In these feared performance and social situations, individuals with social anxiety experience concerns about embarrassment and are afraid that others will judge them to be anxious, weak, “crazy,” or stupid. They may fear public speaking because of concern that others will notice their trembling hands or voice or they may experience extreme anxiety when conversing with others because of fear that they will appear inarticulate.

A person with social anxiety disorder may avoid eating, drinking, or writing in public because of a fear of being embarrassed by having others see their hands shake. Individuals with social phobia almost always experience symptoms of anxiety — such as heart palpitations, dry mouth, tremors, sweating, gastrointestinal discomfort, diarrhea, muscle tension or trembling, a shaky voice, blushing, and even confusion. In severe cases, a person may experience a full-blown panic attack.

People with social anxiety recognize their fear is excessive or unreasonable.

These symptoms can become a source of added concern where a person with social anxiety will worry that the symptoms they’re experiencing will result in unwanted and embarrassing attention. People with social phobia either avoid social or performance situations, or endure them with intense anxiety or stress. They can also suffer from anticipatory anxiety regarding the upcoming event or social situation. This can set up a vicious cycle of anticipatory anxiety leading to poor performance (whether real or just perceived) in the situation, which leads to even more anxiety for future situations.

Most people who have social anxiety recognize that their fear is excessive or unreasonable. They seek to avoid any of the feared situations in their life. If they are forced into one of their feared situations, they experience it with intense anxiety.

The incidence of social anxiety disorder in the United States is somewhere between 5 to 13 percent of people who will experience it during their lifetime.

Research indicates that women outnumber men three to two among those with symptoms of social phobia. Men, however, have been more likely to seek treatment.

A variety of studies have demonstrated that social phobia is most likely to develop in the teenage years, though it can start earlier or later. Mental health professionals report that many people suffer quietly for years, looking for help only when their fears have precipitated a major life crisis.

Social anxiety disorder is readily treated through a combination of psychotherapy and medications.

Types of Social Phobia

For some people, almost any social circumstance is a cause for fear and anxiety. These individuals are said to have generalized social phobia. People for whom just one or two situations produce anxiety are considered to have the nongeneralized form of the disorder.

Some researchers have suggested that another way to group people with social anxiety disorder is based on the kind of situation that triggers anxiety. Two primary categories have been proposed: performance and interactional.

The performance group includes people who have strong anxiety at the idea of doing something in front of, or in the presence of, other people. Such situations include dining out, working, giving a speech or using a public restroom.

The interactional group includes people whose fears center on circumstances where they have to converse or otherwise engage with others, such as meeting new people.

Mental health professionals also have recognized that some people develop symptoms of social phobia as an outgrowth of other medical or physical problems. Individuals with Parkinson’s disease, obesity, disfigurement or other conditions sometimes can have severe anxiety that their physical appearance or actions will attract attention and disdain. While sharing similar symptoms, the Diagnostic and Statistical Manual for Mental Disorders specifically excludes a diagnosis of social phobia if the fears exhibited can be tied to these medical or physical conditions.

• Specific Symptoms of Social Anxiety Disorder
• Social Anxiety Disorder Treatment

While both psychotherapy and medications have been shown to be effective in the treatment of social anxiety disorder, a combination approach to treatment — utilizing both at the same time — may be the most timely and beneficial.

While some people may find relief from some social anxiety symptoms through trying simple self-help techniques, most people with a diagnosed social phobia condition will need professional treatment in order to overcome it.

Psychotherapy for Social Anxiety

Psychotherapy is a very effective method of treatment for social anxiety disorder. Specifically, cognitive behavioral treatments — which include techniques such as exposure therapy, cognitive restructuring without exposure, exposure therapy with cognitive restructuring, and social skills training — appear to be highly effective in treatment social anxiety, in a time-limited manner. Most cognitive-behavioral therapy (CBT) can be administered within 16 sessions (usually one session per week). At the end of treatment, a person’s anxiety symptoms are greatly reduced or even disappear in some cases.

In addition to CBT, other psychological treatments have also been found effective in the treatment of social anxiety. These include cognitive therapy (a form of CBT), social skills training alone, relaxation exercises, exposure therapy alone, behavioral therapy, and some other types of less-practiced forms of psychotherapy.

Exposure therapy is often a primary component of psychotherapy treatment of social anxiety disorder. Exposure therapy involves a person learning to understand the irrational basis for their fears (cognitive restructuring), teaching simple relaxation skills to practice while in the moment, and gradually being “exposed” to the situation which causes the anxiety. The exposure is done first in the safety of the psychotherapy office, imagining the scenario and walking through it with the therapist. As the patient’s confidence grows, he or she will begin to apply the skills they’ve learned in the therapy session to outside world events and environments.

Psychotherapy treatments have been shown to be highly effective in treating social anxiety disorder (Acarturk et al., 2009; Powers et al., 2008). Most people who try psychotherapy with a therapist who has experience in treating social anxiety disorder will find relief from their symptoms.

Medications for Social Anxiety

The primary class of drugs used to treat social anxiety are called selective serotonin reuptake inhibitors (SSRIs). This class of drugs was first developed to treat depression and so are often referred to as antidepressants. Since then, however, they have been found to be effective in the treatment of a wider range of disorders. Common SSRIs include Paxil (paroxetine), Zoloft (sertraline), Prozac (fluoxetine), and Luvox (fluvoxamine).

Another type of antidepressant called Effexor (venlafaxine) may also be prescribed to help with the symptoms of social phobia.

These kinds of medications generally take 6 to 8 weeks in order to start feeling the full therapeutic effects of them. While it may be frustrating to wait during that time and feel little relief, always take all medications as prescribed by your doctor. If you experience any distressing side effects, talk to your doctor immediately.

There is little specific reason to prescribe one antidepressant over another for the treatment of this disorder. Your doctor may choose your medication based upon their own experience in prescribing it, or based upon the typical side effects most people who take it experience. If you are not experiencing relief in 6 to 8 weeks from the first medication prescribed, talk to your doctor. He or she may decide to either up your dose or try a different medication altogether.

Other Medications

In addition to SSRIs, others kinds of medications are occasionally prescribed in the treatment of social anxiety disorder.

Anti-anxiety medications called benzodiazepines are rarely prescribed for social anxiety disorder, because they are extremely habit-forming and act as a sedative. However, because they act quickly in the short-term, they may be prescribed when a specific situation warrants their use — such as an unexpected public speaking engagement that can’t be avoided.

A class of drugs called beta blockers may also be used for relieving social anxiety. Beta blockers work by blocking the flow of epinephrine (more commonly known as adrenaline) that occurs when you’re anxious. This means they can help to control and block the physical symptoms that often accompany social anxiety — at least for a short while. They are primarily used for short-term situations, such as when you need to give a speech. However, like benzodiazepines, they are not generally recommended for the treatment of social anxiety and are rarely prescribed for it.

Danny comes up with the typical excuses many of us might use to get out of some situation or event: a stomachache, headache, or some other form of pain. His classroom, friends’ homes, places he has never been and even his own home are presented as obstacles. Situations such as school assignments, public speaking, playground play and gym class trigger negative reactions in Danny, bringing out the need to find a way out.

The book includes a class bully, Sam, who finds any way he can to tease or annoy Danny.  There is the savior (in Danny’s eyes), Tiago, who seems to pull him out of a bad situation or save him from the Sam. A typical class — including the smart kid, Mark, who is Danny’s scholastic competition, and a teacher with rules that affect Danny’s behavior — are some of the examples the authors use to illustrate Danny’s suffering.

Danny’s mother is a prominent figure but his father only shows up as attending a school science fair. Danny’s schoolmate, Jack, also is a prominent character and has absent parents. Jack’s grandfather is his guardian while his parents travel. You can’t help but wonder if the authors are trying to send a message about the way absent parents or the lack of a strong father figure may add to the feeling of self-consciousness and social anxiety.

Danny’s mother starts off being a bit distant, almost uncaring, and gradually is shown to be more considerate and helpful.  Jack’s grandfather plays a larger role in Danny’s evolution– he finds everyday solutions to anxiety-causing situations by introducing the term BRAVE: Be Ready and Victory’s Easy.

Most school-age children will be able to relate to Danny, but the subject matter is not as successful as it could have been. Recovery from social anxiety is possible, but usually only with some kind of therapy or sustained self-help or support group work. The book shows an example of only the support group aspect of recovery.

I would not recommend the book as a helpful tool for this disorder, but being such an easy read, it may help in other ways. It would be best for children between the ages of 8 to 12 or for young parents starting to notice slight issues with their child’s ability to fit in.

Toward the back of the book there is a section listed as Note to Parents. It states Danny suffers from “symptoms” of social anxiety. Someone truly suffering from social anxiety could not so easily accept some of the solutions offered. On the other hand, when Jack’s grandfather talks about how he helped Jack fit in with his soccer team by taking him to a college team’s practices so Jack could see how the game is played and what the rules are, it was a better example of working through a tough situation.

I have a very mild form of social anxiety brought on by being constantly teased as a child and in my teen years. Not as much as a child but built up from my childhood. I oftentimes choose to stay home where it is safe rather than go where I might be uncomfortable. I envy people who get up and go on a whim with no thought as to who will be there, what might happen or even how they look. I was extremely taunted for how I looked growing up and now feel I need to look my very best before heading out to a social gathering. This book may have helped me to seek out someone willing to listen and help like Danny found with Jack’s grandfather.

BRAVE: Be Ready and Victory’s Easy, A Story about Social Anxiety
By Marjie Braun Knudsen and Jenne R. Henderson PhD
Summertime Press, August 2008
96 pages
Paperback, $11.95

In A Brief History of Anxiety: Yours and Mine, Pearson describes the Flu Wiki:

“The conversations ranged widely, from scientific discourses on virus mutation to historical analysis of pandemics, to tips for home fuel storage—on the presumption that self-quarantine would be the only effective protection from contracting the virus.”

Though she realizes that her fears may be unwarranted and absurd, she can’t stop stockpiling her house with twelve containers of freeze-dried vegetables and powdered butter, which requires 27 cups of water. Still, she isn’t hypervigilant about everything: She doesn’t fear house fires, terrorism, crime or harm striking her two small children.

But she fears other things, including the dark, the state of her finances and on one occasion, her car exploding. Her phobias are chameleons:

“My anxiety is a shape-shifter. It visits me in unfamiliar guises. Phobias, in particular, tend to take me by surprise, as they rear up and then fade away depending upon the stresses in my life. One minute, I’ll be going about my business, being the sort of person who likes to fly on airplanes and to marvel at the deceptive fluffiness of clouds, and the next thing I know I’m in a state of white-knuckled panic as the jet I’ve just boarded powers itself off the tarmac. After a few years, that phobia resolves and something else—some other act or object—unexpectedly becomes the embodiment of all that is terrifying.”

As she delves into her own anxiety — triggered by a devastating relationship — Pearson tries to understand our anxiety, too, wondering why America tops the list of countries with anxiety disorders. While 28.8 percent of us suffer from anxiety disorders, only 6.6 percent of Mexicans do. We’re also nine times more likely to be anxious than citizens in Shanghai.

For insight, Pearson looks to a variety of experts, including psychologists, psychoanalysts, psychiatrists, philosophers and writers. In turn, she creates a book that’s rich with research without being overwhelming or reading like a textbook. She weaves her own experiences with the work of today’s thinkers and luminaries from long ago. Her writing is witty, humorous and powerful. There’s no highfalutin’ language. No psychobabble. Individuals with anxiety may very well see themselves and find that Pearson captures perfectly the gnawing angst of anxiety:

“There are several ways to cope with dread, but I specialize in what psychologist Maria Miceli calls ‘hypothetical analytical planning.’ This is where you lie in bed at night and run through as many perspective scenarios as you can imagine and then rehearse them in French, or from the vantage point of a cat.”

“The signature vexation of anxiety is that it is objectless. It washes over one in formless waves, pulls one under until the pressure and constriction are tangible and panic rears: I’m in deep, I’m going to drown.”

Part of our problem, Pearson concludes, is that we turn to pills at a time when our anxiety might be telling us that we’re “caught and flailing in arrested development.” She draws on this conclusion after quoting Danish philosopher Søren Kierkegaard:

“Anxiety is an alien power which lays hold of an individual, and yet one cannot tear oneself away, nor has a will to do so; for one fears, but what one fears, one desires.”

Kierkegaard viewed his own time as “the cowardly age,” when a person “does everything possible by way of diversions and the Janizary music of loud-voiced enterprises to keep lonely thoughts away.” Pearson sees the same thing with today’s society, except that we push existential philosophy aside. We’ve also sidelined meaning, a result of rationalism, which was supposed to reduce our fears. Instead it’s only “invalidated meaning, which merely served to heighten our dread.” The idea that we can control our lives hasn’t helped us either.

Pearson also talks about the culture of the workplace, where employee loyalty has been replaced with fake “team building” and traits viewed as positive and polite in countries like Japan — “being deferential, soft-spoken, courteous and self-effacing” — are considered disordered here in the U.S. (i.e., “social phobia,” “avoidant personality disorder,” “workplace depression”).

She dedicates a chapter to “a drug’s odyssey,” in which she describes her own experience with medication. In the first few weeks taking Effexor, Pearson feels like it’s “heaven-sent.” But then she begins to feel “apathetic insincerity.” She likens her “secure and yet largely disengaged” state of being to her first job out of college ghost-writing letters at Ontario’s Ministry of Labour:

“I did not enjoy this ghostwriting job, mostly because I spent the day responding to genuine human calamity by (a) pretending that I was someone else, and (b) lying. Yet, it was effortless. Paperwork and coffee breaks and lunch, all at a placid pace. I watched the clock a lot, waiting for it to hit five. ‘Dear Widow Whose Husband Drowned in a Vat of Toner at the Wallpaper Factory, thank you for—‘Oh, five o’clock, gotta go.”

Pearson was addicted to Effexor for five years. Of her horrifying, heroin-like withdrawal, she writes:

“My withdrawal featured night sweats, muscle aches, and shortness of breath. There were the electric pulses but I was used to those from the times I missed a dose. (Seth Silverman in Slate best described them as feeling like someone had removed your skull cap and dragged a staticky blanket across your naked brain.)…On most days, I felt a sort of hypercaffeinated wiring and buzzing sensation, a feeling of continuous adrenal rush. It was like being mildly electrified. And then on certain days, it was as if someone had pulled the plug from the socket and the energy simply winked out. I experienced nothing but darkness, an unbearable density and weight that almost brought me to my knees.”

She faults her psychiatrist for failing to inform her of Effexor’s side effects, and criticizes psychiatry as a whole for steering away from talk therapy and withholding important information:

“How can so many thousands of people, very possibly millions, have been abandoned by so many of the practitioners of medical science and been made to fall back upon rumors and whispers about how to manage their meds? At first, I could only think that these particular doctors needed to be in control, to fix what they’re interested in fixing; they suspect that they’ll lose control if they allow their patients to make an informed choice. ‘I can repair your illness, but you need to know that you’ll become emotionally bland, sexually absent, likely fat, probably at risk of getting diabetes, and every time you miss a dose, you’ll feel like you’ve been shocked with a cattle prod. It’s up to you.’ They don’t want it to be up to you. They don’t trust your judgment. They think you’re nuts.”

It’s understandable why Pearson holds such a negative view of medication. Had she been provided with all the facts—which would’ve taken mere minutes to discuss—she could have avoided years of agony. However, as she scours history for insights on anxiety, she does little to explore all facets of pharmacology. Medication does help many people. It can be used to facilitate psychotherapy, jump-start recovery or help diminish debilitating, severe anxiety. But Pearson gives little in a well-rounded discussion. Her “cautionary tale,” as she describes it, certainly can help others to seek better treatment. If you’re considering medication, see a psychiatrist who specializes in anxiety disorders and who can answer all of your questions (and be sure to ask many). Don’t hesitate to do your own research and remember that you and your doctor are a team. You should never feel like a powerless bystander when it comes to your treatment.

Cognitive-behavioral therapy (CBT) is the first line of treatment for anxiety disorders — and a highly successful one at that. In fact, the success rates make other researchers envious, as one expert put it. So it’s disappointing that Pearson devotes just several pages to her experiences with the treatment. This does a disservice for readers who are learning about anxiety disorders for the first time. They may easily feel like there’s nothing out there that can help them. Pearson could’ve noted CBT’s efficacy and demystified the treatment for her readers.

What’s Pearson’s prescription for anxiety? For one, she calls for American society to grow up. She writes:

“What we need is to bend to the tempest like pine and palm trees—flexible, adaptive, attuned, yet fully rooted in our principles. What we need, in essence, is to grow up.”

We also should look inward and seek meaning. Pearson introduces her last chapter with a quote from the philosopher Rumi:

“Don’t look for the remedy for your troubles outside yourself. You are the medicine. You are the cure for your own sorrow.”

While this quote is empowering, it also implies that it’s best to treat an anxiety disorder on your own. And if you can’t reduce your anxiety, there’s something inherently awry. Again, anxiety disorders are treatable, and oftentimes, avoiding treatment only amplifies the anxiety. Seeking treatment means that you’re taking care of yourself; you’re seeking the resources that will help you get better. There’s no reason to suffer with anxiety. But Pearson’s point is important: Meaning is missing from our lives. In our “I want,” ever-entitled culture, it can be tough to find. But it’s key to us thriving.

Overall, Pearson’s book is a powerful read, which provides a refreshing perspective on anxiety in our age. It offers profound words of wisdom, coming from both Pearson and a slew of gifted, inspiring thinkers. And it can help jump-start your exploration into your own anxiety. At the same time, however, there’s no need to suffer. If you’re experiencing anxiety, make an appointment with a therapist who specializes in anxiety disorders.

A Brief History of Anxiety: Yours and Mine
By Patricia Pearson
Bloomsbury USA; Reprint edition (paperback) March 3, 2009
$13
208 pages

Surprisingly, this didn’t happen at school. The bully wasn’t even a peer of his. The bully was his swim coach, a young lady of perhaps 26. She was desperately trying to motivate her swimmers to swim fast in the big meet the next day. And this was her attempt at motivation.

In speaking to the lady in charge of the coaches on this swim team, it quickly became apparent that this type of “incentive” was not only okay with her, it was actually encouraged. She said that 9- and 10-year-old boys were “squirrelly” and “needed to be taken down a notch.” She was in full support of her coaches yelling at, embarrassing and insulting young children to motivate them to swim faster. “That’s just the way swimming is,” she said. Had I not spent 12 years of my childhood swimming competitively, I may have believed her.

How Do I Know if My Coach Is a Bully?

To determine if a coach is a bully, you must first know what bullying behavior looks and feels like.

Bullying is aggressive behavior that occurs repeatedly over time in a relationship where there is an imbalance of power or strength. Bullying can take many forms, including physical violence, verbal abuse, social manipulation and attacks on property. Physical violence is not usually a component of a coaching relationship. If your coach is physically violent with an athlete, call the authorities.

Verbal and emotional abuse is much more common in athletics. It can lead to severe and long-lasting effects on the athlete’s social and emotional development. In a world where “more is better” in terms of training and “no pain means no gain,” there is a great deal of machismo in coaches. Most coaches coach the same way that they were coached while playing the sport growing up. This means that many coaches are still operating as if the training methods used in the Soviet Union in the 1970s are state of the art. “Ve vill deprive you of food until you win gold medal.” Central to this old school mindset is the idea that threat, intimidation, fear, guilt, shame, and name-calling are all viable ways to push athletes to excel.

News flash: None of these is a worthwhile motivator for anyone. These are the bricks which line the road paved to burnout, rebellion and hatred of a once-loved sport.

What Does Verbal and Emotional Abuse Look Like in Athletics?

Usually, this involves a coach telling an athlete or making him or her feel that he or she is worthless, despised, inadequate, or valued only as a result of his or her athletic performance. Such messages are not conveyed merely with the spoken word. They are conveyed by tone of voice, body language, facial expression and withdrawal of physical or emotional support.

This is a large part of why bullying in athletics is so hard to quantify: A clear definition of bullying is somewhat elusive. Even if we can define it, as above, it’s highly difficult to measure.

Bullying is partly defined by the athlete’s subjective experience. In other words, if the athlete feels shamed, frightened, or anxious around the coach due to his or her constant shouting, name-calling or threatening, then the label “emotional abuse” is warranted.

How Widespread Is Bullying by Athletic Coaches?

There are no hard and fast figures on coaches who bully. In school, we know that 90 percent of 4th through 8th graders report being victims of some form of bullying at some point in their past. In a 2005 UCLA study, Jaana Juvonen found that nearly 50 percent of 6th graders reported being the victim of bullying in the preceding five-day period.

In general, boys are more physically aggressive (physical bullying), whereas girls rely more on social exclusion, teasing, and cliques (verbal or emotional bullying).

In 2006, Stuart Twemlow, MD gave an anonymous survey to 116 teachers at seven elementary schools, and found that 45 percent of teachers admitted to having bullied a student in the past. In the study, teacher bullying was defined as “using power to punish, manipulate, or disparage a student beyond what would be a reasonable disciplinary procedure.”

Psychological research has debunked several myths associated with bullying, including one that states bullies usually are the most unpopular students in school. A 2000 study by psychologist Philip Rodkin, Ph.D and colleagues involving fourth- through sixth-grade boys found that highly aggressive boys may be among the most popular and socially connected children in elementary classrooms, as seen by their peers and teachers.

Another myth is that bullies are anxious and self-doubting individuals who bully to compensate for their low self-esteem. However, there is no support for such a view. Most bullies have average or better than average self-esteem. Many bullies are relatively popular and have “henchmen” who help with their bullying behaviors.

And so it is with the swim team that supports the coach’s bullying. Bullying does not take place in a vacuum. There has to be an environment around bullying behavior which allows it and enables it to survive.

We know that bullying is rampant among children as well as adults. We know that 45 percent of teachers admit to having bullied a student in the past. On average, teachers have more training (1 to 2 years postgraduate) in areas such as child development and educational and motivational theories than the average youth athletic coach. So it appears safe to assume that teachers are less likely than the average coach to engage in bullying. Assuming that’s the case, it seems safe to assume that roughly 45 to 50 percent of coaches have bullied an athlete in their past.

According to the National Center for Chronic Disease Prevention and Health Promotion, there are approximately 2.5 million adults in the United States each year who volunteer their time to coach. Using our tentative number of 50 percent would mean that there are roughly 1.25 million adult coaches who have bullied a child athlete in the past. And this number does not even take into account coaches who are paid for their services and who may be more likely to bully due to the pressures and expectations placed upon them.

“She’s so shy. Whenever we get together with people, I mean even one or two people, she hangs behind me. I don’t know how to encourage her.”

MJ is four years old. When I first meet her, I see what her mother means. MJ stands behind her mom. She sneaks a peak at me. She retreats. When she finally does come forward, she holds tight to her mom’s hand. I ask her to tell me her whole name. “MaryJane,” she whispers. I tell her that her mom and I are going to talk a bit and that it’s okay if she decides she’d like to see what’s in the toy corner. Mom and I talk. Sure enough, in about 10 minutes, MJ is exploring the books and toys.

Normal Shyness

MJ is perfectly normal. What looks to her mom like shyness is a developmental stage. Many preschoolers are reticent when confronted with new people, new situations, or new demands. They hang back a bit and observe what is going on rather than jump right in. Once MJ had time to survey the room and to decide that I was probably a benign grownup, she felt confident enough to explore new territory. As kids like MJ get more accustomed to meeting new people and mastering new challenges, their “shyness” often naturally fades away.

Other children are “shy” by temperament. Ask any mother of two or more children. Children are different from the time they start moving in the womb. Some are active and bouncy. Others quietly shift from one position to another. Once they pop out into the world, they are still very much themselves with temperaments to match the activity their mothers felt while they were getting ready to be born.

Quieter infants often become the children who are more comfortable being with one or two friends instead of a large group, who are uncomfortable with unexpected social demands, and who are sensitive to how others are behaving. Often they are more easily upset by transitions and change and take longer to settle down. This shy temperament is as much a part of who a child is as eye color and handedness.

Not surprisingly, temperamentally shy children often have at least one shy parent. The shy child may have inherited his temperament from his shy and sensitive parent or he may have learned to approach new situations with some caution because that’s what he’s observed his parent doing. Probably, as with most things, it’s a combination of both nature and nurture.

Dos and Don’ts for Helping Normally Shy Children Learn to Manage the Social World

• Don’t consider shyness a character flaw. It’s a difference, not a defect. Shy people are often sensitive observers who provide balance, thoughtfulness, and care to the social mix.

• Don’t try to cajole, scold, or pep-talk the child out of his shyness. This will only frustrate you and embarrass the child. Some kids even come to believe that their parents don’t like them!
• Don’t insist that your child show off new skills. Some children are natural performers. Not the shy child. The shy child prefers to be in the audience or stay backstage. Accept that not everyone needs to be in the spotlight.

Social phobia or anxiety is more common than you might think, since sufferers are reluctant to speak up about the problem. It usually consists of a persistent fear of scrutiny by others, alongside a fear of doing something that may be humiliating or embarrassing. Social events tend to make the sufferer anxious, even if they realize the fear is irrational.

Shyness is similar to social phobia. Both involve self-consciousness and self-deprecating thoughts and can lead to avoidance of social situations. But social phobia is rarer than shyness and more debilitating. It can make parties, gatherings, meals out, or trips to the bar a terrifying experience. This is a distressing condition that affects a person’s quality of life. It is associated with increased risk of depression, substance abuse and even attempted suicide.

Aside from the physical discomfort involved in having a pounding heart, breathlessness and blushing, the long-term effects of social phobia on general happiness can be severe. It becomes a vicious circle: you feel uncomfortable in groups, so you avoid social situations, then you feel left out the next time you meet with the group.

Ideas for Tackling Social Phobia

• Write down your signs and symptoms in a notebook. How does it affect your thinking, your behavior, your body, your feelings?
• Try to identify the thought patterns that bring on these symptoms. Make a “thought record” and describe the situation in which you felt anxious, your symptoms, and the thoughts and feelings that triggered them.
• Once you have identified them, work on changing the underlying thoughts. You can do this alone or with the help of a close friend or a therapist.
• One step at a time, do things differently. Experiment with letting go of your avoidance behaviors. For example, keep a conversation going a little longer, or say hello to a waiter or shop assistant. This will build your confidence.
• Lower your self-consciousness by focusing on others. Bear in mind that not everybody is looking at you.

Research Findings

A 2003 study investigated whether sociable people are more resistant to infections.

Healthy, adult volunteers were interviewed and exposed to a cold virus. The researchers found that “sociability” was directly linked to risk of developing a cold, as those who had more and higher-quality social interaction got significantly fewer cold infections. The link remained even after several lifestyle factors that could affect health were taken into account. Researchers concluded that “sociability predicts resistance to infectious disease” and this link is “attributable to the quality and quantity of social interactions and relationships.”

Another study tested the theory that diverse ties to friends, family, work, and community help protect us against infections. It found that volunteers with a wider variety of social ties were less susceptible when exposed to a cold virus, and those who did develop symptoms recovered faster. This effect was proportional, meaning that resistance to bugs directly increased as the individual’s social network widened.

Despite the increased risk of exposure to bacteria and viruses during the “cold season,” it’s not worth reducing your social interactions to avoid a cold, according to Dr. Sheldon Cohen, professor of psychology at Carnegie Mellon University in Pittsburgh. Just make sure you wash your hands frequently to rid yourself of others’ germs.

Humor also is linked to sociability and may affect the immune system by regulating white blood cells and stress hormone levels.

Dr. Cohen studied emotions and risk of developing a cold. He hypothesized that people who typically report experiencing negative emotions are at greater risk than those who typically report positive emotions. His team tested 334 healthy adults for their tendency to experience positive emotions such as happy, pleased, and relaxed and for negative emotions such as anxious, hostile, and depressed.

When exposed to a cold virus, those with a “positive emotional style” were at a lower risk of developing symptoms. These individuals also took better care of their health in general.

References

Cohen S. et al. Social ties and susceptibility to the common cold. The Journal of the American Medical Association, Vol. 277, June 25, 1997, pp. 1940-44.

Cohen S. et al. Sociability and susceptibility to the common cold. Psychological Science, Vol. 14, September 2003, pp. 389-95.

Cohen S. et al. Emotional Style and Susceptibility to the Common Cold. Psychosomatic Medicine, Vol. 65, July-August 2003, pp. 652-57.

The extroversion-introversion axis is a way of thinking about differences in personality. Traditionally, a contrast is made between the assertive, self-expressive, and generally dominant personality, and the withdrawing, secretive, and more yielding personality.

An extrovert “is one whose mental images, thoughts, and problems find ready expression in overt behavior,” according to the psychologists Allport and Allport in 1921, whereas an introvert “dwells largely in a realm of imagination.” Introverts, given sufficient ability, may become visionary poets or artists, they suggest.

The distinction was originally made by Freud and has since been widely used as a concept to help us understand one another. Tests to measure introversion and extroversion have been devised, but the rich internal life which defines an introvert is difficult to detect and measure.

Are You An Introvert?

As a rough guide, you are an introvert if:

• You prefer spending time alone or with one or two close friends, especially when tired.
• You concentrate best when alone, and often give the impression of being quiet, calm and even mysterious.
• You feel that you gain energy and strength from being alone.

Make It Work for You

There are tools you can use to overcome the barriers that introversion can present. How about learning a trick or two from extroverts? Developing slightly more outgoing traits can help you cope “amid the noise and haste” and stand your ground in busy crowds of people. Here are some ways to boost your confidence:

• Notice and copy social skills of outgoing people you admire. In time it will come naturally.
• Speak out. The more you make your voice heard, the more positive feedback you’ll receive, and the easier it will become.
• At parties, try playing the role of the host. Introduce people to each other. Let them begin a conversation that isn’t about you, so you can relax. Ask open-ended rather than closed-ended, yes or no questions.
• Develop your networking skills. Use your memory for details to put people at ease and develop friendships.
• Don’t put yourself down or make excuses for your shyness. Others usually can relate to feelings of awkwardness, so it’s OK to talk about it.
• Above all, don’t let yourself retreat from the world and avoid situations you think you might enjoy. Stay positive and remember you can always leave if it’s becoming a trial.

This vision has stayed with me through my life. There have been many times when I felt like I was on one side of a chasm looking across to a place where everyone else was having a good time. For me it was a very clear description of loneliness.

My studies, and my years of work in the mental health field, have convinced me that loneliness is a key factor in all kinds of mental and emotional distress. In addition, I have found that the incidence of loneliness in this country, and perhaps in the world, is at pandemic proportions. The value of meaningful interpersonal connection in our society is often minimized.

The frenetic pace of modern society and the need to be very financially successful to “just get by ” seems to have eclipsed the importance of having good people in our lives who affirm and support us. Many of us have little or no contact with family members or neighbors. Our work situations may increase our loneliness. Some people say they have forgotten how to connect with others, or perhaps they never learned. I feel so strongly about this topic that I wrote a book about it, The Loneliness Workbook (Oakland, CA: New Harbinger Publications, 2000). This column will help you to think about loneliness in your life and give you some ideas on how to relieve it.

What Is Loneliness?

There are many descriptions of loneliness. They often contain words that describe feelings like despair, emptiness, hopeless and longing. Which one of the following descriptions of loneliness feels right to you?

• A feeling of having no common bond with the people around you
• Feeling disconnected from others
• Feeling sad because there is no one else available to be with you
• Feeling uncomfortable being by yourself
• Feeling that there is no one in your life who really cares about you
• Being without friends or a companion
• Feeling like you don’t have anyone who wants to be with you
• Feeling abandoned
• Being unable to connect with anyone on either a physical or emotional level
• Feeling left out
• Being alone and not comfortable being with yourself

You may want to write your own definition of what loneliness means to you.

What Would It Feel Like If You Were Not Lonely?

To begin changing any situation or circumstance in your life that is troubling to you, it helps to envision what your life would be like if you accomplished this change. For instance, a woman with a disability who felt lonely and disconnected from others said, “If I had several friends, we could call each other and chat. I could share with them how I ‘really feel,’ about the sadness of having a disability, about the excitement of developing a new career, and about my separation from my family. They could stop by and visit with me. Perhaps they could even take me out from time to time.”

Not feeling lonely may mean that you have a sense of balance in your life between being with others and being alone, and that you feel loved and cared about. This connection is so strong that, even when you are by yourself, you feel bonded to someone, that others are there and will be there in spirit if not in person for you always. You have true friends and close family and the security of having someone there for you when you need them.

Obviously, there was a lot I didn’t know about life at the time.

Everyone has at least one childhood memory of public embarrassment. These events tend to occur early in life, at a time when you probably don’t understand all that is happening around you. Perhaps you offered your opinion and found it wasn’t wanted. Maybe you fell and everyone laughed. Or your young body made an unanticipated public noise.

That would never have happened to Loretta Young!

Most people can easily recall a burning feeling of shame from childhood. Since you were too young to understand the incident, chances are your little mind made the same mistake that most other children make. You decided that something was seriously wrong with YOU.

What makes this so significant and yet so sad is that people cannot learn, grow, and develop themselves without mistakes. Growth is messy. You make mistakes, have painful feelings, and don’t have a clear mental picture of what to do next.

“Oops” Events

These are “oops” events. “Oops” events are normal and healthy. They are an indication that you are courageous, taking risks, and trying to grow.

Loretta Young must have rehearsed her television entrance multiple times. Like all actresses, she practiced. I never saw her “oops” events. By the time her television show aired, she had learned her task. Her growth for that week ended before we saw her on the screen.

This is a very difficult aspect of personal growth for most people. We don’t give ourselves practice and rehearsal time. There is no stage. Your learning and growth take place in real time, and in the real world. Your “oops” events usually happen in front of other people. Then these “oops” events wrongly diminish your self-esteem.

Self-Talk to the Rescue!

This is where the tool of self-talk enters the picture. As you move through life, you will undoubtedly experience “oops” events. Guaranteed. When you do, you will automatically revert to old mental behavior and shame yourself. This is all part of a natural psychological process.

With some effort, you can change this sequence of thoughts. When you feel bad about yourself, tell yourself something different. Say all the supportive things you might say to a good friend:

• “Everybody makes mistakes.”
• “It’s okay.”
• “You did a good job.”
• “You just took a risk.”
• “That was hard and you did it anyway.”
• “I like you anyway.”
• “What you just did doesn’t really matter. No one will remember it tomorrow.”

This too is a process that takes time. The only aspect of it that you can control is what you say to yourself in response to old mental behaviors.

So, be Loretta Young, and practice, practice, practice! Eventually you will learn your new skill. In the meantime, you can work toward feeling better about yourself.

While growing up, we learn three styles for meeting our needs: assertion, submission, and aggression. Each style is necessary for dealing with the variety of situations we experience. Problems emerge, however, when we are submissive or aggressive in situations that call for assertion.

When inappropriately submissive, we deny our own needs and rely on the good will of others or their need to control to meet these needs.

When we are in the submissive mode, it is difficult to say “no” when something does not suit us.

When inappropriately aggressive, we deny the needs of others and may abuse the very people who can meet our needs for caring and affection.

When we are in the aggressive mode, it is difficult to stay calm and simply say, “I am angry” if someone invades our space. We will, more likely, fly into a rage to express our displeasure.

Three Response Styles

Submissive behavior may be necessary or advisable when it is physically dangerous or socially inappropriate to express oneself more directly. Submissiveness is a problem, however, if it is our usual way of responding to others. Submissive behavior seeks to avoid conflict, risky situations, and confusion. Our communication is emotionally dishonest when we do not directly express our thoughts, feelings, and desires. We may withhold entirely or express ourselves indirectly. We may say “yes” to others when we want to say “no.”

Submissiveness as a lifestyle revolves around the belief that our rights to personal space or to engage in efforts to meet our personal needs are subject to the approval of others. When we are prevented from getting what we require, we may try to meet our needs in a passive-aggressive manner, or by withholding, guilt, manipulation, or sneakiness.

When we are submissive, we may blame ourselves for this perceived denial of rights and attempt to calm the situation with apologies or by talking around the point. We may agree to do things we really do not want to do. Allowing violations of boundaries, denial of rights, and exploitation, coupled with an ignorance of our own needs, are all part of a pattern of avoiding conflict and gaining the approval of others. “You” statements, which proclaim innocence and blame others, and assumptions that others should meet our needs, avoid personal vulnerability and responsibility. A reduced sense of “being alive,” unsatisfactory relationships, low self-esteem, martyrdom, negativity, disappointment, hurt, not getting what we want, and periodic outbursts of rage are characteristic consequences of submissiveness.

All extravagant behaviors are reactions to it, says Philadelphia psychiatrist Donald I. Nathanson, M.D.

It’s the root of dysfunctions in families, says Montpelier, Vt.-based Jane Middelton-Moz, author of “Shame & Guilt: Masters of Disguise.”

After decades of obscurity — spent, Middelton-Moz says, confused with and overshadowed by guilt — shame is increasingly recognized as a powerful, painful and potentially dangerous emotion,- especially for those who don’t understand its origins or know how to manage it.

A Complex Response

According to Alen J. Salerian, M.D., psychiatrist and medical director of the Washington, D.C., Psychiatric Center Outpatient Clinic, shame is a complex emotional response that all humans acquire during early development. “It’s a normal feeling about ourselves and our behavior,” he said, “not necessarily a symptom of an illness or pathology. In many situations, it’s abnormal if we don’t experience it.”

Embarrassment and shyness, for example, are two forms of shame that seldom cause trouble — unless they’re extreme or long lasting. And humility, another of the forms shame can take, is generally considered socially desirable.

But there’s mounting evidence that problems occur when shame or humiliation becomes an integral part of a person’s self-image or sense of self-worth. Over the past two decades, psychologists, psychiatrists and other mental health professionals have reported that abnormal styles of handling shame play an important role in social phobias, eating disorders, domestic violence, substance abuse, road rage, schoolyard and workplace rampages, sexual offenses and a host of other personal and social problems.

The Importance of Feeling Adequate

Marilyn J. Sorensen, Ph.D., author of “Breaking the Chain of Low Self-Esteem” and clinical psychologist in Portland, Ore., explains how such disorders originate.

“Early in life, individuals develop an internalized view of themselves as adequate or inadequate within the world,” she said. “Children who are continually criticized, severely punished, neglected, abandoned, or in other ways abused or mistreated get the message that they do not ‘fit’ in the world — that they are inadequate, inferior or unworthy.”

These feelings of inferiority are the genesis of low self-esteem, Sorenson says.

“Individuals with low self-esteem become overly sensitive and fearful in many situations,” she said. “They are afraid they won’t know the rules or that they’ve blundered, misspoken or acted in ways others might consider inappropriate. Or they might perceive that others reject or are critical of them.”

Once low self-esteem is formed, the person becomes hypersensitive — they experience “self-esteem attacks” that take the form of embarrassment or shame, Sorenson adds.

“Unlike guilt, which is the feeling of doing something wrong,” she said, “shame is the feeling of being something wrong. When a person experiences shame, they feel ‘there is something basically wrong with me.’”

Middelton-Moz says this is a common emotional response in adult children of alcoholic parents, as well as those who grew up with depressed parents, abuse, religious fanaticism, war, cultural oppression, or adult or sibling death. All of these experiences cause an individual to feel vulnerable, helpless and shamed.

A Deep, Unproductive Well

Aaron Kipnis, Ph.D., author of “Angry Young Men: How Parents, Teachers and Counselors Can Help Bad Boys Become Good Men” and a clinical psychologist in private practice in Santa Barbara, Calif., agrees. He says that shame’s effects are more damaging than those of guilt.

“Guilt is positive,” he said. “It’s a response of psychologically healthy individuals who realize they have done something wrong. It helps them act more positively, more responsibly, often to correct what they’ve done.”

But shame is not productive, Kipnis says. “Shame tends to direct individuals into destructive behaviors. When we focus on what we did wrong, we can correct it; but when we’re convinced that we are wrong as a result of shame, our whole sense of self is eroded.”

That’s why guilt doesn’t produce the anger, rage or other irrational behaviors shame does, Kipnis adds. “Many violent behaviors lead back to a deep well of shame,” he said.

In “Shame & Guilt: Masters of Disguise,” Jane Middelton-Moz, a Montpelier, Vt.-based trainer, consultant and community interventionist, lists the following as common features of adults who were shamed in childhood:

• You suffer extreme shyness, embarrassment and feelings of being inferior to others.
• You don’t believe you make mistakes, you believe you are a mistake.
• You react to feelings of helplessness or vulnerability by bypassing productive responses and going straight to rage.
• You feel controlled from the outside and from within. You feel that your normal expression of spontaneous emotion is blocked.
• You suffer from debilitating guilt; you apologize constantly.
• You have little sense of emotional boundaries. On the one hand, you feel constantly violated by others; on the other hand, you often build false boundaries.
• You blame others for your shortcomings and don’t feel accountable for how you feel or what you do.

Marilyn J. Sorenson, Ph.D., author of “Breaking the Chain of Low Self-Esteem” and clinical psychologist in private practice in Portland, Ore., provides several additional profiles of shame:

• You have extreme anxiety and fear of being in a situation in which you don’t know the rules or expectations.

• You consistently engage in negative self-talk, including constantly questioning past actions or words, putting yourself down or perceiving that others are reacting negatively to you.
• You exhibit self-sabotaging behaviors, such as avoidance of new situations (“I won’t be able to handle it”), reluctance to meet people (“I won’t know what to say” or “They won’t like me once they get to know me”) and reluctance to make changes in a bad work situation (“I won’t be able to get another job” or “I don’t know how to do anything else”).
• You maintain extremely high expectations of yourself and others, including a tendency to be a perfectionist.
• You’ve become a workaholic or overachiever to prove your adequacy to yourself and others.
• You’ve become an underachiever because you’re so afraid you’ll fail that you don’t even try.

People who have phobias often are so overwhelmed by their anxiety that they avoid the feared objects or situations. Specific phobias involve a fear of an object or situation, such as small animals, snakes, closed-in spaces or flying in an airplane.

Social phobia is the fear of being humiliated in a social setting, such as when meeting new people, giving a speech, or talking to the boss. Most people experience these fears with mild to moderate intensity, and the fear passes. For people with social phobia, however, the fear is extremely intrusive and can disrupt normal life, interfering with work or social relationships in varying degrees of severity.

Fortunately, through research supported by the National Institute of Mental Health (NIMH), effective treatments have been developed to help people with phobias.

How Common Are Phobias?

Approximately 4 to 5 percent of the U.S. population has one or more clinically significant phobias in a given year.

Specific phobias occur in people of all ages. The average age of onset for social phobia is between 15 and 20 years of age, although it can often begin in childhood.

What Causes Phobias?

Traumatic events often trigger the development of specific phobias, which are slightly more prevalent in women than men. Research shows that social phobia may have a hereditary component and occurs in women and men in equal proportions. However, men may seek treatment for social phobia more frequently than women.

What Treatments Are Available for Phobias?

Social phobia can be effectively treated with medications including, MAOIs, SSRIs and high- potency benzodiazepines. People with a specific form of social phobia called performance phobia have been helped by drugs called beta blockers.

There is no proven drug treatment for specific phobias, but certain medications may help reduce symptoms of anxiety before one faces a phobic situation. A type of cognitive-behavioral therapy known as “exposure therapy” is also a very useful treatment for phobias. It involves helping patients become gradually more comfortable with situations that frighten them. Relaxation and breathing techniques are also helpful.

Can People With Phobias Also Have Other Physical and Emotional Illnesses?

People with phobias, particularly social phobia, may also have problems with substance abuse. Many people with social or a specific phobia become so anxious that they experience panic attacks, which are intense and unexpected bursts of terror accompanied by physical symptoms.

As more situational panic attacks occur, people with phobias may take extreme measures to avoid situations where they fear another attack might happen or where help would not be immediately available. This avoidance, similar to that in many panic disorder patients, may eventually develop into agoraphobia, an inability to go beyond known and safe surroundings because of intense fear and anxiety. Appropriate diagnosis and treatment of other disorders are important to successful treatment of phobias.

Specific Phobia

“I’m scared to death of flying, and I never do it anymore. It’s an awful feeling when that airplane door closes and I feel trapped. My heart pounds, and I sweat bullets. If somebody starts talking to me, I get very stiff and preoccupied.”

“When the airplane starts to ascend, it just reinforces that feeling that I can’t get out. I picture myself losing control, freaking out, climbing the walls, but of course I never do. I’m not afraid of crashing or hitting turbulence. It’s just that feeling of being trapped.”

“Whenever I’ve thought about changing jobs, I’ve had to think, ‘Would I be under pressure to fly?’ These days I only go places where I can drive or take a train. My friends always point out that I couldn’t get off a train traveling at high speeds either, so why don’t trains bother me? I just tell them it isn’t a rational fear.”

Social Phobia

“I couldn’t go on dates or to parties. For a while, I couldn’t even go to class. During my sophomore year of college, I had to come home for a semester.”

“My fear would happen in any social situation. I would be anxious before I even left the house, and it would escalate as I got closer to class, a party, or whatever. I would feel sick to my stomach — it almost felt like I had the flu. My heart would pound, my palms would get sweaty, and I would get this feeling of being removed from myself and from everybody else.”

“When I would walk into a room full of people, I’d turn red and it would feel like everybody’s eyes were on me. I was too embarrassed to stand off in a corner by myself, but I couldn’t think of anything to say to anybody. I felt so clumsy, I couldn’t wait to get out.”