Social anxiety

# Overview
Social anxiety is an experience of fear, apprehension or
worry regarding social situations and being evaluated by others. People vary in how often they experience anxiety in this way or in which
kinds of situations. Anxiety about public speaking, performance, or
interviews is common. Social anxiety can be related to shyness. The
experience is commonly described as having physiological components (e.g.
sweating, blushing), cognitive/perceptual components (e.g. belief that
-ne
may be judged negatively; looking for signs of disapproval) and
behavioral
components (e.g. avoiding a situation). Not all cases deal with fear of being judged negatively, as some cases have social anxiety without any specific reason.
The remainder of this article concerns the diagnosis of social anxiety disorder (social phobia) rather than social anxiety in general.
Social anxiety disorder, also known as social phobia, is a
diagnosis within psychiatry and other mental health professions referring to excessive
long-lasting social anxiety causing relatively extreme distress and
impaired ability to function in at least some areas of daily life. The
diagnosis can be of a specific disorder (when only some particular
situations are feared) or a generalized disorder. Generalized social
anxiety disorder typically involves a persistent, intense, and chronic
fear of being judged by others and of potentially being embarrassed or
humiliated by their own actions. These fears can be triggered by
perceived
-r actual scrutiny by others. While the fear of social interaction may be
recognized by the person as excessive or unreasonable, considerable
difficulty can be encountered overcoming it. Approximately 13.3% of the
general population may meet criteria for social anxiety disorder at some
point in their lifetime, according to the highest survey estimate, with
the male to female ratio being 1:1.5 respectively.
Physical symptoms often accompanying social anxiety disorder include
excessive blushing, sweating (hyperhidrosis),
trembling, palpitations, nausea, and stammering.
Panic attacks may also occur under intense fear and discomfort. An
early diagnosis may help in minimizing the symptoms and the
development of additional problems such as depression. Some sufferers may
use alcohol or other drugs to reduce fears and inhibitions at
social events.
A person with the disorder may be treated with psychotherapy,
medication, or both. Research has shown cognitive behavior therapy,
whether individually or in a group, to be effective in treating social
phobia. The cognitive and behavioral components seek to
change thought patterns and physical reactions to
anxious situations. Prescribed medications
includes
two classes of antidepressants: selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors
(SNRIs). Attention given to social anxiety disorder has significantly
increased in the US since 1999 with the approval and marketing of drugs for its
treatment.

# Overview
According to the Diagnostic and Statistical Manual of Mental Disorders, social phobia is a persistent fear of one or more
situations in which the person is exposed to possible scrutiny by others
and fears that he or she may do something or act in a way that will be
humiliating or embarrassing.  For one to be socially phobic, exposure
to the feared situation must provoke anxiety and the person must
recognize this anxiety as irrational (although this may be absent in
children). If another disorder is present, the social phobic fear is
unrelated to it. For instance, if a person has a history of panic
attacks,
having a panic attack must not be the sufferer's fear. Sufferers are
typically more self-conscious and self-attentive than others.  As a result, social phobics
tend to limit or remove themselves from situations where they may be
subject to evaluation. Sufferers often recognize their fear is excessive
-r irrational, yet can't seem to break out of the cycle. As such, the
diagnosis of social phobia is made only when the fear leads to avoiding
-ccupational functions, social activities, or relationships with others.
Mental health professionals often distinguish between generalized and
specific social anxiety disorders. People with generalized social anxiety
have great distress with most or all social situations. A study by
Stanford University established that distress was more likely when
social encounters were unfamiliar, involved power or status differences,
difference in gender, or the presence of a group of people. Those with
specific social phobias may experience anxiety only in a few situations. For example the most
common specific social phobia is glossophobia, the fear of public speaking
-r fear of performance,  known as stage fright. Other examples of specific
social phobias include fears of writing in public (scriptophobia) and
using public restrooms (paruresis).
There is much debate concerning the relationship between social phobia
and
shyness. Shyness is not a criterion for social anxiety disorder.
People
with social anxiety disorder may be quite comfortable with certain people
-r many people, but still feel intense anxiety in specific social
situations. Child psychologist Samuel Turner provides a summary
between shyness and social phobia. Both share several features: negative
cognitions in social situations, heightened
physiological reactivity, a tendency to avoid social
situations, and deficits in social skills. Negative cognitions include
fear of negative evaluation, self-consciousness, devaluation of
social
skills, self-deprecating thoughts, and self-blaming attributions for
social
difficulties. Social phobia is distinct from shyness in that it has a
lower
prevalence in the population, follows a more chronic course, is more
functionally debilitating, and has a later age of onset. There are
problems with these kinds of comparisons. It may be that the differences
between them are quantitative rather than qualitative. There are some that argue
that shyness is mistakenly treated with medication intended for
social
phobia, effectively labeling the personality trait a mental
illness.
Social phobia should not be confused with panic disorder. Sufferers
-f
panic disorder are convinced that their panic comes from some dire
physical
cause, and often go to the hospital or call for an ambulance during or
after their attacks. Social phobics may experience a panic attack when
triggered, but they are aware that it is extreme anxiety they are
experiencing, and that the cause is an irrational fear. Few social
phobics would willingly go to a hospital in that instance because they
fear rejection and judgment by authority figures (such as the medical
staff). The general form of social anxiety is sometimes incorrectly
called
generalized anxiety disorder. The principal difference between the
two
is that the social phobia deals with anxiety in a social setting, while
generalized anxiety disorder is extreme anxiety for any situation (work,
school, et al.), not necessarily one involving other people.

# Symptoms

## Cognitive aspects
In cognitive models of Social Anxiety Disorder, social phobics experience
dread over how they will be presented to others. They may be overly
self-conscious, pay high self-attention after the activity, or have high
performance standards for themselves. According to the social psychology
theory of self-presentation, a sufferer
attempts
to create a well-mannered impression on others but believes he or she is
unable to do so. Many times, prior to the potentially anxiety-provoking
social situation, sufferers may deliberate over what could go wrong and
how to deal with each unexpected case. 
After the event, they may have the perception they performed
unsatisfactorily. Consequently, they will review anything that may have
possibly been abnormal or embarrassing. These thoughts do not just
terminate soon after the encounter, but may extend for weeks or
longer. Those with social phobia tend to interpret neutral or
ambiguous conversations with a negative outlook and although still
inconclusive, some studies suggest that socially anxious individuals
remember more negative memories than those less distressed. An example of an instance may be that of an employee
presenting to his co-workers. During the presentation, the person may
stutter a word upon which he or she may worry that other people
significantly noticed and think that he or she is a terrible presenter.
This cognitive thought propels further anxiety which may lead to further
stuttering, sweating and a possible panic attack.

## Behavioral aspects
Social anxiety disorder is a persistent fear of one or more situations in
which the person is exposed to possible scrutiny by others and fears that
he or she may do something or act in a way that will be humiliating or
embarrassing. It exceeds normal "shyness" as it leads to excessive
social avoidance and substantial social or occupational impairment.
Feared activities may include almost any type of social interaction,
especially small groups, dating, parties, talking to strangers,
restaurants, etc. Physical symptoms include "mind going blank", fast
heartbeat, blushing, stomach ache. Cognitive distortions are a hallmark,
and learned about in CBT (cognitive-behavioral therapy). Thoughts are
-ften self-defeating and inaccurate.
The groundless fear of the telephone is typical, both calling
somebody and answering the phone. It may appear early in childhood.
According to psychologist B.F. Skinner, phobias are controlled by
escape and avoidance
behaviors.
For instance, a student may leave the room when talking in front of the
class (escape) and refrain from doing verbal presentations because of the
previously encountered anxiety attack (avoid). Minor avoidance behaviors
are exposed when a person avoids eye contact and crosses arms to avoid
recognizable shaking. A fight-or-flight response
is then triggered in such events. Preventing these automatic responses is
at the core of treatment for social anxiety.

## Physiological aspects
Physiological effects, similar to those in other anxiety disorders, are
present in social phobics. Faced with an uncomfortable situation,
children
with social anxiety may display tantrums, weeping, clinging
to parents, and shutting themselves out. In adults, it
may be tears as well as experiencing excessive
sweating, nausea, shaking, and palpitations as a
result of the fight-or-flight response. The walk
disturbance may appear,
especially when passing a group of people. Blushing is commonly
exhibited by individuals suffering from social phobia. These visible symptoms further reinforce the anxiety in the presence
-f
-thers. A 2006 study found that the area of the brain called the
amygdala, part of the limbic system, is hyperactive when
patients are shown threatening faces or confronted with frightening
situations. They found that patients with more severe social phobia
showed
a correlation with the increased response in the
amygdala.

# Prevalence
When prevalence estimates were based on the examination of psychiatric
clinic samples, social anxiety disorder was thought to be a relatively
rare disorder. The opposite was instead true; social anxiety was common
but many were afraid to seek psychiatric help, leading to an
understatement of the problem. Prevalence rates
vary
widely because of its vague diagnostic criteria and its overlapping
symptoms with other disorders. There has been some debate on how the
studies are conducted and whether the illness truly impairs the
respondents as laid out in the official criteria. Psychologist Dr. Ray Crozier argues, "it is difficult to ascertain whether the person being
interviewed adheres to the DSM-III-R criteria or whether they are merely
exhibiting poor social skills or shyness."
The National Comorbidity Survey of over
8,000 American correspondents in 1994 revealed a 12-month and lifetime
prevalence rates of 7.9% and 13.3% making it the third most prevalent
psychiatric disorder after depression and alcohol dependence and the most
apparent of the anxiety
disorders. According to U.S.
epidemiological data from the National Institute of Mental Health,
social phobia affects 5.3 million adult Americans in any given year.
Cross-cultural studies have reached prevalence rates with the
conservative
rates at 5% of the population. However, other estimates vary within 2% and 7% of the
U.S.
adult population.
Onset of social phobia typically occurs between 11 and 19 years of age.
Onset after age 25 is rare. Social anxiety disorder occurs in females
nearly twice as often as males, although men are more likely to seek
help. The prevalence of
social
phobia appears to be increasing among white, married, and well-educated
individuals. As a group, those with generalized social phobia are less
likely to graduate from high school and are more likely to rely on
government financial assistance or have poverty-level salaries. Surveys carried out in 2002 show the youth of
England, Scotland, and Wales have a prevalence rate of .4%,
1.8%, and .6%, respectively. The prevalence
-f
self-reported social anxiety for Nova Scotians older than 14 years was
in June 2004 with women (4.6%) reporting more than men (3.8%). In
Australia, social phobia is the 8th and 5th leading disease or illness
for
males and females between 15-24 years of age as of 2003. Because of the
difficulty in separating social phobia from poor social skills or
shyness,
some studies have a large range of prevalence.
The table also shows higher prevalence in Brazil. As a Latin American country, one could argue that social pressure for being like deeply-rooted stereotypes acts as an additional cause to this disease.

# Comorbidity
There is a high degree of comorbidity with other psychiatric
disorders. Social phobia often occurs alongside low self-esteem and
clinical depression, due to lack of personal relationships and long
periods of isolation from avoiding social situations. To try to reduce
their anxiety and alleviate depression, people with social phobia may use
alcohol or other drugs, which can lead to substance abuse. It is
estimated that one-fifth of patients with social anxiety disorder also
suffer from alcohol dependence. The most common complementary psychiatric condition is
unipolar depression. In a sample of 14,263 people, of the 2.4% of persons
diagnosed with social phobia, 16.6% also met the criteria for
clinical depression. Besides depression,
the most common disorders diagnosed in patients with social phobia are
panic disorder (33%), generalized anxiety disorder (19%),
post-traumatic stress disorder (36%), substance
abuse disorder (18%), and attempted suicide (23%). In one study of social
anxiety disorder patients who developed comorbid alcoholism, panic
disorder or depression, social anxiety disorder preceded the onset of
alcoholism, panic disorder and depression in 75%, 61%, and 90% of
patients, respectively. Avoidant personality disorder is also highly
correlated with social phobia. Because of its close relationship and overlapping
symptoms
with other illnesses, treating social phobics may help understand
underlying connection in other psychiatric disorders.
There is research indicating that social anxiety disorder is often correlated with bipolar disorder .
Some researchers believe they share an underlying cyclothymic-anxious-sensitive disposition.  In addition, studies show that more socially phobic patients treated with anti-depressant medication develop hypomania than non-phobic controls , although this can be seen as the medication creating a new problem, and also has this adverse effect in a proportion of those without social phobia.

# Causes and perspectives
Research into the causes of social anxiety and social phobia is
wide-ranging, encompassing multiple perspectives from neuroscience to
sociology. Scientists have yet to pinpoint the exact causes.
Studies suggest that genetics can play a part in combination with
environmental factors.

## Genetic and family factors
It has been shown that there is a two to threefold greater risk of
having
social phobia if a first-degree relative also has the disorder. This
could
be due to genetics and/or due to children acquiring social fears and
avoidance through processes of observational learning or parental
psychosocial education. Studies of identical twins brought up (via
adoption) in different families have indicated that, if one twin
developed
social anxiety disorder, then the other was between 30% and 50% more
likely
than average to also develop the disorder. To some extent this
'heritability' may not be specific - for example, studies have found that
if a parent has any kind of anxiety disorder or clinical depression, then
a child is somewhat more likely to develop an anxiety disorder or social
phobia. Studies suggest that parents
-f
those with social anxiety disorder tend to be more socially isolated
themselves (Bruch and Heimberg, 1994; Caster et al, 1999), and shyness in
adoptive parents is significantly correlated with shyness in adopted
children (Daniels and Plomin, 1985);
Adolescents who were rated as having an insecure (anxious-ambivalent)
attachment with their mother as infants were twice as likely to develop
anxiety disorders by late adolescence,
including social phobia.
A related line of research has investigated 'behavioural inhibition' in
infants  early signs of an inhibited and introspective or fearful
nature. Studies have shown that around 10-15% of individuals show this
early temperament, which appears to be partly due to genetics. Some
continue to show this trait in to adolescence and adulthood, and appear
to
be more likely to develop social anxiety disorder.

## Social experiences
A previous negative social experience can be a trigger to social
phobia.
 perhaps particularly
for individuals high in 'interpersonal sensitivity'. For around half of
those diagnosed with social anxiety disorder, a specific traumatic or
humiliating social event appears to be associated with the onset or
worsening of the disorder; this kind of event appears
to
be particularly related to specific (performance) social phobia, for
example regarding public speaking (Stemberg et al., 1995). As well as
direct experiences, observing or hearing about the socially negative
experiences of others (e.g. a faux pas committed by someone), or verbal
warnings of social problems and dangers, may also make the development of
a social anxiety disorder more likely. Social anxiety
disorder may be caused by the longer-term effects of not fitting in, or
being bullied, rejected or ignored (Beidel and Turner, 1998). Shy
adolescents or avoidant adults have emphasised unpleasant experiences
with
peers or childhood
bullying or harassment (Gilmartin, 1987). In one study, popularity was
found to be negatively correlated with social anxiety, and children who
were neglected by their peers reported higher social anxiety and fear of
negative evaluation than other categories of children. Socially phobic children appear less likely to
receive positive reactions from peers
and anxious or inhibited children may isolate themselves.

## Social/cultural influences
Cultural factors that have been related to social anxiety disorder
include
a society's attitude towards shyness and avoidance, affecting ability to
form relationships or access employment or education. One study found
that
the effects of parenting are different depending on the culture -
American
children appear more likely to develop social anxiety disorder if their
parents emphasise the importance of other's opinions and use shame as a
disciplinary strategy (Leung et al., 1994), but this association was
not found for Chinese/Chinese-American children. In China, research has
indicated that shy-inhibited children are more accepted than their peers
and more likely to be considered for leadership and considered competent,
in contrast to the findings in Western countries.
Purely demographic variables may also play a role - for example there are
possibly lower rates of social anxiety disorder in Mediterranean
countries and higher rates in Scandinavian countries, and it has been hypothesised
that hot weather and high-density may reduce avoidance and increase
interpersonal contact.
Problems in developing social skills, or 'social effectiveness', may be a
cause of some social anxiety disorder, through either inability or lack
-f
confidence to interact socially and gain positive reactions and
acceptance
from others. The studies have been mixed, however, with some studies not
finding significant problems in social skills while
-thers have. What does seem clear is
that the socially anxious perceive their own social skills to be low. It
may be that the increasing need for sophisticated social skills in
forming
relationships or careers, and an emphasis on assertiveness and
competitiveness, is making social anxiety problems more common, at least
among the 'middle classes'. An interpersonal or media
emphasis
-n 'normal' or 'attractive' personal characteristics has also been argued
to fuel perfectionism and feelings of inferiority or insecurity regarding
negative evaluation from others. The need for social acceptance or social
standing has been elaborated in other lines of research relating to
social
anxiety

## Evolutionary context
A long-accepted evolutionary explanation of anxiety is that it reflects
an
in-built 'fight or flight' system, which errs on the side of safety. One
line of research suggests that specific dispositions to monitor and react
to social threats may have evolved, reflecting the vital and complex
importance of social living and social rank in human ancestral
environments. Charles Darwin originally wrote about the evolutionary
basis of shyness and blushing, and modern evolutionary psychology and
psychiatry also addresses social phobia in this context. It has been hypothesised that in modern day society these
evolved tendencies can become more inappropriately activated and result
in
some of the cognitive 'distortions' or 'irrationalities' identified in
cognitive-behavioural models and therapies

## Neurochemical and neurocognitive influences
Some scientists hypothesize that social phobia is related to an imbalance
-f the brain chemical serotonin. Sociability is also closely tied
to dopamine neurotransmission. Low D2 receptor
binding is found in people with social anxiety.
The efficacy of medications which affect serotonin and dopamine levels
also indicates the role of these pathways. There is also increasing focus
-n other candidate transmitters, e.g. Norepinephrine, which may be
-ver-active in social anxiety disorder, and the inhibitory transmitter
GABA.
Individuals with social anxiety disorder have been found to have a
hypersensitive amygdala, for example in relation to social threat
cues
(e.g. someone might be evaluating you negatively), angry or hostile
faces,
and while just waiting to give a speech. Recent research has
also indicated that another area of the brain, the 'Anterior cingulate cortex', which was already known to be involved in the experience of
physical pain, also appears to be involved in the experience of 'social
pain', for example perceiving group exclusion.

## Psychological factors
Research has indicated the role of 'core' or 'unconditional' negative beliefs (e.g. I am inept) and 'conditional' beliefs nearer to the surface
(e.g. If I show myself, I will be rejected). They are thought to develop
based on personality and adverse experiences and to be activated when the
person feels under threat. One line of work has focused more specifically on the key
role of self-presentational concerns. The resulting anxiety
states are seen as interfering with social performance and the ability to
concentrate on interaction, which in turn creates more social problems,
which strengthens the negative schema. Also highlighted has been a high
focus on and worry about anxiety symptoms themselves and how they might
appear to others. A similar model emphasises
the development of a distorted mental representation of their self and
-ver-estimates of the likelihood and consequences of negative evaluation,
and of the performance standards that others have. Such
cognitive-behavioral models consider the role of negatively-biased
memories of the past and the processes of rumination after an event, and
fearful anticipation before it. Studies have also highlighted the role of
subtle avoidance and defensive factors, and shown how attempts to avoid
feared negative evaluations or use 'safety behaviours' (Clark & Wells,
1995) can make social interaction more difficult and the anxiety worse in
the long run. This work has been influential in the development of
Cognitive Behavioural Therapy for social anxiety disorder, which has been
shown to have efficacy.

# Treatment
Arguably the most important clinical point to emerge from studies of
social anxiety disorder is the benefit of early diagnosis and treatment.
Social anxiety disorder remains under-recognized in primary care practice,
with patients often presenting for treatment only after the onset of
complications such as clinical depression or 
substance abuse disorders. The patients who
achieve full resolution are usually far fewer; there are still many who,
after receiving treatment, are unable to function in the long-term
without
anxiety symptoms.
Research has provided evidence for the efficacy of two forms of treatment
available for social phobia: certain medications and a specific form of
short-term psychotherapy called Cognitive-behavioral therapy (CBT), the
central component being gradual exposure therapy.

## Pharmacological treatments

### SSRIs
Selective serotonin reuptake inhibitors (SSRIs), a class of
antidepressants, are considered by many to be the first choice medication
for generalised social phobia. These drugs elevate the level of the
neurotransmitter serotonin, among other effects. The first drug formally
approved by the Food and Drug Administration was paroxetine, sold
as Paxil in the US or Seroxat in the UK, Compared to older forms of medication, there is
less risk of tolerability and drug dependency. However, their efficacy and increased suicide risk has
been subject to controversy.
In a 1995 double-blind, placebo-controlled trial, the SSRI
paroxetine was shown to result in clinically meaningful improvement
in
55% of patients with generalized social anxiety disorder, compared with
23.9% of those taking placebo.
An October 2004 study yielded similar results. Patients were treated with
either fluoxetine, psychotherapy, fluoxetine and psychotherapy,
placebo and psychotherapy, and a placebo. The first four sets saw
improvement in 50.8 to 54.2% of the patients. Of those assigned to
receive
-nly a placebo, 31.7 percent achieved a rating of 1 or 2 on the
Clinical Global Impression-Improvement scale. Those who sought both therapy and
medication did not see a boost in improvement.
General side-effects are common during the
first weeks while the body adjusts to the drug. Symptoms may include
headaches, nausea, insomnia and changes in sexual behavior.
Treatment safety during pregnancy has not been established. In late 2004 much media attention was given
to
a proposed link between SSRI use and juvenile
suicide.
For this reason, the use of SSRIs in pediatric cases of depression is now
recognized by the Food and Drug Administration as warranting a cautionary
statement to the parents of children who may be prescribed SSRIs by a
family doctor. Recent studies have shown no increase in rates
-f suicide. These tests, however, represent those diagnosed with depression, not necessarily with social anxiety disorder. However, it should be noted that due to the nature of the conditions, those taking SSRIs for social phobias are far less likely to have suicidal
ideation than those with depression.

### Other drugs
Although SSRIs are often the first choice for treatment, other
prescription drugs are also commonly issued, sometimes only if SSRIs fail
to produce any clinically significant improvement.
In 1985, before the introduction of SSRIs, anti-depressants such as
monoamine oxidase inhibitors (MAOIs) were frequently used in the
treatment of social anxiety. Their efficacy appears to be comparable or
sometimes superior to SSRIs or Benzodiazepines. However, because of the
dietary restrictions required, high toxicity in
-verdose, and incompatibilities with other drugs, its usefulness as a
treatment for social phobics is now limited. Some argue for their
continued use, however, or that a special diet does not need to be
strictly adhered to.
A newer type of this medication, Reversible inhibitors of
monoamine
-xidase subtype A (RIMAs) inhibit the MAO enzyme only temporarily,
improving the adverse-effect profile but possibly reducing their
efficacy.
Benzodiazepines are a short-acting and more potent alternative to SSRIs. The drug is often used for
short-term relief of severe, disabling anxiety. Although benzodiazepines
are still sometimes prescribed for long-term use in some countries, there
is much concern over the development of drug tolerance, dependency and recreational abuse.
Benzodiazepines augment the action of GABA, the major inhibitory
neurotransmitter in the brain; effects usually begin to appear within
minutes or hours.
Some people with a form of social phobia called performance phobia have
been helped by beta-blockers, which are more commonly used to control
high blood pressure. Taken in low doses, they control the physical
manifestation of anxiety and can be taken before a public performance.
A novel treatment approach has recently been developed as a result of
translational research. It has been shown that a combination of acute
dosing of d-cycloserine (DCS) with exposure therapy facilitates the
effects
-f exposure therapy of social phobia (Hofmann, Meuret, Smits, et al.,
2006). DCS is an old antibiotic medication used for treating tuberculosis
and does not have any anxiolytic properties per se. However, it acts as
an
agonist at the glutamatergic N-methyl-D-aspartate (NMDA) receptor site,
which is important for learning and memory (Hofmann, Pollack, & Otto,
2006). It has been shown that administering a small dose acutely 1 hour
before exposure therapy can facilitate extinction learning that occurs
during therapy.

## Psychotherapy
Research has shown that a form of psychotherapy that is effective for several anxiety disorders, particularly panic disorder and social phobia is cognitive-behavioral therapy (CBT). It has two main components. The cognitive component helps people become aware of and to change thinking patterns that keep them from overcoming their fears. A person with social phobia might be helped to question how they can be so sure that others are continually watching and harshly judging him or her. The behavioral component of CBT seeks to change people's reactions to anxiety-provoking situations. It also serves as a logical extension of cognitive therapy where people are shown proof in the real world that their dysfunctional thought processes are unrealistic. A key element of this component is gradual exposure, in which people confront the things they fear in a structured, sensitive manner. Gradual exposure is an inherently unpleasant technique. It involves four components, duration, frequency, graded and focused. Ideally the person should be exposed to a feared social situation that is anxiety provoking but bearable (graded) for as long as possible (duration), two to three times a day (frequency), and the person must endure the anxiety until it declines (focused). A hierarchy of feared steps is constructed and the patient is exposed to each step. The aim is also to learn from acting differently and observing reactions (behavioral 'experiments'). This is intended to be done with support and guidance when the therapist and patient feel they are ready. Cognitive-behavior therapy for social phobia also includes anxiety management training, which may include techniques such as deep breathing and muscle relaxation exercises, which may be practiced 'in-situ'. CBT may also be conducted partly in group sessions (Cognitive behavioral group therapy), facilitating the sharing of experiences, a sense of acceptance by others and undertaking behavioral challenges in a trusted environment (Heimberg).
Some studies have suggested social skills training can help with social anxiety. Whether specific social skills techniques and training are required, rather than just support with general social functioning and exposure to social situations, does not seem to be clear.
Interpersonal Therapy has been shown to have efficacy for depression and a small study of the therapy in the treatment of social phobia suggests it may also work with social phobia.

# History
Literary descriptions of shyness can be traced back to the days of
Hippocrates around 400 B.C. Hippocrates described someone who 'through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him'.
Charles Darwin wrote about the physiology
and social context of blushing and shyness. The first mention of a
psychiatric term, social phobia ("phobie des situations sociales"), was
made in the early 1900s. Psychologists used the term "social neurosis"
to describe extremely shy patients in the 1930s. After extensive work by
Joseph Wolpe on systematic desensitization, research in phobias
and their treatment grew. The idea that social phobia was a separate
entity from other phobias came from the British psychiatrist, Isaac Marks in the 1960s. This was accepted by the American Psychiatric Association and was first officially included in the third edition of
the Diagnostic and Statistical Manual of Mental Disorders. The definition
-f the phobia was revised in 1989 to allow comorbidity with avoidant personality disorder, and introduced generalized social phobia.  Social phobia had been largely ignored prior to 1985.
After a call to action by psychiatrist Michael Liebowitz and
clinical psychologist Richard Heimberg, there was an increase in
research and attention on the disorder. The DSM-IV gave social phobia the
alternative name Social Anxiety Disorder. Research in to the psychology
and sociology of everyday social anxiety continued. Cognitive Behavioural
models and therapies were developed for social anxiety disorder. In the
1990s, paroxetine became the first prescription
drug in the US approved to treat social anxiety disorder, with others
following.

# Criticisms
Some argue that inherent problems with society such as a competitive
culture, power imbalances, lack of care and poor social education in families cause social anxiety. And consequently the diagnostic boundaries have been
stretched too far and that clinical and media work is promoting the idea
that any problems with shyness or social worries are a pathological
medical condition requiring medical treatment. Some see this as being
driven by pharmaceutical companies, either by direct advertising to
the public or their financial influence on psychiatry. This view can be associated with, but is
not exclusive to, anti-psychiatry.