Anxiety: Social phobia

Question 1

Define

Answer 1

ICD-10: fear scrutiny by other people leading to avoidance of social situations

Associations: low self-esteem and fear of criticism

M = F (the only anxiety disorder to affect equally)

Consistently occurs in ≥ 1 social situations such as social interactions, being observed, or performing in front of others.

The individual is concerned that they will act in a way, or show anxiety symptoms, that will be negatively evaluated by others

Question 2

Symptoms

Answer 2

• First episode occurs in a public place, usually without a reason
• Complaints of blushing, hand tremor, nausea or urinary urgency in social situations (i.e. explore situations)
• The core fear is being scrutinised or criticized by others
• Feeling self-conscious / low self esteem
• Tolerate anonymous crowds
• Small groups can be intimidating (e.g. dinner parties, board meetings)

N.B. will tolerate anonymous crowds, unlike agoraphobics, but smaller groups may spike anxiety

• Specific worries e.g. eating in public
• Often engages in safety behaviours and excessive self-monitoring
• Self-medication with alcohol or drugs perpetuates the problem as it offers psychological avoidance
• Social withdrawal

DDx

• Shyness - when it doesn’t cause avoidance of situations
• Poor social skills
• Anxious personality disorder
• Autism - repetitive behaviour, not aware of way others think, poor communication, rigidity in autism

Question 3

Investigations

Answer 3

Cardiorespiratory examination

Rule out: ECG, TFTs, LFTs, U&Es, glucose, urine drug screen, urine VMAs

SPIN questionnaire for social phobia

Hospital Anxiety and Depression Scale

Collateral history

Social and occupational assessments for effect on QoL

Question 4

Management

Answer 4

Education, reassurance and self-help

1st Line: CBT with exposure therapy

• 12 wks
• Individual : Aim: educate, tests negative beliefs, examine and modify core beliefs, graded exposure to feared social situations
• Group-based

2nd Line:CBT-based supported self-help (if CBT is declined by require another psychological intervention)

3rd Line: Biological (offered if all cognitive behavioural interventions declined)

1st: SSRI- escitalopram or sertraline

2nd: SNRI- venlafaxine

3rd Line: MAOI- phenelzine, moclobemide

4th Line: Psychodynamic psychotherapy (offered if decline all cognitive behavioural and pharmacological intervention)

Short term- 25-30 sessions of 50 minutes’ over 6-8 months

Focuses on education, modify insecurities, focuses on shame, encouraging exposure to feared social situations, establish self-affirming inner dialogue, improves social skills