by Marc D. Feldman, M.D.
Many people would rather die than give a speech—literally. In a survey asking the general public, "What is your deepest fear?" the fear of death ranked sixth, but the fear of public speaking ranked at the very top.
Even among business executives who regularly make presentations to large groups, 20% said they would rather figure their income taxes than give a speech; another 20% would rather try to lose 10 pounds in a month; and 15% would rather have a cavity filled.
Previously under-diagnosed and misunderstood, social phobia is now known to afflict one out of every seven Americans at some time in their lives. Going far beyond simple bashfulness, social phobia is defined as the marked and persistent fear of social or performance situations in which embarrassment might occur.
In fact, any exposure to the dreaded situation almost invariably leads to immediate and intense anxiety. In contrast, the person feels fine when alone. Although we all feel self-conscious at times, people with social phobia will go to great lengths to avoid speaking, eating, drinking, or writing when others are around.
They are afraid that others will notice their frazzled appearance—their trembling and clammy hands, shaking voices, sweating foreheads—and that they will be thought of as weak, foolish, or ridiculous. In most cases, the fear of scrutiny spans more than one social situation.
Remarkably enough, even some of our best-known celebrities have been victims of social phobia. Barbra Steisand's fear of forgetting song lyrics led to a self-imposed absence from the concert stage for 20 years. Baseball legend Mickey Mantle's fear of making personal appearances led him to escalate his use of alcohol, which culminated in full-blown alcoholism and fatal liver cancer.
Staring Down the Problem
Until recently, social phobia had been overlooked by health care professionals for two basic reasons: first, people with the disorder have rarely sought help, embarrassed even by the thought of talking about their affliction; and second, those who have never experienced the disorder have often dismissed it as a sign of immaturity or, like a child's distaste for vegetables, something the person would eventually outgrow.
But the consequences of social phobia can be massive. Persons with social phobia are less likely to marry or to have friends. School or work performance may suffer because of excessive anxiety in taking tests, interacting with others, or speaking to the teacher or boss; as a result, some patients drop out of school, remain dependent upon their parents, and either miss opportunities for job advancement or do not even seek work because of their fear of being interviewed. More than 20% of patients with true social phobia end up on welfare.
The Treatment Armamentarium
The good news: social phobia is much more treatable than many other problems. Organizations such as the Anxiety Disorders Association of America http://www.adaa.org have been working to promote public and professional awareness of the many treatment approaches that are available to those with the disorder.
For example, benzodiazepines such as clonazepam (Klonopin), antidepressants such as phenelzine (Nardil) or fluoxetine (Prozac), and other classes of medication may be useful options. Be careful about taking benzodiazepines for any prolonged period, however. Some people experience very unpleasant withdrawal symptoms that can go on for weeks, if not months. If they are used, they are best used for short period of time, while behavioral skills are learned with a specifically trained psychotherapist.
Behavioral techniques that can be used alone or in combination with medications include systematic desensitization or graded exposure (both described in the article, "'Fear Itself'": Simple Phobia"), social skills training, cognitive restructuring, and role playing.
In social skills training, the therapist models appropriate social behaviors and the patient then rehearses them. Cognitive restructuring involves detecting and modifying the self-castigating, catastrophic thinking that perpetuates social phobia (such as the internal statements "Everyone finds me abhorrent" and "People find me odd and they don't like me"). Role playing helps therapists teach their patients how to handle the symptoms that develop in situations typically fraught with anxiety; through such activities, patients expand their self-confidence.
If you are looking for a psychotherapist to help you with behavioral techniques, be sure to properly interview potential psychotherapists and ask them if they have been certified in cognitive behavioral psychotherapy.
References:
Feldman MD, Feldman JM. Stranger Than Fiction: When Our Minds Betray Us. Washington, DC, American Psychiatric Press, Inc., 1998
Hansen RA, Gaynes BN, Gartlehner G, et al. Efficacy and tolerability of second-generation antidepressants in social anxiety disorder. Int Clin Psychopharmacol 2008; 23:170-179
Stein MB, Stein DJ. Social anxiety disorder. Lancet 2008; 371:1115-1125
About the Author:
Marc D. Feldman, M.D. is the author of "Playing Sick? Untangling the Web of Munchausen Syndrome, Munchausen by Proxy, Malingering, and Factitious Disorder" (2004) and co-author of "Stranger Than Fiction: When Our Minds Betray Us" (1998).
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