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Last Updated Friday September 29 2017 10:51 PM IST

Heal Thy Self | Clinically proven strategies to overcome Social Anxiety

Nirmala Ferrao
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anxiety

Remember that quiet kid in the class who never raised his hand, who sat on a back-bench and hoped the teacher wouldn’t call on him to answer a question? Or the mid-level executive who hardly speaks at office meetings and fumbles when asked for his opinion?

Or, was that quiet kid you? Is that mid-level executive you today?

The world is full of shy people. Indeed, there is an important place in our world for quiet, sensitive, reserved people. There is respect and dignity and often economic payoffs for those who like to work alone – scientists, computer programmers, writers, music composers. T.S. Eliot was a shy child and a shy adult, so he closed the door and wrote his poetry and plays and won a Nobel Prize.

Read: Heal Thy Self | Know your risk profile for mental illness

And almost everyone experiences shyness now and then – feeling occasionally awkward, embarrassed or even nervous in front of others. Some of us are more shy than others. But everyday shyness doesn’t come anywhere close to the kind of extreme fear and anxiety that some people feel in any social situation – whether it’s an office meeting, a party or – in extreme cases – even eating in a restaurant or answering the doorbell. This is not someone who’s “just shy”. This is someone suffering from an anxiety disorder called SAD (Social Anxiety Disorder), also called Social Phobia.

anxiety

WHAT SAD FEELS LIKE

SAD may look like shyness on steroids, but although there is some overlap with shyness, SAD is a different kettle of fish. People with SAD feel that they are under constant scrutiny from others, that people are critically evaluating every word they say and every move they make. They fear they will come across as inarticulate, stupid, incompetent. They have such an overwhelming fear of being embarrassed or humiliated in a social situation that they end up saying and doing nothing.

Situations that most of us simply take in our stride can cause distress and even fear in people with SAD. They include:

    » Being introduced to others

    » Talking on the phone if there’s someone else in the room

    » Being watched while doing something (e.g., filling up a form if someone’s seated across from them)

    » Eating in front of other people

    » Attending a party or going on a group excursion

    » Expressing an opinion, even when asked for it

    » Being in a performance situation, such as playing a musical instrument, or having to make a presentation

The individual symptoms of SAD vary, but typically fall into three categories: the mental symptoms (what you think), the physical reactions (how your body feels) and the avoidance behaviors that you take refuge in (what you do).

The Mental Symptoms. The kind of thoughts that run through the head of someone with SAD who’s in a social situation include:

    » I don’t want to be here

    » Everyone is staring at me

    » Everyone can tell how nervous I am

    » I don’t have anything interesting to say

    » I don’t fit in

    » This meeting is going to be a disaster

    » I have to get out of here before I embarrass myself any more

    » If I blow this presentation, it’s the end of the world

Read: Heal Thy Self | Why we get duped and how to avoid it

The Physical Symptoms. As anxiety builds up in a social situation, people with SAD may begin experiencing one or more physical symptoms, including:

    » Heart palpitations

    » Choking sensation; lump in throat; dry mouth

    » Tightness in chest

    » Shortness of breath

    » Hand tremors or facial twitching

    » Sweating

    » Nausea or abdominal distress

    » Numbness

    » Dizziness

    » Feeling of weakness (e.g., legs turning to jelly)

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The Avoidance Behaviors. SAD sufferers will engage in a whole range of behaviors to avoid or minimize exposure to a social situation. These “avoidance behaviors” include:

    » Using alcohol or drugs before entering a feared social situation

    » Staying only a certain length of time if (s)he does attend a social event

    » Setting other conditions on attendance, such as staying close to certain “safe” people

    » Staying “busy” to avoid interacting with other people, say, by tapping away incessantly on a cell-phone.

    » Avoiding eye contact with anyone

Someone who has experienced anxiety in a particular situation begins to anticipate the physical symptoms of anxiety at the mere thought of facing that situation again; this anticipation of the symptoms may then actually bring on the feared symptoms, such as rapid heartbeat and sweating and – in their wake – further anxiety. This is the vicious “fear of fear” cycle.

CONSEQUENCES

Quality of life can be severely compromised for someone with SAD. Milder forms of the disorder – which are far more common – take their toll in missed opportunities for advancement, lonely evenings and just plain frustration.

People with a moderate degree of this disorder can function, but with enormous effort and pain. They can work at a job, but often below their capabilities. They find it difficult to form intimate relationships or to socialize.

Those at the extreme high end of the continuum become increasingly isolated, they may drop out of work, end up being supported by their families. They also run a higher risk for depression, substance abuse (as they attempt to anesthetize the negative feelings) and even suicide.

Read: Heal Thy Self | Why does your smart kid keep failing in Maths?

MISCONCEPTIONS

SAD affects millions of people. It is the most common of the 6 Anxiety disorders; it is also the most neglected one. Social anxiety was recognized as a disorder only in the mid-1980s.

Many people still labour under the misconception that Social Phobia is a character flaw, a problem that happens because you are weak. They’ll say to a person who’s struggling with the problem, “Get over it!” or “Pull yourself together!” or “Don’t let it control you!”. For that matter, most people who suffer from SAD typically berate themselves for not being able to “get over it”. But, although they are aware, at the rational level, that their fear is excessive and unreasonable, they are unable to overcome it. That is because anxiety is mostly a matter of biology and mental mechanisms that are automatic and involuntary.

WHY YOU?

If the burning question in your mind is, “What made me this way?”, know that this is the No. 1 question that people ask after receiving a diagnosis of SAD. Most likely, many factors, not just one, play a role in birthing social anxiety.

We do know that it runs in families, so those who have a first-degree relative (say, a parent) run a higher risk than those who don’t. What is inherited is not a “shy temperament”, but the tendency to over-react to anything that’s new or unfamiliar. Taking center-stage here is the fear center in the brain, known as the amygdala. Research has established that in people with SAD, nerve activity in the amygdala is higher than in those who do not have this disorder.

Mood chemicals in the brain are also believed to play a role in SAD. It was earlier thought that people with social anxiety produce low levels of the chemical, serotonin, but more recent research finds that, in fact, the opposite is true – people with SAD produce more serotonin, not less, and the higher the serotonin levels, the more severe the anxiety disorder.

Biology apart, life circumstances may also play a role. Studies suggest that SAD sufferers may be especially likely to have grown up with parents who were socially isolated and who devalued sociability, thus providing ample opportunity for the vicarious learning of social fears.

WHAT YOU CAN DO

While there is no cure for SAD, major improvement is possible, going up to 90 per cent. But it takes hard work and persistence.

Break out of your comfort zone. It takes courage to do that. It’s easier to tell yourself that you are “like this only”, and to hide under a rock for the rest of your life.

But you can’t live with SAD without struggling every day. That is why it is worth taking the risk of breaking out of your comfort zone, standing in the hurricane, and doing what needs to be done to get the living back into your life.

Two approaches have been used in the treatment of SAD.

MEDICATIONS

Three types of drugs are generally prescribed in the treatment of social anxiety: anti-depressants; anti-anxiety medications; and beta-blockers.

We may have cause for pause in the use of drugs that raise serotonin levels (in view of the new findings, mentioned above, about the higher levels of serotonin in the brains of people with SAD).

Beta-blockers are used to reduce heart rate, blood pressure, and shaking voice and limbs. They are therefore prescribed selectively to control such symptoms in a particular situation such as making a speech. They are not recommended for general treatment of SAD.

anxiety

PSYCHOTHERAPY

Counseling therapy has an established track record in the treatment of SAD. Among the techniques used are:

CBT (Cognitive Behaviour Therapy). CBT begins at the beginning. In all of us, there is a constant internal monologue going on through all our waking hours – what we call our ‘thoughts’. Social anxiety feeds on thoughts that exaggerate danger, foresee dire consequences and attribute negative judgments to others. Thoughts like, “This meeting will be a disaster” or “I feel nervous, and it shows” sow seeds from which the whole nasty experience – racing heart, cold sweat – grows. From there, it’s a short step to avoidance behaviors – staying away from a dreaded situation being the favorite one of all.

CBT works on the premise that if you overturn those negative thoughts, you don’t experience those anxious feelings, and you don’t suffer those clammy hands and tummy pain; and if you’re not having those fearful thoughts and feelings and physical symptoms, you don’t have the desperate urge to avoid that meeting or party.

So, how do you overturn those negative thoughts? By critically challenging them and replacing them with – not ‘positive’, but – realistic, rational thinking. Let’s say, you are terrified of asking someone out on a date. You are thinking, “I know she’ll say ‘no’.” And, “If she says ‘no’, I just couldn’t take it, I’ll be crushed.” Now, you challenge each of those thoughts: “How do I know she’ll say no? What’s the evidence I have for believing she’ll turn me down?” You’re likely to find there are no grounds for that negative belief at all. The second presumption can be challenged, too. “What if she does turn me down? It’s not the end of the world. Everybody faces rejection some time or the other. There are many reasons for being turned down, and it doesn’t mean I’m not worthy of being accepted and loved by someone else. Life will go on, why should I feel crushed?”

In CBT, the therapist will guide you through challenging each negative thought that a particular situation brings on, whether it’s eating in company or performing on stage. Negative thinking is a habit that is cultivated over time. Like all habits, it can be changed.

Graded exposure. This is therapy that calls for action. It consists in taking baby steps forward in tackling a situation that causes intense anxiety. Starting with a scenario that evokes the least anxiety, and repeatedly exposing yourself to this low-grade anxiety situation until you feel comfortable in it, you gradually work your way up to more challenging situations until you can meet the most anxiety-provoking situation head-on. It’s like climbing a step-ladder to your destination.

To take the same example as above, if asking someone out on a date freezes you, you would begin by calling her up just to say hello – a brief, casual conversation. You would do this from time to time until you felt completely at ease doing it. Then you would move to the next level – somewhat longer calls, more chit-chat. Asking her out for coffee would be the culmination of this graded process.

Breathe away anxiety. One of the worst things about anxiety is the feeling that, once it starts, it will build uncontrollably. That fear can quickly bring on rapid and shallow breathing. Learning to breathe deeply and slowly from your abdomen eases anxiety. Therapists include relaxation training (such as deep breathing) in the therapy plan, but this is also something you can practice on your own until it becomes easy and natural. Then, whenever you feel the anxiety begin to rise, you can consciously shift to taking deep, slow breaths.

Working with a competent therapist, it generally takes about 6 weeks to begin to see improvement with SAD. But recovery is not a linear progression. There will be times when you feel you’re making great progress, and times when you feel you’re getting back into that spiral of anxiety. That’s nothing to be discouraged about. Just pick yourself up and get back on track. The successes will build up.

You might want recovery to happen next week. But it is not easy, it won’t happen as quickly as you may like. But with courage and hope, it can be done.

(The author, a former editor of 'Health & Nutrition' magazine, now works as a counselling therapist)

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