Trip Answers

Question answered:25/02/03 Warning! this question is over two years old.

eMedicine has an article on social phobia (1) where they outline the criteria for social phobia from DSM-IV:

• A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others: The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. In children, evidence of the capacity for age-appropriate social relationships with familiar people must exist, and the anxiety must occur in peer settings, not just in interactions with adults.
• Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
• The person recognizes that the fear is excessive or unreasonable. In children, this feature may be absent.
• The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
• The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (academic) functioning, or social activities or relationships, or marked distress about having the phobia exists.
• In individuals younger than 18 years, the duration is at least 6 months.
• The fear or avoidance is not due to the direct physiological effects of a substance (eg, a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (eg, panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, schizoid personality disorder).
• If a general medical condition or another mental disorder is present, the fear in one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others is unrelated to it; for example, the fear is not of stuttering, trembling in Parkinson disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa.
• The phobia is specified as generalized if the fears include most social situations (also consider the additional diagnosis of avoidant personality disorder).
• Associated features
  • Depressed mood
  • Somatic/sexual dysfunction
  • Addiction
  • Anxious/fearful/dependent personality

In terms of treatment, the Cochrane Library holds a protocol for a review on pharmacotherapy for social phobia (2). When complete (expected publication date Issue 2, 2003) this should highlight best evidence in this area.

In addition we found two meta-analyses on the treatment of social phobia (3)(4).

In their meta-analysis Stravynski et al examined the effects of psychological and pharmacological treatment of social phobia (3). In their results they state:

"Exposure versus cognitive restructuring (10 studies): both produced a clinical improvement in distress and avoidance in either the group or individual format. Gains were not seen in control groups. Cognitive restructuring proved to be no more effective than exposure.

Social skills training, exposure and cognitive restructuring (3 studies): social skills training was as effective as exposure and cognitive restructuring in reducing anxiety and avoidance.

Pharmacological approaches (13 studies): four classes of medication were shown to be more effective than placebo; these were monoamine oxidase inhibitors, reversible monoamine oxidase inhibitors, anxiolytics, and selective serotonin re-uptake inhibitors. However, 2 studies, one of moclobemide and one of buspirone, failed to show effects beyond that of placebo. The medications also had undesirable effects. The number of studies, and in some cases samples, was small.

Combined psychological and pharmacological approaches (4 studies): in none of the studies did the combination of psychological and pharmacological approaches exceed the effects of psychological approach alone. A strong placebo response was noted in 3 studies."

Taylor conducted a meta-analysis of cognitive-behavioural treatments for social phobia (4). In their conclusion they state that their results support the use of cognitive-behvioural therapies in the treatment of social phobias. However the Centre for Reviews and Dissemination are critical of the methodology employed in the review and state that more reliable evidence from randomised controlled trials is required.

1. http://www.emedicine.com/med/topic3121.htm
2. van der Linden et al, Pharmacotherapy for social phobia [portocol], expected publication date Issue 2, 2003.
3. Stravynski A et al, The treatment of social phobia: a critical assessment, Acta Psychiatrica Scandinavica 1998, 98(3), 171-181.
4. Taylor S, Meta-analysis of cognitive-behavioural treatments for social phobia, Journal of Behaviour Therapy and Experimental Psychiatry 1996, 27(1), 1-9.

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