Treatment of social phobia - Dr David Veale

Veale Advances in Psychiatric Treatment (2003), vol. 9, 258–264Treatment of social phobiaDavid VealeAbstractSocial phobia (or social anxiety disorder) manifests as a marked and persistent fear of negativeevaluation in social or performance situations.The epidemiology, diagnosis and psychopathology arereviewed, including clinical presentation, cultural aspects and the differences between agoraphobiaand social phobia. Behavioural treatments, including graded self-exposure and cognitive restructuring,are considered. A cognitive model of the maintenance of social phobia is discussed. It is hypothesisedthat attentional shifting towards imagery, safety behaviours and ‘post-mortem’ analyses play a keyrole in symptom maintenance. The implications of this for treatment are described, and guidelines forpharmacological treatment are summarised.Social phobia (or social anxiety disorder) consistsof a marked and persistent fear of social orperformance situations. Affected individuals fearthat they will be evaluated negatively or that theywill act in a humiliating or embarrassing way.Exposure to social or performance situationsinvariably leads to panic or marked anxiety, andsuch situations therefore tend to be avoided orendured with extreme distress.Social phobia is the third most common mentaldisorder in adults worldwide, with a lifetimeprevalence of at least 5% (depending on thethreshold for distress and impairment). There isan equal gender ratio in treatment settings, butin catchment area surveys, there is a female preponderanceof 3:2. Individuals are more likely tobe unmarried and have a lower socio-economicstatus. Although common, social phobia is often notdiagnosed or effectively treated. There have,however, been a number of developments in ourunderstanding and treatment of social phobia overthe past decade, and these are the focus of thisarticle.PresentationThe onset of social phobia usually takes placeduring adolescence, although a minority of causesinvolve a late onset after a significant life event (suchas an episode of failure). The typical course ischronic and life-long. Predisposing factors includea shy or anxious temperament from childhood. Thereis significant comorbidity, especially of depression,alcohol or substance misuse or body dysmorphicdisorder. In body dysmorphic disorder, patients areoften too ashamed to reveal their preoccupation withtheir appearance, and present with symptoms ofsocial anxiety and depression, fearing that themental health professional will view them as vainor narcissistic. A similar situation exists in patientswith olfactory reference syndrome, who believethat they have body odour that others will findunpleasant, which they may camouflage withperfume. Therefore, all patients with symptoms ofsocial anxiety should be routinely asked whetherthey are very concerned about some aspect of theirappearance or about body odour. It should beemphasised that patients with social phobia do notlack social skills. Most affected individuals will havenormal social skills in a consultation with you, orwith a friend or partner. In social situations, theyare trying too hard and can appear to lack socialskills, because they might interact less, keep theirhead down or not reveal personal information.Patients (for example, those with Asperger syndrome)who do lack communication skills have adifferent problem.The presentation of social phobia can depend oncultural contexts. In Western cultures, patients mightpresent to surgeons for cures for complaints ofexcessive blushing or sweating. In Japan, socialphobia is manifested as an extreme fear of bringingoffence to others, and is referred to as taijin kyofusho.Sufferers of this disorder may fear that makingeye contact, blushing, imagined defects in theirappearance or their body odour would be offensiveto others.David Veale is an honorary senior lecturer at the Royal Free and University College Medical School and a consultant psychiatristat the Priory Hospital (The Bourne, Southgate, London N14 6RA, UK). He has a special interest in cognitive–behaviouraltherapy and its application to anxiety disorders and body dysmorphic disorder.258 Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/

Treatment of social phobiaPsychopathologyThe core psychopathology in social phobia is a fearof negative evaluation in social and performancesituations. It overlaps with the concept of shame,although the two sets of literature have largelyignored one other (Gilbert & Andrews, 1998). Socialanxiety is best described as the fear of feelingashamed (e.g. of the emotions aroused and theirinterference in one’s presentation) or the fear of beingshamed (e.g. by the negative evaluation of oneselfand potential loss of rank), or both.Social phobia usually leads to avoidance ofsituations such as public speaking or talking to agroup, parties, meetings, eating or drinking inpublic, working or writing while being observed,telephone calls, intimacy or dating. Groups arenearly always more anxiety-provoking than is anindividual. Peers of the same age are usually moreanxiety-provoking than older individuals. Forheterosexual individuals, people of the oppositegender are usually more anxiety-provoking thanthose of the same gender. Sometimes individuals inauthority, especially at work, are more anxietyprovokingthan individuals at the same level.There tend to be two sub-types of social phobia –generalised and non-generalised. Generalised socialphobia is more disabling and involves a more diverserange of feared stimuli. Those affected by it includesome patients with avoidant personality disorderand it has a worse prognosis. Non-generalisedsocial phobia is associated with avoidance of alimited range of performance situations or interactions(such as public speaking), and this overlapswith performance anxiety in sexual dysfunction.Non-generalised social phobia is easier to treat, witha better prognosis.A person afraid of speaking in public would notreceive a diagnosis of social phobia if publicspeaking was not routinely encountered and theperson was not particularly distressed about it. It isusually the degree of distress or impairment thatwarrants a diagnosis of social phobia, and thepossible indicators need to be considered in theappropriate context. For example, transient or mildsocial anxiety is especially common in adolescence.The degree of severity in social phobia is veryvariable, ranging from individuals who are virtuallyhousebound and have never had a relationship, toothers who are highly functioning except in certainareas such as making a presentation, which theyfind very distressing and which handicaps them intheir occupation.Social phobia might be confused with agoraphobia.Individuals with agoraphobia tend tobe female and to be anxious about their physicalor mental health. They misinterpret physicalsensations as evidence of an immediate catastropheto their health. Panic attacks in agoraphobia tend tobe both situational and spontaneous. Affectedindividuals are concerned with a wider range ofautonomic sensations such as palpitations andfeeling dizzy or short of breath. Those with socialphobia, however, are more likely to be concernedwith autonomic sensations of blushing, shaking orstammering (which the person believes may benoticeable to others). Panic attacks in social phobiaoccur almost exclusively in social situations. Sometimes,a patient with agoraphobia also has comorbidsymptoms of social anxiety. For example, he mightbelieve that he will collapse or go mad as a result ofa panic attack, but in a social situation, he mightalso fear causing a scene and others evaluating himnegatively. Typical beliefs in an individual withsocial phobia focus on the perceived negativeevaluation by others of revealing a flaw or unacceptablebehaviour (for example, the personbelieves that her hands will shake or she will soundstupid or boring). This is also referred to in theliterature as ‘external shame’.Such individuals tend to have high standards orrules about how they must perform in socialsituations. Their assumption is that failing toachieve these standards might lead others to seethem as inferior, flawed or inadequate and they themselvesalso agree with this assessment (referred toas ‘internal shame’). They predict that this failurewill lead to rejection or a further failure to achievean important goal. Individuals with no internalshame may know that others are rejecting them andview them as inferior, but not believe it aboutthemselves.The emotions in social phobia are predominantlythose of anxiety and shame, and sometimes selfdisgustor anger (which will depend on beliefs andsafety behaviours). As in other anxiety disorders,the main coping (or defensive) behaviour is to escapefrom the situation. There is a strong urge not to beseen. Eye gaze is commonly averted and there isbehavioural inhibition (discussed in more detailbelow under ‘safety behaviours’). These behavioursmight be linked to the submissive defensivebehaviours used to reduce aggression in anotherperson in response to the threat of rejection.When the focus is on another person as being badand doing something to expose the individual asinferior, then the main emotion is of humiliation(rather than social anxiety). There is a sense ofinjustice and unfairness, often leading to anger anda strong desire for revenge against the one who isexposing the self as weak or inferior.Alcohol and other substances are commonly usedin social phobia, but such usage might result in aself-fulfilling prophecy as patients may indeed makeAdvances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/259

Treatment of social phobiaModifying post-interaction ruminationsThose affected by social phobia often engage in ‘postmortems’.Here, the therapist helps the patient toidentify the content of the event (not the feelings)and review what actually happened by shifting toexternal processing and constructing an alternativedata log of information that is normally disregardedor distorted.Therapy would normally take between 8 and 20out-patient sessions, depending on the severity andchronicity of the phobia. Patients with very severephobia, who are housebound or dependent onalcohol, might do better on an intensive programmeof CBT as either day-patients or in-patients in theright setting.PharmacotherapyMedication is indicated if it is the patient’s firstchoice, CBT has failed, there is a long waiting-listfor CBT or there is significant comorbidity ofdepression. The treatment of choice in social phobiais a selective serotonin reuptake inhibitor (SSRI)(Ballenger et al, 1998). Of the SSRIs, only paroxetineis licensed and marketed in the UK for social phobia,although there is no reason why other SSRIs maynot be as effective. Most affected individuals cantolerate a normal starting dose of an SSRI, as theydo not usually experience an ‘activation syndrome’(as in panic disorder). The starting dose is used for2–4 weeks and then increased as necessary. Theonset of action is usually within 6 weeks and anadequate trial period is 8 weeks. The full responsemay occur after up to 12 weeks.About 50% of patients relapse on discontinuationof an SSRI and treatment is therefore continued for aminimum of 12 months. Once in remission, the dosemay be reduced slowly (e.g. a 25% reduction every2 months). If a patient fails to respond to an SSRI,then some evidence exists for the efficacy of a monoamineoxidase inhibitor (MAOI) (e.g. phenelzine,45– 90 mg daily) or a reversible monoamine oxidaseinhibitor (RIMA) (e.g. moclobemide, 300–900 mgdaily). Allow 2 weeks between discontinuing anSSRI (5 weeks if fluoxetine) and commencing anMAOI or RIMA. Although there are no evidencebasedguidelines on the treatment of patients whohave failed to respond fully to an SSRI or an MAOI,expert opinions suggest the adjunctive use of betablockers(e.g. propranolol, starting dose 20 mg daily,gradually increased to 60 mg, or atenolol 50–100 mgdaily) to augment the response. Similarly, clonidinemay augment the response for symptoms of blushingwhen used as an adjunct to an SSRI. The use ofbenzodiazepines (especially short-acting ones) isnot recommended, because side-effects at a higherdose can include sedation, forgetfulness, impairedconcentration and disinhibition, especially whenused intermittently. Benzodiazepines are especiallycontraindicated for patients with comorbidity ofdepression and/or a history of alcohol or substancemisuse.Which treatment for whom?Only one trial has compared later versions of CBTwith an SSRI (Clark et al, 2003), and it found CBT tobe superior to fluoxetine. No trials have yet comparedlater versions of CBT with a combination ofCBT and another SSRI, especially in the long termand after discontinuation of the active treatment.As always, treatment will depend upon patientchoice and availability of therapy, but in commonwith other anxiety disorders, CBT is the initial choiceof treatment for social phobia, as it is usually moreacceptable and has a reduced risk of relapse. Asalways, the main problem is user choice and accessto CBT in a timely manner.ReferencesArntz, A. & Weertman, A. (1999) Treatment of childhoodmemories: theory and practice. Behaviour Research Therapy,37, 715–740.Ballenger, J. C., Davidson, R. T., Lecrubier, Y., et al (1998)Consensus statement on social anxiety disorder from theInternational Consensus Group on Depression andAnxiety. Journal of Clinical Psychiatry, 59, 54–60.Bogels, S. M., Mulkens, S. & De Jong, P. J. (1997) Taskconcentration training and fear of blushing. ClinicalPsychology and Psychotherapy, 4, 251–258.Clark, D. M. (2001) A cognitive perspective on social phobia.In International Handbook of Social Anxiety: Concepts, Researchand Interventions Relating to the Self and Shyness (eds W. R.Crozier & L. E. Alden). pp. 405–430. Chichester: JohnWiley & Sons.––– & Wells, A. (1995) A cognitive model of social phobia. InSocial Phobia – Diagnosis, Assessment, and Treatment (eds R.G. Heimberg, M. R. Liebowitz, D. Hope, et al), pp. 69–93.New York: Guilford.–––, Ehlers, A., Hackmann, A., et al (2003) Cognitive therapyvs. fluoxetine plus self exposure in the treatment ofgeneralized social phobia (social anxiety disorder): Arandomised placebo controlled trial. 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