Is fear built socially or biologically

Social phobia and its effects on sexuality and relationships

Table of Contents


2.1 Diagnosis
2.1.1 The diagnostic criteria according to DSM-VI
2.1.2 Subtypes
2.2 epidemiology
2.2.1 Prevalence
2.2.2 Socio-demographic risk factors
2.2.3 Age of first appearance
2.2.4 Comorbidity
2.3 Etiology
2.3.1 Two older cognitive models from the 1980s
2.3.2 The cognitive model of Clark & ​​Wells (1995)
2.3.3 The cognitive-behavioral model according to Heimberg et al. (1995)
2.3.3 Neurobiological models

3.1 Different forms of sexual dysfunction
3.1.1 Disorders of the appetite phase
3.1.2 Disturbances of the excitation phase
3.1.3 Disorders of the orgasm phase
3.1.4 Faults outside the reaction cycle
3.2 epidemiology
3.3 Etiology
3.3.1 Etiology of sexual appetite
3.3.2 Etiology of erectile dysfunction
3.3.3 Etiology of orgasmic disorders

4.1 Epidemiological and descriptive findings
4.2 Etiological models
4.2.1 The Barlow cognitive model
4.2.2 Neurobiological models
4.3 Influence of the medication of social phobia on sexual functions
4.3.1 Alprazolam
4.3.2 Serotonin reuptake inhibitors (SRI)
4.3.3 Conclusion

5.1 Finding a partner and getting married in the case of social phobia
5.2 Social phobia and interpersonal communication styles



1 Introduction

Doesn't everyone have the need for social contact, a sense of belonging, the desire to love and be loved? In any case, when we observe our behavior, it seems like we are doing a lot to find and maintain social contact. However, there are people who would like to enter into social contacts, but are so afraid of criticism and rejection that they avoid social situations or only get through with severe fear. These people suffer from a social phobia, a mental disorder belonging to the group of anxiety disorders. This disorder with the main characteristic of a "pronounced and persistent fear of one or more social or performance situations in which the person is confronted with unknown people or could be judged by other people" (APA, 1994, p. 479) leads to impairments in the everyday life, especially in the professional or social sphere (APA, 1994; Stein & Kean, 2000). Social activities and relationships are restricted and avoided, which can lead to significant suffering (APA, 1994). The need for social contact, friendship and partnership does not seem to be sufficiently feasible for fear of negative evaluation.

It is easy to imagine the serious effects this disorder must have on quality of life, especially in the area of ​​intimate relationships and partnerships (Wittchen & Beloch, 1996; Figueira, 2001). Although an intimate relationship is likely to be severely weighed down by a partner's social phobia, few studies have reported it. Most of the research has been done on the relationship between social phobia and sexual dysfunction, since sexual dysfunction, in contrast to other aspects of a relationship, such as affection or communication style, is clearly quantifiable and measurable. For example, penis swelling in men or the amount of vaginal fluid in women can be determined with the help of objective instruments. For the reasons mentioned above, little is known about the consequences of social phobia on other aspects of a relationship.

Studies speak of a high comorbidity between social phobia and sexual dysfunction (Figueira et al., 2001; Ernst et al., 1992; Kaplan, 1988). The most important pioneers who have dealt with the connection between social phobia and sexual dysfunction are Helene Singer chaplain and David H. Barlowwith Kaplan coming from sex research and Barlow from research into anxiety disorders. Recently, several other researchers have come along with important findings (Figueira et al., 2001; Bodinger et al., 2002; et al.). In general, it can be said that, even at the level of research into this connection, social phobia is likely to lag behind other anxiety disorders.

The work is structured in such a way that first an overview of the disorders of social phobia and sexual dysfunction is given, followed by an explanation of the connection between the two disorders. Then other areas of a relationship that can be affected by the social phobia are addressed. Since these relationship problems do not represent a disorder of their own and usually follow a psychological or physical disorder as a secondary consequence, they are not explained per se, but presented in connection with the social phobia.

2 Description of the social phobia

In the past, social phobia was a disorder that was little researched and published about compared to other anxiety disorders. Today, however, research into social phobia seems to have increased significantly and is currently experiencing a real boom. Since the publication of the third edition of the "Diagnostic and Statistical Manual of Mental Disorders" (DSM-III, APA, 1980), there has been a clear diagnostic idea of ​​what a social phobia is and should contain. Social phobia is a widespread disorder in our society and, according to current knowledge, ranks third after major depression and alcoholism (Juster et al., 2000). The fact that so many studies on social phobia have not yet been published could be a consequence of the late definition of the disorder. Since social phobia has only been diagnosed as an independent disorder since 1980, it took time to develop specific knowledge of the various areas of the disorder. In addition to the epidemiological findings, there are also various aetiological models that try to clarify the causes of the social phobia.

2.1 Diagnosis

Social phobia, also known as social phobia, belongs to the group of anxiety disorders. "People with a social phobia" ... "suffer from a severe, persistent and irrational fear of social and performance-related situations in which they could get embarrassed." (Comer, 1995, p. 199). This fear can relate to one or more situations.

2.1.1 The diagnostic criteria according to DSM-VI

In 1980 the social phobia appeared for the first time as an independent disorder in the classification system DSM-III (APA, 1980). The diagnostic criteria were based on the concept of Marks & Gelder (1966). This describes social phobia as fear that occurs in situations in which a person is the focus while doing certain activities. This can be, for example, public writing, speaking, or eating. The person experiences fear when they think they may say or do something embarrassing, even if it is just that others notice their fear (Juster et al., 2000). The situations only cause fear for those affected if they have to carry out the activity in the presence of others.

In the DSM-IV (APA, 1994), which has been in force since 1994, the diagnosis of social phobia requires the criteria A-H shown in Table 1:

Table 1

Diagnostic criteria for social phobia according to DSM-IV1

Figure not included in this excerpt

A. Persistent and pronounced fear of one or more social situations, fear of being conspicuous, of being ridiculous.
B. In the dreaded situation, fear almost inevitably arises, which can resemble a panic attack.
C. People perceive the fear as excessive or unfounded.
D. The dreaded situation is avoided or only confronted with great fear.
E. The fear or avoidance interferes with normal routine, skills, relationships, or social activities.
Q. People under the age of 18 have been afraid for at least 6 months.
G. No organic causes for the fears.
H. The fears do not relate to symptoms of other mental or physical disorders, such as B. binge eating, tremors in Parkinson's disease.

Figure not included in this excerpt

2.1.2 Subtypes

In the case of a social phobia without additional coding, those affected fear certain performance-related situations such as using the public toilet, giving a lecture in front of people or eating in public (APA, 1994). According to today's diagnostic system (DSM-IV, APA, 1994), people for whom the fear relates to almost all social situations receive the additional coding generalized subtype. This type also considers the additional diagnosis of avoidant self-insecure personality disorder (APA, 1994). People with generalized social phobia usually fear both public performance situations and social interaction. Patients of the generalized subtype show more severe impairments in social and occupational functional areas and develop social deficits more often than patients without corresponding additional coding (APA, 1994). Furmark (2002), however, is critical of the determination of subtypes in social phobia and points out that there is still no agreement on how to categorize social phobia in subtypes. The discussion on the subtypes is still based mainly on theoretical speculations. The social phobia probably only existed as a diverse continuum in the population. Seen from this perspective, the division into subtypes is purely arbitrary.

2.2 epidemiology

Social phobia is a common mental disorder. Nevertheless, it is difficult to find consistent information on the epidemiological area.

2.2.1 Prevalence

The studies do not agree with one another when it comes to the information on the prevalence of the disorder. The APA (1994), for example, reports a lifetime prevalence of 3-13 percent of the population, with women being affected somewhat more frequently than men. Furmark (2002) obtained a lifetime prevalence of 7-13 percent in his meta-study. According to Furmark, the ratio of women to men is 3 to 2. The lifetime prevalence according to the "National Comorbidity Survey" study with a sample of 8000 subjects is 13.3 percent. According to this, social phobia is the third most common mental disorder after major depression and alcoholism (Kessler et al., 1994). The 12-month prevalence of social phobia is estimated at 8 percent (APA, 1994; Kessler et al., 1994).

2.2.2 Socio-demographic risk factors

In most studies, the proportion of women is higher, reaching the approximate proportion of 70-75 percent (Furmark, 2002, Kessler et al., 1994). However, there are also studies that show the opposite result. For example, under Mannuzza et al. (1990) read that more men than women undergo therapy for social phobia. The reasons for the conflicting data could be socio-cultural or gender-specific. Therefore, more men with social phobia could find themselves in psychological treatment, since in many countries the image of a fearful, shy character does not fit into the ideal image of a man. The men feel disturbed by their fear in their ideal, male self-image, suffer from it and seek treatment. However, shyness and restraint are consistently part of the conventional image of women in many countries. The disorder is not recognized, perceived and treated as such by the women themselves or by the social environment (Juster et al., 2000). However, since this reason has not yet been investigated enough, the considerations are purely speculative.

It does not seem surprising that people diagnosed with social phobia are more likely to be unmarried than people in a healthy control group (Furmark, 2002; Bodinger, 2002; APA, 1994). Since many people with generalized social phobia are afraid of social events such as parties, conversations with strangers and appointments, the likelihood of the person concerned getting to know a potential partner at all decreases. And even if an interaction takes place, the social fear can be perceived by the interaction partner as a negative and undesirable character trait, with the result that the person with social phobia no longer appears attractive to the potential partner. The fears, because they are kept secret, are often misinterpreted as disinterest, stubbornness or arrogance (Marshall, 1994). The failures of such situations increase fears and make social events even rarer. The likelihood of a relationship or marriage decreases (Marshall, 1994; Schneier et al., 1992).

Sociodemographic findings according to Schneier et al. (1992) summarize the following picture. A person with social phobia is typically female, young, with low educational attainment, low socioeconomic status, and unmarried, divorced, or separated.

2.2.3 Age of first appearance

The age of onset varies depending on the subtype. The onset of non-generalized socialophobia is around 22.6 years, while the generalized subtype begins earlier at 13 years of age (Holt et al., 1992). The average age of first appearance is 15 years in the adolescent phase of life. But there are also people who report onset in early childhood (APA, 1994).

The fact that the generalized subtype begins before the sexually active phase of life and the non-generalized social phobia only begins in the sexually active age raises the following question. Are the sexual dysfunctions the expression of a generalized social phobia preceding the sexual problems, or are the sexual problems rather the trigger for a subsequent non-generalized social phobia with regard to sexual situations? The question of these subtype-specific cause-and-effect relationships cannot yet be answered according to the current state of knowledge.

2.2.4 Comorbidity

69 percent of the social phobia is comorbid with other disorders (Schneier et al., 1992). The most common comorbid disorders are other anxiety disorders (specific phobia 59%, agoraphobia 45%), substance abuse (32%) and depression (17%) (Schneier et al., 1992). The comorbidity of sexual dysfunction is 33.3 percent (Figueira, 2001).

2.3 Etiology

When looking at the development of social phobia, the focus today is on cognitive etiology models. Your main content point is that increased self-awareness. Various studies have confirmed that socially anxious people are overly aware of themselves as a social object and therefore devote a large part of their attention to their own actions. They show a highly self-directed metacognition and lapse into excessive introspection (Kaplan, 1988; Barlow, 2002).

2.3.1 Two older cognitive models from the 1980s

These are two important cognitive etiology models Self-expression model von Schlenker & Leary (1982) and that Cognitive Vulnerability Model by Beck and Emery (1985).

According to the Schlenker & Leary model, fear arises from the increasing polarization between the motivation to make a good impression and one's own perception of a lack of self-efficacy. Accordingly, in a situation in which the person has the need to look good, but in his own opinion does not have the abilities to do so, a discrepancy arises that leads to social anxiety in the person.

In the second model, Beck & Emery assume that people with social anxiety are in "vulnerability mode", i.e. they are increasingly exposed to uncontrollable internal and external dangers, which leads to a lack of security. The people react extremely sensitively to social threats. As a result of the uncertainty, those affected focus on their own weaknesses and on previous failures. Cognitive distortions in the form of illogical, automatic and negative thoughts prevent the person from correctly assessing his or her own self-efficacy and weighing it up against the threat. Ultimately, the inability to cope with the situation is evoked in the form of a self-fulfilling prophecy. Due to the fear of a certain social situation, the fearful person often behaves in such a way that the people involved in the situation actually notice them negatively in the area affected by the fear. If those involved react negatively, this is interpreted by the person concerned as confirmation of their own inability. Action in vulnerability mode is thus increasingly intensified.For example, a socially anxious person who is afraid of a serious conversation with a good friend or partner tries to avoid the subjectively perceived danger by avoiding the conflict topic during communication, holding back his own emotions, giving few explanations and the other person hardly listens, but sometimes tells all the more about himself (Davila & Beck, 2002). From this behavior, the friend or partner concludes that they are not being taken seriously, the other is not interested in their problems and stamps the socially fearful person as self-centered and unsympathetic. The distanced behavior of the friend or partner increases the fear and insecurity of the person concerned and the longer the situation appears to him the more dangerous and uncontrollable.

A more recent model, which takes up these processes again, comes from Clark & ​​Wells (1995) and is carried out in the next section.

2.3.2 The cognitive model of Clark & ​​Wells (1995)

The cognitive model of social phobia according to Clark & ​​Wells (1995) is based heavily on the earlier models by Leary & Emery (1985, Chapter 3.2.1) and Barlow (1988, second edition 2002, Chapter 4.2.1). Figure 1 illustrates the processes that, according to Clark & ​​Wells, occur when a person with social phobia enters a dreaded situation.


1 This is a summary of the diagnostic criteria. The more detailed original can be found in DSM-IV of the "American Psychiatric Association" (1994) on pp. 473-480.

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