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Specific Phobias and Social Anxiety Disorder (Social Phobia)

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C.E. Zupanick, Psy.D. and Mark Dombeck, Ph.D.

There are three basic types of phobias:

1. Agoraphobia is the intense fear, anxiety, and avoidance of a variety of non-specific situations where escape is difficult or help might be unavailable if a panic attack occurs. 

dog and cat2. Specific phobia is the intense fear, anxiety, and avoidance of a specific object or situation (e.g., flying, heights, injections, animals).

3. Social phobia, or Social Anxiety Disorder, is the intense fear, anxiety, and avoidance of social situations where there is the potential of being scrutinized or negatively judged by others. Exposure to the phobic object or situation will usually precipitate cued (expected) panic attacks, and subsequently lead to avoidance. In children, the fear and anxiety may be expressed by crying, tantrums, freezing, or clinging to caregivers. The fear must be considered within a cultural context and must be out of proportion to any actual danger or threat. Some children and some adults recognize their fear is excessive or unrealistic. Others do not. To meet diagnostic criteria, the symptoms must be persistent, usually lasting at least 6 months or more.

Specific Phobia

Specific Phobias involve an excessive fear or anxiety that is triggered by the anticipation or exposure to a particular object or situation. There is a quick response to the stimulus; usually cued (expected) panic attacks, or limited symptom panic attacks. Children may express this fear as crying, tantrums, freezing, or clinging to caregivers.

Specific Phobias are divided into five types. They are listed here in order of frequency in adults, beginning with the most common:

1. Situational Type (bridges, boats, airplanes, etc.);
2. Natural Environment Type (thunderstorms, heights, etc.);
3. Blood-Injury-Injection Type (seeing blood, getting an injection, etc.);
4. Animal Type (dogs, snakes, rats, etc.);
5. Other Type (clowns, fear of vomiting, etc.).

It is not unusual to have more than one phobia. Having one phobia increases the chances of having another.

The phobic object or situation nearly always provokes an immediate fearful or anxious response. The fear and anxiety is out of proportion to any real danger, or it is more intense than needed. For instance, fear of certain objects such as snakes, or certain situations such as the dark, are quite common. However, an intense fear of snakes in an environment populated by poisonous snakes, or the fear of darkness in high crime areas might not be out of proportion to the real danger. In these cases, the diagnostic criteria might not be met. Therefore, context and culture must be considered.

It is important to keep in mind that a diagnosis is not warranted if there is no marked impairment in functioning or significant distress. For example, having an irrational fear of kangaroos would not be diagnosed as a phobia if someone does not live in the Australian Outback since it is unlikely to cause impairment in functioning.

To meet diagnostic criteria, the symptoms must be persistent, usually lasting at least 6 months or more. Treatment for Specific Phobia is found in the treatment section.

Social Anxiety Disorder (Social Phobia)

Social Anxiety Disorder (Social Phobia) is an excessive, intense fear of public performance, or social situations. People with this disorder are highly fearful of public embarrassment. They have an intense fear of appearing foolish, weak, or otherwise inadequate. Like all phobias, cued (expected) panic attacks are a common symptom. Also like other phobias, phobic situations are avoided or tolerated with great distress. Blushing, trembling, or difficulty speaking are frequently evident during cued (expected) panic attacks. In children, the symptoms may be expressed as crying, tantrums, freezing, clinging to caregivers, shrinking away from social interactions, or a failure to speak in social situations. Children must demonstrate these symptoms in peer settings, not just during interactions with adults. The fearful or anxious response must persistently occur in reaction to, or anticipation of, most social situations.

Clearly, culture determines social norms. Therefore, symptoms must be considered within a cultural context. For example, in some cultures it is impolite to make direct eye contact. Furthermore, it is quite normal to become highly anxious when other people attempt to make direct eye contact. Therefore, a person who exhibits this behavior does not meet the diagnostic criteria because the fear is not excessive or extreme for that culture.

Social Phobia typically includes fear of: 1) public performance or other observation by others, 2) social interactions. Public performance anxiety occurs in the context of public speaking. Some examples are a teacher calling upon a student in class, or an employee making a sales presentation at work. People with public performance anxiety are typically worried that others will notice their shaking hands and trembling voice. They fear they will be dreadfully embarrassed and negatively judged by others. Children and adults with this disorder may also be afraid to eat or drink in front of others because they fear people will notice their shaking hands, or that they will do something embarrassing (such as spill their drink).

Social interaction anxiety occurs in the context of social events. Some examples are birthday parties, office parties, wedding receptions, or any gathering of people such as a nightclub. It also includes having conversations with others, and meeting unfamiliar people. People with this type of anxiety have excessive concerns about negative judgment, ridicule, or embarrassment.

In children, typical symptoms include being very shy in unfamiliar places; staying close to familiar individuals (like their parents); and turning down playgroups; or being the outsider of the group. Unlike adults, children usually cannot avoid these situations and can have a hard time understanding why they are anxious. Signs may include refusing to go to school, or avoiding participation in activities appropriate for their age. In older children and teens, some temporary social avoidance or anxiety can be normal. However, this diminishes after a short period of time. For instance, a preteen boy goes through a phase where he avoids speaking with girls his own age. In order to meet the diagnostic criteria, children and teens must demonstrate diminished functioning (when compared to their prior level of functioning), or fail to meet generally accepted standards of functioning for their age group and culture.

To meet diagnostic criteria, the symptoms must be persistent, usually lasting at least 6 months or more. Treatment for Social Phobia is found in the treatment section.