Social phobia has been one of the least well researched and most underrated of all mental health problems. Prior to 1980, it did not even rate for inclusion as a distinct disorder in the American Psychiatric Association's Diagnostic and Statistical Manual. The neglect of this disorder by mental health researchers seems to mirror the reluctance of people with social phobia to come forward with their problems. In fact, people with social phobia tend to avoid treatment longer than those diagnosed with any other anxiety disorder, preferring to suffer in silence than risk exposing their fears.

Social phobia is a potentially debilitating disorder affecting approximately two percent of the general population at any particular point in time. It stops people from interacting and forming relationships by evoking terror and/or avoidance at the prospect of human contact. It exacts a heavy toll on the professional and private lives of people who all too often find themselves under-educated, under-employed and lonely. Compared with other anxiety sufferers in their mid-thirties, Sanderson, DiNardo, Rapee and Barlow (1990) found more people (about half) with social phobia who were ever married.

Definition
Social phobia is a fear of negative evaluation. It is a grossly exaggerated version of the "jitters" many of us get when we perform or think about having to perform under public scrutiny: We worry about not dong well or getting so nervous that people begin to notice. We worry about humiliating or embarrassing ourselves. We worry about other people thinking poorly of us.

The qualities that distinguish social phobia from normal "jitters" are the duration and intensity of the fear. Unlike "stage fright" and other forms of performance anxiety, the fear of social phobia persists well into the performance. A benchmark for intensity of fear given by the American Psychiatric Association (1987) in the fourth edition of their Diagnostic and Statistical Manual is that the fear (or avoidance associated with the fear) must cause either significant interference with social and occupational functioning, or marked distress.

Most of this interference and distress results from the direct and indirect effects of physiologic arousal. Direct effects include accelerated heart rate, sweating, trembling, flushing/blushing, muscle tension/twitching, confusion, and gastrointestinal discomfort. Indirect effects include recognizing symptoms of arousal as signs of anxiety, and worrying about these signs becoming apparent to others.

Discrete Type
There appear to be at least two different types of social phobia. In its most narrowly defined form, called the discrete type, the feared situation is relatively circumscribed. According to Holt, Heimberg, Hope and Liebowitz (1992) the most commonly reported of these situations is speaking or interacting at formal gatherings (e.g., public speaking), followed by speaking or interacting at informal gatherings (e.g., talking one-on-one or in small groups), assertion (e.g., approaching strangers), and being observed performing an activity such as eating, drinking or writing. Some would argue for the inclusion of using public washrooms (or "bashful bladder") with these other activities, however there isn't consensus.

In all of these situations, the fear is regarded as excessive or unreasonable, even by the person suffering from it. Consequently, the person with the phobia is often recognized as having the necessary skills to perform adequately in the feared situation, but is prevented from doing so by their negative or faulty thinking. Negative thinking is an appraisal of threat about some aspect of a social situation that focuses attention on doing badly, rather than on the social tasks themselves. That is, instead of listening to other people in a conversation and trying to think of a response, the person with social phobia is wondering if they will be nervous, if it will be noticed, and what the consequences of this will be.

For example, a person who is fearful of speaking in small groups may start by being mildly apprehensive about their ability to find the right words to say. Next they notice their hands are trembling, their voice is quavering, or that beads of perspiration are forming on their brow. They think about how embarrassed they will become as people notice their discomfort. Soon their anxiety becomes high enough that their functioning is actually impaired. This relationship between anxiety and performance was first described in 1908 by Yerkes and Dodson.

The choices available to a person with social phobia are to endure the anxiety and the effect it has on performance, or to avoid the feared situation altogether. Unfortunately, neither choice provides the perfect solution. Even in the complete absence of exposure to a social phobia stimulus, the client reexperiences anxiety in anticipation of exposure.

Generalized Type
The more broadly defined form of social phobia is called the generalized type. It involves the fear of most, if not all social situations, and is associated with social skills deficits. These are people who generally report being shy much of their lives, and having relatively limited social contact with other people. Their social difficulties appear to emerge as an ever expanding rift between their development and the development of social skills by their peers. They tend to be marginalized, are sometimes mistreated, and become extremely sensitive to all forms of rejection. Their style of coping is to minimize opportunities for negative evaluation by shunning social contact. At times, they may even appear socially indifferent. All the while they secretly crave social involvement, a place of safety and acceptance amongst people who are important to them. Overall, people with this more generalized form of social phobia tend to have greater work and social impairment, and may have features of avoidant personality.

Extent of the Problem
Social phobia is the third most prevalent psychiatric disorder, following only depression and alcohol dependence (Kessler et al., 1994). A survey of over 8000 individuals across 48 states, using criteria similar to the more narrowly defined form above, found the lifetime prevalence of social phobia to be 13.3%, compared with 17.1% for a major depressive episode and 14.1% for alcohol dependence. With a typical age of onset either during the early grade school years or around puberty, it is also one of the earliest of the major psychiatric disorders (Schneier, Johnson, Hornig, Liebowitz & Weissman, 1992).

Finally, there is some evidence to suggest that social phobia may contribute to the onset of other major psychiatric disorders such as mood disorders, substance abuse disorders and other anxiety disorders (Hirschfeld, 1995). Sadly, it is often one of these co-existing problems that will bring a person with social phobia in for treatment. People suffering from social phobia alone are slightly less likely to seek treatment than people with no disorder (Schneier et al., 1992).

References
      American Psychological Association. (1994). Publication manual of the American Psychological Association (4th ed.). Washington, DC: Author. \

     Hirschfeld, R. (1995). The impact of health care reform on social phobia. Journal of Clinical Psychiatry, 95 (suppl 5), 13 - 17.

     Holt, C. S., Heimberg, R. G., Hope, D. A., and Liebowitz, M. L. (1992). Situational domains of social phobia. Journal of Abnormal Psychology, 6, 63-77.

     Kessler, R. C., McGonagle, K. A., Zhao, S., Nelson, C. B., Hughes, M., Eshleman, S., Wittchen, H. U., and Kendler, K. S. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8 - 19.

     Sanderson, W. C., DiNardo, P. A., Rapee, R. M., and Barlow, D. H. (1990). Syndrome comorbidity in patients diagnosed with a DSM-III-R anxiety disorder. Journal of Abnormal Psychology, 99, 308-312.

     Schneier, F. R., Johnson, J., Hornig, C. D., Liebowitz, M. R., and Weissman, M. M. (1992). Social phobia: Comorbidity and morbidity in an epidemiologic sample. Archives of General Psychiatry, 49, 282-288.

     Yerkes, R. M. & Dodson, J. D. (1908). The relation of strength of stimulus to rapidity of habit-formation. Journal of Comparative Neurological Psychology, 18(5),459 - 482.