Social Anxiety Disorder: Information & Specialists in Social Anxiety Disorder

Social phobia is one of the so-called anxiety disorders. It involves intense fears of social situations.

Those affected are afraid of behaving in an embarrassing or shameful way when they are the center of attention. They fear being judged by others.

Social phobia is one of the most common mental disorders. According to recent surveys, it ranks third in prevalence, following alcohol dependence and depression.

The one-year prevalence in Germany is just under 8 percent of the total population. Over the course of a lifetime, about one in nine people will develop social phobia at some point. Women are affected about 1.5 times more often than men.

The causes of social phobia are varied. A notable factor is a family history of the disorder. Relatives of people with social phobia have about three times the risk of developing the disorder compared to people from families without a history of the condition.

In addition to a biologically based susceptibility to the disorder, learning processes play an important role. Of particular significance here is the theory of avoidance learning proposed by the American psychologist Mowrer.

This theory states that, in the first step, the affected individual learns to have an anxiety reaction to certain stimuli. For example, a boy stutters when answering a question from the teacher, and the other students laugh. As a result, social situations in which the student feels judged can become associated with anxiety and shame.

In the next step, the student will try to avoid such situations. For example, he might skip school and avoid contact with his classmates. As a result, he experiences less fear and shame. The reduction in anxiety feels like an internal reward for avoiding these social situations. As a result, this behavior becomes more frequent.

This example illustrates the importance of learning processes in the context of social phobia. Those affected learn that avoidance leads to less anxiety. Conversely, this behavior can also be unlearned.

Social phobia involves a specific fear of being judged or devalued by others. Due to a negative self-assessment, those affected are convinced that they cannot meet others’ expectations of them. They are therefore afraid of embarrassing themselves.

People with social phobia tend to experience intense feelings of shame. “I could sink into the ground out of shame.” This idiom succinctly summarizes the feeling that those affected fear when interacting with others.

Situations in which judgment seems more likely are particularly feared. This includes, for example, speaking in the presence of other people

• speaking,
• eating, or
• writing.

In these situations, those affected often experience distinct physical symptoms accompanying their anxiety or shame, such as

• blushing,
• heart palpitations,
• dry mouth,
• trembling,
• dizziness, and
• gastrointestinal problems.

They are particularly afraid that outsiders might notice their own insecurity: This insecurity could serve as an indication of their perceived inability.

The fear of social situations can become so intense that they avoid such situations entirely. As a result, those affected are often severely limited in many areas of their lives, e.g., in

• work,
• social interactions,
• finding a partner.

They withdraw, even though they long for contact with others.

Social anxiety during adolescence is relatively common. It should be distinguished from social phobias, which usually develop before the age of 25.

People with social phobia often have little or no sexual contact. Their experiences with romantic relationships are also limited.

Depression or alcohol dependence often develops as a comorbid condition of social phobia. In cases of severe social phobia, suicidal thoughts and attempts may also occur. This is linked, among other things, to the patients’ increasing isolation.

Social phobia can be treated with medication and psychotherapy. A combination of both approaches is often recommended.

Medication for Social Phobia

The medications recommended and proven effective for treating social phobia belong to the class of antidepressants. These are medications that are also frequently used to treat depression. They also have an effect on anxiety.

Selective serotonin reuptake inhibitors (SSRIs), in particular, have proven effective in treating social phobia. These include active ingredients such as

• citalopram,
• sertraline, and
• paroxetine.

Other antidepressants are also effective (e.g., venlafaxine). These medications alter the concentration of neurotransmitters—the chemical messengers that transmit signals between nerve cells. They are not addictive. Regular use of these medications is necessary because this is the only way to achieve an effective blood level.

Caution is advised when treating social phobia with medications that directly relieve anxiety, such as benzodiazepines. Well-known active ingredients include lorazepam and diazepam (the suffix “-am” indicates the corresponding chemical class). While these medications are highly effective in the short term because they directly alleviate anxiety, they have a high potential for addiction or dependence.

Regular use over several weeks leads to drug dependence. This must be treated long-term as part of an inpatient addiction therapy program. While the long-term use of these sedative medications does alleviate social phobia, it also causes drug dependence.

This risk does not exist when treating social phobia with antidepressants!

Warning: Alcohol also has a short-term anxiety-relieving effect. As a result, people with social phobia often turn to alcohol as a form of self-medication. This can subsequently lead to alcohol dependence.

Psychotherapy for the Treatment of Social Anxiety Disorder

In addition to medication, psychotherapy is an important component of social phobia treatment. Typically, those affected undergo psychotherapy while also taking medication. However, it is also possible to attempt treatment with psychotherapy alone. The treating physician decides which treatment is most effective in each individual case.

Various methods can be used in the context of psychotherapy. Treatment for social phobia can take the form of individual or group therapy.

Cognitive Behavioral Therapy for the Treatment of Social Anxiety Disorder

Cognitive behavioral therapy, in which the patient discusses their thoughts and fears, is very helpful. Through this process, the patient becomes aware of the irrationality of their thoughts.

For example, many people with social phobia fear that a catastrophe will occur if others notice that they are anxious or insecure, sweating, trembling, or blushing. The therapist discusses with the patient that these fears are unfounded. On this basis, patients are guided to calm themselves—that is, to counter their catastrophic thoughts with calming ones.

As therapy progresses, patients then expose themselves to anxiety-provoking situations in real-life settings. There, they learn to apply the strategies they have acquired.

In this way, practice leads to a reduction in social phobia. Gradually, the patient also overcomes their avoidance behavior. They are then able to increasingly engage in social situations that previously caused anxiety.

Other Psychotherapy Approaches for Treating Social Phobia

Other psychotherapy approaches, such as

• psychodynamic therapy,
• relaxation techniques (autogenic training, progressive muscle relaxation),
• social skills training, and
• hypnotherapy

can be helpful for social phobia.

Attending a support group can be particularly effective precisely because of the social interaction it provides.

Cognitive behavioral therapy has been shown to be effective in improving social phobia and reducing avoidance behavior. More than 50 percent of those affected are reported to experience an improvement in symptoms.

However, a long duration of the condition and comorbid disorders tend to have a negative impact on the recovery process for social phobia.

A 20-year-old man moves from his parents’ home in a village in the Eifel region to Aachen to begin his studies. At the recommendation of his primary care physician, he makes an appointment with a psychiatrist.

The Patient’s Symptoms

The patient reports that he is in his first semester of college. From the very beginning, he has felt very uncomfortable in lectures, lab sessions, and seminars. At first, he still attended the relevant classes. However, he repeatedly felt that other students did not take him seriously and were laughing at him.

In particular, he describes a specific situation. When answering a question from the professor, he blushed and stuttered. Other students laughed at him.

Since then, he has stopped attending classes and spends most of his time at home. He has been drinking more alcohol lately because it helps him feel his anxiety less intensely. He is not in a relationship and does not have any close friends. On weekends, he visits his parents, where he feels somewhat better. He is considering dropping out of college.

As his life story unfolds, it becomes clear that the patient grew up in a very strict household. There, he often felt like a failure.

Treatment with Antidepressants and Psychotherapy

The patient is prescribed an antidepressant that is also effective for anxiety disorders and has no potential for dependence. He is to take it for the next 6 months.

In addition, he is referred to an outpatient psychotherapist specializing in behavioral therapy. There, the patient learns about the connection between his current social phobia and his life history.

In particular, the therapist makes it clear to him that his fears will only improve if he confronts anxiety-provoking situations. As the patient repeatedly experiences that the feared catastrophes do not occur, a habituation effect will set in.

The patient is guided to seek out and endure embarrassing social situations. For example, he should

• pay with a lot of small change,
• cut in line, and
• deliberately tell nonsense in front of other students.

He learns to calm himself down in anxiety-provoking situations.

As part of a 50-hour course of behavioral therapy held once a week, the patient’s social phobia improves. The student is able to continue his studies. After completing therapy, the patient is largely symptom-free.