While most of us prefer to avoid embarrassment and humiliation, people with social phobias, develop such an intense fear that it can become almost impossible to function in many social and work settings.. Any situation in which others could be judging them may provoke crippling anxiety. They are constantly concerned about being scrutinized and embarrassed in all kinds of social settings. They can be especially anxious in when interacting with persons in authority. The National Comorbidity Study found social phobia to be the third most common psychiatric disorder, after major depression and alcohol dependence. Nevertheless, social phobia remains one of the least well known of the anxiety disorders. Most people do not regard generalized social phobia as a psychiatric disorder. The characteristic symptoms are often interpreted by others as aloof indifference or passive-aggressive resistance to influence. These reactions compound shame and make it seem even more necessary to conceal a disorder discouraging all approaches to strangers, including psychotherapists.

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) defines social phobia as "a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing." The fear must be seen as excessive or unreasonable by the patient, lead to avoidance of feared situations or cause anticipatory anxiety, and significantly interfere with the patient's social or occupational life. The fear or avoidance must not be the direct effect of any substance or general medical condition. Social phobia can extend to most situations (generalized subtype) or be limited to only one or a few of them (non-generalized subtype).

Symptoms and Causes
As a consequence of negative social experiences, persons with social phobia develop a pattern of negative perceptions about themselves and the world. Beliefs that upon entering one of the feared situations, they will behave inappropriately creates a circular pattern of self-depreciating ideation and avoidant behavior. The anticipatory anxiety that precedes the social situation becomes an additional source of fear. Preoccupation with these internal signals leads persons with social phobia to have difficulty focusing their attention on the social cues or performing abilities that would help them fare better in the feared situation.

Symptoms can include; concern about where to direct one's eyes and how to respond when others look at them, fear that people will read their true feelings and openly or covertly reject them, feedback from others that they are aloof and uninterested, blushing, stammering, sweating, stomach upset, a racing heart, trembling limbs and even a full-scale panic attack. Avoidance of anxiety producing situations is a short term and, ultimately, ineffective coping strategy. Some go to great trouble to conceal their dread and wear a public mask. Others may worry about an upcoming event weeks or even months before it occurs.

Social phobia is often associated with other psychiatric disorders. Simple phobias, panic disorder, alcohol abuse, and major depression are common secondary issues.

For many, the origins of social phobia often lie in childhood. Most people with the generalized form of the disorder say they have always been uncomfortable around company even as small children. Their parents usually confirm that they were shy. The rate of social phobia in a person's family members is about three times higher than average. The behavior of parents may contribute to difficulties created by genetic pre-dispositions. Many people with social phobias describe their parents as both overprotective and insufficiently affectionate. There may have been constant criticism and worry that they will do something wrong. Parents may overemphasize manners and grooming or exaggerate the danger of approaching strangers. If they avoid social situations because of their own shyness, the children may imitate them.

Treatment
Social Skills Training is based on the assumption that a person is having trouble in social situations because they don't have the skills necessary for successful interactions. I've worked with many clients who have been isolated, withdrawn or shy and, as a result, simply don't know how to initiate, respond to or engage others. We discuss and rehearse social situations and have them visualizes various social situations and settings. Patients are thought how to make better eye contact, increase vocal tone and articulate more clearly. They learn how to greet people and take leave of them, how to ask for favors, respond to requests, and answer criticism. They monitor themselves with diaries and practice the new skills in real life as homework. Daily logs are used as a part of the self-monitoring, to increase awareness of avoidant behavior.

Systematic Desensitization, is based on the assumption that habits of avoidance are reinforced by relief from fear. A person who has never had long enough contact with the feared object never becomes sufficiently accustomed to it to lose the fear. We attempt to create conditions in therapy where this response will not occur and then expose the patient to the situations that have been provoking it. Physical relaxation techniques may be necessary to prevent the emergence of physical symptoms that can be interpreted as anxiety. Clients can be trained in progressive muscle relaxation, breathing exercises, visualization, or meditation. They are then presented with a graded hierarchy of increasingly frightening situations to overcome each level of fear.

Affirmations are an important part of recovery from social phobia as well. This behavioral technique helps with the process of extinguishing negative and self-depreciating ideation. The result is more confidence, increased motivation and a more positive and hopeful perception of recovery. Clients write lists of positive self statements, not just about themselves, but about overcoming their social phobia. These affirmations can be integrated into visualizations. I suggest reading their list several times a day.

I also assign the "The Anxiety & Phobia Workbook" by Edmund J. Bourne, Ph.D.. We use it as a source of discussion and, I find, it generates questions specific to that particular client's concerns. It's comprehensive explanations and detailed exercises give my clients a sense of more personal control and involvement in their recovery as well as a home reference they can rely on during difficult periods.

Conclusion
Social phobia is a common and treatable problem. The quality of one's life and, especially, one's social and work interactions can be substantially improved with it's resolution. For more information regarding social phobia and other anxiety disorders, check the links on the "Resources" page or contact; The Anxiety Disorders Association of America; ADAA 6000 Executive Boulevard, Suite 200, Rockville, MD 20852-3901

References:
Current and New Approaches to Social Phobia by Carlos Blanco, MD, PhD, Franklin R. Schneier, MD, Columbia College of Physicians and Surgeons and the New York State Psychiatric Institute

The Harvard Mental Health Letter, October 1994 (Part I), November 1994 (Part II)

The Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV)[2]

Article Updated 1/18/01