When the World's a Stage ...
and You Have Stage Fright
All the world's a stage,
And all the men and women merely players:
They have their exits and their entrances;
And one man in his time plays many parts....
Shakespeare, As You Like It
When I first met Gina and asked what brought her to see me, she looked toward the floor and started crying. "I feel like there's something terribly wrong with me. The way I am is not normal." I asked Gina to tell me more.
"I feel like I'm always under the spotlight, as if people are evaluating every word I say, every move I make. Sometimes I feel paralyzed by it. I just know I'm going to do or say something to make others disapprove of me. I don't want to go on like this," she continued.
Gina told me she was single, had never dated, and worked in a pharmacy as a technician. She liked her job but worried about the social aspects of it. For example, when coworkers invited her to eat lunch with them she made excuses for why she couldn't. Recently, someone commented about how she stayed to herself"Gina thinks she's too good for us." This sent Gina to the bathroom in tears.
Then, twice last week when customers acted grumpy and complained to her about waiting in line, Gina became so upset she thought she might be having a heart attack. Her chest hurt and she could hardly breathe. I told her she was probably having a panic attack, but I suggested shesee her physician for a checkup to be on the safe side.
Later in the session I asked Gina what her childhood was like. She told me that while growing up she'd always heard her mother say to others, "She's just a little shy."
Gina thought it was normal that she didn't have many friends. She assumed the popular girls in her class wouldn't want to have anything to do with her, so she mostly kept to herself. Although Gina was bright, she hated school. She dreaded being called on by the teacher to answer a question. She knew she'd freeze up and wouldn't be able to speak. Lunchtime was the worst. She never had anyone to sit by, and she felt too nervous to eat much. She was so miserable, she frequently had stomachaches and begged to stay home. Somehow, though, she struggled through school and began working at the local pharmacy.
Until now, Gina had accepted her mother's explanation that she was "just shy." But lately she worried she was going crazy. "I'm always falling apart at work. I don't know what's wrong with me," she said.
Jim's story is similar to Gina's; he felt as if life was one frightening performance after another. Also like Gina, he had been told more than once that he was "just shy."
Jim explained his main problem to me. "When I talk to people, particularly people in an authority position, or those I think are better than me, I blush," he said. "It starts with a hot, tingling sensation on my neck and chest, and works up to my face. I'm sure everyone notices how red and splotchy my skin gets."
Jim became so bothered by this problem that he mustered up his courage and talked to his physician about it. He thought maybe something physical was wrong. Unfortunately, Jim's doctor was like many other doctors. He knew little about social anxiety and hadn't a clue about what questions to ask in order correctly to diagnose the problem. He dismissed the severity of Jim's situation, and told him, "You're just shy. Don't worry about it."
Jim persisted, though. He no longer believed his problem was simply shyness. He did some research on the Internet, and, to his amazement, he found entire web sites devoted to explaining this condition.
"It helped so much learning that I'm not crazy, and that I'm not the only one with this problem," he told me.
Gina and Jim aren't "just shy." They're painfully shy. Although most people have had butterflies in their stomach before giving a speech or have felt a little nervous on a first date, these natural reactions don't come close to the extreme fear and anxiety experienced by people like Gina and Jim. The technical term for the condition is social anxiety disorder, or social phobia as it's sometimes called. In the rest of the chapter, you'll learn what social anxiety is, at what point it becomes a disorder, and the common symptoms that someone with this problem is likely to experience. You'll also have the opportunity to take a self-assessment test and see where your particular social anxiety problems lie. Perhaps the most important information you'll take from this chapter is the realization that you're not aloneand that help is near.
What Is Social Anxiety?
Social anxiety is a universal experienceone that's necessary for survival. Perhaps it was easier to see its survival value in previous times, when people had to band together to hunt food, build shelter, and ward off enemies. Social anxiety served the function of keeping people close to the "pack." To veer off from the group was to risk death.
Even now, we've evolved in such a way that we're motivated to remain a part of the group. We want to be accepted. We want to fit in. Thus, some social anxiety is normal and beneficial. After all, people who never care about others' opinions are often not very pleasant to be around and have a completely different set of problems.
But what exactly is social anxiety? It's the experience of apprehension or worry that arises from the possibility, either real or imagined, that one will be evaluated or judged in some manner by others. We know, this definition is a mouthful. Perhaps it's easier to explain what social anxiety is by listing some ordinary, everyday examples:
embarrassment after spilling a drink
"stage fright" before a big performance
awkwardness while talking to someone you don't know well
nervousness during a job interview
feeling jittery before giving a speech
These are common experiences almost everyone has had at one time or another.
Since social anxiety is so universal, how do you know where your reactions fall? Are they within the range of normal? Or like Gina and Jim, does your social anxiety pose more of a problem? In other words, how can you tell when social anxiety becomes social anxiety disordera clinical diagnosis?
Recognizing Social Anxiety Disorder
Mental health professionals frequently use The Diagnostic and Statistical Manual of Mental DisordersFourth Edition (DSM-IV) to make diagnostic decisions. While it's not a perfect system, diagnoses are important for a number of reasons. Without a name for the problem, research vital to understanding a problem and developing effective treatments for it simply doesn't take place. On a practical level, if you try to receive mental health services for a problem that has no diagnosis, you're not likely to get your health insurance to pay.
Let's look at the specific criteria that must be met for a clinical diagnosis of social anxiety disorder. The DSM-IV says an individual with social anxiety disorder will:
Show significant and persistent fear of social situations in which embarrassment or rejection may occur;
Experience immediate anxiety-driven, physical reactions to feared social situations;
Realize that his or her fears are greatly exaggerated, but feel powerless to do anything about them; and
Often avoid the dreaded social situationat any cost.
Someone may fear just one or a few social situationspublic speaking being a common examplein which case the problem is referred to as a specific, or discrete social phobia. In contrast, generalized social anxiety disorder exists when a person is afraid and avoids many, or most social situations.
Once these basic criteria are met for a diagnosis of social anxiety disorder, the individual symptoms can vary, but they generally fall into three categories: the cognitive or mental symptoms (what you think); the physical reactions (how your body feels); and the behavioral avoidance (what you do). Let's look at these areas in more detail.
The mental anguish
People with social anxiety disorder are plagued with negative thoughts and doubts about themselves such as:
Do I look okay?
Am I dressed appropriately?
Will I know what to talk about?
Will I sound stupid, or boring?
What if other people don't like me?
What if people notice I'm nervous?
What if people think I'm too quiet?
The fear of possible rejection or disapproval is foremost in socially anxious people's minds, and they scan for any signs that confirm their negative expectations.
Let's look at an example. Imagine that George has gathered his nerve to talk to a woman he frequently sees in the break room at work. He has a topic of conversation planned out ahead of time, something fairly neutral such as the nice weather they've been enjoying lately. When George starts talking to her she seems friendly enough, but she yawns several times. George manages to get through the brief conversation, but when he's back at his desk, he berates himself for his performance. He attacks himself: How could I be so stupid as to talk about the weather? Anyone would find that boring. No wonder she was yawning. She must think I'm a complete idiot. George didn't consider any other explanation for her yawning; the whole situation was distorted based on his fears and expectations. Alternative explanations, such as maybe the woman had been up late, hadn't even made it into his consciousness.
The pain that such pervasive, negative-thinking patterns causes cannot be underestimated. Without appropriate intervention, these kinds of self-deprecating thoughts can lead to many other complications, including low self-esteem and deep feelings of inferiority.
The physical distress
Many people don't realize that actual physical discomfort can accompany social anxiety. For example, someone may experience a panic attack in a social situation, in which they feel an acute and severe rush of fear and anxiety, accompanied by some or all of the following symptoms: shortness of breath, tightness or pain in the chest, racing heart, tingling or sensations of numbness, nausea, diarrhea, dizziness, shaking, and sweating. Panic attacks usually come on quite quickly, build to a peak in approximately five to twenty minutes, and then subside. It's not uncommon to hear people say that their panic attacks last a lot longer; however, it's probably the aftereffects of the attack that they're feeling, such as residual anxiety and increased alertness to bodily sensations, rather than the panic attack itself.
It's important to note that many people are misdiagnosed with panic disorder when, in fact, they have social anxiety disorder. The key to knowing which of the two is the real problem lies in understanding the root fear. In panic disorder, the person fears the panic attack itself and often feels as if he or she is dying during such an episode. In the case of social anxiety disorder, the fear is centered around the possibility that people might witness the panic attack and the resulting humiliation that would occur. Keep in mind, though, that some people have both panic disorder and social anxiety disorder. The appendix, "Recognizing and Coping with Coexisting Problems" covers this in more detail.
Not everyone with social anxiety experiences full-blown panic attacks, though. Instead, some people are extremely bothered by and focused on a particular physical aspect of their condition. The most common examples include blushing, sweating, and shaking. For example, Patty couldn't lift a fork or a glass of soda without worrying that her hand would shake uncontrollably and that others would notice. In fact, she did have a slight tremor that was exacerbated when she was anxious. She avoided eating or drinking in public whenever possible. Constantly making up new excuses as to why she couldn't go out to lunch with coworkers, she ate alone in her cubicle at work. If people see me shaking, they'll know how nervous and scared I am.
Patty thought everyone at work must think she was odd and strange, and this belief made her all the more uncomfortable around them. She thought if she could only control the shaking, she could deal with the rest of her social anxiety problem. Similarly, people with a tendency to blush often believe this is their major problem and will go to great lengthssome people even undergo surgeryto correct this physical "defect."
Regardless of which particular physical symptoms someone experiences, anxiety is never pleasant. Having one's body in a state of constant alert takes its toll and can lead to chronic fatigue, muscle tension, and sleep disturbances.
The toll of avoidance
It's human nature to avoid pain and suffering. From an evolutionary perspective, we're "hard-wired" either to fight or flee from a dangerous situation. It's no surprise then that people with social anxiety disorder tend to avoid or painfully bear situations that they believe will cause them harm. This might mean never attending a party or going to a restaurant. It might mean having few, if any, friends. It might mean never having an intimate relationship. It might mean dropping out of school or working at a job beneath one's potential. I always think I'll go through with whatever it is, but I usually end up making up some excuse and canceling. I feel like a liar.
The consequences of avoidance will naturally vary depending upon the person and the severity of their anxiety. In all cases, though, people with social anxiety disorder limit their choices out of fear. Decisions in life are based upon what they're comfortable with rather than what they might truly want to do.
In addition to the outright avoidance of situations, people with social anxiety disorder may engage in other, more subtle methods of avoidance. Examples of partial avoidance include using alcohol to cope with anxiety (drinking before a party in order to be able to go at all) and setting certain parameters on a social situation (only staying at the party a short period of time). In the self-assessment test at the end of the chapter, you'll be asked about your use of partial avoidance. You'll learn as you progress through this book that engaging in any type of avoidance, even partial avoidance, is detrimental to your recovery. In avoiding threatening situations, you never realize that you actually can manage your anxiety and cope with your fears. In short, avoidance prevents learning.
Obviously, this is a bit of an oversimplification. In fact, some clients have told us that they have exposed themselves to feared situations repeatedly, and it didn't help. If this has happened to you, don't despair. We'll go over the intricacies of conquering avoidance behaviors in Chapter 8.
You're Not Alone:
Social Anxiety Affects Millions of People
A college student, Rachel, believed she had some freakish affliction because she got extremely nervous in any type of group situation. She'd heard about lots of "weird" problems on Oprah, but never anything like what she experienced. I must be the only one with this horrible problem. Why am I like this? Why me?
While the other girls in her dormitory loved the first day of classes because they usually got out early, Rachel dreaded it. She worried herself sick that the teacher might make them introduce themselves to the class. In fact, she often skipped the first day. She also hated social activities sponsored by the dormitory. On one occasion everyone was asked to wear fifties-style clothes during the day and then attend a sock-hop in the evening. Just the thought of calling attention to herself in this way was enough to send Rachel's anxiety soaring. She told her roommate she was sick and stayed in bed all day.
Like Rachel, you may have thought that no one else shared your problem. But you are not alone. The most up-to-date information suggests that one in eight Americans will, at some point in his or her life, suffer from social anxiety disorder. As we mentioned in the introduction, this makes social anxiety disorder the third most common psychiatric disorder, after depression and alcoholism. Millions of peoplefrom ten to nineteen million depending on the particular survey citedare affected by social anxiety.
Who are these millions of people?
The millions of people with social anxiety disorder are ordinary people, just like Gina, Jim, Rachel, you, and me. Included in these millions are not only men and women of all ages, but children and adolescents, as well.
In fact, social anxiety typically shows up before the age of twenty, often during the teenage years. However, many people remember being shy and anxious even earlieras far back as they can remember. Carla's words reflect this: "Ever since I was a child, I remember feeling different from the other kids. I didn't know how to join in on the playground. I just watched. I was very lonely."
Current research suggests that several problems seen in the elementary grades, such as school phobia (refusing to go to school) and selective mutism (not speaking at school) are actually manifestations of social anxiety disorder. Because of the early age at which social anxiety can surface, it's important to work toward increasing awareness and intervening as early as possible. We'll cover these topics and explore other ways to help the socially anxious child in Chapter 11.
In addition to the age factor, many people want to know more about whom social anxiety disorder affects. In large studies of the general population, women outnumber men by a ratio of three to two. When looking at groups of people seeking treatment, however, the gender distribution is nearly equal. Social anxiety disorder appears to cut across racial and ethnic lines, although there may be some variations depending on cultural norms. We've personally been contacted by people in countries all over the worldfrom Canada to Indiawanting to learn more about social anxiety.
Some studies show that people with social anxiety disorder are less likely to be married and also are more likely to have occupational difficulties than others. These findings make sense when you think about the "normal" anxiety many people feel when they're dating someone new or going on a job interview. Throw social anxiety disorder into the mix, and you can probably imagine how trying these events can be. Despite these findings, we've worked with many individuals who function very well, people who you'd never suspect had social anxiety. Still, what matters most is how someone feels on the inside. When someone is tormented by anxiety, even if it's not readily apparent to others, it's a problem worth addressing.
You're Not Crazy: Social Anxiety Is
Underrecognized, but It's Real and Treatable
Another crucial thing to know about having social anxiety disorder is you're not "crazy." You may, however, frequently feel like you're crazy. A large part of this feeling comes from the general lack of awareness and understanding people have about social anxiety.
We've already mentioned the lack of media coverage about social anxiety disorder, and how this contributes to the general public's ignorance of this common problem. Why, you might wonder, when social anxiety disorder is the third largest mental health problem in the United States, is there not more attention paid it? Psychologist Thomas Richards, whom we mentioned in the introduction, makes some interesting comments about this issue. He muses, "Can you see a movie-of-the-week about a very shy person who rarely leaves the house except to go to work, who has no friends, and is afraid of answering the door at times? This would be highly interesting drama, wouldn't it?" The very nature of social anxiety disorder makes it less likely to receive media attention than other problems.
After Dying of Embarrassment was published, I was asked to do numerous radio shows, many of which were call-in formats. I tried to tell the interviewers that I doubted people with social anxiety were going to call and talk on a radio show, much less to an "expert." These radio personalities never seemed to "get it" and were shocked when we had to fill an entire hour of time with absolutely no calls.
Another time a popular, national television talk show called me and said, "We want you on our show if you can bring several articulate, outgoing social phobics with you." This was enough to make me feel crazywhat kind of therapist was I that I hadn't cured all these people, turning them into outgoing, social butterflies who wanted to go on national television and talk about their problems?
Unfortunately, this lack of awareness and understanding extends to professional circles. It's still unusual for health care professionalsphysicians, psychiatrists, or psychologiststo make a primary diagnosis of social anxiety disorder. It's frequently misdiagnosed as panic disorder or agoraphobia, or it's not diagnosed at all. We have had very few people referred to us who have already been correctly diagnosed, much less been given the appropriate treatment.
In my own case, I was never diagnosed with social anxiety. The mental health professionals I saw focused on my depression and general tendency to worry too much. In fact, I had never heard mention of social anxiety or social phobia until I began my fellowship year at St. Louis University Medical Center's Behavioral Medicine Department. There, while working in the Anxiety Disorders Center, I first learned about social anxiety and began to see patients who seemed to fight, perhaps to a more severe degree, the same fears I had. The people who came to the Center expressed so much relief when learning their problem had a name. It was real, and it was treatable.
Excerpted from Painfully Shy by Barbara G. Markway, Ph.D., and Gregory P. Markway, Ph.D.. Copyright © 2001 by Barbara G. Markway, Ph.D., and Gregory P. Markway, Ph.D.. Excerpted by permission.