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Social Anxiety Disorder

Ever feel like you're on the outside looking in? Are you shy? Do you find yourself wanting to crawl inside your shell?

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You can tell when I've been working with someone for a while. They're the people whose eyes squint and heads tilt to one side as they lean in closer to see if they can see where I'm "going with that."

That often happens when I start to compare human beings to a wolf pack.

The 'Wolf Pack' spiel goes something like this:

"Imagine human beings like a pack of wolves. The wolves belonging to the pack are safe and protected. They have each other's backs and are less likely to be targeted by predators because they travel together. Everyone wants to belong to the pack because belonging equals survival.

Now imagine the wolf on the outer. The lone wolf. He's isolated and vulnerable and much more likely to be the one plucked off and killed by the predators. No-one wants to be on the outside of the wolf pack. No-one. Belonging to the pack is a primal need for survival."

What's a wolf pack got to do with social anxiety?

A lot, if you ask me!

Here are some examples of some common thoughts people have before going into a social situation. Keep a mental tally of how many you identify with.

  • What if no-one talks to me?
  • What if I make a fool of myself?
  • I won't know what to say.
  • I'm not as smart/funny/beautiful as everyone else.
  • I'm going to look like an idiot.
  • What if I have an anxiety attack in front of everyone?
  • What if no-one helps me?
  • What if I can't get out quickly if I need to?
  • What if everyone laughs at me?
  • What will everyone think of me?
  • What if people judge me or think negative things about me?
  • How do I look?
  • What if everyone looks at me?
  • If I don't do this perfectly, everyone will think I'm a failure.
  • What if I'm too early/late?
  • Am I dressed appropriately?
  • What if I go to the wrong place/door?
  • What if I do something wrong?
  • What if there is something on my face/clothes?
  • What if no-one talks to me and then everyone notices that no-one is talking to me and thinks that I'm strange?
  • What if someone does talk to me and I don't know what to say?
  • What if I say something wrong/silly/stupid?
  • What if I blush?
  • What if someone is nice to my face but talks about me behind my back?
  • What if they think I'm an idiot?
  • What if they ask me what I do for a living and then don't like the answer?

Remember that time I put a call out on our Facebook page asking you for some examples of the kinds of social worries you have? Well that's the list we came up with (especially me!). Did you notice how repetitious the worries were as more and more of you brave villagers answered my call for help? That's not a coincidence, because the underlying theme here is one of a need to have a sense of belonging.

Read them again and you can easily identify the underlying core fear present in all of those worries - what if I don't belong to the pack? Just like the lone wolf. And remember, belonging = survival. This is a primal need people. It relates immediately (in our brains at least) to life or death.

The examples of the social worries we've listed above are very common - we've just shown that through our Facebook request. That very question was enough to increase the social anxiety in many of you, "what will people think of my response?" which led to many of you not replying at all, and some of you being brave enough to share your thoughts, and perhaps delete them later!

So, if these worries are so common, when do they become a problem and when should we seek help for them?

What is Social Anxiety Disorder (previously Social Phobia)?

As many as 12.1% of the population suffer from Social Anxiety Disorder in their lifetimes (Kessler, Berglund, et al., 2005) making it the second most prevalent anxiety disorder, after specific phobia (e.g. fear of spiders, heights, etc.) which we'll write about next.

While many more people are shy, their shyness is not severe enough to meet criteria for a Social Anxiety Disorder.

In the clinic, we would begin using the phrases Social Anxiety Disorder or Social Phobia when someone has been experiencing intense fears of social situations over an extended period of time (longer than six months) so much so, that those fears (out of proportion to the situation) cause the person significant distress and impact negatively on their day-to-day functioning (at work or school and/or socially).

This means that the person has probably started to avoid situations that make them feel uncomfortable, which unfortunately means they're more and more likely to lean towards avoiding things in order to feel good. Avoidance is great in the short term - it provides immediate relief from the anxiety and a false sense of safety, but most situations aren't 100% avoidable forever, so...

In our article Anxiety - An Evolutionary Recap  we discussed how our oversensitive amygdalae (there are two of them) can overestimate the danger of threats in our internal and external environments, sending us into a state of fight or flight and heightened anxiety. In social anxiety, the 'threats' come in the form of an array of social situations where we typically fear being judged negatively or criticised by other people through being embarrassed or humiliated in some way.

There are three main components to social anxiety:

1. The 'body' component - what we feel - and as we know, anxiety is a very 'physical' emotion due to all of the physiological changes that occur during fight or flight

2. The 'thinking/beliefs' component which we refer to as cognitions - see our huge list above!

3. The 'actions/behaviours' component - what we do when we feel anxious - ironically, high enough levels of anxiety will actually impede our performance making us more likely to make mistakes in public, like saying the wrong word or worse still, not being able to speak at all. This means that our anxious worries are more likely to actually make our fears come true!

Let's use the ABC Model to illustrate how what we think can influence what we feel, and how what we feel can influence how we behave.

The ABC Model

The ABC Model is a theory that underpins all cognitive therapies.

A stands for 'antecedent' or 'activating event' - the situation that triggers our response

B stands for 'beliefs' - our thoughts, perceptions and evaluations of the situation that just happened

C stands for 'consequences' - the feelings and actions that come after the thinking

Here's a recent example of social anxiety from 'a friend':

A - My 'friend' is invited to their boss' house to celebrate a work success along with three couples and their children.

B - My 'friend' thinks "I'm going to be the only single person there and they'll think there's something wrong with me"

C - My 'friend' feels incredibly anxious and sad thinking she is so different to everyone else and tries to come up with an excuse not to attend the celebration even though she'd really love to be able to go.

Referring back to the above example of my friend, we can see that the situation (A) was not unusual in anyway. It's very common for work mates to want to celebrate and socialise together - these are not usually life or death situations.

But when we look at the thoughts she had (B) we can tell something is not right. In fact, we could classify her thoughts as a combination of several Unhelpful Thinking styles (see http://www.cci.health.wa.gov.au/ for some great free resources), including:

Catastrophising - assuming the worst and blowing the situation out of proportion "they'll think there's something wrong with me" which the amygdalae read as "I'm going to lose my job, have no money, won't be able to eat and then I'll die." Catastrophe.

Jumping to Conclusions - if this happens then that will happen (even if that thing has only ever happened once, or never!).

Negativity/Pessimism - always looking at the glass half-empty "they'll all think that there's something wrong with me and won't like me anymore".

Labelling - thoughts that begin with "I am..." or "I'm not..." are very easy to believe as facts. "I'm a freak/ loser/unlovable etc.". Thoughts like those will never make us feel good.

In terms of the 'C', my 'friend' wanted to avoid the situation by turning down the invitation and stay safely in the comfort of their own home, in their pj's eating chocolate on the couch, feeling relieved. In the beginning, they would have felt better and probably even enjoyed their chocolate.

But what would have come to pass is that they'd eventually feel guilty for turning down the invitation and then felt sad about missing out on the celebration. They would've felt isolated from the group and even more 'different' and excluded than before. This would impact negatively on their self-esteem, causing a cycle of low mood and unhelpful thinking to ensue, all the while ensuring an increase in anxiety the next time an invitation was offered.

Worst of all, they would have missed out on being with their colleagues, people whose company they actually enjoy. Something they actually value doing in their life.

Social anxiety is problematic because it makes us forget what is important to us - it stops us from living our lives - and it reduces our quality of life.

What causes Social Anxiety Disorder?

We have previously discussed how we seem prepared by evolution to fear certain dangerous situations, but what might surprise you is that we also seem prepared to fear angry, critical or rejecting people (Blair et al., 2008).

Some of us have a generalised biological vulnerability to becoming anxious, but this alone is not enough to cause the development of an anxiety disorder. Usually, there are multiple factors that contribute and it would be virtually impossible to identify them all accurately.

There can be several psychological contributors to social anxiety. For example, a person who's had a negative experience with anxiety is likely to develop an internal focus of their physiological changes, becoming sensitive to things like changes in heart and breathing rate. The person who is afraid of having an anxiety attack in public is more likely to misinterpret changes within their body as the beginning of an anxiety attack. The subsequent anxiety about the anxiety is enough to bring on an anxiety attack through a self-fulfilling prophecy. Sadly, events like those serve to reinforce the anxiety.

For anyone who has experienced any kind of social trauma in their past, social situations become very real triggers or alarms that their limbic system are on high alert for. It's very difficult to challenge the belief that social situations can be traumatic when someone has actually had such an experience.

Another cause of social anxiety can be the developmental belief that social evaluations can be dangerous. This could be modelled by parents who overvalued the opinions of others, for example.

How is it maintained?

Focussing attention on negative things makes it easy to find reasons to stay afraid. Every time we 'listen' to an unhelpful fear or worry, we are strengthening that thought or belief, making it more automatic and engrained, if you like. As mentioned above, becoming too in-tune and sensitive to changes in our bodily functions can also become problematic if we misinterpret the reason for our faster heart-rate, for example. This sometimes happens when someone walks up a flight of stairs and their heart-rate quickens due to the physical exertion. If however, instead of realising this they tell themselves they're about to have an anxiety attack, it's more likely that they will indeed begin feeling more and more anxious, reinforcing the faulty belief that it was anxiety all along.

Thinking styles play a vital role in the maintenance of all anxieties, including social anxiety. Follow this link to read more about common unhelpful thinking styles on the Centre for Clinical Interventions website.

Sadly, one of the biggest maintainers of social anxiety is avoidance. As we've previously discussed, avoidance provides a short-term relief from the anxiety which negatively reinforces the need to avoid situations in order to feel better. What happens though is that we become sensitised to this feeling very quickly and we need to avoid more and more things, on a larger scale each time, in order to get the relief that avoidance can provide. It doesn't take long at all before someone finds it difficult to leave the house for any reason. Avoidance also reduces the opportunities for positive experiences so it's hard to build evidence to support the beliefs that socialising is a good thing and that nothing bad will happen.

What can be done about it?

Most clients will tell me that their goals for therapy are to "never feel anxious again" which launches me into my 'we-need-anxiety-to-survive-so-it's-a-good-thing' spiel.

We can't make your anxiety go away, but we can reduce it and make it more manageable for you and less problematic in circumstances where it isn't required.

The one thing most clients hate hearing is that the best way to combat anxiety is to do the very things you don't feel like doing.

We achieve this through a process called systematic desensitisation where we focus on a person's functional goals and we break them down in order of how anxiety provoking they are, from least to most.

The person is taught some effective anxiety management strategies like the ones we detailed in our article Very Quick & Easy Anxiety Management Strategies which they then build confidence using whilst undertaking their anxiety producing tasks. In essence, these are relaxation strategies but may also include mindful grounding strategies too.

Don't worry though, we use a scale of 0 - 10 when describing our anxiety levels (0 = completely relaxed and 10 = I'm bursting out of my body with anxiety) and we always begin with the activity that is only 1/10. We only ever move to the next task once the 1 becomes a 0. The beautiful thing is that by the time you get to the task that was originally a 10/10, it's now actually only a 4/10.

We typically incorporate cognitive therapies to assist with the unhelpful thinking and irrational fears. There are many ways to accomplish this but two common therapies are called Cognitive Behavioural Therapy (CBT) and Acceptance and Commitment Therapy (ACT). Two excellent self-help style books, one for each therapy, are Change Your Thinking by Sarah Edelman and Get Out of Your Mind and Into Your Life by Steven Hayes.

Mindfulness techniques can be very helpful when managing anxiety but a word of caution - never begin with any internal focus for your mindfulness practice. Become proficient first of all at being mindful of your external environment. Learn to focus your attention to the things happening in your environment in the moment. Focussing internally on your physical sensations or thoughts can be incredibly confronting in the beginning. We'd want you to master the art of the non-judgemental observation well before you attempted to sit with your anxiety or fears.

Of course, there are also medication options for anxiety management. Some classes of these drugs are required to be taken regularly and others only as you need them. It's always best to discuss these options and the appropriateness of medication with your doctor or psychiatrist.

For some, psychological strategies alone will be sufficient, for others a combination of pharmaceuticals and psychotherapy is more beneficial. In any case, remember, we are all individuals with our own individual needs and if you have any questions about what might be helpful for you, have a conversation with your doctor as a great starting point.

I hope you've found this article useful. The next in our anxiety series will be on Specific Phobias. Do you have one? If so, drop us a line and let us know.

As always, feel free to share our page or articles with all your friends. It's so wonderful watching our village grow!

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References:

Blair, K., Shaywitz, J., Smith, B., Rhodes, R., Geraci, M., & Pine, D. S. (2008). Response to emotional expressions in generalised socialised phobia and generalised anxiety disorder: Evidence for separate disorders. American Journal of Psychiatry, 165(9), 1193-1202. doi: 10.1176/appi. ajp.2008.07071060.

Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593-602.

1 comment

  • Comment Link paul Sunday, 31 July 2016 08:15 posted by paul

    well said Jodie a lot of things said that have made anxiety easier to understand for me anyway cheers Paul.

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