Epidemiological studies indicate that social anxiety disorder as one of the most common mental health disorders. However, many patients do not seek or receive help, despite the prevalence of social anxiety disorder, the large amount of information, the possibilities of psychotherapy and medical treatment.
Generalization of actual knowledge and research on the aetiology and pathogenetic mechanisms of social phobias and coverage of the actual issues of low referral of people suffering from social phobia.
For review, the following databases, such as ScienceDirect, ResearchGate, PubMed and Google Scholar, were used. The search was performed using the keywords: social anxiety disorder, sociophobia, social anxiety, cognitive-behavioral model, neurobiology, mental health.
The general information about social anxiety disorder, its prevalence and its consequences were covered. The main etiological mechanisms, modern views on the neurobiological and psychological basis of the disorder are considered. In addition, the peculiarities of the clinical picture and its influence on the social functioning of the individual, including the referral of help, were analyzed. The aspects that are useful to consider during the development of recommendations for specialists in general medical practice and centers of public mental health were suggested.
A social anxiety disorder should be considered as a complex mental health disorder. Recognition of signs of social anxiety disorder in their component often leads to a false interpretation of clinical signs as manifestations of depression or other neurotic disorders among primary care professionals. Informing general practitioners and specialists of public mental health centers about the traits of the clinical picture and the social functioning of patients with this disorder can help to overcome the stigma and improve the referral of qualified assistance.
Social phobias (sociophobia, social anxiety disorder) are typically characterized by a strong sense of tension and anxiety during social interaction or activity because of the individual's thoughts about being evaluated by others or assumptions on people’s opinions. Being in constant emotional distress, such people experience significant difficulties in the professional, academic and financial aspects of life, which usually involve an individual into interpersonal communication [
Epidemiological studies indicate that social anxiety disorder is one of the most common mental health disorders with lifetime prevalence at 12-15% [
This disorder entails economic losses for the individual and his family very often, which is related to the avoidance or significant difficulties in the professional and educational functioning, weakness of social activity, formation of a certain dependence on the special conditions and circumstances in which the individual could feel comfortable. At the same time, high comorbidity with other anxiety disorders, depression and the use of psychoactive substances creates an additional financial burden [
Unfortunately, in Ukraine, we do not have high-quality epidemiological studies to highlight the prevalence of sociophobia and its impact.
A number of etiologic factors are common for the most mental health disorders, and they support, activate or modify the conditions for their occurrence and development in one way or another.
The genetic factor for social phobia plays an important role, just as it is with other anxiety or affective disorders. Studies show that there is a connection between direct relatives who had a social phobia in anamnesis, especially for generalized forms, and/or signs of agoraphobia [
Innate peculiarities of temperament are seen as important determinants of social phobias development, which according to the model of R. Cloninger is connected with neurobiological bases. A positive correlation between the features of temperament and the formation of social anxiety and social anxiety disorder was noted. Thus, avoiding the threat and reducing the initiative before gaining a new experience are due to a decrease in the activity of serotonergic and dopaminergic systems, described in some studies [
A critical review of various neurobiological models by Mathew S.J. indicates a decrease in serotonergic and dopaminergic activity, a disturbance of the oxytocin metabolism and activity of the hypothalamic-pituitary-adrenal system [
It is believed that people with this disorder will be more sensitive to the facial expressions recognition in situations of social interaction. Usually, they tend to interpret them as signs of hostility or assumption that these people do not like something about them. In accordance to the integrative model of etiology and the maintenance of social phobias, proposed by S.H. Spence and R.M. Rapee (2004), social assessment factors (emotional expression evaluation, visual contact, posture assessment, situational behavior or social position/role of the environment) reflect individual neurobiological and cognitive aspects [
The deterioration of the activity and control of the prefrontal cortex causes the perturbation of the amygdala (reducing its protective functions) in response to the recognition of conditionally hazardous signals that arise in social interaction. Such evidence suggests that the activation of the amygdala in the emergence of "threat" during an interpersonal interaction may be caused by the severity of the symptoms of social anxiety of individual patients, and not by the general state of anxiety or tension [
The review of the literature also shows an increase in the activity of the insular cortex, which participates in the visual recognition of manifestations of negative emotions and behavior, including at once, anger and fear during public appearances [
According to experts future studies may be aimed at verifying the effects of neuroendocrine factors (such as vasopressin and oxytocin) that are involved in the process of social affiliation (the desire and need to be in emotionally significant relationships with other people) and the activity of the nervous system in response to the formation of trusting and safe relationships [
Reviews of literature on cross-cultural and experimental research show that people who are suffering from social anxiety show a tendency to a more negative perception of themselves, low self-esteem, persistent prejudices and judgments about the social assessment of others, and show a rigorous and negative interpretation of possible consequences when trying to solve these problems [
In a number of studies variation of parental behavior or behavior of other meaningful individuals may form the basis for the formation of social phobia, especially in sensitive periods of growing up [
The influence of relationships with peers is also recognized as an important factor in shaping social anxiety [
Neuroimaging studies confirm the positive effect of cognitive behavioral therapy, aimed at processing rigid cognitive strategies of self-criticism and social evaluation, on changes in the activity and interaction of neural networks, which proves the importance of considering the impact of social and psychological factors in the development of the disorder [
At the same time, the peculiarities of occurrence of certain somatic disorders, external defects or physical manifestations of PTSD can also be the cause of social phobia. They are considered as factors that determine the concentration of attention on how people feel while being among others.
The social anxiety disorder was first isolated from the group of specific phobias in the mid 60's. Over the next few years, the definition of this disorder was refined.
As mentioned above, despite the prevalence of information and the availability of assistance, people continue to live with most symptoms of social anxiety for a long time without asking for help. Feeling the periods of relief and exacerbation, they arrange the restrictions of their own lives.
At the same time, the recognition of signs of social anxiety disorder in their totality usually causes difficulties for specialists in general medical practice and often leads to an erroneous interpretation of clinical signs as manifestations of depression or other neurotic disorders [
social anxiety is a part of a personality structure or temperament, and it is not possible to change it;
spent personal resources are not relevant for success, and treatment provides sedative drugs at best;
children can overgrow it, and for teenagers it is a typical sign of their age.
When communicating with specialists, people with sociophobia try to minimize visual contact and usually can easier maintain contact when responding to direct questions than when they are given the opportunity to share their complaints without encouragement. Thoughts about taken individual’s complaints not seriously by specialist hinder the maintenance of an effective communicative alliance, reduces the process of interaction to formalities and focuses attention on somatic complaints and physical examination. Along with this constant attention to the manifestations of social assessment (expression of the face, posture, situational behavior or position) by medical personnel create the basis for reinforcing the misinterpretation and strengthening manifestations of social anxiety.
Diagnostic variants of social anxiety disorder include specific and generalized forms. The first is characterized by fear and avoidance of specific situations and is the most widespread one. The generalized form describes both persistent and recurrent feelings of fear, and a wide range of social situations, and is more maladaptive. With the introduction of DSM-V, the forms of the disorder have been simplified and replaced by an interpretation of the fear of one or more social situations [
An understanding that the embarrassment or anxiety that arises in a situation of social relations is not typical for a particular environment and is not proportional to responding to a real danger (regardless of their social or socio-cultural context) was an important point in the new DSM edition [
More often, the onset of the disease manifests itself in the adolescence and acquires its peak before 20 years, occasionally begins later [
On average, one-third of adolescents who had shown signs of social phobias in childhood have spontaneous remission. However, most of the symptoms of this disorder are eventually accompanied by a generalized anxiety disorder or panic disorder without agoraphobia [
Modern trends in psychological research indicate that there is a correlation between self-perception and social anxiety. They usually cover a range of persistent and maladaptive beliefs about the existence of negative perceptions about themselves, organized in unconscious or partially conscious cognitive schemes. According to the cognitive model, they are related to schemes of deficiency, social isolation and alienation. In vital situations, the activation of these schemes is accompanied by an increase in anxiety symptoms as a sign that these qualities can be seen (exposed) by the environment [
Critics of nosological psychiatry tend to consider manifestations of social anxiety disorder as a normal personality response and behavior [
Social phobia is one of the most common anxiety disorders with a lifetime prevalence of more than 12%. Given the combination of a clinical picture with other anxiety disorders, depression or problems with the use of psychoactive substances, this percentage can be higher. Abuse by medications (tranquilizers or other sedative substances) and alcohol in particular often masks the clinical picture of this disorder by depression or panic conditions.
At the same time, the relevance of the aforementioned problem lies in the fact that, despite the existence of effective evidence-based interventions, people who suffer from this disorder do not receive professional care in a timely manner. A false cognitive interpretation of the signs of social assessment and response of the environment, in particular, medical personnel, increases the maladaptive beliefs about oneself. It also correlates with the severity of manifestations of social anxiety and causes an irrational behavior strategy. Children and adolescents can be referred to the specialist providing psychotherapy or other psychological interventions because of anxiety and lower school performance. However, occasionally they include focused psychotherapy for social anxiety disorder.
Also, the current problem lies in the lack of clear and understandable screening skills that a general practitioner should have. Problems with the organization of care for people with mental health disorders in the primary link of health care may be caused by a small number of specialists in medical and clinical psychology that the patient can be referred to. At the same time, pessimism and bias in the effectiveness of psychological/psychotherapeutic interventions in anxiety disorders in general among primary care physicians, as opposed to drug therapy, also reduces the effectiveness of therapy and restricts the involvement of patients.
Appropriate steps may include developing recommendations for specialists in general medical practice in diagnosing and directing people with sociophobia, as well as developing a general guide for professionals from narrow-line hospitals, offices or centers for public mental health. Such developments should take into account, as:
availability of diagnosis and treatment for the population;
valid diagnostic tools (including screening) of social phobia;
effective and proven methods of psychological and psychotherapeutic interventions (cognitive behavioral therapy, exposure therapy, social skills training, interpersonal psychotherapy, psychodynamic psychotherapy);
opportunities and limitations of psychopharmacological interventions (selective serotonin reuptake inhibitors, monoamine oxidase inhibitors, and other antidepressants, beta-blockers and benzodiazepines) and their combinations with psychological interventions and psychotherapy;
group interventions (based on the KPT method, if possible) aimed at supporting parents/relatives and significant others involved in social support for children and adolescents with social anxiety disorder;
management and prevention of comorbid conditions and disorders;
alternative methods and means of social, professional and educational adaptation.
The joint efforts of general and mental health professionals, people who suffer from social phobia and communities can overcome the barriers of stigmatization and improve the psychological well-being of this category of patients.
The author declare that no competing interests exist.