Many people are concerned and slightly apprehensive when they are in social situations that may be unfamiliar to them or where they may need to perform in front of others. For some people, however, this concern and apprehension is of sufficient high intensity and severity and such individuals may be suffering with social phobia, also known as social anxiety disorder.

Social phobia is an anxiety disorder, where the anxiety is triggered by thoughts and perceptions surrounding social and performance situations. The person with social phobia worries excessively:

• that others may be scrutinising them for the behaviours; 
• about what others might think of them,
• about embarrassing themselves in front of others, and/or
• about being rejected, humiliated, or negatively evaluated by others.

The distressing factor for these individuals is that they ‘crave’ and ‘desire’ social contact. Although they may engage in social situations, they over-value the opinions of others and, therefore, their fear of humiliation and criticism often keeps them isolated. They fear being in situations where they may be scrutinised by others and, when in these situations, are faced with ruminative and unhelpful self-talk (e.g. “I don’t want to make a fool of myself”) and concern that such evaluation by others will be negative. As a consequence, they also experience high levels of physical distress.

Importantly, the things that the person fears (e.g. “I’ll say something stupid and others will laugh at me”) may not happen, but the person worries excessively that they might happen or that they may have happened and they believe it to be true.

Chris finds social situations stressful

Chris is a 29-year-old accountant who finds it an effort to attend social functions as he worries constantly that he will have nothing interesting to say and that others will find him “dry” and “unintelligent”. Chris avoids these situations as much as possible, which has an impact on his work relationships, networking possibilities, and his social life. He has never had many close friends and the few close friends he has, have stopped phoning him up to do things, as on 9/10 times he would make an excuse to not go. He is saddened by this as, as he still desperately wants to maintain friendships and meet new people. If he does go out, Chris drinks a number of beers before leaving the house and ensures that he has a drink in his hand at all times. He chooses to stand on the edge of groups and if he is asked a question, he will answer it as briefly as possible, limit eye contact with the person, and not ask a question in return.

After these situations, Chris spends days ruminating about the situation, “I can’t believe I said that!”; “Sam will probably think I’m too stupid to hold up a conversation”; “I’m sure that they saw my shaking like a leaf! I bet that’s why they were laughing when I walked up to the group.”   

At work, Chris spends most of his time in his office. He eats privately, in his office, as he feels excessively anxious and self-conscious in situations where others may be watching him.

In summary, Chris’s extreme self-consciousness and his fear of being evaluated negatively by others, results in him missing many opportunities to socialise with others. This results in him being alone most of the time, even though he would like to be around others.

Each person with social phobia has a unique set of social or performance situations that may lead to the experience of anxiety. The situations may be few and specific (as in circumscribed social phobia) or more general (as in generalised social phobia). The may include:

• Any type of social situations, encounters, or associations;
• Meeting people who hold positions of authority (including employers and lecturers);
• Doing things in situations where others may be able to observe the person (e.g. eating or writing in public);
• Being introduced to others;
• Being the centre of attention; 
• Initiating or maintaining conversation in social or group situations (e.g. at parties or informal work functions);
• Arriving late for a meeting or lecture;
• Participating in sporting activities;
• Talking on the telephone; and
• Speaking in formal social situations (e.g. work meetings; university lectures; addressing an audience; making a speech at a wedding).
  

The cognitive-behavioural model of social phobia

Unhelpful thoughts (cognitive symptoms)

The main concerns lie in worries and fears that others will evaluate the person negatively or that they may do something to be embarrassed by:

• “I’ll make a fool of myself!”
• "People will laugh at me”
• “Ill have no idea what to say”
• “I’ll be so nervous that I’ll mess food on my clothes and people will think I’m clumsy”
• “No one will find anything I have to say interesting”
• “I’ll blush/sweat/shake/stutter so much that people will know that I’m nervous!”

Feelings (emotional symptoms)

• Intense anxiety – may escalate to panic
• Fear

Physical symptoms

In threatening situations, the body becomes prepared to fight or flee

The bodily effects in social anxiety include:

• Increased heart rate and strength of beat
• Increased rate and depth of breathing – leading to over breathing
• Sweating
• Widening of the pupils
• Decreased activity of the digestive system – person may feel nauseas
• Muscle tension
• Focused attention on surroundings to scan for danger
• Reduced ability to concentrate on ongoing tasks.
• Shakiness
• Dry mouth
• Numbness or tingling sensations
• Light headedness
  

Behaviours that exacerbate the problem

The way in which a person acts in response to their anxiety can exacerbate the anxiety. People with social phobia often do things or avoid situations to avoid the feeling of anxiety or reduce its intensity, but these usually serve as the driving force behind the cycle and it continuing influence in the person’s life.

Focus on internal sensations

After a person experiences anxiety in certain situations and is concerned about being anxious in those situations again (e.g. hot flushes or trembling at a staff meeting), he/she can become very focused on his/her internal physical sensations in those or similar situations.

This can result in the person being very sensitive and focused on their physical sensations (e.g. increase in heart rate, or shortness of breath) and may come to interpret any mild sensations as indicating that something is wrong e.g. interpreting a heart flutter as a heart attack, or dizziness as ‘going crazy’.

Hyper vigilant to possible threat

As the person is already anxious in social situations, such situations are perceived as threatening, making them more likely to be on the ‘lookout’ for possible threats.

The person may be more attentive to others’ facial expressions and body movements (e.g. “He frowned. He must think I’m, a twit!”) or attentive to their own bodily reactions – “I can feel my face hotting up. I bet I’m red as a beetroot! Everyone will laugh at me!”

Avoidance behaviours

Since the person feels fearful or anxious in social situations, they see it as a realistic option to avoid or prematurely leave these situations.

The avoidance allows the person to temporality avoid feelings of anxiety and, thus, reinforces their need to avoid such circumstances by not allowing the person to objectively test if the situation is safe.  Thus, thus they continue these avoidance behaviours and the cycle is further maintained.

More subtle avoidance behaviours include wearing sunglasses to avoid eye contact with others or concentrating only on ‘safe’ topics of conversation (e.g. topics of interest that they know a lot about).

Safety behaviours

Similar to avoidance behaviours, the person engages in behaviours that will prevent them from doing something embarrassing, thus ensuring minimal focus of attention on them.

For example, the person may constantly check that their zipper is done up; may speak softly so to avoid people picking up on any mistakes that they might make; carry water with them in case they start to feel hot; only go out if a friend accompanies them.

These behaviours are likely to draw more attention to the person (e.g. if someone asks them to speak louder), thus achieving the opposite of what they had hoped. 

How is social phobia different from normal shyness or “normal” social anxiety?

Most people experience discomfort in social situations at some point in their life (e.g. feeling shy). However, shyness is often manageable and specific to the situation. Even the most extroverted and confident people may experience times of uncertainty, discomfort or doubt in social situations. The apprehension for these people is often of a low intensity and the person can use helpful coping techniques to reduce the anxiety and/or use it productively to drive their performance.

Social phobia is an extreme form of shyness and social anxiety and is associated with the activation of the anxiety response and the associated behaviours for reducing this anxiety. The anxiety for people with social phobia is often debilitating and restrictive and severely affects day-to-day living and opportunities.

Unlike those who are shy and mildly anxious in social situations, a person with social phobia:

• Experiences excessive doubts, worries, and fears in anticipation of the social or performance event,, and afterwards; 
• Does not experience a reduction of anxiety during the event because of the manner in which the cycle is maintained; and
• Experiences anxiety that is disabling enough to limit their interactions and make it more likely that the interaction/performance is not successful. 

What impact can social phobia have on a person’s life? 

The fears associated with social phobia can interfere with many areas of a person’s life and the associated behaviours (e.g. avoidance) can result in:

• Isolation and feelings of loneliness;
• Limited opportunities for establishing social networks and developing and maintaining platonic and intimate relationships; and
• Reduced opportunities for developing and expanding ones potential (e.g. at work and university).

Social phobia is often associated with and accompanied by other difficulties, including:

• Being overly sensitive to criticism from others;
• Difficulty asserting oneself;
• Low self-esteem;
• Poor social skills (associated with safety behaviours e.g. poor eye-contact or low voice levels);
• Depression and other anxiety disorders;
• Bulimia nervosa; and
• Use of alcohol, drugs and other medication in an attempt to reduce the experience of anxiety and manage situations that they may perceive as threatening.

Who is affected by social phobia?

• Social phobia is the third most common psychiatric condition (Anxiety Disorders Alliance, 2003).
• It is estimated that 3%-13% of the population will experience social phobia at some point in their lifetime (APA, 2002).
• Social phobia typically begins in mid-adolescence, with onset in early childhood for some (APA, 2002). Onset after 25 years of age is considered quite rare.
• Social phobia is equally prevalent in men and women.
• Social phobia occurs in all cultures, but may present differently across cultures, based on culturally specific social codes of conduct.

The causes of social phobia

No one single factor gives rise to anxiety disorders such as social phobia, but rather various factors coalesce in the onset of anxiety symptoms.

According to the American Psychiatric Association (2002), social phobia can develop slowly over time, or may develop suddenly after a humiliating situation. 

External factors

Various factors in a person’s environment can contribute to feelings of anxiety and worry.

• Childhood experiences: A child observing an adult responding anxiously in certain social situations may learn certain ways of thinking about and acting in those situations.
• Abuse and bullying in childhood may contribute to the onset of anxiety in later life.
• Negative experiences with social encounters or performance situations throughout ones youth.

Internal factors

Person’s biological makeup (predisposition): Based on twin studies and family studies, there appears to be a biological component contributing to the onset of anxiety disorders like social phobia.

Personality and coping skills: Each person has a different personality and an array of different coping skills that determines how they deal with various situations. These characteristics are partly inherited but are also shaped by ones life experiences, particularly throughout childhood.

Unhelpful thinking: Interpreting or perceiving situations to be threatening, thus triggering an associated stream of unhelpful and negative self-talk.

How might social phobia change over time?

Some people may experience the abrupt onset of social phobia after a situation that they perceive as stressful, critical, or degrading, whereas others may develop the disorder over time. Without treatment, social phobia may continue without end, whereas some people may experience a reduction in its severity or cessation of the symptoms as adults (APA, 2002). 

A person may set up their life in such a way that the full impact of social phobia is not always apparent. However, the impact may become apparent when the person’s life situation changes or if the person faces increased life demands, for example:

• A person who has a fear of public speaking may continue through much of life without many difficulties. However, a promotion at work may involve the need for presentations, thus triggering the person’s fears.
• A recently divorced person (who has avoided much social contact while married), may face again the fears of social dating (including eating and drinking in front of others), which may re-trigger previously held anxieties.

What does treatment involve?

Cognitive Behaviour Therapy

Cognitive Behaviour Therapy (CBT) is an approach that helps to break the cycle of anxiety and reduce the experience of anxiety by focusing on the way that a person thinks, feels, and behaves. Research has shown the use of CBT in a group format to be highly effective in the treatment of social phobia (Barlow, 2002).

CBT for social phobia incorporates a package of techniques aimed at targeting the person’s:

• unhelpful thinking styles;
• emotional and bodily reactions experienced in social situations (or when thinking of the situations), and
• behaviours in response to these situations (e.g. avoidance).

Specific components include:

Education about social phobia:

• Similar to that presented in this brochure, and as specific to the person.

Breathing and relaxation exercises:

• Help the person experience a relaxed state, allowing the person to be able to better assess the situation in a calm and objective manner. 

Challenging unhelpful thinking:

• Targets the thinking patterns of people with social phobia, which are most often peppered with negative evaluations. 

Graded exposure tasks (and response prevention): 

• Avoidance behaviours are one of the strongest maintaining factors of the social anxiety, and an important part of the cycle that need to be addressed and broken.
• This part of treatment involves setting up tasks that place the person in the feared and avoided situation and allows them to test out within the situation the very thing that they worry will happen.

Social skills training:

• The person is provided with an opportunity to learn and practice specific social skills, such as assertive communication, appropriate levels of eye contact and addressing people within various situations.
• The process of treatment is graded and gentle and ensures that the person feels comfortable with each step that they complete, making it more likely that they will continue with treatment.

Treatment continues for approximately 16-24 weeks

Medications

Medications may be helpful in reducing the levels of anxiety that a person might feel in or leading up to a social situation.

Effective medications include:

• Monoamine oxidase inhibitors (MAOI’s): phenelzine (Nardil)
• Selective Serotonin Reuptake Inhibitors (SSRI’s): paroxetine (Aropax); fluvoxamine (Luvox), and sertraline (Zoloft).
• Benzodiazepines: clonazepam (Klonopin) and alprazolam (Xanax).
• Anxiolytic: buspirone (BuSpar).

It is important that a person consult with their doctor before taking any such medication(s), so as to enure that the most suitable medication is prescribed and that the levels and possible side-effects are monitored and managed as needed.

What can I do to help myself?

If you have read this brochure and feel that the information in it is relevant to you, then it is important that you seek the appropriate help. This can be done by:

Arranging to see a Clinical Psychologist at Sentiens for individual counselling, where a thorough assessment can then be conducted and an individual treatment plan developed.

Talking to one of the Mental Health Professionals at Sentiens about Sentiens group programs that may be most suitable for you.

Organising a consultation with your doctor or psychiatrist.

If you are currently taking medication it is important that you continue to take the prescribed dose at the appropriate times, on those days when things may feel challenging, as well as on days when you are feeling good. This will help you to prevent future episodes and relapse.

If you are concerned about medication side effects and wish to change or stop taking you medication it is important that you discuss this with your doctor before taking any action. This is important as some medications must be stopped gradually in order to protect the person from dangerous side effects.

Family and friends can offer great support during challenging times. Also, local support groups running in your community may be a place where you can meet other people experiencing similar difficulties.

Some people find self-help books to be a valuable resource. Self help books can be used in isolation or in combination with another form of treatment. Some self-help resources that are relevant for people with social phobia are listed below.

Further reading

There have been some good texts written primarily for clients experiencing social phobia related symptoms. Some suggested readings include:

Books:
•    Berent, J. (1993). Beyond Shyness - How To Conquer Social Anxieties. New York: Fireside.
•    Anthony, M. & Swinson, R. (2002). The Shyness and Social Anxiety Workbook. Oakland, CA: New Harbinger.
•    Rapee, R.M. (1998). Overcoming Shyness and Social Phobia: A Step-by-Step Guide. Northvale, NJ: Jason Aronson.

Websites:
•    http://www.anxdepaust.com - Anxiety and Depression Support Groups Australia
•    http://www.healthinsite.gov.au (with links to relevant social phobia sites)
•    http://www.ada.mentalhealth.asn.au - Anxiety Disorders Alliance 

References

American Psychiatric Association. (2002). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington: American Psychiatric Association.

Andrews, G., Crino, R., Hunt, C., Lampe, L., & Page, A. (1994). The treatment of anxiety disorders: Clinician’s guide and patient manuals. Melbourne: Cambridge University Press.

Antony, M. M. & Barlow, D. H. (2002). Handbook of assessment and treatment planning for psychological disorders. New York: Guildford Publications.

Anxiety Disorders Alliance (2003). Social Phobia. Retrieved, 28 December 2005, from http://ada.mentalhealth.asn.au/social.html

Bennet-Levy, Butler, Fennell, Hackamn, Mueller & Westbrook (Eds).  (2004). Oxford Guide to Behavioural Experiments in Cognitive Therapy. Oxford: Oxford University Press.

Bruce, T. J. & Saeed, S.A (1999). Social Anxiety Disorder: A Common, Underrecognized Mental Disorder. American Family Physician. Retrieved, 18 January 2005, from http://www.aafp.org.afp/991115ap/2311.html

Hofmann, S.G. & Barlow, D. (2002). Social Phobia (Social Anxiety Disorder). In D.H. Barlow (Ed.), Anxiety and its disorders: The nature and treatment of anxiety and panic (2nd ed), pp. 454 – 476. New York: The Guilford Press.

Kingsep, P. & Nathan, P. (2001). Social anxiety in schizophrenia: A cognitive behavioural group therapy programme therapist manual. Perth: Riobay Enterprises. 

Norcross, J. C., Santrock, J. W., Campbell, L. F., Smith, T. P., Sommer, R., & Zuckermam, E. L. (2003). Authoritative Guide to Self-Help Resources in Mental Health. New York: The Guilford Press.

Social Phobia/ Social Anxiety Association. What is Social Anxiety?  Retrieved, 28 December 2005, from http://www.socialphobia.org/whatis.html