The fear of being rejected is such a widespread experience that it can even be considered universal. And the fact is that, at a time already forgotten by the ups and downs of history, parting with the herd involved an almost assured death at the hands (or claws) of any predator.
And it is that our species has been able to progress and be what it is today mainly thanks to its ability to collaborate with large groups, within which it could find the help of other individuals when needed. Loneliness and ostracism, in these primitive societies, was something that deserved to be feared and avoided.
Because so much of the brain we possess today is identical to that of times past to which we refer, the fears that once conditioned behavior and thought continue to prevail in one way or another in every. To be human.
At the root of this ancestral fear is social phobia, an anxiety disorder very common in today’s society, often associated with a large number of co-morbidities. In this text we will not miss, precisely, such a question: comorbidities of social phobia.
What is social phobia?
Social phobia is a high prevalence anxiety disorder, which is characterized by an intense fear of exchange situations involving a trial or assessment. The affection that arises is of such intensity that the person anticipates with apprehension (even for days, weeks or months) any event in which it is necessary to interact with others, mainly when his performance must be put under analysis or review. Such sensations have an aversive experiential component, upon which a constant “effort” is built to avoid interpersonal encounters.
In the case of not being able to avoid them, the exposure takes place with intense and unpleasant physiological sensations (tachycardia, sweating, redness, tremors, rapid breathing, etc.), accompanied by the emergence of automatic thoughts that plunge the person in negativity and desolation (“they’ll think I’m a fool”, “I have no idea what I’m saying”, etc.). Attention to the body increases; and a very clear repudiation of blushing, trembling and sweating occurs (To consider them more obvious to a viewer). The “judgment” on one’s own performance is cruel / punitive, disproportionate to the actual performance appreciable by others (which is generally described as “better” than what the patient perceives).
There are different degrees of severity for the disorder in question, distinguishing between patients who exhibit specific profiles (or who are afraid of only a narrow range of social stimuli) and those who suffer from generalized fear (aversion to practically all). ). In both cases, there would be a substantial deterioration in the quality of life, and the development of the individual would come to be conditioned at the family, school or professional level. It is a problem that usually begins in adolescence, extending its influence into adulthood.
An essential feature of this diagnosis is that has a particular risk of coexisting with other clinical mental health conditions, which strongly compromise its expression and development. These co-morbidities of social phobia are of paramount importance and must be considered for an appropriate therapeutic approach. The following lines will cover them.
Main comorbidities of social phobia
Social phobia can coexist with many mood and anxiety disorders currently considered in the text of diagnostic manuals (such as DSM or CIE), as well as other particularly debilitating problems.
It should be noted that the co-occurrence of two or more disorders has a synergistic effect on how they are experienced, as they are mutually influenced. The end result is always greater than the mere sum of the parts, so their processing requires special skill and sensitivity. So let’s see what are the most relevant comorbidities of social phobia.
1. Major depression
Major depression is the most common mood disorder. Those who suffer from it identify two cardinal symptoms: deep sadness and anhedonia (difficulty in feeling pleasure). However, he also often appreciates sleep disturbances (insomnia or hypersomnia), suicidal ideation / behavior, ease of crying and general loss of motivation. Many of these symptoms are known to overlap with those of social phobia, the most important being isolation and fear of being judged negatively (the root in the case of depression lies in torn self-esteem).
Depression is 2.5 times more common in people with social phobia than in the general population. In addition, the similarity that they lodge in the examined aspects could cause that in certain cases it is not made detect of the suitable form. The presence of these two disorders simultaneously results in a more severe clinical social phobia, a less use of the support that the environment can offer and an accentuated tendency to acts or thoughts of an autolytic nature.
The most common is that social phobia sets in before depression (69% of cases)As the latter emerges in a much more sudden manner than the former. About half of patients with social anxiety will suffer from such a mental disorder at some point in their life, while 20-30% of those living with depression will suffer from social phobia. In these cases of comorbidity will increase the risk of work problems, academic difficulties and social barriers; which in turn will intensify the intensity of emotional suffering.
People with generalized social phobia have a higher likelihood of atypical depressive symptoms (such as sleep and overeating, or difficulty regulating internal states). In these cases, the direct consequences in daily life are even more numerous and pronounced, requiring in-depth therapeutic monitoring.
2. Bipolar disorder
Bipolar disorder, included in the category of mood psychopathologies, generally has two possible pathways: type I (with manic phases of emotional expansion and probable periods of depression) and type II (with less effusive episodes ). Intense than the previous one, but alternating with depressive moments). We now estimate a wide range of risks of comorbidity with social phobia, ranging from 3.5% to 21% (according to the research consulted).
In the event that the two problems coexist, there is usually a more intense symptomatology for both, a marked level of disability, more lasting emotional episodes (both depressive and manic), shorter euthymic periods (stability of the emotional life) i a significant increase in the risk of suicide. Also, in these cases, it is more common for additional anxiety issues to arise. As for the order in which they are presented, the most common is that it is the bipolarity that erupts earlier (which manifests itself after a correct story).
There is evidence that drugs (lithium or anticonvulsants) are generally less effective in co-morbidities such as the one described., Making obvious a worse response to them. Particular caution should also be exercised when taking antidepressant medication, as it has been documented that they sometimes precipitate a turn towards mania. In the latter case, it is therefore essential to make more precise estimates of the possible advantages and disadvantages of its administration.
3. Other anxiety disorders
Anxiety disorders share many basic elements beyond the notorious differences that demarcate the boundaries between them. Worry is one of those realities, alongside the overactivation of the sympathetic nervous system and the extraordinary tendency to avoid stimuli associated with it. It is for this reason that a high percentage of those who suffer from social phobia will also report another anxious picture while throughout their life cycle, generally more intense than what is usually observed in the general population. More specifically, it is estimated that this comorbidity extends to half of them (50%).
The most common are specific phobias (intense fears of stimuli or situations of great concretion), panic disorder (crisis of great physiological activation of uncertain origin and experienced in an unexpected / aversive) and generalized (a concern very difficult to control. For a wide range of everyday situations). Agoraphobia is also common, especially in patients with social phobia and panic disorder (Overwhelming fear of having episodes of acute anxiety somewhere to escape or seek help might be difficult). The percentage of comorbidity varies from 14% -61% in specific phobias to 4% -27% in panic disorder, these two being the most relevant in this context.
It is important to note that many patients with social anxiety report experiencing sensations equivalent to those of a panic attack, except that they can identify and anticipate the detonating stimulus very well. Likewise, they complain about recurring / persistent concerns, but only focus on issues of a social nature. These peculiarities make it possible to distinguish respectively social phobia from panic disorder and / or generalized anxiety disorder.
4. Obsessive-compulsive disorder (OCD)
Obsessive-compulsive disorder (OCD) is a clinical phenomenon characterized by the appearance of intrusive thoughts that generate great emotional distress, followed by actions or thoughts intended to relieve. These two symptoms often forge a functional and close relationship, which cyclically “fuels” their strength. It is estimated that 8% to 42% of people with OCD will suffer from social phobia to some extent, while around 2 to 19% of people with social anxiety will experience symptoms of OCD throughout their lives. .
It has been observed that the comorbidity between obsessive-compulsive symptoms and social anxiety is more likely in patients who also have a confirmed diagnosis of bipolar disorder. When this happens, all social symptoms and fears are often compounded, exacerbating the emphasis on self-observation of one’s own body when interacting with others. Suicidal ideation increases to the same extent and less beneficial effects on pharmacological treatments are manifested. However, they are generally well aware of the problem and seek help quickly.
The presence of a bodily dysmorphic disorder is also very common. This alteration generates an exaggerated perception of a very discreet physical defect or complaints about an appearance problem that does not really exist, and increases the feelings of shame that the person might have. Up to 40% of patients with social phobia experience it, which greatly underscores their reluctance to overexpose others.
5. Post-traumatic stress disorder (PTSD)
Post-traumatic stress disorder (or PTSD) occurs when a complex response after experiencing a particularly tragic or aversive event, such as sexual abuse, natural disaster, or serious accident (Especially in cases where it was experienced in the first person and / or the event was deliberately caused by the action or omission of another human being).
Clinically, three cardinal symptoms are evident: re-experimentation (thoughts or images about the trauma), hyperactivation (feeling of constant vigilance) and avoidance (flight / flight from everything when it could evoke the facts of the past).
Throughout the course of PTSD, it is common for symptoms to appear fully compatible with this social anxiety (43%)., Although the reverse situation is much more “strange” (7%). In both cases, regardless of the order of presentation, the risk of suffering from major depression and different anxiety disorders (among those indicated in a previous section) is higher. There are also studies that suggest that people with PTSD and social phobia tend to feel more guilty about the traumatic events they have witnessed, and that there may even be a more pronounced presence of abuse (physical, sexual)., Etc.) in their life story.
6. Alcohol addiction
About half (49%) of people with social phobia develop addiction to alcohol at some point, Which results in two phenomena: tolerance (need to consume more substance to obtain the effect of the principle) and withdrawal syndrome (formerly popularized under the name of “monkey” and characterized by deep discomfort when is not near the substance on which it depends). Both contribute to the emergence of incessant seeking / consuming behavior, which takes a long time and gradually degrades those who exhibit it.
Many people with social phobia use this substance to feel more uninhibited in times of a social nature when they demand extraordinary performance. Alcohol works by inhibiting the activity of the prefrontal cortex, so this task is accomplished, despite a significant toll: the erosion of “natural” adaptation strategies to fight against interpersonal demands. In this context, social anxiety is expressed before addiction, which is formed as a result of a so-called self-medication process (alcohol consumption to reduce subjective pain and never to obey medical criteria).
People with this comorbidity also have a higher risk of developing personality disorders. (Mostly antisocial, limiting and avoiding), and the fear of bonding is heightened. In addition, and how could it be otherwise, the risk of physical and social problems arising from one’s own consumption would be greatly increased.
7. Avoidant personality disorder
Many authors postulate that there are hardly any clinical differences between avoidant personality disorder and social phobia, all of which are relegated to a simple matter of degree. And the truth is, they share many symptoms and consequences for everyday experience; How? ‘Or’ What interpersonal inhibition, feelings of inadequacy and emotional hypersensitivity to criticism. However, other research finds qualitative differences, despite the difficulty of recognizing them in the clinical setting.
The degree of overlap is such that a comorbidity of 48% between the two frames is estimated. When this happens (especially when living with the ‘prevalent’ subtype of social anxiety), the social avoidance becomes much more intense, as does the feeling of inferiority and ‘non-integration’. . Panic disorder is generally more common in these cases, as are suicidal thoughts and behaviors. There appears to be an obvious genetic component between these two mental health issues, as they typically recur mostly in first-degree relatives, although the exact contribution of learning within the family is not yet known.
- Fehm, L., Beesdo, K., Jacobi, F., Fiedler, A. (2008). Social anxiety disorder above and below diagnostic threshold: prevalence, comorbidity and impairment in the general population. Social psychiatry and psychiatric epidemiology, 43, 257-65.
- Lydiard, R. (2001). Social anxiety disorder: comorbidity and its implications. The Journal of Clinical Psychiatry, 62 (1), 17-23.