Social Phobia: Treatment Considerations
The mistaken ideas that underlie a social phobia.
Posted June 7, 2012
A social phobia, like phobias, in general, is an exaggeration of a normal concern. Everyone is self-conscious at times, especially in situations where making a good impression is important. The larger or more important the audience is, the more intimidated someone is likely to feel talking or “performing.” Someone took a poll once and discovered that fear of public speaking was more common and severe than fear of death. Stage fright is a familiar manifestation of this fear. When children try to avoid standing up in class to speak, they are showing early evidence of a social phobia. There is some relationship to shyness, which may be an inborn psychological response. When I was in training as a child psychiatrist, we watched a group of mothers with young children through a one way mirror. When the children came into the room, some immediately went over to the other children, while others hid behind their mothers’ dresses. Repeating the same observation with the same families five years later, the same children showed either a shy or outgoing tendency to the same extent they had initially. Of course, even shy children learn over time to cope with social situations by entering into them: going to parties, having play dates and sleep-over dates, and getting up, willy-nilly, in class when called upon. The general rule is that people learn to be comfortable by doing uncomfortable things or going into uncomfortable places over and over again. Nevertheless, some adults, by avoiding social situations, have learned a different lesson. They learned that they cannot feel comfortable in ordinary places, like a bar or a classroom, where people congregate. And they develop certain misconceptions about what other people are thinking.
First, I would like to distinguish social phobics from another group of people who are much sicker. These people, too, are sometimes called social phobics because they are so exquisitely sensitive to what other people are thinking, and because they end up avoiding even casual social interactions. These very troubled people are delusional. One such patient is a woman who blushes easily, (she thinks) and who feels that other people blush in response to her. She cannot be reassured. Since she upsets even casual acquaintances, (she thinks) she stays home. Another man cannot walk down the street without other people looking with disgust as his facial expression (he thinks). What makes his ideas delusional is his complete resistance to any contrary idea or evidence. I walked with him down a street passing two women who were talking to each other and who looked up briefly at us as we passed. My patient insisted that they had grimaced and shied away from him. Nothing of the kind happened; but he would not listen to me. Body dysmorphic syndrome, in which the individual is utterly convinced that he/she is deformed in some way, is a similar condition. The underlying idea of these people is that there is something repulsive about them, something palpable and visible. It is almost impossible to get them to consider that they may be wrong. Consequently, they are resistant to cognitive-behavioral therapy. The treatment for all the anxiety disorders involves patients learning new, more accurate, beliefs.
There are three ideas which social phobics subscribe to:
1 That people are examining them much of the time. (They are not.)
2. That these people are making disapproving judgments about them. (They are not.)
3. That other people will remember every mistake or bit of clumsiness they have exhibited in the past. (Of course, they do not.)
I saw a young man who had grown up in a family of alcoholics. They were always behaving in a loud and embarrassing manner. The young man had a terrible fear that others who saw his hands shaking when he got nervous would think he was an alcoholic. So whenever he went out socially he would first drink a tumbler of vodka so that his hands wouldn’t shake!
One reason phobics imagine other people are examining them carefully, is that they, themselves, notice when other peoples’ hands shake, or when they stumble in some way. It is hard to convince them that most other people do not think the way they do. But that is the task of therapy. In order for them to re-think these fixed ideas, they have to enter social situations, repeatedly. Usually, they go accompanied by a trained Phobia Aide to facilitate and interpret their interactions with others. Phobics must learn that they will not embarrass themselves noticeably, even if they stutter or their hands shake. After a while, when they are more relaxed, they are not likely to stumble or shake in the first place.
There are drugs that have been shown to have a small, but significant effect on social phobia, including Paxil, and other serotinergic drugs; but in my experience they do not work very well
The tragedy of life, every knows, is not that there are hostile people waiting to pounce on every weakness and mistake, it is that no one is paying attention at all! If you give a talk and talk nonsense, no one will notice. (I have done it. Inadvertently.) If you throw up in the gutter, people step away. You cannot dress in a manner so bizarre that people will think it strange or memorable; because they are not thinking about you at all! Perhaps some people notice, and some people care, but very few. And they are not likely to be critical, except a special few who are always critical. No one pays any attention to them. (c) Fredric Neuman 2012 Follow Dr. Neuman's blog at fredricneumanmd.com/blog