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Joyce Boaz & Dr. Frank Ochberg, M.D.

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Social Phobia

Q: Dear Frank, Could you discuss Social Phobia? One GFW correspondent asks, "Is social anxiety hereditary at all? My father is agoraphobic to a degree and will only leave the house for 1 of 3 places. I am not agoraphobic, but I have social anxieties in crowds, with people, in waiting rooms (a lot), etc. So I'm just wondering if there's a connection. My psychiatrist gave me Ativan to use in social situations. Besides talk therapy and medication are there any other forms of treatment (say exposure to social situations)?" Another notes, " I don't have it (Social Phobia) as a disorder, but being away form home or out in groups can freak me out. I try not to fall apart or get too anxious when alone at parties or at events when I don't know anyone. I have currently joined an agoraphobic, general anxiety and panic group so its interesting being on line with people who haven't been grocery shopping outside for years." This may be a condition that several GFW website visitors have encountered in themselves or others.

A: Dear Joyce, There is a recognized diagnosis called Social Anxiety Disorder and it is also called Social Phobia. I knew about it as a psychiatrist, but hadn't met many people with the condition until recently. Now, probably by coincidence, but perhaps because I am on the lookout for it, I find that five of my patients fit the description exactly. And they never knew they had the diagnosis, nor did their closest friends and relatives. Just knowing that the condition exists can be a powerful source of help, with relief from confusion and embarrassment. There are many forms of anxiety in which people experience fear, dread, physical symptoms such as rapid breathing, palpitations, tremors, sweats and a sense of being near death. Extreme anxiety is no simple matter. Some people describe it to me as suffocating or drowning. I always take it very seriously.

When the anxiety is always caused by a particular trigger -say the sight of blood or a spider or a snake- it is called Simple Phobia. There is nothing simple about Simple Phobia because it results in a state of terror. But it is called Simple because one specific creature or condition is the cause. When the anxiety is caused by certain types of environments -wide open spaces or crowded marketplaces- it is called Agoraphobia (from the Greek agora meaning market and phobia meaning fear). Agoraphobics often isolate themselves at home. The poet, Emily Dickinson, ended up living in her bedroom. But Social Anxiety Disorder isn't exactly Agoraphobia or Simple Phobia. People with this phobic condition can make friends and trust certain individuals, but they have a strong negative response to social situations that place them on the spot. A college student who is my patient can go to class, which he finds impersonal and non-threatening, but he can't go to a party unless he is with well-trusted friends. If his friends were to leave him at the party he would "freak," just as the second writer above describes. "Freaking" means needing to escape but fearing that leaving would be rude, attention-getting and might create a scene. Staying with strangers feels like drowning. This is far worse than ordinary fear, and seldom understood by classmates.

Another patient feels betrayed by best-friends who think they do her a favor by introducing her to their friends, then leaving her. A person with Social Phobia is extremely vulnerable to abandonment, because the trusted friend is like a scuba suit and an oxygen tank for a person underwater. Take away the airway and you can't breathe.

In some cases, this Social Anxiety condition has been present since earliest memory. The person was "born shy." About 20% of people are shy from infancy and this is most likely a genetic trait. By the time these people are in their late teens, half have overcome shyness due to experience, learning and peer pressure.

In other cases, the person was not of a shy temperament, but in late childhood or early adolescence, they began to experience Social Anxiety, exactly as described above. They don't know how to explain it. They are usually embarrassed. They cover it up or adapt through avoidance. The condition has secondary effects, impairing school performance, social adjustment, occupational choices and self-esteem. This is a shame, because the disorder can be diagnosed, de-stigmatized and overcome.

Yes, Social Anxiety has a hereditary component. It runs in families. Relatives may have a different form of anxiety, but the common thread is a low threshold for the fear response -and a high degree of fear. Think of it as too much adrenalin or as an easily triggered nervous system, or both at once. The trigger may differ among relatives, but the over-reaction is much the same. And usually, this biological tendency was there before any traumatic experience occurred. Trauma may shape the response and may result in certain triggers. But some of us are more prone to an over-anxious reaction from birth, even though this doesn't become evident until teen-age years.

Yes, there are good treatments besides medication and talk therapy. Exposure therapy involves careful, well-timed, constructive exposure to the feared situation. I've seen patients do this on their own, once they knew more about their diagnosis, could explain it to others, and met a few others with the same condition. Without prompting from me, they went to a social event that would have terrified them before. In other cases, the exposure was carefully planned in discussions we had, and was calibrated to succeed.

Cognitive-behavioral treatment involves learning how to think about emotional circumstances, changing the things one tends to say to oneself. CBT, added to exposure, support, talk-therapy and other sources of assistance, is very useful.

Learning about this condition can help oneself and others. There are some excellent websites out there, and some sites that bring people with Social Phobia together. Gift From Within specializes in self-help and peer-help for persons with PTSD. But there is an overlap between PTSD and Social Phobia, even if one condition does not necessarily cause the other. I'm glad that Joyce asked about Social Anxiety and I hope that the GFW network helps to bring information, dignity and respect to those out there who have a very difficult time among strangers.

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