When Paul R. was 13 years old, his parents noticed that he had become quite shy. When he failed to make a single new friend during eighth grade, they began to worry. Still, they continued to believe Paul’s shyness was only part of growing up, that when the next school year arrived, he would feel more settled.
Instead, Paul’s isolation from his peers became more obvious. He refused to take part in any of the sports he’d loved as a younger boy, became obsessed with studying to make perfect grades, and grew increasingly resistant to his parents’ attempts to lure him out of his room. Even the simplest chore, such as running to the store for a loaf of bread, met with refusal. As Paul’s perfectionism heightened to an unnatural level, he became terrified to drive a car for fear he’d be seen making a mistake.
His mother and father took him to a mental health professional at their son’s request, but his discomfort that someone would actually see and judge his flaws kept him silent throughout most of the session, making an informed diagnosis nearly impossible.
After he left high school, Paul attended a prestigious college. He dropped out after one semester and then found a low-paying job as a night watchman where he could make his rounds alone. At age 24, Paul took his own life.
Paul R. is a fictional compilation of real-life events, but similar stories happen all too often. More than 15 million American adults suffer from social phobia, also called social anxiety disorder. They feel overwhelming anxiety and excessive self-consciousness in everyday situations. The disorder can lead to depression, loneliness, low self-esteem, substance abuse, and suicide attempts. In fact, social anxiety holds a greater risk for these problems than any other form of anxiety.
Anxiety in social situations is common to everyone in different degrees; imagine how you would feel before giving a speech. Social anxiety disorder, however, amplifies the anxiety to the point of impairment.
In Paul’s case, the continuous influx of adrenalin and his lack of appropriate treatment led him to the decision that he could no longer face life.
Symptoms in adults and children are similar, although small children express them in different ways.
From the outside, these can appear as small quirks. From the inside, this person rarely feels comfortable with others, has constant feelings of shame and loneliness, and always feels powerless to control the anxiety.
People with this disorder have few, if any, social or romantic relationships.
Recognition that the anxiety is groundless does not alleviate the fear that they will embarrass or humiliate themselves. This type of anxiety can interfere with school and work, so it becomes difficult to make progress in their personal lives. For example, a sufferer could turn down a promotion that would require them to speak in public.
Normal people may sweat or experience nausea prior to a public performance — piano recital or poetry reading, for example — but people with social anxiety disorder have physical symptoms before or during social situations. A young bride with social anxiety disorder trembled visibly throughout the ceremony, which included only her close family and friends.
Blushing, headaches, heart palpitations, sweating, chest discomfort, dizziness, shortness of breath, or a choking sensation.
Selective mutism can accompany social anxiety disorder in both adults and children. While the person can speak, he refuses to do so in certain situations or with certain people. Selective mutism in children creates enormous stress and can contribute to depression, poor grades, and additional emotional problems.
Often appearing during preschool, selective mutism is a problem that is unlikely to disappear as a child ages unless it is treated effectively.
Social phobia is not necessarily generalized; it may be focused on a single activity, such as talking on the phone or speaking in front of an audience. The person can interact comfortably in all other situations. This localized anxiety is the exception, however, not the rule.
While social phobia usually begins around age 13, it can start earlier in childhood. When it begins at a young age, symptoms include tantrums, clinging, or mutism.
Children can’t or won’t admit they feel anxious; instead, they will complain of physical symptoms, which may include stomachaches, queasiness or butterflies in the stomach, dizziness, blushing, nausea, headaches, shortness of breath, rapid heartbeat, and dry mouth.
Children who seem unable to make friends, won’t participate during class or play at recess may be shy. If the behaviors persist, however, and the child doesn’t appear to be outgrowing them, he may have social phobia. As a child gets older, he learns how to avoid social situations without drawing attention, hiding the extreme discomfort from family.
Anxiety arises from self-defeating thoughts and beliefs.
For example, if you believe you are a terrible public speaker but you are forced to give a speech, it doesn’t matter how well you performed, your brain points out every misstep and fails to recognize the more positive parts of your performance.
What if you are invited to a party? Before treatment, the most likely behavior would be outright refusal, possibly followed by spending the night of the party sleeping to avoid having to think about it.
Let’s say you decide to fight your better judgment and attend the party anyway. Can you feel the hot thoughts bombarding you?
Out of all these automatic thoughts, the most intense is typically “People will think poorly of me.” At its core, remember that social phobia is a fear of being judged.
Core beliefs form your mindset about yourself and your attitude.
Getting back to that party you decided to attend, how does your anxiety present itself?
These behaviors show that you are focused on yourself and your symptoms. You have made a conscious choice to self-monitor, which probably includes a running mental commentary on how badly you think you’re doing.
Why do some children and adults fall prey to social anxiety disorder while others do not? The mental health community believes social anxiety disorder stems in part from an inherited vulnerability.
If the child also lacks a good role model who displays the correct ways to be social with others, or if the child did not have ample opportunities to practice, he may feel less self-confident in social situations. This vulnerable child may then experience an inciting event, such as an interaction that went terribly wrong or made the child feel rejected. The event triggers the start of behaviors that spiral into social anxiety disorder.
Children who have a family member who suffers from anxiety or depression have a greater chance of experiencing social phobia.
While social anxiety disorder is an under-recognized illness, it is highly treatable. Early diagnosis in children will ensure the best outcomes. In addition to improving their social life and helping them perform better in school, early intervention may prevent the development of other disorders.
Adults, as well, see significant improvement in their symptoms after treatment.
Children are treated with CBT sometimes coupled with medication.
Children with selective mutism are best treated with CBT and behavioral strategies.
Therapists employing behavioral strategies create a plan for a child to speak in progressively more difficult situations, followed by positive reinforcement. If necessary, medication can be used to address the most difficult situations for the child. Medication alone, however, is ineffective unless combined with other treatments.
CBT functions on the premise that our emotions are based on our core beliefs about ourselves and the situations we face. Confident people are more likely to make good first impressions because they believe they are likable and interesting. People who are anxious, feel uninteresting and socially unskilled, tend to make a poor first impression.
CBT is considered the most effective treatment because it empowers the patient to handle future problems and reach personal goals. CBT attacks self-defeating behaviors and unhealthy core beliefs by applying four primary strategies.
Mindfulness practice trains the patient to pay attention to the present moment without judging. With practice, thoughts and feelings that engender the patient’s self-defeating actions become background noise, and he learns to redirect his attention on the conversation.
Note: Many people confuse mindful focus or mindfulness with meditation. In fact, meditation is not recommended to sufferers of social anxiety disorder because it is the practice of turning inward, the opposite of outward-focused mindfulness.
Defusion is the ability to disconnect from thoughts and emotions. This allows the patient to have an awareness of thoughts and emotions while disengaging from them at the same time.
Cognitive restructuring challenges the patient’s core beliefs to be more realistic, helpful, and compassionate. Today, mobile apps exist to help the patient practice cognitive restructuring.
Experimentation allows the patient to test the anxious thoughts and beliefs in real-life situations. Also called “exposures,” these activities help show the patient that he can cope safely with his worst fears.
For the children in your life, be sure to set an example for healthy social interaction and to allow the children many opportunities to interact as well with their peers and others.
Practice mindfulness in every interaction, which means listening closely, asking questions, and paying attention to the answers. Be as compassionate toward yourself as you are to others. Many sufferers of social anxiety disorder find that they work hard to gain approval and berate themselves if they fall short. If you discover that you criticize yourself for social ineptitude, make note of your thoughts and feelings and seek immediate treatment.
Social phobia does not have a one-size-fits-all solution, but cognitive-behavioral therapy is the keystone for all treatment methods. By paying attention to those you care about, including yourself, you may recognize social anxiety disorder in its early stages and obtain help before the disorder can take hold and disrupt lives.