Specific phobia and social anxiety disorder (social phobia): Clinical sciences

Specific phobia and social anxiety disorder are characterized by intense, irrational fear or anxiety triggered by a specific object, situation or activity that poses no inherent danger. This heightened sensation of fear or anxiety often causes significant distress impacting daily life and function.

Often, individuals develop avoidance behaviors of a known trigger to deter these feelings. Common examples of specific phobias include arachnophobia, or fear of spiders; claustrophobia, or fear of confined spaces; and aerophobia, or fear of flying. On the other hand, social phobia, also known as social anxiety disorder or SAD, is the persistent fear of being in a social situation and being scrutinized by others.

Alright, when a patient presents with a chief concern suggesting a phobia, your first step is to perform a focused history and physical examination including a mental status exam. On history, patients often report active avoidance of phobic stimulus, which can be an object, situation, or activity that provokes excessive fear and anxiety to a greater degree than in the general population.

The physical exam might be grossly normal, but the mental status exam can reveal anxious behavior, abnormal speech patterns, and a change in affect by the phobic stimulus. The patient might also exhibit illogical thinking regarding the stimulus but have an insight into the exaggerated response.

With these initial findings, your next step is to assess for social anxiety. When social anxiety is present, the patient will report fear of humiliation or embarrassment and anxiety in response to an anticipated social activity. They might experience physical symptoms of sweating, trembling, or a shaky voice when exposed to the trigger, and thereby avoid social situations.

On mental status exam, the patient might display a depressed or anxious mood, soft speech with hesitancy, and normal thought content. In severe cases, they might even have suicidal ideation. In this case, suspect social anxiety disorder and assess with the DSM-5 criteria to confirm the diagnosis.

To meet the criteria, your patient must report intense fear of being in a social situation due to being embarrassed or humiliated; avoidance of anxiety-producing social situations; excessive social anxiety out of proportion to the situation; and anxiety causing impairment in daily living. These disturbances must have been present for at least six months and cannot be explained by other medical conditions, medication, or substance use. If all these criteria are met, you can diagnose SAD.

Here’s a high-yield fact! Agoraphobia is similar but distinct from social phobia. Patients with agoraphobia express marked fear or anxiety in two or more situations like public transportation; open spaces like a parking lot; or enclosed spaces like a theater; standing in line or in a crowd; or being alone outside of their home.

Now, treatment for SAD includes cognitive behavioral therapy, exposure therapy, and pharmacotherapy. Cognitive behavioral therapy focuses on negative or inappropriate perceptions and thought processes in an effort to reduce or eliminate undesirable associated behavior patterns.

Exposure therapy, on the other hand, provides gradual exposure to phobic stimulus with the goal of reducing or eliminating the fear and avoidance response. When it comes to pharmacotherapy, first line agents include selective serotonin reuptake inhibitors, or SSRIs, like paroxetine and sertraline; as well as serotonin-norepinephrine reuptake inhibitors, or SNRIs, like venlafaxine.