Social phobia - causes, symptoms, overcoming, treatment

According to the ECA epidemiological studies, the lifetime prevalence of social phobia was 2.8%, of which 70% were in women. However, more accurate studies have shown a prevalence of 13.3%. The average age of onset of phobia is 15 years. It is the second most common phobia after agoraphobia.

Social phobia manifests itself in the form of an intense and persistent fear of one or more social situations, followed by their obvious avoidance, which leads to a decrease in anxiety at the cost of disruption of the social sphere of life. Patients, as a rule, realize the irrationality of their fear, but this does not help them. Fear comes from the anticipation of the fear itself.

Social phobia is diagnosed relatively rarely, since patients are usually ashamed to contact a specialist. They believe that their fear is either just a character trait, or they are afraid of being labeled as suffering from a mental disorder. Moreover, they do not believe in the possibility of treatment.

Social phobia can be specific, that is, it concerns only certain social situations (for example, eating in public places or the possibility of asking something from a passerby), or generalized, concerning a wide range of social situations.

Social phobia is an extremely common mental disorder. If not treated properly, it can often deprive a person of a normal life.

The most common symptoms of social phobia are fear of:

• others watching;
• being embarrassed;
• being the center of attention;
• unnatural behavior;
• parties/meetings;
• eating in front of people;
• using public places;
• speaking in front of an audience or doing any action in public;
• starting a conversation;
• keeping up a conversation;
• asking for something.

This also includes avoidance of the social situation, the manifestation of vegetative symptoms when getting into this situation. Also observed in social phobia are low self-esteem, blushing and difficulty making eye contact, hand tremors, nausea, urgent need to urinate, vomiting. All these symptoms must be associated with the frightening situation.

Predisposing factors

Biological factors. Similar to other anxiety disorders, dysfunction of the serotonergic and noradrenergic systems, as well as genetic vulnerability, are suggested. In particular, a significant familial component has been found with a tenfold risk of developing social phobia or avoidant personality disorder in first-degree relatives (Stein, 1998). The importance of the genetic factor was also confirmed by twin studies by Kendler (1992).

Learning. Despite the biological predisposition, social phobia is generally considered a learned fear, both through direct conditioning and through modeling and receiving information from the environment. The fear develops gradually and is usually the result of repeated, often minor, traumatic experiences, or arises through imitation of parental behavior. Much less often, a single psychotraumatic situation is considered as a cause. Thus, the behavior of parents and the immediate environment in childhood can serve as predisposing factors.

Learning in a situation of social phobia is well explained by Maurer's two-factor theory (1960). First, the patient associates social interaction with the emotion of fear through classical conditioning or imitation learning, and then begins to avoid social situations, which, on the one hand, reinforces his phobic behavior (since it leads to stress relief), and, on the other hand, negatively affects the formation of social skills and self-esteem. Fear gradually generalizes to different situations.

Example. Pavel developed social phobia when he was 13. At that time, he had surgery on his tongue, and it seemed to him that he spoke with a nasal voice. Therefore, he began to speak quietly, hiding his deficiency, for which his classmates made fun of him. Pavel completely stopped talking to them, he had difficulty passing exams, he stuttered and blushed. While other guys began dating girls, Pavel felt an obstacle in his path - he thought that he still stuttered and blushed when talking, he had nothing to talk about. As a result, having withdrawn into himself and refused to communicate, he was unable to acquire important social interaction skills. Later, Pavel sought treatment for social phobia. After his anxiety was removed, additional social skills training had to be carried out.

Core Beliefs

People with social phobia are characterized by unhealthy childhood family relationships: close people were overly critical, laughed at the child or shamed him in front of others. Parents of people with social phobia raise their children in such a way that they prevent them from encountering social situations in various ways (modeling, overprotection, criticism, comparison with others, intimidation about social consequences), which interferes with the development of social skills.

This is where global attitudes towards the world arise: "I am poor", "The world is a dangerous place", "Other people reject the weak."

Example. As a child, Veronica experienced severe anxiety when her parents argued. Veronica's parents divorced when she was five years old, and her mother began to raise her alone. Her mother never had another partner; on the contrary, she spoke of men with disdain. The girl completely submitted to her mother, who called her weak. She demanded that her daughter study well, be nice, beautiful, and neat, and was very critical of the child. Her mother, despising her father, often emphasized the fact that Veronica was very similar to him. However, the girl herself loved her father very much, since he gave her unconditional love and did not demand anything. Veronica set excessively high standards for herself, but was convinced that she would never be able to cope with them. She came to the conclusion that her usual behavior was unacceptable for other people.

Traumatic (initiating) situation

Social phobia is characterized, rather, by prolonged stress and a certain childhood developmental situation, rather than a single traumatic event. However, the most striking situations in the development of such patients are ridicule (for example, a teacher made fun of him in front of the whole class), rejection (a child brought a picture to his mother, and she did not pay attention to him), and family violence. Trauma is also possible in an overprotective family. In such a case, a child who is used to having all his wishes fulfilled, at the moment of meeting with the external environment (for example, when it is time to go to school) encounters strong external rejection - other boys and girls do not want to give up their toys, share anything and generally treat the individual with disrespect. Since the child was not taught the proper social interaction skills in the family, he is not ready for such a situation, and it traumatizes him.

Example. Veronica's problems began already in the first grade of elementary school. She studied well, but when speaking in front of the class she experienced excessive anxiety. During her speech, she often stopped, blushed and began to cry. For this reason, the teachers stopped calling her and tormenting her unless it was necessary. In the second grade, however, some teachers did not want to put up with this situation. For Veronica, testing became a traumatic event. She blushed and could not answer even the questions she knew the answers to. She became the object of ridicule in class, so she began to avoid testing. Thus, Veronica's social phobia began to develop in elementary school, when she blushed and was unable to say anything. This reinforced her belief that she was terrible.

A significant worsening of symptoms occurred during puberty. She does not remember any sudden onset, she simply suddenly realized that she was no longer able to stand at the board or talk to more than one person at a time. After that, the symptoms began to increase and multiply. Apparently, endogenous variables became an important factor in the development of the disease.

Intermediate beliefs

Based on deep beliefs and traumatic events, rules of interaction with society in specific situations are formed: "If I do everything perfectly, I will not be rejected", "If everyone does not accept me, it will be unbearable", "I am calm and happy only if I have everything under control", "Everyone is looking at me and judging me."

Example. Veronica's intermediate beliefs concerned her self-esteem and interactions with other people: "I can't speak in front of people," "If I do something in front of people, they'll laugh at me," "I can't handle this kind of stress." Her ideas about relationships were also important: "Relationships are too complicated."

Current model of the problem

Automatic thoughts.Automatic thoughts are formed from a combination of the patient's beliefs and the current situation. They are most often characterized by catastrophizing.

Emotions.On the eve of a social situation or during it, the patient experiences fear and anxiety, which can sometimes lead to panic. At the same time, anger and resentment towards oneself and others can manifest. If the individual avoids the social situation, he feels relief.

Physiology.The physiology characteristic of social phobia corresponds to other types of anxiety disorders - increased sweating, tachycardia, trembling, urge to vomit.

Behavior. The behavior is manifested in the deterioration of the interaction process (awkward silence, stuttering, closedness, misunderstanding of what is said, an attempt to leave), as well as in avoiding the social situation.

Consequences. Social phobia entails quite serious consequences for the patient's life. His social connections are disrupted, problems appear in his personal life, career, studies.

Example. Veronica is unable to look anyone in the eye, her gaze is directed at the ground, due to tension she makes a strange facial expression, her body is bent over, her hands are clasped between her knees, she is full of fear and anxiety. She is afraid that she will not know what to say, she will blush, and her voice will tremble. Already five minutes after the start of the conversation, she wants to leave, as she is unable to withstand the tension in a situation with a stranger. These problems have become so severe that Veronica has stopped riding the subway because she was afraid of being noticed, so she has locked herself in her home and isolated herself. She has no family relationships. Although she does not share her mother's "All men are pigs" opinion, she still believes that relationships between men and women are so complicated that it is better to remain alone.

Supporting factors

1. Avoidance behavior. Social phobics tend to avoid social situations, which leads to a vicious circle. Avoidance leads to reinforcement of the behavior, decreased self-esteem and loss of social skills, after which the fear of getting into a social situation increases, which again leads to avoidance.
2. Defensive behavior. Defensive behavior involves diverting attention from oneself. It may consist of inconspicuous clothing, attempts to be unnoticeable, avoiding eye contact, and using the shortest possible sentences when speaking.
3. Underdeveloped communication skills. Such patients often have impaired communication skills (e.g. poor eye contact, difficulty maintaining a conversation), which can lead to a negative reaction from other people and, thus, to reinforcement of the disease.
4. Hypersensitivity. Patients gradually develop a specific sensitivity to the perception of threat in interpersonal situations. They react to the slightest signals that, in their opinion, may mean rejection. Despite the fact that most of these signals have nothing to do with the patient, he still interprets them in this way.
5. Anticipatory anxiety. Social phobia is characterized by catastrophic thoughts about an upcoming social situation. The patient expects the worst, which leads to subsequent avoidance.
6. Attention directed at themselves. Patients tend to redirect their attention inward when they feel stressed. They pay attention to their physical sensations, feelings, emotions, thoughts and ideas and shut themselves off from external information, including other people. This also leads to a deterioration in the process of social interaction and a return to the vicious circle of anxiety.
7. Negative self-esteem. The longer the disease develops, the worse the patient's opinion of himself usually becomes. Moreover, as studies show, the patient's negative thoughts about himself are in most cases subject to distortion and do not correspond to reality. The patient focuses on how he looks in a particular social situation, and these thoughts block his thinking, he no longer thinks about solving the problem.
8. Interpersonal factors. People around a person usually notice the presence of social phobia, but they classify it not as a disease, but as "shyness", and sometimes as "stubbornness". These qualities subsequently become targets for ridicule and reproach, which further strengthens the individual in his illness. The opposite situation is also possible, when the patient's relatives do everything they can to protect him from social interaction (call him on the phone, resolve issues in various institutions). This, in turn, also forces the patient to remain in a vicious circle of anxiety.
9. Cognitive distortions. For patients with social phobia, selective thinking is most characteristic, when they do not pay attention to everything positive, but notice only the negative ("They praised me only because they feel sorry for me"). There is also "mind reading", when the patient makes unfounded assumptions about the intentions of other people ("He looked at me askance", "I could not please him.")

Example. The most important supporting factor for Veronica since elementary school was avoidance behavior. She avoided being tested in front of the class, looking at others face to face, talking to boys, people in authority, and interacting with classmates during breaks. Her teachers in the first grade tried to shield her from public speaking instead of gradually teaching her how to speak, which also prevented her from developing the necessary skill. The same situation repeated itself in middle school. Veronica’s cognitive processes included constant self-condemnation. She considered herself incapable, useless, and weak. She was also convinced that others underestimated her and thought that they had the same opinion of her as she did. Veronica is unable to accept any positive assessment from others, she immediately downplays and distorts it ("They say this because they feel sorry for me, but in reality it is not so").

Modulating factors

The following modulating factors are most common.

1. Degree of social closeness. It is most difficult for a patient with social phobia to communicate with strangers, while he can maintain quite normal communication with close friends.
2. Form of social interaction. It is often easier for patients to use certain forms of interaction. In most cases, preference is given to communication by correspondence. However, the opposite situation is also possible, when it is easier for an individual to communicate face to face than, for example, when interacting by telephone, since in this situation he receives more information about the other person (an illusion of control is created).
3. Initial impression of the person. People suffering from social phobia find it easier to communicate with those whom they initially assess as "safe" even before the start of communication. Some people by their behavior, manner of speech, appearance may seem "dangerous" to the patient. The patient will avoid communicating with such people.
4. The gender of the communication partner. Often, social phobia can concern a specific gender, for example, male or female. This is primarily due to childhood experience of interaction. For example, if the father constantly beat the mother, then the child will be predisposed to fear men. The situation can be the opposite, when the child was abused by the mother, but cared for by the father.
5. Duration of interaction. The duration of interaction is also important for the patient, which, in essence, represents the degree of knowledge of the other person. It will be much easier for him to approach a person he has known for quite a long time, even if he has never spoken to him (for example, a classmate), than a complete stranger.
6. Formal and informal communication. For some patients, it is much easier to maintain informal communication than formal, for others it is the opposite.
7. The degree of power of the communication partner. For some individuals, communication with powerful and authoritative people is a big problem.
8. The number of interaction partners. For many patients, the number of interaction partners is critically important. Often, the patient can maintain quite adequate communication with one person, but experience tension when communicating with a group.

Example. During therapy, Veronica trusted her therapist completely, as he reminded her of her father. She completed all the tasks and was very responsible in therapy. She was able to express herself in the treatment group, where she also felt supported. However, in the early stages, she was able to extend her successes only to formal interactions, continuing to experience problems with informal ones.

Treatment of Phobias

In cognitive behavioral therapy, the main methods of treating social phobia are exposure therapy (gradually exposing the patient to increasingly frightening situations) and teaching social interaction skills.

Example. Veronica was admitted to a day hospital. She was treated with a combination of CBT and pharmacotherapy. At first, she was explained the cognitive behavioral model of social phobia, taking into account her symptoms. The therapist supported her in interacting with other people. Very often she had the urge to stop the treatment, as she could not stand the tension of being in the group in which she was treated. But soon she adapted, and after two weeks she was already able to talk to individuals.

After four weeks of exposures, Veronica was already reading a short text in front of the group, then retelling it, and finally speaking in front of the group on a free topic. However, there was still a tendency to devalue successful results, which was the focus of further therapy. Soon she feels a significant improvement, but the generalization of her skills is still insufficient. She can quite well maintain formal communication with people: talk to a saleswoman, ask for directions, etc., but informal communication is difficult. She continues to work successfully on this with the help of exposure therapy. Attention is also paid to her parent-child relationships, in particular, the relationship with her mother.

After 14 weeks of treatment, she found a job in the city administration, and after another 6 months she has adapted to the workplace and can speak freely with colleagues.