Imagine yourself stammering and having nothing to say on a date. Or panicking so badly that you can’t write your final exam. We are all afraid sometimes, but for people with social phobia, the fear is so overwhelming their lives are significantly limited.
Social phobia is the most common anxiety disorder in Canada, affecting approximately 13 per cent of the population. The illness is associated with an intense fear of evaluation in social or performance situations. According to Dr. Martin Katzman, a psychiatry professor who works with patients at the Anxiety Disorders Clinic at the Centre for Addiction and Mental Health here at U of T, social phobia is exceedingly common in our community.
“We all get a little nervous on a date, but that’s not social phobia, that’s shyness,” Katzman explained. Among individuals with social phobia, the problem is not only shyness, but also the negative thoughts and feelings that get triggered by their feared situations, which cause them to avoid the situation altogether. Even signing a cheque in front of someone else can be potentially humiliating, because there is the possibility of a nervous shake of the hand.
Social phobia is intensely painful and disruptive for those who crack under pressure. Physical symptoms include rapid heart rate, shortness of breath, trembling, and urgency—or failure—to urinate. For some men, relieving oneself in the presence of others can be stressful. Katzman had a client show him a series of what the client called “safe bathrooms”—they were ones where he would be all by himself.
Other situations commonly feared are public speaking, eating and drinking in a restaurant, and meeting new people. In some cases, the fear escalates to a point where individuals experience panic attacks. “Things become surreal to them,” said Katzman. “[It’s] almost as if they’re watching themselves from the outside and they’re not part of the story.”
For many sufferers of social phobia, what fuels their fears is the desire to be perfect. An array of hypothetical questions floods their minds: What if I say something silly? What if I start sweating? What if I pass out?
“Perfectionism is really about fear of scrutiny and bad outcome,” said Katzman. There are artists who never show their work purely because they are afraid of being evaluated. One question they constantly ask themselves is, “What if it’s not good enough?”
Because they avoid social situations, individuals with social phobia live in a diminished world. Many are unable to develop their careers, build long-term relationships and lead full lives. Though they may crave success, students with social phobia might fear rejection so much they’d rather give up applying for school than to risk failure.
A 1998 study showed that 11 per cent of people with social phobia are unemployed, compared to 3 per cent among controls. To make things worse, a significant portion also suffer from other disorders, such as depression, alcohol and substance dependence.
People who fear scrutiny will not go to their doctors to be evaluated for their problems. “If you have social phobia, you don’t want others to be aware of you—you want to blend.” As a result, health professionals are not helping as many patients as they would like to.
There is very effective treatment for social phobia, consisting of psychotherapy combined with medication. To date, cognitive-behavioural therapy is the most thoroughly studied form of psychotherapy. Extremely effective for most, it aims at breaking the patient’s tendency to associate anxious thoughts and behaviour with social situations. Together the patient and psychiatrist devise a hierarchy of feared situations, to be confronted by the patient from the least to the most feared.
Throughout therapy, the psychiatrist will assist the patient in changing his or her thought patterns. They will judge the likelihood of worst-case scenarios, consider other probable outcomes, and evaluate their severities. The goal is to help the patient realize that more often than not, the probabilities of worst-case scenarios occurring are, in fact, very small. For example, individuals who never attend parties for fear of blushing and being humiliated for the rest of their lives will realize such thoughts are unrealistic.
The other treatment component consists of the patient getting used to feared situations by repeating them over and over. One way of helping people with a fear of public speaking, for instance, is to have them give a speech to a group of people three times a day for a period of time until it becomes less and less of an issue. The advantage to this method is individuals often generalize what they learn to other situations and come to believe that the things they find terrifying are really not as bad as they expect.
In some cases, putting patients on anti-depressant drugs allows them to better tolerate their feared situations and consequently better undergo therapy. “Therapy can be done in as little as twelve sessions,” said Katzman. “You watch people get back their lives.”
