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Many people get a minor case of the “jitters” before performing in
public. For some, this mild anxiety actually enhances their performance. However,
this anxious reaction is massively exaggerated in the individual with social
phobia. While mild normal anxiety can actually enhance performance, excessive
anxiety can severely impair performance.
An anxious episode may be associated with some or all of the symptoms of a panic
attack. These might include sweaty palms, palpitations, rapid breathing, tremulousness
and a sense of impending doom. Some individuals, particularly those with generalized
social phobia may have chronic anxiety symptoms. Individuals with social phobia
may turn down accelerated classes and after school activities because of their
fears that these situations will lead to increased public scrutiny.
The individual with a specific social phobia feels anxious during the feared
social situation and also when anticipating it. Some individuals may deal with
their fear by arranging their lives so that they do not have to be in the feared
situation. If the individual is successful at this, he or she does not appear
to be impaired. Types of discrete social phobia may include:
 Fear of public speaking—by
far the most common. This seems to have a more benign course and outcome.
Fear of interacting socially
at informal gatherings (making small talk at a party)
Fear of eating or drinking
in public
Fear of writing in public
Fear of using public washrooms
(bashful bladder) Some students may only urinate or defecate at home.
Individuals with generalized social phobia are characterized as extremely shy.
They often wish that they could be more socially active, but their anxiety prevents
this. They often have insight into their difficulties. They often report that
they have been shy most of their lives. They are sensitive to even minor perceived
social rejection. Because they become so social isolated, they have greater academic,
work and social impairment. They may crystallize into an avoidant personality
disorder.
Social phobia is the third most common psychiatric disorder. (Depression—17.1%
Alcoholism—14.1% Social phobia—13.3%. (Kessler et al 1994.) Onset
is usually in childhood or adolescence. It tends to become chronic. It is often
associated with depression, substance abuse and other anxiety disorders. The
individual usually seeks treatment for one of the other disorders. Individuals
with SP alone are less likely to seek treatment than people with no psychiatric
disorder (Schneier et al 1992) Social phobia is vastly under-diagnosed. It is
not as likely to be noticed in a classroom setting because these children are
often quiet and generally do not manifest behavior problems. Children with SP
often show up with physical complaints such as headaches and stomach aches. Parents
may not noticed the anxiety if it is specific to situations outside the home.
Additionally, since anxiety disorders often run in families, the parents may
see the behavior as normal because they are the same way themselves. On the other
hand, if the parent has some insight into his of her own childhood anxieties,
he or she may bring the child into treatment so that the child will not have
to experience the pain the parent experienced as a child.
Treatment
Psychotherapy: There is the most evidence for cognitive-behavioral psychotherapy.
Since the child or adolescent is more dependent on his parents than an adult,
the parents should have some adjunctive family therapy.
Both individual and group therapy are useful. The basic premise is that faulty
assumptions contribute to the anxiety. The therapist helps the individual identify
these thoughts and restructure them
Identifying out automatic thoughts: “If I sound nervous when I present
my paper, my teacher and classmates will ridicule me.” The patient then
identifies his physiological and verbal responses to the thoughts. Finally he
identifies the mood associated with the thoughts.
Irrational beliefs that underlie automatic thoughts:
Emotional reasoning: “If
I am nervous, then I must be performing terribly.” All or nothing:
Absolute statements that do not admit any partial success of gray areas. “I
am a failure unless I make an A.”
Overgeneralization: One unfortunate
event becomes evidence that nothing will go well.
Should thoughts: Insisting
that an unchangeable reality must change in order for one to succeed.
Drawing
unwarranted conclusions: Making connections between ideas that have no logical
connection.
Catastrophizing: Taking a relatively small negative event
to illogically drastic hypothetical conclusions.
Personalization: Believing
that an event has special negative relationship to oneself. (“The whole
group got a bad grade because my hands trembled during my part of the presentation”.)
Selective negative focus: Only seeing the negative parts of an event and negating
any positive ones.
Challenge negative beliefs: Once the patient and therapist have identified and
characterized the negative thoughts, the therapist should help the patient examine
the lack of data supporting the beliefs and look for other explanations of what
the patient sees.
Exposure: Create a hierarchy of feared situations and start to allow one to experience
them. One starts with situations that only elicit a little anxiety and then gradually
move up to more intense experiences. This must be done in reality, not just as
visualization in the office.
Group therapy: This can be a powerful modality for individuals with social phobia.
A patient may need to use individual therapy to prepare for group therapy. In
the group patients can encourage each other and can try out new behaviors within
the safety of the group. They can get immediate feedback that may refute their
fears. Patients should not be forced to participate more actively than they wish.
Medication Treatment
Recent studies have shown that some of the SSRI medications can be helpful in
the treatment of SP. Paroxetine (Paxil) Sertraline (Zoloft) have been approved
by the FDA for treatment of SP. Other medications that may be useful include ß blockers
(propranolol, atenolol) Benzodiazepines (lorazepam, clonazepam) buspirone, and
the MAO inhibitors (Parnate, Nardil.) MAO Inhibitors are only rarely used in
children and adolescents because one must go on dietary restrictions while taking
them. SSRI and other antidepressant medications are going to now have special
cautionary statements about the potential activation of suicidal thoughts. However
the SSRI medications are still useful if monitored carefully.
Courtesy of : Carol E. Watkins. MD (Pyschiatrist) in the U.S.A.
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