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 it is that, in times already forgotten by the ups and downs of history, being separated from the herd 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, above all because of its ability to collaborate with large groups, within which he could find help from other individuals in the event of need 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 We refer, the fears that once conditioned behavior and thought continue to prevail in one way or another within each human being.

Underlying this ancestral fear is 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 abound, precisely, in such a question:

comorbidities of social phobia.

• Related article: "Types of Phobias: Exploring Fear Disorders"

What is 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 you must interact with others, especially when your performance is going to be subjected to analysis or scrutiny. Such sensations have an aversive experiential component, on which a constant "effort" is built to avoid interpersonal encounters.

In the case of not being able to avoid them, the exposure causes intense and unpleasant physiological sensations (tachycardia, sweating, flushing, trembling, rapid breathing, etc.), along with to the emergence of automatic thoughts that plunge the person into negativism and desolation ("they will think I'm stupid", "I have no idea what I'm saying", etc.). Attention to the body increases; and there arises a very clear repudiation of blush, trembling and sweat (for considering them as more obvious to a viewer). The "judgment" on one's performance is cruel / punitive, disproportionate to actual 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 fear only a restricted range of social stimuli) and those who suffer from a generalized fear (aversion towards practically all of the these). In both cases there would be a substantial impairment of the quality of life, and the development of the individual at the family, academic or work level would be conditioned. It is a problem that usually begins during adolescence, extending its influence into adult life.

An essential peculiarity of this diagnosis is that 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 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 that are currently considered in the text of diagnostic manuals (such as DSM or ICD), in addition to 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 reciprocally. 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 in feeling pleasure). However, sleep disturbances (insomnia or hypersomnia), suicidal ideation / behavior, ease in 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 in a negative way (whose root in the case of depression is found in a self-esteem lacerated).

Depression is 2.5 times more common in people with social phobia than in the general population. In addition, the similarity that they harbor in the aspects outlined could cause that in some cases they are not detected in the proper way. The presence of these two disorders simultaneously translates into a more severe clinical picture of social phobia, a lower taking advantage of the support that the environment can offer and a marked tendency to acts or thoughts of nature autolytic.

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 former. Around half of patients with social anxiety will suffer from such a mood disorder at some point in their life, 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 affective suffering.

Among people with generalized social phobia, a greater probability of atypical depressive symptoms (such as sleeping and eating excessively, or having difficulty regulating states internal). 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 expansiveness and probable periods of depression) and type II (with episodes of less intense effusiveness than the previous one, but alternating with moments depressive). Nowadays, a wide range of risk is estimated for its comorbidity with social phobia, which ranges between 3.5% and 21% (depending on the research that is consulted).

In the event that both problems coexist, a more intense symptomatology is usually appreciated for both, an accentuated level of disability, longer affective episodes (both depressive and manic), shorter euthymic periods (stability of life affective) and a relevant increase in the risk of suicide. Also in such cases it is more common for additional anxiety problems to arise. Regarding the order in which they are presented, the most common is that bipolarity is the one that erupts 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 outlined., becoming evident a worse response to them. Special caution should also be exercised 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.

3. Other anxiety disorders

Anxiety disorders share a large number of basic elements, beyond the notorious differences that demarcate the limits between one and the other. 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 refer to another picture anxious throughout its life cycle, generally more intense than what is usually observed in the population general. Specifically, it is estimated that this comorbidity extends to half of them (50%).

The most frequent are specific phobias (intense fears of highly specific stimuli or situations), panic disorder (crisis of great physiological activation of origin uncertain and experienced in an unexpected / aversive way) and generalized anxiety (worry that is very difficult to "control" due to a wide range of situations everyday). Agoraphobia is also common, especially in patients with social phobia and panic disorder (Irresistible fear of experiencing episodes of acute anxiety somewhere where escaping or asking for help could be difficult). The percentage of comorbidity pendulous 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 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 stimulus very well detonating. In addition, complain of recurring / persistent concerns, but only focused 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, to which acts or thoughts continue to alleviate it. These two symptoms usually forge a functional and close relationship, which "boosts" their 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 that around 2% -19% of those with social anxiety will present symptoms of OCD throughout their life.

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 be noticeably aggravated, 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 tend to have a good awareness of the problem and request 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 the own appearance that does not really exist, and increases feelings of shame that the person might hold. 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 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 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: re-experiencing (thoughts or images about the trauma), hyperarousal (feelings of constant alertness) and avoidance (running away / escaping from everything when it could evoke the events of the last).

Throughout the evolution of PTSD, it is common for symptoms that are fully compatible with this social anxiety to appear (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 major depression and different anxiety pictures (among which have been pointed out in a section previous). Likewise, there are studies that suggest that subjects with PTSD and social phobia tend to feel more guilty about the traumatic events that affect them. It corresponded to testify, and even that there could be a more accused presence of child abuse (physical, sexual, etc.) in his history of life.

• You may be interested: "PTSD: A Quick Guide to Your Treatment"

6. Alcohol dependence

About half (49%) of people with social phobia develop alcohol dependence at some point, which translates into two phenomena: tolerance (need to consume more substance to obtain the effect of the beginning) and syndrome of abstinence (formerly popularized as "mono" and characterized by deep discomfort when the substance on which it depends is not around). Both the one and the other contribute to the emergence of an incessant search / consumption behavior, which requires a lot of time and gradually deteriorates the person presenting 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 of themselves a performance extraordinary. Alcohol works by inhibiting the activity of the prefrontal cortex, which is why this task is achieved, despite the fact that a significant 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 forming as a result of a process that It is known as self-medication (consumption of alcohol whose purpose is to reduce subjective pain and that never obeys criteria doctors).

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 ties is accentuated. In addition, and how could it 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 everyday experience; What interpersonal inhibition, feelings of inadequacy and affective hypersensitivity to criticism. However, other investigations do find qualitative discrepancies, despite the difficulty of recognizing them in the clinical setting.

The degree of overlap is such that a 48% comorbidity is estimated between the two conditions. 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 to fit 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, since they tend to reproduce especially in first-degree relatives, although the exact contribution of learning within the breast is not yet known family.

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.