علت هراس اجتماعی: به سوی یک پروفایل تکاملی

Social phobia is an extremely disruptive and distressing anxiety disorder that can impact on many areas of an individual's life. Yet, despite the fact that lifetime prevalence rates are relatively high, its etiology is still poorly understood. The aim of this review is to draw together findings from the broad base of nonclinical literature associated with behavioral inhibition (BI), shyness, social anxiety, and passive-anxious withdrawal and to compare these findings with those from the limited number of clinical studies with social phobics. Such comparison is not unproblematic due to conceptual differences between terms used and methodological divergence; these issues are discussed in some detail. The consonance of findings, however, suggests a viable profile for the developmental course of social phobia. This profile incorporates temperament variables, behavioral motivational, parenting styles, peer relationships, and internalization problems. Finally, specific suggestions for future research are offered.

Social phobia is an anxiety disorder characterized by “a marked and persistent fear of social or performance situations in which embarrassment may occur” (American Psychiatric Association, 1994, p. 411). People with social phobia are concerned that they will react with noticeable and embarrassing signs of strong physiological arousal, such as blushing, shaking, or trembling. As a consequence, activities such as eating, drinking, writing or speaking in public, expressing an opinion in a group, and talking to a member of the opposite sex or to an authority figure may actively be avoided to evade the perceived negative evaluation of others. As most of our everyday functioning involves contact with other people, social phobia can be an extremely disruptive disorder, which usually causes great distress in the sufferer and sometimes for those close to them. Epidemiological studies based on Diagnostic and Statistical Manual of Mental Disorders Third Edition Revised (DSM-III-R) (American Psychiatric Association, 1987) criteria suggest that social phobia may be far more prevalent than earlier studies examining extreme social anxiety suggested. Indeed, social phobia may be the most frequently occurring anxiety disorder. Lifetime prevalence rates as high as 13.3% have been reported in the United States (Kessler et al., 1994) and 14.4% in France (Weiller, Bisserbe, Boyer, Lepine, & Lecrubier, 1996). Age of onset varies considerably. Although a number of studies have found the mean to be during midadolescence Davidson et al., 1993, Ost, 1987 and Turner et al., 1986, other epidemiological data suggest greatest risk of onset to be between ages 5 and 9 Boyd et al., 1990 and Schneier et al., 1992. In addition, the course of social phobia is usually chronic and unremitting and the quality of life is poorer than in other anxiety disorders in relation to childhood, friends, partner, and health Bech & Angst, 1996, Beidel et al., 1999 and Weiller et al., 1996. Research into social phobia has taken place in a number of countries, indicating that it is an ubiquitous phenomenon. Despite its prevalence, however, scant attention has been paid to researching the etiology of this disorder, suggesting that little has changed since Bruch's (1989) review of familial and developmental antecedents. Several recent studies have taken a more general approach, consistently finding an association between overinvolved and controlling parental behaviors and anxiety disorders in children Hudson & Rapee, in press and Siqueland et al., 1996. In addition, social learning within the family environment appears to be related to presence of anxiety disorders, in that anxious children's selection of avoidant responses to ambiguous scenarios have been found to increase following discussions with their parents (Barrett, Rapee, Dadds, & Ryan, 1996). While these studies include themes that are relevant to social phobia, their primary objective was not to identify differential etiological determinants of the various anxiety disorders. Indeed, only a handful of studies have explicitly explored parent–child relationships in relation to social phobia and none have looked at the wider spectrum of interpersonal relating that occurs during the developmental years. Specific research investigating an association between social phobia and temperamental correlates is also extremely limited. This is in stark contrast to the broad base of related literature that has emerged in terms of descriptive accounts of adult and childhood social phobia (e.g., Beidel et al., 1999 and Fones et al., 1998), theoretical debate as to its underlying dynamics (e.g., Clark & Wells, 1995, cognitive model; Leary & Kowalski, 1995, self-presentation model), and pharmacological and psychotherapeutic effectiveness in treatment (e.g., Liebowitz et al., 1985, Liebowitz & Marshall, 1995 and Potts & Davidson, 1995). While this growing body of evidence has provided a much needed and valuable heuristic framework, longitudinal research designed to identify the formative dynamics underlying typical cognitions and behavior is clearly lagging behind. To speculate about these dynamics, we therefore turn both to the nonclinical literature that suggests an association between social phobia and childhood experience of behavioral inhibition (BI) (Turner, Beidel, & Wolff, 1996) and to the concepts such as shyness and social withdrawal that reflect behavioral, cognitive, and affective components of social phobia. In doing so, an important caveat must be held in mind throughout the following review—this being that the clinical expression of social anxiety is qualitatively different from BI, shyness, withdrawal, and possibly even “mere” high levels of social anxiety. In everyday parlance, these terms are used interchangeably, but in the research literature, they also possess specific meanings. Inhibition is believed to be an aspect of temperament (Kagan & Snidman, 1991) that predominantly indicates a latency to approach unfamiliar objects and people or to verbalize in their presence. However, much reticence may also be an expression of approach and avoidance behaviors, the combination of which may present as shyness, avoidance, or unsociability (Asendorpf, 1990a). In some ways, though, shyness is a more elusive construct than inhibition. The proposition that, in addition to the experience of an approach/avoidance conflict, shyness involves social evaluative concerns (Cheek & Buss, 1981) suggests that the young child must have the cognitive capacity, and therefore the maturity, for comparative self-appraisal in a social context. Behaviorally, shyness and other forms of social reticence may manifest as social withdrawal, which primarily denotes a child's self-isolation from familiar peers. This self-isolation is described in the peer relationship literature as anxious or passive-anxious withdrawal and suggests the activity of avoidant strategies that are similar to those adopted by social phobics. Finally, it is argued that social phobia is distinct from social anxiety, in that some individuals may describe themselves as highly socially anxious and yet not experience the degree of avoidance in feared situations that leads to distress and/or impaired functioning in daily life. Although we have suggested that this distinction may be qualitative, other authors (e.g., Rapee, 1995) argue that degree of avoidance and functional impairment is more likely to indicate that differences are purely quantitative. Furthermore, while semantic variation has been stressed, there is still substantial psychological and behavioral convergence between constructs such as shyness and social phobia (Turner, Beidel, & Townsley, 1990), suggesting more similarities than differences. As social phobia often emerges during adolescence, it seems logical to propose that it is the temperamental factors, together with an ongoing pattern of interpersonal relating—both the concrete facts of behavioral exchange and the subjective interpretation of this experience—established across relationships, contexts, and time, that cumulatively create a diathesis to this disorder. The subjective construal of the dynamics of social exchange typical of people with social phobia, for example, is evident in the tendency to evaluate aspects of their own performance negatively Alden & Wallace, 1995, Rapee & Lim, 1992 and Stopa & Clark, 1993 and to interpret others' responses as critically appraising and disapproving, even when this may not actually be the case Nichols, 1974 and Roth et al., 2001. Thus, the developmental trajectory of perception of interpersonal events and preoccupation with social evaluative themes may be part of the process that transforms childhood inhibition, shyness, and withdrawal from fleeting developmental states into long-term experiences that have adverse psychosocial consequences Caspi et al., 1988, Hamer & Bruch, 1994, Schwartz et al., 1999 and Younger et al., 1993. This review is therefore based on the hypothesis that particular socially derived or socially referenced variables may predispose an individual toward social phobia. Its objective is to summarize information from the nonclinical literature appertaining to BI, shyness, withdrawal, and social anxiety and from the clinical literature appertaining to social phobia and to suggest avenues for future research. The review is divided into three main sections. The first section evaluates research relating to BI, concentrating on particular aspects that have a bearing on the development of social anxiety/social phobia and extending to the motivation accompanying inhibited behavior in the form of an approach/avoidance conflict. The second section seeks to establish whether there are common features in the parenting of inhibited, shy, or withdrawn children and the parental upbringing retrospectively recalled by shy or socially anxious adults and adult social phobics. The final section looks at children's interactions with their peers and summarizes studies investigating the relationship among passive-anxious withdrawn behavior, sociometrically assessed acceptability to peers, and internalizing problems, which include loneliness and depression.

In drawing on disparate areas of nonclinical and clinical research connected to temperamental factors and on the child's social environment in terms of relationships with parents and peers, strikingly contiguous themes have emerged which are summarized below in a proposed developmental profile for social phobia. These themes are relatively consistent despite interference from the conceptual discontinuities and methodological digression that have been commented on throughout this paper. The semantic interface of concepts such as BI, shyness, social anxiety, and passive-anxious withdrawal is of concern, especially as many of the behaviors, cognitions, and affects associated with them appear to be active psychological factors in social phobia. Exploration of how they interrelate may therefore be of value. For example, how approach latencies in unfamiliar social situations are connected to passive-anxious self-isolation from familiar peers, and if social evaluative concerns define both behaviors as the child matures, may produce indices of cumulative or additive risk in terms of internalization problems and social phobia. Methodologically, there are vast differences among developmental longitudinal research, short-term studies limited to the school environment, and retrospective recall of socially anxious and phobic adults. Some of the problems associated with (a) observational methods central to childhood research, (b) external ratings by parents, teachers, and peers rather than child self-report, and (c) accuracy of recall associated with adult retrospective designs have already been mentioned. However, as the life course perspective taken in this review suggests that a diathesis to social phobia is likely to follow a developmental pattern, findings from longitudinal research initially appear to carry the greatest weight in their relevance to outcome. However, concurrent and short-term child and adult studies serve to affirm the findings of longitudinal research and crucially suggest empirical gaps that need to be addressed if life course research is to be more effective in determining psychopathology associated with inhibited behavior. These gaps include gender, age, physiological differences, extremity of interpersonal difficulty, assessment context, and cultural origin. Furthermore, in terms of identifying long-term outcome and associated consequences, the utility of the aggregated classification systems used in BI and peer relationship research is challenged by recent research that has taken a more heterogeneous approach. Multidimensional research, linking temperamental qualities and interpersonal experiences, may therefore lead to a greater understanding of the developmental variables that create a diathesis toward social phobia as opposed to other forms of psychopathology. From the data reviewed in this paper, the following developmental profile for social phobia is proposed.