What to Do About Social Anxiety Disorder

The holidays are coming, with lots of convivial occasions — fun for most, but distressing if you suffer from social phobia.

It's not unusual to feel nervous about meeting new people or attending parties. But if you're so anxious that you dread or avoid such situations, you may have social anxiety disorder, also called social phobia. People with the disorder feel inordinately uneasy and self-conscious in everyday social situations. The source is an unreasonable fear of doing or saying something embarrassing and being negatively judged by others.

If you have social phobia, you might be terrified by just the thought of proposing a toast, or even making small talk. Even if you make yourself attend gatherings, you may feel miserable before, during, and afterward — worrying for days about people's opinion of you. Avoiding these get-togethers is not the answer, of course; it can result in misunderstandings and other personal problems.

Social phobia received little attention until data from the National Comorbidity Survey published in the late 1990s showed that the disorder is widespread, often disabling, often associated with problems such as alcohol abuse, and usually untreated. Since then, studies have shown that certain medications and certain types of psychotherapy can help. Meanwhile, scientists have been investigating the roots of the disorder, as a step to discovering new therapies.

What does social phobia look like?

There are two types of social phobia. Specific social anxiety (also called performance anxiety) arises in limited situations. It's a problem mainly for people whose work (for example, acting, music, or lecturing) requires them to perform in public. Far more prevalent and disabling is generalized social anxiety. People with this disorder fear common social situations, such as eating or ordering food in public; asking questions or seeking help; meeting new people; speaking to strangers; and even using public facilities, such as restrooms. They may lose out on job opportunities because they're afraid of interviews; they may forgo training and education because they fear being called on in class.

Symptoms include a racing heart, dry mouth, shaky voice, blushing, trembling, sweating, and nausea. In specific social anxiety, fear that people will notice these symptoms may impair performance, leading to a downward spiral in which worsening performance reinforces worsening anticipatory anxiety. Generalized social anxiety can produce a similar downward spiral: others feel ill at ease when they sense a person's discomfort, and it's natural to interpret that discomfort as rejection that justifies further social withdrawal.

Who gets social anxiety disorder?

About 12% of U.S. adults — up to two-thirds of them women — will experience social phobia at some point in their lives, and 7% have it at any given time. Social phobia is the third most prevalent psychiatric disorder, behind substance abuse and depression, and the most common anxiety disorder (which includes panic disorder, obsessive-compulsive disorder, generalized anxiety, situational anxiety, and others).

Social phobia typically starts in adolescence, sometimes emerging in someone who's been shy or socially inhibited since early childhood. Other times, chronic social fears develop after a particularly stressful or humiliating episode. Symptoms can come and go depending on circumstances; for example, they may disappear during a marriage but re-emerge after the loss of a spouse.

It's not clear why some individuals are vulnerable to the disorder. Psychological experiments show that certain children are biologically vulnerable. As early as 4 months old, they show a tendency to cry and shrink back from new situations and people. When strangers approach, their hearts beat faster and their pupils dilate — signs of a stress response.

These responses persist into adulthood, according to a study in which positron emission tomography (PET) scans were performed on young adults. When they looked at the faces of strangers, participants who were classified as behaviorally inhibited at age 2 showed much greater activity in the amygdala (a center of fear conditioning). In those judged to be extroverted as young children, the amygdala remained relatively quiet. Chronic fearfulness is also associated with irregularities in the activity of the neurotransmitters dopamine and serotonin — and with high levels of corticotropin-releasing factor, a key element in the stress response.

In a brain imaging study sponsored by the National Institute of Mental Health, the brains of people with generalized social phobia — but not those without the disorder — showed increased activity in the amygdala as well as in brain regions involved in self-awareness when they read negatively critical comments about themselves (Archives of General Psychiatry, October 2008). The results suggest that people with social phobia may have a different self-image, which could be a factor in their fear of being judged negatively by others.

What to do

Certain types of psychotherapy and several medications can be helpful in treating and managing social phobia.

Psychotherapy. Cognitive behavioral therapy (CBT) is the most widely studied psychological intervention for the treatment of social phobia. It aims to correct ingrained patterns of negative thinking and the behaviors it causes. As the name suggests, CBT has two parts. The cognitive therapy helps change habitual thoughts ("People will think what I say is stupid") that prevent you from overcoming your fears. The behavioral element involves working to face those fears directly in anxiety-provoking situations.

The therapist typically begins by asking you to record your thoughts and level of anxiety in various situations. Then, you and the therapist discuss these thoughts, evaluate how realistic they are, and work together to substitute more productive thought patterns. The behavioral component involves a strategy called exposure, or desensitization, in which you face your fears — sometimes through role-play, sometimes by imagining and describing the situations that make you anxious. Your therapist may also ask you to put yourself in a real-life situation (like a party) that sparks your worst fears, to let you practice recognizing negative thoughts and exchanging them for more realistic ones. With repeated exposure, you may eventually become desensitized to these fear-provoking situations. A related behavioral strategy teaches you coping skills for such situations. If parties are your worst nightmare, for example, you may work on conversational skills. CBT may also include learning relaxation techniques, such as deep breathing.

A therapist-guided variation of exposure therapy, called exposure and response prevention, aims to not only desensitize you to the feared situation but also prevent you from reacting with the usual avoidance behaviors.

To find a qualified therapist in your area, contact the Anxiety Disorders Association of America, www.adaa.org, 240-485-1001. Information about support groups and other resources is available on the Web site of the Social Phobia/Social Anxiety Association, www.socialphobia.org.

Medications. As research uncovers the roots of anxiety in brain chemistry, anti-anxiety medications (see table) have become increasingly important, usually in combination with CBT. Typically, the first choice is a selective serotonin reuptake inhibitor (SSRI), often with a benzodiazepine tranquilizer added to quell symptoms for the four to six weeks until the SSRI kicks in. Some dual (norepinephrine and serotonin) reuptake inhibitor antidepressants — including venlafaxine (Effexor) and duloxetine (Cymbalta) — are also effective. For people who have a lot of physical symptoms, such as heart pounding, a beta blocker may be prescribed.

Scientists continue to study new therapies and combinations of therapies. For example, some clinical trials are testing the effectiveness of the antibiotic D-cycloserine in conjunction with CBT. The drug, normally used in higher doses to treat tuberculosis, is thought to interact with brain receptors involved in the fear response. (To find out more about clinical trials, visit www.clinicaltrials.gov.)

During the holidays, try to avoid isolation, which only serves to reinforce social anxiety. But it's okay to be selective. If small family or religious events are the least threatening, stick with those. And be careful with alcohol — there are serious pitfalls in using it to ease your worries or boost your courage. Consider volunteering to help out in a food pantry or soup kitchen; it can do a world of good for others and may do the same for you. Leave time for relaxation. Eat a balanced diet, avoid caffeine, and exercise regularly, which can also help with managing weight and stress at holiday time. Finally, keep in mind that social phobia is likely to get worse if it's not treated. If social fears are preventing you from fully participating in your life, seek therapeutic help. Yes, it may mean making an appointment with someone you've never met before. If necessary, enlist the help of a trusted friend or relative to take that step. Making this effort is a gift you can give yourself.