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Social Phobias |
Overcoming Anxiety (Home) > Social Phobias > Clinical Features Clinical Features of Social PhobiasAs mentioned above, the central feature of social phobia is a marked and persistents fear of one or more social or performance situations in which the person is exposed to unfamiliar people or feels to be under scrutiny. The psychopathological foundations of SP are rather specific and typically phobic: exaggeration of autonomic responses, anticipation, repeated presentation of the fear and the awareness that the fear is unreasonable and excessive, accompanied by the feeling of being unable to control these emotions. Therefore, anxiety emerges when the patient is exposed to the phobic stimulus or contemplates future contact with the feared situations. This anxiety reaction may be experienced sometimes as a full-blown panic attack with the characteristic fears of losing control, dying or going mad, accompanied by autonomic responses. For SP patients the most commonly trigger situations are interactions as speaking or eating in public, writing in front of others, attending a party, meeting new people, contacting members of opposite sex, interacting with people in authority, using public bathrooms. The types of social situations feared by children and adults with SP are similar; one exception are the fears of meetings, a situation not generally encountered during childhood. The range of feared situations is an important element to subclassify the disorder. The subtypes uniformly accepted are ‘‘nongeneralised’’ and ‘‘generalised’’ social phobia. The first one is usually confined to a fear of one or two social or performance situations, of which the most common is speaking in public; the second form of SP is pervasive and more extensive, and regards most interactions and social situations. Generalised social phobia has been observed to be highly familiar, more severe and disabling, more persistent, with higher rates of comorbidity, higher incidence of help-seeking behaviour and often requires more intensive medical intervention. The boundary between this latter form of social phobia and avoidant personality disorder is blurred. It is important to distinguish the ‘‘normal’’ anxiety experienced by most individuals in social and performance situations and the exceptional anxiety experienced by the individual with social phobia. The first one usually reaches a peak at the beginning with adaptive advantage (greater efficacy) and it attenuates over the course of any given performance or social encounter, while the intense social phobics’ anxiety increases during the course of the social event or performance and this can result in impediment of functional ability. The clinical symptoms of SP can present at physical, cognitive and behavioural level and play a role in vicious circles that may contribute maintaining the disorder. Blushing is the principal physical symptom and with tachycardia, sweating and trembling suggests heightened autonomic arousal. Muscle tension, dry throat and gastrointestinal distress, such as nausea or diarrhoea are other common symptoms. SP patients have an exaggerated awareness of minimal somatic symptoms associated with a tendency to overreact with great anxiety to them and with an exaggerated fear that others may notice that they are anxious, distressed or unfit. Then, these physical indicators of anxiety may become part of a vicious circle: as social phobics anticipate or face feared social encounters, they experience an increase of somatic discomfort, which alerts them that they have become more anxious. This event leads to distraction, feelings of embarrassment or humiliation, these latter lead to further symptoms and then to more distraction, perception of impaired performance, and so on. The resulting negative experience fuels further anticipatory anxiety when faced with future social situations. Compared with agoraphobics, social phobics have significantly more cardiovascular symptoms, sweating and tremor and fewer respiratory symptoms during their situational panics. This may have a role in determining SP since blushing, sweating and trembling may be more easily noticed by the others. Children and adults have a similar somatic presentation, the only difference being that children frequently report ‘‘butterflies in their stomach’’, an expression that may reflects children’s limited ability to say what they feel. Cognitive symptoms include maladaptive thoughts about social situations. Sufferers may have rigid concepts of appropriate social behaviour, they exaggerate the impact of social blunders and ruminate about them afterwards. These beliefs are important in adults whereas are absent in children. Other features of SP are: an unrealistic tendency to experience others as critical or disapproving, associated with hypersensitivity to rejection or criticism, low assertiveness al least in phobic situations and low self-esteem. The behavioural symptoms include a freezing response, in which the sufferer may perform badly in social situations, and phobic avoidance. Avoidance of feared situation relieves anxiety, thus reinforcing further avoidance behaviour. The latter prevents the sufferer from being able to have positive experiences of social situations, and therefore negative expectations during interactions with others are perpetuated. A broad avoidance pattern frequently exacerbates problems with education, occupational, social functioning and increases the individual’s distress. SP may therefore become a disabling disorder leading to an egodystonic social isolation, unstable employment record, poor achievement and often financial dependence for the patients. However, social disability and the discomfort determinated by SP are not fully explained by the severity of the disorder. It is the resultant of a combination of personal skills (of which SP is an important factor), actual needs for social performances and social pressures. It is noteworthy that individuals with SP are reticent to seek help in view of the nature of the symptoms since pathological anxiety is often mistaken for shyness without the awareness that treatment is possible. Sometimes SP sufferers use alcohol in an attempt to self-medicate their distressing anxiety symptoms. Anxiety, depressive and substance abuse problems may then follow. When the disorder does not present these complications, sleep discomfort, appetite and sexual distress are usually absent.
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Clinical Features
