What is social phobia?
Cognitive Behaviour Therapy
What drives social phobia?
Changing the way you think
Facing your fears
See also www.climate.tv for a patient education package for social phobia that your doctor can arrange for you for $10. It contains elements of the cognitive behaviour therapy in an illustrated story line to show you just what to do to recover. And pictures can speak louder than words.
What is social phobia?
Social phobia is a fear of social situations that involve interactions with other people. If you have social phobia you tend to worry about being judged badly by other people - being criticised, "put down" or embarrassed.
How common is it?
Social phobia is equally common in men and women and is found across different cultures. Approximately 3 percent of the population suffer from social phobia.
A much larger percentage of the population describe themselves as shy. In addition, many people in the general population report fear associated with public speaking, and anxiety associated with other social situations such as meeting new people and dealing with criticism. Most of these people would not be identified as having social phobia, however, unless the fear and avoidance significantly interfered with their life.
Some people with social phobia fear only a few situations where they might be the centre of attention. Others, suffering from generalised social phobia, fear many situations.
What is Avoidant Personality Disorder?
If you have had generalised social phobia for most of your life you may think that others see you as too quiet or boring. You may avoid meeting other people and not want to risk telling others much about yourself in case they reject you. If you have these sorts of fears, you may have a more severe social phobia, called avoidant personality disorder.
About one-third of people seen at specialist anxiety clinics for treatment of social phobia have avoidant personality disorder. If you have this more severe social phobia, it is very likely that you will have experienced episodes of depression (see complications).
Coping with severe social anxiety for most of your life may have badly affected your self esteem. You may also have become quite socially isolated. If you have spent many years avoiding social situations or speaking to certain people because of fears about what others think, you need to be aware that it will probably take longer to improve with treatment (see cognitive behaviour therapy),.
What causes social phobia?
Regarding possible causes of social phobia, research suggests that both genetic and environmental factors are relevant. The origins of social phobia are multiple. In order to treat your social phobia, rather than focusing on why you have the problem, it is more useful to look at what is maintaining the problem [see cognitive behaviour therapy].
Some typical social situations feared by people with social phobia include:
- Speaking in a group
- Giving a presentation or speech
- Meeting new people
- Being introduced
- Talking to someone in authority
- Being observed doing an activity
- Eating or drinking in public
- Using the telephone
- Going to a party
- Expressing your opinion
- Returning faulty goods
- Using public toilets
- Being the centre of attention
- Speaking to someone you're attracted to
If you have social phobia you usually worry that others will notice your anxiety because of your blushing, sweating, shaking, or difficulty getting your words out, (for example).
Other fears triggered by social situations include:
- I'll look uncomfortable or awkward
- I'll seem weird or strange
- I'll appear stupid or incompetent
- I'll look embarrassed
- I'll be boring
These fears tend to be triggered when just anticipating the social situation. You may also have noticed that, after the event, you often feel bad or worse when thinking about how you "performed". How you actually felt in the situation can play a big role in this "post-mortem".
There are a number of typical physical symptoms experienced by people with social phobia. These include:
- Shaking or trembling
- Heart going fast
- Mind going blank
- Shaky or soft voice
- Problems concentrating
- Urge to use the toilet
- Breathe faster
- Nausea or vomiting
- Urge to escape
As a result of your fears, you may do a number of things to try to prevent something bad from happening. These may include:
- Avoiding the situation altogether
- Avoiding similar sorts of situations
- Leaving prematurely
- Focusing on yourself
- Trying not to draw attention to yourself
- Keeping quiet
- Not looking at other people
A large number of people with social phobia also suffer depression, a disorder characterised by persistent low mood, loss of pleasure, hopelessness about the future, feelings of worthlessness and a number of physical symptoms, including sleep and appetite disturbance. Sometimes people also experience thoughts of suicide. If you have been having suicidal thoughts or if you have been experiencing a number of these other symptoms you may be clinically depressed and you must see a doctor.
People with social phobia often rely on alcohol to cope in social situations. Unfortunately, alcohol use can become a problem in itself. Alcohol abuse is one of the main additional problems for people with social phobia. You may need to talk to a health professional about your alcohol use.
Benzodiazepines such as diazepam have been prescribed for social phobia and other anxiety disorders, however they are not the treatment of choice as they are highly addictive, so withdrawal symptoms are experienced when the drug is stopped. In addition, people rapidly develop tolerance to the drug, so that greater doses are required to achieve the same effect.
Cognitive Behaviour Therapy
Cognitive-behaviour therapy (CBT) is the treatment of choice for social phobia. It involves changing the way you think, feel and behave in social situations.
What drives social phobia?
We all have the fight or flight response which is designed to protect us from harm. When the fight or flight response is activated, adrenaline is released which produces a number of physical sensations, including rapid heart rate and breathing, sweating, shaking, tense muscles and "butterflies" in the stomach. An urge to flee the situation is often experienced.
This fight or flight response occurs whenever we judge a situation to be threatening. In social phobia this threat is a psychological one, as the fear is about not being respected, approved of, or liked. Whilst we all desire to be liked by other people, in social phobia this need for approval is exaggerated and the detection of threat too sensitive.
Imagine the following situation: you are at a dinner where you don't know many people in the group. If you have social phobia, you may already have been feeling anxious in anticipation of the evening. So your fight or flight response is already activated. Then, while in conversation with someone, you notice them glance away. You immediately think to yourself: "They think I'm boring" or "They can see how anxious I am". By now you can't concentrate on the conversation because you are so focused on how anxious you are feeling and what you think the other person is thinking about you. You see yourself through the other person's eyes. Your anxious thoughts then increase the anxious feelings even further and so the cycle continues.
Thinking negatively about the situation after the event (the "post-mortem") triggers further anxious feelings and tends to reinforce how badly you thought you "performed". Negative thinking plays a major role in maintaining your anxiety response in these situations.
Your breathing rate increases automatically as part of the fight or flight response. Learning to slow down your breathing rate when you are anxious can settle some of the other anxious sensations as well as help you to focus your mind.
- First, time your breaths for one minute (1 breath in and out equals one).
- Then sit down comfortably in front of a clock or a watch with a second hand and start to focus your mind on your breathing.
- Breathe only through your nose.
- Try to breathe using your lower stomach/ diaphragm, rather than your chest muscles. Relax your stomach as much as possible.
- Take a regular breath in for 3 seconds and then breathe out for 3 seconds. Each time you breathe out, think to yourself the word "relax" and let a little more tension go from your muscles - let your shoulders drop, relax your face.
- Continue breathing in this 6-second cycle for 5 minutes.
- At the end of this, count your breaths again for one minute. Write this down.
The average person takes 10 to 12 breaths per minute at rest. Your breathing rate may be higher than it should be. Some people with social phobia overbreathe constantly, while other people find that their breathing rate only goes up when they are anxious. In both cases slow breathing can help.
To begin, you will need to practice when already relaxed. Then you can gradually practice in anxious situations. Like learning any new skill, slow breathing takes time and regular practice. You should practice this at least 4 times a day.
Changing the way you think
Step One: Identifying the way you think:
If you have social phobia it is likely that you have developed ways of thinking about social situations that are unhelpful and often inaccurate. Social situations are difficult in the sense that they tend to be quite ambiguous - it's not as though we get an actual score out of 10 for our conversational skills!
People with social phobia tend to misinterpret comments or facial expressions, believing that the other person is thinking negatively about them.
- Mindreading is a common habit, where you assume that you know what others are thinking about you (e.g. "she can see I don't know enough about politics").
- Personalising is also typical, where you assume that someone's behaviour or reaction is directly related to you (e.g. "he looks bored - I should never have organised the dinner").
By now your thinking has probably become automatic, so that you may not be as aware of exactly what thoughts are going through your mind when you are anxious. Think about a recent anxiety-provoking situation. What sorts of concerns do you have when you think about (e.g.) giving a presentation at university, or expressing your opinion in a group discussion? What sorts of things go through your mind? Write down all these negative thoughts.
Step Two: Challenging your negative thoughts:
Having listed some of your main concerns, you can start to critically evaluate them by asking yourself questions such as:
- Is there another way of thinking about this situation?
- Is it possible I have misinterpreted things?
- What objective evidence is there that other people have noticed my anxiety?
- What real evidence is there that other people think I am stupid or boring? Am I mindreading?
- How likely is it that no-one at all will talk to me at the party?
- How likely is it that my signature will be rejected because of my shaking (How many times has this actually happened)?
- How much would it really matter if someone did know how I was feeling?
- Would it be the "end of the world"?
- Am I taking things too personally?
- Did things really go that badly or did I just feel bad (anxious)?
Step 3: Putting it all together:
Drinking coffee in front of workmates at a work function
|I can't cope with this - I feel so anxious
||I've felt anxious in other situations and still got through - I will cope. I'll try to concentrate on what people are saying, rather than just on how I'm feeling.
My hands will shake and I'll spill the drink
|Even when I've felt anxious in the past in these sorts of situations, I usually don't spill my drink.
They can see how anxious I am
What real evidence do I have that they've noticed my anxiety?
|They'll think I'm weird for being anxious
||Even if they did notice my anxiety, they'd probably just think I was a bit stressed. I'm probably mindreading.
|They'll question my ability to do my job
||No actual evidence for this. Actually, I have evidence that I have been able to do my job in spite of my anxiety. Assessment of work performance is usually based on many areas.
Facing your fears
You are probably aware that avoiding situations where you feel anxious seems like a reasonable solution to your anxiety in the short-term, but in the long-term it means greater limitations in your life. Also, the number of situations you find anxiety-provoking has probably grown as your fear has generalised. In order to overcome your fear of these situations, you will need to gradually face them again.
Step One: Identify goals to work towards:
What are you avoiding because of your social phobia? Make a list of up to 10 situations you avoid or find difficult because of your social anxiety. What do you fear will happen? Design your program so that it enables you to actually test out some of these things you fear. For example, if you avoid catching the bus because you feel too self-conscious and believe that everyone is looking at you, a task could involve sitting on a seat facing people in the bus and looking up at other people. This may provide you with some evidence against the idea that you are so conspicuous (i.e. everyone is noticing you).
Step Two: Break these goals into steps:
Where possible, try to come up with some steps that are easier than the ultimate goal. These may include different sorts of situations that still present the same concerns.
For example, an ultimate goal might be:
To manage my anxiety when I'm the centre of attention
A series of steps could include:
- Tell a brief story about something funny or unusual that happened to you recently in front of a couple of people you know
- Express your true opinion about an issue being discussed with people you know
- Relate an experience in front of a group of people which includes those you don't know so well
- Make a brief toast at dinner with a group of people you know
- Make a toast in front of a group which includes people you don't know
Step 3: Putting it into action.
You may need to practice a particular step a few times before you feel comfortable enough to move on to the next step. Set yourself the task and go through with it even if you feel anxious. Afterwards, think about what you learned from your experience. Did anything bad really happen? If you are still feeling very anxious in the situations, you need to check your negative thinking. You can also use the slow breathing technique to settle some of your anxious symptoms. Remember, not all social situations can be planned - you may need to take advantage of spontaneous encounters - use these opportunities to practice your anxiety management skills, e.g. slow breathing, challenging your negative thoughts.
e.g. oxazepam, diazepam, alprazolam Benzodiazepines are not a useful treatment for anxiety disorders in the long-term, because of rapid physical tolerance and dependence. They provide only symptomatic relief. They do not deal with the negative thoughts driving social phobia.
2. Selective Serotonin Re-uptake Inhibitors (SSRIs)
e.g. fluoxetine, sertraline, citalopram,
These drugs are commonly prescribed for social phobia, and can be particularly useful if the person with social phobia is also depressed. They are as powerful as CBT and can be used in combination with CBT.
Edited by Gavin Andrews MD, UNSW, 2007
Extracted from: Clinical Research Unit for Anxiety &
Depression .. www.crufad.org
* All information is intended as a
guide only and should be used in association with your health professional