Saturday Night Fever - Forum on Social Anxiety Disorder
by Pauline Jestadt
Reprinted with permission from The Health Journal - Sept/Oct 1999
Most people get a little nervous when they have to give an important presentation, and that nervousness can be healthy. But some people get positively panicky at the thought of doing anything in public. They have what's known as social phobia or social anxiety disorder, and it makes commonplace activities exceedingly difficult, like eating in a restaurant for fear of the waitress striking up a conversation. It means avoiding social functions because they might have to say a few words to the host. The condition generally strikes young, but isn't usually caught or treated until later years. Consequently many suffer for years in silence, cut off from the world around them, lonely and often depressed.
This serious condition, which has only recently received significant medical attention, took the Health Journal to a group of professionals, each a specialist on the issue, to find out more. The forum panelists are;
Dr. Michael Van Ameringen, psychiatrist, co-director of the anxiety disorders clinic, Hamilton Health Sciences Corp., McMaster University Medical Centre, and assistant professor at McMaster
Dr. Michael Evans, general practitioner and co-chair of the Ontario committee developing guidelines for treating anxiety disorders, Toronto
Dr. Stanley Kutcher, psychiatrist and head of the department of psychiatry at Dalhousie University, Halifax
Dr. Shaila Misri, psychiatrist and director of the reproductive mental health program, St. Paul's Hospital and B.C. Women's Hospital, and clinical professor of psychiatry and obstetrics and gynecology, University of British Columbia, Vancouver the Health Journal
(HJ): How do you define social phobia or social anxiety disorder?
Dr. Michael Van Ameringen: It's a fear of situations you think will encourage scrutiny by others. People who suffer from social phobia find it hard to go to social gatherings, to speak in meetings, to eat in front of other people, to sign their name when others are looking, to talk to strangers or to use the telephone in public. They're afraid they will do something that results in embarrassment or humiliation.
Dr. Shaila Misri: It's because these people have been humiliated and embarrassed that they end up with avoidance behavior. They go to great lengths to avoid being in a particular situation for fear of the consequences. This impairment can have an enormous occupational and socio-economic impact.
HJ: How does that differ from extreme shyness?
Dr. Stanley Kutcher: Shyness is on a spectrum of normal behavior and usually doesn't cause significant impairment. Social phobia, on the other hand, impairs people's function and cognitive abilities.
HJ: What separates social phobia from panic disorder?
Dr. Misri; Social anxiety includes panic disorder, but it's not the other way around.
Dr. Kutcher: Panic disorder sufferers avoid situations because they fear having a panic attack, while social anxiety sufferers avoid situations because they fear the social situation itself. Blushing and severe negative thoughts about embarrassment and social scrutiny set people with social phobia apart.
Dr. Michael Evans: Everyone is anxious sometimes; anxiety is a good thing. But in social phobia, this anxiety goes overboard and has major consequences on people's work and relationships. To move forward in a lot of work environments, you have to be able to lead a meeting and talk in a group situation. In many cases, people with social phobia display physical symptoms, things like sweating, heart palpitations, nausea and diarrhea, in addition to the blushing, stammering and dry mouth.
HJ: What causes it?
Dr. Kutcher: We don't know for sure. It seems to run in families and is associated to some degree with other anxiety disorders. This suggests a genetic component. However, we also know it's caused by a brain disturbance, and the neurotransmitter serotonin is involved in the control of social behavior.
"Sometimes these patients simply avoid their feared situations altogether, leaving them virtually housebound" Dr. Evans
Dr. Misri: A variety of factors come into play. First of all, you have to have a predisposition for this disorder. This predispostion interacts with certain kinds of tem-perment personalities. Life experiences are probably another factor. Oftentimes, these people are traumatized in one way or another during their lifetime.
HJ: So relatives of patients with disorder are more at risk?
Dr. Van Ameringen: At our clinic, preliminary results of a study we're doing show that the offspring of people with social phobia are at increased risk.
Dr. Misri: Studies show if one identical twin has it, there's a 24 percent chance the other twin will too.
HJ: How common is this disorder?
Dr. Van Ameringen: Most would agree that about 10 percent of the population suffer from social phobia at some point in their life. It's the third most common psychiatric disorder after depression and alcohol abuse.
Dr. Misri; It's more common among women. It might be 10 percent in men but closer to 16 percent in women.
HJ: Why is that?
Dr. Misri: Most mental illnesses are more common in women, starting with depression. Neurotransmitters, particularly serotonin, are exquisitely sensitive to hormone changes like the onset of menstruation in adolescence. Women with postpartum depression respond well to drugs that affect serotonin since the shifting hormones seem to affect serotonin more than any other neurotransmitter. This is the case with depression. For social anxiety disorder, further research needs to be done to understand its etiology.
HJ: Is it more common in Canada?
Dr. Misri: Social phobia is a relatively new diagnosis and to my knowledge, no cross-cultural studies have been carried out yet. Most of the studies we're quoting now are American.
HJ: How does it affect daily life?
Dr. Van Ameringen: Many sufferers are either unemployed or, if they do have a job, they often work part-time or at jobs beneath their level of education. Many drop out of school early and almost half never marry, are divorced or separated. There also seems to be an increased rate of suicide attempts.
Dr. Evans: Was it Freud who said that happiness is predicted by our ability to work and love? People with social phobia have a hard time with both. Studies show that a whopping 90 percent have some occupational impact. After awhile, to avoid their feared situations, these patients simply avoid them altogether. That can leave them virtually housebound. And they also have a hard time on the relationship front.
Dr. Misri: Many people with social phobia have a particular problem with authority figures. They're unable to have a conversation with the person in charge. They break out in a sweat, blush, feel dizzy, have fainting spells and start having panic attacks so severe they have to leave the room.
HJ: How is it diagnosed?
Dr. Evans: It's often difficult to diagnose because sufferers don't want to talk to the doctor about it. The whole nature of social phobia is to not ask for help. It's typically another condition that brings them into the office, for example, depression.
Dr. Kutcher: Social anxiety is not being diagnosed or treated by many physicians because most people who have the disorder don't seek treatment. They're very disabled but they aren't sure they can get effective treatment. The good news is that there's an increasing amount of educational information out there to teach psychiatrists and general practitioners about the disorder and its treatment.
Dr. Van Ameringen: The average age of onset of social phobia is around 12 years, but people who have it have it for a long time. At our clinic, the average age of the patients was in the mid-30s. Only two percent had sought treatment. So there's a long lag between the disorder interfering with your life and coming in for treatment. In the meantime, these people suffer in silence. It simply doesn't get identified as a problem early.
Dr. Misri: My practice is exclusively for women, and very few come to me because of social anxiety disorder. I sometimes have to probe to discover the true underlying problem, and holding sessions with the patient's partner helps. For example, I'm treating a woman who works in a large software company, a line of work she chose to avoid any kind of social contact. She functioned adequately until she was offered a promotion, then she started having panic attacks. I met with her husband who described how serious the situation really was: This woman couldn't speak in public and had a real problem sitting in a room with her colleagues. She was going to turn down her promotion. Her history of social anxiety disorder goes back to her adolescence.
HJ:b Why is the problem eing missed?
Dr. Van Ameringen: Doctors write it off as shyness; they think it's just a phase and the patient will outgrow it. Perhaps people even normalize it, convincing themselves that it's really okay to be sheltered from the public, avoiding even the briefest social encounter.
Dr. Misri: How many kids visit doctors? What happens now is that this problem goes unrecognized and untreated for a very long time. By the time these patients come in, the patterns have been set.
HJ: Does this condition lead to other psychiatric problems?
Dr. Evans: One study found that 69 percent had another disorder as well.
Dr. Van Ameringen: Many also have other anxiety disorders, major depression or substance abuse, but in most cases the social phobia predates the onset of any other psychiatric condition.
HJ: How is it treated?
Dr. Van Ameringen: In the past, the gold standard had been a group of drugs called monoamine oxidase inhibitors (MOAIs). Benzodiazepines were also used and proved effective. More recently, a number of controlled trials showed that selective serotonin reuptake inhibitors (SSRIs) are also useful. In the study at our centre using SSRIs, there was significant improvement in social and leisure functioning. Sufferers' work function improved; they got on with their lives.
Dr. Kutcher: An increasing body of evidence shows the effectiveness of several of the SSRIs. Health Canada has recently approved one of them, Paxil, for treatment. Using SSRIs in social phobia is exceedingly new.
"Its the third most common psychiatric disorder after depression and alcohol abuse"
Dr. Van Ameringen
HJ; How important are SSRIs as a treatment?
Dr. Van Ameringen: I use the analogy of aspirin, a pain reliever that's now being used for a number of other things, including preventing heart attacks and strokes. It's a similar story with the SSRIs. Originally, they were found to work with depression, then we discovered they also work with obsessive compulsive disorders and panic attacks. Now we think this medication can also treat people's fears and social avoidance.
Dr. Misri: I have some severe patients whom I have been treating with a high dose of an SSRI, and it works.
HJ: If we could diagnose people earlier, would it make a difference?
Dr. Van Ameringen: One of the exciting things is that SSRIs can be used for children; they're very safe. In fact, we found that they're tolerated better in children and adolescents than in adults. They have fewer side effects. Here at McMaster, we did a case series on seven children and adolescents with social phobia who responded wonderfully to these agents. The youngest boy was seven years old. He couldn't talk to his extended family, he never talked to his teacher, and if a neighbour was around he'd hide. With SSRI treatment he was completely changed.
"It's caused by a brain disturbance, and the neurotransmitter serotonin is involved"
HJ: What about non-drug therapies?
Dr. Van Ameringen: Cognitive behavioral therapy and assertiveness training appear to help, but these therapies aren't readily available outside large university medical centres. Even in these large centres, there are long waiting lists to access trained professionals.
HJ: What exactly is cognitive behavioral therapy?
Dr. Evans: Cognitive behavioral therapy (CBT) is "here, and now" therapy that attempts to break the cycle of automatic thoughts. People who suffer from social phobia automatically have a thought or concern that they will behave inappropriately in a feared situation and that there will be major consequences. During therapy, we get people to visualize this feared situation and share their automatic thoughts. Then we get them to estimate their chances of that bad thing happening. Let's say they believe there's an 80 percent fear they'll lose their job if they allow others to see how red in the face they get in front of others. This is especially effective in a group situation because others see there's no way there's an 80 percent chance of losing a job over something as trivial as that. The therapy also involves getting people to complete small tasks, for example, to make two comments during the next business meeting. Ideally, it's done over 12 weekly sessions.
Dr. Misri: Over the course of eight, 10 or 12 sessions, the therapist typically recreates the feared situation. The patient relives it in an effort to overcome the anxiety. It's a highly personalized experience.
HJ: Is CBT more appropriate than drugs?
Dr. Kutcher: A lot of people are looking in a very thoughtful and critical way at the assumptions that medicine is the best treatment choice, that psychotherapy is best, or that adding psychotherapy to a medication is best. It may be that only some patients get better on psychotherapy, some on medication and some will need both. The best study compared CBT with an MAIO. Although the drug was better after six weeks, they were equally effective after three months. However, if you stop the drug, the patients get sick again, but if you stop CBT, they don't seem to get sick as fast.
Dr. Misri: The best approach in my experience is a combination. My patient at the software company was treated with eight or 10 cognitive behavior sessions along with an SSRI. It changed her life. She ended up taking the promotion. However, I agree that it's sometimes difficult to access CBT for your patients. The recognition of this disorder is so new, and until things fall into place in terms of treatment options we have to resort to some kind of intervention. At the moment, it appears that intervention with an SSRI is the most obvious choice. It does relieve symptoms.
HJ: What else does treatment entail?
Dr. Misri: In addition to the SSRIs and structured CBT from a psychologist where available, it's important to engage in a couple of psychoeducational sessions talking not only to the patient but to his or her significant other.
HJ; What other rips do you have to overcome social phobia?
Dr. Evans; I tell people who have a specific social phobia around public speaking to look up their local Toastmasters. I'm sure the prevalence of social phobia at Toastmaster's meetings is quite high. This organization operates in most towns, even in rural areas.
Pauline jestadt is a medical writer based in Toronto.
This Forum on Social Anxiety Disorder was made possible by an educational grant from: SmithKline Beecham Pharma