The 7 most important comorbidities of social phobia

These are the psychological disorders that most overlap with social phobia.

The fear of being rejected is such a widespread experience that it can even be considered universal in nature. In times long forgotten by the ups and downs of history, being separated from the herd meant almost certain death at the hands (or in the claws) of any predator.

Our species has been able to progress and become what it is today mainly because of its ability to collaborate with large groups, within which it could find help from other individuals if needed. Loneliness and ostracism, in those primitive societies, were something to be feared and avoided.

Because an important part of the brain we possess today is identical to that of the past, the fears that once conditioned behavior and thought continue to prevail in one way or another in every human being.

This ancestral fear underlies social phobia, a very prevalent anxiety disorder in today's society, which is usually associated with a very significant number of comorbidities. In this text we will deal precisely with this issue: the comorbidities of social phobia..

What is social phobia?

Social phobia is an anxiety disorder of enormous prevalence, characterized by an intense fear to the situations of exchange that imply a judgment or evaluation.. The affect that arises is of such intensity that the person apprehensively anticipates (even for days, weeks or months) any event in which he/she must interact with others, especially when his/her performance is to be subjected to analysis or scrutiny. Such sensations have an aversive experiential component, upon which a constant "effort" to avoid interpersonal encounters is built.

If they cannot be avoided, the exposure is accompanied by intense and unpleasant physiological sensations (tachycardia, sweating, blushing, trembling, accelerated breathing, etc.), together with the emergence of automatic thoughts that plunge the person into negativism and desolation ("they will think I am stupid", "I have no idea what I am saying", etc.). The attention on the body increases; and a very clear repudiation of blushing, trembling and sweating emerges. (because they are considered to be more obvious to an onlooker). The "judgment" of one's own performance is cruel/punitive, disproportionate to the actual performance perceived by others (which is generally described as "better" than the patient perceives).

There are different degrees of severity for the disorder in question, 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 individual's development at family, academic or work level would be conditioned. It is a problem that usually begins during adolescence, extending its influence into adulthood.

An essential peculiarity of this diagnosis is that has a special risk of coexisting with other clinical mental health conditions, which strongly compromise their expression and evolution.. These comorbidities of social phobia are of paramount importance and must be taken into consideration for a correct therapeutic approach. The following lines will deal with them.

Main comorbidities of social phobia

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

It should be kept in mind that the co-occurrence of two or more disorders has a synergistic effect on the way we experience them, as they influence each other. The end result is always greater than the simple sum of its parts, so its treatment requires special expertise and sensitivity. So, let us see what are the most relevant comorbidities of social phobia.

1. Major depression

Major depression is the most prevalent mood disorder.. Sufferers identify two cardinal symptoms: profound sadness and anhedonia (difficulty in feeling pleasure). However, sleep disturbance (insomnia or hypersomnia), suicidal ideation/behavior, tearfulness and general loss of motivation are also commonly seen. Many of these symptoms are known to overlap with those of social phobia, the most relevant being isolation and fear of being judged negatively (the root of which in the case of depression lies 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 in the aspects mentioned above could cause that in some cases it is not detected in the appropriate way. The presence of these two disorders simultaneously results in more severe clinical manifestations of social phobia, less use of the support offered by the environment and an accentuated tendency to acts or thoughts of a self-injurious nature.

Most commonly, social phobia sets in before depression (69% of cases).The latter emerges much more suddenly than the former. About half of patients with social anxiety will suffer from such a mood disorder at some point in their lives, while 20-30% of those living with depression will suffer from social phobia. In these cases of comorbidity, the risk of occupational problems, academic difficulties and social impairment will increase, which in turn will increase the intensity of affective distress.

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

Bipolar disorder

Bipolar disorder, included in the category of mood psychopathologies, usually has two possible courses: type I (with manic phases of affective expansiveness and probable periods of depression) and type II (with episodes of less intense effusiveness than the previous one, but alternating with depressive moments). Nowadays a Wide range of risk is estimated for comorbidity with social phobia, ranging from 3.5% to 21% (depending on the research consulted).

In the case of coexistence of both problems, there is usually a greater intensity of symptomatology for both, an accentuated level of disability, longer lasting affective episodes (both depressive and manic), shorter euthymic periods (stability of the affective life) and a significant increase in the risk of suicide.. Also in such cases, additional anxiety problems are more common. As for the order in which they occur, bipolarity is the one that usually appears first (which becomes evident after an adequate anamnesis).

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

3. Other anxiety disorders

Anxiety disorders share a large number of basic elements, beyond the notorious differences that demarcate the limits between them. Worrying is one of these realities, together with the 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 condition 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 concreteness), panic disorder (crises of great physiological activation of uncertain origin and experienced unexpectedly/aversively) and generalized anxiety (worry that is very difficult to "control" over a wide range of everyday situations). Agoraphobia is also common, especially in patients with social phobia and panic disorder. (irresistible fear of suffering episodes of acute anxiety in some place where escape or asking for help could be difficult). The percentage of comorbidity ranges 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 bear in mind that many patients with social anxiety report that they experience sensations equivalent to those of a panic attack, but with the exception that they can identify and anticipate the triggering stimulus very well. They also complain of recurrent/persistent worries, but only centered on issues of a social nature.. These particularities help to distinguish social phobia from panic disorder and/or generalized anxiety, respectively.

4. Obsessive-Compulsive Disorder (OCD)

The Obsessive-Compulsive Disorder (OCD) is a clinical phenomenon characterized by the irruption of intrusive thoughts that generate great emotional discomfort, followed by acts or thoughts aimed at alleviating it.. These two symptoms tend to forge a close, functional relationship, which "boosts" their strength in a cyclical fashion. It has been estimated that 8%-42% of people with OCD will have some degree of social phobia, while about 2%-19% of those with social anxiety will have OCD symptoms in their lifetime.

It has been observed that comorbidity between obsessive-compulsive symptoms and social anxiety is more likely in those patients who also have a confirmed diagnosis of bipolar disorder. When this occurs, all symptoms and social fears are often markedly aggravated, exacerbating the emphasis on self-observation of one's own body during interactions with others. Suicidal ideation increases to the same extent, and there are milder beneficial effects of pharmacological treatments. However, they are usually well aware of the problem and seek help promptly.

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

5. Post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (or PTSD) arises as a complex response to a a complex response after experiencing a particularly distressing or aversive event, such as sexual abuse, a natural disaster or a serious accident. (especially in cases where it was experienced in first person and/or the event was deliberately provoked by action or omission of another human being).

At the clinical level, three cardinal symptoms are evident: re-experiencing (thoughts or images about the trauma), hyperarousal (feelings of constant alertness) and avoidance (flight/escape from everything that could evoke the events of the past).

Throughout the course of PTSD it is common for symptoms fully compatible with this social anxiety to emerge (43%), although the reverse is true.although the reverse situation is much more "strange" (7%). In both cases, regardless of the order of presentation, there is an increased risk of major depression and various anxiety disorders (among those mentioned in a previous section). Likewise, there are studies that suggest that subjects with PTSD and social phobia tend to feel more guilty about the traumatic events they witnessed, and that there may even be a more pronounced presence of childhood abuse (physical, sexual, etc.) in their life history.

6. Alcohol dependence

Approximately half (49%) of people with social phobia develop alcohol dependence at some point in time.This results in two phenomena: tolerance (the need to consume more substance to obtain the effect of the beginning) and withdrawal syndrome (formerly popularized as "mono" and characterized by a profound discomfort when the substance on which one is dependent is not near). Both contribute to the irruption of an incessant search/consumption behavior, which requires a lot of time and gradually deteriorates the person who presents it.

Many people with social phobia make use of this substance in order to feel more uninhibited in moments of a social nature where they demand extraordinary performance from themselves. Alcohol acts by inhibiting the activity of the prefrontal cortex, which is why it achieves this goal, even though a significant toll is paid: the erosion of "natural" coping strategies for dealing 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 aimed at reducing subjective pain and never obeying medical criteria).

Those who present this comorbidity also have a higher risk of personality disorders (especially antisocial, borderline and avoidant) and a heightened fear of bonding. (especially antisocial, borderline and avoidant), and the fear of forming bonds is accentuated. In addition, and as could not be otherwise, the risk of physical and social problems derived from the consumption itself 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, relegating all of them to a simple question of degree. And the truth is that they share many symptoms and consequences on everyday experience; such as interpersonal inhibition, feelings of inadequacy, and affective hypersensitivity to criticism.. However, other research does find qualitative discrepancies, despite the difficulty of recognizing them in the clinical setting.

The degree of overlap is such that there is an estimated 48% comorbidity between the two conditions. When this occurs (especially when living with the "generalized" subtype of social anxiety), social avoidance becomes much more intense, as does the feeling of inferiority and of "not fitting in". Panic disorder tends to be more common in these cases, as well as suicidal ideation and behavior. There seems to be an obvious genetic component between these two mental health conditions, as they tend to be reproduced especially in first-degree relatives, although the exact contribution of learning within the family is not yet known.

Bibliographic references:

• Fehm, L., Beesdo, K., Jacobi, F., Fiedler, A. (2008). Social anxiety disorder above and below the 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.