Social Anxiety (Social Phobia)
Some people find social situations leave them feeling traumatised - they endure them, rather than enjoy them. They worry so much about being judged or about 'making a fool of themselves' that they feel exhausted, so try to avoid social events whenever they can.
Many of us worry a little before entering social situations, but usually find that we manage to enjoy them. However, about 1 or 2 in a hundred men and about 2 or 3 in every hundred women find social situations terrifying. They suffer from social anxiety (also known as social phobia, social anxiety disorder or simply 'SA'). The term 'social anxiety has largely replaced the older term 'social phobia' and is defined in the diagnostic manual DSM IV as:
"A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others".
For people with social anxiety, fears concerning social situations exert an undue influence over their thoughts and behaviour. Thinking about social situations is stressful and sufferers often spend a good deal of time thinking about how awful social situations will be - we call this 'anticipatory anxiety'.
Do you think you might suffer from social anxiety? The Liebowitz Social Anxiety Scale (LSAS) is commonly used to assess social anxiety symptoms; it's reproduced at the end of this page for your convenience, or take a look at our easy-to-complete social phobia inventory (SPIN).
'General' social anxiety
People who suffer from general social anxiety tend to worry about becoming the centre of attention in social situations. People with social anxiety might worry that people are looking at them and criticizing them. Some will be afraid of being introduced to other people and might worry about eating or drinking in public. They might be acutely afraid of blushing, or of feeling embarrassed, exposed, ashamed, ridiculed or humiliated in front of other people.
Many of us are shy as children or as adolescents, often we 'grow out' of such feelings. Social anxiety has been likened to an extreme form of shyness, which lasts too long and hurts a great deal.
People with social anxiety may find it difficult to go into shops or restaurants; parties and social events are likely to be especially difficult. It can be tempting to use alcohol or street drugs to help us cope, starting to drink before going out socially so that we can relax enough to enjoy ourselves.
In practice this rarely helps, and more often leads to regrets and further feelings of inadequacy. So routine and accepted is 'binge drinking' in some cultures that people find they can hide behind it, preferring to be drunk than admit their social anxiety to others.
'Specific' social anxiety
A 'specific' anxiety affects people in a specific, defined area of their lives. For example, fear of public speaking ('glossophobia') commonly affects people who have to perform or speak in front of others. Salesmen, actors, musicians, teachers or union representatives may all suffer from glossophobia, either regularly or just from time-to-time.
Many people find they can socialise quite easily. However, when they have to talk in front of others, they may become very anxious or 'dry up' completely. Some people find their throat closes up, making speaking very difficult indeed.
Even experienced public speakers can be affected. At its worst, it can make it almost impossible for the sufferer to speak in public at all. Some people experience a painful 'lump in the throat' when they're anxious that makes talking very difficult or painful - this is sometimes known as 'globus hystericus' or simply 'globus'.
Other common specific social anxieties include paruresis or 'shy bladder syndrome' (an inability to urinate in public); the inability to eat in public (sometimes called 'sitophobia') and severe 'stage fright' or performance anxiety.
People with social anxiety may worry about 'making a fool of themselves' in front of other people. They may rehearse, in great detail, all the embarrassing things that could possibly happen in order to prepare for them (of course, this doesn't help at all - it just becomes part of the problem). We might worry so much about appearing worried, that we actually do begin to look worried!
After the event we might find ourselves worrying about how we handled the situation. We might go over, again and again, how we might have behaved or talked differently. The physical symptoms of both 'specific' and 'general' social anxiety are very similar.
We might get a dry mouth, sweat a lot, have palpitations (the feeling that our heart is beating very fast or irregularly) and want to use the toilet. Other people might be able to see some of the signs of this anxiety, such as blushing, stammering or trembling. The idea that other people can see the symptoms and might be judging you is acutely embarrassing, and some people 'implode' into shame and bitterly painful self-recriminations as a vicious circle starts.
Sometimes we may breathe too fast, which can give feelings of numbness or 'pins and needles' in our fingers and toes. This might feel quite alarming and can make our anxiety even worse.
The 'social anxiety triad'
The experience of social anxiety can be thought of as comprising cognitive components - what we think and remember; physiological components (how we feel in the body) and a behavioural dimension - what we do (see figure 1).
At their worst, these feelings of fear and bodily symptoms can end in a panic attack. This is a short period, usually lasting only a few minutes, during which we feel overwhelmingly anxious, terrified of losing control and may even feel as though we're going going crazy or dying. These feelings tend to reach a peak and then pass over us, leaving us feeling weak and exhausted.
Although these attacks are very alarming, they eventually stop on their own and don't seriously harm us.
Making 'adjustments' to cope
Some sufferers cope by arranging their lives around their symptoms. This means that they miss out on things they might otherwise enjoy. They can't visit their children's school, can't do the shopping or go out with friends. They might avoid promotion at work, even though they're quite capable of doing a more demanding job.
Paruresis or 'bashful bladder' sufferers are restricted in their movements; having to find a toilet they're able to use restricts the range of their travels. When we begin to avoid situations we can enter a 'cycle of avoidance', making it less likely that we'll face up to (and overcome) our fears.
Sometimes we can develop so-called 'safety behaviours' - patterns of behaviour we adopt to lessen tension and reduce distress. These might take the form of reciting 'lucky words' or performing a certain ritual to help soothe ourselves. Occasionally these can become ritualised and become a problem in their own right.
If we constantly avoid places where people meet, we may in the end develop a fear of those places - even when there's nobody there. We may then find ourselves struggling to go out at all - this is called 'agoraphobia'.
There are several different ways of dealing with social phobia. These may be used on their own or together, depending on our needs.
Getting help and support
What we know doesn't work well
- Avoiding situations
- Blaming ourselves
- Thinking the worst
- Trying to hide the problem
- Feeling ashamed
- Focussing on our symptoms
What we know does work well
- Facing up to our fears
- Learning physical relaxation
- Accepting ourselves
- Remembering and building on our successes
- Turning our attention outwards
Turning our attention outwards
People with social anxiety tend to concentrate a lot on their own experiences. They tend to focus on their anxiety symptoms, e.g. shaking, sweating, blushing or stammering. We intensify what we notice, so we need to:
- Pay close attention to what is happening around us
- Really listen to what is being said
- Don't take all the responsibility for keeping conversation going
- Remember that your physical symptoms of anxiety are probably not as noticeable as you might think
- Remember that other people may be feeling quite anxious too
Checking our thinking
There are several ways of thinking which can make the symptoms of social anxiety worse. It's quicker and easier to change our thoughts than to change how we feel. Checking and changing our thoughts can be quite hard but helps us feel better in the long run. Persistence and practice are vital.
Am I mind-reading? People with low self-esteem can assume other people think poorly of them too. We might assume other people think we're boring, weak, stupid, ugly or critical. Instead of finding out what the other person really thinks, we can 'project' own negative views of ourselves onto other people, assuming they have a low opinion of us too!
Am I fortune-telling? We can forget about all of our successes and achievements and instead predict that something will turn out badly: ' It will be awful, I won't know what to say, I'll go red, sweat and stammer, I'll wish the ground could swallow me up'. Far from protecting ourselves from anything bad happening, we simply make ourselves more anxious!
Am I personalising? A form of grandiose thinking, if something happens we assume it's because of us. If we're out and hear people laughing our first thought might be: 'they're laughing at me'. We immediately become alarmed or defensive and may flee rather than share in the joke.
Am I focusing on failure? Do I just notice the bad stuff? When we're anxious we automatically notice things that we perceive as threats. This is an important survival mechanism - things that threaten us should capture our attention. However this process goes too far when we recall and dwell on the bad things to the exclusion of our triumphs and successes.
Self-help If you're a naturally shy or quiet person, you might find it helpful to join a self-confidence or assertiveness course at an adult education centre. Relaxation exercises may also help you feel generally less anxious - you can get details of these from many G.P. surgeries or your local leisure or community centre.
'Social skills' training Helps to make people feel more relaxed and confident in company. It does this by teaching some of the simple 'social skills' that we tend to take for granted, like how to start a conversation with a stranger. There's lots of practice with other people and feedback - people might watch themselves practising on video to get an idea of what they're doing and how they appear to others.
Graded exposure Involves helping a person to relax while in the situation that they find frightening. It can be done in stages, each time making the situation a little bit more challenging. We need to stay in the situation that causes our anxiety until our anxiety levels have dropped by at least half to help 'desensitise' ourselves.
Cognitive behaviour therapy We can make ourselves more anxious by the way we think about things. CBT helps people change the way they think about themselves and other people and helps support new behaviours which test out and challenge our fears.
Beta-blockers These drugs are usually used to treat high blood pressure. In low doses they can help control the rapid heartbeat and physical shaking of anxiety - which can be a symptom of the social anxiety - and can be taken shortly before meeting people or before speaking in public. They don't suit people who have asthma.
Antidepressants More recently developed anti-depressants, known as SSRIs, have been found to be helpful in social phobia, but can sometimes cause headaches and dizziness in the first few weeks.
Anxiolytics Drugs like diazepam (Valium) were used in the past to treat all sorts of anxiety. We now know that they're addictive and don't help in the long run. They shouldn't usually be used to treat people with a social phobia, except only for very short periods of time. Newer drugs are much less addictive and many people find them very helpful. Your G.P. can advise you.
Support online Several helpful online communities support people with social anxiety, such as those at SAUK(Social Anxiety UK). They can be very supportive, and are best used as a 'stepping stone' to greater social contact, rather than as a way of avoiding it!
Thanks for reading to the end.
Best wishes to you
Page last updated: Monday, January 4, 2016