Living with Social Anxiety

Social Anxiety Help

Larry Cohen, LICSW

Living with Social Anxiety

Kirstan Fawcett
U.S. News & World Reports
June 10, 2015

When he was younger, Angelo Andreatos, now 48, was so self-conscious about his peers’ opinion of him that he skipped out on social events if he had a pimple. After college, the aspiring actor put his Broadway dreams on hold when his fear of commuting from New Jersey to Manhattan, surrounded by people on the train each day, outweighed his desire to see his name in lights. By middle age, Andreatos stopped leaving his house for extended periods – sometimes a year or two at a time. He couldn’t answer the phone because the mere thought of making conversation with a stranger – a takeout delivery person, a sales representative – terrified him.

Andreatos knew he wasn’t just shy or antisocial. He had a problem. So in 2014, Andreatos – who had previously seen a therapist for depression and related conditions – returned to therapy and was diagnosed with social anxiety disorder.

According to experts, social anxiety disorder is the most common anxiety disorder, as well as one of most prevalent psychiatric disorders in America. Just like Andreatos, millions of people are so paralyzed by the fear of being judged or embarrassed in front of others that they’re unable to lead the life they want.

Some cases of social anxiety – like Andreatos’ – are extreme; these individuals can’t hold down a job, maintain friendships, use public restrooms or walk down a supermarket aisle. In particularly dire circumstances, they can’t leave home. Yet others are less severe, says Dr. Beth Salcedo, medical director of the Ross Center for Anxiety and Related Disorders in the District of Columbia. These people might appear to function normally – complete school, transition into a successful career and attend social gatherings. However, their social anxiety disorder still impacts them, albeit in a more insidious way. They might be unable to, say, raise their hand during a lecture or speak up in a work meeting. As a result, they’re thwarted from achieving their fullest potential – hence why some therapists have dubbed social anxiety “the disorder of missed chances.”

“I see a lot of people who’ve stepped short academically or professionally,” Salcedo says. “People who say things like, ‘I really wanted to go get my MBA, but there was no way I was going to do all that group work. So I decided to become a data entry person for the IRS because I don’t have to interact with anybody.'”

As humans, we all want to be liked. We all want to fit in. So where, exactly, does ordinary, run-of-the mill shyness or fear of humiliation end and social anxiety begin?

“It’s all on a continuum,” says Jennifer Shannon, co-founder of the Santa Rosa Center for Cognitive-Behavioral Therapy in California and author of “The Shyness and Social Anxiety Workbook for Teens.” “I think of social anxiety disorder, or any anxiety disorder, as a ‘disorder’ when it starts interfering with the person’s functioning – when it’s interfering with the goals they have in their life.”

Plus, people who are merely shy are able to let down their barriers as they become more familiar with a situation or group, says Dr. Richard Heimberg, director of Temple University’s Adult Anxiety Clinic. People with social anxiety? Not exactly.

Typically, those with social anxiety disorder engage in escapist or avoidant behavior, Heimberg says. Sometimes they purposely avoid places or events where they know they’d be forced to interact with people; they skip conversations with small talk because they’re worried about awkward silences or being judged. Or they drink too much because they find alcohol makes them feel less uncomfortable around others. One patient, Heimberg says, almost didn’t attend his own wedding because he was so nervous about walking down the aisle in front of a crowd of people. These actions are spurred by exaggerated thoughts and beliefs about how someone is viewed by others. What if I accidentally offend someone? What if I make a bad joke? If I’m not interesting, will people no longer like me? They’re all watching me. They’re laughing at me.

“They believe they need to be socially perfect, and then if they’re not, they feel this exaggerated sense of threat that they’re going to get kicked out of the tribe,” Shannon says. “People who don’t have social anxiety disorder … just kind of jump into conversations. They don’t worry too much” about being boring or awkward, or making a social faux pas. And research supports the notion that people with social anxiety disorder rate their own behavior more poorly than others observing them, Heimberg says. They’re not as socially inept as they imagine they are – but their social anxiety tells them otherwise.

Most of the time, it’s not externally obvious that someone is struggling with such thoughts. In fact, many people with social anxiety appear fine in social interactions, Heimberg says. But there are, occasionally, physical clues that reveal the person’s anxiety. For instance, Andreatos used to sweat profusely during social interactions and occasionally has anxiety attacks. Others with social anxiety might avoid eye contact – they’re afraid they’ll be met with a harsh or mocking gaze – or tremble, blush or speak in a quaking voice. And in addition to anxious thoughts, people with social anxiety disorder might also experience a quickened heart rate, dry mouth or nausea in social settings.

In addition to missing out on life events, avoidant behavior spurred by social anxiety disorder reinforces negative thought patterns, Shannon says. “You’ll think, ‘It’s good I didn’t speak up at the meeting, because people didn’t see how stupid I am,'” she says. “[Or], ‘I’m glad I ended that conversation early because the other person now doesn’t know how boring I am.'”

Those who struggle with social anxiety are often told to be “less self-conscious” or to “care less about what other people think.” Often, children are told they’ll outgrow it. But it’s a little more complicated than that, Salcedo says.

Social anxiety disorder can manifest at a young age – say, elementary or middle school – but sometimes it presents even earlier. It often occurs during adolescence. And some individuals, like Andreatos, recall having it their entire life.

Researchers think social anxiety is partially genetic; people with the disorder, including Andreatos, often note that it runs in their families. Environmental factors, such as childhood bullying and social stressors, or parents who also have anxiety and/or exhibit avoidant behaviors, can also contribute to development.

You don’t “outgrow” social anxiety or snap out of it; you’ll likely need therapy, a medication like a selective serotonin reuptake inhibitor or a combination of the two to alleviate your symptoms. Heimberg notes that an average of 15 to 20 years typically lapses between the onset of social anxiety disorder and seeing a professional.

Since social anxiety can worsen with time – and eventually lead to substance abuse problems or depression – early intervention is important, experts say. “The data are getting stronger and stronger that things like childhood bullying [and] cyberbullying … really do have an effect” on the development of social anxiety disorder, Heimberg says. “So monitoring some of those kinds of things, and developing prevention programs at the school and community level, are really important.”

Even if early intervention isn’t possible, individuals of all ages can benefit from cognitive behavioral therapy, Salcedo says – the go-to therapy most professionals use for anxiety disorders. In a typical session of cognitive behavioral therapy, therapists help patients with anxiety challenge their distorted thoughts – for example, “If I walk into a room, everyone’s staring at me and thinking bad things” – and replace it with a more rational one. And by exposing themselves to stressors that cause anxiety – say, visiting the dry cleaner and complaining about a missed stain on a shirt, thus drawing unwanted attention to themselves – they can learn coping tools to deal with their symptoms.

Andreatos recently started cognitive-behavioral therapy. He’s now leaving the house, and he’s trying to pick up the phone when it rings. Eventually, he’ll make it to a mall. He’s slowly but certainly making progress against his social anxiety, he says. “I’m trying to get better.”

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

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