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Social phobia diagnosis and psychological treatment

Social phobia is a persistent fear of performing in social situations, especially where strangers are present or where the person fears embarrassment. Patients fear that others will think them stupid, weak or crazy, and exposure to the feared situation provokes an immediate anxiety attack. Patients recognise that their fear is excessive, but their anxiety and avoidance behaviour may interfere markedly with their daily routine, work or social life. Blushing is common, and patients may avoid eating, drinking or writing in public.

There is some genetic predisposition, onset may follow a particular stressful or embarrassing experience, or be insidious, and the disorder usually follows a chronic course. Symptoms often start in adolescence or even childhood, and may be associated with poor social or academic performance. The incidence of social phobia is about 2%, but lifetime prevalence ranges from 3% to 13%. In some community studies social phobia is more common in women than men, but the sexes are equally represented in clinical samples. Alcohol is used by many people as a coping strategy. Assessment should include a drinking history.

Social phobias – diagnosis

Extreme, persistent fear of social situations

Fear of humiliation or embarrassment

Exposure provokes extreme anxiety

Fear recognised as excessive or unreasonable

Avoidance of situations

Anxious anticipation

Psychological treatment

Cognitive behavioural therapy has proven efficacy in social  phobia. Paradoxically, this does not focus on external threat but on the internal image of how the patient thinks he looks to others. Treatments combining imaginary and actual exposure produce modest gains but seem as effective as more complex regimens. Cognitive behavioural therapy is promising, either alone or in combination with an antidepressant, but seems most effective in the third of cases with circumscribed social phobias.

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