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

The fact is that our species has been able to progress and become what it is today above all because of its ability to collaborate with large groups, within which it could find help from other individuals in the event that it needed it. Loneliness and ostracism, in those primitive societies, were something to be feared and avoided.

Because an important part of the brain that we possess 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 every human being.

Underlying this ancestral fear is social phobia, a very prevalent anxiety disorder in today’s society, which is often associated with a 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, which is characterized by an intense fear of exchange situations involving judgment or evaluation . The affection that arises is of such intensity that the person apprehensively anticipates (even for days, weeks or months) any event in which he or she must interact with others, especially when his or her performance is going to be subjected to analysis or scrutiny. Such feelings have an aversive experiential component, upon which a constant “effort” is built to avoid interpersonal encounters.

In the case of not being able to avoid them, the exposure takes place with intense and unpleasant physiological sensations (tachycardia, sweating, blushing, trembling, accelerated breathing, etc.), together with the emergence of automatic thoughts that submerge the person in negativism and desolation (“they’re going to think I’m stupid”, “I have no idea what I’m saying”, etc.). The attention on the body increases; and a very clear repudiation of blushing, trembling and sweating arises (for considering them more evident before a spectator). The “judgment” on one’s own performance is cruel/punitive, disproportionate to the actual performance appreciable by others (which is generally described as “better” than what the patient perceives).

There are different degrees of severity for the disorder in question, with a distinction being made between patients who show specific profiles (or who are only afraid of a restricted range of social stimuli) and those who have a generalised fear (aversion to almost all of these). In both cases, there would be a substantial reduction in the quality of life, and the development of the individual would be conditioned at a family, academic or work level. This 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 coexisting with other clinical mental health conditions, which strongly compromise its expression and evolution . These comorbidities of social phobia acquire a capital importance, and should 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 covered in the text of diagnostic manuals (such as the DSM or the ICD), in addition to other problems that are particularly disabling.

It should be noted 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 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 disturbance (insomnia or hypersomnia), suicidal ideation/behaviour, easy 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 fear of being judged negatively (whose root in the case of depression is 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 above-mentioned aspects could cause that in some cases it is not detected in the appropriate way. The presence of these two disorders simultaneously translates into a more serious clinical manifestation of social phobia, a lesser use of the support that the environment can offer and an accentuated tendency to acts or thoughts of an autolytic nature.

Most commonly, social phobia sets in before depression (69% of cases) , since 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 have a social phobia. In these cases of comorbidity, the risk of work problems, academic difficulties, and social impairment will increase, which in turn will fuel the intensity of emotional suffering.

Among people with generalized social phobia, a greater likelihood of atypical depressive symptoms (such as excessive sleeping and eating, or difficulty regulating internal states) has been observed. In these cases, the direct consequences on daily life are even more numerous and pronounced, making a deep therapeutic follow-up necessary.

2. Bipolar disorder

Bipolar disorder, included in the category of psychopathologies of the mood, 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). Today a wide range of risk for comorbidity with social phobia is estimated, ranging from 3.5% to 21% (depending on the research consulted).

In the case that both problems coexist, a greater intensity of symptoms is usually observed for both, an accentuated level of disability, more lasting affective episodes (both depressive and manic types), shorter euthymic periods (stability of emotional life) and a relevant increase in the risk of suicide . Likewise, in such cases it is also more common for additional anxiety problems to arise. As regards the order in which they occur, it is most common for bipolarity to appear first (which becomes evident after adequate anamnesis).

There is evidence that drugs (lithium or anticonvulsants) are usually less effective in comorbidities such as the one described above , making evident a worse response to them. Special caution should also be taken 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 obvious differences that demarcate the boundaries between them. Worry 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 report another anxious picture 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 that are lived in an unexpected/aversive way) and generalized anxiety (very difficult to “control” concern for a wide range of daily 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 escaping or asking for help could be difficult). The percentage of pendulum comorbidity ranges from 14%-61% in specific phobias to 4%-27% in panic disorder, these two being the most relevant in this context.

It’s important to note that many patients with social anxiety report experiencing sensations equivalent to those of a panic attack, but with the caveat that they can identify and anticipate the trigger stimulus very well. Likewise, they complain about recurrent/persistent concerns, but only focused on issues of a social nature . These particularities contribute to distinguish social phobia from a panic disorder and/or from generalized anxiety, respectively.

4. Obsessive-Compulsive Disorder (OCD)

Obsessive-Compulsive Disorder (OCD) is a clinical phenomenon characterized by the irruption of intrusive thoughts that generate great emotional distress, which are followed by acts or thoughts whose purpose is to relieve it . These two symptoms usually forge a functional and close relationship, which “enhances” 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 about 2%-19% of those with social anxiety will have OCD symptoms 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 the symptoms and social fears are usually significantly aggravated, exacerbating the emphasis on self-observation of one’s body during interactions with others. Suicidal ideation is increased to the same extent, and milder beneficial effects are manifested in drug 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 alteration generates an exaggerated perception of a very discrete physical defect or complaints about a problem in one’s appearance that in reality does not 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 reticence to excessive exposure to others.

5. Post-Traumatic Stress Disorder (PTSD)

Post-traumatic stress disorder (or PTSD) emerges as a complex response to a particularly distressing or upsetting 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).

On a clinical level, three cardinal symptoms are evident: re-experimentation (thoughts or images about the trauma), hyper-activation (feelings of constant alertness), and avoidance (running away from everything when it could evoke the events of the past).

Throughout the evolution of PTSD, it is common for symptoms to appear that are fully compatible with this social anxiety (43%) , despite the fact that the inverse 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 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 for the traumatic events they had to witness, and even that there could be a more pronounced presence of child abuse (physical, sexual, etc.) in their life history.

6. Alcohol dependency

Approximately half (49%) of people with social phobia develop at some point a dependence on alcohol , which translates into two phenomena: tolerance (needing to consume more substance to obtain the effect of the principle) and withdrawal syndrome (previously popularized as “mono” and characterized by a deep malaise when the substance on which one depends is not around). 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 use this substance in order to feel more uninhibited at times of a social nature where they demand extraordinary performance from themselves. Alcohol acts by inhibiting the activity of the prefrontal cortex, so this is achieved, despite paying a significant toll: the erosion of “natural” coping strategies to deal 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 whose purpose is to reduce subjective pain and which never obeys medical criteria).

Those who present this comorbidity are also at a higher risk of suffering from personality disorders (especially antisocial, borderline and avoidance), and that the fear of forming bonds is accentuated. In addition, and as it could not be otherwise, the risk of physical and social problems derived from the consumption itself would be greatly increased.

7. Avoidance 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, the feeling 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 an estimated 48% of comorbidity between the two tables exists. 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 more common in these cases, as is suicidal ideation and behavior. There seems to be a clear genetic component between these two mental health conditions, since they tend to reproduce themselves 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.