Pages 258-262 from the Management of Mental Disorders, published by World Health Organization, Sydney. Editions in Australia, Canada, China, Italy, New Zealand and the United Kingdom.

4.4 Social Phobia

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Social phobia, the fear of being judged negatively, is often not recognised because patients do not like to talk about their fears. It is also not recognized because clinicians either confuse it with shyness, or judge the secondary depression or substance dependence to be the primary disorder. Social phobia is not uncommon and should be considered whenever someone says that "people make me anxious". The key to treatment is for the person to learn to control their anxiety and then accept that, even if they make mistakes because of anxiety, friends and colleagues will not judge them adversely as a person, only think that something must have been troubling them on the day.

4.4.1 Description and diagnosis

Description
The key feature of social phobia is the fear of being scrutinised or being evaluated negatively by other people. The individual worries that he or she may do something embarrassing or act in a way that may be humiliating (which includes showing obvious symptoms of anxiety). The fear may be circumscribed to particular situations or may generalise to most social situations.

Situations that are commonly feared by individuals with social phobia include:

• Eating or drinking in public
• Speaking in public
• Writing in the presence of others
• Using public toilets
• Being in social situations in which the individual may say foolish things

Exposure to the feared situation usually creates an immediate anxiety response, with the usual fight or flight response symptoms, but in addition may include blushing, shaking, nausea, and the urge to go to the toilet. These symptoms are considered to be particularly embarrassing.

The fear of specific social situations usually results in avoidance of those particular situations. A more generalised social phobia may lead to almost complete social isolation.

Diagnosis
According to the World Health Organization's (WHO) International Classification of Diseases (ICD)-10th Edition, social phobia is diagnosed when the individual displays the following features:

• A marked and persistent fear of being scrutinised by others in one or more social or performance situations. The fear involves acting in a way that will be embarrassing or humiliating (including showing symptoms of anxiety).
• Exposure to the feared situation causes anxiety and may lead to a panic attack.
• The fear is recognised to be irrational and excessive.
• The fear leads to marked distress during exposure to the social situation, or may lead to avoidance of that situation.

Differential diagnosis
`Normal' social anxiety or avoidance as experienced by most of the population, such as the fear associated with public speaking, does not necessarily justify a diagnosis of social phobia if the fear does not interfere with the individual's social or occupational functioning.

Avoidant Personality Disorder usually involves social anxiety and avoidance. The discrimination between this disorder and social phobia may be quite difficult and one may be an extension of the other. For further information about avoidant personality disorder, see Chapter 11: Personality Problems.

Agoraphobia may lead to avoidance of social situations, but this avoidance is usually secondary to the fear of having a panic attack in a public place. It is not the social situation per se which is feared but rather the possibility of having a panic attack, where escape would not be possible or help not forthcoming.

Specific phobia involves fear of a particular stimulus, however, the stimulus is not usually a social situation but more likely to be an insect or animal. It is usually the stimulus itself which is feared rather than the possibility of being embarrassed or humiliated in public.

Schizophrenia may involve delusions that one is being watched or scrutinised by others, however, careful history taking and the use of the Mental State Examination should lead to a correct diagnosis. Unlike schizophrenia, social phobia is not associated with typical schizophrenic symptoms such as thought disorder, blunted affect, or hallucinations.

Some social phobia beliefs may be so unshakable that the additional diagnosis of delusional disorder will be appropriate. Examples of such delusions (i.e., false beliefs that are firmly held despite contradictory and objective evidence) are that people stare or make negative evaluations because the individual smells or has a misshapen or ugly body part.

Epidemiology
Social phobia is as common as panic disorder and agoraphobia. Men develop this disorder as frequently as women. Social phobia tends to be a chronic disorder that may fluctuate over time. If untreated, the disorder typically causes marked impairment in social or occupational functioning. If the individual perceives his or her performance to be inadequate during exposure to a feared stimulus, this perception may lead to a worsening of the disorder. With treatment involving cognitive-behavioural therapy, individuals may experience good outcomes. Drug treatment can also be of benefit.

Assessment
The rationale for assessment was discussed in previous sections. The measuring instruments discussed in that section (i.e., the Fear Questionnaire and Hopkins Symptom Checklist) will also be useful for assessing symptom levels and measuring improvement of social phobia.

4.4.2 Management plan for social phobia

Management strategies will always vary from one individual to the next depending on the individual's particular problems. Generally, social phobia tends to be a severe and chronic disorder (especially if this disorder occurs in the context of an avoidant personality disorder - see Chapter 11: Personality Problems). Considerable expertise is required for effective treatment, particularly in dealing with the individual's beliefs regarding scrutiny by others and negative evaluation. In milder cases, or if referral for cognitive-behavioural treatment is not available, the following treatments are suggested:

1. Ongoing assessment of the disorder (above)
2. Education about the nature of anxiety, tailored to each individual's needs. Some basic information about anxiety is provided in Section 4.1 and includes:
   • The nature of anxiety
   • Management of the fight-or-flight response
   • The role of hyperventilation in anxiety
   Handouts on panic attacks and hyperventilation if these problems are present (Section 4.14.3 & 4.14.4)
   Education about phobic avoidance (Section 4.3.3)
3. Providing training in strategies to control anxiety symptoms, and encouraging the individual to practise these techniques regularly.
4. Graded exposure to feared situations (see Section 4.3.4 for general instructions). For example, if an individual is fearful of eating in front of others and would like to be able to eat a meal in a local cafe, the following hierarchy could be adapted according to how fearful he or she finds each step.
   • Have a soft drink at the cafe early in the morning when there are not many people around.
   • Have a soft drink at lunch time when the cafe is busy.
   • Have a cup of tea and a sandwich early in the morning.
   • Have a cup of tea and a sandwich at lunchtime.
   • Have a full meal (using cutlery) and stay for 20 minutes even if the meal is not fully eaten.
   • Have a full meal (using cutlery) and stay until all the meal is eaten.
   The steps could be adapted to include the presence or absence of friends, or to accommodate slightly different goals or problems (e.g., to be able to sign a bank slip or other form while people are watching). The last step on the hierarchy represents the situation or activity the individual fears most.
5. Encourage people to let go of `safety behaviours' such as avoiding others gaze, sitting out of the way in a corner, mumbling or speaking very softly, and having to pre-plan all social encounters.
6. Encourage them to focus on the here and now and think realistically about the present situation rather than some feared future outcome.
7. Some people may need to learn basic conversational and social skills and practice these in minimally aversive social situations.
8. Individuals are to be encouraged to avoid using alcohol and sedative medication to control anxiety. (See Chapter 2: Medication for a discussion of drug treatments).
9. Referral or specialist consultation if social anxiety or avoidance persist despite the above measures. 4.4.3 social phobia case study

Presenting problem
Ms Thompson, a 28-year old supervisor, has been dreading going to work because of fears that in meetings she will blush, her heart will race, and her thoughts will "block" so that she cannot express herself clearly. She is very worried about being seen to be anxious or uncomfortable, as she believes that her colleagues will think that she is not able to do her job properly. She has also begun to avoid eating lunch at work.

History of present illness
Two months ago Ms Thompson received a promotion and was anxious about the extra demands being placed upon her. She was starting to use alcohol regularly to relax at the end of the day. Ms Thompson had always placed a lot of importance on other people's opinions of her at work, and probably had tended to be over-aware of others observing her. Now she was feeling even more self-conscious, particularly in situations involving being challenged by a staff member in front of others. She had previously found meetings quite stressful, however now was very uncomfortable in anticipation of a meeting, and had avoided attending on a number of occasions. She did not understand what was happening to her and was considering requesting extended leave from her employer.

Personal and family history
Ms Thompson describes her mother as a hard-working, "stressed" person, and her father as fairly strict and perfectionistic. Both parents encouraged Ms Thompson and her younger brother to focus on work and to strive in their respective jobs. Ms Thompson has been working with her current company for 5 years; her second job since graduating from university. Premorbidly a "serious and quiet", shy person, she has always been sensitive to the opinions of others.

Standardised assessment
On the Fear Questionnaire Ms Thompson identifies her main phobia as "fear of people at work seeing me anxious". Her scores on the social phobia items total 33. Her scores on the agoraphobic items total 3. She rates the present state of her phobic symptoms as 7 out of 8 in terms of disturbance/disablement.

Management
Management strategies will depend on an individual's particular problems. Social phobia tends to be a severe and chronic disorder (especially if the person also has avoidant personality disorder - see Chapter 11: Personality Problems). Considerable expertise is required for effective treatment, particularly in dealing with an individual's beliefs regarding negative evaluation. In the case of Ms Thompson, if referral to a specialist service for cognitive-behavioural treatment is not available, the following management strategies are suggested:

1. Education about anxiety and social phobia, including information about:
   • the nature of anxiety and the fight-or-flight response
   • the role hyperventilation can play in anxiety
   • education about phobic avoidance
2. Training in de-arousal techniques of slow breathing and relaxation training.
3. Graded exposure to feared situations. In the case of Ms Thompson, the following hierarchy could be developed towards an ultimate goal of managing her anxiety while presenting a report at the two hour monthly managers' meeting (she should repeat each step until her anxiety is only mild).
   
   Step 1: Attend half-hour daily staff meeting and make one comment
   
   Step 2: Eat lunch at work with other staff
   
   Step 3: Attend half-hour daily staff meeting and question a colleague's comment
   
   Step 4: Eat lunch with others at work and make comments
   
   Step 5: Attend two hour monthly meeting and make one comment
   
   Step 6: Attend two hour monthly meeting and make two comments or questions
   
   Step 7: Attend two hour monthly meeting and present report
   
   Some steps may need to be modified, depending on Ms Thompson's progress. Other graded exposure tasks for Ms Thompson which may elicit similar concerns as the meeting, include: making an announcement at work, making a toast at lunch, questioning a colleague on a one-to-one basis about their work performance.
   
   
4. Cognitive therapy:
1. Encouraging Ms Thompson to consider (and to check out) how much attention people at work are actually paying to her while she is eating lunch, etc.
2. Questioning what evidence Ms Thompson has that her anxiety is noticeable at work.
3. Encouraging her to generate some alternatives regarding the significance of being seen to be anxious/uncomfortable (to challenge negative beliefs of people at work noticing her anxiety and thus believing that she is incompetent).
5. Ms Thompson should be encouraged not to engage in "safety behaviours" such as avoiding eye contact, making only minimal contributions, speaking exclusively from notes, etc. Avoidance of safety behaviours may need to be addressed in a gradual manner, however, as part of her graded exposure hierarchy. \
6. She should be encouraged to avoid using alcohol as a coping strategy.
7. On-going assessment of the disorder is important. Consider referral or specialist consultation if Ms Thompson's social anxiety persists despite these measures.

  Edited by Gavin Andrews MD, UNSW, 2007
©2007 CRUfAD