I Feel Shy

Shyness is a common reaction when being exposed to unfamiliar situations or new people. When you are shy, you may have feelings of apprehension or awkwardness when you are around others, and will often find it uncomfortable when you need to talk to people. This can lessen, though, as you become more familiar with your surroundings and peers.

When shyness becomes debilitating, and impacts heavily on your life and life choices, you may be suffering from a form of anxiety known as social anxiety, or social phobia. If you find it very difficult to be involved in social situations, or situations where you will be around other people, reading this information on social phobia may help.

What is Social Phobia?

Social phobia is the fear of being the centre of attention, being evaluated negatively, or showing physical signs of anxiety in social situations. This usually leads to avoidance of certain situations, such as social gatherings and job interviews, or eating, speaking, and writing in front of others.

The key feature of social phobia is the fear of being scrutinised and being evaluated negatively by other people. A person with social phobia worries that they may do something embarrassing, or act in a way that may be humiliating (which includes showing signs of anxiety). The fear may be circumscribed to particular situations (e.g., public speaking) or may be generalized to most social situations.

Social phobia is often not recognised because these people are very uncomfortable in a clinic waiting room and do not like to talk about their fears. Clinicians often fail to make the diagnosis either because they confuse social phobia with normal shyness, or judge the secondary depression or substance dependence to be the primary disorder.

Situations that are commonly feared by people with social phobia include:
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Talking in front of others
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Going to parties
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Talking to strangers
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Eating, drinking, writing, or using the phone in front of others
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Using public toilets
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Using public transportation
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Waiting in line

The fear of negative evaluation in specific social situations usually results in avoidance of those particular situations. A more generalized social phobia may lead to almost complete social isolation. Entering the feared situation usually creates an immediate anxiety response with fight-or-flight response symptoms, which may include blushing, shaking, heart palpitations, sweating, nausea, and the urge to go to the toilet. People with social phobia consider these symptoms to be particularly embarrassing. Common behaviours, as a result, include avoiding social situations, leaving social situations, not initiating conversations, or avoiding eye contact.

Social phobia is one of the most common mood and anxiety disorders, with 13% of individuals developing the disorder throughout their lifetime (lifetime morbid risk), and 7.4% of individuals are diagnosed with the disorder in a given year. Men develop this disorder as frequently as women, and social phobia tends to be a chronic disorder that may fluctuate in levels of severity and impairment over time. Social phobia, when chronic, overlaps with avoidant personality disorder.

If a person has had generalised social phobia for most of their life, they may think that others see them as too quiet, or boring. They may avoid meeting other people, and not want to risk telling others much about themselves, in case they are rejected. If a person has these sorts of fears, they may have a more severe social phobia called avoidant personality disorder.

About one-third of people seen for treatment of social phobia have avoidant personality disorder. If they have this more severe social phobia, it is very likely that they will also have experienced episodes of depression.

Coping with severe social anxiety for most of their life will badly affect a person’s self-esteem. They may also have become quite socially isolated. If a person has spent many years avoiding social situations or certain people because of fears about what others think, they need to be aware that it is likely to take longer to improve with treatment.

Complications

Depression

A large number of people with social phobia also suffer depression, a disorder characterised by persistent low mood, loss of pleasure, hopelessness about the future, feelings of worthlessness, and a number of physical symptoms, including sleep and appetite disturbance.

Sometimes people also experience thoughts of suicide. If you have been having suicidal thoughts, or if you have been experiencing a number of these other symptoms, you may be clinically depressed and you must see a doctor.

Alcohol Problems

People with social phobia often rely on alcohol to cope in social situations. Unfortunately, alcohol use can become a problem in itself.

Alcohol abuse is one of the main additional problems for people with social phobia. You may need to talk to a health professional about your alcohol use.

Benzodiazepine Dependence

Benzodiazepines, such as diazepam, have been prescribed for social phobia and other anxiety disorders.

They are not the treatment of choice, however, as they are highly addictive, so withdrawal symptoms are experienced when the drug is stopped. In addition, people rapidly develop tolerance to the drug, so that greater doses are required to achieve the same effect.

What are the Signs of Social Phobia?

Physical Symptoms

There are a number of typical physical symptoms experienced by people with social phobia. These include:

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Blushing
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Shaking or trembling
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Increased heart rate
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Sweating
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Mind going blank
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Shaky or soft voice
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Problems concentrating
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Urge to use the toilet
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Increased breathing rate
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Dizziness
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Nausea or vomiting
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Urge to escape

Behavioural Symptoms:

As a result of their fears, a person with social phobia may do a number of things to try to prevent the negative evaluation from happening. These may include:

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Avoiding the situation altogether
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Avoiding similar sorts of situations
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Leaving prematurely
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Focusing on yourself
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Trying not to draw attention to yourself
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Keeping quiet
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Not looking at other people

What Causes Social Phobia?

We all have the fight or flight response that is designed to protect us from harm. When the fight or flight response is activated, adrenaline is released, which produces a number of physical sensations, including rapid heart rate and breathing, sweating, shaking, tense muscles, and butterflies in the stomach. An urge to flee the situation is often experienced.

This fight or flight response occurs whenever we judge a situation to be threatening. In social phobia this threat is a psychological one, as the fear is about not being respected, approved of, or liked. Whilst we all desire to be liked by other people, in social phobia this need for approval is exaggerated and the detection of threat, too sensitive.

Thinking negatively about situations after an event also triggers further anxious feelings and tends to reinforce how badly you thought you performed. Negative thinking plays a major role in maintaining your anxiety response in these situations.

Regarding possible causes of social phobia, research suggests that both genetic and environmental factors are relevant. There are multiple origins of social phobia. In order to treat your social phobia, rather than focusing on why you have the problem, it is more useful to look at what is maintaining the problem.

Main Fears:

If you have social phobia, you usually worry that others will notice your anxiety because of your blushing, sweating, shaking, or difficulty getting your words out, for example.

Other fears triggered by social situations include:

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I’ll look uncomfortable or awkward
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I’ll seem weird or strange
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I’ll appear stupid or incompetent
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I’ll look embarrassed
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I’ll be boring

Feared Situations:

Some typical social situations feared by people with social phobia include:

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Speaking in a group
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Giving a presentation or speech
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Meeting new people
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Being introduced
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Talking to someone in authority
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Being observed doing an activity
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Eating or drinking in public
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Using the telephone
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Going to a party
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Expressing your opinion
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Returning faulty goods
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Using public toilets
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Being the centre of attention
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Speaking to someone you’re attracted to

How to Deal with Social Phobia


Cognitive Behaviour Therapy

 

Cognitive-behaviour therapy (CBT) is the treatment of choice for social phobia. It involves changing the way you think, feel and behave in social situations. CBT is offered either face to face, or through internet CBT providers, such as our shyness course.

A course of CBT should include:

1. Ongoing assessment of a person’s levels of anxiety in relation to their social phobia.

2. Education about anxiety, tailored to each individual’s needs. For more information about anxiety, please see the anxiety fact sheet

3. Training in strategies, such as mindfulness, to manage anxiety symptoms, and encouragement in practicing these techniques regularly.

4. Behavioral interventions

•   CBT should focus on graded exposure to feared situations. For example, if a person is fearful of eating in front of others and would like to be able to eat a meal in a local cafe, the following hierarchy could be adapted according to how difficult they find each step.

1) Have a soft drink at the cafe early in the morning when there are not many people around.
2) Have a soft drink at lunchtime when the cafe is busy.
3) Have a cup of tea and a sandwich early in the morning.
4) Have a cup of tea and a sandwich at lunchtime.
5) Have a full meal (using cutlery) and stay for twenty minutes even if you do not eat the whole meal.
6) Have a full meal (using cutlery) and stay until you’ve eaten the whole meal.

•   the steps can be adapted to include the presence or absence of friends, or to accommodate slightly different goals or problems (e.g., to be able to sign a form, or use a telephone, while people are watching). The last step on the hierarchy represents the situation or activity the individual fears most.

•   CBT may also include “social mishap” exposure, with people putting themselves in situations where they embarrass themselves in public. During these exposures, people with social phobia are able to confront very uncomfortable situations, thereby increasing the power of the exposure, and challenge common thoughts (i.e., “What’s the worst that could happen?”).

•   People with social phobia should also be encouraged to identify and let go of safety behaviors. These behaviours include avoiding other peoples’ eyes, sitting alone in a corner, mumbling or speaking very softly, and pre-planning all social encounters. People with social phobia often rely on these safety behaviors, and believe that they cannot cope without them.

6. Cognitive interventions

•   CBT helps people with social phobia to identify and challenge their fears. A person should monitor their thoughts, and label their thinking distortions during specific situations throughout the day.

7. Shifting attention:
Once a person has identified and challenged their maladaptive thoughts, they should be encouraged to focus on the present, and to think realistically about the present situation rather than feared future outcomes. Mindfulness-based interventions can also help individuals practice remaining present-focused.

Some people with social phobia may need to learn basic conversational and interpersonal skills and practice these in minimally aversive social situations.

A person with any kind of anxiety should avoid the use of alcohol or sedative medication to control their anxiety, as this can often lead to complications with dependency.

Referral or specialist consultation will be necessary if social anxiety or avoidance persists despite the above measures.

Medication

Benzodiazepines

E.g. oxazepam, diazepam, alprazolam

Benzodiazepines are not a useful treatment for anxiety disorders in the long-term, because of rapid physical tolerance and dependence. They provide only symptomatic relief. They do not deal with the negative thoughts driving social phobia.

 

Selective Serotonin Re-Uptake Inhibitors (SSRIs)

E.g. fluoxetine, sertraline, citalopram

These drugs are commonly prescribed for social phobia, and can be particularly useful if the person with social phobia is also depressed. They are as powerful as CBT, and can be used in combination with CBT.

Coping with Symptoms of Social Phobia

 

Slow Breathing

Your breathing rate increases automatically as part of the fight or flight response. Learning to slow down your breathing rate when you are anxious can settle some of the other anxious sensations, as well as help you to focus your mind.

1. First, time your breaths for one minute (1 breath in and out equals one).

2. Then sit down comfortably in front of a clock or a watch with a second hand and start to focus your mind on your breathing.

3. Breathe only through your nose.

4. Try to breathe using your lower stomach/ diaphragm, rather than your chest muscles. Relax your stomach as much as possible.

5. Take a regular breath in for 3 seconds and then breathe out for 3 seconds. Each time you breathe out, think to yourself the word “relax” and let a little more tension go from your muscles – let your shoulders drop, and relax your face.

6. Continue breathing in this 6-second cycle for 5 minutes.

7. At the end of this, count your breaths again for one minute. Write this down.

8. The average person takes 10 to 12 breaths per minute at rest. Your breathing rate may be higher than it should be. Some people with social phobia over-breathe constantly, while other people find that their breathing rate only goes up when they are anxious. In both cases slow breathing can help.

9. To begin, you will need to practice when already relaxed. Then you can gradually practice in anxious situations. Like learning any new skill, slow breathing takes time and regular practice. You should practice this at least 4 times a day.

Take our online Social Phobia course

THIS WAY UP offers a highly effective internet delivered course for people with social anxiety disorder, or social phobia.  Four out of five people improve, over half to the point of no longer being troubled by social anxiety.

The course can be undertaken on the prescription of a GP or on a self-help basis, and costs just AUD$59 for 90 days access.

View course