1. Social Phobia Dr. Fouad Antoun. Lebanon

2. 2 Social Phobia  Over 7% of the population suffers from SAD.  Social anxiety is the 3 rd largest Mental Health care problem in the World.  Lifetime prevalence is 11% in men and 15% in women.  Co-morbidity : GAD, specific phobias, panic disorder, avoidant personality disorder, mood disorders.  Onset generally takes place during adolescence when social awareness and interaction are evolving. Cultural influences play a role.

3. 3 Social Phobia: Aetiological Theories  Psychoanalytic: Freud was the first to attempt a systematic account for the development of phobic behaviour. Supporting evidence is drawn from clinical case reports.  Behavioural theories: Focus on learning. Avoidance Conditioning, based on the 2 factor theory proposed by Mowrer (1947): 1.Via classical conditioning. 2.Learning to reduce conditioned fear by the C.S. avoiding.

4. 4 Social Phobia: Speculative Theories  Stabler et.al. 1996 – 38% of short people, correlated to the deficiency of the growth hormone in childhood and adolescence, develop social phobia.  Family difficulties, conflicts, frequent family moves, physical and sexual abuse in childhood, school difficulties.  Genetic factors- Parents of social phobics are more likely to develop major depression (Biedermen et.al. 2001).

5. 5 Social Phobia  Socio-cultural variations in social phobia are beginning to emerge and receive more attention. Findings suggest that there are similarities in the expression of social phobia across cultures.  Epidemiological studies suggest that social phobia has similar patterns of prevalence and co-morbidity across cultures and in different countries (Lecrubier and Wirller 1997, Wissman et.al. 1996).

6. 6 Social Phobia: Aetiological Considerations  TEMPERAMENTAL FACTORS – inborn temperament of Behavioural Inhibition (BI): reluctance to interact, usually from childhood. Evidence suggests that behaviourally inhibited temperament may predispose a child to high social anxiety.  PHYSIOLOGICAL FACTORS – recent studies have shown that adults with social phobia have high autonomic nervous system reactions, but results have been contradictory. However the “amygdala” is involved in conditioned fear responses, and hypersensitivity of the neural circuitry that centers on the “amygdala” may be responsible for behavioural inhibition in children. Neuro-imaging is useful in elucidating such differences.  THE AMYGDALA AND SOCIAL BEHAVIOUR AND PHOBIA – the amygdala may play an important role in regulating social behaviour. Thus, in adult macaque monkeys, selective bilateral lesions of the amygdala result in a lack of fear response to inanimate objects and a “socially uninhibited” pattern of behaviour. The amygdala may function as a protective “brake” during evaluation of a potential threat, and it has been suggested that social anxiety may involve a disregulation or hyperactivity of the amygdala evaluative process. Studies in rats also suggest that the basolateral nucleus of the amygdala may play a crucial role in the consolidation of information that leads to the formation of a specific phobia.

7. 7 Social Phobia: Aetiological Considerations  GENETIC FACTORS: 1. Twin Studies – inconclusive. Overall studies suggest that genetics play a modest role in symptom development and temperamental traits associated with social phobia. 2. Family studies – rates of social phobia in offspring, or first degree relations of social phobia show a higher incidence of the condition than relatives with other anxiety or no disorder. This suggests that social phobia is somehow familial and possibly specific in its transmission.

8. 8 Social Phobia: Aetiological Considerations  PARENTING AND FAMILY ENVIRONMENTAL FACTORS: Parental modeling or avoidant responses and restricted exposure to social situations has an effect on the development of social phobic “parent/child” reinforcement of each other’s anxiety. Controlling and over-protectiveness also play a role.

9. 9 Social Phobia: Summary

10. 10 AETIOLOGY OF SAD-AN INTEGRATIVE MODEL  A. Genetic Factors (about 30 %): * May work through proneness to generalised anxiety. * May work through inheritance of Social phobia with diathesis to Panic and Social Anxiety Disorders.  B. Behavioural Inhibition  C. Learning Experience: * Children may learn socially avoidant patterns of behaviour through modelling patterns of siblings or parents and families that discourage socialisation.  D. Biological Basis: * Research is still very incomplete, yet it has shown that people with SAD are more sensitive to Caffeine CO2, Yohinbine, and Nicotinic acid. * SAD show normal sensitivity to lactate and adrenaline. * An increased pressor response to IV TRH.  E. Pharmacological Models: * Suggest 5HT, DA and NA systems involved but not worked out.  F. Neuro-imaging: * Show non-specific and controversial changes in cortical grey matter, basal ganglia, amygdala and insula.

11. 11 Conclusion  Amygdala is the site of fear response control.  Looks inherited (gene in mice that affects learned fearfulness).  Heightened sensitivity to disapproval may be physiologically or hormonally based.  Environmentally acquired due to observational learning or social modeling. SOURCE:NMH,2003