering supported self-help.  If the person wishes to proceed with a pharmacological intervention, offer a selective serotonin reuptake inhibitor (SSRI) (fluvoxamine or escitalopram).

Relapse rates are high following discontinuation of medications, and symptoms can be intensified, particularly in the long term. It could be overcome through combination of pharmacotherapy with CBT which, as evidence suggests, has been more effective than medication alone in the short-term. However, combining CBT with pharmacological treatment is only a valid approach if the combination yields greater effects than either treatment alone.

Psychological Therapies

There is a substantial research evidence for the effectiveness of cognitive behaviour therapy in the treatment of SAD.  Cognitive and behavioural treatments explain psychopathological development as occurring due to dysfunctional cognitions and maladaptive reinforcement behaviours. Some researches have developed a cognitive model for the management of social phobia that takes into considerations both cognitive and behavioural aspects, and currently their model is the commonly utilised in treatment of SAD. Extensive research has demonstrated the effectiveness of a combined approach that uses cognitive techniques and behavioural methods.

Treatment strategies that are empirically supported for SAD include cognitive therapy, exposure to feared situations, social skills training, and applied relaxation. Treatment packages vary depending on the needs of the patient. Treatment typically lasts 10 to 15 weeks.

Among key methods of cognitive behavioural therapy are problem oriented focus, collaborative-empirical therapeutic relationship, use of structuring, psycho-education, and rehearsal to enhance learning, eliciting and modifying automatic thoughts, uncovering and changing schemas, and behavioural methods to reverse patterns of helplessness, self-defeating behaviour, and avoidance.

Conclusions

Over the past decade, our understanding of the nature and treatment of social phobia has increased enormously. Both CBT and pharmacological therapies for social phobia have been proven to be effective for treating this condition. Nevertheless, several important questions need to be answered to further improve the quality of treatment of SAD. It is still unclear whether the combination of medication and CBT works as well as or better than either approach alone. Also, if combined treatments are suggested as most beneficial, the issue of the treatment sequencing will need to be addressed. Finally, treatments with minimal therapist contact have been shown to be useful in other anxiety disorders. More research should be aimed at developing self-administered treatments for social phobia and may be helpful for social phobia.