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Definition: The fundamental feature of social anxiety disorder is the marked and persistent fear of social or performance situations in the presence of.

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Presentation on theme: "Definition: The fundamental feature of social anxiety disorder is the marked and persistent fear of social or performance situations in the presence of."— Presentation transcript:


2 Definition: The fundamental feature of social anxiety disorder is the marked and persistent fear of social or performance situations in the presence of unfamiliar people or when scrutiny by others is possible, even in the context of small groups. Exposure to such social and performance situations almost invariably provokes an immediate anxiety response or avoidance behavior. Ibtihal M.A. Ibrahim

3 Associated features of social anxiety disorder poor social skills negative evaluation difficulty of being assertive hypersensitivity to criticism low self-esteem and feelings of inferiority Ibtihal M.A. Ibrahim

4 initiating or maintaining conversation participation in small groups interacting with people in authority attending parties writing or performing in front of others eating or drinking in public using public toilet facilities dating somebody The most frequent social trigger situations are Ibtihal M.A. Ibrahim

5 simple performance anxiety, stage fright, as well as shyness in social situations should not be diagnosed as social anxiety disorder unless the anxiety and avoidance are marked and persistent and lead to clinically significant impairment or subjective suffering in a systematic way whenever exposed. It is important to note that: Ibtihal M.A. Ibrahim

6 Social Anxiety or Shyness Shyness is a term used to describe the feeling of apprehension, lack of comfort, or awkwardness experienced when a person is in proximity to, especially in new situations or with unfamiliar people.feelingapprehensionlack of comfort awkwardness proximity Shyness may come from genetic traits, the environment in which a person is raised and personal experiences. There are many degrees of shyness. Ibtihal M.A. Ibrahim

7 Social Anxiety or Shyness Social anxiety disorder has been portrayed as the extreme of shyness. Shyness is more likely to be a lifelong characteristic of an individual’s temperament, whereas social anxiety disorder is characterized by a group of coexisting symptoms that might be independent of shyness. Evidence to support the distinction between shyness and social anxiety disorder comes from developmental studies. Shy children who were followed over several years from the first school years through to early adolescence were not at an increased risk for developing social anxiety disorder. Shyness is usually present in all social situations while social anxiety may be triggered by very specific situations. Ibtihal M.A. Ibrahim

8 Epidemiology: Because of the difficulty in separating social phobia from poor social skills or shyness, some studies have a large range of prevalence. Social anxiety disorder occurs in females nearly twice as often as males, although men are more likely to seek help The prevalence of social phobia appears to be increasing among white, married, and well-educated individuals. It is the third most common psychiatric disorder, with a lifetime prevalence of approximately 13% of the general population The average age of onset is mid-adolescence, but the disorder occurs in children as young as age eight Ibtihal M.A. Ibrahim

9 DSM-IV Diagnostic Criteria: A. 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. B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. C. The person recognizes that the fear is excessive or unreasonable. D. The social or performance situation is avoided or else is endured with intense anxiety or distress. E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person's normal routine, occupational (or academic) functioning, or social activities or relationships, or there is marked distress about having the phobia. F. In individuals under age 18 years, the duration is at least 6 months. G. The fear or avoidance is not due to the direct physiological effects of a substance or a general medical condition and is not better accounted for by another mental disorder. H. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of stuttering, trembling in Parkinson's disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa. Ibtihal M.A. Ibrahim

10 For diagnostic purposes, SAD has been divided in two subtypes: The specific subtype (sSAD):refers to the fear and avoidance of a particular performance situation such as public speaking. Indeed, this is frequently the most symptom-provoking social situation in specific SAD. Generalized SAD (gSAD):patients, in turn, fear and avoid a wide array of social situations, and are consequently more impaired than patients suffering from specific SAD Ibtihal M.A. Ibrahim


12 Cognitive Behavioral Physiological Ibtihal M.A. Ibrahim

13 Cognitive symptoms: prior to the potentially anxiety-provoking social situation, sufferers may deliberately go over what could go wrong and how to deal with each unexpected case. They experience dread over how they will be presented to others. They may be overly self- conscious, pay high self-attention after the activity, or have high performance standards for themselves.dreadself- conscious After the event, they may have the perception they performed unsatisfactorily. Consequently, they will review anything that may have possibly been abnormal or embarrassing.perception Event After Before Ibtihal M.A. Ibrahim

14 Behavioral symptoms: Escape avoidance behaviors Controlled by Major avoidance behaviors Minor avoidance behaviors Ibtihal M.A. Ibrahim

15 Physiological symptoms: Blushingsweating palpitationsshakingnausea Mind go blank stomach ache The walk disturbance children with social anxiety may display tantrums, weeping, clinging to parents tantrums weeping children with social anxiety may display tantrums, weeping, clinging to parents tantrums weeping Ibtihal M.A. Ibrahim


17 Biological Genetic and family factors Neural mechanisms. Neuroanatomical. Psychological Cognitive context. Evolutionary context. Social Social experiences Social/cultural influences Ibtihal M.A. Ibrahim

18 Genetic and family factors: It has been shown that there is a 2-3 folds greater risk of having social phobia if a first-degree relative also has the disorder. This could be due to genetics and/or due to children acquiring social fears and avoidance through processes of observational learning.geneticsobservational learning Studies of identical twins brought up (via adoption) in different families have indicated that, if one twin developed social anxiety disorder, then the other was between 30 – 50% more likely than average to also develop the disorder.identical twins adoption Ibtihal M.A. Ibrahim

19 Neural mechanisms: Dopamine Other neurotrans mitters Hormones and neuropeptid es Serotonin Norepinephrine and Glutamate. GABA Serotonin Norepinephrine and Glutamate. GABA Oxytocin, Vasopressin, CRF and Cortisol Sociability is closely tied to dopamine neurotransmission dopamineneurotransmission Sociability is closely tied to dopamine neurotransmission dopamineneurotransmission Ibtihal M.A. Ibrahim

20 Neuroanatomical: Amygdala Anterior cingulate cortex involved in the experience of physical pain, also appears to be involved in the experience of 'social pain' related to fear cognition and emotional learning. hypersensitive amygdala. related to fear cognition and emotional learning. hypersensitive amygdala. Ibtihal M.A. Ibrahim

21 Cognitive Context: Research has indicated the role of 'core' or 'unconditional' negative beliefs (e.g. I am inept) and 'conditional' beliefs nearer to the surface (e.g. If I show myself, I will be rejected). They are thought to develop based on personality and adverse experiences and to be activated when the person feels under threat. Ibtihal M.A. Ibrahim


23 Evolutionary context: evolutionary explanation of anxiety in-built 'fight or flight' system vital and complex importance of social living Specific disposition s to monitor and react to social threats in modern day society tendencies can become more inappropriatel y activated and result in some of the cognitive 'distortions' Ibtihal M.A. Ibrahim

24 Social experiences: Person with increased interpersonal sensitivity Specific social phobia Specific humiliating social event observing or hearing or verbal warning longer-term effects of not fitting in Ibtihal M.A. Ibrahim

25 Social/cultural influences: Society's attitude towards shyness and avoidance, affects the ability to form relationships or access employment or education.relationships In China, research has indicated that shy-inhibited children are more accepted than their peers and more likely to be considered for leadership and considered competent, in contrast to the findings in Western countries.Chinapeers lower rates of social anxiety disorder in Mediterranean countries and higher rates in Scandinavian countries, and it has been hypothesized that hot weather and high density may reduce avoidance and increase interpersonal contact.MediterraneanScandinavian Ibtihal M.A. Ibrahim


27 Other anxiety disorders. Depression. Bipolar disorder. Substance use disorders. Eating disorders. Axis I Avoidant personality disorder (APD). Axis II Ibtihal M.A. Ibrahim

28 Avoidant personality disorder is in many ways equivalent to pathologic shyness pervasive pattern of social inhibition and hypersensitivity to negative evaluation Avoids occupationa l activities Restrains from intimate relationships Embarrassed by engaging in new activities Denies to get involved with people Inhibited in new interpersonal situations Occupied with being criticized or rejected Views self as socially inept V V O O I I A A R R E E D D four or more Avoidant Personality Disorder Ibtihal M.A. Ibrahim


30 Psychotherapy Combination Pharmacotherapy Ibtihal M.A. Ibrahim


32 MAOIsBenzodiazepines SSRIsSNRIs β- Blocker Ibtihal M.A. Ibrahim

33 Pharmacologic Treatment of Social Phobia Common Side EffectsMaximum Dosage Daily Dosing Range Starting Dosage Drug Dry mouth, blurred vision, constipation, urinary hesitancy, orthostasis, somnolence, anxiety, sexual dysfunction 250 mg100–250 mg50 mg at bedtime Imipramine Dry mouth, drowsiness, nausea, anxiety/nervousness, orthostatic hypotension, myoclonus, hypertensive reactions 90 mg30–90 mg15 mg twice daily Phenelzine Nausea, diarrhea, anxiety/nervousness, sexual drysfunction, somnolence 60 mg20–40 mg20 mg Paroxetine Nausea, diarrhea, anxiety/nervousness, sexual dysfunction 80 mg20–60 rug20 mg Fluoxetine Nausea, diarrhea, anxiety/nervousness, sexual dysfunction 200 mg50–150 mg50 mg Sertraline Somnolence, ataxia, memory problems, nausea, physical dependence, withdrawal reactions ––– Benzodiazepines (various) Drowsiness, headache, orthostatic hypotension, bradycardia, exacerbation of asthma or obstructive pulmonary disease 240 mg/day10–40 mg as needed10 mg as needed Propranolol Ibtihal M.A. Ibrahim



36 CBT Exposure Applied relaxation Social skills training Cognitive restructuring Cognitive Behavioral Group Therapy (CBGT) Ibtihal M.A. Ibrahim

37 Exposure: creation of a fear and avoidance hierarchy which acts as a roadmap for exposure practice. stay in the feared situation, with the expectation that an exposure of sufficient length will produce new learning or habituation exposures begin with lower- ranked situations (e.g., moderately anxiety- provoking) and move up gradually performed both in and out of session Ibtihal M.A. Ibrahim

38 Applied relaxation: Progressive muscle relaxation (PMR) is a well-known technique for the management of the physiological arousal that often accompanies anxiety. PMR alone is generally accepted as insufficient as a treatment for social anxiety disorder, and we know of no evidence that counters this consensus. Ibtihal M.A. Ibrahim

39 Social skills training: Modeling Behavioral rehearsal Corrective feedback Positive reinforcement inevitably involves exposure to feared situations NB: people with social anxiety disorder may possess adequate social skills Ibtihal M.A. Ibrahim

40 Cognitive restructuring: Identify negative thoughts Evaluate the accuracy of their thoughts Derive rational alternative thoughts In cognitive restructuring, individuals are taught to: Ibtihal M.A. Ibrahim

41 Cognitive-Behavioral Group Therapy: 6 patients 6 patients 2.5 hours 2.5 hours 12 weeks 12 weeks 1&2 sessions 1&2 sessions rationale instructio ns Ibtihal M.A. Ibrahim

42 Predictors of treatment response to CBT: 1.Expectancy for improvement. 2.Homework compliance. 3.Subtype of social anxiety disorder and avoidant personality disorder. 4.Axis I comorbidity. 5.Anger. Ibtihal M.A. Ibrahim


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