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Anxiety Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions
Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions

Section 20
Phobias: Causes of Social Anxiety

CEU Question 20 | CEU Test | Table of Contents | Phobias
Counselor CEUs, Social Worker CEUs, Psychologist CEs, MFT CEUs, Nurse CEUs

Among the anxiety disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2001) is social phobia. Although not new to the nomenclature, the disorder has received a great deal of attention in the professional and popular press in recent years as a condition that is prevalent and is treatable. Of concern to me is the extent to which social phobia, of which shyness can be considered a mild form, is being conceptualized as a mental disorder with an emphasis on its treatment with medication.

Social phobia provides a striking example of the pathologizing of personality characteristics and the willingness of many consumers and professionals to accept or condone such stigmatization. This article describes the characteristics of social phobia, considers its status as a mental disorder, and discusses the kinds of non-medical interventions that can be offered to those who seek to overcome it. I will refer to the condition most often as "social anxiety" to reflect my position that it represents a "problem in living" rather than a mental disorder. A problem in living is a person--environment transaction that blocks an individual's experience of satisfactory social functioning (Karls & Wandrei, 1994). A mental disorder is conceptualized as a dysfunction occurring primarily within the person (American Psychiatric Association, 2001).

The profession of social work is characterized by a consideration of systems and the reciprocal effect of people and their environments. Whereas strong arguments exist for the biological origins of some conditions, such as bipolar disorder and schizophrenia, the evidence is less compelling for many others. From a transactional perspective, most problems in living, including shyness, arise from a variety of factors and can be resolved by altering one's relationship to the environment rather than by using drugs. Furthermore, from an empowerment perspective, people who are shy should not be encouraged to relinquish judgments about the nature of their mental status to professionals who maintain a medical orientation and perceive many problems as being caused by biological abnormalities. Social workers tend not to classify individuals as abnormal or disordered, because this tends to place problems "within" people.

Anxiety and Social Phobia
Anxiety is an unpleasant but normal and functional effect that provides people with warning signs for perceived threats (Rapee, 1996). Its physical and psychological symptoms prepare an individual to confront or avoid the threat. A person's genetic temperament, psychosocial development, past experiences, and cognitive appraisals of events all influence its regulation (Kaplan & Sadock, 1998). Anxiety begins as a physiological reaction to a threatening stimulus, and its symptoms include tension, autonomic nervous system hyperactivity (for example, racing heart, blushing, perspiring, dry mouth, trembling, difficulty swallowing, muscle twitches), and hypervigilance. Anxiety becomes problematic when it creates a sense of powerlessness, suggests a danger that is unrealistic, or produces a level of self-absorption that interferes with social functioning (Campbell, 1996).

Social phobia, also known as social anxiety disorder, is a fear of social situations and interactions. It is a fear of being judged negatively by others and leads to feelings of inadequacy, embarrassment, humiliation, and depression (Den Boer, 1997). People with social phobia may experience distress when being introduced to other people, being teased or criticized, being the center of attention, or being watched while doing something. Such people understand that their anxiety is irrational. The phobia may be considered a mental disorder when it interferes significantly with the person's interpersonal and social lives (American Psychiatric Association, 2001). Social anxiety is distinguished from other anxiety disorders by its early age of onset, occasional symptom remissions followed by relapses, and exclusive association with social and performance situations (Liebowitz, 1999). The condition does not usually become prominent until ages 15 to 20, with a mean age of onset of 16 years (Magee, 1996).

There is an apparent inconsistency in the DSM-IV subtypes of the disorder. The specific subtype refers to the fear of speaking in front of groups--one-third of people with the disorder have this fear exclusively (Kessler, Stein, & Berglund, 1998). It is less persistent, less impairing, and less often associated with other DSM disorders. In the second subtype, generalized social phobia, the person is anxious in most social situations. He or she perceives negative social events as catastrophes and negatively interprets ambiguous social events (Stopa & Clark, 2000). The psychiatric manual offers no concept of a continuum that might support the significance of person-in-environment processes in the initiation, maintenance, and possible extinction of social anxiety over time.

Causes of Social Anxiety
Social anxiety may have a variety of causes. The psychiatric literature often emphasizes genetic and biological causes. Many writers assert, however, that it is only the generalized form of the anxiety that is inherited. Stein, Chartier, et al. (1998) found a high rate of phobias among relatives of people with generalized social phobia. They added that avoidant personality disorder, which is sometimes comorbid with social phobia, also seems to have a familial base. Symptoms of the anxiety may begin in childhood (often before age five) with another risk period just before puberty. The anxious child may demonstrate a fear of strangers as early as seven months, and behavioral inhibitions may be observed at 21 to 31 months (Rosenbaum, Biederman, Hirschfeld, Bolduc, & Chaloff, 1991). There is no need to assume a genetic or biological basis for transmitted emotional or behavioral patterns, because social learning theory can also account for them (Bandura, 1977). That is, children born into families with anxious adults may acquire related behaviors through modeling and subsequent reinforcement.

Some researchers state that there is an altered brain structure in people with many anxiety disorders, including social phobia. LeDoux (1996) described the functional evolution of certain brain pathways in which a stimulus can be apprehended as a threat before it registers cognitively. The amygdala, the portion of the brain associated with the alarm response, receives a stimulus before the cortex, which governs cognitive function, receives a stimulus. Although this process is adaptive for species survival, an overactive amygdala, said to be present in some anxiety disorders, can foster an extreme reaction to a perceived threat. Other brain conditions postulated as being significant in anxiety disorders include serotonin and dopamine dysfunction (in the striatal system) and an overactive sympathetic nervous system (Tiihonen, Kuikka, Bergstrom, Koponen, & Leinonen, 1997). Biological theorists maintain that, as a result of these dysfunctions, a person with social phobia develops a low arousal threshold and has difficulty assimilating novel stimuli.

Cognitive and behavioral theorists argue that the condition results from an individual's development over time of cognitive distortions based on social learning patterns. Young school children with social anxiety demonstrate a low expected performance level, high negative self-talk on social evaluation tasks, and social skills deficits. They are less likely to receive positive evaluations from their peers (Spence, Donovan, & Brechman-Toussaint, 1999). A person's biased assessments of social situations and negative self-evaluations can become so ingrained in patterns of thought (schema) that they may persist even after social success experiences (Poulton & Andrews, 1996). That is, positive social interactions can produce negative responses in people with social anxiety. Still, the implication is not that the anxiety is necessarily biological in origin. Cognitive and behavioral patterns may be quite rigid, and interventions must include considerable rehearsal and repetition by the client to break through these patterns (Wallace & Alden, 1997).

In summary, considering the perspectives discussed, I present a view of the etiology of social anxiety that incorporates biological, psychological, and social influences. The condition may reflect an outcome of situations in which a person's constitutional temperament interacts with family and social factors such as chronic exposure to environmental stressors or experiences of humiliation and criticism in early life. Social anxiety may be more or less severe depending on the person's schema, comfort with various levels of external stimulation, and reinforcement patterns.

The social work profession has always had an uneasy relationship with the DSM and its medical perspective on problems in living. This diagnostic process perpetuates the myth that an independent entity--a disorder--exists within a person. The DSM views people in isolation, fails to address interactive problems, and obscures the role played by systems. The social work profession's person-in-environment (PIE) classification system (Karls & Wandrei, 1994) takes a more balanced perspective on problems in living. It offers an alternative to the DSM in organizing assessment around the four themes of social functioning problems (social roles, types of problems, their severity and duration, and the client's coping ability), environmental problems (social system contexts, types of problems, and their severity and duration), mental health problems (axes I and II of the DSM system), and physical health problems. The broad classification scheme helps to ensure that a clients' range of needs are addressed and avoids the label of mental illness. Unfortunately, PIE is not sanctioned for use in most clinical settings.

It is sometimes said that conceptualizing problems in living as mental disorders reduces stigma, because the person need not then feel responsible for the condition. This is no doubt true for some people and perhaps for some disorders; but the perspective also supports the interests of medical professionals, who dominate the health care field. Social workers need to preserve their perspective that difficulties in social functioning, whether in terms of behavior or neurotransmitter function, need not be synonymous with illness and that treatment need not always imply drugs or drugs alone. Still, as long as extreme shyness is conceptualized as mental disorder, it is likely that drugs, at times appropriate, will persist as the sole intervention. Research indicates that psychosocial interventions such as those described in this article, all of which can be provided by social workers, are effective and do not include risks for adverse physical and psychological effects. In keeping with professional values, they also may help clients develop a greater sense of self-efficacy.
-Walsh, Joseph; Shyness and Social Phobia; Health & Social Work; May 2002; Vol. 27, Issue 2.

Anxiety Disorders in Children and Adolescents

- Faulkner, Molly, Anxiety Disorders in Children and Adolescents. UNM, Dept of Psychiatry and Behavioral Sciences Division of Community Behavioral Health.

Personal Reflection Exercise #3

The preceding section contained information regarding social phobia.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 20
What argument do cognitive and behavioral therapists use regarding how social phobia is formed? Record the letter of the correct answer the CEU Test.

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Diagnosis & Treatment of Phobias with Cognitive Restructuring Interventions

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