Editorial, Social Phobia

 

Editorial,

Social Phobia

Abdalla Abdelrahman

Professor of Psychiatry, University of Khartoum
MBBS, MDPsych, DCAPsych

Social phobia (SP) also referred to as social anxiety disorder (SAD), is characterized by a significant and persistent fear of social or performance situations where one may experience embarrassment.⁽¹⁾ This fear often leads individuals to avoid such situations altogether or endure them with intense anxiety or distress. The Diagnostic and Statistical Manual of Mental Disorders officially recognized this condition in 1980, and subsequent research has revealed that it is a diverse disorder with a wide range of symptoms.⁽²⁾

The estimated lifetime prevalence of SAD in the general population is between 2% to 5%. However, it is important to note that this condition is often under-reported. Failing to address SP can result in the development of comorbid mental disorders, increased disability, and a higher risk of suicide.⁽³⁾ Therefore, understanding and addressing SP is crucial in the field of mental health research and practice.

One key aspect of SP that requires attention is the presence of specific interpretive biases that can perpetuate the disorder.⁽⁴⁾ Individuals with SP tend to interpret ambiguous social events in negative light and mildly negative social events in a catastrophic manner. These biases can lead to heightened anxiety, engagement in safety-seeking behaviors, and avoidance of social situations. Consequently, this may elicit fewer warm responses from others and reinforce the individual's negative self-perception. This cycle undermines self-efficacy and increases the likelihood of future social avoidance, contributing to the maintenance of SP.^(2,4) Therefore, research into these interpretive biases and their consequences can inform more effective treatment strategies for SP, highlighting the significance of cognitive approaches in understanding and treating this condition.

The etiology of SAD/SP is complex and involves a combination of genetic and environmental factors.^(3,5,6) Research conducted on twins and families has indicated a genetic predisposition towards anxiety, with higher rates of concordance observed in monozygotic twins compared to dizygotic twins.⁽⁶⁾ This suggests that there is a certain level of heritability for SP. However, it is important to note that these studies often find stronger evidence for a general predisposition towards anxiety rather than a specific heritability for SP.

In addition to genetic factors, environmental influences also play a significant role in the development of SP. Factors such as parenting styles, exposure to social situations, and parental modeling contribute to the familial aggregation of SP.^(2,5,6) A study conducted on a community sample of parents further supports the role of familial and environmental factors in the development of SP. This study examined the 5-year risk of offspring developing SP during adolescence and found evidence for the influence of familial and environmental factors.⁽⁶⁾

Developmental models propose that vulnerability factors, including genetic factors and behavioral inhibition, contribute to the development of social fear and avoidance behavior.^(5,6) This can potentially lead to a restricted lifestyle and impact developmental pathways. Behavioral inhibition in childhood has been identified as a risk factor for SAD, including SP.

The diagnosis of SP is achieved by utilizing diagnostic criteria such as DSM-5 and ICD-11. SAD (SP), as described in the DSM-5, encompasses a range of symptoms characterized by an individual's significant fear or anxiety in social situations that involve potential scrutiny.⁽¹⁾ These situations include various social interactions, being observed while engaging in activities such as eating or drinking, and public performances. In children, the anxiety must be evident in peer settings. The individual is afraid of negative evaluation, expecting humiliation or rejection due to perceived inadequate behavior or anxiety symptoms. Social situations consistently trigger fear or anxiety, leading to avoidance or enduring experiences that are marked by intense distress. Importantly, the fear or anxiety is disproportionate to the actual threat posed by the situation and the socio cultural context. This persistent fear, lasting for a minimum of six months, causes clinically significant distress or impairment in social, occupational, or other important areas of functioning including learning. Furthermore, the disorder is distinguished by its independence from the physiological effects of substances or medical conditions and its exclusion from being better explained by symptoms of other mental disorders or concurrent medical conditions.⁽¹⁾

The evaluation of SAD relies on a variety of standardized scales that systematically measure symptoms and quantify the severity of social anxiety in both adults and children.^(3,5) These scales play a crucial role in clinical assessments and research studies that focus on social anxiety. Noteworthy instruments include the Social Interaction Anxiety Scale (SIAS), Social Phobia Scale (SPS), SP and Anxiety Inventory (SPAI), and SP Inventory (SPIN). Another widely used tool for self-reported evaluation is the Liebowitz Social Anxiety Scale-Self-Report (LSAS-SR). In addition, adults are further evaluated using instruments such as the Social Anxiety Questionnaire for Adults-30-item version (SAQ-A30), while children's anxiety is measured using the Multidimensional Anxiety Scale for Children (MASC), Revised Screen for Child Anxiety Related Emotional Disorders (SCARED), Spence Children's Anxiety Scale (SCAS), SP and Anxiety Inventory for Children (SPAI-C), Social Anxiety Scale for Children-Revised (SASC-R), and the Liebowitz Social Anxiety Scale for Children and Adolescents-Self-Report (LSAS-CA-SR). These diverse scales provide a comprehensive framework for clinicians and researchers to accurately assess and comprehend the intricacies of social anxiety across different age groups.⁽⁷⁾

The current therapeutic approaches for SP encompass both pharmacotherapy and psychotherapy.^(3,8) Clinical trials have demonstrated the potential of selective serotonin reuptake inhibitors (SSRIs) such as paroxetine and fluvoxamine in effectively treating SAD. These medications have shown efficacy in alleviating symptoms. Additionally, cognitive-behavioral therapy (CBT) has proven to be another successful approach to addressing SAD. By employing cognitive techniques to modify negative thought patterns and behaviors associated with social anxiety, CBT has shown long-term benefits for individuals with moderate impairment. Group therapy has also exhibited effectiveness when compared to control groups or placebo pills. However, social skills training and relaxation training have not yielded convincing evidence of a specific anxiolytic effect in social situations. It is important to consider comorbidity, or the presence of other disorders, as it may complicate treatment strategies and necessitate tailored approaches. The role of combined or sequential psychotherapeutic and pharmacologic treatment is still unclear, and further research is needed to determine the optimal treatment strategies for SAD.^{(3, 5,8)}

Coping with social anxiety encompasses a wide range of evidence-based strategies. Various relaxation techniques, such as deep breathing, progressive muscle relaxation, and mindfulness meditation, have been proven effective in alleviating symptoms of anxiety. Gradual exposure to increasingly challenging situations can help desensitize individuals to anxiety-provoking stimuli. Social skills training can enhance confidence by teaching effective communication strategies. ^(5,9) Engaging in self-care practices, such as regular exercise, sufficient sleep, a balanced diet, and stress management, can contribute to overall well-being. It is also important to build a supportive network and challenge negative self-talk. Mindfulness and acceptance techniques can assist in observing and accepting anxious thoughts without judgment. While the effectiveness of these strategies may vary, it is advisable to seek professional help for a personalized treatment plan that offers tailored guidance and support in managing social anxiety.^(4,5,9)

The prognosis and long-term outcome of SAD can vary depending on various factors. With appropriate treatment and support, many individuals with SAD can experience significant improvement in their symptoms and overall functioning. However, without treatment, SAD can persist and have a chronic course.^(4,9)

In this issue of The Journal there is a study conducted at Alfajr College for Science and Technology (ACST) among medical students, evaluating the distribution pattern of social phobia and its impact on academic achievement. Authored by: Rahaf Ali, Amani Burbur and Egbal Abukaraig. This study significantly contributes to the existing literature on social anxiety disorder among the young Sudanese population.

The researchers adopted a descriptive cross-sectional design and utilized the Social Fear Scale (SFS) by Raulin and Wee, which exhibits high accuracy, internal validity, and consistency.

Despite the statistical potentials of the social fear scale , it's essential to note that it was initially tailored for a specific type of social fear associated with genetic predisposition to schizophrenia, making the use of a generalized scale for social phobia more appropriate. Furthermore, the adoption of convenience sampling for data collection diminishes the representativeness of the sample and is better suited for by a probability sampling technique.

The researchers concluded a prevalence of 27.2% which exceeds the rates reported in the literature. However, the high female percentage is consistent with the worldwide literature as reported by the American Psychiatrists Association.

This paper serves as an eye opener and provides a more accurate portrayal of the social anxiety situation among Sudanese youth. Additional research, building upon the findings and recommendations of this article, is essential to fully comprehend the reality of social anxiety disorder within the Sudanese population especially young adults.

 

References

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7.        Wong QJJ, Gregory B, McLellan LF. A Review of Scales to Measure Social Anxiety Disorder in Clinical and Epidemiological Studies. Current Psychiatry Reports. Current Medicine Group LLC 1; 2016;18:1–15.

8.        Alomari NA, Bedaiwi SK, Ghasib AM, Kabbarah AJ, Alnefaie SA, Hariri N, et al. Social Anxiety Disorder: Associated Conditions and Therapeutic Approaches. Cureus. 2022 Dec 19;

9.        Stangier U, von Consbruch K, Schramm E, Heidenreich T. Common factors of cognitive therapy and interpersonal psychotherapy in the treatment of social phobia. Anxiety Stress Coping. 2010;23(3):289–301.

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