Social Phobia and Perfectionism: Theories, Types and Models

Published Date: 18 Apr 2018

Contents (Jump to)

Abstract

Chapter 2 – Epidemiology of Generalized and Specific Social Phobia

Chapter 3 - Etiological Hypotheses and Findings

Chapter 4 - The Behavioral Models of Social Phobia

Abstract

Derived from the Greek word for ‘fear’, a phobia represents a ‘fight or flight’ response that is described by the American Psychiatric Association as “… an uncontrollable, irrational and persistent fear of a specific object … situation …activity” (Phobia King, 2006). Social phobia, which is known as ‘phobia des situations socials’, was first termed by Pierre Janet (1903) whereby he described patients that demonstrated and or had a fear of being observed as they were either speaking, writing or performing other functions.

Hurka (1993, p. 3) tells us that perfectionism is a “… moral theory (that) starts from an account of the good life ...” Hurka (1993, p. 3) goes on to add that the ‘good life’ develops humanity properties to a high degree and or thus realizes what is important as well as central to human nature. The history of perfectionism can be traced back to Aristotle’s conception of eudaimonia, the good life, and his belief that political structures and politics should thus promote this in its individuals (Aristotle and Irwin, translator, 1999, pp. 1-4). Other notable individuals throughout history noted for their devotion to perfectionism in varied forms are Thomas Aquinas, Francis of Assisi, Clement of Alexandria as well as Jesus who stated in his Sermon on the Mount said “Be ye therefore perfect, even as your Father which is in heaven is perfect” (MainBelieve.com, 2006).

The dictionary defines ‘perfectionism’ as “a tendency to set rigid high standards of personal performance” (free dictionary.com, 2006). In psychology, perfectionism represents the belief that this is something which should be strived for and in its pathological sense it represents the unhealthy belief anything that is not perfect is unacceptable (coping.org, 2006). It also represents not making mistakes and striving to be the best, as well as the attitude that what one attempts needs to be done perfectly and a habit that is developed in one’s youth keeping one consistently alert to imperfections as well as weaknesses and failings in one’s self as well as others (coping.org., 2006).

This paper shall examine these two areas, delving into their individual specificities as well as linkages and commonalities, revealing opposing views concerning the diagnosis and causes of these afflictions and the views which seemingly share many similar aspects.

The term, phobia, is generally classified by psychiatrists and psychologists into three basic categories (Bourne, 2005, pp. 33-42) (Kessler et al, 2005, pp. 629-640):

• Social Phobias
• Specific Phobias
• Agoraphobia

Isaac Marks (1969, p. 362) advises that the syndromes representing shyness, social anxiety along with social avoidance had been described as early as Hippocrates. Marks (1969, p. 362) reported that individuals with this affliction “… through bashfulness, suspicion, and timorousness, will not be seen abroad, … he dare not come in company, for fear he should be misused, disgraced, overshoot himself in gestures of speeches … he thinks every man observed him …” Mark’s (1969) views and analysis is amplified by Heimberg et al (1995, p. 96) who state that individuals having this affliction “… experience excessive fear of being humiliated or judged negatively in social or performance situations.”

Juster et al (1996, pp. 403-410) state that perfectionism is linked to social phobia and is also related to anxiety as well as depression. Frost et al (1990, pp. 449-468) ‘Multidimensional Perfectionism Scale assesses perfectionism in terms of it being a phenomenon that consists of three segments:

• Self oriented,

is described as the tendency for a person to seek as well as set high self standards concerning performance,

• Other oriented,

is the tendency for a person to expect others to be perfect in their performance(s),

• Socially prescribed

represents the tendency that a person expects others to think and or believe others expects them to be perfect in their performance.

Frost et al (1990, pp. 449-468) define perfectionism as a malady that entails excessive self criticism that is associated with the setting or belief in higher personal standards and the allied concern of meeting expectations on a social level. The preceding also includes the tendency for excessive self criticism that is associated with their higher personal standards as well as their concerns for meeting what is, in their internal view, social expectations, along with the excessive focus concerning organization as well as neatness and doubts with regard to their effectiveness in their actions (Frost et al, 1990, pp. 449-468).

The preceding describes the inter relatedness between social phobia and perfectionism that will be explored herein which shall examine each aspect and their links. Perfectionism has roots in aspects of social phobia, as well as the reverse being true. These two afflictions sometimes are present in individuals having social anxiety and are generally conditions that have their roots in early childhood. In examining these two areas, attention shall be paid to their individual diagnosis areas, signs, conditions and foundations, as well as the linkages between the varied forms of social phobia and perfectionism. This examination has been organized to set forth the preceding via segmenting the foregoing into areas that identify and explain the aspects of social phobia as well as perfectionism revealing the foregoing linkages and commonalities.

The Diagnostic and Statistical Manual of Mental Disorders (2000, pp. 154-156) defines social phobia as a persistent and marked fear of one or more performance and or social situations whereby an individual is exposed to people that are unfamiliar and thus subject to scrutiny by others whereby the person in question thus feels (fears) that they might or will act in such a manner, and or exhibit anxiety, which will either be embarrassing and or humiliating. The preceding concurs with Heimberg et al (1995, p. 96) who stated that individuals having this affliction “… experience excessive fear of being humiliated or judged negatively in social or performance situations.” Social Anxiety Disorder represents the third highest mental health care problem globally and afflicts an estimated seven percent of the world’s population at any given point in time, with a thirteen percent chance that it will affect any one of us during our lives (Social Phobia / Social Anxiety Association, 2005).

The Diagnostic and Statistical Manual of Mental Disorders (Social Anxiety Institute, 2006) defines social phobia as:

• A persistent fear of either one or more performance and or social situations whereby an individual is exposed to potential scrutiny by unfamiliar people and that they, the person in question, will act in a manner, and or show anxiety symptoms, which will be either humiliating and or embarrassing.
• That the exposure to the situation in almost all situations results in anxiety that can and usually does take the form of what is termed as being based upon situations and thus pre-disposed or bound Panic Attack.
• The individual experiencing the symptoms of social anxiety recognizes that they have a fear that is excessive and or unreasonable.
• The feared situations are thus avoided by this type of individual or are endured under intense distress and anxiety.
• The individual’s avoidance, distress and or anticipation of the feared situation thus significantly interferes with this person’s normal routine, functioning and an occupational and or academic manner, their social activities /relationships, and or they experience a marked distress concerning having the phobia.
• In those persons 18 years of age or less the general period of the duration of such an experience is generally six months.
• That the fear and or avoidance of the aforementioned is not due to the direct physiological effects of either drugs or medications, and or a general medical condition which could be accounted for by virtue of another mental disorder.

The preceding diagnostic criteria provide a guideline, however they do not substitute an analysis and or visit to a mental health practitioner (Ohio State University, 2005). Examples of diagnostic criteria historical facets are described as (The Diagnostic and Statistical Manual of Mental Disorders (2000) :

• patients having a hypersensivity to criticism, along with a difficulty in being assertive, and or low self esteem as well as potentially inadequate social skills.
• They avoid speaking in front of groups of people, with the preceding potentially leading to difficulties in either work or education.
• In order to reach a diagnosis concerning social phobia in children the situation calls for observing their interactions with peers as opposed to observing them with adults, which represents a different context.
• In reaching and or considering a diagnosis, clinicians should seek to consider what is termed the co-morbid diagnosis represented by avoidant personality disorder when an individual exhibits generalized social phobia.
• It has been determined that a high percentage of individuals with social phobia have or have developed alcohol and or sedative abuse that aids them in tolerating social situations, however the preceding is not universally true.

Symptoms and characteristics of social phobia consist of one, some or all of the following (Helpguide.org, 2006):

• Avoidance,

Whereby an individual will go to great lengths to avoid the prospect of socializing based upon the fear that they will by either perceived in an adverse manner or be humiliated. If left untreated this condition can accelerate or develop into the condition known as agoraphobia.

• Low Self Esteem,

Represents a condition which most individuals who are afflicted with social phobia experience and it is marked by the fact that the longer one remains in this condition the more it affects one’s sense of self worth.

• Depression,

A common outgrowth of having a social anxiety disorder is that the feelings of extreme anxiety as well as the sense of the lack of control over one’s life can very well lead to depression.

• Alcohol and or Drug Abuse,

It has been estimated that one fourth of the individuals with this condition abuse either alcohol and or drugs usually starting to alleviate the pain and then accelerating into wholesale abuse.

• Academic and Occupational Difficulties,

The condition has been known to interfere with one’s ability to function at work as well as academically and can as well as has presented obstacles in these regards.

• Interpersonal Difficulties,

Statistics and studies have determined that as a result of this condition, individuals are prone to be less likely to marry and also have fewer friends as well as social support.

The symptoms represented by social phobia defer in respect to children and adults as generally represented by the fact that in the earlier stages children tend to fail to achieve their levels, and adults show declines from prior functioning levels (Biederman et al, 2001, pp. 49-57) (Stein, 2001, pp. 28-39). The symptoms as manifested by children frequently are observed as temper tantrums, clinging to parents, crying and interactive aspects such as the refusal to talk to others (Biederman et al, 2001, pp. 49-57). In adults, the symptoms include a number of physical anxiety signs along with behavior and attitude manifestations (Bruce and Saeed, 1999, pp. 2311-2322):

• blushing, nausea, dry mouth, sweating, tremors and other similar types of anxiety indicators,
• difficulty as represented with self assertion,
• an extreme sensitivity concerning criticism, negative evaluations and or rejection,
• an intense preoccupation and concern regarding the responses as well as reactions of other individuals,
• increased fears regarding the prospect of being either humiliated and or embarrassed,
• and the avoidance of situations that cause or create fear and or anxiety

Olfson et al (2001, pp. 521-527) advise that the diagnosis of social phobia is generally based upon the history of the patient, along with reported symptoms. In keeping with an accurate diagnosis the physician may also utilize what is termed a diagnostic questionnaire which aids in ruling our other possible phobias, anxiety orders as well as major depression (Olfson et al, 2001, pp. 521-527). Screening and testing procedures for adults suspected of suffering from social phobia represents a problematic assessment as some general screeners, for example the Structured Clinical Interview does not include questions that are related to social phobia and such a test can take upwards of twenty-five minutes (Bruce and Saeed, 1999, pp. 2311-2322). In addition to the foregoing there are instruments such as the Fear of Negative Evaluation Scale as well as the Social Avoidance and Distress Scale which are long and in general are useful more in the measurement of therapy progress (Bruce and Saeed, 1999, pp. 2311-2322). Interestingly, physicians have found that the utilization of a selected group of questions added to a general screening questionnaire has proved helpful in their detection of this condition; examples of the preceding are as follows (Olfson et al, 2001, pp. 521-527):

• Are feeling embarrassed or feeling as if you look stupid among your worst fears?
• Does the fear of embarrassment cause you to avoid doing certain things and or speaking to people?
• Do you avoid situations where you could be or are the center of attention?

The diagnosis of children takes into account additional factors as a result of their age. Such includes the fact that they do not have the options of avoiding most situations which frighten them (Bogels and Zigterman, 2000). The preceding provides an explanation as to why children are less likely to be able to provide why they are thus anxious. Bogels and Zigterman (2000) advise that thus it is important for physicians to therefore evaluate their capacity concerning social relationships with individuals the child knows, as well as assess their interactions with those in their peer group for signs of social phobia indications in addition to their behavior with and around adults. Examples of the procedural aspects for the preceding entail the utilization of what are termed the Anxiety Disorders Interview Schedule for Children, the Liebowitz Social Anxiety Scale for Adolescents and Children, the parent completed Child Behavior Checklist and the Teacher’s Report Form (Bogels and Zigterman, 2000).

Social phobia differs from shyness in that the former condition causes individuals to avoid the anxiety producing situations by all means, whereas shyness can be attributed to a number of broad classifications as it represents different things to differing individuals. Crozier (1990, p. 2) states that “… shyness is not a precise term. It refers to feeling awkward or uncertain in social situations.” Crozier (1990, p. 2) continues that shyness is associated with being and or feeling self conscious, the “… excessive monitoring of one’s behaviors and over rehearsal of potential utterances” “The shy person feels anxious and often … appears anxious to others” (Crozier, 1990, p. 2). Berent and Lemley (1994, p. 9) state that the word itself is “… too general to be of much help in identifying a problem and solving it” and that shyness has varied degrees of complexity and intensity from extremely mild and applicable in a few situations, to more perverse whereby it can thus be termed as a social phobia. Berent and Lemley (1994, p. 10-11) advise us that shyness and social anxiety are closely related and in both instances as they represent a “… learned response to social interaction”. They go on to explain that shy and or socially anxious individuals “… may hesitate to pursue the things he or she is interested in, or even begin to avoid situations that cause nervousness or anxiety”. Thus, the spectrum entailing shyness ranges from relatively few instances to actual social phobia. Shyness is not necessarily a criterion for social phobia in that individuals having a social anxiety disorder can be comfortable with certain types and or many differing people; however, they feel intense regarding certain specific situations (CNN.com, 2006).

Social anxiety disorder is termed as a social phobia, and or as a psychiatric anxiety disorder which entails overwhelming anxiety as well as excessive self consciousness concerning everyday situations (Crozier and Lynn, 2001, pp. 18-24). Individuals with this affliction often exhibit an intense, chronic as well as persistent fear that they are being watched along with being judged by others, thinking that they might be either humiliated and or embarrassed as a result of their own actions (Crozier and Lynn, 2001, pp. 18-24). The distinction between generalized and specific social anxiety is indicated as those having the generalized type have significant distress with most, if not all social type situations, whereas specific, as the word implies, refers to such situations with specific connotations. Examples of the preceding are evidenced by glossophobia, which is the fear of speaking or performing in public, scriptophobia, which is the fear of writing in public, or paruresis, the fear of utilizing public restrooms (Bruch, 1989, pp. 37-47).

Sometimes referred to as anxious personality disorder, avoidant personality disorder is recognizable as a result of a pattern of social inhibition that is pervasive (Mental Health Matters.com, (2006). The foregoing description includes feelings of inadequacy as well as an extreme sensitivity regarding negative evaluation, and people with this affliction very often consider that they are socially inept and or unappealing on a personal level, thus they avoid situations entailing social interaction due to a fear of either being humiliated and or ridiculed. In general, avoidant personality disorder is usually first noticed in one’s early childhood and is usually associated with either a real or perceived rejection by one’s parents and or peers in that period (Dayhoff, 2000. pp. 29-38). The Diagnostic and Statistical Manual of Mental Disorders (2000) is widely utilized in diagnosing avoidant personality disorder and is identifiable by four or more of the following (Rettew, 2006):

1. Avoidance of occupational activities which involve degrees of significant interpersonal contact as a result of fears regarding criticism, rejection and or disapproval.
2. Being unwilling to get or be involved with someone unless being certain that one will be liked.
3. Through showing restraint in intimate relationships as a result of fearing shame or ridicule.
4. Being preoccupied in social situations with being criticized and or rejected.
5. By being inhibited in new situations entailing interpersonal relationships due to feelings of being inadequate.
6. Viewing one’s self as inept socially, being unappealing and or inferior to other people.
7. Being reluctant to take on personal risks and or to engage in new activities as such could or might thus prove embarrassing.

Comorbidity is defined by the American Heritage Dictionary (2006) as “A concomitant but unrelated pathological or disease process” with in the context of social phobia means the presence of either one or more such disorders as well as the primary disorder. Schuckit et al (1990, pp. 34-41) state that it represents the disorder that occurred first or the one representing the symptoms that are most dominant, which Klerman (1990, pp. 13-17) refers to as the primary disorder. The critical issues in dealing with comorbidity represents the proper and correct analysis of the varied disorders and understanding which one is the prevalent or primary one as well as the order, and impact of the associated disorders in which there are combination and their influences on the patient. Biederman et al (1991, pp. 565-577) indicates that there are several hypotheses which may be utilized to account for the true patterns of comorbidity and critical issues:

1. that comorbid disorders are not distinct entities, they represent expressions termed phenotypic variability in the same disorder,
2. that each comorbid disorder is a distinct as well as separate entity,
3. that these disorders share vulnerabilities that are common, represented by genetic and or psychosocial,
4. that these disorders have a distinct subtype, or genetic variant, and a heterogeneous disorder,
5. that one syndrome represents what is termed an early manifestation, and
6. that the development as represented by one syndrome can increase the risk of comorbid disorder.

Caron and Rutter (1991, pp. 1063-1080) advise that the failure in understanding and attending to comorbidity patterns can thus cause researchers and physicians to come to misleading conclusions thereby creating negative intervention results. Achenbach (1990. pp. 271-278) warns us that the appearance of comorbidity might develop as a result of varied conceptual and or diagnostic models which can result in boundaries between disorders that are inappropriate and can potentially lead to the tendency for comparison of one diagnosis against normal individuals as opposed to other diagnosis. He warns that there is a need for well defined diagnosis in the instance of this occurrence, comorbidity (Achenbach, 1990. pp. 271-278).

Chapter 2 – Epidemiology of Generalized and Specific Social Phobia

Termed the study of the scientific factors which affect the illness and health of populations, epidemiology serves as the logic and foundational basis for interventions that are made in the interests serving public health, along with preventive medicine (Rothman and Greenland, 1998, p. 29). The field is regarded as a cornerstone in the methodology of health research for the public sector and has the reputation of being highly regarded in the field of what is termed evidenced based medicine for the identification of disease risk factors and the determination of optimal treatment in the approaches representing clinical practice (Rothman and Greenland, 1998, p. 29). Morabia (2006, p. 3) explains that epidemiology, in terms of the public, represents a medical discipline dealing with the “… large scale outbreaks of infectious diseases”. Chronicled in “Epidemiologia Espanola” spanning a period of thirteen centuries, Villalba, a Spanish physician, complied a listing of epidemics as well as outbreaks which helped to define the term (Morabia, 2006, p. 3). Even though the practice extends back to the 16^th century, as a scientific discipline it is relatively recent. The mission of epidemiology has “… historically been to identify determinants of human diseases … mostly at the population level” (Morabia, 2006, p. 3), and this holds true today.

Epidemiology is prevalent in today’s communities under the term ‘Community-oriented primary care’, or COPC) and represents a systematic health care approach that is based upon principles of epidemiology (Rhyne et al, 1998). Usage has demonstrated that COPC, representing primary care, health promotion and preventive medicine has positive community benefits on a global basis (Rhyne et al, 1998). The methodology, ‘Community-oriented primary care’, entails the process of seeking to improve the health of a community utilizing the aforementioned principles, public health, primary care and epidemiology, which traditionally has been used to describe the health care system whereby a community and or targeted population is thus the focus (Wright, 1993). The American Public Health Association description of Community-oriented primary care states that it represents a “… systematic process … identifying and addressing … health problems of a defined population” and that it thus can be implemented via the resources which are already available within most communities (Rhyne et al, 1998). It, COPC, represents a team comprised of health professionals, along with community members, who work in partnership over a long duration in treating and diagnosing patients in a community in a similar manner as does a primary care doctor, and while primary care physicians are not needed for or in every project, they nevertheless need to be involved in the process (Rhyne et al, 1998).

The availability of epidemiologic studies from Europe, Asia and the United States over the past twenty years has permitted a clearer and sharper picture of social phobia with respect to its incidence, severity, prevalence and other correlations (Zucchi et al, 2000, pp. 17-24). The preceding historical base of epidemiologic information helps to provide a comprehensive reference point concerning the age of onset and incidence of social phobia from a broad population cross section. Studies conducted indicate that social phobia is the most prevalent of anxiety disorder (Carta et al, 2004), as shown by the following:

Table 1- Lifetime Prevalence of Social Phobia in the

General Populations of Europe and the United States

(Carta et al, 2004)

The preceding show the lifetime prevalence of Social Phobia of 2.2% across the board, representing 1.5% for males and 2.8% for females.

Table 2 – Lifetime Prevalence of Social Phobia According to Age and Sex

(Carta et al, 2004)

The preceding Table represents studies conducted in Europe and the United States for the countries indicated with OR representing the degree of associated disorders that were observed regarding frequency in the populations that were not affected by social phobia.

Table 3 – Lifetime Comorbidity of Social Phobia

(Carta et al, 2004)

* Where p is less than 0.001

The preceding Table represents the rate of comorbidity concerning major psychiatric disorders which were observed in the overall general populations of Europe and the United States, along with the degree of associated disorders (OR) in the reported populations which were not affected by social phobia. The mean age representing the onset of comorbid DE represented 6.5 plus or minus 6.6 years, whereas GAD represented a mean of 4.3 plus or minus 7.8 years later (Carta et al, 2004).

In a study conducted by the Johns Hopkins Medical Institute, they found six regions in the human genome that very well could play a role with regard to the susceptibility of obsessive compulsive disorder (Johns Hopkins Medical Institute, 2006). The study added to the growing evidence of a genetic basis for obsessive compulsive disorder and thus its inheritability through the finding of genetic markers, or what are termed similarities, in the genomes of individuals with obsessive compulsive disorder as represented by six significance regions within the genome that are on five differing chromosomes which appeared to be linked to obsessive compulsive disorder (Johns Hopkins Medical Institute, 2006). Dorak (2006) advises us that genetic epidemiology is related to and overlaps molecular epidemiology and that the epidemiological evaluation aims to seek the detection of the inheritance pattern regarding a disease, localize it and find the marker that is associated with its susceptibility. Dorak (2006) states that the steps in genetic epidemiologic research are:

• the establishment of the fact that there is a genetic component concerning the disorder,
• establishing whether there is a relative size of the potential generic effect in consideration of the other possible sources of disease risk variation,
• and lastly the identification of the gene or genes that are thus responsible for the component of the genome

Dorak (2006) further advises that the preceding can be achieved through the utilization of family studies, which includes comparisons of twins, as well as associative studies as represented by the population and he further advises that the following represent general methods which are employed:

1. Genetic Risk Studies

This seeks to find the contributory aspects of genetics as opposed to that as represented by the environment to the trait and it requires the utilization of family based and or twin, adoption studies.

2. Segregation Analysis

This aspect seeks to determine what the genetic component looks like and the transmission model of the genetic trait. Its analysis requires the utilization of multi generations of family trees, preferably using more than one affected family member.

3. Linkage Studies

This aspect seeks to determine the location of the gene(s) and screen the entire genome using parametric and or nonparametric methodologies as represented by allete sharing, which are sibling pairs that are affected. The preceding makes no assumptions concerning the mode of inheritance, disease allele frequency as represented by the parameters. The principle of linkage seeks to determine the cosegregation regarding the two genes.

4. Association Studies

Through this methodology the study seeks to determine the allele associated with the susceptibility of the disease. It represents the principle concerning the coexistence of the marker on the same chromosome regarding individuals that are affected, also termed linkage disequilibrium.

Research focusing on the brain, more specifically the section termed amygdale, is based upon this section serving as the area that processes sensory signals that are incoming (NIMH, 2005). Said signals indicate whether a threat is present and thus triggers a fear or anxiety response. There exists other research that centers on the hippocampus which also is responsible for the processing of traumatic and or threatening stimuli, explaining why people with certain phobias have what are termed as flashbacks. Clues regarding individuals that have a higher incidence of social phobia generally are found to be associated with comorbid disorders, and are higher among individuals that exhibit shyness and other extreme personality traits, including perfectionism (Stein et al, 2001). Other clues represent traits that have been and or still present from childhood along with a demonstrated history, comorbidity as well as individuals from lower socio economic groups (Stein et al, 2001). The preceding rests in the fact that all and or some of the preceding are shown and or manifested over a period of time and are observable, as are associated other social phobias.

Research by neuroscientists is increasingly solving the mysteries of the brain, along with molecular biologists, in understanding how and what which genes do. While still fragmentary, the base of knowledge has been and is expanding at exponential rates regarding genes and their alleles which affect a behavioral pattern or contribute to same (Murray, 2000, p. 46). Research is uncovering the manner in which genes work in combination and their extremely complex and complicated hormonal and neural processes which affect and contribute to behavior (Murray, 2000, p. 46). An analysis of where molecular genetics is today is a subject that could change as early as tomorrow morning considering the breakthroughs and discoveries being worked upon and made, thus any such discussion by its nature is general and forward looking rather than dogmatic. Researchers have found that there are statistically different genetic codes that separate males from females as well as differing cultural groups, using differences of the French from the British, employed and unemployed, those who practice a religion on a regular basis as opposed who have lapsed into non observance (Murray, 2000, p. 46). Research suggests that some genetic responses are learned as well as inherited thus contributing to the former multiple aspects of gender, socio economic and cultural aspects (Murray, 2000, p. 46). Murray suggests that as genetic engineering progresses we shall be able to amplify human behavior and program offspring by sex, height, intelligence and other characteristics.

Murray (2000) points out that various studies utilizing animals has seemingly indicated that environment represents a stronger correlation upon behavior that do genes, pointing to studies entailing baby rats. In such studies it was determined that the strong maternal behavior in baby rats exhibited a tendency to breast feed having an arched back and to groom frequently and that such is passed on without genes being the cause (Murray, 2000, p. 46). Beiderman et al (1991, pp. 333-348) suggests that the development of anxiety in early childhood may possibility be genetically medicated as a result of family oriented anxiety disorders affecting them, thus the correlation to environmental influences in human beings. The overall findings, as suggested by Beiderman et al (1991, pp. 333-348) states that it is possible anxiety disorders might be genetically influenced regarding adults, however it is strongly suggested that such is a result of environmental childhood and or adolescent influences. Beiderman et al (1991, pp. 49-57) advise that there is little that is known regarding childhood anxiety genetics, and that what is known regarding behavioral inhibition has been as a result of linkages to anxiety disorders in childhood. Thapar and McGuffin, 1995, pp. 439-447) caution us that direct research regarding this aspect has been inconclusive. Barnhill (2004) states that the study of behavioral phenotypes, which focuses upon the relationship between behavior and genes, has found that while genes for many types of inherited disorders thus far has been identified, the research regarding the search representing candidate genes that are responsible concerning psychiatric disorders has been hampered as a result of their clinical heterogeneity. Barnhill (2004) continues that thus the genetic models regarding psychiatric disorders have therefore relied upon the studies of family pedigrees, linkage studies with known biological markers and, twins. A study conducted by Stein et al (2000, pp. 1046-1052) within a community was undertaken with the following objectives:

1. identification of the prevalence of social phobia in the sample (community),
2. ascertain the range representing functional impairments that were attributable to social phobia,
3. identification of social phobia subtypes, if any

From a total of 1956 subjects in Winnipeg, Manitoba and Alberta Canada, the findings were as follows (Stein et al, 2000, pp. 1046-1052):

1. the percentage representing no social fears were 60.4%,
2. those in the sampling with 1 to 3 social fears represented 27.8%,
3. those within the sampling with a number of social fears, 7, represented 3.4%,
4. the DSM-IV diagnosis representing social phobia was 7.2% with a median of three and a mode representing five social fears.

The study also attempted to subtype the individuals utilizing DSM-IV social phobia with the attempted classifications based on Stein et al (2000, pp. 1046-1052):

1. the number of fears,
2. the content of fears, for example speaking versus other fears, etc.

It was found that (Stein et al, 2000, pp. 1046-1052):

1. social fears represent a common occurrence, however they reach a diagnostic threshold at around 7.2%,
2. that functional impairments are proportionate to the fears reported, and that
3. valid phenomenological subtyping regarding social fears was not feasible.

Judd (1994, pp. 5-9) advises that as an anxiety disorder, social phobia typically is experienced during childhood and adolescence, with the onset being rare beyond the age of 25. DiNardo et al, 1990, pp. 308-312) indicate that without treatment, that the clinical course of anxiety disorders, social phobia, are often unremitting as well as chronic, and that depression as well as other anxiety disorders are usually associated with the affliction. Yates and Reich (1988, pp. 72-75) point out that varied research conducted on the etiology of social phobia seemingly indicates that it might be the result of varied biological as well as environmental factors, which Hugdahl and Ost (1981, pp. 439-447) point to the fact that anxiety disorders can be a result of environmental causes, such as a traumatic social event whereby its effects result in a fear conditioning to social stimuli. Biederman et al (1994, pp. 10-16) concur with the preceding, and suggest that the condition, social phobia, might be the outgrowth of vicarious conditioning, whereby children in seeing their parents responding to fear repeatedly as a result of a particular stimuli might also follow or model this type of behavior. Yates and Reich (1988, pp. 72-75) add that a biological basis can be postulated as a result of their observations that people who experience social phobia very often have close and or distance relatives displaying these symptoms.

The risk factors associated with individuals afflicted with social phobia are compensation to mask and or escape via easing their pain through the utilization of alcohol and or drugs as a means to relax (Medical Encyclopedia, 2006). Social phobia has life disabling effects in that it causes individuals afflicted with the fear of situations to avoid them and that can and usually does, if left untreated, develop into a vicious cycle which can be severely debilitating, distressing as well as demoralizing (American Psychiatric Association, 1994, pp. 411-417). The disability aspects from social standpoint can be both severe as well as pervasive in that an estimated 85% of individuals with this condition have academic as well as difficulties in their occupations as a result of not being able to function in certain aspects of their social lives and relationships with others (McGonagle, et al, 1994, pp. 8-19).

Helstad et al (1998) advise that in one study they found that almost 50% of the individuals identified with social phobia were not able to complete high school, with seventy percent in the lowest socioeconomic quartiles, and twenty-two percent were on welfare. This same study also found that approximately 50% of all patients with social phobia have comorbid alcohol, drug and or mental problems (Helstad et al, 1998). Weissman et al (1992, pp. 282-288) indicate that this condition, social phobia, can increase an affected individual’s risk of having depression by a factor of approximately four, with approximately 16% having alcohol abuse. The preceding aspects can and do affect an individual’s quality of life. Kobak, et al (2001, pp. 1999-2007) state that there is a difficulty in measuring patterns of diagnosis as well as treatment and health care utilization regarding individuals with social anxiety disorders as these sources exclude those who are uninsured or face other barriers and thus do not show up in overall figures. In addition, Kobak, et al (2001, pp. 1999-2007) point out that a great percentage of individuals with social phobia occupy lower socioeconomic and educational percentiles and thus do not seek health care, and or cannot afford it. With the foregoing understanding, the indicated study focused on insured members of the Dean Health Plan, utilizing a sampling of 7,165 individuals, of which 3,862 participated, and 2,073 consented to contact (Kobak, et al, 2001, pp. 1999-2007). The results indicated 31.4% had utilized their Plan for a mental health specialty visit, with 44.1% utilizing the Plan for a mental health specialty visit and or antidepressant prescription.

Chapter 3 - Etiological Hypotheses and Findings

Beiderman et al (1991, pp. 333-348) have advised us that the onset of social phobia related disorders has shown that it develops primarily prior to the age of twenty five years of age and is strongly considered to be developed in early childhood. Beiderman et al (1991, pp. 333-348) states that it is possible anxiety disorders might be genetically influenced regarding adults, however it is strongly suggested that such is a result of environmental childhood and or adolescent influences. Caster (2001, p. 4) in discussing an etiological hypotheses for social phobia concurs with Beiderman et al (1991, pp. 333-348) and adds that only recently has the high prevalence of psychopathology been recognized in adolescence. Caster (2001, p. 4) adds to the postulation by Beiderman et al (1991, pp. 333-348) in stating that the physiological reactivity of an individual can very well represent an influence upon their interpretations and perceptions of social situations that could potentially in turn be the cause of social anxiety development in some individuals. Caster’s (2001, pp. 4- 23) study entailed 111 subjects and divided the aforementioned into the following groupings:

1. social phobia,
2. sub clinical social anxiety, and
3. normal control group

The findings indicated that social anxiety starts during early to middle adolescence, with most youths experiencing this disorder in varying degrees with evidence pointing to specific traumatic events. The preceding hypotheses has been correlated to comprise approximately 50% to 58% who developed the condition after a specific traumatic event (Caster, 2001, pp. 4- 23). The study also found “… first degree relatives of socially anxious individuals are more likely to suffer from a diagnosis of social phobia than … first degree relatives of a normal control group…” (Caster, 2001, pp. 7- 8). The study also found “… that shy and anxious children had biological mothers “… who were socially anxious and less socialable than the mothers of non-anxious children” (Caster, 2001, p. 8). Caster’s (2001, p. 8) study also confirmed, along with studies conducted by Bruch and Heimberg (1994, pp. 155-168) and Bruch (1989, pp. 37-47) that the differences between people having social anxiety and “… both normal control groups …” and normal control groups as well as “… other types of anxiety disordered groups on environment factors” (Caster, 2001, p. 8) were basically consistent in their underlying causes. The findings from said studies found that socially anxious people usually perceive that their parents were more protective when they were children (Bruch and Heimberg, 1994, pp. 155-168), as well as also being less emotionally supporting (Arrindell et al, 1983, pp. 183-187). Bruch and Heimberg (1994, pp. 155-168) and Bruch (1989, pp. 37-47) found that socially anxious parents also isolated their children from normal everyday social experiences, along with them being more concerned with respect to the opinions of others, and did not place an emphasis on socializing within the family group.

Chavira and Stein (2000, pp. 347-352) advise that as a result of so many social phobia disorders having their base in childhood and adolescence that researchers need to turn their attention in this direction. Twin studies capitalizing upon identical twins who are genetically identical, termed monozygotic, as well as fraternal twins, dizygotic, where the twins share half of the genes have resulted in being able to separate genetic as well as environmental trait contributions along with disorders and behaviors (Martin et al, 1997, pp. 387-392). The preceding twin studies have identified that a portion, modest, of familial social phobia was inherited, approximately 51%, and that the genetic risk for social phobia is shared in part with other anxiety disorders such as agoraphobia (Kendler et al, 2001, pp. 257-265).

Grant et al (2000, 797-804) indicate that there is potentially an overlap in the genes influencing social phobia and depression which seemingly indicates the potential for a high comorbidity between them which might have a genetic basis. Cooper and Eke (1999, pp. 439-443) conducted a study that examined the mothers of children who are shy and the findings strongly support that there is an etiopathological relationship that exists between social phobia and shyness. In a study sampling of 867 four year olds, 12.5%, 108 children were identified with shyness (Cooper and Eke, 1999, pp. 439-443). In the follow up examination it was found that the mothers of purely shy children had demonstrated rates of higher anxiety disorders and social phobia than the mothers of children who were not shy (Cooper and Eke, 1999, pp. 439-443). Millon et al (1999, pp.188-198) indicated the estimated heritability can be anywhere from 12% through 60% based upon the study, with the average around 37%.

Biederman et al (2001, pp. 49-57) points to studies conducted at Harvard and Columbia showing a high risk regarding depressive disorders for children whose parents are at high risk for social phobia. Fyer et al (1995, pp. 564-573) suggest that social phobia actually aggregates separately of other anxiety disorders. In a study representing 2163 female twins conducted by Kendler et al (1992, pp. 273-281) found that the age pattern at the onset of simple phobias and comorbidity differed from that representing agoraphobia which onset later in life and had lower comorbidity rates. Environmental factors such as the indicated family patterns as well as specific situations that are negative can and do influence the form as well as degree of social phobia (Shyness & Social Anxiety Treatment Australia, 2006).

As reported by Barylnik (2003, pp. 31-32) children from families with a high level of environmental risk factors such as parents who drink, criminality, neglect and abuse are contributing factors to the development of social anxiety problems. Franken (2003, pp. 151-163) points out that unfavorable child rearing styles such as overly demanding and guilt inducing parents can develop into varied anxiety disorders. Franken (2003, pp. 151-163) adds that parenting styles that induce excessive hurt, abuse, guilt and criticism as opposed to nurturing, reinforcement, understanding and communication are facets in adding the development of anxiety disorders in children and young adults. He cites (Franken, 2003, pp. 151-163) that trust versus distrust, autonomy versus doubt or shame, initiative versus guilt, industry versus inferiority, identity versus role confusion, intimacy versus isolation are parenting actions in the development of their children from birth through adolescence, with the negative connotations resulting in the development of varied social anxiety disorders. Franken (2003, pp. 151-163) advises that infants can sense hostility, hurt and hate and the foregoing damages the ego as the child learns it can not trust, which turns the infant into a slightly fearful, shy and or inhibited being whereby the child starts to withdraw. Social phobia can be explained by the cognitive-behavioral model through the emphasis of the roles of conditioning and or learning (Appalachian State University, 2005).

The cognitive behavioral model argues the principle that avoidance behavior representing social situations is a learned experience from prior exposure in varied social settings (Appalachian State University, 2005). Individuals having negative experiences will avoid situations based upon the original situation which then expands, in many cases, to include other related situations thus increasing the effects and including other disorders (Appalachian State University, 2005). This learned behavior is a slow deterioration process which can be viewed from the perspective that lowered social skills lead to social phobia, and or certain experiences that represent social phobia lead to ever decreasing social skills (Appalachian State University, 2005). The preceding represent traumatic conditioning which also can lead to a sense of a lack of control as well as biased expectations and thus that individual thinks in terms of others having negative evaluations of their behaviors and actions (Appalachian State University, 2005). These learned conditional areas slowly condition one’s behavior to project and expect negative results from the feared type of encounter and thus further withdrawal. People having social phobia hold more negative and irrational beliefs concerning themselves than those without social phobia problems with said needs typically based on need or acceptance and or approval (Appalachian State University, 2005). This conditions the individual into self defeating thoughts about themselves thus creating a vicious cycle that fulfills their fears and further reinforces the downward spiral (Appalachian State University, 2005).

Behavioral theories point out three primary factors in the development of anxiety disorders (Filakovic et al, 2002):

1. Direct fear conditioning,
2. Secondary fear conditioning, as represented by learning through observation,
3. Verbal and nonverbal transfer of information regarding social phobic situations.

External, environmental and childhood experiences as well as parental upbringing are predisposition influences that can cause and or result in the onset of varied social phobia conditions (Filakovic et al, 2002). Situational influences such as socioeconomic status, friends, neighborhood, one’s cultural background, such as upbringing beliefs, specific cultural influences and beliefs all have a bearing on not only the onset of anxiety disorders but their degree. These factors create the environment that maintains and adds to the problem for the affected individual as it represents their living environment (Filakovic et al, 2002). The isolation caused and created as a result of withdrawal from situations that caused and created the anxiety, which accelerates into broader spheres. The preceding has the effect of causing withdrawal and avoidance on the part of the individual from increasing situations that create the fear thus adding the dimension of increased loneness as they struggle with their own inner fears (Filakovic et al, 2002).

The etiological findings and hypotheses are indicated by the foregoing indicates varied causality facets present in social phobia, as well as the relative age of onset. In addition, environmental, parental and anxiety aspects have been indicated to most likely have their onset in childhood and or early adolescence. Studies conducted by Caster (2001, P.8) as well as Bruch and Heimberg (1994, pp. 155-168) as well as Arrindell et al (1983, pp. 183-187) concur with the preceding. Chavira and Stein (2000, pp. 347-352) indicate that the incidence and historical data is strong enough in these areas so that researchers should turn a good degree of their efforts in this direction to develop an understanding of the patient’s causality factors to aid in their understanding.

Chapter 4 - The Behavioral Models of Social Phobia

Rapee and Heimberg (1997, pp. 741-756) cognitive behavioral model is generally considered the definitive framework. They explain that individuals with social phobia start life under over intrusive and or protective parents thus having the message that they are not complete to deal with and or meet life’s challenges. In addition, the parents of these individuals deliver the message that the opinions and evaluation of others is important thus setting the framework for anxiety over meeting these types of expectations (Rapee and Heimberg, 1997, pp. 741-756). The rearing of their parents has these types of individuals believing that other people will evaluate them negatively and critically, thus it is extremely important to them to be perceived and appraised positively (Rapee and Heimberg, 1997, pp. 741-756). Prior to social situations, individuals with social phobia form a mental perception of how they will be perceived. The preceding is developed from their long term memories of social situations, somatic sensations, which are internal cues, along with others tone of voice and or facial expressions, known as external cues (Rapee and Heimberg, 1997, pp. 741-756).

The individual is conditioned through past experiences and situations whereby the fear has built upon itself to create a conditioned fear reaction as they attempt to meet the standards they think others expect, even when these others are unknown to them. Rapee and Heimberg (1997, pp. 741-756) advise that this conditioned response, as a result of the built in mind set, thus creates a situation that is doomed to failure as the individuals inner mind set of how they are seen by other individuals is biased negatively and that they thus see or envision negative consequences from said social engagement. Clark et al (1995, pp. 153-161) explain that the core of people afflicted with social phobia believe that the evaluation by others is important to them. The foregoing, when combined with their negatively biased self representation within their mind causes them to think and believe that they are seen by others negatively and creates a circumstance called hyper vigilance on their part (Clark et al, 1995, pp. 153-161). Leary and Kowalski’s self presentational theory (1995, pp. 94-112) amplify the preceding explanation by adding that anxiety in social situations for individuals with social phobia as a