Most teenagers are ruled by their social lives. But if 19 year old Lucy*, who suffers from social anxiety, kept a diary, there wouldn’t be too much in it. Her mother, Sarah*, said Lucy turned down most invitations, not because she didn’t like her friends, but because social gatherings made her too anxious.
“If she’s invited to something she goes into total panic because she knows she’s going to have to deal with a crowd of people, so then I get tears and anxiety and panic attacks that are quite severe sometimes.” Sarah said.
Sometimes Lucy’s whole body shook as the anxiety took hold.
“She actually said to me she sometimes feels like she almost leaves her body and I guess that’s her coping mechanism to try and deal with what’s going on. Social anxiety holds my daughter back in many ways, preventing her from trying new activities. She will sit back, afraid of people watching her so it’s a self-esteem thing. She feels people might laugh at her.
However she said Lucy often watched other, younger children trying new things and felt frustrated that she couldn’t bring herself to join in.
“It’s quite a crippling thing and I don’t know if people know how crippling it is, the anxiety.”
Clinical psychologist Catherine Gallagher told the RNZ parenting podcast Are We There Yet? that social anxiety was often driven by perfectionism and a fear of criticism or rejection by others.
“Underlying it are often fears that something is wrong with us or we will do something wrong, such as make a mistake, go red in the face or perform poorly.” People with social anxiety then worry that these mistakes will be exposed to others and they will be judged negatively. Our worry brains can tell us we need to be perfect or flawless or, to the other extreme, we’re destined for an epic YouTube-worthy fail and there’s no in between. So anxious brains are often black and white brains we’re either on fire or it’s a complete disaster. Lucy’s experience of turning down invitations and then worrying that she won’t be invited to anything else is a lovely example of anxiety. You’re damned if you do and you’re damned if you don’t.”
She said the anxiety stemmed from a primal alarm system that triggered a “fight”, “flight” or “freeze” reaction and normally occurred when someone was threatened. That heightened sense of danger meant anxious people often went into a social situation on edge
“So we’re thinking about things like: no one’s going to talk to me, or they’ll think I’m boring or what if I say the wrong thing, what if I trip up? Ultimately, these worry thoughts alter the way people act. So we can seem less engaged, look awkward or be over the top as we try to cover our anxiety or we can actually just avoid the whole thing in the first place and opt out of situations.”
This meant many young people didn‘t expose themselves to social situations where they would actually build up the skills and confidence to manage those experiences better.
Tips to help your socially anxious child
Build a solid understanding of what anxiety is and validate and normalise your child’s struggle with it.
”The feeling is real. It feels dangerous. The challenge is the situation is not dangerous and that’s the bit the child has to work through with support from Mum and Dad.” Gallagher said.
Don’t always leap in to ”rescue” them or answer questions on their behalf. Children needed to learn to negotiate their own way into a social situation and to cope with its ups and downs. ”If they pull out when they’re most anxious then those situations remain dangerous” she said.
Encourage your child to face their fears by exposing them to social activities while they are feeling anxious, rather than waiting for the anxiety to subside first.
“They need to do life, do these things while anxious.”
Find activities that have “scaffolding” such as a group that is led by an adult. This can allow the child to engage with others without having to take the lead or engage in free play.
In a school setting, socially anxious children might find it useful to have a ”job” such as a library assistant where they can talk to others without having to ask to join a game.
”Integrating yourself into someone else’s play or into a game, that can be quite tough”
Don’t allow your child to avoid anxiety inducing situations by staying home from school or other activities.
“You’re supporting them to be at school even if it’s through tears and distress.” Gallagher said. And, when they return, focus on the things that went well, rather than any perceived failures.
Limit the time spend talking about worries. “Only allow so many worry questions a day or set aside a short worry time so it doesn’t leak into every moment.” (And make sure the worry time is not just at bedtime as it can start the child on a train of thought that’s difficult to get out of.)
Help your child to distinguish between a worry and a genuine problem such as bullying. “Most children, when they learn this distinction themselves actually then start to be more robust about how they do deal with social situations and also they have the confidence that they don’t need to come to Mum and Dad to fix it.”
Plan for anxiety and have realistic expectations for your child.
“Because if Mum’s and Dad’s expectation is that I should be able to go into this situation and be awesomely comfortable, that might not be the case”, Gallagher said.
However if the parents expected the child to get anxious and validated those feelings by accepting that the situation would be hard, the child would be better equipped to handle it.
“So we actually expect anxiety to turn up. We come up with a plan for it so the child goes into that situation much more realistically prepared for it and, typically, is going to manage it a lot better.”
Social Anxiety Fact Sheet: What is Social Anxiety Disorder? Symptoms, Treatment, Prevalence, Medications, Insight, Prognosis
Thomas A. Richards, Ph.D
Social Anxiety Disorder (social phobia) is the third largest mental health care problem in the world today.
The latest government epidemiological data show social anxiety affects about 7% of the population at any given time. The lifetime prevalence rate (i.e., the chances of developing social anxiety disorder at any time during the lifespan) stands slightly above 13%. (See journal citation on the Social Anxiety Association home page.)
Social anxiety is the fear of social situations that involve interaction with other people. You could say social anxiety is the fear and anxiety of being negatively judged and evaluated by other people. It is a pervasive disorder and causes anxiety and fear in most all areas of a person’s life. It is chronic because it does not go away on its own. Only direct cognitive behavioral therapy can change the brain, and help people overcome social anxiety.
People with social anxiety are many times seen by others as being shy, quiet, backward, withdrawn, inhibited, unfriendly, nervous, aloof, and disinterested.
Paradoxically, people with social anxiety want to make friends, be included in groups, and be involved and engaged in social interactions. But having social anxiety prevents people from being able to do the things they want to do. Although people with social anxiety want to be friendly, open, and sociable, it is fear (anxiety) that holds them back.
People with social anxiety usually experience significant distress in the following situations:
Being introduced to other people
Being teased or criticized
Being the center of attention
Being watched or observed while doing something
Having to say something in a formal, public situation
Meeting people in authority (“important people/authority figures”)
Feeling insecure and out of place in social situations (“I don’t know what to say.”)
Embarrassing easily (e.g., blushing, shaking)
Meeting other peoples’ eyes
Swallowing, writing, talking, making phone calls if in public
This list is not a complete list of symptoms, other symptoms may be associated with social anxiety as well.
The feelings that accompany social anxiety include anxiety, high levels of fear, nervousness, automatic negative emotional cycles, racing heart, blushing, excessive sweating, dry throat and mouth, trembling, and muscle twitches. In severe situations, people can develop a dysmorphia concerning part of their body (usually the face) in which they perceive themselves irrationally and negatively.
Constant, intense anxiety (fear) is the most common symptom.
People with social anxiety typically know that their anxiety is irrational, is not based on fact, and does not make rational sense. Nevertheless, thoughts and feelings of anxiety persist and are chronic (i.e., show no signs of going away). Appropriate active, structured, cognitive behavioral therapy is the only solution to this problem. Decades of research have concluded that this type of therapy is the only way to change the neural pathways in the brain permanently. This means that a permanent change is possible for everyone.
Social anxiety, as well as the other anxiety disorders, can be successfully treated today. In seeking help for this problem, we recommend searching for a specialist, someone who understands this problem well and knows how to treat it.
Social anxiety treatment must include an active behavioral therapy group, where members can work on their “anxiety” hierarchies in the group, and later, in real life situations with other group members.
Social anxiety is a fully treatable condition and can be overcome with effective therapy, work, and patience.
Cognitive behavioral therapy for social anxiety has been markedly successful. Thousands of research studies now indicate that, after the completion of social anxiety specific CBT, people with social anxiety disorder are changed. They now live a life that is no longer controlled by fear and anxiety. Appropriate therapy is markedly successful in changing people’s thoughts, beliefs, feelings, and behavior. The person with social anxiety disorder must be compliant and do what is necessary to overcome this disorder. National Institutes of Mental Health funded studies report a very high success rate using cognitive therapy with a behavioral therapy group. Both are essential to alleviating anxiety symptoms associated with social anxiety disorder.
Social anxiety medication is useful for many, but not all, people with social anxiety disorder. For social anxiety, research indicates use of the anti-anxiety agents, and (perhaps) certain antidepressants in conjunction with CBT have proven most beneficial. Medication without the use of active, structured cognitive behavioral therapy has no long term benefits. Only CBT can change the neural pathway associations in the brain permanently.
The therapy used must “fit” the way the human brain is structured. Current research indicates many antidepressant medications for social anxiety disorder to be useless, even in the short-term. About 15% of our in-person socially anxious people are helped by antidepressants. Some of the large scale medication studies for social anxiety have been questioned and found to be skewed in favor of the drugs marketed by the same pharmaceutical companies who paid for these studies to be done in the first place. These kind of studies are conflicts of interest, and their conclusions should be thoroughly questioned.
In addition, each person is different, and there is no general rule that works concerning social anxiety and medications. For a typical person with social anxiety, who has an “average” amount of anxiety, along the quantifiable continuum, we have found an antianxiety agent to be most effective, if the person has no history of substance abuse. Antidepressants do not work anywhere near as well, in general.
A typical superstititon, promoted by the drug companies, is that antidepressants have anti-anxiety properties. This is not true. If anything, many of the antidepressants make a person MORE anxious.
However, not all people want or need medication. One of the big changes in the last decade is the gradual non-use of medications by people coming into active therapy for social anxiety. The majority of people in our groups now choose not to use medications and to concentrate solely on CBT.
Nevertheless, it is the combination of cognitive and behavioral therapy that changes the brain and allows you to overcome social anxiety. Medications can only temporarily change brain chemistry and can be useful in some cases. This is very general advice, and you must consult with your psychiatrist when it comes to medications. Try to find someone who understands that anti-anxiety agents are not addictive to people with diagnosable anxiety disorders. In twenty years, we have never had even one patient who has moved up their dosage of an anti-anxiety agent once an adequate baseline is established as being effective. Social anxiety people can be helped by a low dose of an anti-anxiety agents (there is a reason why we prefer a low dose of either lorazepam or clonazepam for this purpose).
THIS ADVICE (above) only applies to people who have a diagnosable (DSM-5: 300.23) case of social anxiety disorder. You cannot generalize this out to other mental health care conditions.
Compliance with Cognitive Behavioral Therapy
Cognitive-behavioral (rational) therapy is not difficult to do, and has not been seen this way by participants. The first factor in not complying with the therapy is that “I can’t remember to do it every day” and “I have a hard time committing to something in which I don’t see immediate results”. The psychologist or group leader should have time-tested solutions to these irrational arguments.
Prognosis is markedly good. People completing CBT training report a high success rate, compared to control groups. In the National Institute of Mental Health longitudinal studies, people continued to report progress after CBT behavioral group therapy was over. Studies repeatedly indicate that treatment compatibility (i.e., did the person carry out the prescribed therapy?) is the key element in success. Using different terminology, the social anxiety people who understand and follow the directions to be repetitive with the therapy report the most positive changes in lessening anxious feelings and thoughts. Repetition and reinforcement of rational concepts, strategies, and methods (and their implementation) is the key to alleviating social anxiety disorder on a long-term basis.
People can and do overcome social anxiety if they stick with the cognitive strategies and pratically apply them to their lives.
Differential Diagnosis and Comorbidity
Social anxiety disorder is one of the five major anxiety disorders as listed in the DSM-5.
Social anxiety is many times confused with panic disorder. People with social anxiety do not experience panic attacks (they may experience “anxiety attacks”), in which the principal fear is of having a medical problem (e.g., heart attack). People with social anxiety realize that it is anxiety and fear that they are experiencing. They may say things like “It was awful and I panicked!”, but, when questioned, they are talking about feeling highly anxious. They are not talking about the fear of having a medical problem. People with social anxiety do not go to hospital emergency rooms after an anxiety situation. People with panic disorder many times go to hospital emergency rooms, or doctor’s offices, at first because they feel there is something physically wrong with them.
High rates of alcoholism and other substance abuse, family difficulties and problems, lack of personal relationships, and difficulty in obtaining and continuing with employment are among the everyday problems experienced by many people with social anxiety disorder.
A Big Problem
Lack of professional and knowledgeable therapists is the biggest and most relevant problem to overcoming social anxiety. While it can be done, and a vast amount of clinical and research evidence supports this, overcoming social anxiety is difficult because of the scarcity of treatment facilities for people with this persistent anxiety disorder.
Often, we are led to the conclusion that effective therapy -whether from a psychologist or from a nonlicensed person -comes only from people who have experienced this disorder themselves. Twenty years of experience points to the fact that people who have lived with this disorder and overcome it, make the best group leaders.
Thomas A. Richards, Ph.D., Psychologist President, Social Anxiety Association