Social Phobia – Under the Spotlight

Social phobia is a common mental disorder; yet most sufferers feel isolated and alone.  They often fear seeking help from friends or health professionals because they feel their condition is not taken seriously or that they will be ridiculed. Ironically, this is the root of their problem.

Feeling shy is normal; fear is a normal response. Most of us find first dates, meeting new people and speaking in public daunting. But for some people their butterflies become unmanageable and chronic.

Social phobics can’t put a brake on extreme feelings – even normal events trigger them. They feel nervous and extreme anxiety. Their pulse races and they go puce; they feel extreme nausea and physically ill when in public. Others label them as too timid or quiet. Far from just excessive shyness, social phobia is a chronic, disabling disorder of extreme anxiety and stress. It carries considerable personal burden.

Social phobics feel they are under a constant spotlight and scrutinised by others, so they avoid social situations. They underachieve academically, are usually unemployed, have difficulty starting and maintaining relationships, and become socially isolated with impaired quality of life. Many social phobics have problems with doing simple things when in public. They can’t shop or go to the bank, and may shake uncontrollably when even just asked to sign their name.

An overactive amygdala triggers the difficulties experienced by social phobics. The fear response protects us in times of attack; the brain prepares us to respond either to flee or to fight. 

Social phobia initiates in childhood or in the teens with a slight bias towards presentation in females. It triggers after a single traumatic event or results from a series of setbacks eroding self-esteem. 

Taking a family history can help make a differential diagnosis as it has a genetic component.  Selective mutism presenting in a child may indicate underlying social phobia. Comorbidity can mask diagnosis, but social phobia usually manifests first.  Anxiety disorders occur in up to one third of those with social phobia; two thirds have a history of depression and one quarter of alcohol abuse. They have a heightened suicide risk.

Selecting the best treatment depends on the presence of comorbidity, eg anxiety disorder, or depression, or suicide risk. Non-pharmocological approaches such as CBT can change patterns of thinking and improve coping skills.

Benzodiazepines may alleviate anxiety associated with social phobia in the short-term, but side-effects limit usefulness. MAOIs help some patients, but concomitant interactions and the ‘cheese effect‘ with patients needing to avoid dietary tyramine is cumbersome. Using RIMAs reduces this dietary risk and offers similar benefit to MAOIs.

SSRIs help social phobics, especially if depression is present. In one study, long-term paroxetine reduced relapses, which occur in 50% of patients when medication is discontinued.

Social phobia needs addressing and is a public health issue. Assessing the effectiveness of various combination therapies and evaluating the benefit of SSRI long-term use require further investigation.


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