Social phobia

from Wikipedia, the free encyclopedia
Classification according to ICD-10
F40.1 Social phobias
ICD-10 online (WHO version 2019)

Social phobias belong to the group of phobias within anxiety disorders . The central characteristic is a pronounced fear of being the center of attention in social situations and of behaving in an embarrassing or shameful manner.

In the DSM-5 , the term social anxiety disorder is used because the problem is less trivialized (even among doctors).

description

People with social phobia avoid social gatherings because they fear that they will not meet the expectations of others and that they will be rejected. They fear that their nervousness or fear could be seen, which often increases their fear even more. The fear is often accompanied by physical symptoms such as blushing (see also "fear of blushing" ), tremors , rapid heart rate , sweating , shortness of breath , cramping, speech arrest and frequent slips of the tongue, dizziness, urinary urgency, anxiety feelings in the chest, head and stomach pain, Diarrhea, nausea (gag reflex) or panic as well as cognitive symptoms such as thought circles , derealization and depersonalization .

To avoid all of this, people with social anxiety often avoid situations in which they are exposed to judgment by others in the first place. This can make professional and private advancement very difficult and sometimes lead to complete social isolation . The disorder can persist over a long period of time, and many sufferers also develop depression or become dependent on alcohol, sedatives or other drugs or medications that can mask or suppress the symptoms.

Social phobias usually begin in childhood and puberty. To a certain extent and to a certain extent, shyness and social inhibition are still considered normal. The diagnosis should only be made when unusually strong fears lead to fatal avoidance behavior in corresponding situations.

Cultural differences

Cultural background also plays a role in how exactly a social phobia expresses itself. In East Asian cultures, for example, an altruistic variant is more often observed, which is accompanied by the fear that “one's own appearance, facial expression or natural movement sequences or body odor, eye contact or blushing will make another person uncomfortable” (see Taijin Kyōfushō ). In western countries, on the other hand, a more egocentric variant dominates , accompanied by the fear of embarrassing or being embarrassed.

frequency

It is estimated that between two and ten percent of the population suffer from social anxiety. Exact information is difficult because social phobias can vary greatly in their severity and, in particular, the transition from shyness to social phobia is difficult to determine. In addition, social anxiety must not be confused with social deficits, although the social phobia can arise from social deficits (or can lead to them in the first place).

A representative study with around 4100 participants from the general German population aged 18 to 65 determined a 12-month prevalence of 2% using a standardized diagnostic interview . According to American studies, 7–12 percent of the adult population were affected by a social phobia over their entire lifetime; Women a little more often than men.

Narrowly circumscribed social phobias, for example just fear of public speaking and eating, are rather rare. The most common is the general social phobia of most interpersonal activities, such as attending parties or family celebrations, writing to others, making new contacts (especially with people of the desired sex) or having a conversation with the boss, colleagues, neighbors and others to lead even with loved ones.

diagnosis

The brief description of the social phobia according to ICD-10 is:

“Fear of scrutiny by other people, which leads to avoidance of social situations. Larger social phobias are usually associated with low self-esteem and fear of criticism. They can manifest themselves in symptoms such as flushing, hand tremors, nausea or an urge to urinate. Sometimes the person concerned thinks that one of these secondary manifestations of fear is the primary problem. The symptoms can increase to panic attacks . "

In order to be able to diagnose a social phobia, either the 1st or the 2nd criterion must be met:

  • Pronounced fear of being the center of attention or being embarrassed or degrading.
  • Clearly avoiding being the center of attention or situations in which there is a fear of being embarrassing or degrading.

These fears arise in social situations: for example when eating or speaking in public, meeting friends in public, joining or participating in small groups (e.g. at parties, conferences or in classrooms).

At least two of the following anxiety symptoms must have occurred in the feared situations:

  • Vegetative symptoms ( palpitations , palpitations or increased heart rate, sweating, tremors , dry mouth)
  • Symptoms affecting the chest or abdomen (difficulty breathing, tightness, chest pain , nausea or abdominal discomfort)
  • Psychological symptoms (feeling dizzy, insecure, weak or light-headed, feelings of derealization or depersonalization , fear of losing control, going crazy or “freaking out”, fear of dying)
  • General symptoms (hot flashes or chills, numbness or tingling sensations)

In addition, at least one of the following symptoms must have occurred:

  • Blushing or trembling
  • Fear of vomiting

There is significant emotional strain from the anxiety symptoms or avoidance behavior, and an understanding that the symptoms or avoidance behavior are exaggerated and unreasonable.

The symptoms are limited exclusively or primarily to the feared situations or to thoughts about them.

The symptoms are not caused by delusions , hallucinations or other symptoms of the disorder groups organic mental disorders , schizophrenia , mood disorders or an obsessive-compulsive disorder and are not the result of culturally accepted beliefs.

Subtypes

Social phobia was first described by Isaac Marks and Michael Gelder in 1966 as a fear of social situations in which the person concerned is the focus of attention and carries out specific activities (e.g. writing publicly or writing a check). In DSM-III 1980 is first referred to this definition, so that there is a fear of very specific situations. Since 1987, however, two sub-forms have been distinguished: a discrete ( non-generalized ) subtype and a generalized subtype . The generalized form was introduced because many patients fear several different situations. Although subtyping is controversial, this distinction can still be found in DSM-IV (1994). In the DSM-5 , this classification was retained, but reversed.

Delimitations

A main problem with the differential diagnosis of social phobia is the considerable overlap of criteria with anxious avoidance personality disorder (AEVPS) . However, social phobics usually have narrowly defined fears (e.g. of exams, public speaking), while those of fearful-avoidant personalities are extended to many different situations. In addition, the anxious-avoidant personality disorder is experienced to a greater extent than I-synton : This means that those affected regard their anxious thought patterns and their insecure behavior as an integral part of their personality despite the stress of suffering. Social phobics, on the other hand, clearly experience their symptoms as a disorder that is not part of their personality ( ego dystonia ).

People with social phobias are more likely to fear the accompanying social circumstances than the intimacy of close personal relationships - which fearful-avoidant people fear. Finally, important distinguishing features of people with an anxious avoidant personality disorder are the general discomfort in most social situations, the clear fear of criticism and rejection, and pronounced shyness. In contrast to social phobia, the first signs of AEVPS appear in early childhood and then develop throughout life.

Comorbidity

All anxiety disorders occur frequently among each other and together with other mental illnesses . More than half of people with social phobia will also have one or more other anxiety disorders at some point in their life. The rare and still largely unexplored communication disorder mutism can occur in conjunction with social phobia. Depression is also often associated with anxiety disorders. About a third consumes alcohol . The combination of social phobia and ADHD can also be observed very often (especially with SCT symptoms ).

causes

Psychological factors

Learning theory approaches see social fears as conditioned by avoidance conditioning. Avoiding an anxiety-inducing situation reduces anxiety. If fear is felt in social situations, this situation is largely avoided. Model learning processes can also be responsible for the social phobia. Observational learning, i.e. observing phobic reactions, can itself be fear-inducing.

Prevention is seen in phobic disorders as the cause for the maintenance of the disorder because no corrective experience can be collected and no tolerance to the anxiety-provoking stimuli ( habituation occurs). However, since social situations cannot be consistently avoided, David M. Clark and Adrian Wells (1995) assume three factors in their cognitive model that make them responsible for the perpetuation of the social phobia:

  • stronger self-awareness
  • Safety behavior
  • other processing processes before, during and after the social situation

Cognitive psychological theories focus above all on the role which fears influence the processing of information. People with social fears tend to see themselves more negatively and worry more. The social contacts are perceived as more negative than they are. At the core of the disorder are negatively distorted self-images, which represent a sustaining condition of the disorder. (Hackmann, Clark & ​​McManus, 2000, p. 605).

In this context, however, a physiological willingness to develop certain fears is always cited. So it is apparently possible that fear of certain objects and situations is more easily learned. In addition, there is also a possible innate or acquired disposition to develop fears. Often negative experiences with certain objects and situations as well as a genetic disposition (see below) are responsible.

The psychoanalysis assumes that different conditions promote the development of anxiety. It states that fear is a reaction of the ego to an impending danger. Both traumatic experiences and repressed psychological content can trigger a fear response in the ego. But bonding theory aspects are included in the contemporary theories. Here especially the separation anxiety is crucial. The defense-security model is also used as an explanatory model. In psychoanalysis, a distinction is made between different types of fear. Depending on the psychoanalytic theory to be distinguished, the reasons for the fear are seen in different causes.

A special meaning is ascribed to the fear of shame in connection with the social phobia. It describes an imminent danger of being exposed or of humiliation and rejection. At the same time, it serves as a defense against grandiose and exhibitionistic desires, to look particularly good in the eyes of others and to be able to show yourself as a special person. These wishes are fended off by creating a real fear of the social situation, and this is avoided. A deficit in self-concept leads to overcompensation . The affect of shame should also be viewed in connection with overwhelming traumatic experiences of helplessness and concrete shame. In a different context, however, shame fear can be understood as a concrete signal fear that is supposed to protect against rejection.

Biological factors

Twin studies (studies with identical twins who grew up separately) suggest that a genetic disposition is one of the causative factors. If one twin falls ill with a social phobia, the other has a 30-50 percent chance of developing it as well. It probably depends on environmental influences whether the predisposition manifests itself. Since 2013, scientists at the Bonn University Clinic have been researching the (genetic) causes of social phobia.

treatment

psychotherapy

In the first place, cognitive behavioral therapy is recommended as an effective psychotherapeutic treatment. Those affected check and change their negative evaluation patterns and basic beliefs. At the same time, they learn to take risks and deal with possible mistakes and rejection. Claims to perfection are questioned, and self-acceptance and independence from the opinion of others are strengthened. A specific approach is imagery rescripting , with which negative self-images are to be changed. In a number of EMDR studies, fear of examinations, appearances and speeches were significantly improved; it is assumed here that the EMDR stimulation changes negative self-images by means of reconsolidation in the working memory .

In addition to therapy, physical activity and relaxation exercises (such as progressive muscle relaxation , autogenic training ) are considered to reduce anxiety. The effectiveness has been demonstrated both in combination and without drug therapy. In specific training courses , social skills can be expanded and consolidated, and fear reactions through stimulus confrontation can be reduced.

In the psychoanalytic treatment is tried to edit underlying psychological conflicts that may cause fear. A possible weakness of the structural level can also be the goal of treatment. Sven Olaf Hoffmann criticized the fact that social fears have so far been underestimated in psychoanalysis, and accordingly there are hardly any therapeutic models. Hoffmann therefore developed a special, manualized psychodynamic therapy for social phobias.

Participating in support groups that address the problem of social phobia can also be useful.

Medication

Most commonly, antidepressants are used to treat social phobia. The serotonin reuptake inhibitors (SSRI) escitalopram , paroxetine , sertraline and the SNRI venlafaxine are approved in Germany. The SSRI and venlafaxine are the first choice.

Also fluoxetine and mirtazapine may be effective, but both considered more of a second-line treatment. The MAO inhibitor phenelzine has also proven to be very effective and has one of the highest effect sizes, but is not recommended as the first choice because of the need for a low-tyramine diet. The only irreversible MAO inhibitor still available in Germany is tranylcypromine, which also has a high rate of remission against social phobia and, in particular, cormorbid depression . However, tranylcypromine also has a rather unfavorable side effect profile, as does the risk of hypertensive crises. An alternative is the reversible MAO inhibitor moclobemide , which does not require a diet, but is rather low-potency.

Anti-anxiety drugs from the benzodiazepine family, such as alprazolam or lorazepam, have proven to be particularly effective in particularly stressful situations . In contrast to antidepressants, for example, these drugs do not only work after weeks, but a few minutes after ingestion. In addition, benzodiazepines generally have a comparably favorable side effect profile, but always involve the risk of abuse (see also Abuse of Benzodiazepines ). The duration of treatment with benzodiazepines should be as short as possible because of the risk of dependency development and the often rapid onset of tolerance, or should only be used on a sporadic basis. In the case of long-term therapy, the need to continue treatment should be clarified regularly.

In addition, other classes of active substances such as neuroleptics (e.g. promethazine ), antiepileptics (e.g. gabapentin ), or beta blockers can also be used. However, beta blockers mainly work against physical symptoms (e.g. tremor in extremities and voice). In the USA, amphetamines such as dextroamphetamine are also used on an off-label basis , as they also have an effect on neurotransmitters .

See also

literature

  • Hansruedi Ambühl, Barbara Meier, Ulrike Willutzki: Understanding and treating social anxiety. A cognitive-behavioral approach . Pfeiffer at Klett-Cotta, Stuttgart 2001, ISBN 3-608-89692-9 .
  • Borwin Bandelow : The book for the shy - ways out of self-blockade. Rowohlt, Reinbek near Hamburg, 2007, ISBN 978-3-498-00650-1 .
  • Andre Christophe, Patrick Legeron: Jitter , panic, goose bumps - the fear of others. Structure, Berlin 2001, ISBN 3-7466-1747-2 .
  • Thomas Heidenreich, Ulrich Stangier: Social phobia: Basics and new developments in cognitive behavioral therapy. Behavioral Therapy and Psychosocial Practice. Hogrefe, Göttingen 2003, 35 (3), pp. 499-515, ISBN 978-3-8017-1463-5 . ( online - PDF; 139 kB ).
  • Ulrich Stangier, David M. Clark, Anke Ehlers: Social Anxiety Disorder . (= Progress in psychotherapy. Volume 28). Hogrefe, Göttingen 2016. ISBN 978-3-8444-2719-6 .
  • Peter M. McEvoy, Lisa M. Saulsman, & Ronald M. Rapee. Imagery-Enhanced CBT for Social Anxiety Disorder . Guilford Press, New York 2018. ISBN 978-1462533053 .
  • Anna-Konstantina Richter: EMDR for social anxiety disorders. 1st edition. Klett-Cotta, Stuttgart 2019, ISBN 978-3-608-96388-5 .

Web links

Individual evidence

  1. ↑ a b Richard Heimberg, Stefan Hofmann (2014): Soxial Anxiety DIsorder in DSM-5 . doi: 10.1002 / da.22231
  2. ↑ a b c d e Borwin Bandelow (Hrsg.): S3 guideline treatment of anxiety disorders . 2015, ISBN 978-3-662-44136-7 ( dgppn.de [PDF]).
  3. ↑ Wielant Machleidt: Transcultural Aspects of Mental Illnesses . In: Hans-Jürgen Möller (Ed.): Psychiatry, Psychosomatics, Psychotherapy . 4th edition. tape 2 . Springer, 2011, ISBN 978-3-642-03636-1 , pp. 406 ( limited preview in Google Book search).
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  5. ↑ a b c Jihong Lin, Iryna Struina, Ulrich Stangier: Social anxiety disorder . In: PSYCH up2date . 2014, doi : 10.1055 / s-0034-1369828 .
  6. ↑ DIMDI ICD-10 - F40.1 Social phobias. Retrieved July 23, 2020 .
  7. ↑ World Health Organization; Dilling H, Mombour W, Schmidt MH, Schulte-Markwort E (Eds.) (2011). International classification of mental disorders. ICD-10 Chapter V (F). Diagnostic criteria for research and practice. 5th edition. Bern: Huber.
  8. ↑ Jürgen Margraf: Behavior Therapy: 2: Disorders of Adulthood . Springer-Verlag, 2013, ISBN 978-3-662-10774-4 , pp. 43 ( limited preview in Google Book search).
  9. ↑ Ulrich Stangier, Thomas Fydrich: Social phobia and social anxiety disorder . Hogrefe, 2002, ISBN 978-3-8409-1463-8 , pp. 41 ( limited preview in Google Book search).
  10. ↑ Ronald J. Comer: Clinical Psychology . 6th edition. Spektrum, Heidelberg 2008, ISBN 978-3-8274-1905-7 , Self-insecure personality disorder, p. 438 .
  11. ↑ Peter Fiedler, Michael Marwitz (2016): Differentiation of social phobia from AVPS
  12. ↑ Deutscher Ärzte Verlag: Guidelines for the diagnosis and therapy of mental disorders in infants, children and adolescents. 3. Edition. 2007. ISBN 978-3-7691-0492-9 , pp. 277-289.
  13. ↑ Nina Müller: The social anxiety disorder in adolescents and young adults. P. 46f, Waxmann 2002. ISBN 978-3-8309-6136-9 .
  14. ↑ David B. Schatz (2006): ADHD With Comorbid Anxiety. A Review ( Memento of October 11, 2010 in the Internet Archive ) (PDF). doi: 10.1177 / 1087054706286698 .
  15. ^ Richard G. Heimberg: Social Phobia: Diagnosis, Assessment, and Treatment . Guilford Press, 1995, ISBN 978-1-57230-012-5 , pp. 69 ( limited preview in Google Book search).
  16. ↑ Ulrich Stangier, David M. Clark, Anke Ehlers: Social phobia (=  progress in psychotherapy . Volume 28 ). Hogrefe, Göttingen 2006, ISBN 3-8017-1102-1 , p. 15–20 ( limited preview in Google Book search).
  17. ↑ a b Ulrich Stangier: Cognitive behavior therapy for social phobia . In: Psychotherapy . tape 8 , no. 1 . CIP-Medien, Munich 2003, p. 133–144 ( PDF download 105 kB ).
  18. ↑ Hackmann, A., Clark, DM & McManus, F. (2000). Recurrent images and early memories in social phobia. Behavior Research and Therapy, 38 (6), 601-610.
  19. ^ GC Davison, JM Neale: Clinical Psychology. 6th edition. Beltz PVU, Weinheim 2002.
  20. ↑ H. Hopf, E. Windaus (Ed.): Textbook of Psychotherapy. Psychoanalytic and depth psychologically founded child and adolescent psychotherapy. CIP-Medien, Munich 2007.
  21. ^ E. Heinemann, H. Hopf: Mental disorders in childhood and adolescence. Symptoms - psychodynamics - case studies - psychoanalytic theory . Kohlhammer, Stuttgart 2004.
  22. ↑ The Psychodynamics of Social Phobias - An overview with a first “guide” to psychoanalytically oriented psychotherapy. In: Forum of Psychoanalysis. 18 (2002), pp. 51-71.
  23. ^ Günter H. Seidler (1995). The other's gaze. An analysis of shame. With a foreword by L. Wurmser and a foreword by OF Kernberg. 4th edition, Stuttgart 2015: Klett-Cotta. (Translated into American by A. Jenkins: In Others' Eyes: An Analysis of Shame. Madison, CT: International Universities Press, Inc.)
  24. ↑ www.SocialPhobiaResearch.de
  25. ↑ Peter M. McEvoy, Lisa M. Saulsman, & Ronald M. Rapee (2018). Imagery-Enhanced CBT for Social Anxiety Disorder. New York: Guilford Press.
  26. ↑ Anna-Konstantina Richter: EMDR for social anxiety disorders. 1st edition. Klett-Cotta, Stuttgart 2019, ISBN 978-3-608-96388-5 .
  27. ↑ Jonathan R. T. Davidson et al. a .: Fluoxetine, Comprehensive Cognitive Behavioral Therapy, and Placebo in Generalized Social Phobia. In: Arch Gen Psychiatry. 2004; 61, pp. 1005-1013. (PDF)
  28. ↑ Marion Sonnenmoser: Social anxiety disorders: Underestimated by psychoanalysis. In: Deutsches Ärzteblatt. P. 2, March 2003, p. 131 ( PDF ).
  29. ↑ Sven Olaf Hoffmann: Psychodynamic therapy of anxiety disorders. P. 71f. Schattauer 2008, ISBN 978-3-7945-2622-2 .
  30. ↑ a b c Carlos Blanco et al .: The evidence-based pharmacotherapy of social anxiety disorder. 2012. doi: 10.1017 / S1461145712000119 (Review).
  31. ↑ M. Versiani, FD Mundim, AE Nardi, MR Liebowitz: Tranylcypromine in social phobia . In: Journal of Clinical Psychopharmacology . tape 8 , no. 4 , August 1988, ISSN  0271-0749 , p. 279-283 , PMID 3209719 .