Social Avoidance And PTSD: The Role Of Comorbid Social Phobia

By Susan M. Orsillo, Ph.D.

NCP Clinical Quarterly 7(3): Summer 1997

Individuals with PTSD often experience significant interpersonal problems including fear of intimacy, diminished social support, and impairment in occupational functioning (1). Traumatic events, particularly those of an interpersonal nature such as combat, rape, and incest, can threaten basic assumptions about relationships and disrupt an individual’s sense of connection with their community (2). Some have argued that social disconnectedness may in fact be one of the most profound consequences of trauma (3).

Relatedly, social support may play an important role in the recovery of trauma victims (4). Herman argues that recovery from traumatic experiences can only occur within the context of intimate relationships (3). Therefore a major focus of therapy for individuals with PTSD must be increasing the frequency of their positive social contacts. Choosing the optimum way in which to accomplish this goal requires that we understand the etiology and function of social avoidant behavior among individuals with PTSD. Although social avoidance as a symptom can look similar across individuals, there can be idiographic differences in the function of the behavior that may have important implications for treatment.

What Does Social Avoidance Represent?

Several possibilities exist to explain the cause and function of the socially avoidant behavior that so frequently presents with PTSD. Some individuals with PTSD may limit their social contacts to avoid encountering cues that could trigger a conditioned emotional response related to the traumatic event. For example, a rape victim may avoid parties for fear that interacting with men will bring back memories of the rape. A second possibility is that the hyperarousal symptoms of PTSD, such as irritability and hypervigilance, may adversely impact upon an individual’s family members and friends, decreasing the probability of fulfilling social contact. For instance, friends may be driven away from the Vietnam veteran who is constantly verbally abusive. Further, some patients may experience emotional numbing and anhedonia to the extent that they no longer experience pleasure in the context of social interactions. Thus, an incest survivor may decline social invitations because she does not expect that they will be enjoyable. Alternatively, social avoidance displayed by an individual with PTSD may in some cases be best conceptualized as reflecting social anxiety, or in more severe cases an actual comorbid diagnosis of social phobia.

Social phobia is defined in DSM-IV as "a marked and persistent fear in one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others" (5). The specifier "generalized" can be used when the fears are pervasive across most social situations such as informal conversations, dating situations, and work-related interactions. An individual with true comorbid PTSD and social phobia would avoid at least some social situations for fear of social evaluation. For instance, a crime victim who avoids crowds both because she fears for her safety and because she is embarrassed about being evaluated and scrutinized would likely meet criteria for both diagnoses.

On the surface it may seem unimportant to determine whether or not social avoidance is a product of social phobia. Some may feel that this is a nosological distinction lacking in clinical significance. However, ignoring the hypothesized function of avoidance behavior could negatively impact treatment decisions. For instance, encouraging an individual to engage in more frequent activities with their family may not be efficacious if family members are irritated and annoyed by the patient’s symptoms. Further, prescribing a trauma-related in vivo exposure assignment, such as asking a rape victim to spend 30 minutes in shopping mall, may result in non-compliance if she also has social fears that have not been addressed. Thus, a careful functional analysis of social avoidant behavior will provide the clinician with the best information regarding treatment choices.

Social Phobia As A Comorbid Condition

The remainder of this paper will focus specifically on the presentation and impact of social phobia on PTSD. I will first present a rationale for why social phobia may be a common complaint among individuals with PTSD. Next, I will discuss assessment and treatment implications regarding this potential comorbidity.

Why Might Social Phobia And PTSD Co-Occur ?

There is a small, but growing, body of literature suggesting that PTSD and social phobia may frequently co-occur. The overall comorbidity of anxiety disorders has been shown to range from 50 to 70%, with social phobia being one of the most common co-occurring anxiety disorders (6-7). Unfortunately, few well designed studies have directly assessed the comorbidity of social phobia and PTSD. However, current prevalence estimates of social phobia among Vietnam veterans with PTSD appear to be approximately 15% which is significantly higher than the rate of social phobia among a non-PTSD comparison group (8).

Two major theories regarding the development of social phobia have etiological components that underscore the potential role of traumatic events in the development of social anxiety and avoidance. Buss (9) proposed four distinct emotional-behavioral patterns associated with social anxiety: embarrassment, shame, audience anxiety and shyness. Most relevant to this paper is the proposal that shame is associated with the development of social anxiety. Thus, the other components of social anxiety will not be discussed here.

Shame is characterized by self-disgust or self-abasement. As compared to embarrassment (which is a more personal, temporary state), shame is conceptualized as a more serious, enduring, and public emotional state often associated with judgments of morality.

Buss described several causes of shame. Most relevant to this paper is that shame can be caused by failure at a task that is highly valued by society or by engagement in a task that is deemed immoral by society. For example, a soldier may feel shame as a direct result of losing a firefight, or in response to harming a civilian. Or, a child sexual abuse survivor may feel shame because she engaged in a taboo sexual act.

Shame endures because the failure or immoral act comes to represent a stigma. A stigma can be viewed as a "black mark" on an individual’s identity or character which directly impacts upon social functioning in two important ways. If a stigma is revealed, the individual risks ongoing negative appraisal from society. For instance, if a Vietnam veteran discloses his combat history he risks reproachment and rejection as a result of his behavior. However, even if the stigma is unrevealed, the individual may experience private shame concerning his or her shortcomings and fear of future, public disclosure. For example, a rape victim may withdraw from intimate relationships because she is unwilling to risk the reaction her partner might have upon learning about the sexual assault. Thus, she may avoid all social contact and appear inhibited in interpersonal contexts as a result of her feelings of shame.

Barlow (10) has also advanced a theory of social phobia. He proposed three pathways through which an individual could develop social phobia. Most relevant to this paper is the "true alarm" pathway. Barlow’s model suggests that social phobics inherit a biological vulnerability to states of generalized autonomic arousal and/or social inhibition. Given this biological predisposition, an individual would be more likely to experience a "true alarm" or a panic-like reaction in response to a socially threatening event. After this alarm, the individual is at risk to experience heightened anticipatory anxiety at the prospect of experiencing similar reactions in social situations. Barlow proposes that this anxiety interferes with the individual's ability to focus in a social situation and thus leads to poor task performance (e.g., stumbling over one’s words). Inevitably, this poor performance reinforces the individuals concern about social situations and leads to avoidance, which paradoxically decreases the opportunities to have successful social encounters and to break this vicious cycle.

Unfortunately, true alarms or direct experience with socially traumatic events are likely to be quite common among individuals with PTSD. The social psychology literature suggests that we have a motivated cognitive style by which we tend to blame victims for their own misfortunes. Victims are perceived as responsible for their own fate, a cognitive strategy that allows nonvictims to maintain their own sense of invulnerability, safety and justice (11). Examples of how this victim blaming stance can lead to socially traumatic experiences are plentiful in the area of trauma and PTSD (e.g., denial of acquaintance rape, labeling and discrimination toward Vietnam veterans).

A preliminary study in this area demonstrated the contributions of both shame and direct experiences with socially traumatic events to the development of social phobia among trauma victims. My colleagues and I (12) examined the impact of the shame Vietnam veterans felt about their military service and the perceived adversity of their homecoming on their current level of social anxiety. Controlling for premorbid social anxiety and severity of combat exposure, shame and adversity of homecoming experiences together accounted for a significant proportion of the variance in current level of social anxiety.

How Can Social Phobia Be Assessed In A Patient With PTSD?

Thus, social phobia is likely to be a co-occurring problem for some individuals with PTSD. Fortunately, there appear to be some promising treatments for social phobia (13) that may be applicable for patients with PTSD. However, as discussed earlier, before initiating treatment, the first step must be to determine whether or not a patient’s social avoidance actually reflects social anxiety/ phobia rather than representing a lack of social opportunities or interest.

Traditional self-report measures of social anxiety may not be sufficient to address this issue. Questionnaires focused on social phobia often include items that tap into both the behavioral component of social phobia (e.g., "I avoid parties.") and the affective component (e.g., "I get nervous at parties."). For instance, although approximately half of the items comprising the Social Interactional Anxiety Scale (14) include an affective component of social behavior (e.g., embarrassment), the remaining items are worded such that a given social situation is described as being difficult (or for reverse scored items easy) such as "I have difficulty making eye-contact with others". The latter set of items could be endorsed by a rape victim who is fearful of making eye contact because it reminds her of aggressive behavior, a PTSD-related symptom, or because she perceives negatively evaluated, which is more likely related to social phobia. Given the complexity of this issue, both interview and questionnaire data should always be utilized when assigning a diagnosis.

Relatedly, clinical experience suggests that the validity of an individual's ability to predict his or her level of social anxiety in a given situation may be questionable. If a patient has avoided social situations for a long period of time, his or her ability to accurately predict an emotional response in a given social situation may be severely limited. Furthermore, social anxiety can be masked by anger in individuals who have suffered prolonged social rejection. For example, a veteran who reports that he does not care what others think may be covering up the anxiousness and hurt he feels about being rejected. One way to better assess social anxiety in this population may be to have subjects participate in a behavioral assessment or role-play of a potentially anxiety-provoking situation and to have physiological and behavioral ratings obtained in addition to self-report.

The Impact Of Social Phobia On Trauma-Related Treatment

The implications of the high rate of comorbidity of PTSD and social phobia for treatment need to be empirically addressed. Currently, cognitive-behavioral therapies, including exposure therapy, show the most promise as effective treatments for PTSD (15). However, it is unclear how a comorbid diagnosis of social phobia may impact on the efficacy of these approaches. Although research in this area is clearly needed, it is possible that supplemental treatments could be useful to address related social deficits.

Further, although there have been fewer studies examining the effectiveness of trauma-related group therapy, this approach may be quite helpful in resolving PTSD symptomatology and associated features. Herman (3), based on extensive clinical experience, discussed group treatment as an advanced stage of healing. She proposed that where traumatic events destroy the sustaining bonds between an individual and the community, a group can recreate a sense of belonging. Groups may allow a trauma victim to discover the commonality of his or her traumatic experience that has been previously hidden away as a "shameful secret".

Given these theoretical considerations, as well as the current economic atmosphere which supports the development of cost-effective delivery of services, group therapy may prove to be a viable option for many patients with PTSD. However, it may be more difficult for an individual with comorbid social phobia and PTSD to accept referral into a therapy group. By definition, individuals with social phobia fear and avoid situations that are inherent in group psychotherapy, such as being exposed to the scrutiny of others and speaking in front of a group. In addition to refusing referral, social phobic patients may attend but not actively participate in a trauma group, or they may prematurely drop out of therapy.

Suggestions For Treatment

Although there is no research on treating social phobia as a comorbid diagnosis to PTSD, several suggestions can be made based on the existing social phobia literature (13, 16). In vivo exposure, which requires the patient to enter and remain in a feared situation until their fear level subsides, can be extremely useful in treating phobic conditions. An example of an in vivo assignment would be to have a social phobic patient invite a co-worker to lunch.

Although this method is effective in reducing anxiety, it can be very difficult to adequately conduct with social phobics. Social situations are often unpredictable and uncontrollable (17). An individual with a specific phobia, such as a fear of dogs, can be systematically exposed to their feared object for a scheduled period of time. However, social situations are difficult to schedule and they may vary in context and content depending on the actions of the other party. Further, in vivo exposure is typically conducted in a prolonged manner. Unfortunately, many social interactions are fleeting (e.g., asking a question in class) and they do not allow sufficient time for habituation (17). Further, social situations are not always easily available (13). Unlike the height phobic who can gain easy access to exposure situations, a Vietnam veteran who has become completely isolated due to his hypervigilance and anger control problems may not have many opportunities for social interaction.

In order to address these issues, Heimberg (13) incorporates within session exposure simulations or role-plays into his treatment. Simulations can be set up to emulate reading a prepared speech to an audience, making small talk at a party, or refusing an unreasonable request from a co-worker. Heimberg emphasizes the use of simulations because unlike in vivo assignments, they are always available, schedulable, controllable, "moldable" to the needs of a specific client, open to therapist observation, and less subject to avoidance and non-compliance. In Heimberg’s protocol, these simulations occur in the context of a group therapy program in which other patients both can serve as "role-players" and maximize their opportunities for exposure to social situations. Nonetheless, with adequate creativity and resources, simulations can also be conducted in the context of individual therapy.

Another technique often used in the treatment of social phobia is cognitive restructuring. Heimberg (13) outlines a systematic approach to cognitive restructuring which includes several steps. First, the patient is encouraged to anticipate a feared social situation and report experienced automatic thoughts (e.g., "She will think I am a fool."). Next, the patient is instructed to review his or her thoughts looking for cognitive errors using a list of common cognitive distortions (e.g., mind reading; all or nothing thinking). Patients are then encouraged to question their automatic thoughts ("How do I know what they are thinking? What is the probability that my feared consequence will occur?") and develop a rational response that they can use to cope with their fear (e.g., "A conversation is not all my responsibility"). Heimberg incorporates cognitive restructuring into each exposure simulation.

Recent meta-analytic studies evaluating treatment programs for social phobia suggest that the cognitive component may not be essential (16). However, more research is needed before definitive conclusions can be made about the exact agent of change in the current treatment packages for social phobia. Nevertheless, Heimberg’s (13) manual provides an excellent starting point for the clinician who is confronted with a patient with comorbid PTSD and social phobia.

Conclusions

Several recent advances in the field have resulted in the development of efficacious treatments focused on alleviating symptoms of re-experiencing, avoidance, and hyperarousal expressed by our patients. However, we need to continue to make progress in improving their quality of life. One potential approach is to focus our treatment efforts on the social isolation that continues to be a problem for many trauma patients. As suggested in this paper, social phobia may be one comorbid condition that can be targeted in some patients to improve their daily functioning. Although more research is needed to adequately assess the needs of PTSD patients with comorbid social phobia, clinicians can use the guidelines delineated in this paper to begin to think about the function of their patients’ social avoidance and to determine adequate treatment strategies.

References

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17. Butler, G. Exposure as a treatment for social phobia: Some instructive difficulties. Behavior Research and Therapy, 23, 651-657.

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