The 7 Most Important Comorbidities Of Social Phobia
The fear of being rejected is such a widespread experience that it can even be considered universal And the fact is that, in times already forgotten by the vagaries of history, being separated from the herd implied an almost guaranteed death at the hands (or in the claws) of any predator.
And our species has been able to progress and be what it is today above all because of its ability to collaborate with large groups, within which it could find help from other individuals if it was needed. 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, to which a very significant number of comorbidities are usually associated. In this text we will elaborate precisely on this question: comorbidities of social phobia
Social phobia is a highly prevalent anxiety disorder, characterized by an intense fear of exchange situations that involve 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 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, on which a constant “effort” to avoid interpersonal encounters is built.
In the case of not being able to avoid them, the exposure causes intense and unpleasant physiological sensations (tachycardia, sweating, flushing, trembling, accelerated breathing, etc.), along with the emergence of automatic thoughts that immerse the person in negativity and desolation (“they’re going to think I’m stupid”, “I have no idea what I’m saying”, etc.). Attention to the body increases; and a very clear repudiation of blushing, trembling and sweat arises (because they are considered more obvious to a viewer). The “judgment” of one’s own performance is cruel/punitive, disproportionate to the actual performance appreciable by others (which is generally described as “better” than the patient perceives).
There are different degrees of severity for the disorder in question, distinguishing between patients who show specific profiles (or who only fear a restricted range of social stimuli) and those who suffer from a generalized fear (aversion towards practically all of these). In both cases there would be a substantial impairment of the quality of life, and the individual’s development at the 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 its expression and evolution These comorbidities of social phobia acquire capital importance, and must be taken into consideration for a correct therapeutic approach. The following lines will be about them.
Main comorbidities of social phobia
Social phobia can coexist with many of the mood and anxiety disorders that are currently included in the text of diagnostic manuals (such as the DSM or ICD), in addition to other problems that are particularly disabling.
It must be taken into account that the co-occurrence of two or more disorders has a synergistic effect on the way they are experienced, since they influence each other. 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 which are the most relevant comorbidities of social phobia.
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 often seen. It is known that many of these symptoms overlap with those of social phobia, the most relevant being isolation and the fear of being judged negatively (the root of which in the case of depression is found in a lacerated self-esteem).
Depression is 2.5 times more common in people with social phobia than in the general population. Furthermore, the similarity they harbor in the aspects outlined could mean that in some cases they are not detected in the appropriate way. The presence of these two disorders simultaneously translates into a more serious clinical picture of social phobia, a lesser use of the support that the environment can offer and a marked tendency towards acts or thoughts of an autolytic nature.
The most common thing is that social phobia sets in before depression (69% of cases), since the latter emerges much more suddenly than the first. Around 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 work problems, academic difficulties and social impediments will increase; which in turn will intensify the intensity of emotional suffering.
Among people who suffer from generalized social phobia, a greater probability of atypical depressive symptoms (such as sleeping and eating excessively, or having difficulties regulating internal states) has been observed. In these cases, the direct consequences on daily life are even more numerous and pronounced, making in-depth therapeutic follow-up necessary.
2. 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 normal). above, but alternating with depressive moments). Nowadays, a wide range of risk for comorbidity with social phobia is estimated, ranging between 3.5% and 21% (depending on the research consulted).
In the event that both problems coexist, there is usually a greater intensity of symptoms for both, a marked level of disability, longer lasting affective episodes (both depressive and manic), shorter euthymic periods (stability of emotional life). ) and a significant increase in the risk of suicide Likewise, also in such cases it is more common for additional anxiety problems to arise. Regarding the order in which they occur, the most common thing is that bipolarity is the one that breaks out beforehand (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 reviewed, making a worse response to them evident. Special caution should also be taken in the case of treatment with antidepressants, since 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 drawbacks of its administration.
Anxiety disorders share a large number of basic elements, beyond the notable differences that demarcate the limits between them. Worry is one of these realities, along with hyperactivation 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 other anxious symptoms 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 common are specific phobias (intense fears of highly specific stimuli or situations), panic disorder (crisis of great physiological activation of uncertain origin and experienced in an unexpected/aversive way) and generalized anxiety (very difficult worry). of “controlling” 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 a 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 keep 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. In addition, They complain of recurring/persistent concerns, but only focused on issues of a social nature These particularities help distinguish social phobia from a panic disorder and/or generalized anxiety, respectively.
4. Obsessive-Compulsive Disorder (OCD)
Obsessive-Compulsive Disorder (OCD) is a clinical phenomenon characterized by the emergence of intrusive thoughts that generate great emotional discomfort, which are followed by actions or thoughts whose purpose is to relieve it These two symptoms usually forge a functional and close relationship, which “enhances” its strength in a cyclical way. 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 who suffer from social anxiety will experience symptoms of OCD 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 a confirmed diagnosis of bipolarity. When this occurs, all symptoms and social fears tend to significantly aggravate, exacerbating the emphasis on self-observation of one’s own body during interactions with others. Suicidal ideations increase to the same extent, and milder beneficial effects are manifested in pharmacological treatments. However, they usually have a good awareness 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 discrete physical defect or complaints about a problem in one’s appearance that does not actually exist, and increases the feelings of shame that the person may feel. Up to 40% of patients with social phobia report experiencing it, which greatly underlines their reluctance to be excessively exposed to others.
5. Post-traumatic stress disorder (PTSD)
Post-traumatic stress disorder (or PTSD) arises as a complex response after experiencing a particularly painful or aversive event, such as sexual abuse, a natural disaster, or a serious accident (especially in cases where it was experienced first-hand and/or the event was deliberately caused by the action or omission of another human being).
At a clinical level, three cardinal symptoms are evident: re-experiencing (thoughts or images about the trauma), hyperactivation (feelings of constant alert) and avoidance (flight/escape from everything that could evoke the events of the past).
Throughout the course of PTSD, it is common for symptoms to emerge that are fully compatible with this social anxiety (43%), despite the fact that the reverse 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 noted in a previous section). Likewise, there are studies that suggest that subjects with PTSD and social phobia tend to feel more guilty for the traumatic events that they had to witness, and that there could even be a more pronounced presence of childhood abuse (physical, sexual, etc.) in their history. of life.
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 initial effect) and withdrawal syndrome (previously popularized as “mono” and characterized by a deep discomfort when the substance that is being consumed is not close. it depends). Both one and the other contribute to the emergence of an incessant search/consumption behavior, which requires a lot of time and gradually deteriorates those who present it.
There are many people with social phobia who use 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, so this task is achieved, despite paying a significant toll: the erosion of “natural” coping strategies for dealing with interpersonal demands In the context, social anxiety is expressed before addiction, the latter forming as a result of a process known as self-medication (alcohol consumption whose purpose is to reduce subjective pain and which never obeys medical criteria).
Those with this comorbidity also have a higher risk of suffering from personality disorders (especially antisocial, borderline and avoidant), and that the fear of forming bonds becomes accentuated. Furthermore, and as it could not be otherwise, the risk of physical and social problems derived from consumption itself would greatly increase.
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 matter of degree. And the truth is that they share many symptoms and consequences on daily experience; as interpersonal inhibition, the feeling of inadequacy and emotional 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 an estimated 48% comorbidity between both conditions is estimated. 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 “not fitting in.” 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, given that they tend to reproduce, especially in first-degree relatives, although the exact contribution of learning within the family is not yet known.
