Phobias and Social Anxiety Disorder

Specific Phobia

Phobia is a Greek word that means fear. A person diagnosed with a specific phobia (formerly known as simple phobia) experiences excessive, distressing, and persistent fear or anxiety about a specific object or situation (such as animals, enclosed spaces, elevators, or flying) (APA, 2013). Even though people realize their level of fear and anxiety in relation to the phobic stimulus is irrational, some people with a specific phobia may go to great lengths to avoid the phobic stimulus (the object or situation that triggers the fear and anxiety). Typically, the fear and anxiety a phobic stimulus elicits is disruptive to the person’s life. For example, a man with a phobia of flying might refuse to accept a job that requires frequent air travel, thus negatively affecting his career. Clinicians who have worked with people who have specific phobias have encountered many kinds of phobias, some of which are shown in Table 1.

Specific phobias are common; in the United States, around 12.5% of the population will meet the criteria for a specific phobia at some point in their lifetime (Kessler et al., 2005). One type of phobia, agoraphobia, is listed in the DSM-5 as a separate anxiety disorder. Agoraphobia, which literally means “fear of the marketplace,” is characterized by intense fear, anxiety, and avoidance of situations in which it might be difficult to escape or receive help if one experiences symptoms of a panic attack (a state of extreme anxiety that we will discuss shortly). These situations include public transportation, open spaces (parking lots), enclosed spaces (stores), crowds, or being outside the home alone (APA, 2013). About 1.4% of Americans experience agoraphobia during their lifetime (Kessler et al., 2005).

Acquisition of Phobias Through Learning

Many theories suggest that phobias develop through learning. Rachman (1977) proposed that phobias can be acquired through three major learning pathways. The first pathway is through classical conditioning. As you may recall, classical conditioning is a form of learning in which a previously neutral stimulus is paired with an unconditioned stimulus (UCS) that reflexively elicits an unconditioned response (UCR), eliciting the same response through its association with the unconditioned stimulus. The response is called a conditioned response (CR). For example, a child who has been bitten by a dog may come to fear dogs because of her past association with pain. In this case, the dog bite is the UCS and the fear it elicits is the UCR. Because a dog was associated with the bite, any dog may come to serve as a conditioned stimulus, thereby eliciting fear; the fear the child experiences around dogs, then, becomes a CR.

The second pathway of phobia acquisition is through vicarious learning, such as modeling. For example, a child who observes his cousin react fearfully to spiders may later express the same fears, even though spiders have never presented any danger to him. This phenomenon has been observed in both humans and nonhuman primates (Olsson & Phelps, 2007). A study of laboratory-reared monkeys readily acquired a fear of snakes after observing wild-reared monkeys react fearfully to snakes (Mineka & Cook, 1993).

The third pathway is through verbal transmission or information. For example, a child whose parents, siblings, friends, and classmates constantly tell her how disgusting and dangerous snakes are may come to acquire a fear of snakes.

Interestingly, people are more likely to develop phobias of things that do not represent much actual danger to themselves, such as animals and heights, and are less likely to develop phobias toward things that present legitimate danger in contemporary society, such as motorcycles and weapons (Öhman & Mineka, 2001). Why might this be so? One theory suggests that the human brain is evolutionarily predisposed to more readily associate certain objects or situations with fear (Seligman, 1971). This theory argues that throughout our evolutionary history, our ancestors associated certain stimuli (e.g., snakes, spiders, heights, and thunder) with potential danger. As time progressed, the mind has become adapted to more readily develop fears of these things than of others. Experimental evidence has consistently demonstrated that conditioned fears develop more readily to fear-relevant stimuli (images of snakes and spiders) than to fear-irrelevant stimuli (images of flowers and berries) (Öhman & Mineka, 2001). Such prepared learning has also been shown to occur in monkeys. In one study (Cook & Mineka, 1989), monkeys watched videotapes of model monkeys reacting fearfully to either fear-relevant stimuli (toy snakes or a toy crocodile) or fear-irrelevant stimuli (flowers or a toy rabbit). The observer monkeys developed fears of the fear-relevant stimuli but not the fear-irrelevant stimuli.

Social Anxiety Disorder

Social anxiety disorder (formerly called social phobia) is characterized by extreme and persistent fear or anxiety and avoidance of social situations in which the person could potentially be evaluated negatively by others (APA, 2013). As with specific phobias, social anxiety disorder is common in the United States; a little over 12% of all Americans experience social anxiety disorder during their lifetime (Kessler et al., 2005).

The heart of the fear and anxiety in social anxiety disorder is the person’s concern that he may act in a humiliating or embarrassing way, such as appearing foolish, showing symptoms of anxiety (blushing), or doing or saying something that might lead to rejection (such as offending others). The kinds of social situations in which individuals with social anxiety disorder usually have problems include public speaking, having a conversation, meeting strangers, eating in restaurants, and, in some cases, using public restrooms. Although many people become anxious in social situations like public speaking, the fear, anxiety, and avoidance experienced in social anxiety disorder are highly distressing and lead to serious impairments in life. Adults with this disorder are more likely to experience lower educational attainment and lower earnings (Katzelnick et al., 2001), perform more poorly at work and are more likely to be unemployed (Moitra, Beard, Weisberg, & Keller, 2011), and report greater dissatisfaction with their family lives, friends, leisure activities, and income (Stein & Kean, 2000).

When people with social anxiety disorder are unable to avoid situations that provoke anxiety, they typically perform safety behaviors: mental or behavioral acts that reduce anxiety in social situations by reducing the chance of negative social outcomes. Safety behaviors include avoiding eye contact, rehearsing sentences before speaking, talking only briefly, and not talking about oneself (Alden & Bieling, 1998). Other examples of safety behaviors include the following (Marker, 2013):

• assuming roles in social situations that minimize interaction with others (e.g., taking pictures, setting up equipment, or helping prepare food)
• asking people many questions to keep the focus off of oneself
• selecting a position to avoid scrutiny or contact with others (sitting in the back of the room)
• wearing bland, neutral clothes to avoid drawing attention to oneself
• avoiding substances or activities that might cause anxiety symptoms (such as caffeine, warm clothing, and physical exercise)

Although these behaviors are intended to prevent the person with social anxiety disorder from doing something awkward that might draw criticism, these actions usually exacerbate the problem because they do not allow the individual to disconfirm his negative beliefs, often eliciting rejection and other negative reactions from others (Alden & Bieling, 1998).

People with social anxiety disorder may resort to self-medication, such as drinking alcohol, as a means to avert the anxiety symptoms they experience in social situations (Battista & Kocovski, 2010). The use of alcohol when faced with such situations may become negatively reinforcing: encouraging individuals with social anxiety disorder to turn to the substance whenever they experience anxiety symptoms. The tendency to use alcohol as a coping mechanism for social anxiety, however, can come with a hefty price tag: a number of large scale studies have reported a high rate of comorbidity between social anxiety disorder and alcohol use disorder (Morris, Stewart, & Ham, 2005).

As with specific phobias, it is highly probable that the fears inherent to social anxiety disorder can develop through conditioning experiences. For example, a child who is subjected to early unpleasant social experiences (e.g., bullying at school) may develop negative social images of herself that become activated later in anxiety-provoking situations (Hackmann, Clark, & McManus, 2000). Indeed, one study reported that 92% of a sample of adults with social anxiety disorder reported a history of severe teasing in childhood, compared to only 35% of a sample of adults with panic disorder (McCabe, Antony, Summerfeldt, Liss, & Swinson, 2003).

One of the most well-established risk factors for developing social anxiety disorder is behavioral inhibition (Clauss & Blackford, 2012). Behavioral inhibition is thought to be an inherited trait, and it is characterized by a consistent tendency to show fear and restraint when presented with unfamiliar people or situations (Kagan, Reznick, & Snidman, 1988). Behavioral inhibition is displayed very early in life; behaviorally inhibited toddlers and children respond with great caution and restraint in unfamiliar situations, and they are often timid, fearful, and shy around unfamiliar people (Fox, Henderson, Marshall, Nichols, & Ghera, 2005). A recent statistical review of studies demonstrated that behavioral inhibition was associated with more than a sevenfold increase in the risk of development of social anxiety disorder, demonstrating that behavioral inhibition is a major risk factor for the disorder (Clauss & Blackford, 2012).