More about Social Anxieties and Phobias

BY DR. R. REID WILSON , REPRINTED WITH PERMISSION

Learn how the socially anxious person can define the simplest of social interactions as a need for performance. Discover what they can do about it.

"I can't just start talking! He'll think I'm superficial!"

"If I sign my name, I'm sure my hands will shake and everyone will notice!"

"I'll go blank. We'll just stand there and stare at each other."

"I should be able to make a statement without stumbling over a word!"

"I'm so anxious! I know I'm coming across wrong."

"I'll never meet anyone. I'll be alone the rest of my life."

Most people consider the term "performance" to mean some type of formal presentation of our skills or knowledge. The socially anxious person, on the other hand, can define the simplest of social interactions as a performance. Even shaking someone's hand in a casual setting can lead to performance anxiety and extensive, critical analysis afterwards. Their anxiety can cause them to forget their train of thought, stumble over words, respond to questions with one word answers, or begin laughing at inappropriate moments.

Some people only fear a few situations. Others, suffering from generalized social phobia, dread a broad number of situations where there is some chance of receiving disapproval. The following chart lists the common situations which socially anxious people can dread.

Anxiety-provoking social situations

Acting, performing, or giving a talk in front of an audience

Talking to people in authority

Expressing opinions

Job interview

Expressing disagreement

Speaking up at a meeting

Responding to criticism

Giving a report to a group

Giving and receiving compliments

Eating in public places

Asking for a date

Drinking in public places

Answering personal questions

Urinating in a public bathroom

Meeting strangers

Being the center of attention

Calling someone unfamiliar

Entering a room when others are already seated

Returning goods to a store

Going to a party

Making eye contact

Giving a party

Resisting a high-pressure salesperson

Joining on-going conversations

Making mistakes in front of others

Participating in small groups

Bumping into someone you know

Writing while being observed

Talking with people you do not know very well

Working while being observed

Taking a test

Social anxieties often begin to surface in adolescence, although there is much variation. Some people describe themselves as shy and inhibited since early childhood; others develop the symptoms after one or more embarrassing events in adulthood.

About twenty percent of the U.S. population suffers some degree of social anxiety, with two to three percent so significantly impaired that they fit the diagnosis of social phobia. Over eighty percent of people with social phobia never seek professional help.

Biology and Experience: The Possible Contributions to Social Fears

Researchers have not yet identified the exact causes of social anxieties. Biological scientists are actively studying the arenas of biochemical irregularities and genetic predispositions.

Fascinating studies are exploring the social order and interactions of rhesus monkeys, the primates whose brains are most similar to humans. The current outcomes show a clear trend that approximately twenty percent of the rhesus population, both in captivity and in the wild are "behaviorally inhibited," or socially avoidant. (For instance, during mildly stressful times they will exhibit extreme anxiety responses while the rest of the monkey population responds normally.) Researchers are now able to breed behaviorally inhibited young monkeys by matching up the right parents.

Substantial evidence with humans parallels this work with primates. Harvard psychologist Jerome Kagan's groundbreaking research supports his theory that inhibited children are born with a nervous system that is more easily stressed and excited—including increased heart rate and increased secretion of the stress hormone cortisol—when they are faced with changes in their social system. Looking at the available research, it appears that of all human personality traits, social shyness and inhibition have the most genetic involvement, including passing this trait on from one generation to the next.

This means it is possible that some of us are preprogrammed to watch for others who are more "dominate" than us, to evaluate the possibility, however slight, of their rejection, and to act in any way needed to indicate our social submissiveness. If our more subtle gestures, such as avoiding eye contact, do not reassure us of our acceptance, then we will act out more primitive responses, by escaping, freezing, or avoiding contact altogether. These responses, when reflective of a biological predisposition, will occur instinctually, with little or no conscious thought.

In addition to the biological factors, childhood learnings can contribute to increasing or decreasing the likelihood of social anxieties in adolescence and adulthood. Kagan found that by age 7 1/2 the physiological differences began to narrow between children who were socially inhibited and those who were outgoing. You might say that as children have more time to get feedback about their degree of acceptance into their family, peer group and community, they learn not to react so fearfully. They discover that they are a welcomed member of the group and others will tolerate their mistakes or weaknesses. Again, this result is matched in the primate population. Remember those rhesus monkeys who were bred to be the most behaviorally inhibited? If the scientists removed them from their natural mother and allowed mothers with stronger and more nurturing traits to raise them, these adolescent monkeys became some of the most socially outgoing!

This, of course, is great news. Even if you are biologically predisposed to develop social anxieties, your life experiences can influence your future comfort with people. You can learn how to loosen up the grip of fear.

The opposite is also true. Childhood experiences may reinforce social anxiety, hesitation and avoidance in those who are already genetically vulnerable to such problems. From parents who are shy or reclusive, children can learn that the world is not so safe. These parents model avoidance as a means to cope with social anxieties.

Any significant adults or peers can influence a vulnerable child in the direction of fear and intimidation. For instance, a third grader "freezes" as she gets up in front of the class for a presentation, her teacher reprimands her and later her classmates tease her. After a meal at the diner, a young boy's mother can chastise him, "You embarrassed me with your behavior," without informing him of his error or of proper restaurant etiquette.

One client of mine was ridiculed by his mother for years at the family dinner table. By the time he entered seventh grade, attending his first school with a cafeteria, he felt too threatened to enter the lunch room. When he entered treatment in our clinic at the age of 53 he was on disability insurance from severe social phobia. [Continued in sidebar]

© Copyright 2003, reprinted with permission

TREATING SOCIAL PHOBIAS

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Below is a brief description of professional treatment of social phobias. [See The Seven Issues in Recovery and How to Get Comfortable for the self-help skills of this program.]

Most people with social phobia can be helped by a therapy program. Although results vary, it appears as many as 80% of those who enter treatment programs report significant improvement, and say that they are able to get their social phobia under control.

Treatment for social phobia generally centers around a combination of a type of behavior therapy called exposure, and cognitive therapy. In exposure therapy people gradually confront the situation that brings on their anxiety. Repeated exposure, combined with practice in coping with the dreaded situation, is designed to show people that they can perform satisfactorily without embarrassing themselves.

Exposure therapy for some disorders may be administered in one-on-one sessions with the therapist. In social phobia, the treatment can have an even greater impact if it takes place in a group setting, because the key feature of this disorder is that anxiety is only triggered by an activity performed in front of others. Additionally, group members may benefit by observing simulations and borrowing others' coping techniques.

Most treatment programs include homework, in which the patient initiates his own exposure sessions according to plans made in the group session. A report is then made at the next group meeting.
Exposure therapy alone may not be sufficient to control some people's social anxiety. Therefore, cognitive therapy is added, designed to alter their thinking about themselves and their social abilities.

Cognitive therapy examines people's expectations of social situations and perceptions of their own performance. Typically the individual with social phobia exaggerates others' competence and expectations while belittling his own.

This therapy is intended to help the individual with social phobia learn to separate realistic from unrealistic assumptions. Training in social skills may support cognitive therapy and exposure by boosting confidence levels.

Medication is sometimes useful in easing the core symptoms of social phobias. Individuals whose anxiety is triggered by just a few predictable situations may be helped by taking medication about an hour before a feared event. Those with more pervasive or less predictable anxiety may do better with medication that is administered daily. See our section on medications for general information.

© Copyright 2003, reprinted with permission. Dr. R. Reid Wilson is a licensed psychologist specializing in the treatment of all anxiety disorders. He directs the Anxiety Disorders Treatment Program in North Carolina. Clinical Associate Professor of Psychiatry at the University of North Carolina School of Medicine, he is author of Don't Panic: Taking Control of Anxiety Attacks and is co-author of Stop Obsessing!: How to Overcome Your Obsessions and Compulsions (Revised Edition), and co-author of "Achieving Comfortable Flight", a self-help kit for the fearful flier. He designed, and served as lead psychologist for, American Airlines' first national program for the fearful flier. He holds a Ph.D. in Clinical Psychology, and his television appearances have included The Oprah Winfrey Show, Good Morning America, and America's Talking.