Social Phobia is defined at DSM-IV-TR 300.23 as follows:
A. 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.
B. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.
C. The person recognizes that the fear is excessive or unreasonable.
D. The feared social or performance situations are avoided or else are endured with intense anxiety or distress.
E. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes with significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
F. In individuals under age 18 years, the duration is at least 6 months.
G. The fear or avoidance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., Panic Disorder With or Without Agoraphobia, Separation Anxiety Disorder, Body Dysmorphic Disorder, a Pervasive Developmental Disorder, or Schizoid Personality Disorder).
H. If a general medical condition or another mental disorder is present, the fear in
Criterion A is unrelated to it, e.g., the fear is not of Stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in Anorexia Nervosa or Bulimia Nervosa.
SAD is particularly responsive to the question because the diagnostic criteria for its application are imprecise even by DSM standards and it depends significantly on cultural criteria and interactions in culturally-mediated social situations. Epidemiologically SAD is the most common type of anxiety disorder with a lifetime prevalence of 7% to 13.3%. By and large it is a pathology of adolescence; 80% of cases occur before age 18 (Goldin et al., 2009). Teenage girls are particularly vulnerable (Rapee & Spence, 2004).
SAD implicates several different etiological factors. None of them are necessary or sufficient which is why an integrative model is the most appropriate one to follow in diagnosing its presence or absence. Even more so than other DSM disorders involving emotional dysregulation SAD is equifinal and multifinal.
SAD fundamentally involves a person’s emotional hyperreactivity to a social situation, possibly accompanied by cognitive distortions. There now is a large body of work on the neurophysiology of emotion. Illustrative is Antonio Damasio’s (2003) theory of “somatic markers.” Damasio theorizes that normal decision-making uses two complementary paths. One is cognitive. It prompts options for action, the anticipation of consequences related to particular outcomes, and reasoning strategies. Stimuli are processed through the thalamus to the cerebral cortex and through the hippocampus before reaching the amygdala. The second is emotional. It is far more visceral. Based on previous experience it marks options and outcomes with a positive or negative signal that narrows the decision-making space and increases the probability that the action will conform to past experience. This emotional signal results in “gut feelings” and intuitions that operate entirely beneath the radar of consciousness. Stimuli are processed directly from the thalamus to the amygdala, short-circuiting the cerebral cortex and the hippocampus. Since there is less processing involved, they arrive at the amygdala first and therefore primarily affect emotional response. (1)
Damasio supports his work with brain imaging and genotyping techniques. There also are neurochemical correlates to the activity he describes. SAD’s pathogenesis likely involves reuptake of serotonin transporter proteins (e.g., 5-HT and 5-HTT) and density of dopamine receptors. While it is unlikely it ever will be possible to correlate specific emotions with specific neurochemicals we now are on the verge of being able to identify various neuropeptides with the presence of emotional states or moods. Core limbic brain structures (such as the amygdala and the hippocampus) contain 85% – 95% of the neuropeptide receptors involved in the expression of emotion. Opiate receptors for example are densest in the frontal lobes, which in turn share many connections with the amygdala (Pert, 1997).
Damasio and related predecessors and successors such as Eric Kandel (2006) and Joseph LeDoux (1996) in effect reverse the sequence of events hypothesized by CBT, which is that “thoughts” precede feelings and behavior (Albert Ellis, Aaron Beck, David Burns, Martin Seligman). It seems far more likely the former school is correct.
According to social psychology one’s concept of self primarily is culturally-based (Baumeister, 1999). Culture shapes personality, emotion, motivation and even ways of perceiving the world. Markus & Kitayama (1991) for example studied differences between the relationships, roles and social obligations of Western cultures versus Asian ones. They concluded that Western societies are more concerned with individualism, freedom of expression and self-actualization. Asian societies on the other hand emphasize collaboration, cooperation and mutual inter-dependence. It stands to reason that the sociocultural dynamics of self-construal play a significant role in the development of sociologically-based pathologies such as SAD.
The best way to determine the heritability of personality traits is by analyzing similarities and differences between identical and fraternal twins raised in the same family environment. These studies show there is a genetic predisposition for SAD. One large twin study found concordance rates of 24.4% for female monozygotic twins versus 15.3% for dizygotic twins. Another study concluded the rates of disorder in relatives of proband patients were higher compared with base rates among nonaffected control samples (Kashdan & Herbert, 2001). While gender is a significant predisposing factor (supra) there are no studies assessing the influence of sibling position.
Adolescence is a critical stage in personal development. Adolescents frequently are preoccupied about peer acceptance and body image. They are in the process of forming their identity and developing social skills. They differentiate themselves from their parents, adapt gender-appropriate behaviors, develop romantic (and sexual) interests, and construe a sense of self. They learn how to interpret reality. They also discern their role in social structures and hierarchies (Rao et al., 2007). Significantly this also is a period of enhanced neural plasticity. It stands to reason that a maladaptive family environment (with a high level of parental criticism and control) will predispose one to SAD. So will victimization experiences, peer-group rejection, or experiencing panic in perceived social-evaluative settings (such performing in front of a class).
SAD’s fundamental pathology is a desire to present oneself favorably to others, coupled with the perception that one is unable to do so. People who suffer from SAD believe that no matter what they do they will predictably be rejected or negatively evaluated by others. In this respect they develop a temperamental style, the fundamental characteristics of which are avoidance, social inhibition and shyness.
If one sets unrealistic social standards and cannot select attainable social goals then one develops social apprehension. From a psychodynamic standpoint it is reasonable to assume that in a challenging social situation somebody with SAD reflexively shifts their focus of attention towards their own anxiety. They come to view themselves negatively as social objects and overestimate the negative consequences of social encounters. They believe they cannot control their emotional responses and that they cannot cope effectively with social situations. As a result they develop maladaptive strategies of relating to peers and events in the world. They revert to avoidance and safe-haven behaviors. Following social encounters they engage in extensive rumination (Hofmann, 2007). These factors then converge with others to create an overwhelming feeling of other-worldliness, lack of accommodation and strangeness in one’s own environmental milieu.
Role of the Media
In conclusion I would like to suggest that one of the main contributors to SAD is the role of the media in contemporary Western society, both tabloid and mainstream. The media offers personalities such as Paris Hilton, Britney Spears and Lindsay Lohan as role models or icons for popular consumption. In those capacities Paris, Britney and Lindsay powerfully affect the common meanings we take for granted – the ways in which we “attune” ourselves to modern society. In fact the best way to refer to them might be as “agents of common meaning” because they pervasively influence (for example) what is erotically appealing or our perception of Gen Y women. They have absorbed the prevailing cultural ethos of the time and processed it – translated it, synthesized it, distilled it – and then fed it back to the rest of society (incidentally, consuming themselves in the process).
As female role models their influence is predominantly negative. The at-risk population for SAD is adolescent girls who become fascinated with their various contretemps and use them as paradigms to structure their own behavior. They experience a form of resonance with them – properly understood, a form of transference in almost a psychoanalytic sense. Figures like Paris, Britney and Lindsay recruit constituents and bring them into a condition of attunement when they speak or act in such a way as to make them sensitive to the feel of things in their world, thereby focusing their environmental interactions, psychological propensities, even their concept of self (Spinosa, 2000). This power is neither subjective nor objective – it does not reside in either a subjective response to or in them as people or personalities. Rather it is a process of the mutual interaction between subject and object and the creation of a transitive relationship between the two.
It’s important to note that people like Paris, Britney and Lindsay have no discernible aptitudes, qualities or features that qualify them for this role. Their primary skill is to activate emotional responses, daydreams and other forms of fantastical ideation. By deploying their personality, they transform an ordinary geographic location – say, a teenage girl’s bedroom, which is a humdrum, mundane place (in Cartesian space) – into one sizzling with excitement, potential and opportunity (when perceived as existential space). They act as surrogates for unsatisfactory family and social relationships. They unfold a clearing, which in turn permits people, places and objects to be seen as something other than what they are, interpreted in the semiotics of modern pop culture.
The media in turn offers up personalities such as Paris, Britney and Lindsay to the public in order to service the public’s insatiable demand for scandal, gossip, curiosity, perversity, titillation, and other prurient behavior. It solicits its participants to experience a cheap vicarious thrill by perusing and experiencing its wares. All the time pandering to a lowest common denominator of public taste and opinion, in order to achieve the broadest possible circulation and exposure, amortize its fixed economic cost, and achieve profitability. Without personalities such as Paris, Britney and Lindsay those structural elements would wither. Which is to say, if Paris, Britney and Lindsay were not there to service the media’s architectural framework, “the media,” understood as an organism requiring constant servicing in order to maintain its infrastructure, would invent them. Paris, Britney and Lindsay simply are the deer caught in the headlights. They pose fetchingly and assume their allotted roles, bewildered at why they are not regarded as anything more than zombies. They only are temporarily luminescent, at a certain moment in space and time. They only are as in control of their celebrity as (speaking figuratively) the culture-gods will allow. In the meantime however they have significant influence over a developmental cohort that is seriously at risk.
(1) Though confusingly Damasio also believes that one does not “have” an emotion unless one can cognitively construct a mental representation of the somatic state. Thus for example “pain” is the perception of a certain class of sensory signals, as opposed to “suffering” which is the feeling that comes from perceiving the emotional reaction to that perception. The reason why this is dubious is because pain is pain; it is not culturally variable or cognitively mediated. Damasio would say, “you just think you’re in pain” without conceding that you actually are.
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