Phobias: Vol 7 (WPA Series in Evidence & Experience in Psychiatry)

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How to Overcome Fears and Phobias - Marisa Peer

The first line of treatment for social anxiety disorder is cognitive behavioral therapy CBT. The attention given to social anxiety disorder has significantly increased since with the approval and marketing of drugs for its treatment. In cognitive models of social anxiety disorder, those with social phobias experience dread over how they will present to others. They may feel overly self-conscious , pay high self-attention after the activity, or have high performance standards for themselves. According to the social psychology theory of self-presentation , a sufferer attempts to create a well-mannered impression towards others but believes he or she is unable to do so.

Many times, prior to the potentially anxiety-provoking social situation, sufferers may deliberately review what could go wrong and how to deal with each unexpected case. After the event, they may have the perception that they performed unsatisfactorily. Consequently, they will perceive anything that may have possibly been abnormal as embarrassing. These thoughts may extend for weeks or longer. Cognitive distortions are a hallmark, and are learned about in CBT cognitive-behavioral therapy. Thoughts are often self-defeating and inaccurate. Those with social phobia tend to interpret neutral or ambiguous conversations with a negative outlook, and many studies suggest that socially anxious individuals remember more negative memories than those less distressed.

An example of an instance may be that of an employee presenting to their co-workers. During the presentation, the person may stutter a word, upon which he or she may worry that other people significantly noticed and think that their perceptions of him or her as a presenter have been tarnished. This cognitive thought propels further anxiety which compounds with further stuttering, sweating, and, potentially, a panic attack. Social anxiety disorder is a persistent fear of one or more situations in which the person is exposed to possible scrutiny by others and fears that he or she may do something or act in a way that will be humiliating or embarrassing.

It exceeds normal "shyness" as it leads to excessive social avoidance and substantial social or occupational impairment. Feared activities may include almost any type of social interaction, especially small groups, dating , parties, talking to strangers, restaurants, interviews, etc.

Those who suffer from social anxiety disorder fear being judged by others in society. In particular, individuals with social anxiety are nervous in the presence of people with authority and feel uncomfortable during physical examinations. As a result, they often choose to isolate themselves from society to avoid such situations. They may also feel uncomfortable meeting people they do not know, and act distant when they are with large groups of people. In some cases, they may show evidence of this disorder by avoiding eye contact, or blushing when someone is talking to them.

According to psychologist B. Skinner , phobias are controlled by escape and avoidance behaviors. For instance, a student may leave the room when talking in front of the class escape and refrain from doing verbal presentations because of the previously encountered anxiety attack avoid. Major avoidance behaviors could include an almost pathological or compulsive lying behavior in order to preserve self-image and avoid judgement in front of others.

Physiological effects, similar to those in other anxiety disorders, are present in social phobias. The walk disturbance where a person is so worried about how they walk that they may lose balance may appear, especially when passing a group of people. Blushing is commonly exhibited by individuals suffering from social phobia. A study found that the area of the brain called the amygdala , part of the limbic system , is hyperactive when patients are shown threatening faces or confronted with frightening situations. They found that patients with more severe social phobia showed a correlation with the increased response in the amygdala.

SAD shows a high degree of co-occurrence with other psychiatric disorders. To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to substance abuse. It is estimated that one-fifth of patients with social anxiety disorder also suffer from alcohol dependence. The DSM-IV criteria stated that an individual cannot receive a diagnosis of social anxiety disorder if their symptoms are better accounted for by one of the autism spectrum disorders such as autism and Asperger syndrome. Because of its close relationship and overlapping symptoms, treating people with social phobia may help understand the underlying connections to other mental disorders.

Social anxiety disorder is often linked to bipolar disorder and attention deficit hyperactivity disorder ADHD and some believe that they share an underlying cyclothymic-anxious-sensitive disposition. Research into the causes of social anxiety and social phobia is wide-ranging, encompassing multiple perspectives from neuroscience to sociology. Scientists have yet to pinpoint the exact causes.


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Studies suggest that genetics can play a part in combination with environmental factors. Social phobia is not caused by other mental disorders or by substance abuse. This will develop over time as the person struggles to recover. Eventually, mild social awkwardness can develop into symptoms of social anxiety or phobia. It has been shown that there is a two to threefold greater risk of having social phobia if a first-degree relative also has the disorder. Studies of identical twins brought up via adoption in different families have indicated that, if one twin developed social anxiety disorder, then the other was between 30 percent and 50 percent more likely than average to also develop the disorder.

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Growing up with overprotective and hypercritical parents has also been associated with social anxiety disorder. A related line of research has investigated ' behavioural inhibition ' in infants — early signs of an inhibited and introspective or fearful nature. Studies have shown that around 10—15 percent of individuals show this early temperament, which appears to be partly due to genetics.

Some continue to show this trait into adolescence and adulthood, and appear to be more likely to develop social anxiety disorder. A previous negative social experience can be a trigger to social phobia, [37] [38] perhaps particularly for individuals high in " interpersonal sensitivity". For around half of those diagnosed with social anxiety disorder, a specific traumatic or humiliating social event appears to be associated with the onset or worsening of the disorder; [39] this kind of event appears to be particularly related to specific performance social phobia , for example, regarding public speaking Stemberg et al.

As well as direct experiences, observing or hearing about the socially negative experiences of others e. Shy adolescents or avoidant adults have emphasised unpleasant experiences with peers [41] or childhood bullying or harassment Gilmartin, In one study, popularity was found to be negatively correlated with social anxiety, and children who were neglected by their peers reported higher social anxiety and fear of negative evaluation than other categories of children.

Cultural factors that have been related to social anxiety disorder include a society's attitude towards shyness and avoidance, affecting the ability to form relationships or access employment or education, and shame. In China , research has indicated that shy-inhibited children are more accepted than their peers and more likely to be considered for leadership and considered competent, in contrast to the findings in Western countries. Problems in developing social skills, or ' social fluency ', may be a cause of some social anxiety disorder, through either inability or lack of confidence to interact socially and gain positive reactions and acceptance from others.

The studies have been mixed, however, with some studies not finding significant problems in social skills [47] while others have. The need for social acceptance or social standing has been elaborated in other lines of research relating to social anxiety.

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While alcohol initially relieves social phobia, excessive alcohol misuse can worsen social phobia symptoms and cause panic disorder to develop or worsen during alcohol intoxication and especially during alcohol withdrawal syndrome. This effect is not unique to alcohol but can also occur with long-term use of drugs which have a similar mechanism of action to alcohol such as the benzodiazepines which are sometimes prescribed as tranquillisers.

Like the anticonvulsants, they tend to be mild and well tolerated, although there is a risk of habit-forming.

Benzodiazepines are usually administered orally for the treatment of anxiety; however, occasionally lorazepam or diazepam may be given intravenously for the treatment of panic attacks. The World Council of Anxiety does not recommend benzodiazepines for the long-term treatment of anxiety due to a range of problems associated with long-term use including tolerance , psychomotor impairment, cognitive and memory impairments, physical dependence and a benzodiazepine withdrawal syndrome upon discontinuation of benzodiazepines. Many people who are addicted to alcohol or prescribed benzodiazepines when it is explained to them they have a choice between ongoing ill mental health or quitting and recovering from their symptoms decide on quitting alcohol or their benzodiazepines.

Research has indicated the role of 'core' or 'unconditional' negative beliefs e. They are thought to develop based on personality and adverse experiences and to be activated when the person feels under threat. Also highlighted has been a high focus on and worry about anxiety symptoms themselves and how they might appear to others.

Such cognitive-behavioral models consider the role of negatively biased memories of the past and the processes of rumination after an event, and fearful anticipation before it. This work has been influential in the development of Cognitive Behavioral Therapy for social anxiety disorder, which has been shown to have efficacy. There are many studies investigating neural bases of social anxiety disorder.

Sociability is closely tied to dopaminergic neurotransmission.

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Some evidence points to the possibility that social anxiety disorder involves reduced serotonin receptor binding. Some researchers believe that SSRIs decrease the activity of the amygdala. The amygdala is part of the limbic system which is related to fear cognition and emotional learning. Individuals with social anxiety disorder have been found to have a hypersensitive amygdala ; for example in relation to social threat cues e.

ICD defines social phobia as a fear of scrutiny by other people leading to avoidance of social situations. The anxiety symptoms may present as a complaint of blushing, hand tremor, nausea or urgency of micturition. Symptoms may progress to panic attacks. Prevention of anxiety disorders is one focus of research. The first line treatment for social anxiety disorder is cognitive behavioral therapy CBT with medications such as selective serotonin reuptake inhibitors SSRIs used only in those who are not interested in therapy.

There is some emerging evidence for the use of acceptance and commitment therapy ACT in the treatment of social anxiety disorder. ACT is considered an offshoot of traditional CBT and emphasizes accepting unpleasant symptoms rather than fighting against them, as well as psychological flexibility — the ability to adapt to changing situational demands, to shift one's perspective, and to balance competing desires. Some studies have suggested social skills training SST can help with social anxiety.

Given the evidence that social anxiety disorder may predict subsequent development of other psychiatric disorders such as depression, early diagnosis and treatment is important. Selective serotonin reuptake inhibitors SSRIs , a class of antidepressants, are the first choice of medication for generalized social phobia but a second line treatment. Patients were treated with either fluoxetine , psychotherapy, or a placebo.

The first four sets saw improvement in Of those assigned to receive only a placebo, Those who sought both therapy and medication did not see a boost in improvement.


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  4. Citalopram appears to be also effective. General side-effects are common during the first weeks while the body adjusts to the drug. Symptoms may include headaches , nausea , insomnia and changes in sexual behavior. Treatment safety during pregnancy has not been established. For this reason, [although evidential causality between SSRI use and actual suicide has not been demonstrated] the use of SSRIs in pediatric cases of depression is now recognized by the Food and Drug Administration as warranting a cautionary statement to the parents of children who may be prescribed SSRIs by a family doctor.

    In addition, studies show that more socially phobic patients treated with anti-depressant medication develop hypomania than non-phobic controls. The hypomania can be seen as the medication creating a new problem. Other prescription drugs are also used, if other methods are not effective. Benzodiazepines are an alternative to SSRIs. These drugs recommended usage is for short-term relief, meaning a limited time frame of over a year, of severe, disabling anxiety.

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