Running head: FEAR OF PYSIOLOGICAL SYMPTOMS

Fear of Physiological Symptoms in Social Anxiety Disorder/Social Phobia

Tom Cremer

December 15, 2000

Fear of Physiological Symptoms in Social Anxiety Disorder/Social Phobia

Teresa considers herself an average person. Although a shy child she developed normally and even flourished as she got older. In the fifth grade she moved to a new city after her father transferred. The new school was much bigger than her last and all her classmates seemed to be absorbed in their own little groups of friends. Things did not seem easy for Teresa as she struggled to fit in. Despite doing well academically she remained socially isolated and she felt she did not connect well with any group of friends. One day after being called on in class she was unable to answer. She felt her heart beat furiously and she began to feel the sweat drip from her palms and a blush appear on her face. One student sitting nearby yelled out "Look she’s blushing!" to which the other students erupted in laughter. This was a terribly humiliating experience for Teresa and she soon began to worry about sweating or blushing when she was called on. While taking tests she worried that the teacher would notice wet marks on her papers. The more she worried about these problems the worse it became. She soon found herself avoiding the teacher’s gaze by sitting in the back of the class and pretending not to listen. She would wake up in the morning in dread of what might happen in the coming day.

Despite doing well in school and making a few friends over the coming years, she continued to dread appearing socially anxious in school. Not only was it bothering her in school, it started to bother her in other situations as well. Teresa found herself becoming nervous in more and more situations. She soon began to fear common everyday social interaction. Driver’s training was almost unbearable as her hands poured sweat onto the steering wheel, which visibly irritated the driving instructor. One time after going out with her boyfriend, a close friend jokingly accused her of a little "hanky panky." She laughed and was startled when her friend said, "Look, she blushing!" This caused her to examine herself more closely in other social situations, which invariably led to more blushing and sweating. Soon a vicious cycle started where anxiety over appearing embarrassed caused her to be hyper-vigilant over these symptoms appearing. As soon as she would entertain the thought of these symptoms appearing, they almost surely did.

Life was now a struggle as she tried to avoid situations that made her uncomfortable. She imagined that everyone was aware of her problem and were waiting for her to perform as expected. She cringed at the thought of people noticing her symptoms and could accurately recall all the situations where someone had pointed it out. She was sure that everyone was laughing at her, or thought of her as some sort of strange object for displaying these signs of embarrassment in seemingly normal situations.

Teresa’s story is typical of those suffering from Social Phobia. Social Phobia is the excessive fear of being negatively evaluated or humiliated, or embarrassment over appearing anxious (DSM-IV, 1994). Recently Liebowitz et al. (2000) has proposed using the term Social Anxiety Disorder (SAD), as it better conveys the seriousness of the problem. SAD has two distinct subcategories. These subtypes are related to the etiology of the anxiety symptoms. The first term is Specific, Circumscribed, or Non-Generalized and is characterized by only one or a few situations that a sufferer fears, and Generalized SAD is a more general fear of almost all social situations (Marshal, 1996).

The successful avoidance of a social interaction leads to a decrease in anxiety. This leads to a feeling of relief, but also continues a cycle of avoidance. One may adopt certain behaviors which are negatively reinforcing. Some of these behaviors include diverting the eyes, smiling, fleeing the situation, clenching one’s hand to prevent trembling, fidgeting with books to divert attention away from blushing, or holding a cold soda can to prevent sweating of the palms (Miller, 1996). These behaviors help to reduce anxiety in the short term, but they do nothing to improve the underlying problem. Typically the people that suffer fear people are judging them negatively and so great caution is taken in trying to present themselves favorably. Often the sufferer is aware that they are being overly critical of themselves (DSM-IV, 1994), that the fear is illogical, and that in reality they have nothing to fear or be embarrassed about (Belliner, 2000).

A principle component in many people with SAD is that one will show physiological symptoms (blushing, sweating, shaking) that will lead to negative evaluation (Stein, 1998; DSM-IV, 1994). These fears often become all encompassing and often lead to more Generalized SAD. This paper will deal primarily with the two most documented physiological aspects of SAD, which is of excessive blushing (Erythrophobia), and excessive sweating (Hyperhidrosis). Conventional therapies include pharmacological intervention, and combinations of stress reduction, assertiveness training, cognitive-behavioral therapy, systematic desensitization, social skills training, and paradoxical intention. According to Telaranta (1998) in cases where psychotherapy and long term use of psychotherapeutic agents have been tried without success, it is appropriate to try Endoscopic Thoracic Sypathectomy (ETS). The use of ETS is well documented in the case of excessive sweating and blushing (e.g., Wittmoser, 1985; Yilmaz 1996; Cohen, 1998; Sayeed 1998).

Epidemiology

It is estimated that 1 out of eight people (13.3%) suffer from SAD at some time in their lives. At any given time, about 2 percent suffer from the advanced form of this disorder. This makes it the third most common psychiatric illness next to major depression and alcohol dependence (Kessler et al., 1994). Despite its prevalence, it has received little attention because of the very nature of the disorder. People with SAD typically shun the spotlight and are unlikely to bring it to the attention of a doctor or mental health professional (Roy-Byrne, 1993).

As seen in table 1, anxiety symptoms are common and often lead to functional impairment. In a study on the National Comorbidity Survey, Kessler (1998) reports on six different fears. These are presented in the graph below:

Table 1. Lifetime Prevalence of social Fears and Social Phobia Among Respondents in

The National Comorbidity Survey (N=8,098) Graph in Kessler et al (1998)

As seen in the graph, lifetime prevalence of all social fears is 38.6%. Of the 38.6% sample, 34,5% have a lifetime prevalence of SAD. This results in an overall lifetime prevalence of SAD at 13.3%. This represents a sizeable proportion of the population. Kessler (1998) criticizes the National Comorbidity Study as not being specific enough in the types of fears investigated. It does not distinguish between simple phobias and disabling phobias. This study did not parcel out who has the fear of blushing or sweating.

Kessler et al. (1998) reports that other mood disorders that run concurrent with SAD with one or more social fears are 46.7%. Those people with SAD who have any other anxiety disorder are 60.8%. Those with any addictive disorder are 40.6%. Those with Antisocial personality disorder are 9.5%. Those with any disorder are 82.4%.

For those with public speaking fears only 10.7% found significant life impairment. Those with one other non-public speaking fear, 22.3 found significant impairment. Of those with two fears, 20.7 found significant impairment. Those with three or more fears, 41.6% found significant impairment. This results in an overall total of 33.9% of people with any social fear having significant impairment. Of those with any fear, 23.1 had sought treatment from a medical doctor, 15.7 had sought help from any other professional, and 9.5% had taken medication more than once for their fear. (Kessler et al., 1998) Those with significant impairment often turn to drugs and alcohol (Telaranta, 2000).

Treatments

SAD is often considered to respond well to treatment. In most studies 89% respond to treatment. However, according the National Comorbidity Study, Kessler (1998) reports on a study by Turner that found only 51% maintained their gains and for those with a fear of sweating, shaking or blushing, treatment appears to be much more difficult (Leary, 1995). The first treatment option we will discuss is stress reduction. Usually treatment options are combined for the best possible outcome.

Stress reduction

Physiological arousal can be lessened through stress reduction. To reduce overactivity of the sympathetic nervous system (Katkin, date unknown) says it is advisable to

1. Diet: Avoid caffeinated beverages, and high sugary snacks. A Diet high in complex carbohydrates such as fruits and vegetables, whole wheat breads, and lean meats, is also advisable.
2. Exercise: Aerobic (jogging, walking, and cross-country skiing) exercise 3 times a week. Weight training on the odd days contributes to overall fitness and lean muscle tissue. Exercise also leads to a better capacity to handle stress.
3. Relaxation exercises: Done three times daily reduces stress and adds to an overall feeling of well being. progressive relaxation or yoga is recommended. Relaxation exercises helps you recognize when you are feeling stressed and uptight, and to release the tension when tension is felt.

Assertiveness Training

Learning to be assertive increases self-confidence. This means learning to express views and being able to say "no" to people. The patient must learn to face the people who have intimidated them in the past. It is important for the patient to express feelings and hidden fears (Katkins, date unknown).

Cognitive Behavioral Therapy

In order to understand the Cognitive Behavioral Therapy (CBT) model for treating anxiety, one must first understand the theory behind it. According to Otto (1999) people with SAD bring negative expectations to social situations. These fears include poor social performance, negative evaluations from others, and uncontrollable anxiety. The result is that the person with SAD goes into a social interaction worrying about impending failure. Attending to what might go wrong leads the person unable to fully concentrate on the social interaction and leading the person to interpret minor social pratfalls worse than what they really are. Instead of focusing attention on the conversation at hand, the socially anxious attends to a wide array of "off task" thoughts and events. A person with SAD worries about making too much eye contact, or too little. A person with SAD may worry that they are not assertive enough, that they are too loud or too quiet, or that the other person is noticing the sweat on their brow or a blush on their face. Add to this mistaken certainties or mistaken beliefs that the person holds. Feeling that one has to perform flawlessly, making errors equals failure, or that being different will lead to rejection (Otto 1999). Three beliefs are most common according to Otto (1999):

1. Errors, even small errors, are evidence that a person is socially inept.
2. The anxiety response itself in social situations is a sign that a person is defective and a failure.
3. Any behavioral performance that diverges from "normal" is additional evidence that a person is defective and deserves to be rejected.

According to Otto (1999) the experience of anxiety is one of the most important cues to a person with SAD that they are failing. Otto (1999) quotes McEwan (1983) who states that "there is evidence that individuals with Social Phobia tend to believe that the way they feel is the way in which they are perceived by others." The increased anxiety, attention to performance, and expectation of negative social outcomes leads to the desire to escape and avoid these situations.

When one goes into a situation with negative expectations, this leads to apprehension and hyper-vigilance. This failure focused attention leads to diverted attention and detection of errors, which leads to anxiety. Faulty cognition’s leads to amplifying these mistakes causing extreme anxiety. This anxiety leads to the perception of failure and avoidance or escape and use of safety behaviors. All this leads to a confirmation of negative expectations (Otto, 1999).

The goal of CBT is to identify problem areas that maintain the cycle of anxiety. CBT treatments for SAD need to:

1. Correct dysfunctional thoughts that create apprehension and anxiety.

2. Correct core amplifying cognitions.
3. Modify failure-focused attention.
4. Decrease avoidance and safety behaviors.
5. Increase exposure to and accurate evaluation of performance and outcome in social situations.

(Otto, 1999). Often CBT is combined with pharmacological therapy.

Pharmacological Treatment

Available pharmacological treatments include Beta-Blockers, Monoamine Oxidase Inhibitors (MAOIs), Benzodiazepines, and Selective Serotonin Reuptake Inhibitors (SSRIs). Initial treatment options should consider comorbidity, prior treatment history, patient preference, and adverse effects (Pollack 1999).

Beta Blockers. Beta-Blockers decrease over activity of the sympathetic nervous system. This decrease in sypathetic action leads to a decrease in tachycardia, tremors, sweating, and blushing. Pollack (1999) mentions a study by Gorman et al. (1985) in which an open clinical trial suggested that atenolol (50-100 mg/day) was effective for both generalized and non-generalized performance-related symptoms. Response rate was 40% in specific SAD and 28% in Generalized SAD. Propranolol (10-80 mg/day) or atenolol (10-50 mg/day) can be used either daily or on an as-needed basis. Atenolol appears to cause less sedation and other adverse central nervous system effects than Propranolol. (Pollack 1999).

Monoamine Oxidase Inhibitors (MAOI). Once considered the treatment of choice, MAOI’s are being replaced with SSRI’s as the first line of pharmacological treatment. Because MAOI’s have many side effects, food restrictions, and contradictions, SSRI’s are often tried first. Phenelzine effectiveness was shown in a double-blind comparison trial against atenolol and placebo in 74 patients with SAD. Among patients on Phenelzine, 64% responded to treatment versus 30% on atenolol or placebo (23%)(Liebowitz et al, 1992).

Side effects of phenelzine can include dizziness, diarrhea, weight gain, insomnia, tiredness, difficulties in initiating urination, hypertensive crisis, and sexual dysfunction. Interest in Reversible Inhibitors of Monoamine Oxidase A (RIMAs), which have few side effects and no food restraints. Moclobermide and Brofaromine have proven effective but are unavailable in the United States. They may not be any more effective than other drug treatments (Pollack, 1999).

Benzodiazepines. Benzodiazepines have demonstrated their effectiveness in treating SAD. Liebowitz et al (1999) reports on a study by Davidson et al., where 75 patients were evaluated who underwent clonazepam treatment and reported a 78% response rate. In a study comparing CBT, Alprazolam, and Phenelzine, Alprazolam demonstrated a 38% response. Alprazolam also had a high incidence of relapse after treatment ended.

Advantages of benzodiapines include rapid response rate, use as needed, and rapid dose adjustment. The disadvantages are sedation, ataxia, cognitive impairment, and withdrawal symptoms. In addition, there is the danger of addiction in alcoholics, which are more likely to abuse these drugs. Benzodiazepines can be administered during the time that other medications such as SSRI’s need to take effect, and may blunt adverse symptoms that are common in the early weeks of administration.

Selective Serotonin Reuptake Inhibitors. Considered the first line of treatment for SAD (Pollack, 1999). Recently Paxil has been approved by the FDA for use in the treatment of SAD. However, most SSRI’s including Prozak, Zoloft, and Celexa are all about equally effective. Administration is dependant on patient preference and the ability to tolerate the side effects. Reported studies on the effectiveness of SSRI’s include Fluvoxamine. In the trial, 46% of the patients improved versus 7% with placebo (Van Vliet, 1994). Other studies have reported similar results (Pollack 1999).

Systematic Desensitization is a method of therapy to gradually expose a person to a feared situation. A person with SAD is asked to make a list of situations that are feared, and list them in order from least feared to most feared. The person is then exposed to the least feared situation until they are comfortable with it. The therapist then asks the patient to confront the next feared situation and so on up the hierarchy until they can master the most feared situation with ease (Corsini, 1999).

Paradoxical Intention operates under the theory that the harder you try to make something happen, the less likely it will occur (Miller, 1995). People cannot consciously control physiological symptoms, and so people cannot blush, sweat or tremble on demand. It is well known that consciously trying to inhibit a symptoms only increases it. Trying to stop blushing is nearly impossible, as well as consciously trying to start a blush. Very little has been studied on this type of therapy (Leary and Miller 1986) and much more study needs to be done. Snyder (1991) says ". . . paradoxical interventions holds considerable promise as a framework from which to view the maintenance and alleviation of emotional disorders."

Social Skills Training operates under the theory that people suffer from social anxiety because they do not know how to act in social situations. By learning proper ways to interact, people with social anxiety no longer fear that they will not know how to act in a social situation, thereby reducing anxiety. For most, it is not knowing how to act, but intense anxiety makes the person unable to act appropriately (Berent, 1993).

Although there are no studies to confirm this statement, Marshall (1994) says that SAD is a severe disorder and the sufferer generally needs professional help. Self Help books are rarely of any significant help by themselves. Self-help books can be a valuable tool in conjunction with therapy. The patient can read these while at home and come to a better understanding of his condition. It is also good for refreshing and emphasizing what was learned in the therapy session and to prepare the patient for better understanding during the therapy session. It is often helpful for the patient to read about his condition as it often is a relief to them to find out that they are not alone and that there are treatment options available (Marshall, 1994).

Although considered a relative newcomer in the treatment of anxiety disorders, Rex (1998) reports that Kotzareff (1920) used sympathectomy for Hyperhidrosis over 80 years ago. Sympatectomy has been used for the treatment of Erythrophobia for about ten (Drott, 1998). The invasiveness of the original procedure caused it to remain almost unknown and little used. After the first large-scale studies in English came out in the 1980’s ETS has become the treatment of choice in Hyperhidrosis (e.g., Byrne et al, 1990; kux 1978 Zacherl 1998). Its use is still controversial and not without its side effects. Further acceptance of the procedure is going to depend on the success of recent developments in the field. Some doctors do not consider this a valid option for a benign condition. For those unfamiliar with the procedure, it is important to understand the history, and how the sympathetic nervous system relates to ETS.

The autonomic nervous system. The autonomic nervous system is a set of neurons that sends and receives information from the organs of the body. It is composed of two parts: The sympathetic and parasympathetic nervous system. The sympathetic nervous system consists of two paired chains of ganglia (collections of neuron cell bodies) lying to the left and right of the spinal cord. The chains have bundles of nerve fibers called ganglions running along it’s length and are numbered T1-T12. The sympathetic nervous system prepares the body for the "fight or flight" response (Kalat, 1994). Innvervation of the hands, face, and heart lies at the second thoracic ganglion (T2) level of the sympathetic nervous system. This usually lies on the second rib. By cutting or clamping the sympathetic nerve at the T2 level, activation is reduced closer to normal (Joffe, 2000).

Drott (1996) talks about the history of sympathectomy at the First International Symposium on ETS. Alexander did the first sympathectomy in 1889. In 1920 Kotzaref operated on a woman with Hyperhidrosis, and in 1921 Jonnesco performed sympathectomy for Angina Pectoris. The initial indications for surgery were Angina, Hyperhidrosis and vasospastic conditions (Drott, 1996). Various methods for accessing and transecting the sympathetic chain were used in the ensuing years. Some called for dividing the pre-ganglionic fibers and others called for the removal of the sympathetic chain. All these methods involved an "open" approach where a 3 to 5 inch cut was made to access the sympathetic chain. These methods involved considerable trauma to the patient and involved a long recovery time. In 1951 Kux was the first to use a thorascope to access the sympathetic chain. A thoroscope is a long thin tube which can be inserted into a small hole in the chest. The chain can then be located by peering through the thoroscope and surgical instruments can be inserted through the tube to transect the sympathetic chain. In 1954 Kux was the first to publish a large-scale review of approximately 1000 patients. Acceptance of the procedure did not begin until the 1980’s when reports began appearing in English journals (Drott, 1996). More recently Lin (1998) reported on a reversible procedure, using a surgical clip to block nerve transmission (See also Telaranta, 1998).

ETS and SAD. To date very little is known about the effects of endoscopic thoracic sympathectomy for the treatment of SAD in patients who do not have the obvious outward physical manifestations of sweating and blushing. One study by Dr. Telaranta points to the efficacy of ETS for the treatment of SAD (Table 2) but does not differentiate how many patients had only anxiety with no outward physical manifestations. The scale below has patients rate the annoyance and severity of symptoms rated on a six point scale from 0, not at all feared or debilitating, to 5 extremely feared and debilitating. The average rating of annoyance is printed first under the columns, followed by the average that people differed in their ratings on the amount of annoyance it caused them. The figure in brackets is the margin of error. For palmer sweating, the average annoyance to patients before sympathectomy was 3.1 and varying plus or minus 1.6 points and after sympathectomy the average was 0.55 +/- 0.78.

Table 2.

Changes in perceived sweating after bilateral sympathicotomy **

*p<0.001

**Graph reprinted from Telaranta (1998), the column for Raynaud’s sydrome was not included.

ETS for Hyperhidrosis. Hyperhidrosis is excessive sweating beyond physiological needs. It is often marked with increased social anxiety and marked impairment in social, educational, and occupational situations. Excessive sweating of the palms causes an inability to handle tools and writing utensils, and the smudging of paper. Conservative treatments such as ionepress, anti-perspirants, and psychotherapy often prove ineffective for severe cases. ETS is the treatment of choice for severe cases (Kux, 1978; Zacherl 1998).

ETS for Facial Blushing. Patients who underwent sympathectomy for hyperhidrosis expressed relief to their doctors that their capacity to blush was markedly reduced or eliminated (Drott, 1998). Chronic facial blushing is considered a sub-type of SAD and is the leading complaint among patients with social phobia. Patients fear blushing in response to common everyday social interaction, such as conversing with a friend, speaking out in class, or making a transaction at a store or bank. It is often that the patient is embarrassed of the physical symptom of blushing and therefore blushes, instead of blushing as a result of embarrassment. As the patient unexpectedly blushes in new situations, more and more situations become feared. This leads to a phobic avoidance of those situations which the patient fears blushing (Miller, 1996). Conservative treatments of psychotherapy often work well to help the patient cope, but do little to stop the blushing. Occupational advancement and educational advancement are avoided as one fears that others will belittle or not take seriously the person who blushes. An observer often misunderstands blushing as either illness or a sign of romantic interest. In some cases it is pointed out and ridiculed by the observer.

Conclusion

Some common fears in SAD include blushing, sweating, or shaking in public. These fears are often central to the experience (Marks and Gelder 1966). The relief of these symptoms is as effective as CBT (Heimberg RG, 1991). Scholing (1993) says, "A central characteristic is a vicious circle, in which maladaptive cognitive processes (like anticipatory fear of the symptoms) produce distress and, as a self-fulfilling prophecy, subsequently lead to exacerbation of the symptoms."

With the recent attention that SAD has received, very little attention has been paid to the fear of physiological symptoms that are so prevalent in the disorder. While conventional therapies seem to work well for mild symptoms, it is evident that treatment of more severe physiological symptoms is not as effective. As many as one third undergoing cognitive-behavioral and pharmacological interventions do not respond to treatment (Lipsitz, 1999). Scholing (1999) reports about a study by Turner (1994) on the National Comorbidity Study that only 51% benefit from cognitive-behavioral treatment. These studies are a little difficult to interpret as they do not distinquish between SAD with a fear of physiological symptoms and SAD with broader negative cognitions.

While many have learned to improve their negative cognitions, reducing the symptoms satisfactorily is another matter. Medications improves symptoms remarkably in a large number, but for many they do not. ETS is the only therapy that has proven effective in the total elimination of symptoms and the parallel cognitions. When other treatments have failed, ETS should be considered.

For patients considering treatment options, it is important to consider CBT to help learn better ways of coping and relating to other people. Although for many people, eliminating the symptoms is enough to spur progress on the cognitive side, many will still need therapy or social skills training to better assimilate into society.

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