15.

SOCIAL PHOBIA AND SPECIFIC PHOBIAS

RoGert D.Davies, M.D.

1. What is the difference between fear and a phobia? Fear is a normal psychological and physiological reaction to an actual threat or danger, or to the anticipation of an actual threat or danger. A phobia is an excessive and unreasonable degree of fear triggered either by exposure to or anticipation of a specific object or circumstance. People with specific phobias realize that their level of fear is excessive, but they still try to avoid any exposure to the feared object or circumstance. These avoidance attempts and the anxiety that results when avoidance is unsuccessful cause a significant disruption in normal functioning. Common Phobias
Animal type Insects Snakes Dogs
Storms

Bloodlinjury type

Nature type

Situational type

Heights Water

Injectionshlood draws Seeing blood Seeing an injured person Driving Tunnels Bridges Flying Elevators

2. How do people develop phobias? Good question. It is not clear why some people develop specific phobias. Many phobias begin in childhood-particularly those of the animal and nature type. Very often there has never been an exposure to the feared object or situation. In fact, if there has been a traumatic exposure (for instance, an attack by a dog), then future avoidance more accurately reflects the type of avoidance seen in post-traumatic syndromes. People with phobias tend to overestimate the degree of danger that a given situation or object represents. Again, if the level of fear is reasonable and appropriate, then the individual is not considered to have a phobia.

3. How do you treat a specific phobia? Cognitive behavioral therapy is probably the most effective treatment for a specific phobia. Through a process of graded exposure called systematic desensitization, individuals with a phobia
are able to extinguish or control their response. They are first instructed in techniques to decrease anxiety, such as diaphragmatic breathing and progressive muscle relaxation. They then develop a hierarchy of exposure to the feared situation or object, based on the amount of anxiety they estimate each degree of exposure would elicit. For example, someone with a phobia of venipuncture might place talking about having blood drawn at the low end of their hierarchy, eliciting an anxiety response rated at 1. Seeing a blood drawing kit might elicit an anxiety response of 5, while actually having his or her blood drawn would be a 10. The therapist exposes the patient to these situations, starting at the least anxiety provoking and working up to the actual fear situation. At each stage the patient practices calming down and tolerating the exposure, until the phobic situation or object can be experienced without an excess of anxiety. When the phobia is of a specific situation that can be anticipated, such as a fear of flying, the use of low-dose benzodiazepines prior to the experience also can be effective. The medication allows them to tolerate the exposure, but generally does not affect future exposures to the feared situation.
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4. What is social phobia?

Social phobia is a form of phobia-distinct from specific phobias-in which an individual has an excessive and persistent fear of a given social situation where they might be exposed to the scrutiny of others. The exposure to, or anticipation of, the feared situation causes a marked anxiety response, and the individual either avoids those situations or endures them with significant discomfort. The person usually recognizes that the fear is excessive. Avoidance attempts and/or the anxiety disrupts social or occupational functioning. When there is only one situation that is feared, the person is considered to have a specific social phobia. The most well-known specific social phobia is performance anxiety-the fear of public speaking. When more than one situation is feared, it is called generalized social phobia. People with generalized social phobia tend to be more disabled, as almost all social settings and interpersonal contacts elicit anxiety and avoidance. Someone with a specific social phobia may be able to structure his or her life in such a way as to avoid or limit exposure to the particular situation that causes anxiety. The most common fears seen in social phobia include speaking before a group or being the center of attention, eating in public, writing in public, and using public lavatories. For many people, the fear of scrutiny and anxiety is the result of a physical condition such as a tremor, Tourettes syndrome, scarring, obesity, or physical deformity. In these situations, however, the individual is not considered to have social phobia (as his or her assessment of being negatively scrutinized by others may well be accurate).

5. How common a problem is social phobia? Social phobia is now known to be one of the most common psychiatric disorders in the general population. Epidemiologic researchers have found that there is a 13.3% lifetime prevalence of social phobia, with a higher prevalence existing in women (15.5%) than in men (1 1.1%). Unfortunately, it is estimated that only 2% of the people with social phobia actually seek treatment for it. Many people end up structuring their lives to avoid whatever situation triggers their anxiety. This may work for some people with specific social phobias, but for those individuals with generalized social phobia, their ability to lead a full life often is significantly impaired. Alcohol commonly is utilized in an attempt to decrease the anxiety and allow the individual to tolerate the feared social situation. In approximately 85% of the people with both social phobia and alcohol abuse, the social phobia precedes the alcohol problem.
6. What are the cognitive processes involved in social phobia? People with social phobia tend to overestimate their own symptoms of anxiety-for instance, if they are feeling anxious and flushed, they may assume that they are beet red. They also misinterpret the responses of others in negative ways. They overestimate the degree to which other people are paying attention to them, and the likelihood that they will be embarrassed or rejected. Finally, they tend to overemphasize any perceived or actual failures, while discounting their achievements and positive feedback.

7. What other conditions might be confused with social phobia? The differential diagnosis for social phobia includes agoraphobia, panic disorder, generalized anxiety disorder, depression, body dysmorphic disorder, avoidant or schizoid personality disorders, and nonpathological shyness.
8. Can medications help in social phobia? Absolutely. For individuals with specific social phobia, such as performance anxiety, P-blockers (e.g., propranolol) can be beneficial. These drugs target the physiologic symptoms of anxiety (such as increased heart rate) rather than the emotional experience. This ends up having an indirect effect on the cognitive component of the anxiety-as the physiologic feedback to the cognitive aspect of the anxiety is blocked. Benzodiazepines (e.g., alprazolam, lorazepam, clonazepam) also are effective in these individuals and can be used on an as-needed basis. For those people with generalized social phobia, both monoamine oxidase inhibitors (e.g., phenelzine, tranylcypramine) and serotonin specific reuptake inhibitors (e.g., paroxetine, sertraline, fluoxetine) can be effective

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Generalized Anxiety Disorder

treatments. The use of these antidepressants also has the benefit of treating comorbid depression when it occurs. Other medications that are showing some promise in treating social phobia include venlafaxine (which inhibits the reuptake of both serotonin and norepinephrine) and gabapentin (which works at the GABA receptor complex). Tricyclic antidepressants, however, have not been shown to be efficacious.

9. Are there other types of treatment for social phobia? An important form of treatment for social phobia is cognitive behavioral therapy (CBT). This type of therapy involves cognitive restructuring by helping the individual with social phobia identify his or her cognitive distortions and challenge the accuracy of their perceptions. They also learn how to decrease their physiologic response of anxiety with various techniques including deep-breathing and progressive muscle relaxation. Graded exposure to the feared situation also is employed as they learn to tolerate increasingly greater exposure to the feared situation. Eventually, the anxious response is extinguished. Group CBT also is helpful in the treatment of social phobia. This form of treatment includes social skills training and role-playing, and allows individuals to get direct, immediate feedback on their perceptions of how others view them.
BIBLIOGRAPHY
1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC, American Psychiatric Association, 1994. 2. Goisman RM, Allsworth J, Rogers MP, et al: Simple phobia as a comorbid anxiety disorder. Depress Anxiety 7(3):105-112, 1998. 3. Heimberg RG, Juster HR: Treatment of social phobia in cognitive-behavioral groups. J Clin Psychiatry S5(Suppl):3846, 1994. 4 . Jefferson JW: Social phobia: A pharmacologic treatment overview. J Clin Psychiatry 56(Suppl 5): 18-24, 199s. 5. Keck PE, McElroy SL: New uses for antidepressants: Social phobia. J Clin Psychiatry 58(Suppl 14):32-38, 1997. 6. Kessler RC, McGonagle KA, Zhoa S, et al: Lifetime and 12-month prevalence of DSM-111-R psychiatric disorders in the United States: Results from the National Comorbidity Survey.Arch Gen Psychiatry 51 :8-19, 1994. 7. Schneier FR, Johnson J, Hornig CD, et al: Social phobia: Comorbidity and morbidity in an epidemiologic sample. Arch Gen Psychiatry 49:282-288, 1992.

16. GENERALIZED ANXIETY DISORDER

Robert D.Davies, M.D., and Leslie Winter, M.D
1. What is generalized anxiety disorder? Anxiety and worry are commonly experienced responses to the stress of day-to-day life. We all worry at times about various aspects of our lives-particularly the unknown or novel. This is absolutely normal. However, when worry and anxiety are the predominate approach to life, it is not normal. People with generalized anxiety disorder (GAD) experience excessive levels of anxiety and worry most of the time and have great difficulty controlling their worry. The excessive level of anxiety they experience causes significant distress and often impairs their ability to function in various areas of their life (such as socially or occupationally). Many people with GAD become preoccupied with the physical symptoms associated with anxiety (such as gastrointestinal distress and fatigue) and worry about their health. This worry may lead them to repeatedly seek out medical evaluations and reassurance. Thus, GAD typically is seen in primary care settings rather than i n mental health settings.