When Shyness Needs Treatment

For many of us, our biggest fear is just the opposite. We’re OK in small groups or one-on-one, but public speaking is terrifying. In fact, public speaking often rates as the #1 fear of many people, ahead of snakes or death.

If you’re afraid of one specific thing, like elevators or flying, we call it a simple phobia. If you’re generally anxious and uptight in many situations, we call it generalized anxiety disorder, but if your fears mostly focus on situations involving other people and you are basically not anxious when you are by yourself, we call it social phobia or social anxiety disorder. The word “social” here does not mean it has to be at a tea party or ladies luncheon, it can be any situation involving other people.

Where do we draw the line between being a bit shy and having the psychological diagnosis we call social phobia or social anxiety disorder? We draw the distinction based on the negative impact shyness has on your life. If fear and anxiety in social settings is getting in the way of your success, if it is cutting you off from others and making you lonely, or if you are having difficulty getting hired, promoted, or married because of shyness, then you have a problem worth fixing.

Social phobia can take many different forms. A childhood friend of mine was afraid of authority figures. He got along great with his peers, but any time he had to talk to a teacher or counselor, he would get extremely nervous. His palms would sweat, his voice would stammer, and he could not maintain eye contact. If he grew up to be an artist, perhaps he might not often notice his problem, but if he wanted a career in the military, with its long chain of authority, he would be at a significant disadvantage, no matter how good a solider he was.

Another friend had no trouble with authority figures, and in fact, preferred the company of adults, but was terrified of his peer group. He went through school almost completely unable to make friends with kids his own age, but the adults who knew him thought he was charming, articulate, and highly poised. They would have been shocked to learn that such a mature young man suffered from crippling social phobia. He could talk to a famous musician with ease but was terrified of turning to the kid next to him in history class and asking how his weekend was.

A girl I knew was great in large groups. She could get up in front of 300 people and deliver a fantastic speech, captivating her audience. But if you rushed up afterwards to meet her in person, she would avoid eye contact, answer in monosyllables, and make her voice so quiet you could barely hear her.

What is wrong with these people?! Well, they’re scared senseless of course. In the minds of the sufferers of social phobia, they have an irrational fear of being judged, ridiculed, and rejected. They know the fear is irrational, just like the fear of stepping on a sidewalk crack is irrational, but they can’t help themselves. In certain social settings, they are overwhelmed with fear and preoccupied with the idea that others are judging and criticizing them, even though their rational mind tells them this is not the case.

Many people are cautious and a bit shy in new settings, like the first day of school or the first day on a new job, but patients with social phobia have much more fear and can’t get past it. Also, it is common to be a bit nervous when in front of a large group, but if even the idea of talking in public is terrifying, then we would consider it a phobia.

Sometimes, the situation which triggers the phobia is very specific. A single friend of mine is fantastic with the ladies. Charming, witty, and funny; they all love him. But he is terrified of actively approaching a woman he does not know. If approached or introduced by someone else, he’s off and running, but he is terribly fearful of doing the approaching himself, even in a bar full of drunk people.

Some patients are terrified of making phone calls or afraid to eat in public. There is even a variant where patients are unable to urinate in public bathrooms. But overall, the most common forms are anxiety with potential social/romantic peers, authority figures, public speaking, or strangers.

Social phobia is extremely common, affecting millions of people, about 5% of the population, and it is woefully underdiagnosed. It usually begins in the mid-teen years and will persist for decades unless properly treated. Social phobia tends to run in families. Actually, you can breed socially phobic rats and identify genes which cause the disorder. The analogy to rats is apt because many effective treatments are behavioral in nature.

It can be a tricky diagnosis to make. A teenager may appear totally socially normal around family members and close relatives but be highly fearful around classmates. An adult might seem perfectly in control in a doctor’s office, but be unable to talk to members of the opposite sex in a dating setting. The socially anxious person has a quiet, very interior type of anxiety. They don’t look like I do when watching a scary movie (closing my eyes, hunched over, screaming “No Jan, not Marsha’s HAIR!”) Instead, theirs is a quiet anxiety. Most are semi-frozen in fear. Their face near expressionless, maybe a weak smile, a lack of eye contact, a quiet voice. If you didn’t know better and you were talking to someone with social phobia, you’d might think they didn’t like you very much. This creates an unfortunate vicious cycle where the behavior of socially anxious people actually becomes a self-fulfilling prophecy. People do judge them negatively because they seem unfriendly. Some socially anxious people take on a superior or negative view of others as a defense mechanism. (“All the people at work are idiots.”) My experience is that some socially phobic patients tend to do well in “scripted” environments where they have a defined role. A socially phobic dentist, for example, might be great at greeting patients, discussing their teeth, and even making small talk, but put that same dentist in a party, outside of his scripted role, and he is quite uncomfortable.

I’ve also noticed that patients with social phobia related to one-on-one settings tend to be quite talkative when they finally encounter someone they are comfortable with. There is a pent-up need to communicate which is expressed in a safe setting.

Social phobia, like obsessive-compulsive disorder, is often a silent illness with silent sufferers. They might come to the attention of professionals because of depression, loneliness, poor school performance, or difficulties in the work setting, but rarely do patients walk into a psychologist’s office and say, “Hi, my name’s Dave and I have social phobia.”

In fact, many professionals miss the diagnosis. It wasn’t until the 1990s that the condition really got on the map as a treatable entity, and yet pathologic or excessive shyness has been with us since ancient times. It is an error to only treat anxiety or depression in someone with social phobia when that social phobia is significantly contributing to the disturbance of mood.

So what is effective for patients with social phobia? Well, first I should point out what is not effective. Old fashioned, insight-oriented psychotherapy is not an appropriate initial treatment. It is natural to wonder about the origins of social phobia and to postulate that early experiences might have something to do with the disorder, but a continual rehashing of these early experiences plays no role in actually getting over these fears and can make social phobia and the associated depression worse. The effective treatments are behavioral and cognitive therapy, with a role for medications as well.

Behavioral treatments for shyness and social phobia

are similar to behavioral treatments

for other phobias.

Behavioral treatments for social phobia are similar to behavioral treatments for other phobias. Patients make a list of situations which would cause anxiety and rank them from least to most anxiety provoking. For example, a patient with social phobia at parties and in small groups might rank situations such as talking to a family member or helping serve dinner as not very fearful, but being introduced to strangers or introducing oneself as most fearful.

Patients can then be taught exercises to relax and reduce anxiety. One approach is to practice systematically relaxing all the major muscle groups, one at a time, in the whole body. Another approach is to tense muscle groups first, and then relax them. In either case, the net result is that total body muscle relaxation helps reduce anxiety.

The next step is to imagine these situations, in a state of calm and relaxation, starting with the least anxiety-provoking, and very gradually over several weeks or longer, working up to the most anxiety-provoking. This approach, called systemic desensitization, works to eliminate the anxiety response to social situations. You could do the same thing for public speaking by starting with a very small, friendly group of three people and gradually moving up to larger and more unfriendly groups, and at each phase mentally working through the images without generating anxiety. If the problem were authority figures, you might start with a bus driver and work your way up to the president of the United States.

For some patients, we then proceed to practice in real world situations. The unsuspecting checker at Albertson’s might be your key to getting over a phobia of making friendly small talk with strangers. One research group hired college students to “pretend” they were at a party, so that patients could practice with them. It probably took a lot of training to teach the college kids how to act as if they were guests at a party. Again, the principle is the same. We work gradually from easy to more challenging situations and always keep the anxiety level as low as possible.

Another complimentary approach is to work on the distorted and inaccurate thoughts that a socially anxious person has. Such an individual might think, “I don’t deserve to ask for a raise because I am not valuable to my company.” Or, “If I say ‘hi’ to someone standing in line at the bank, that person will probably call me a freak.” Clearing out these inaccurate thoughts is valuable, but it generally needs to be done along with the behavioral interventions noted above. Patients do need to practice in real-world situations.

The SSRI drugs like Prozac and Paxil are often advocated for social phobia. I don’t recommend using them without cognitive and behavioral treatments because once the drugs are stopped, symptoms will likely return. They can be an additional tool in difficult cases. If you have social phobia, you are not alone. This is an extremely common problem. The biggest challenge is making the diagnosis because many clinicians still miss it and many patients do not see the connection between their uneasiness in social settings and other life problems. Treatments are very effective. Patients should just call the office and come in to see me. I can refer you to several excellent clinical psychologists who treat this problem routinely, and I am happy to work with patients here for a short time as well.

Patients with social phobia are often quite intelligent and highly capable. Often, they organize their lives in such a way as to avoid fear-producing situations, but because these fears are mostly unfounded, the better approach is to slowly and gradually overcome social phobia using proven psychological techniques, as opposed to arranging a life built on avoidance of these anxiety provoking situations.