Phobias : Social Phobia, Agoraphobia

by Food and Drug Administration (FDA)

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Everyone's Looking at Me!

Social phobia is a complex disorder, characterized by the fear of being criticized or humiliated in social situations. There are two types of social phobias: circumscribed, which relates to a specific situation such as "stage fright," and generalized social phobia, which involves fear of a variety of social situations.

People suffering from social phobia fear the scrutiny of others. They tend to be highly sensitive to criticism, and often interpret the actions of others in social gatherings as an attempt to humiliate them. They are afraid to enter into conversations for fear of saying something foolish, and may agonize for hours or days later over things they did say.

"I always believed that everybody else knew the secret to enjoying themselves in social situations, that I was the only one who was so afraid," says Lorraine from Birmingham, Ala., who asked that her last name not be used. "For a long time, I avoided as many situations as possible, even talking on the telephone. After a while, the loneliness and boredom would overwhelm me, and I would try again. I wanted to have fun, but I never really enjoyed myself because of the anxiety I felt. I always believed that others were looking at me and judging me."

Many people with social phobia are so sensitive to the scrutiny of others that they avoid eating or drinking in public, using public restrooms, or signing a check in the presence of another. Social phobia may often be associated with depression or alcohol abuse.

Neurotransmitter-receptor abnormalities in the brain are suspected to play a part in the development of social phobias. Neurotransmitters are substances such as norepinephrine, dopamine and serotonin that are released in the brain. The substance then either excites or inhibits a target cell. Disorders in the physiology of these neurotransmitters are thought to be the cause of a variety of psychiatric illnesses.

Negative social experiences, such as being rejected by peers or suffering some type of embarrassment in public, and poor social skills also seem to be factors, and social phobia may be related to low self-esteem, lack of assertiveness, and feelings of inferiority.

Treatment can include cognitive-behavior therapy and medications, though no drug is approved specifically for social phobia. In addition to the anti-anxiety drugs and beta-blockers, medications may include the monoamine oxidase (MAO) inhibitor antidepressants Nardil (phenelzine) and Parnate (tranylcypromine), and serotonin specific reuptake inhibitors (SSRIs) such as Prozac (fluoxetine), Paxil (paroxetine), Zoloft (sertraline), and Luvox (fluvoxamine). Of the latter four drugs, Prozac, Zoloft and Paxil are approved for depression; Prozac, Paxil, Luvox, and Zoloft are approved for obsessive-compulsive disorder; and Paxil is approved for panic disorder.

Chris Sletten, Ph.D., a clinical psychologist and behavioral medicine specialist at the Mayo Clinic, says the use of SSRIs with behavior therapy is becoming more popular in the treatment of social phobia. Because there are fewer side effects associated with these drugs and a very low addiction potential, practitioners are more comfortable prescribing them. Plus, the antidepressant action of these drugs is helpful in treating patients who suffer from depression in addition to social phobia, he says.

"My therapist prescribed Prozac, and it has been an absolute godsend for me," Lorraine says. "After only a couple of months taking it, those voices in my head, the ones that always assured me that everyone was judging me — and finding me lacking — just seemed to shut up. I didn't feel high or drugged in any way. I felt like I always thought a "normal" person would feel. It's not a complete cure, of course. I still feel anxiety in social situations. But I don't avoid them as much. In fact, I actually pick up the phone now and ask friends to dinner, and I can relax enough to have fun. It's a whole new life for me."

The Wide Open Spaces

Agoraphobia comes from Greek, meaning literally "fear of the marketplace," but it usually is defined as a fear of open spaces. Sletten says it stems more from the fear of being someplace where you will not be able to escape. It is closely identified with panic disorder, and in many cases, agoraphobia is directly related to the fear of experiencing a panic attack in public.

A person with panic disorder suffers sudden bouts of panic for no apparent reason. These attacks can occur anywhere at any time. One minute everything is fine, the next the person is engulfed by a feeling of terror. The heart races, breathing comes in gasps, and the entire body trembles. The attack may last only minutes, but its memory is etched indelibly in the brain, and the anticipation of another causes almost as much terror as the attack itself.

People who suffer agoraphobia avoid places and situations where they feel escape would be difficult in case an attack occurs. This could be anywhere — the grocery store, a shopping mall, the office. As the fear of an attack increases, the agoraphobic's world narrows to only a few places where he or she feels safe. In the most severe cases, this is limited to the home.

Agoraphobia is the most disabling of all the phobias, and treatment is difficult because there are so many associated fears — the fear of crowds, of elevators, of traffic. As with social phobias, treatment involves behavioral therapy combined with anti-anxiety or antidepressant medications, or both. Paxil has received FDA approval for use in treating panic disorders with or without agoraphobia, and at press time, Zoloft was being considered for this additional use.

"The most important thing for people with phobias to remember," says Sletten, "is that phobic disorders do respond well to treatment. It's not something they have to continue to suffer with."

About the Author

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