Social anxiety disorder or social phobia is the most common anxiety disorder; it starts early in life and can lead to depression and substance abuse in adulthood. While clinicians are concerned with finding better treatment (as many as 40% of patients do not respond to first-line therapies), critics argue that the label is unnecessarily medicalising a normal personality trait. The issues are discussed in a Seminar in this week’s edition of The Lancet.
Professor Murray B Stein, University of California San Diego, USA, and Professor Dan J Stein, University of Cape Town, South Africa, look at how our understanding of social anxiety disorder has changed over the past decade. They say it has moved from “rudimentary awareness that it is not merely shyness to a much more sophisticated appreciation of its prevalence, its chronic and pernicious nature, and its neurobiological underpinnings.”
People with social anxiety disorder avoid meeting other people, and are subdued in new social settings. As well as blushing, they might have other symptoms such as a racing heart, sweating, or trembling. Often these stem from the fear that as individuals, they are boring, stupid or unlikable. Understandably perhaps, there is some criticism that classifying such symptoms as a mental health disorder is inappropriate. But, the authors point out, while shyness itself is not a pathological condition, debilitating shyness that has a detrimental effect on a person’s everyday functioning “can no longer be regarded as normal”.
The authors discuss possible causes for this disorder. Research shows that a heritable temperamental trait known as behavioural inhibition is commonly an antecedent to the development of social anxiety disorder. Understanding how social anxiety disorder relates to conditions such as autism might help in determining how we process socially relevant information. Neuroimaging studies suggest that activity of the amygdala –which responds to emotional human faces - is heightened in people with social anxiety disorder.
Treatment of the disorder is not straightforward, and specialised psychotherapy (eg, cognitive behavioural therapy) or pharmacotherapy (eg, selective serotonin reuptake inhibitors) are beneficial for many, though not all, individuals. Which method of treatment to choose is currently left to clinical judgment. The authors say that the view that social anxiety disorder is a false condition created by the pharmaceutical industry is flawed: “a view that accepts the validity of expanding markets for general medical disorders (eg, hypertension, hyperlipidaemia), but that is automatically critical of psychiatric diagnosis and treatment, is questionable and reinforces stigmatisation of mental disorders”.
Professor Murray B Stein, University of California San Diego, La Jolla, CA, USA; T) +1 858 534 6400; mstein@ucsd.edu
http://multimedia.thelancet.com/pdf/press/Anxiety.pdf
Journal
The Lancet