Approximately 2% of the population suffer from social phobia to the extent that it is debilitating, and as such this represents a significant mental health problem. For 91% of sufferers, social phobia develops before the age of 25. In sufferers, interaction with others and of forming relationships provokes overwhelming fear, and is avoided as a consequence. The effect on career and quality of life can be devastating.
A key fear in social phobia is that of being negatively evaluated by others. Possible feared situations range from fear of public speaking at the mild end of the continuum, to fear of one-to-one conversations in its most severe form. Some social phobics fear, and thus avoid, almost any interpersonal contact.
Panic attacks may be experienced in a variety of social situations, and additionally there may be a particular fear of blushing, sweating and tremors, and other physical symptoms, that the sufferer believes will be visible to others, thereby compounding his or her social anxiety. Very often such situations will be avoided in future if found intensely unpleasant, and social isolation is therefore common. A vicious cycle of avoidance may be set up.
Self-report questionnaires are often used to assess social phobia, such as The Social Avoidance and Distress Scale. Such questionnaires assess anxiety and avoidance in a variety of social and performance situations, as well as concerns about being negatively evaluated by others in those contexts. The practitioner may also ask the client to self-monitor the occurrence of anxiety and avoidance behaviour on a day-to-day basis, and use this information to build a bigger picture of the social phobic's overall experience. Physiological responses to situations (such as heart rate measurements) may also be taken into account.
In some cases of social phobia, medication may be prescribed. Monoamine oxidase inhibitors can be effective in reducing symptoms. Beta blockers are another alternative, being effective in reducing speaking and performance anxiety, and these have the advantage that they can be taken as and when needed (ie just before entering a feared situation). Benzodiazepines (eg valium) are sometimes used, but there is a risk of dependency on this group of drugs, and symptoms tend to recur on withdrawal of the medication. It is likely that psychological treatments will be offered in addition to, or instead of, medication.
Cognitive Behavioural Group Therapy (CBGT) is the most likely psychological treatment strategy that will be offered, as the group approach allows for the testing of new skills in a social setting along with other sufferers. There are three primary components to CBGT: exposure to feared situations, challenging distorted thoughts and beliefs, and homework assignments which incorporate the other two components.
Individuals will be asked to rate their anxiety in a variety of stressful social situations, ranging from mildly threatening situations, to those found most threatening (eg from talking with one individual, to addressing a group of strangers). The client will then be encouraged to approach those situations they have previously been avoiding, starting with the least stressful, and building up gradually to face those most feared, until eventually a sense of mastery and control is achieved. It may be unrealistic to expect complete relief from anxiety related symptoms, but the list of avoided situations should diminish over the weeks of therapy, and consequently a release from social isolation can be anticipated.
The second component of CBGT - cognitive restructuring - involves identifying automatic negative thoughts and challenging them, so that they can be replaced with more realistic appraisals of the self, and of feared social situations. For example, a client concerned that their physical symptoms such as blushing and sweating will be apparent to others, can be helped to see that their judgement of the visibility of the symptoms is in all probability exaggerated. This will involve self monitoring, and coming to understand the irrationality of some beliefs that are contributing to the social anxiety. This will be done both within the supportive group atmosphere, and as homework assignments set during the therapy sessions. As a result of reducing their social phobia in CBGT, clients are likely to begin to create new opportunities to face their fears in their everyday lives.
“For many years I lived with the acute discomfort of social phobia, and the condition really hampered my life. Take any social event involving more than one other person, and I would experience all the classic symptoms: sweating, blushing, trembling, and so on. I would constantly fear saying the wrong thing, and making a fool of myself in some way. Or I would respond to social situations by going very quiet, which then led to me feeling isolated and alone. The anxiety I felt before a social event, was often as bad, if not worse, than the event itself. Having a forthcoming social occasion on the calendar would make me lose sleep, and even lose my appetite.
My university years were particularly bad, and at one point I had to pull out of university altogether, although I did manage to regain entry after a period of recovery. I used to experience a phobic response every time I entered a lecture theatre; I would walk in and be overwhelmed by the sea of faces of the students already seated, all apparently looking at me. This would make my heart race, and my head swim. I felt desperately self conscious, and could not wait until the time I could find my place to sit, and be looking in the same direction as everybody else. Even then it would take a while before my breathing slowed down, and before I could concentrate on anything else apart from my physical symptoms, and the crushing feeling of embarrassment. Having to give talks at university held a terror all of their own, and I even fortified myself before one such occasion with a large brandy and a couple of tranquillizers. Then, provided I had thoroughly planned and rehearsed my talk, I could just about get through it.
Other social contexts were difficult for me too. Job interviews were just horrendous, although I used to tell myself that everyone feels a degree of fear in such a situation. Parties, however, were even more difficult to cope with; after all, they are supposed to be for enjoyment, and that dreaded word 'socialising', but to me they presented an often overwhelming challenge. I used to feel reasonably comfortable with friends provided I saw them on a one-to-one basis, but as soon as that number increased, up my stress levels would go. Meals out were nearly as bad for me as parties, as there was the added difficulty of trying to eat when at times I felt too shaky to even hold a knife and fork steadily; soup I had to avoid altogether. All this made me feel so alone, and so inadequate. I used to continually wonder how my other friends and colleagues used to appear so relaxed and confident, so at ease in company.
In desperation I went to my G.P. who referred me to a Behavioural Psychotherapist. I had tried repeatedly to get my doctor to prescribe me tranquillisers so that I could cope with university life, but he pointed out that there was a real danger of me becoming addicted, if every time I hit a rough patch I resorted to valium. Also, I would not learn how to deal with social situations using my own coping resources. My therapist was incredibly helpful, and he did teach me some useful strategies to deal both with the symptoms of social phobia, and new ways of looking at myself within social situations. In one exercise he got me to breathe in a very shallow and rapid way, so that I effectively induced my own panic attack; he then taught me to control my out-breath, so that I exhaled very slowly, to prove to me that I was also capable of reversing the hyperventilation. This really did make me feel I had some control, at least over my physical symptoms.
My therapist also gave me some homework exercises. For example, I was to rate how anxious I was feeling on a scale of one to ten, when I first entered the lecture theatre. I was also asked to note how long the severe symptoms lasted, and then rate my anxiety again after I had been sitting quietly for a few minutes. This effectively proved to me that although my stress levels could rocket in a stressful situation, that they also subsided fairly quickly. It made me realise that I had been over-exaggerating in my own mind, the severity and duration of my attacks. My therapist also pointed out to me that people are rarely as interested in us and our appearance as we sometimes believe when we are experiencing social phobia, and that in any case my symptoms - the sweating, shaking, blushing etc - are not as noticeable to others as I might fear. He helped me to realise that other people in social situations are often experiencing their own difficulties and issues, even though this may not be visibly apparent, and that often people are more focused on themselves, than on others.
Today, with the help of my behavioural psychotherapist, my reading of self-help books, and my own continued efforts, I am all but symptom free. One of the most important things I learned, I believe, is to not avoid social situations because we see them as threatening in some way. Backing away from invitations, interviews and so on, not only limits the opportunities available to you, but reinforces the fear - the belief that you can't cope under stress. Graded exercises helped me, whereby I entered situations where my perception of social threat was low, such as going out with a small group of friends, and then working up to more stressful situations, such as parties, job interviews or joining new classes. Each individual experience of successfully dealing with a situation, can then increase confidence for the next social challenge, and so on.
I still experience some social anxiety, but today it feels manageable. If I have a social event to attend that is causing me some discomfort at the thought of it, I try writing out my fears before I go, as well as giving them a rating between one to ten for level of severity. I then review what I have written after the feared event, and I usually find that I had over-estimated the threat. In fact, by doing this I am often pleasantly surprised by my reaction to the actual event. I also have a couple of strategies that I still use to this day when in the midst of a social gathering; one is to ask other people questions, so that I can really focus on the other person, instead of on myself. The chances are that I become genuinely interested and absorbed by whom I am talking to, and discovering a shared interest can really help me to connect with them. I also make sure I know where the exit is, even keeping this in view if need be! Very rarely do I feel the need to escape, but it helps to know exactly what I can do if I need a few minutes out to retrieve my equilibrium!”