Together alone

“Relationships, dating, sex, working, career goals, future… socially anxious people can’t do these,” says Dr. Martin Katzman, a psychiatrist in the mood and anxiety disorders clinic at the Centre for Addiction and Mental Health (CAMH).

“They get trapped,” Katzman continues, “A lot of them can’t maintain jobs. If they get a job they can’t move up. It’s the gift that keeps on giving.”

Katzman is also scientific advisory chair for the Anxiety Disorders Association of Canada (ADAC)-an organization dedicated to promoting the diagnosis and treatment of anxiety.

One of the most common anxiety disorders, social anxiety (or social phobia) is an intense fear of scrutiny or embarrassment that causes a person to avoid social situations and severely disrupts their ability to lead a happy, healthy life.

Last month, the CAMH held a talk at the Addiction Research Foundation (ARF) on Russell street, discussing anxiety and co-occuring depression.

One of the speakers at the talk was Earla Dunbar, a patient of Katzman’s and also the founder of the Social Anxiety Support Group of Toronto-which she has been running for three years.

Several members of Dunbar’s group agreed to speak to The Varsity, but only under pseudonyms.

“Mark,” 24, related his experiences. Mark was verbally abused by his father in his childhood. This contributed to severe feelings of shyness that impaired his social life in high-school and beyond. “If I was at a party or a group interaction, I would withdraw. I would stand behind people so that I was presenting as little of myself as I possibly could.”

Dunbar herself began suffering social anxiety at age five. She frequently felt sick at school and had trouble interacting with other children. This continued throughout adolescence and into adulthood, leading her to drug and alcohol abuse in high-school; which she dropped out of in grade 12. Dunbar’s ordeal was punctuated by episodes of severe depression-the occurring after the death of her father, when she was ten.

At various times in her life, Dunbar was agoraphobic-effectively house-bound. “I had to hide behind a chair if somebody knocked on the door-just so I knew they couldn’t see me.”

“Theo” describes social anxiety as a kind of extreme perfectionism. “We tend to be perfectionists. If that’s the way we can be all the time, no one can find fault with us. So if we do foul up, that’s the worst thing that can happen.”

“I just say ‘fuck it,'” says Paul Rennie, who co-facilitates the group with Dunbar. “I dropped my pop on the subway today. There’s this gorgeous chick sitting across the way, so I’m thinking she probably saw that.”

For a socially anxious person, even something as simple as dropping a beverage can become a source of horrific terror-the feeling of being severely judged or ridiculed for being clumsy.

But Rennie has been battling social phobia for many years, and knows how to handle his fear. “I just say ‘fuck it’ and move on, because it takes up too much time in your head. You can’t possibly think what that person’s thinking…. I just don’t waste time with those thoughts. I’m a lot better, but I have to fight it all the time.”

It’s a disease that revolves around judgment and perfection. Rennie elaborates, “The biggest fear for a socially phobic person is to be embarrassed. The other person is going to judge, and if they judge, I’m not going to be good enough. That’s really what it’s about.”

He adds, “When I realized it’s okay to fail, and that it’s a good experience sometimes to fail, all that pressure came off.”

Of course, until a patient gets to that point, it can be very difficult to function. When anxious emotions take over, the fear of embarrassment often becomes a self-fulfilling prophecy. The anxiety itself makes it difficult to have positive social experiences.

“Sometimes you get so anxious your mind goes blank,” says Dunbar. This can make it extremely difficult to respond effectively in conversation.

“Most of us are really great actors,” says Dunbar. “People thought I was the happiest, luckiest person in the world. Meanwhile I was dying inside. We don’t want other people to know, so we disguise it.”

“It’s so hard for many of us to be functional on a day to day basis,” says Theo, “because all your energy goes into your disorder; your thought patterns. It becomes really difficult to focus on a task, or your education…”

“Or to keep a job,” interjects Rennie. “I got to the point where I just couldn’t work.”

But the disease itself makes it difficult for a sufferer to seek help.

Dunbar was 44 years old before she was finally treated for her illness. Up until then, she’d kept her problems a secret. Dunbar explains, “I was afraid I’d be locked up. I would never tell anyone the whole story. I was terrified.”

“Physical symptoms come into play,” adds Theo. “Sweating, trembling, headaches, stomach problems, muscle tension, breathing problems, hyperventilating, weak legs, aches and pains.”

“And you go to the doctor,” continues Dunbar, “and they can’t find anything wrong with you. It’s very frustrating.”

“You can really get down,” says Rennie, “you can become suicidal. It can be very bad.”

“A lot of people turn to substance abuse or things to numb the reality,” says Theo.

In addition to substance abuse, untreated socially anxiety can lead to further complications.

“Rob,” 28, explains: “The thing with social phobia, there’s usually another disorder attached to it. Panic disorder, depression, agoraphobia…”

But the social anxiety is still there, making it difficult to access treatment for all the other problems it has caused.

“I would go to AA,” says Rennie, “and I would go to the washroom, and I’d shake so bad, because there were so many people out there… and you have to hide that terror, because you’re so ashamed.”

“You can lose a lot of years to avoidance,” says Rennie, “because you don’t want to do things that will make you afraid, so you avoid it. The more you avoid the more you become isolated. Then you’re just alone. Until you find out what you have, it’s pretty tough.”

Anxiety can become a kind of downward spiral-particularly when combined with another illness like depression. The disorders feed each other, sucking the sufferer into a vicious cycle of withdrawal and despair.

Yet despite the severity of these conditions and efforts to educate the public, there is still a tremendous stigma associated with mood and anxiety disorders.

“People always look at you as if there’s something wrong with you,” says Selma. Selma is not part of the social anxiety group, but has also received treatment for depression and anxiety at the CAMH.

She took early retirement from teaching kindergarten due to severe anxiety and chronic depression, but only after experiencing severe discrimination: “My former principle told half the neighborhood about my depression. They didn’t want their kids in my class-even though they knew I was a great teacher.”

“I was really disappointed after all my years of service and stuff I’d done… and the [school] board was no better… And yet if it had been a physical disability, they would have gone to the wall.”

Even families can harbor negative views of mental illness. “When I told my mom about my social phobia,” said one member of the social anxiety group, “she took me out of the will. She wouldn’t talk to me. It was like I was the crazy one in the family. And my mom’s got depression and anxiety disorders, too-but we don’t talk about it.”

Dr. Katzman suggests that a lot of this stigma may come from the difficulty in understanding a disease which is effectively invisible.

“Think about what you can do with coronary artery disease. You can go dancing. You can go to a movie. You might be able to have a sexual relationship. You probably can’t if you’re socially anxious.”

“You can die from this disease.” Katzman continues, referring to suicide, “but the cause of death is a little harder to deal with than a heart attack or a stroke.”

This is why Katzman has made it his mission to get the word out about anxiety-which is even less frequently, diagnosed and treated than depression, and less well understood.

“There’s a message out in the media that the drug companies are selling social anxiety disorder-that we’re treating shyness, personality quirks. But Earla’s story is not about a personality quirk. It’s a damaging, destructive, horrific illness.”

Katzman explains that there are a lot of genetic factors involved in social anxiety. Twin studies show that if one twin has the disease, the other twin’s chance of developing it are about twice as high for identical twins than fraternal ones. Similarly, the odds of having the disease are much higher if you have a first degree relative who is diagnosed with a mood or anxiety disorder.

A lot of the connection seems to be related to “behavioral inhibition.” Behaviorally inhibited children (about 10 per cent of the population) have a very low tolerance for novelty-they perceive new situations as threatening.

Many kids manage to outgrow their behavioral inhibition by age four or so. But the ones that don’t change? “They have huge risks of developing multiple anxiety disorders,” explains Katzman. “The more co-occurring illnesses you have, the more likely you are to be suicidal.”

Not every behaviorally inhibited child will develop anxiety, but the rates are high, and our medical system simply isn’t geared to catching them early in life.

Katzman illustrates: “If I gave my daughter a stamp pad, and let her stamp ‘anxiety disorder’ on every behaviorally inhibited kid’s chart, she’d be right 1 in 4 times. We pick up less than one in 200 anxiety disorders. My daughter is much better than our system. She’s five years old.”

Forget about catching anxious people early-we can’t even catch them later on. According to the Anxiety Disorders Association of Canada, if you make four or more visits to a doctors office (not counting call-backs and pregancy), one study says you’ve got a 25 per cent chance of having a generalized anxiety disorder right now.

Katzman: “The most common presentation of post-traumatic stress disorder, generalized anxiety disorder, and social phobia is a medical visit.”

But doctors don’t usually detect these illnesses.

“You actually can make more money treating warts than anxiety disorders,” explains Katzman. “The system isn’t designed for you to be motivated… Not that doctors don’t care, but our medical system is swamped.”

The sad part is that there are very effective treatments for anxiety. New medications have relatively few side effects compared with older drugs, and are highly effective.

“Ironically,” says Katzman, “because the drug companies are developing a market niche, they’re improving the quality of care. As far as I’m concerned that’s a good thing.”

Treatments such as cognitive behavioral therapy (CBT), which involves uncovering and stopping anxious thinking habits while at the same time gradually exposing oneself to ever more challenging situations, is also highly effective.

“CBT is a very effective treatment. Some studies have suggested that CBT is better long term. A lot of studies have suggested that a combination is the best approach, but CBT is not as well proven as pharmaceutical treatments,” says Katzman.

Drug companies, who provide most of the research dollars, aren’t as interested in exploring treatments they won’t profit by.

At the CAMH, the practitioners in the mood and anxiety disorders clinic are also experimenting with a new technique, called Mindfulness Based Cognitive Therapy (MBCT), to treat patients. MBCT combines meditation techniques that train attention with conventional cognitive therapy.

“We’re very impressed with the research,” enthuses Katzman, “the data is very exciting.”

Selma has been using MBCT to manage her depression and anxiety under the supervision of Kate Kitchen, a collegue of Dr. Katzman. Selma is very happy with the results: “I just think differently about a whole lot of things. Even the social anxiety, I find that it has helped tremendously. I’m not as afraid to approach people.”

Unfortunately, CBT is extremely hard to come by-let alone something experimental like MBCT. “We’re a city of five million people in the Toronto area. How many people in the city of Toronto do CBT? The numbers are not that great. The under-serviced area is probably North of College, all the way north.”

Financial barriers are a problem as well. OHIP and medical insurance typically do not provide enough coverage to adequately treat the illness.

Still, even with all these difficulties, it’s absolutely worthwhile for anxiety sufferers to seek treatment. Patients can be pro-active and speak to their doctors, check out websites like the Canadian Mental Health Association, the Centre for Addiction and Mental Health, and the Anxiety Disorders Association of Canada. Groups like Dunbar’s are also a great way to connect with people who understand and know how to access professional treatment.

And if you feel like donating, the Social Phobia Support Group can use funding as well.

“Anton,” one of the quieter members of Dunbar’s group, summarizes a life spent battling anxiety: “When I was in grade one, I couldn’t interact with people. At recess I would just stand where we were supposed to go when recess was over. I wouldn’t associate with people. The obsessive-compulsive disorder (OCD) hit at about 17 or 18, and there was no point of return. The social phobia is much smaller, but it still controls it. I can’t say how much-say, 30 per cent social phobia, and the rest OCD. Then there’s depression and alcohol addiction. That’s why I don’t want to grow old, because I haven’t lived. I want to live.” Anton is 41.

But Dunbar is optimistic. “I started living at 44,” she says. “Most people in their 20’s & 30’s try to get help, and they say they can’t do it-they’re too old, whatever. Well, I didn’t start until I was 44. You still can get well.”

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