According to the World Health Organization, mental health is “a state of well-being in which an individual realizes his or her abilities, can cope with the normal stresses of life, can work productively and can make a contribution to his or her community. Mental health and well-being are fundamental to our collective and individual ability as humans to think, emote, interact with each other, earn a living and enjoy life” (Mental Health: Strengthening our Response, 2014, para. 3). One of the factors jeopardizing mental health, along with mood disorders, eating disorders and substance-related disorders, is social anxiety or phobia. In Saudi Arabia, the specifics of treatment (or lack thereof) of social anxiety disorder are conditional upon various religious restrictions and customs, Islam is the state religion. Unlike it is with the USA, where about 6.2 % of Americans (15 million American adults) suffer from social anxiety disorder according to the Anxiety and Depression Association of America (Social Anxiety Disorder, 2015, para. 3), “there are no projections on the burden of mental disorders specific to the Arab world” (Okasha, Karam, & Okasha, 2012), which indicates certain unawareness of the problem. Moreover, Saudi Arabia has yet to implement the Mental Health Legislation, which is a mandatory attribute for civilized countries, as its goals include facilitation of mental health awareness, promotion of mental health, and making the mental health services accessible, affordable and available (Trivedi & Tripathi, 2014). Against the backdrop of inadequate attention to addressing mental disorders, there is also a problem of insufficient treatment of certain social categories, including females, children, and domestic workers. This paper shall focus on social anxiety in Saudi women.
Main body
Social anxiety disorder is one of the most common and frequent disorders among mental disorders. The anxiety inherent in social phobia is a special psychological and physiological state, which includes the following components: physical (somatic), emotional, cognitive, and behavioral. In addition to the social factors, the causes of anxiety and phobic disorders include heredity (genetic profile), the individual characteristics of the nervous system (temperament), and the presence of congenital abnormalities. It is necessary to define that occasional disturbance is a normal reaction to stressors as it helps the human body to cope with them. However, if the worriment starts to prevail over the rest of emotions, increases in intensity and becomes constant, one may talk about anxiety and phobic disorders. The anxiety that arises in patients with social phobia is perceived as an uncontrolled, non-specific, dissipated, free-floating, or inevitable situation. It is characterized by “an intense fear in one or more social situations causing considerable distress and impaired ability to function in at least some parts of daily life” (Myers & DeWall, 2014). Social anxiety disorder consists of two components: the fear of human society in general, and the fear of action, related to a possible assessment from the side. People suffering from social phobia experience excessive anxiety in a variety of everyday situations; they are afraid to be judged by other people, especially strangers, are worried that their behavior can be interpreted as inappropriate, fear that others will notice their nervousness. Anxiety is strong emotional stress, and since the stressors constantly affect the suffering individual, anxiety greatly interferes with daily activities, career development, training, and interpersonal relationships. Apropos, one of the arguments against Saudi women receiving proper treatment from psychiatrists, is their secluded lifestyle: “for a stay-at-home female, who perhaps rarely socializes outside of her extended family, even high levels of social anxiety are unlikely to be experienced as problematic (Thomas, 2013).” It is particularly alarming in view of the fact that, according to the Anxiety and Depression Association of America, “it’s not uncommon for someone with an anxiety disorder to also suffer from depression or vice versa” (Depression, 2015, para. 3). Whereas the untreated social disorder may be tolerated, it is better to avoid untreated depression and its implications. And here, Saudi society is faced with another problem, the ambiguous perception of mental illnesses and their treatment within the context of the country’s state religion, Islam. According to Gielen, Fish & Draguns (2014), some Muslim psychologists and psychiatrists even reject psychoanalyses, which is the primary means of social anxiety disorder treatment, “not only because of its unscientific stance but also because of its negative view of human nature, which is against Islam” (p. 311). It also applies to many other concepts used in modern psychiatry and psychology. Muslim psychiatry is based on the ideology of Islam and the fact that an individual, its mind and a variety of mental characteristics were created by Allah, and the individual was endowed with a soul, which together with the brain plays a crucial role in absolutely all psychophysical processes. In the Muslim society, mental disorders are usually considered as the result of God’s will and punishment for sin; therefore, religious practices are used for the treatment, with patients seeking salvation in the Koran. It often develops into the concealment of one’s mental problems in the fear of being stigmatized by the society. According to Rassool, “the literature distinguishes two types of stigma: label avoidance and public stigma” (p. 65). Label avoidance refers to instances in which individuals choose not to seek help for mental health problems to avoid negative labels (Ben-Zeev, Young & Corrigan, 2010). Public stigma is “the prejudice and discrimination that occurs when members of the community endorse stereotypes about mental health problems” (Rassool, 2014). In the case of Saudi Arabia, it is mainly the label avoidance that prevents people from addressing their health issues. Provided that stigma is “the situation of the individual who is disqualified from full social acceptance” (Goffman, 2009), it is fair to suggest the presence of a certain vicious circle, where the suppressed individuals (mainly women) further immerse into their anxiety.
Since the basis of mental health is a social environment, which ensures respect and protection of basic civil, political, socio-economic and cultural rights, the status of a woman in the Arab world per se is fertile soil for the development of various anxieties. According to the patriarchal Sharia law, woman’s rights in the Saudi Arabia imply a set of restrictions. Women are prohibited from taking part in elections and engaging in politics. Saudi Arabia is the only country in the world where women are forbidden to drive. As of 2009, the country ranked 130 out of 134 countries on the infringement of women’s rights. It is also the only country that received a zero score on the political and social rights granted to women. “All women, regardless of age, are required to have a male guardian. Saudi Arabia has been the only country in the world to prohibit women from car driving” (Women’s Rights in Saudi Arabia, n.d.). Women are not allowed to study, work, or travel abroad unless permitted by the husband or male relative. Saudi girls are given in marriage at any age, so they often leave school without acquiring secondary education. The Saudi government has a strong psychological pressure on women and their role in the country. In particular, a 2006 survey showed that more than 80% of women did not consider it necessary to have the right to drive a car and work with men.
According to the laws of Saudi Arabia, all women must be accompanied by a mahram, a male relative or husband. The guardian plays an important role in virtually all aspects of a woman’s life. Formally, the system is designed to protect women in accordance with Islamic rules. However, since various officials and institutions, including hospitals, police stations, banks and so on, may require the presence of a male guardian, it may be a hindrance to visiting a psychiatrist. Therefore, Muslim women often “avoid sharing personal distress and seeking help counselors due to fear of negative consequences with respect to marital prospects or their current marriages” (Ciftci, Jones & Corrigan, 2012).
Further obstacles to the mental well-being of women in Saudi Arabia include gender segregation and the low level of employment, which results from the lack of education. Gender segregation affects all women, whom mahrams aim to isolate from the surrounding society to maintain their “feminine purity.” As a rule, festive events are held with the separation of men and women, and mixed parties are extremely rare. In Saudi Arabia, the open world is the prerogative of men, who seek to isolate their women, condoned by the religion. The traditional house projects also provide separate rooms for women, with high walls and small windows with curtains, so that they feel safe while fenced from the outside world. Undoubtedly, it leads to the development of anxieties and depression. When it comes to employment, Sharia allows women to work on the condition that they do not neglect their family duties, although ever since early childhood, girls are taught that their main role is to maintain the family hearth, to bear and raise children. Saudi women are only allowed to work with the explicit consent of their guardians. Needless to say, the “psychological consequences of unemployment include impaired psychological well-being, anxiety, depression, reduced self-confidence, social isolation and reduced level of activity” (McLaughlin, 2002).
Conclusion
Although the detriment of untreated social phobia is undeniable, there are not many ways to cope with the problem, since it stems from the fundamental and imperishable aspects of Islam, the cornerstone of Saudi Arabia society. Abdul Malik Mujahid has suggested four ways of addressing the problem: a) the Muslim community in general and Muslim psychiatrists, psychologists and social service providers in particular, must urgently begin a mental health awareness campaign; b) Imams must present Khutbas (the Friday sermon) on the topic of Muslim mental health, with a special focus on breaking down the taboo nature of this issue; c) masjids (mosques) must be the first institution Muslims can turn to in times of crisis; and d) Muslim schools (full time and weekend) must urgently hire professional counselors and establish mentorship programs for Muslim children, which will offer students a way to share their stress or concerns with qualified personnel who can help them (State of Muslim mental health, 2010).
References
Ben-Zeev, D., Young, M.A. & Corrigan. F.W. (2010). DSM-V and the stigma of mental illness. Journal of Mental Health, 19(4): 318-27
Ciftci, A., Jones, N. & Corrigan, P.W. (2012). Mental health stigma in the Muslim community. Journal of Muslim Mental Health, 7(1) (Stigma).
Depression. (2015). Web.
Gielen, U., Fish, J., & Draguns, J. (2014). Handbook of Culture, Therapy, and Healing. United Kingdom, London: Routledge.
Goffman, E. (2009). Stigma: Notes on the Management of Spoiled Identity. New York, NY: Simon & Schuster
McLaughlin, E. (2002). Understanding Unemployment. United Kingdom, London: Routledge.
Mujahid, A. M. (2010). State of Muslim mental health, Web.
Myers, D., & DeWall, C. (2014). Psychology in Everyday Life. United Kingdom, London: Worth Publishers.
Okasha, A., Karam, E. & Okasha, T. (2012). Mental health services in the Arab world. World Psychiatry, 11(1): 52-54.
Rassool, G. H. (2014). Islamic Counseling:An Introduction to Theory and Practice. United Kingdom, London: Routledge
Social Anxiety Disorder. (2015). Web.
Thomas, J. (2013). Psychological well-being in the Gulf States. United Kingdom, London: Palgrave Macmillan.
Trivedi, J., & Tripathi, A. Mental Health in South Asia: Ethics, Resources, Programs and Legislation (International Library of Ethics, Law, and the New Medicine). (2014). New York, NY: Springer.
Many people have phobias, irrational fear of animals, events, or actions, which cause significant damage to their normal functioning. Such activities as driving and flying and such animals as dogs and insects are among the most widespread phobias. In the United States, approximately 4.4 percent of the population has one or more phobias (Moldovan & David, 2014). This condition is highly treatable compared to other psychological diseases. Cognitive behavioral therapy (CBT) is one of the most relevant ways to assist people with a phobia, which is based on working with a patient’s anxiety response. This paper will target the recent academic literature to examine the role of behavioral treatment of phobias.
One of the key concepts of CBT is that the source of a patient’s problems most likely lies inside the person, not outside. The discomfort experienced because of a phobia is not delivered by situations yet by personal thoughts, assessments of conditions, and attitudes towards other people. A phobia is usually an unrealistic fear of someone or something that is characterized by anxiety, panic, and depression. As a rule, phobias are treatable with a high level of positive outcomes being achieved. In CBT, the patient researches his or her mindset along with the therapist (Triscari, Faraci, Catalisano, D’Angelo, & Urso, 2015). By asking various questions, often ridiculous or tricky, and suggesting conducting experiments, the therapist encourages the client to detect irrational logic and try to challenge it.
The review of the available literature shows that most often, CBT is used in combination with other non-pharmacological methods. In their study, Triscari et al. (2015) explored the integration of CBT with eye movement desensitization and reprocessing (EMDR), overall desensitization, and virtual reality (VR) exposure. Aerophobia was selected as the target phobia, and the efficacy of all the interventions was proved. In particular, the randomized controlled trial revealed that pre-and post-intervention demonstrated the reduction of the fear of flying. The participation of the tested patients in flights after the treatment as well as their self-reporting showed that their anxiety levels decreased. Within a one-year follow-up, the respondents also remained more positive to flights than before the application of CBT in the combination with other therapies.
Another way to address phobias is associated with virtual reality and CBT. This form of psychotherapy is based on technologically advanced applications the goal of which is to create an interactive environment and place a patient in it. Moldovan and David (2014) examined the impact of one session of CBT-VR on specific and social phobias. Based on examining 32 patients, they utilized such measurements as Flight Anxiety Modality Questionnaire (FAM), Self-Statements during Public Speaking Scale (SSPS), and other instruments. In the course of the intervention, the patients were taught to identify their irrational beliefs and replace them with logical thoughts. Together with the patients, the therapists constructed the hierarchy of phobias and built conversations that were specifically called to help to eliminate fears. As a result, it was established that the difference between the control and intervention groups did not achieve the expected significance level. Moldovan and David (2014) note that the small sample size and a variety of measurements may have limited the findings. Nevertheless, the study is representative of the fact that CBT-VR has the potential for changing irrational fears.
Not only adults but also children and adolescents may develop phobias, which makes it important to consider related articles as well. The peculiar feature of children’s phobias is that patients are afraid of the outcomes in real situations like inadequate behaviors in social situations. As a result, their relationships with peers can be challenged and determined the quality of behaviors in the future. According to Öst, Cederlund, and Reuterskiöld (2015), social phobia is the most critical in the identified group, and it may become chronic if untreated for a long period. The authors examined the impact of individual CBT and group exposure on 55 children aged between 8 and 14 years old (Öst et al., 2015). In addition, some children participated in the experiment together with their parents, who received education training on how to help their children to overcome their phobias. The data obtained demonstrated that there was no significant difference between those who participated alone and those whose parents were also involved. In fact, both groups succeeded in recovering or minimizing their unrealistic fears. These results show that CBT is effective for children regardless of the participation of their parents in the treatment process.
Even though the abovementioned studies were successful with regard to phobia treatment, it is essential to focus on some critical points. For example, Triscari et al. (2015) found that CBT with EMDR requires the professionalism of a therapist, who is expected to know and implement a set of theoretical orientations that vary depending on a certain patient and his or her phobia. In its turn, the use of VR along with CBT was recognized as an expensive therapy, which is consistent with another study results provided by Moldovan and David (2014). Therefore, further research should be initiated to improve the understanding of CBT and other behavioral techniques in addressing phobias.
To conclude, it is essential to emphasize that CBT is an effective means of treating various phobias in both children and adults. The contemporary studies show that CBT is often applied in combination with VR, EMDR, and other behavioral methods. However, if several techniques are applied to the same patient, it is important to assess each outcome and behavioral change and continue communication. To promote a greater understanding of the discussed topic, further research should focus on such aspects of behavioral treatment of phobias as costs, benefits, disadvantages, limitations, and opportunities regarding the integration with other techniques.
References
Moldovan, R., & David, D. (2014). One session treatment of cognitive and behavioral therapy and virtual reality for social and specific phobias. Preliminary results from a randomized clinical trial. Journal of Evidence-Based Psychotherapies, 14(1), 67–83.
Öst, L. G., Cederlund, R., & Reuterskiöld, L. (2015). Behavioral treatment of social phobia in youth: Does parent education training improve the outcome? Behaviour Research and Therapy, 67, 19–29.
Triscari, M. T., Faraci, P., Catalisano, D., D’Angelo, V., & Urso, V. (2015). Effectiveness of cognitive behavioral therapy integrated with systematic desensitization, cognitive behavioral therapy combined with eye movement desensitization and reprocessing therapy, and cognitive behavioral therapy combined with virtual reality exposure therapy methods in the treatment of flight anxiety: A randomized trial. Neuropsychiatric Disease and Treatment, 11, 2591–2598.
Almost everyone knows what it feels like to be anxious or uncomfortable in a social situation. From surveys of many individuals from across the United States and elsewhere, Ruscio and his colleagues (2008) found that 40% of individuals considered themselves to be chronically shy, to the point of it being a problem. Another 40% reported that they had previously considered themselves to be shy. Fifteen percent more considered themselves to be shy in some situations, and only 5% reported that they were never shy.
Social phobia (also called social anxiety disorder) is diagnosed when shyness or performance anxiety becomes so intense and so pervasive that it leads to clinically significant distress and impairment. As is reviewed later in this chapter, social phobia is one of the most prevalent psychological disorders. In this chapter we review the empirical literature pertaining to social phobia and social anxiety. We begin with a discussion of diagnostic issues and studies on descriptive psychopathology and epidemiology. Next, we review current theories and empirical evidence pertaining to both psychological and biological approaches to social anxiety. The paper concludes with an up-to-date review of psychological and biological treatments for social anxiety.
Diagnostic Criteria and Description
Social phobia is defined in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) as “a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing (p. 416).” In addition to anxiety and fear related to social and performance situations, the individual must also
experience anxiety or fear almost every time he or she confronts the feared social situations,
recognize that the fear is excessive or unreasonable,
avoid the feared situations or endure them with intense anxiety or discomfort,
have had the problem for at least 6 months (only a requirement if the individual is under 18 years of age), and
experience significant distress and/or functional impairment resulting from the problem.
Furthermore, the anxiety cannot be better accounted for by another mental disorder or be due to the direct effect of a substance or a general medical condition. Finally, if a general medical condition or mental disorder is present, the fear must be unrelated to it. Not all individuals with social phobia fear the same situations. In fact, the range of feared situations can vary from as few as one (e.g., a fear of public speaking) to as many as almost all situations in which other people are present.
Subtypes of Social Phobia
A number of subtyping strategies were considered when the DSM-IV was being developed. In their report to the DSM-IV subgroup on social phobia, Massion (2002) proposed three subtypes for the disorder:
circumscribed type (for people who fear only one or two situations),
generalized type (for people who fear most social situations), and
non-generalized type (for people who have clinically significant anxiety in social interaction situations but have at least one broad domain of social functioning that is not associated with significant anxiety).
Another proposal from the Task Force on the DSM-IV (American Psychiatric Association, 1991) also involved three subtypes for social phobia:
performance type (phobic stimulus includes some activity that is being performed in front of others e.g. public speaking, eating, drinking, urinating, writing),
limited interactional type (phobic stimulus is restricted to one or two interaction situations, such as dating or speaking to strangers), and
generalized type (phobic stimuli include most social situations).
More recently, Swinson et.al. (2006) recommended that individuals with social phobia be classified according to the four situational domains that are feared or avoided:
formal speaking/interaction,
informal speaking/ interaction,
observation by others, and
assertion.
Despite these different proposals for social phobia subtypes, only the generalized subtype remains in the DSM-IV, whereby clinicians are required to specify whether the social phobia is generalized, which is defined to include most social situations. Although the generalized subtype appears to be a reliable and valid way of distinguishing among different types of individuals with social phobia (Fedoroff, 2001), the other subtyping strategies described earlier may still be helpful for understanding the nature of social phobia and are often used by researchers who study this disorder. For the interested reader, there are a number of sources for more detailed consideration of issues related to subtypes in social phobia (Swinson, 2006).
Prevalence of Social Phobia
Perhaps more than with any other anxiety disorder, the prevalence of social phobia has been a source of controversy in the literature. In the Epidemiological Catchment Area (ECA) study Grant, (2005), the lifetime prevalence estimate for social phobia (based on DSM-111 criteria; American Psychiatric Association, 1980) was 2.73%. This figure is based on structured interviews with more than 13,000 people in five American cities. In contrast, the more recent National Comorbidity Survey (NCS), which was based on structured interviews with just over 8,000 Americans, showed a lifetime prevalence rate of 13.3% for social phobia (Iancu, 2006). There are a number of factors that might account for this rather large difference in the estimated prevalence of social phobia.
First, different diagnostic criteria were used in the two studies. Whereas the ECA study used interviews based on DSM-111 criteria, the NCS interview relied on more recent DSM-III-R criteria (American Psychiatric Association, 1987). Second, the sample studied in the NCS study was more representative of the American people at large than the ECA study, which included only people from five specific cities. Most important, however, the interview used in the ECA study (i.e., the Diagnostic Interview Schedule, Version IV [DIS-IV]; Swinson, 2006) used a very narrow definition of social phobia. Participants were asked only about their fear in three different social situations (i.e., eating in front of others, public speaking, and meeting new people). In addition, the definition of social phobia required only that the fear cause significant impairment in functioning. The presence of significant distress was not considered sufficient to meet the criteria for social phobia, even though the DSM-111, DSM-111-R, and DSM-IV (American Psychiatric Association, 1980, 1987, 1994) permit the diagnosis to be given as long as the person experiences significant distress or impairment.
Interestingly, other studies that have relied on the DIS-IV have also yielded similarly low prevalence rates for social phobia. For example, Swinson (2006) found that 1.7% of more than 3,000 individuals in Edmonton, Alberta, Canada, met criteria for social phobia. Recently, however, the overly narrow definition of social phobia used by the DIS-IV has prompted some experts to argue that the prevalence estimates in the ECA and Edmonton studies seriously underestimate the true prevalence of social phobia in the general population (Grant, 2005).
So, it is likely that social phobia is much more common than is suggested by the ECA findings. Nevertheless, it is still possible that the estimate of 13.3% from the NCS study is an overestimate. Swinson (2006) demonstrated in a Canadian sample that the prevalence of social phobia is strongly influenced by the threshold set for distress/ impairment as well as the number of feared situations needed to meet criteria for social phobia. Depending on the threshold used, lifetime prevalence estimates varied from as low as 1.9% to as high as 18.7%. When the threshold was adjusted to conform most closely to the DSM-III-R definition of social phobia, the prevalence was 7.1% (Swinson, 2006). A recent prevalence study in adolescents and young adults (ages 14-24) confirmed that social phobia continues to be a prevalent problem when the most recent DSM-IV definition is used. Kroenke (2007) found the lifetime prevalence of DSM-IV social phobia to be 9.5% in female and 4.9% in male adolescents and young adults. In this study, about a third of participants with social phobia met criteria for the generalized subtype.
Biological Aspects of Social Phobia Neurobiological Findings
Compared with studies of other anxiety disorders, studies of biological correlates have often failed to show significant findings in patients with social phobia (Swinson, 2006). Studies of neuroendocrine functioning in social phobia have failed to show differences between socially phobic patients and nonanxious control participants on measures related to the hypothalamic-pituitary-adrenal axis and hypothalamic- pituitary-thyroid axis. In addition, studies of abnormal mitral valve functioning (Swinson, 2006) and sleep architecture (Kroenke, 2006) in social phobia have yielded negative results. In contrast to the negative results often obtained in biological research on social anxiety, a recent study by Grant, (2005) showed unique patterns of frontal brain electrical activity associated with the personality traits of shyness and sociability. Specifically, shyness was associated with greater relative frontal EEG activity; whereas sociability was associated with greater relative left frontal EEG activity.
Neurotransmitter challenge studies have yielded mixed results. Stein (2004) failed to find differences between socially phobic patients and non-clinical control participants on an indirect measure of dopamine functioning (eye blink rates and prolactin levels following administration of L-dopa). The same group also failed to show a response to dopaminergic (levodopa) challenges in patients with social phobia (Swinson, 2006). Nevertheless, there are studies suggesting that dopamine may play a role in social anxiety. Furthermore, mice bred to be timid have shown deficiencies in brain dopamine concentrations (Kroenke, 2006). The differential response of social phobia to monoamine oxidize inhibitors but not also supports the view that dopamine plays a role in social phobia. Whereas TCAs act primarily on noradrenergic and serotonergic systems, MAOIs act on noradrenergic, serotonergic, and dopaminergic systems.
With respect to serotonin, studies have yielded mixed results. Fedoroff (2001) found augmented cortisol response to fenfluramine in patients with social phobia, lending support to the view that social phobia is associated with selective super sensitivity in the serotonergic system. In addition, selective serotonin reuptake inhibitors (SSRIs) have consistently been shown to be effective for treating social phobia (reviewed later in this chapter). However, Stein (2004) found that [3H] paroxetine binding (which reflects serotonergic functioning) was no different in social phobia patients than in nonanxious participants. Studies of noradrenergic functioning have generally failed to find anything consistent to suggest that norepinephrine plays a significant role in social phobia. Fedoroff (2001) found no significant differences between patients with social phobia and nonanxious individuals to a noradrenergic challenge in which norepinephrine and growth hormone responses to clonidine administration were measured. Furthermore, as was reviewed earlier, people with social phobia tend not to respond to medications such as imipramine, which are helpful for treating PD and act largely on noradrenergic systems (Iancu, 2006).
Psychological Treatments of Social Phobia
Evidence-based psychological treatments for social phobia have primarily included four types of strategies: (a) exposure-based treatments (e.g., graduated in vivo exposure to feared situations, behavioral role play exercises), (b) cognitive treatments (e.g., examining the evidence that supports and contradicts anxious beliefs), (c) applied relaxation (e.g., combining progressive muscle relaxation strategies with gradual exposure to feared situations), and (d) social skills training (e.g., communication training, assertiveness training). In addition, preliminary data support the use of interpersonal psychotherapy (IPT) for treating social phobia. An exhaustive discussion of these studies is beyond the scope of this chapter, but several recent reviews can be found elsewhere (e.g. Swinson, 2006; Iancu, 2006; Grant, 2005; Stein2004). We will instead provide an overview of some of the most important findings related to empirically supported treatments for social phobia.
Cognitive-behavioral group therapy versus supportive group psychotherapy Swinson, (2006) compared cognitive- behavioral group therapy (CBGT), consisting of cognitive restructuring and exposure-based strategies, to an “attention placebo” group psychotherapy consisting of discussion and group support. Both groups were significantly improved following treatment and at 3- and 6-month follow-ups. However, those receiving CBGT were significantly more improved than were those receiving supportive therapy. A portion of the participants in this study were interviewed again a mean of 5 years following treatment. For those who participated in the long-term follow-up assessment, CBGT continued to be superior to supportive group therapy (Swinson, 2006).
Cognitive Therapy versus Exposure
Numerous researchers have investigated the relative and combined effects of cognitive strategies and exposure-based strategies for social phobia. In general, cognitive, exposure-based, and combined treatments were each found to be effective. Whereas several studies have shown no differences in the efficacy of these approaches (Swinson, 2006; Kroenke, 2007; Stein, 2004), other studies have shown differences to varying degrees and in different directions. For example, Ruscio (2008) found that a pure exposure based treatment was superior to CBGT (which included exposure and cognitive strategies) on a small number of measures.
Swinson (2006) found few differences among exposure and two different cognitive treatments, except that exposure-based treatments led to a greater decrease in pulse rate during a behavioral test, compared with the other treatments. In contrast to these findings, Schneier (2006) found that a comprehensive treatment that included exposure and anxiety management (which includes rational self-talk, relaxation, and distraction) was superior to exposure alone. Grant, (2005) found that adding cognitive restructuring to in vivo exposure increased the effectiveness of treatment, and in a related study, Stein (2004) found that the combination of exposure and cognitive restructuring led to improvement on a broader range of measures than either cognitive restructuring alone or exposure alone.
Finally, Stein, (2004) found that the sequencing of treatments affected outcome. The effects of group treatment for social phobia were greatest when cognitive therapy preceded exposure and smallest when cognitive therapy and exposure were both delivered from the start of treatment. At an 18-month follow-up, patients who received 8 weeks of exposure had a superior outcome compared with patients who received a combination of cognitive therapy and exposure, either simultaneously or sequentially.
Whether cognitive therapy, exposure, or the combination is most effective remains to be answered. Even meta-analytic studies addressing this issue have yielded conflicting results. In a meta-analysis of 21 studies, Kroenke (2007) found that CBTs (including both cognitive therapy and exposure) and pure exposure-based treatments were equally effective. In contrast, Schneier (2006) found that treatments combining cognitive therapy and exposure were the only treatments to have significantly larger effect sizes than placebo. Treatments involving exposure alone, cognitive therapy alone, and social skills training had effect sizes that were not significantly larger than placebo treatments. Regardless of whether adding cognitive therapy improves the efficacy of exposure, it appears that exposure alone can lead to changes in the cognitive features of social phobia (Swinson, 2006).
Social Skills Training
Social skills training appear to be a helpful treatment for social phobia. It appears to be as effective as in vivo exposure alone and to lead to improvement in both social skills and social anxiety. Adding social skills training does not appear to have added benefit over and above the effects of exposure alone (Fedoroff, 2001).
Interpersonal Psychotherapy
A large number of studies have shown that interpersonal psychotherapy (In)is an efficacious treatment for depression as well as for a number of other forms of psychopathology (Grant, 2005; Ruscio, 2008). To date, the use of IPT in an anxiety disorder has been examined in only one published study. Kroenke (2007) treated nine individuals with social phobia in a 14-week open trial. Following treatment, 78% of participants were independently rated as much or very much improved. These preliminary findings suggest that IPT may be a useful treatment for social phobia, although controlled studies with larger numbers of participants are needed. Individual response patterns and outcome with therapy A number of researchers have attempted to discover whether individuals who have particular types of symptoms (e.g., cognitive reactors, physiological reactors, or behavioral reactors) respond differently to specific types of treatment (e.g., cognitive therapy, applied relaxation, or exposure). In general, studies have failed to demonstrate that matching treatments to patients’ response styles improves outcome (Swinson, 2006; Kroenke, 2007; Stein2004).
Pharmacological Treatments
Based on controlled clinical trials, a variety of effective pharmacological treatments for social phobia have emerged in recent years. These include traditional MAOIs (e.g., phenelzine), reversible inhibitors of monoamine oxidase A (e.g., moclobemide and brofaromine), SSRIs (e.g., sertraline and paroxetine), and benzodiazepines (e.g., clonazepam and alprazolam). (Stein, 2004)
Relative Efficacy of Psychological, Pharmacological Approaches
Several investigators have begun to conduct trials to compare psychological and pharmacological treatments for social phobia. Furthermore, trials are now underway at several centers to study the efficacy of combining psychological and pharmacological treatments. Although findings from combined- treatment studies are not yet available, results from several comparative treatment studies are now published or in press. Cognitioe-behavioral group therapy versus phenelzine in a 12-week study comparing CBGT, phenelzine, pill placebo, and supportive group psychotherapy (a psychotherapy “attention placebo”), Massion (2002) found that both CBGT and phenelzine were more effective than either control condition. Phenelzine worked more quickly than CBGT, and at 12 weeks, phenelzine was superior to CBGT on some measures. However, analyses of long-term outcome showed that during the follow-up period (after treatment had been discontinued) about a third of patients taking phenelzine relapsed, compared with none of the patients who had responded to CBGT (Kroenke, 2007). Group differences during the follow-up phase approached significance. Unfortunately, the long term results are limited by the relatively small number of participants who participated in the follow-up study. This group, led by Kroenke is now conducting a study to compare the combination of CBGT and phenelzine to each treatment individually. However, data from this study are not yet available.
Behavior Therapy versus Atenolol
In a study by Massion (2002), patients with social phobia were randomly assigned to treatment with behavior therapy (flooding), atenolol, and placebo. Behavior therapy was superior to placebo, which did not differ from atenolol. On behavioral measures and composite indices, behavior therapy was also superior to atenolol. At a 6-month follow-up, responders to behavior therapy and atenolol maintained their gains. Cognitioe therapy versus moclobemide Schneier (2006) compared 15 weeks of cognitive therapy (including cognitive restructuring and behavioral experiments) to treatment with moclobemide or placebo.
After the acute treatment phase, cognitive therapy was superior to moclobemide on a composite measure but not different from placebo. At a 2-month follow-up assessment, cognitive therapy was superior to moclobemide and placebo. At no time was moclobemide significantly different from placebo. Cognitive-behavioral therapy versus alpraqohm versus phenelzine as was reviewed earlier, Stein (2004) found that phenelzine, alprazolam, CBT, and placebo were equally effective on most measures. However, on one measure of social and work disability, phenelzine was more effective than the other three groups, which did not differ from one another. Unfortunately, the interpretation of these results is limited by the fact that the definition for “treatment responder” may have been overly stringent, as well as the fact that patients in all four groups were given instructions to expose themselves to feared situations, which probably blurred the differences between groups.
A Meta-Analytic Study
Ruscio (2008) recently conducted a meta-analysis of 24 studies of CBT and pharmacological treatments for social phobia. Overall, the study confirms that both CBT and medications were more effective than were control conditions. Among medications, SSRIs and benzodiazepines have tended to yield the largest effect sizes. Among cognitive-behavioral interventions, treatments involving exposure (alone or with cognitive restructuring) yielded the strongest effect sizes. Forms of CBGT were projected to be the most cost-effective interventions, compared with individual CBT and a variety of different pharmacological approaches.
Conclusion
Social phobia is a commonly diagnosed condition that has received increased attention from both researchers and practitioners in recent years. Although researchers have identified unique patterns of thinking that may contribute to the maintenance of social phobia, less is known about the biological underpinnings of this disorder. With respect to treatment, CBT, certain antidepressants, and some anxiolytics have been shown to be useful. However, there are still no published studies investigating the combination of psychological and biological treatments. Several studies of combined treatments are currently underway, and results should be available soon. As psychiatry increasingly becomes a clinical neuroscience, delineation of the underlying endophenotypes associated with social anxiety disorder should be a key focus of research. Secondary prevention with the aim of reduction of long-term adverse consequences is a viable goal but will need much more research. Additionally, too many patients remain undiagnosed and untreated, and too many do not respond to first-line therapies. Additional research is needed at all levels, from basic science through to health services research, to improve and appropriately implement the management of social anxiety disorder.
References
American Psychiatric Association. Diagnostic & statistical manual for mental disorders (DSM). 4th edn. Washington, DC: American Psychiatric Press, Inc, 1994.
DSM III Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association (APA), Washington, DC: 1980.
DSM III-R. Diagnostic and Statistical Manual of Mental Disorders. American Psychiatric Association (APA), Washington, DC; 1987.
Fedoroff C, Taylor S. Psychological and pharmacological treatments of social phobia: a meta-analysis. J Clin Psychopharmacol 2001; 21: 311–24.
Grant BF, Hasin DS, Blanco C, et al. The epidemiology of social anxiety disorder in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 2005; 66: 1351–61.
Iancu I, Levin J, Hermesh H, et al. Social phobia symptoms: prevalence, sociodemographic correlates, and overlap with specific phobia symptoms. Compr Psychiatry 2006; 47: 399–405.
Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007; 146: 317–25.
Massion AO, Dyck I, Shea MT, Phillips KA, Warshaw MG, Keller MB. Personality disorders and time to remission in generalized anxiety disorder, social phobia, and panic disorder. Arch Gen Psychiatry 2002; 59: 434–40.
Ruscio AM, Brown TA, Chiu WT, Sareen J, Stein MB, Kessler RC. Social fears and social phobia in the USA: results from the National Comorbidity Survey Replication. Psychol Med 2008; 35: 15–28.
Schneier FR. Clinical practice. Social anxiety disorder. N Engl J Med 2006; 355: 1029–36.
Stein MB, Gelernter J, Smoller JW. Genetic aspects of social anxiety and related traits. In: Bandelow B, Stein DJ, eds. Social anxiety disorder: more than shyness. New York: Marcel Dekker, 2004: 197–214.
Swinson RP, Antony MM, Bleau PB, et al. Clinical practice guidelines: management of anxiety disorders. Can J Psychiatry 2006; 51 (suppl 2): 1–92.
Fear that cannot be controlled and sometimes said to be irrational is called a phobia. This fear is very unreasonable and not linked to the cause in any way yet it interferes with the how the victim functions on daily basis. Among other ways, phobia develops through classical conditioning. This happens when an impartial stimulus is paired along with something that causes pain. Exposing people to natural sounds that instill fear in them may lead to the development of phobia among the same persons. Responses that arise from phobia turn out to be permanent in the life of an organism. This can only be avoided if a living organism gets extinct. In such a case, the unconditioned stimulus comes into play to help the organism to face fear during the process of extinction.
Another way of dousing phobia is using the counter conditioning process. This method entails pairing the pairing an amusing stimulus with the conditioned stimulus. Psychologists like Watson have proved these two methods (Ormrod 2003). Watson for instance used the Little Albert and the white rats. Counter conditioning in this case would have used things such as food as a pleasant stimulus. In the extinction process, the phobia in Little Albert would have been extinguished by avoiding the loud bangs. Classical conditioning results into phobia through association of two stimuli.
Addictions and operant conditioning
Operant conditioning, which is linked to addiction, involves an association between a particular behavior and an outcome. The consequences relating to operant conditioning are four. They include that something bad can begin in one way or the other. Similarly, something good can be presented in addition to something to something bad coming to an end. Good things can as well end. They are the same characteristic behaviors that make operant conditioning to be associated with addiction. The pain pleasure and pleasure stimuli systems are naturally occurring mechanisms that help animals to survive (Pavlov 1927). The nervous systems with its neurones attached in the brain initiate the pain and pleasure that is felt by animals.
Actions that increase chances of animal survival lead to pleasure whereas those actions that fight against reduced chances of survival cause pain. Communication that effects these changes is transmitted via the neurotransmitters. Extinctions of a conditioned behavior occur when the said response keeps on diminishing due to reduced reinforcement. Strengthening of the behavior is a process that takes place either consciously or unconsciously. Undesirable behavior in the animal could also lead to the extinction of the behavior.
Differences between operant and classical conditioning
Operant and classical conditioning are two behavioral concepts whose product is learning. The paths that the two concepts follow are very different. The first distinction comes from the proponents of the two concepts. Whereas classical conditioning was first described by a Russian physiologist called Ivan Pavlov the operant conditioning was stated by Skinner an American physiologist. Classical conditioning is a process that entails having a neutral pointer before a reflex. On the other hand, operant conditioning involves the use of reinforcement after a stated behavior. Furthermore, operant conditioning as a concept deals with the strengths and weaknesses that surround voluntary behaviors. This is different from classical conditioning as it focuses on behaviors that are automatic and instinctive.
The process of classical conditioning encompasses an association between a behavior that is involuntary and a stimulus. This process sharply differs with that of operant conditioning where the association is between voluntary behavior and a consequence. While there are no motivational incentives in classical conditioning, operant has rewards in its process to encourage the learning process. This difference makes operant conditioning a more participatory exercise to the learner and classical conditioning appears more of a passive process. In spite of all these differences, both concepts of classical and operant conditioning are helpful in the modern society. Some of the professionals who use these concepts include among others trainers, who deal animals, teachers, psychologists, health practitioners, counselors, and parents.
Extinction
Extinction refers to behavior reducing over a particular period. Extinction is a process that happens either consciously or unconsciously and may take long duration. The two concepts of classical and operant conditioning associate with extinction. The long time it takes to occur is a result of the said fear being recurrent. Two factors can lead to extinction. It can take place because of lack of reinforcement of the fear and therefore it dies a natural death (Ricker 2011). It might also occur because when the fear turns out to become irrelevant and hence the conditioned behavior is no longer needed. This is especially common in operant conditioning. This behavior means that the animal looks back to its original behavior. Extinction processes are different and always are confined to specific people. Many times however, the process of extinction takes a reversed direction. This means that the person with a particular bad behavior increases the same. This would look like going against the norm where he or she is expected to shed of the bad tag. Such scenarios are dealt with in the other method other than extinction. This is referred to as counter conditioning.
References:
Ormrod, E (2003). Lifespan Development and Learning. Boston: Pearson Custom Publishing.
Pavlov, IP. (1927). Conditioned reflexes. London: Oxford University Press.
Ricker, J (2011). Can classical conditioning cause phobia? Oxford: Oxford University Press.
I have developed a strong phobia towards the use of elevators after an accident that almost left me crippled. Since the fall, I have always avoided elevators even when going on higher floors. I have tried to fight the phobia, but whenever I am faced with the scenario where I am supposed to use the elevator, the memory of the fall becomes so clear, and my fear comes in its raw form. The defective elevator and subsequent accident was the unconditioned stimulus that resulted in pain which was the unconditioned response. The site of an elevator in this case is the conditioned stimulus that would trigger a conditioned response of instant fear.
Introduction
One of the most common learning experiences that many people could have is the fear of heights. Many people are afraid of heights because they associate heights with a possible fall which could lead to serious injury or even death. Personally, I have developed a serious phobia for heights following my past unfortunate experience. I was using an elevator that was transparent and therefore one could see it gaining height.
Unfortunately, the elevator developed mechanical problems when we were on the second floor. It went loose and collapsed at a terrific speed onto the basement. All the three people in it survived but with serious injuries. Both legs were partially broken, and my skull had some fractures. What was even scarier was the sight of the elevator losing height at that terrifying speed. I was hospitalized for over one year and was lucky enough to be able to walk normally. The other two individuals we shared the elevator with have remained crippled. Since then, I have developed a very strong phobia not only of the elevators but also of heights. The memory of that event still remains clear in my mind.
Main body
According to classical conditioning theory, human behavior is always closely related to the interaction that occurs between a person and the environment (Schmajuk, 2010). One learns to associate certain things in the environment with pain or happiness. This creates a mechanism where an individual would relate given stimuli with another stimulus in the environment. For instance, I have come to associate heights and elevators in particular with a fall.
Although it is not guaranteed that when I use elevators or am exposed to heights I will fall, I am always convinced that falling would be easy, making me develop some strange fear. Thus my behavior for fearing heights was shaped by a past learning experience that was very scary. I have kept asking what could have happened if the elevator was to break loose on the fourteenth floor or higher because I was going to the nineteenth floor. Such imagination would always bring untold fears whenever I am to step into an elevator.
According to Elliott (2010), Operant Conditioning Theory has majorly been used when explaining the behavior of people as shaped by reward or punishment. This scholar says that people fear punishment, but like reward and would always try to avoid punishments. People would always want to behave in a way that would earn them some form of reward from people around them. This theory may not apply directly in the scenario given above, but the punishment aspect of this theory may be applicable. Although it is a fact that using elevators is not a crime, my conscience has always insisted that I should avoid it as much as possible.
Using the lift would, therefore, be equated as going against my conscience. When this happens, the incident that took place during the fateful day of the accident comes raw. The memory of how the elevator started falling becomes so clear and the pain so real that it becomes impossible to continue the journey. My conscience would punish me instantly for going against its wish, and it comes with a lot of pain that is always unbearable. To avoid such punishment, I would avoid using the elevators. It is even more satisfying when I avoid heights completely. The satisfaction and sense of security that I always feel when am at the ground level can only be equated to a reward. I always feel at peace and protected when I am on the ground, away from any heights.
Conclusion
Observational Learning Theory is one of the most common theories that have been used to explain the behavior of a human being. According to Law (2009), the observational theory has generally been used to explain how children learn from what they see in their immediate environment. In the case described above, observational learning theory could have played part in reinforcement of the phobia I have towards heights and elevators in particular.
I have witnessed two cases where people suffered painfully through accidents in the elevators. This has reinforced my fear as it validates the feeling that this machine can kill if things go wrong. It has reinforced the feeling that elevators should be avoided because they are life-threatening. The experience has caused me a lot of trouble when faced with a scenario that requires the use of the elevator.
References
Elliott, D. (2010). Vision and goal-directed movement: Neurobehavioral perspectives. Champaig: Human Kinetics.
Law, B. D. (2009). A description of the functions of observational learning in sport. Ottawa: Library and Archives Canada.
Schmajuk, N. A. (2010). Mechanisms in classical conditioning: A computational approach. New York: Cambridge University Press.
The development of the human mind is often complicated by various phenomena, that are called phobias, the essence of which lies in the fact that a human being fears something without obvious grounds for such a fear, and this causes the person to avoid certain people, events, places, etc. The case of Mr. Petersen is an example of the situation when a person acquired a phobia although other mental health areas seem to be intact.
Step 1: Diagnoses
Probable Diagnosis
Possible Diagnosis
Not Probable Diagnosis
Acute Stress Disorder
Generalized Anxiety Disorder
Substance Induced Anxiety Disorder
Paranoid Personality Disorder
Panic Disorder Without Agoraphobia
Anxiety Disorder Due to General Medical Condition
Social Phobia
Posttraumatic Stress Disorder
Schizophrenia
Step 2: Decision Trees
The analysis of the three possible diagnoses reveals that the generalized anxiety disorder is an incorrect diagnosis because it is associated mainly with such physical symptoms as sleep problems, possibility to fatigue, etc (APA, 2000, p. 429). Panic disorder without agoraphobia is also incorrect for this case because it is impossible to check its symptoms in the patient. Posttraumatic stress syndrome is incorrect as well, as Mr. Petersen not merely avoids his job, but has reasons for this as he thinks his boss wants to kill him and all his colleagues are hostile to him.
Drawing front this, the three probable diagnoses allow developing the single correct one. Although the symptoms of acute stress disorder and paranoid personality disorder can be partly observed in Mr. Petersen’s behavior, the most correct diagnosis for him is social phobia, the symptoms of which are almost fully observed in Mr. Petersen’s daily activities and fears. In more detail, the acute stress disorder can be observed in Mr. Petersen as probably a result of his working problems, while the paranoid personality disorder can be assessed as the logical consequence of the acute stress disorder.
Finally, both disorders combined can be viewed as the grounds for the development of the social phobia. In simpler terms, Mr. Petersen experienced considerable mental pressure, the continuing character of which resulted in the paranoid ideas; finally, these experiences and ideas conditioned a social phobia in this patient.
Step3: Diagnostic Criteria
The criteria for diagnosing the established disorders, i. e. acute stress disorder, paranoid personality disorder, and social phobia, in Mr. Petersen are the symptoms of the issues observed in the patient’s behavior. Thus, the major typical feature of the social phobia is the fear that people experience when exposed to common social situations like daily communication in the street, transport, or at work.
This fear is usually groundless, although the people suffering from the social phobia attribute it to the negative activities, like judgments or physical violence, which the society can resort to in their respect (APA, 2000, p. 431). Obviously, Mr. Petersen displays this symptom, which is persistent and uncontrollable for him.
At the same time, Mr. Petersen displays the sings of acute stress disorder, which include the stress situation in the background and the conscious, or unconscious, avoidance of similar situations. According to APA (2000), such a symptom is a mark of acute stress disorder, as a person is in a state of permanent stress although there are no factors that would condition it. Thus, the diagnosis that Mr. Petersen suffers from the acute stress disorder is also correct. Another proof of the correctness of the above diagnosis is that the acute stress disorder can serve as a background factor for social phobia.
Finally, facts also allow arguing about Mr. Petersen suffering from and the paranoid personality disorder. He is suspicious of his colleagues and his boss, is afraid of attending his job, faces horror while having to be in the stress alone and while seeing those cars in the street. So, the proof of acute stress disorder, paranoid personality disorder, and social phobia in Mr. Petersen is that his mental issue is not accompanied by disorders like sleeping or eating ones, which is a sign of the opening stage of the social phobia conditioned by acute stress disorder and paranoid personality disorder.
Step 4: Multiaxial Evaluation
Axis 1: Acute Stress Disorder:
Social Phobia.
Axis 2: Paranoid Personality Disorder:
Delusional Disorder.
Conclusion
The symptoms that can be observed from the case of Mr. Petersen allow diagnosing his mental issue as the social phobia, which is complicated by the acute stress disorder and paranoid personality disorder. The correctness of the diagnosis is supported by the matching of symptoms displayed by Mr. Petersen and the symptoms that characterize the social phobia according to the data presented in the Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR by APA (2010).
Reference List
APA. (2000) Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. American Psychiatric Publishing, Inc., 4th Ed.