As a graduate student at Florida State University, Richard Heimberg, PhD, was fascinated by the effects of people's intense social anxiety on their relationships. However, in the 1970s, no name existed for this type of anxiety, and Heimberg says many people wrote it off as shyness or a personality trait. After all, many people get a little anxious when delivering a speech to a crowd. But it's the more severe cases that cause Heimberg concern--when those fears of being judged by others become so persistent and intense that they extend to almost all social situations, from informal conversations to eating in public.

People diagnosed with the condition, social phobia--also known as social anxiety disorder--may avoid many social situations out of fear that others will notice something unusual about them, like their shaking hands or blushing, and that their actions will embarrass or humiliate them. To help them overcome the condition, Heimberg, a Temple University psychology professor, has made studying the origins of and treatments for social phobia his life's work. In 1983, he became the first researcher to receive National Institute of Mental Health (NIMH) funding to study psychosocial treatments for social phobia after the term first appeared in the third edition of the Diagnostic Statistical Manual of Mental Disorders in 1980 (DSM-III).

"Dr. Heimberg has made huge contributions to social phobia research, developing a cognitive-behavioral treatment for social phobia and carrying out numerous randomized controlled trials that have demonstrated its effectiveness," says psychologist Jacqueline Persons, PhD, a former president of the Association for Advancement of Behavior Therapy (AABT) who served with Heimberg on the AABT board. "He has made important contributions to alleviate a great deal of suffering." Since Heimberg secured the first NIMH social phobia treatment research grant, such funding has been readily available because the condition is quite common: It's the third most prevalent mental disorder behind depression and alcoholism.

About 5.3 million American adults have social phobia, which usually begins in childhood or adolescence, according to NIMH. For many social phobics, preoccupation with what others think may interfere in their job, school, relationships or other social activities. "Everyday interactions can become very problematic for people with social anxiety disorder," says Heimberg who, as director of Temple University's Adult Anxiety Clinic, helps people change their thought processes in such interactions using cognitive-behavioral therapy (CBT) and medication. The treatment also encourages clients to expose themselves gradually to feared events. A debilitating disorder Since 1983, Heimberg has conducted a series of NIMH-funded studies on social phobia. Most recently, he received a $1.2 million, four-year NIMH grant--which he's in the second year of--to investigate whether the addition of CBT to medication treatments can help prevent patients' relapse.

Through his 20-plus years of research, Heimberg has found that nearly everyone fears social situations to some degree. "Some people just think they are shy--that it's a personality trait--and that's just the way they are," says Heimberg. "But...if a person starts fearing many social situations, [and as a result] lives alone or drops out of school, that's not shyness--that's an impairment." What's more, notes Heimberg, social phobia is generally more debilitating than phobias focused on singular circumstances, such as a fear of thunderstorms or animals. "If you are afraid of interacting with people, that can mess you up wherever you turn," he says. "It can have very broad mental health implications."

Heimberg also notes two subtypes of social phobia. For people with a "generalized" type, the social anxiety ranges across a broad number of social interactions; for those with a "specific" type, the anxiety involves only one or a few social encounters, such as public speaking or eating in public. Therapy's staying power The trouble is, despite the proven efficacy of treatment, many social phobics shy away from it, according to Heimberg's research. For example, he found that 92 percent of people who were accessing information on social phobia on an anxiety clinic Web site met criteria for social anxiety disorder.

Yet, only about 36 percent of the respondents reported receiving psychotherapy; 35 percent reported taking medication for social anxiety disorder, according to a study by Heimberg and psychologists Brigette Erwin, PhD, Cynthia Turk, PhD, David Fresco, PhD, and Donald Hantula, PhD, in the 2004 issue of the Journal of Anxiety Disorders (Vol. 18, No. 5, pages 629-646). But, with CBT treatment or antidepressant medication, about 80 percent of social phobics can alleviate their symptoms, Heimberg says. What's more, clients who receive CBT treatment remain improved five years later, whereas clients who receive only medication treatment are more likely to relapse than clients receiving CBT, according to Heimberg's 1998 study in the Archives of General Psychiatry (Vol. 55, No. 12, pages 1,133-1,141).

However, Heimberg suspects a combination of CBT and medication may prove most effective in preventing relapse--something he hopes to prove in his latest NIMH study with Michael Liebowitz, MD, of the New York State Psychiatric Institute, to be completed by 2007. Heimberg is providing participants with a 28-week treatment program that includes medication--in this case, the antidepressant Paxil--and some patients then receive 16 sessions of CBT. Each session helps clients to evaluate their thought processes more critically, such as by filtering out automatic thoughts that others judge them negatively in social interactions. The client and therapist also role-play social interactions to provide the client with confidence they can take into real-world situations.

In Heimberg's CBT, the therapist gradually exposes clients to their feared social situations in real life, perhaps assigning a client to initiate a conversation with a person they don't know, ask someone out on a date or go on a job interview. "They start going into social situations that have made them tense a thousand times before, but the trick now is that they are doing it...with coping skills that will help them turn defeat into victory," Heimberg says.

FURTHER READING:

• Antony, M.M., & Swinson, R.P. (2000) Phobic disorders and panic in adults: A guide to assessment and treatment. Washington, DC: American Psychological Association.

• Beidel, D.C., & Turner, S.M. (1998). Shy children, phobic adults. Washington, DC: American Psychological Association.

• Heimberg, R.G., Liebowitz, M.R., Hope, D.A., & Schneier, F.R. (Eds.) (1995). Social phobia: Diagnosis, assessment and treatment. New York: Guilford Press.

Van Ameringen M, Allgulander C, Bandelow B, Greist JH, Hollander E,Montgomery SA, Nutt DJ, Okasha A, Pollack MH, Stein DJ, Swinson RP. CNS Spectrums. 2003; 8:40-52.

What is the best approach for treating patients with social phobia(social anxiety disorder) over the long term?

Social phobia is the most common anxiety disorder, with reported prevalence rates of up to 18.7%. Social phobia is characterized by a marked and persistent fear of being observed or evaluated by others in social performance or interaction situations and is associated with physical,cognitive, and behavioral (ie, avoidance) symptoms. The onset of social phobia typically occurs in childhood or adolescence and the clinical course, if left untreated, is usually chronic, unremitting, and associated with significant functional impairment.

Social phobia exhibits a high degree of comorbidity with other psychiatric disorders,including mood disorders, anxiety disorders,and substance abuse/dependence. Few people with social phobia seek professional help despite the existence of beneficial treatment approaches. The efficacy, tolerability, and safety of the selective serotonin reuptake inhibitors (SSRIs), evidenced in randomized clinical trials, support these agents as first-line treatment. The benzodiazepine clonazepam and certain monoamine oxidase inhibitors(representing both reversible and nonreversible inhibitors) may also be of benefit. Treatment of social phobia may need to be continued for several months to consolidate response and achieve full remission.

The SSRIs have shown benefit in long-term treatment trials, while long-term treatment data from clinical studies of clonazepam are limited but support the drug's efficacy. There is also evidence for the effectiveness of exposure-based strategies of cognitive-behavioral therapy, and controlled studies suggest that the effects of treatment are generally maintained at long-term follow-up. In light of the chronicity and disability associated with social phobia, as well as the high relapse rate after short-term therapy, it is recommended that effective treatment be continued for at least 12 months.

Anxiety and Stress Disorders Institute of Maryland:
Treating anxiety disorders and stress-related disorders in Towson, Maryland, since 1978.