ALL EYES ON ME: Social Anxiety Disorder

We have all experienced the jitters we feel when we have to perform on stage or in situations where we have to speak publicly. We all know the dread, of saying something wrong, appearing foolish, or just forgetting what to say and going blank. But think about this. What would it be like to experience it every day?

I can’t exactly point to the moment when it began. There are some experiences which have the power to define the way we live our lives and the way we see ourselves. Or at least now I know that we give them that power. But I didn’t know it then. I remember shivering, barely able to hold the tears in my eyes, and all I wanted to do was run and hide. I remember a room full of people and she was yelling at me at the top of her voice, my teacher. “Are you stupid?? You can’t even get one step right!” I was scared and humiliated. I don’t know what changed, but I was never the same again.

Years went by and I moved to a big city for college. It was all new and overwhelming. To top it all, I had braces (!) I was always nervous. And the thoughts would not stop. I am not as good as them, not as smart, not as good-looking. These thoughts troubled me even in trivial situations like asking someone for help, asking a doubt in class, or even entering a class full of people! I had a few strategies of my own, though. I avoided talking to anyone, unless absolutely necessary. And if I had to, I mentally rehearsed sentences over and over, sometimes even wrote them down before speaking. In class, I would find a spot where no one could see me. I thought these helped me. But it just kept getting worse.

One day, there was a group of people next to me excitingly discussing a book one of them was reading. I wanted to be a part of that conversation. I had read the book too. But I couldn’t. All I kept thinking was how stupid they thought I was. But keeping quiet, keeping to myself, not giving eye contact meant that I was safe. As long as no one noticed me, it was okay. But was it?

The irony of it all, I was a student of psychology. I started realizing that I had to fix this. I started reading about it. I sought professional help and it started getting easier. The things that I did to reduce the intense anxiety I experienced in social situations, the things that I thought kept me ‘safe’, were actually the things which made me isolated, made me appear aloof or uninterested, and in a way maintained my anxiety. It never really went away. Therefore I began forcing myself to stop engaging in such behaviours and although initially it created a havoc inside me, I got better at it. I won’t say that I never experience it now. I still do and I still get those thoughts but I have learned healthier ways to respond to them. And I think anyone who is struggling with similar issues can do it too.

As awareness is the first step, let’s get to know about it.

What is Social Anxiety Disorder?

As the DSM-V (Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition) and the ICD-10 (ICD-10 Classification of Mental and Behavioural Disorders) describe, Social Anxiety Disorder or Social Phobia is a marked fear or anxiety about one or more of the social situations in which the individual is exposed to possible scrutiny by others. The individual fears that he or she will be negatively evaluated by others and therefore they either avoid such situations or endure them with intense fear or anxiety. The disorder can either be generalized, i.e. a diffuse fear of almost all social situations or it can be specific to certain situations such as performing in front of others, eating in public, interacting with members of the opposite sex, or with authority figures.

What are the symptoms?

As described by Stein and Stein (2008), “individuals with SAD are typically shy when meeting new people, quiet in groups, and withdrawn in unfamiliar social settings”. Their worst fears involve saying or doing something or appear in a way that will lead to embarrassment or humiliation in public. They fear that others will find them unattractive, unlikeable, stupid, or boring. In spite of wanting to interact with others, they avoid such situations due to the fear of being negatively evaluated, criticized, or rejected by others, which can further lead to social isolation and loneliness. If they are unable to avoid such situations, then they experience a great deal of anxiety and discomfort such as sweating, blushing, increased heart rate, shaking etc. Their minds get flooded with thoughts such as ‘what if I lose control’, ‘they must think I am stupid’, ‘they must be making fun of me’, and so on. It can be overwhelming, and therefore to deal with this discomfort, they resort to a range of behaviours they ‘think’ might reduce their anxiety; such as avoiding eye contact, speaking in a low voice or keeping quiet, grip objects tightly, try to stay ‘in control’, etc. These behaviours may not be exactly helpful and even prove counterproductive.

How common is it?

Existing research indicates that SAD is one of the commonest anxiety disorders. It has been differentiated from mere shyness and has been found to be a highly impairing but a treatable condition. Research indicates a lifetime prevalence rate of 4.0% across the globe and it is found to be more common in high income countries such as the Americas and the Western Pacific regions. Findings across the globe indicate that the disorder has an early onset, usually in adolescence and leads to significant impairment in work, family, relationships, social life. Factors such as unemployment, being unmarried, divorced or separated, lower education and lower income across all countries have been found to be associated with the life-time risk of SAD (Stein et al, 2017).

In India, researchers have focused on investigating the rate of occurrence of SAD in adolescents and youth. Prevalence rates vary from 16% to 28%. The disorder has been found to be equally common in males and females. (Chabra, 2009; Harikrishnan, 2016; Sridhar, 2017). Sadly, very few of those suffering from the disorder seek treatment or seek help only after having endured it for a substantially long period of their lives. Research suggests that it is a common reason behind school refusals or drop-outs in children.

What are the causes and risk factors behind SAD?

Risk and causal factors for social anxiety disorder include a combination of an individual’s biological and psychological vulnerabilities as well as his or her learning from various experiences, such as:

· Having a family history of SAD may make you vulnerable to develop the disorder

· Traits such as ‘behavioural inhibition’ which means a pattern of fearfulness, timidity, avoidance, and guardedness surrounding new or unfamiliar settings (such as strangers or novel objects or events) and a long-standing ‘fear of negative evaluation’

· Childhood maltreatment

What other disorders can it co-occur with or lead to?

· Major depression.

· Anxiety disorders such as panic disorder or agoraphobia, obsessive-compulsive disorder

· Bipolar disorder

· Body-dysmorphic disorder

· Schizophrenia

· Autism spectrum disorders

· Substance abuse is common among these persons, often as self-medication to deal with social fears

How can it be treated?

Research suggests that a combination of medication and psychotherapy as being the most efficacious treatment for SAD. Among psychological treatments, Cognitive Behavioural Therapy (CBT) is one of the most evidence-based treatment for SAD. CBT focuses on identifying an individual’s thought patterns and on helping them develop skills to deal with these troubling thoughts using techniques like cognitive restructuring, problem solving, etc. Other psychotherapeutic interventions include psychoeducation, relaxation training, social skills and assertiveness training. Remember, merely ‘facing the fears’ is not going to reduce the anxiety; the individual needs to learn healthier ways of dealing with the anxiety.

What can you do?

Living with SAD can be really hard and it can have debilitating effects on your personal, social, and work life. But the good news is that it is NOT a permanent condition and you don’t have to suffer alone. If you’re experiencing similar symptoms as described above then it is crucial to seek professional help.

· SAD is treatable. It is not your fault that you have social anxiety, it is nothing to be ashamed of.

· Talk to someone, a trusted friend, or a loved one, or a family member.

· If any of your friends or family member, or a colleague opens themselves up to you about their problem, listen. Try to understand what they are going through and show your support. Do not offer them advice and encourage them to seek treatment.

· No matter how long you have been suffering, it is never too late to ask for help.

· You can consult a psychiatrist (who will prescribe medications) or a clinical psychologist (who will provide with supportive care and psychotherapy), or an experienced psychotherapist.

· If your doctor or therapist is telling you that you’re exaggerating or it happens with everyone or that it will simply go away if you ‘face your fears’, please look for another one.

· Gain knowledge about social anxiety: Make a list of situations in which you feel anxious, describe the thoughts, feelings, and physiological reactions you experience in these situations. The more detailed your knowledge, the closer you are to getting better.

· Learn to manage anxiety in those situations: start by working on the least anxiety-provoking situation. Learn breathing techniques and practice it in that situations.

Here’s a simple one- take a normal breath, hold it and count to 6 — then think or say ‘relax’ or any other word that you associate with feeling calm — and exhale slowly feeling as if you’re releasing all the tension — pause for 2 seconds and repeat this again for a minute or so.

· Begin to identify your unhelpful thinking patterns, those most commonly seen in SAD are — ‘fortune telling’ (assuming the worst will happen), ‘mind-reading’ (assuming that others are thinking negatively about you without actual evidence), ‘mental filter’ (focusing only on the negative aspect of a situation), etc.

· Keep a record of these thoughts and begin to challenge them by seeking objective evidence for your thoughts, finding any alternative ways of looking at the situation, or by asking how likely is your fear to come true and how much would it matter in the long run?

· Be realistic and compassionate towards yourself by applying these strategies in social situations gradually (from the least anxiety-provoking to the most anxiety-provoking) and reward your efforts.

· Set realistic goals and break down difficult ones into smaller, specific steps.

· Do not aim at completely getting rid of anxiety, remember it is okay to feel anxious and even moderate amount of anxiety actually lead to better performance (it motivates you to work harder and do better)!

References:

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

Chhabra, V., Bhatia, M. S., Gupta, S., Kumar, P., & Srivastava, S. (2009).Prevalence of social phobia in school-going adolescents in an urban area. Delhi Journal of Psychiatry 12(1), 18–22.

Kearney, C.A. (2005). Social Anxiety and Social Phobia in Youth: Characteristics, Assessment, and Psychological Treatment. Dordrecht, Springer. Retrieved from: http://ebooks.springerlink.com

Sridhar V & Surya Rekha S.V. (2017). Social Anxiety: Prevalence and Gender Correlates among Young Adult Urban College Students. International Journal of Indian Psychology, Vol. 4, (4), DIP:18.01.097/20170404, DOI:10.25215/0404.097

Stein, M.B., & Stein, D.J. (2008). Social anxiety disorder. (Stein & Stein, 2008)

U Harikrishnan, A Ali, H Sobhana. (2016). Prevalence of Social Phobia among School Going Adolescents. International Journal of Indian Psychology, Volume 3, Issue 4, №74, ISSN:2348–5396 (e), ISSN:2349–3429 (p), DIP:18.01.039/20160304, ISBN:978–1–365–46362–4

WHO. (1992). The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. Geneva: World Health Organization.