Social Anxiety Disorder

Sometimes it's really hard just to talk to my neighbor or to
eat in public. I feel like people really notice how anxious
I get, and I feel very embarrassed.

Social Anxiety Disorder (sometimes called social phobia) has gotten lots of publicity of late, as well it should. According to recent surveys, nearly 13 percent of the population fears social situations. It isn't just shyness or stage fright. It is a persistent fear of being scrutinized by others and getting anxious that public humiliation will occur. For some socially phobic people, the fear is limited to particular situations, such as speaking in public. This fear is sufficiently common that I have developed a specific treatment program for it (click on Fear of Public Speaking ). Other specific social phobias include choking on food when eating in front of others, having a hand tremble when writing in front of others, or being unable to urinate in a public restroom. Typically, however, social fears are much broader, e.g., general fears of saying something foolish, or being unable to answer questions in social situations. In each type of social phobia, people have an anxiety response which can include feeling panicky, sweating, blushing, having a racing heart, and/or difficulty breathing. Repeated experiences of feeling this way often result in a deep sense of being inept or inferior to others. Depression is a common consequence.

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
When is medication helpful?

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.

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