The 7 most important social phobia comorbidities

The fear of being rejected is such an extended experience that it can even be considered universal . And, in times already forgotten by the ups and downs of history, being separated from the pack implied an almost assured death in the hands (or in the claws) of any predator.

And it is that our species has been able to progress and be what it is today especially because of its ability to collaborate with large groups, within which it could find help from other individuals in the case of needing it. Loneliness and ostracism, in those primitive societies, were something that deserved to be feared and avoided.

Because an important part of the brain that we have today is identical to that of the past times to which we refer, the fears that once conditioned behavior and thought continue to prevail in one way or another within each human being.

This ancestral fear underlies social phobia, a very prevalent anxiety disorder in today’s society, which is often associated with a very large number of comorbidities. In this text we will abound precisely in this matter: the comorbidities of social phobia .

  • Related article: ” Types of phobias: exploring fear disorders

What is social phobia?

Social phobia is an anxiety disorder of great prevalence, characterized by an intense fear of exchange situations that involve a trial or evaluation . The affection that arises is of such intensity that the person apprehensively anticipates (even for days, weeks or months) any event in which they must interact with others, especially when their performance is going to be subjected to analysis or scrutiny. Such sensations have an aversive experiential component, upon which a constant “effort” is constructed to avoid interpersonal encounters.

In the case of not being able to avoid them, the exposure involves intense and unpleasant physiological sensations (tachycardia, sweating, flushing, tremor, rapid breathing, etc.), together with the emergence of automatic thoughts that immerse the person in negativism and desolation (“they will believe that I am stupid”, “I have no idea what I am saying”, etc.). The attention on the body increases; and there is a very clear repudiation of the blush, the tremor and the sweat (for considering them as more evident before a spectator). The “judgment” on the performance itself is cruel / punitive, disproportionate to the real performance appreciable by others (which is generally described as “better” than the patient perceives).

There are different degrees of severity for the disorder at hand, distinguishing patients who show specific profiles (or who only fear a restricted range of social stimuli) and those who suffer from a generalized fear (aversion to almost all of them). In both cases there would be a substantial impairment of the quality of life, and the development of the individual at a family, academic or work level would be conditioned. It is a problem that usually begins during adolescence, extending its influence to adult life.

An essential peculiarity of this diagnosis is that it has a special risk of living with other clinical mental health conditions, which strongly compromise its expression and evolution . These comorbidities of social phobia acquire a capital importance, and should be taken into consideration for a correct therapeutic approach. The following lines will be on them.

Main comorbidities of social phobia

Social phobia can coexist with many of the mood and anxiety disorders that are currently contemplated in the text of diagnostic manuals (such as DSM or ICD), as well as with other problems that are particularly disabling.

It should be taken into account that the co-occurrence of two or more disorders has a synergistic effect on the way of living them, since they influence each other in a reciprocal way. The final result is always greater than the simple sum of its parts, so its treatment requires special expertise and sensitivity. So, let’s see what are the most relevant social phobia comorbidities.

1. Major depression

Major depression is the most prevalent mood disorder . Those who suffer from it identify two cardinal symptoms: deep sadness and anhedonia (difficulty feeling pleasure). However, sleep disturbance (insomnia or hypersomnia), suicidal ideation / behavior, ease of crying and general loss of motivation are also usually seen. It is known that many of these symptoms overlap with those of social phobia, the most relevant being isolation and fear of being judged negatively (whose root in the case of depression is in a lacerated self-esteem).

Depression is 2.5 times more common in people with social phobia than in the general population. In addition, the similarity they harbor in the aspects described could cause that in some cases it is not detected properly. The presence of these two disorders simultaneously translates into a more serious clinic of social phobia, a reduced 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 is installed before depression (69% of cases) , since the latter emerges in a much more sudden way than the first. Around half of patients with social anxiety will suffer from such a mood disorder at some time in their life, while 20-30% of those living with depression will suffer social phobia. In these cases of comorbidity, the risk of labor problems, academic difficulties and social impediments will increase; which in turn will enliven the intensity of affective suffering.

Among people suffering from generalized social phobia, a higher probability of atypical depressive symptoms (such as sleeping and overeating, or having difficulty regulating internal states) has been observed. In these cases, the direct consequences in daily life are even more numerous and pronounced, making a deep therapeutic follow-up necessary.

  • You may be interested: ” Major depression: symptoms, causes and treatment

2. Bipolar disorder

Bipolar disorder, included in the category of mood psychopathologies, usually has two possible courses: type I (with manic phases of affective expansivity and probable periods of depression) and type II (with episodes of effusivity less intense than previous, but alternating with depressive moments). Today a wide range of risk is estimated for its comorbidity with social phobia, which ranges between 3.5% and 21% (according to the research that is consulted).

In the case that both problems coexist, a more intense symptomatology can be appreciated for one and the other, an accentuated level of disability, more lasting emotional episodes (both depressive and manic), shorter euthymic periods (stability of affective life ) and a relevant increase in suicide risk . Also, in such cases it is more common for additional anxiety problems to arise. As for the order in which they are presented, the most common is that it is the bipolarity that breaks in before (which becomes evident after an adequate history).

There is evidence that drugs (lithium or anticonvulsants) tend to be less effective in comorbidities such as the one described , making a worse response to them evident. Special caution should also be taken in the case of treatment with antidepressants, as it has been documented that they sometimes precipitate a turn towards mania. In the latter case, therefore, it is essential to make more precise estimates of the possible benefits and disadvantages of its administration.

3. Other anxiety disorders

Anxiety disorders share a large number of basic elements, beyond the notorious differences that demarcate the boundaries between each other. Concern is one of these realities, together with hyperactivation of the sympathetic nervous system and the extraordinary tendency to avoid the stimuli associated with it . It is for this reason that a high percentage of those who suffer from social phobia will also refer another anxious picture throughout their life cycle, generally more intense than what is usually observed in the general population. Specifically, it is estimated that this comorbidity extends to half of them (50%).

The most frequent are specific phobias (intense fears of stimuli or situations of great specificity), panic disorder (crisis of great physiological activation of uncertain origin and living unexpectedly / aversively) and generalized anxiety (very difficult concern to “control” by a wide range of everyday situations). Agoraphobia is also common, especially in patients with social phobia and panic disorder (irresistible fear of experiencing episodes of acute anxiety somewhere where escape or asking for help could be difficult). The pendulum comorbidity percentage of 14% -61% in specific phobias at 4% -27% in panic disorder, these two being the most relevant in this context.

It is important to keep in mind that many of the patients with social anxiety report that they experience sensations equivalent to those of a panic attack, but with the caveat that they can identify and anticipate the trigger stimulus very well. They also complain about recurring / persistent concerns, but only focused on issues of a social nature . These peculiarities contribute to distinguish the social phobia of a panic disorder and / or generalized anxiety, respectively.

4. Obsessive-Compulsive Disorder (OCD)

The Obsessive-Compulsive Disorder (OCD) is a clinical phenomenon characterized by the appearance of intrusive thoughts that cause great emotional distress, which continue acts or thoughts whose purpose is relieve . These two symptoms usually forge a functional and close relationship, which “enhances” your strength cyclically. It has been estimated that 8% -42% of people with OCD will suffer from social phobia to some degree, while around 2% -19% of those suffering from social anxiety will have OCD symptoms throughout their lives.

It has been observed that comorbidity between obsessive-compulsive symptoms and social anxiety is more likely in those patients who also have the confirmed diagnosis of bipolarity. When this occurs, all symptoms and social fears are usually aggravated, with an emphasis on self-observation of the body itself during interactions with others. Suicidal ideations increase to the same extent, and milder beneficial effects are manifested in pharmacological treatments. However, they tend to be well aware of the problem and ask for help promptly.

The presence of body dysmorphic disorder is also very common . This alteration generates an exaggerated perception of a very discreet physical defect or complaints about a problem in one’s own appearance that does not really exist, and increases the feelings of shame that the person could hold. Up to 40% of patients with social phobia report living it, which greatly underlines their reticence to excessive exposure to others.

5. Posttraumatic stress disorder (PTSD)

Posttraumatic stress disorder (or PTSD) arises as a complex response after experiencing a particularly lucrative or aversive event, such as sexual abuse, a natural disaster or a 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).

At the clinical level three cardinal symptoms are evident: reexperimentation (thoughts or images about trauma), hyperactivation (feelings of constant alertness) and avoidance (escape / escape from everything when it could evoke the events of the past).

Throughout the evolution of PTSD it is common for symptoms to appear fully compatible with this social anxiety (43%) , although the inverse situation is much more “strange” (7%). In both cases, regardless of the order of presentation, there is a greater risk of suffering from major depression and different anxiety conditions (among those mentioned in an earlier section). There are also studies that suggest that subjects with PTSD and social phobia tend to feel more guilty for the traumatic events they had to witness, and even that there could be a more pronounced presence of child abuse (physical, sexual, etc.) in their history of life.

  • You may be interested: ” PTSD: a quick guide to your treatment

6. Alcohol dependence

Approximately half (49%) of people with social phobia develop alcohol dependence at some point , which translates into two phenomena: tolerance (the need to consume more substance to obtain the effect of the principle) and withdrawal symptoms (before popularized as “monkey” and characterized by deep discomfort when the substance on which it depends is not close). Both the one and the other contribute to the irruption of an incessant search / consumption behavior, which requires a lot of time and gradually deteriorates the person who presents it.

There are many people with social phobia who make use of this substance in order to feel more uninhibited in moments of social nature where they demand themselves extraordinary performance. Alcohol acts by inhibiting the activity of the prefrontal cortex, which is why this task is achieved, although an important toll is paid: the erosion of “natural” coping strategies to deal with interpersonal demands . In the context, social anxiety is expressed before addiction, the latter being formed as a result of a process known as self-medication (alcohol consumption whose purpose is to reduce subjective pain and that never obeys medical criteria).

Those who present this comorbidity also have a higher risk of suffering from personality disorders (especially antisocial, borderline and avoidant), and that the fear of forming bonds is accentuated. In addition, and how could it be otherwise, the risk of physical and social problems arising from consumption itself would be greatly increased.

7. Avoiding personality disorder

Many authors postulate that there are hardly any clinical differences between avoidant personality disorder and social phobia, relegating all of them to a simple matter of degree. And the truth is that they share many symptoms and consequences on everyday experience; such as interpersonal inhibition, feelings of inadequacy and hypersensitivity to criticism . However, other investigations do find qualitative discrepancies, despite the difficulty in recognizing them in the clinical setting.

The degree of overlap is such that a 48% comorbidity is estimated between both tables. When this occurs (especially when living with the “generalized” subtype of social anxiety), social avoidance becomes much more intense, as well as the feeling of inferiority and “not fit.” Panic disorder is usually more common in these cases, as is suicidal ideation and behavior. There seems to be an obvious genetic component between these two mental health conditions, since they usually reproduce especially in first-degree relatives, although the exact contribution of learning within the family is still unknown.


by Abdullah Sam
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