Descriptions of Social Anxiety Disorder from Patients' Perspectives
“It scares me when I'm in class and the teacher asks a question and I know the answer. From the moment I think 'I know it, I should raise my hand and say it out loud,' I start to feel sick to my stomach. My heart starts pounding. It pounds so hard it feels like it is thumping against my chest. My hands get clammy and I keep rehearsing in my head what I should say. If I did speak, I worry about how it would sound when the words came out. Given how I feel, I wonder if I would even make any sense. Eventually, someone else usually answers the question and I feel instantly relieved and slowly my body starts winding down. Although I'm relieved, I feel so stupid and like such a coward for not speaking up.“
"I plan my life around worries about using public bathrooms. I can't urinate if anyone else is in the bathroom. I simply "lock-up" and can't force myself to go. Things have gotten so bad that sometimes I can't even go if I'm in a single-occupancy bathroom but I can hear noises outside. As a result, I catalog in my head the public locations that have "safe" bathrooms. I also stop drinking liquids well before I have to leave the house to decrease the likelihood of needing to go when I'm out of the house. Even when I really don't need to go, I can’t fully enjoy myself or focus when I'm out…I keep assessing how full my bladder is and worry about when I will need to go. Despite all of my planning, there have been so many times where I find myself so physically uncomfortable in public – full bladder and unable to go…eventually racing home to relieve myself. I feel like I'm planning my life around urination – jobs, trips, dates…what is wrong with me that I've turned something so biologically simple into something that’s so impossible?"
“I hate giving presentations. Throughout my life I never much liked giving them, but who does? But, last year I gave a presentation in front of my whole company. I felt terrified. I think I tried to put off my worry about the presentation by trying as hard as I could not to think about it. But, a few weeks before the presentation, there was no forgetting about it. In fact, I couldn't get it out of my mind. Quiet times were the worst…where I would find my mind drifting to the presentation and my worry that I would look like a fool in front of my whole company. Certainly, if I screwed up, this would affect my chances for future promotions and pay raises. I barely slept the night before the presentation. I knew I would screw up. Sure enough, during the presentation…my mind was whirling. I was saying what I had planned but I felt like I couldn't get enough air, like my throat was constricted and I could barely force the words out. My voice seemed shaky and halting. Although I was saying one thing, I was primarily focused on the thoughts racing through my head - 'I'm totally messing up, I'm sure everyone can tell how nervous I am, I wonder what everyone would think if I just ran out of here'. Somehow I got through it. People said I did fine, but I knew that they were just saying that to be nice. Ever since this time, I can't stand doing even doing small presentations at the office, and get really scared even at the thought of doing these. I don't ever think I could do a large presentation again - even if doing one meant a raise or promotion.“
“I've always been an extremely shy person. As a kid I would never order for myself in a restaurant and I would always tell my parents what I wanted and let them do it for me. In school, I would always find a way to be absent on days when there were class presentations or when we would pick teams in physical education class. I would say that I was sick, and I don't really think that I was lying because I really did feel sick at the thought of going to school - worried that I would do something stupid in front of the whole class and everyone would laugh at me. I still have problems ordering my own food and talking to salespeople. I have to repeat myself a lot because people say I mumble. As I got older, it seemed like everyone else had no problem getting a job. But I couldn't even imagine doing what they were doing - working in the mall. I could never imagine having complete strangers come up to me to ask me a question. What if I didn't know the answer? What if I messed up? What if I gave them the wrong information? What if I couldn't work the cash register right? They would think that I was such a loser. I would be totally humiliated. The job I have now is one that my father got for me. I didn't have to interview because it was a family friend. If I did need to do an interview I probably wouldn't have gone…I'd be so nervous. I work filing things in this man's office. This is what I like…just me and the files. This is where I am comfortable. Unfortunately, the second I leave the job for the day, I am forced into excruciating social situations again until I get home.“
At times, everyone experiences social anxiety, however, for most, the anxiety is relatively fleeting and does not impact their lives in any significant way. However, for those with social phobia (or social anxiety disorder), they tend to have an overwhelming level of anxiety and feelings of self-consciousness in social situations. What drives this fear is a concern that others will watch and evaluate them, and that they will in some way embarrass or humiliate themselves. Sometimes, the social fears are specific to just a few situations (specific social phobia) or are present in many everyday social situations (generalized social phobia). Some of the most commonly feared or avoided social situations are the following: formal speaking, eating in front of others, going to parties, writing in front of others, using public restrooms, speaking to authority figures, and informal/casual conversation.
It is not uncommon for those with social phobia to worry for days or weeks in advance of a dreaded situation - this is called anticipatory anxiety. Social anxiety disorder can also greatly affect peoples' lives - work, school, and social relationships. It is not uncommon for those with generalized social phobia to let their worries dictate their lives, and this may inhibit them from making or keeping friends or from working or going to school. Although people who have specific social phobia tend to have fears limited to certain situations, this can also greatly impact their lives, such as whether they decide to take a promotion at work where they will have to interact with more people, give presentations, etc.
Social anxiety disorder affects about 5.3 million adults in the United States. It is the most common type of anxiety disorder. Social phobia frequently co-occurs with other anxiety disorders, depression, and substance abuse.
The onset of social anxiety disorder is variable, but it most often develops anytime from childhood to early adolescence. For those with generalized social phobia, many people tend to report the onset as being very gradual - sometimes reporting that “I have always been shy“. For those with specific social phobia, they are often better able to state a more precise time of onset (usually connected to a particularly distressing event).
For those who report that they did not develop social phobia until a very late age, often there were signs of the disorder at a much earlier age. For many of these people, often some change in their lives preceded the onset of the social phobia - usually this is the loss of something that may have formerly helped them to cope with their social fears (e.g., leaving a job you've worked at all your life). It is also common for divorce or the death of a loved one to trigger social anxiety - because the person that was relied on to help cope with social situations is now gone.
Without treatment, the course of social anxiety disorder tends to be chronic and unremitting. This disorder tends to be more constant and does not wax and wane as with some other anxiety disorders.
As with the other anxiety disorders, it is not exactly clear what causes some people to develop social anxiety disorder. However, it is likely that it involves a combination of factors - including genetic vulnerability, early developmental experiences, and important life events. For individuals who have generalized social anxiety (anxiety in many different types of social situations), there is a stronger genetic component that is usually involved, and these people are more likely to state that there are others in their family who are also shy or socially anxious. For those with specific social anxiety (anxiety in only one or just a couple limited types of situations), it is often the case that specific important life experiences play a role. For example, a person who once had an embarrassing experience while giving a speech to their junior high English class, may thereafter develop fears of giving speeches. Specific social situations tend to be especially feared if an individual ever had a panic attack in that situation (e.g., fears of making a fool of oneself during meetings at work because s/he once had a panic attack during a meeting). Please see the section on panic disorder for a further description of panic attacks.
The criteria for Social Anxiety Disorder (or Social Phobia) according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are the following:
1. Marked and persistent fear of one or more social or performance situations where the person fears scrutiny or evaluation by others. In particular, the individual fears that they might act in a way that would be humiliating in this situation. For example, they might do or say something that will be embarrassing or they might have physical signs of anxiety that others might notice. For children, anxiety must also occur in peer settings (and not be limited to interactions with adults).
2. Entering the feared social or performance situations almost always provokes anxiety. The anxiety in this situation may be so severe that they may have a panic attack.
3. If they are adults, people typically recognize that their fear is excessive (more than others would experience in this situation) or unreasonable (there is really no rational reason to be nervous in this situation).
4. The social or performance situation that is feared is avoided or, if necessary, endured with intense anxiety or distress (during the situation or in anticipation of the situation).
5. This avoidance or distress interferes with the person's normal routine, occupational functioning, academic functioning, or social activities or relationships.
Several different types of medications have been found to be helpful for those with social anxiety disorder. These include: selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and benzodiazepines. Although medications can often be very helpful to many people, they often do not eliminate many people's anticipatory anxiety and avoidances of many social situations. Many people also relapse after discontinuing these medications. However, many people do experience faster relief from medications than they do from therapy (which can take a little longer to have an effect).
Cognitive-Behavioral Therapy (CBT) is another form of treatment that has been shown to be effective for those suffering from social anxiety disorder. The advantages of CBT over medications are that patients learn skills that can be applied to new situations and they tend to feel better about themselves (they feel like they are creating the change rather than the medications). In addition, these CBT skills tend to be more resilient and people are less susceptible to relapse after being treated with CBT than medications.
In CBT, patients learn how to monitor their anxiety and how to break it down into several different components: what they are thinking, what they are doing (e.g., not making eye contact, mumbling, avoiding the situation), and how they are physically responding (e.g., blushing, voice shaking, sweating). In addition, patients are educated on how these 3 different components often work together - sometimes to make the situation seem progressively more frightening.
Next, patients are taught cognitive restructuring. This is a fancy term for looking at the thoughts that you are having in an anxiety provoking situation (or in anticipation of an anxiety provoking situation) and analyzing the thought to determine if it is realistic or not. Patients are taught to identify the types of thinking or cognitive errors that people with social anxiety disorder frequently make - frequently seeing themselves or the situation in a far more negative light than is actually realistic.
For patients who tend to have panic attacks in social situations or for people who tend to have certain disturbing physical sensations during social situations (e.g., shortness of breath), it is often helpful to also learn breathing techniques. This technique involves learning how to breathe slowly from the diaphragm while focusing on relaxing thoughts. This strategy is often helpful in combating many physical sensations that are induced by over-breathing or hyperventilation.
In addition, with their psychologist, patients also construct a list of the different types of situations that they currently avoid or endure with distress. It is also important to note things that make those situations easier or more difficult (e.g., going with a friend, sitting in the back of the room, size of the group, other person's gender, etc.). Next, these situations are rank ordered in terms of how difficult or anxiety producing they would be. Beginning with the easiest type of situation, patients are then taught how to confront these situations that they fear. The first time a new situation is confronted, it is not uncommon to first practice that with the therapist. However, in this type of therapy, patients are then encouraged to work on these same tasks during the week on their own for “homework“.
For those with more generalized social phobia, the length of treatment is generally longer, as it takes longer to confront the many different situations that have be avoided or endured with extreme discomfort.