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Social Anxiety Help is a founding regional clinic of the National Social Anxiety Center (NSAC): nationalsacenter.com


 

The Purpose of Anxiety

Perception is the Starting Point

Fight, Flight or Freeze

When Dangers are Social

Social Anxiety Does Not Equal Introversion

Social Anxiety Triggers

Biology, Social Anxiety and Medication

Cognitive-Behavioral Therapy for Social Anxiety

 

Listen to this 8-minute radio interview with Larry Cohen, LICSW, Director of Social Anxiety Help, about what social anxiety is. (It aired in August, 2016 on the Not Broken radio show of the Canadian Mental Health Association.)

 


THE PURPOSE OF ANXIETY 

In order to understand and overcome our problems with social anxiety or other forms of anxiety, we need to understand what anxiety is, and most importantly, what is its purpose.

Yes, anxiety has a useful purpose. An essential purpose. We wouldn't be able to function well if we didn't experience anxiety at all. That may be hard to believe given that anxiety has probably caused you a great deal of suffering, and has probably inhibited your life in so many ways. But it's true!

To understand the purpose of anxiety, let's look first at what is meant by anxiety. The problem is that the word "anxiety" is used to mean many different things. In day-to-day usage, "anxiety" is usually used to refer to an uneasy or fearful feeling, such as nervousness. Sometimes "anxiety" is used to mean fear in anticipation of a potential danger, as opposed to fear in the face of present danger. Freudian or other psychodynamic therapists think of anxiety as the feeling resulting from an internal struggle between opposing feelings, drives and values. And least consistent of all, "anxious" is often used to mean something altogether different: "eager" (as in "I'm anxious for the show to get started.") 

Try to drop all of the above usages for now, and think of anxiety in the following way:

Anxiety is our innate response to perceived danger.

First of all, anxiety in this sense is not just a feeling. Anxiety is a response that includes feelings, thoughts, behaviors, and physiological changes. Nor is there a single feeling associated with the anxiety response. Some form of fear (eg. anything from nervousness to panic) is perhaps the most common feeling related to anxiety. But other very different feelings are often associated with the anxiety response, such as anger, embarrassment and sadness.

Secondly, anxiety is innate, or inborn. We are all "hardwired" with an anxiety mechanism. In fact, so are most animals. 

Looking at anxiety as our response to perceived danger, the purpose of the anxiety response become obvious: self-protection. 

Presumably, animals with an effective anxiety response were more likely to survive various dangers (eg. being eaten) than were animals with no anxiety response--or with an ineffective one that didn't protect so well. It is easy to see how the anxiety mechanism is an adaptive response that has evolved over time to help us survive in the face of danger.
 

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Social Anxiety Help .com


PERCEPTION IS THE STARTING POINT

This brings us to perhaps the most important point: anxiety is how we respond when we perceive ourselves to be in some form of danger. (Sometimes physiological factors trigger or contribute to anxiety, such as caffeine, certain medications, and some health problems.) We experience the anxiety response when we think we're in danger...even if we are not. We do not generally experience anxiety when we think there is no danger around...even when there is! And to make matters more complex, we experience an intense anxiety response when we think we are in grave and immanent danger, even if the actual danger is minor, unlikely and we can cope well with it.

For example, someone with a rodent phobia might become terrified when seeing a mouse...even though a mouse would have a very difficult time of actually harming that person. On the other hand, a child who has come to grow up with a friendly dog and stuffed animals might feel excited and approach a pit bull...not knowing that there is a grave potential danger.

A socially anxious person, while correctly perceiving the potential "danger" of negative judgment, rejection or embarrassment, greatly overestimates how likely any of this danger is to occur, and how damaging it would be if it indeed were to come to pass. At the same time, a socially anxious person greatly underestimates his or her ability to effectively cope with the judgment, rejection or embarrassment if it were to occur.  

By contrast, a socially confident person is not someone who believes s/he'll never be judged, rejected or embarrassed. Rather, a socially confident person simply believes that there is a good chance s/he'll be judged well and liked, and doesn't think that it would be so awful if things didn't turn out that way. In addition, a socially confident person believes s/he can cope well with any judgment, rejection or embarrassment (eg. by asserting oneself, or by accepting the situation and moving on.) 

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FIGHT, FLIGHT OR FREEZE

Remember, the anxiety response includes not only feelings, but also physiological changes, behaviors and thoughts.

The physical and behavioral parts of the anxiety mechanism are often called the fight or flight response. This mechanism is triggered by the perception--correct or not--that we are facing something dangerous. That perception then triggers a special part of our nervous system called the sympathetic nervous system. This activates a number of changes in our body that prepares us to take action: some form of counterattack or escape. 

How dramatic these physiological changes are depend on how immanent and dangerous we perceive the threat to be. When we are very anxious, we breathe more rapidly in order to take in more oxygen: a fuel for our body. Our adrenal glands secrete the hormone adrenaline which temporarily raises our blood pressure and gives us a spurt of energy and strength. Our heart beats more rapidly to pump this extra oxygen and adrenaline throughout our body, especially our arms and legs (for fighting or fleeing). Our muscles tense up in preparation for sudden action. We perspire to cool off our heated bodies.

In other words, the anxiety mechanism puts our bodies into "high gear" so that we have the extra strength and energy to fight or run from the source of danger. 

Actually, besides fight or flight, there is an additional component to the anxiety mechanism that often comes first. We frequently freeze upon the first sign of danger. That freeze response allows us to focus our attention entirely on the source of the danger so that we can better assess how to handle it. We also tend to be less noticeable to our potential attackers when freezing. 

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WHEN DANGERS ARE SOCIAL

It is easy to see how the anxiety response could be very helpful when facing a physical danger...being attacked, killed or even eaten. 

But the anxiety response evolved long before the first party...or staff meeting...or personal disagreement. Here, the dangers are social, not physical. Social anxiety is based on the fear of social danger: judgment, rejection and embarrassment.

The very anxiety mechanism that is meant to protect us from physical danger may be quite unhelpful when the dangers are purely social. In fact, as you probably know all too well, a moderate or strong anxiety response could easily increase the likelihood of social danger occurring. 

Believe it or not, a mild anxiety response is actually somewhat helpful in the face of social danger. Mild social anxiety focuses our attention, increases our drive, heightens our sensitivity to others, and gives us a healthy dose of humility. People with no social anxiety at all often come across as brash, arrogant, obnoxious and domineering. Our goal is not to eliminate anxiety altogether, but to reduce it so that it becomes a help, not a handicap.

When dangers are social, moderate and strong anxiety responses becomes our handicap, not our protection. All that extra strength and energy produced by the fight or flight response does us little good when interacting socially, or speaking in front of groups, or asserting ourselves. If we don't expend that energy by fighting or fleeing--seldom an appropriate course of action in social settings!--then we may be left feeling physically tense, hot, sweaty, jittery, agitated and generally uncomfortable.

This is especially a problem for the many socially anxious people who suffer from so-called secondary anxiety: anxiety about anxiety. In other words, many of us get caught in a vicious cycle in which we notice or anticipate an anxiety symptom (eg. blushing, sweating, jitteriness, or nervous speech), and then we fear that others will notice that symptom and judge us as weak or weird. This fear of judgment then increases our anxiety symptoms, which in turn increases the fear that others will see these symptoms and judge us. 

The flight response is quite common with social anxiety, usually in the form of avoidance and other safety behaviors. We often avoid places, activities and interactions where we anticipate social danger: judgment, rejection and embarrassment. When we are in the face of social danger, we may avoid eye contact and withdraw from active communication in order to keep people--and hopefully their judgment--at a distance. We often avoid initiating or joining conversations, speaking about ourselves, elaborating, telling stories, asserting ourselves, or showing interest in someone so as to avoid the risk of disapproval. We may speak briefly, quickly, softly or not at all lest we say something that will be judged. Instead of focusing mindfully on the conversation in the moment, we are often in our heads: trying to script what to say next, criticizing what we just said or how we think we are appearing, trying to control our anxiety symptoms, and/or trying to mind-read what others are thinking of us.

While the flight response may help us survive a physical attack, avoidance and other safety behaviors only make things worse for us socially. These patterns inhibit our ability to enjoy social interactions, and prevent us from having flowing conversations in which we connect well with people. These patterns also tend to keep people at a distance, which may lead them to judge us (as uninterested, uninteresting, unfriendly or aloof)...the very thing we were afraid of in the first place! Finally, avoidance and other safety behaviors prevent us from learning that people will usually react well to us, that it's not so awful if they don't, and that we can cope well with it if this occurs.
 
In this way, we often engage in an unintended vicious cycle and self-fullfilling prophecy: we avoid and engage in other safety behaviors to prevent anxiety and judgment. But avoidance and other safety behaviors tend to backfire, often resulting in greater anxiety and judgment. We may not realize this is happening because we sometimes experience an initial reduction in anxiety when we avoid. But avoidance comes back to haunt us, as it reinforces our distressing hot thoughts which tends to increase our anxiety for the next time. In addition, a pattern of avoidance and other safety behaviors prevents us from testing and overcoming our hot thoughts that led to the avoidance and other safety behaviors in the first place!

Nor is the freeze response helpful when the danger is social. Freezing, remember, involves focusing on the potential danger...in this case, the possibility that others will not think or react well toward us, or that we will embarrass ourselves or otherwise create a bad impression.
But while we are so focused on what we fear others may be thinking of us, or focused on criticizing our own performance and appearance, then we are not focusing mindfully on the conversation or activity that we are involved in. It's awfully hard to carry out a good conversation, or speak well in front of a group, if we're not focused on the conversations or the speech...but are instead worrying about how we are coming across!

There's a terrible paradox in social anxiety: the more we are worried about our "performance" (ie. how well we are speaking, behaving or appearing to others), the more likely our performance will get worse. This is not because we are inadequate or deficient as people. It is because we are so concerned about coming across as inadequate or deficient. This concern then triggers the anxiety response which leads to symptoms and behaviors that adversely effect our "performance." This, in turn, makes it hard for us to connect well with people, and falsely reinforces our original core belief that we are inadequate or deficient.

Of course, there is a positive paradox in reverse: the less preoccupied we are about how we are coming across to others, the greater the likelihood that we will come across well and feel more comfortable. This concept is called the paradox of acceptance: learning to accept our anxiety and our limitations helps up become less anxious and to perform better, because we are then better able to be mindfully focused in the moment, and to drop patterns of avoidance and other safety behaviors.
 

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SOCIAL ANXIETY DOES NOT EQUAL INTROVERSION

Many people mistake social anxiety with introversion. Introversion is a perfectly normal personality trait. More precisely, there is a continuum from extroversion to introversion that describes one dimension of personality. Those who are relatively extroverted have an innate disposition to interact with many different people, often in groups. Those who are relatively introverted are more disposed to solitude and interactions with fewer persons, often one at a time. 

Extroversion and introversion simply describe one element of our basic temperament: what feels natural to us, rather than what feels like work. There is evidence suggesting that there is a genetic basis for introverted and extroverted temperaments. But that doesn't mean we can't behave in a way that doesn't come naturally when a situation calls for it. Healthy people are capable of, and often engage in, both extroverted and introverted activities since each has its advantages. For example, it is easier to meet people and develop support networks through extroverted behaviors. It is easier to get close to people and develop intimate relationships through introverted behaviors. 

Social anxiety, remember, is based on a tendency to be overly concerned about social danger: judgment, rejection and embarrassment. Extroverts and introverts alike may suffer from social anxiety. Nor are all introverts socially anxious. 

Socially anxious extroverts may be fearful of being assertive, speaking in front of groups or talking to attractive strangers...just like socially anxious introverts. When they are feeling socially anxious, extroverts often behave in an avoidant or withdrawn manner which many people misinterpret as meaning they are introverts. 

Compounding this confusion, "mainstream" culture in the United States is decidedly extroverted. Introversion is viewed with derision or pity. This is not true of all subcultures in the United States. Nor is it true of all other societies. American-style extroverted behavior is considered rude, arrogant and domineering by many cultures. 

But within "mainstream" U.S. culture, introverted children and adolescents often have a hard time adapting to extroverted activities, and often are teased or harassed by more outgoing peers in the process. These experiences could easily foster the development of core beliefs among American introverted young people that they are fundamentally different and/or deficient, and do not fit in. (This process is even more intensified among lesbian, gay, bi and trans [LGBT] young people who grow up in a culture that condemns them as sick and sinful.) As a result, this may lead to a higher incidence of social anxiety among introverts in the United States.

Sadly, some clinicians do not seem to not understand the difference between social anxiety and introversion and seek to treat introversion as though it were a mental illness. A glaring example of such ignorance is psychiatrist Peter D. Kramer, whose 1993 best selling Listening to Prozac devotes a chapter to advocating using this medication to help "cure" people of their introversion. In reality, Prozac and other SSRIs (including Luvox, Paxil, Zoloft, Celexa and Lexapro) may help many people to overcome their social anxiety. But there is no evidence that any medication converts introverts into extroverts. Nor is introversion considered a psychiatric disorder or even a psychiatric symptom by the American Psychiatric Society. 

I believe that the basic goal in therapy for social anxiety--whether using cognitive-behavioral therapy and/or medication--is to help extroverts and introverts alike feel more self-confident and interact more assertively. I believe it is both ineffective and unethical to try to change those who are temperamentally introverts into extroverts...or vice versa. Such efforts are not only bound to fail, but they tend to reinforce the distorted core beliefs about personal deficiency that generates social anxiety in the first place.

For more information, please read:
Social Anxiety and U.S. Bias for Extroversion (Advances in Cognitive Therapy Newsletter; see "President's Message" on pp. 1 & 9).
 

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SOCIAL ANXIETY TRIGGERS

An anxiety trigger is a situation that we tend to perceive as dangerous. With social anxiety, triggers could be any type of interaction with people, or simply being around people in certain settings. 

Anxiety triggers vary considerably person to person. What is difficult for one socially anxious person may be relatively easy for another. In addition, some people suffering from social anxiety tend to be anxious in only one or two specific types of interactions, while others are anxious in many settings. We also differ as to how much we tend to avoid our anxiety triggers, or the extent to which we push ourselves to try to handle them. Following is a list of common social anxiety triggers. Please note that certain details or variables (eg. those in parentheses in this list) may make a big difference as to how likely you are to perceive these situations as dangerous. Some terms used to apply to some of these triggers include: shyness, performance anxiety, public speaking anxiety, stage fright, sexual anxiety, shy bladder (pee shy, paruresis), unassertiveness (passivity), and most broadly: social phobia.
 

  • talking to an attractive stranger (the stranger initiates, or you do)
  • joining and participating in a group conversation (how big the group; how well you know the people)
  • mingling at a party, bar or other group social activity (how many people there; how well you know them)
  • speaking in front of a group (how many people there; how well you know them; prepared or ad hoc; controversial or not)
  • speaking up in a meeting or a class (whether are you called on or you volunteer; how well-prepared you are)
  • asserting yourself (with a friend, boss, stranger, partner)
  • phone calls (with strangers or friends; who initiates the call; whether others are near you and can overhear)
  • being alone in public settings (restaurants; movies; on the street; how crowded)
  • eating in front of others
  • writing in front of others
  • dancing (how many others on dance floor)
  • inviting someone out (socially or on a date; how well you know him/her)
  • going out on a first date (how attracted you are)
  • coming out to someone as LGBT: lesbian, gay, bi or trans (friend, family, stranger)
  • physical affection intimacy for first time with someone (whether you or your partner initiates)
  • having sex with someone (how critical/accepting your partner is)
  • urinating in a public bathroom (how large the bathroom is; whether others are present; stall or urinal)   

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BIOLOGY, SOCIAL ANXIETY AND MEDICATION

All aspects of the anxiety response--thoughts, feelings, physiology and behavior--are controlled by our nervous systems, especially our brains. In addition, there is evidence that the anxiety mechanism of some people is oversensitive for biological reasons. It may be helpful to think of the analogy of the anxiety mechanism as a smoke detector that is intended to warn and prepare us when there is the potential danger of fire. Some smoke detectors are set too sensitively, however, so that their alarm goes off frequently when there is no actual danger.

There are various medications available that help many people with different anxiety problems, including social anxiety. Medications have certain key advantages over psychotherapy: drugs are often easier and quicker. But there are important disadvantages, too. 

Drugs often have side effects. For example, the Selective Serotonin Reuptake Inhibitors (SSRIs, such as Paxil, Prozac, Zoloft, Luvox, Celexa and Lexapro), which are commonly prescribed for social anxiety, very often cause sexual side effects (eg. difficulty or inability to achieve orgasm, and lessened sexual desire), as well as other side effects.

It's important to note that not everyone experiences side effects, and some people experience side effects only temporarily. In addition, the side effects for some people are minor and well worth the benefits of the medication.

Some medications used for anxiety (benzodiazepines or tranquilizers such as Xanax, Ativan, Restoril, Klonopin and Valium) are potentially addictive when used long term. Many medications sometimes used for social anxiety have important alcohol or food restrictions that must be adhered to strictly.

Nonetheless, various medications have helped many people with social anxiety and other anxiety problems greatly. It is usually recommended that, if you take a medication, that you do so in conjunction with psychotherapy, especially cognitive-behavioral therapy (CBT). The positive effects of medications for social anxiety tend to be short-lived after you stop using the drug. The positive effects of cognitive-behavioral therapy, however, are likely to be much longer-lived. The two together are an ideal combination for many people. If your symptoms are severe, medication may speed up the progress you make in CBT. In addition, CBT may help you progress to a point that you may be able to go off of medication and continue making progress. 

If you are considering medication, it is important that you consult with a psychiatrist or other medical doctor who has an expertise in helping people with anxiety disorders. It's crucial that you consult with your medical doctor whenever you consider going off a medication that you are already on. Going off various anxiety medications too quickly could trigger a return of the anxiety problems, sometimes with greater severity than you used to have.

For more information, please read:
Drug Advertising Hype for Social Anxiety (The Washington Post),
How Thinking Can Change the Brain (The Wall Street Journal),
Brain Structure and Social Anxiety  (Science and The Washington Post).

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COGNITIVE-BEHAVIORAL THERAPY FOR SOCIAL ANXIETY

It's important to remember that the anxiety response, while biologically based, is triggered by the perception of danger. Even a biologically oversensitive anxiety mechanism generally needs the perception of danger to go off. And a biologically normal anxiety mechanism will go off too sensitively if we have learned to misperceive danger. 

Therefore, the most effective way of overcoming social anxiety for most people is cognitive-behavioral therapy (CBT, also called cognitive behavior therapy or cognitive therapy). This is a systematic approach that can help you:

  • identify, challenge and change your distorted hot thoughts that help make you anxious;

  • understand and change your patterns of avoidance and other safety behaviors that reinforce these hot thoughts;

  • learn to be mindfully focused on the conversation and activity in the moment, and to put your thoughts and feelings into the background;

  • identify, challenge and change your underlying core beliefs (basic attitudes about yourself and others) that make you more likely to get anxious in the first place. 
Click here for more information on CBT for social anxiety.

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If you have any questions or comments,
please email Larry Cohen, LICSW,
with offices in Washington, DC.







[Larry Cohen, LICSW, does not endorse any of the products or services advertised by others on this website.]


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