Is avoidance a factor?
Situations that consistently evoke anxiety tend to be avoided because of the concern that others will detect the symptoms and evaluate the person negatively. The more the feared situations are avoided, the easier it is to believe that humiliation might well have occurred. On those occasions when avoidance is not possible, there is typically marked anticipatory anxiety , often for days or weeks beforehand. A vicious cycle is created in which fearful anticipation creates anxiety that impairs performance. Usually, the person recognizes that the fear is excessive or unreasonable but doesn't know what to do about it. Exposure to the fear-evoking situation usually is not long enough or frequent enough to help the person get used to it and feel more comfortable.
What kind of treatment is most helpful?
The type of psychotherapy with the best-established track record for relieving social anxiety is Cognitive Behavior Therapy (CBT). It is important that this treatment be individualized, but generally the following components are important:
- recognizing erroneous assumptions like "all eyes are on me when I enter the room" and "others will assume I'm incompetent if they see that I look nervous"
- learning abdominal breathing to reduce anxiety
- mastering social skills such as making small talk at parties
- making a hierarchy or graded list of feared social situations from least upsetting to most upsetting
- getting individualized coaching to enter the feared situations and stay there until the symptoms abate
- staying motivated to follow a treatment plan that is systematic, intense, and prolonged
For individuals with a substantial degree of social phobia, taking an appropriate medication is often helpful. While the effects of taking medication without going through therapy are typically only temporary, medication can help people get started. Selective serotonin reuptake inhibitors (SSRIs) like Paxil are widely used because of their established anti-anxiety effects. Arrangements for supplementing Cognitive Behavior Therapy with the use of medication can be made with a psychiatrist in our office or with a physician of the person's choice.