Shyness and social phobia

Shyness is a common sort of mild fear – if it's mild, it doesn't really spoil life.

Many of us get a bit worried before meeting new people but find that, once we are with them, we can cope and even enjoy the situation.

A phobia is also a fear. We all have fears about things such as heights and spiders but, for most of us, they don't really stop us from doing what we want to do.

A fear becomes a phobia when it stops us from enjoying things or doing them easily.

If you have a social phobia, you get very anxious when you are with other people, usually because you worry that:

• they may be critical of you;
• you may do something embarrassing.

This can be so bad that you can't enjoy being with people or speaking in front of them. You avoid social situations altogether.

This information describes what it is like to have a social phobia, how you can help yourself and some of the help you can find for this.

There are two main sorts of social phobia.

General Social Phobia

You:

• worry that other people are looking at you and noticing what you are doing
• dislike being introduced to other people
• find it hard to go into shops or restaurants
• worry about eating or drinking in public
• feel embarrassed about undressing in public, so you can't face going to the beach
• can't be assertive with other people, even when you know you need to.

Parties can be particularly difficult. Many of us hesitate slightly before going into a room full of people, even if we have been looking forward to it.

If you have a social phobia, you may tend to hover around the entrance or outer rooms - because you feel unable to 'go in'.

This leads some people to believe that they are claustrophobic.

If you do finally get into the room with other people, you feel as though everybody is looking at you. You may have to have a drink before you go to a pub or party, so that you can relax enough to enjoy it.

Specific Social Phobia

This affects people who have to be the centre of attention as part of their way of life such as salesmen, actors, musicians, teachers, or union representatives may all feel like this. If you have a specific social phobia, you may find that you can mix and socialise with other people without any problems.

However, when you have to get up and talk or perform in front of others, you become very anxious, stammer or 'dry up' completely. It can affect even people who are experienced at speaking in public and do it regularly.

At its worst, it can make it impossible for to speak in public at all, even to ask a question.

The feelings of anxiety are similar for both types of social phobia. You find yourself:

• worrying a lot about making a fool of yourself in front of other people
• feeling very anxious before going into any of the social situations that worry you
• going through, in great detail, all the embarrassing things that could happen to you
• unable to say, or do, the things you want to
• after an event, worrying about how you handled the situation.  You may go over, again and again, how you might have behaved differently or said different things.

People experiencing both of these types of social phobia also have many of the same physical symptoms.You may get:

• a very dry mouth
• sweating
• heart pounding
• palpitations (the feeling that  your heart is beating irregularly)
• wanting to pass water or open your bowels
• feelings of numbness or pins and needles in the fingers and toes (this happens because you breathe too fast).

Other people may be able to see some of the signs of this anxiety - the blushing, stammering, shaking and trembling.

These symptoms can be quite alarming and make your anxiety worse. It can become a self-fulfilling prophecy.

You worry so much about looking worried that you actually do look worried.  Your worry is your worst enemy.

With either sort of social phobia, these feelings can end in a panic attack.

This is a short period, usually only a few minutes, during which you feel overwhelmingly anxious, terrified of losing control.

You may feel that you are going mad or dying. You will usually try to get out of the situation that has brought it on. These feelings reach a peak and then pass off rapidly, leaving you feeling weak and exhausted.

Although these attacks are very alarming, they do stop on their own and cannot harm you physically.

It can be very wearing to suffer from a social phobia - other people do things easily when you find them impossible.

You may worry that others will think you are boring. You may be over-sensitive and reluctant to bother other people.

It's easy to see how this can make you feel depressed and unhappy. This, in turn, can make the social phobia worse.

Many sufferers cope by arranging their lives around their symptoms.

This means that they (and their families) have to miss out on things they might otherwise enjoy.

They can't visit their children's school, can't do the shopping or go to the dentist. They may even actively avoid promotion at work, even though they are quite capable of doing a more demanding and more financially rewarding job.

About half of those with a severe phobia, particularly men, will have difficulty in making long-term relationships.

About five in a hundred people have some degree of social phobia, with women two or three times more likely to be affected.

We really don't know. It seems to affect people who:

• have particularly high standards for their behaviour in public;
• who have stammered as a child.

Some experts think that it might be due to people getting stuck at the normal stage of shyness that all children go through between the ages of three and seven.

What keeps it going?

Thoughts: Certain thoughts tend to kick in when you enter a social situation and will make you anxious. These include:

• rules for yourself - “I always have to look clever and in control”
• beliefs about yourself - “I'm boring”
• predictions about the future - “If someone gets to know me, they will see how inadequate I am.”

They make you think about – and criticise - your behaviour from moment to moment. Such thoughts are so automatic that they feel true to you – although there is often no evidence for them at all. They can make you imagine that you appear to other people in a certain - usually rather unattractive way. Ths is almost certainly very different from the way that people actually do see you.

Safety behaviours

These are things that you do to make yourself feel more in control in a social situation. They include:

• drinking alcohol
• avoiding eye contact
• not saying anything personal about yourself
• asking too many questions of the other person.

The problem with doing this is that it doesn't allow you to experience the fact that dreadful things don't happen if you stop trying to control your behaviour so much.

Anticipation and post-mortems

Thinking over and over about a social situation, before or after, tends to make you focus on past ‘failures’. It strengthens your habit of over-scrutinising your behaviour and criticising yourself.

There are several ways of helping people with social phobia. These may be used on their own or together, depending on what you need.

Self-help

• If you are naturally shy, you may find it helpful to join a local self-confidence or assertiveness course.
• Learn some relaxation techniques – you can do this from books, tapes, CDs or DVDs. When you do find yourself getting anxious, you may be able to ‘nip it in the bud’ by using one of these techniques.
• Write down the automatic thoughts you have about yourself and the pictures of yourself these conjure up in your mind. Once you have done this, it can be easier to start changing them.
• Try listening more to what other people are saying, rather than what you are saying to yourself in your mind.
• Start to stop using your ‘safety behaviours’, beginning with the easiest.
• Break down a worrying situation into a number of steps, right from the beginning. Then take the first step and learn to feel relaxed while doing it – it may take some practice. Then move on to the next step, and then the next.

It will be easier to do these things with one of the many self-help books that deal with social phobia – see the reading list at the end of this leaflet.

Psychological treatments

Social skills training

This can help you to feel more relaxed and confident in company.

It does this by teaching some of the simple social skills that we tend to take for granted - like how to start a conversation with a stranger.  You can practice with other people and do what is called 'feedback' - people watch themselves practising on video to get an idea of what they are doing and how they appear to other people.

Graded self-exposure

We know that, even if you are very frightened in a particular situation, your anxiety will start to go away after a while. This approach helps you to do this for yourself, one step at a time.

You make a list of all the situations that you find frightening, and then put them in order, from the least frightening to the most frightening.

You start with the least frightening situation and, with the support of your therapist, keep yourself there until you stop feeling anxious.

You then move on to the next one and so tackle these frightening situations one by one. It is done in stages, each time making the situation a little more intense and frightening.

Cognitive Behavioural Therapy (CBT)

Social phobia is tied up very closely with the thoughts that you have about yourself, the world and the people around you - we can make ourselves anxious by the way that we think about things.

This treatment helps you to change the way that you think about yourself and other people.

The therapist will help you to be aware of:

• any unhelpful rules, assumptions or predictions (see above) that you regularly use – and the physical sensations you get when they go through your mind;
• any safety behaviours (see above);
• the unhelpful impact on your behaviour of thinking about these things all the time  - and the connections between these and your anxiety.

For example, take the situation when a conversation dries up. If you have a social phobia, you will tend to think it is your fault – you may have the automatic belief that “I never have anything to say” - and so you will start to feel anxious.

In CBT, the therapist will try to help you to be aware that it is just as likely that the other person has run out of things to say.

This is a more realistic and less worrying way of thinking about the situation. The therapist will help you to test these ideas out in your day to day life.

You can then start to focus on how other people are actually reacting to you, rather than your imaginary version of how they are. For instance, the therapist could ask you to talk while thinking to yourself that you have to appear very intelligent and amusing.

After a few minutes you would stop and try again, this time concentrating on how the therapist is reacting to you rather than what you are thinking.

Other techniques focus on the conversation, or ‘task in hand’ rather than any physical symptoms of anxiety you may be aware of. This sort of treatment is usually given by one therapist for each client. If the problem is very severe, or if you are unable to get out of the house, it can be given as an in-patient or as a day patient in hospital. 

Medication

Antidepressants

Medication should be used if a psychological approach has failed, if you do not want to try a psychological approach, or if you are very depressed.

The newer antidepressants (SSRIs - Selective Serotonin Re-uptake Inhibitors) have been found to be helpful in social phobia, but may sometimes cause headaches and dizziness in the first few weeks.  They usually start to work within 6 weeks, but can take up to 12 weeks to have their full effect.

If the symptoms of social phobia get better, the dose can be slowly reduced over several months.  About half of those who start taking antidepressants will get worse again when they stop taking them.

If SSRIs do not help, Monoamine Oxidase Inhibitors (MAOIs) can be tried. These have drawbacks.

They tend to lower the blood pressure which can make you feel faint. Some foods, such as cheese and yeast extract, can produce dangerous reactions with these drugs, so you have to follow a special diet which leaves out these foods.

Some cough medicines that can be bought at the chemist also produce similar reactions to these foods. There are now some new MAOI drugs called RIMAs (Reversible Inhibitors of Monoamine Oxidase - A). These don't seem to produce the above reactions, and so people taking them can eat what they like. Other types of antidepressants don't seem to work very well in social phobia.

Beta-blockers

These drugs are usually used to treat high blood pressure.  In a low dose, they control the physical shaking of anxiety - which can be a symptom of social phobia - and can be taken shortly before meeting people or before speaking in public.

Tranquillisers

Drugs like Valium were used in the past to treat all sorts of anxiety. We now know that they are addictive and that they do not help in the long run. They should usually not be used to treat a social phobia.

How effective are treatments?

• Pure self-help, using books without a therapist, seems to help some people a bit, but it doesn't reduce the impact of the social phobia on  their life. This may be a good choice if your anxiety about social situations is troublesome, but doesn't stop you from doing too many things
• Self-help with group meetings seems to work better, but is relatively new.
• Graded self-exposure seems to work for about half the people who finish the course - but quite a few people don't complete it.
• CBT seems to be better than SSRI medication and should be provided before medication is tried.

If you want to find out more about social phobia, here is a list of self-help organisations, books, websites and other materials that you may find useful:

Self-help groups

• Anxiety UK Helpline: 08444 775 774. Anxiety UK works to relieve and support those living with anxiety disorders by providing information, support and understanding via an extensive range of services, including 1:1 therapy.
• Depression AlIiance Tel: 0845 123 23 20 Information, support and understanding for people who suffer with depression and for relatives who want to help. Self-help groups, information, and awareness raising for depression.
• Shyness & Social Anxiety Treatment Australia Information about social anxiety, the treatment options, group therapy and workshops, support groups, articles, resources and links to other sites.
• Triumph Over Phobia Tel: 0845 600 9601 Runs a national network of self-help groups to help people with phobia or obsessive compulsive disorder (OCD) to overcome their problems using graded self-exposure. This means learning how to face up to your fears in a very gradual and structured way so that eventually the anxiety should decrease.
• Aware - Helping to Defeat Depression Tel: (00 353) 1890 303 302 A voluntary organisation formed in 1985 by a group of interested patients, relatives and mental health professionals whose aims are to assist that section of the population who are directly affected by depression.

Further Reading

• Shyness and Social Anxiety. Northumberland Tyne and Wear NHS Trust: a short self-help workbook. www.patient.co.uk/pdf/pilsL429.pdf
• Living with Fear by Isaac Marks (McGraw Hill Education).

References

• Craig, A. & Tran, Y.(2006) Fear of speaking: chronic anxiety and stammering. Advances in Psychiatric Treatment, 12: 63-68.
• Rapee et al. (2007) Treatment of social phobia through pure self-help and therapist-augmented self-help. Br J Psychiatry.2007; 191: 246-252.
• Veale, D. (2003) Treatment of Social Phobia. Advances in Psychiatric Treatment, 9: 258-264.

Credits

This information was produced by the Royal College of Psychiatrists' Public Education Editorial Board.

• Series editor: Dr Philip Timms.
• Expert Review: Dr Cosmo Hallstrom