Social Anxiety

This client of mine was a student teacher, about 20 years old. The young man was suffering from a problem that had disrupted his life. He was afflicted with a kind of morbid shyness. If he had to ask a question in class, his heart would start pounding, his breathing would become labored, his body would heat up, his head would spin, his voice would falter, he would sweat, and his throat would go dry. As a result, many times when a question occurred to him, he could not ask the professor. If the professor asked him a question, the same ordeal would repeat itself. When students were scheduled to give presentations in class, he would make various excuses to avoid it, and ultimately he would lose the grade for his presentation. If he arrived a few minutes late to class, knocking on the door, asking permission, and walking past the front of the class to sit in his seat was an excruciating task for him; therefore, it often happened that being a few minutes late would result in him being excluded from the class and marked absent. Most difficult of all was that in the new semester, he had to go to schools for his teaching practicum and teach students, and this was nearly impossible for him. So, despite having endured his affliction for several years, he was forced to see a psychiatrist. This young man was suffering from a disorder called "social anxiety" or "social phobia." Sufferers of this illness have a persistent and significant fear of social situations where they might be scrutinized and evaluated by others. In some patients, these situations are limited; for example, they are only focused on the classroom, but in other patients, the phobia is "generalized," meaning they have trouble both in class and at parties, and even when walking down the street and passing by people who look at them. These individuals worry that they will behave in a way that will cause them embarrassment and humiliation, and as a result, they try to avoid and evade anxiety-provoking situations. For instance, they do not speak in class, they withdraw at parties, they do not participate in job interviews, and so on. It is natural that although this illness does not cause physical pain for the individual, its disability and affliction are more painful than many diseases, and academic decline, lack of career advancement, and family conflicts are inevitable for these patients. In treating social phobia, both medications and psychotherapy are effective, but using both methods together yields better results. Medications reduce the patient's anxiety reaction and their mental sensitivity to the gaze and treatment of others. Alongside this, cognitive-behavioral therapy also has very remarkable results. The psychotherapy method suitable for these patients is the behavioral therapy technique of "gradual exposure." For treatment, it is essential that the patient's "avoidance" be broken, but it is obvious that the patient is not capable of tolerating suddenly abandoning their avoidance, standing up in class, and starting to give a speech. Even thinking about doing this causes the patient unbearable anxiety. So, what should be done?

After providing the patient with sufficient information and education about the basis of this disorder, the therapist devises a behavioral plan for the patient. For example, for this young student, the following plan was designed: In the first week, every day for half an hour, recount one of the academic topics to your close friend. This young man's close friend, who had himself agreed to cooperate in solving his friend's problems, is called a "co-therapist" in this plan. For patients with this severity of phobia, even this amount of planning creates anxiety, but experiencing this anxiety is necessary for the patient's treatment. At the beginning of starting to speak in each practice session, the patient felt high anxiety. But gradually, as this continued, the anxiety would lessen until it reached its lowest level, a level we call "habituation."

The patient would record a report of each practice session. To make the process evaluable, I taught the patient to rate his anxiety; for instance, when the anxiety symptoms were overwhelming, he would give his anxiety a score of 10, when he had no anxiety at all, a score of zero, and the midpoint a 5, and accordingly represent his subjective feeling to us with numbers. These numbers helped the patient to draw his anxiety levels during the exercises in the form of graphs for us. When the young man returned at the end of the week, the graphs clearly showed that the patient had less anxiety about teaching his friend compared to the previous week, so the second week's program was designed. The client lived in a student dormitory, in a room with three roommates. It was arranged that every day at a specific time he would hold a class and speak to his three roommates for 20 minutes. The session reports and graphs the patient brought me at the end of the second week showed that he had made good progress. It is necessary to point out that the therapist's presence, attention, and follow-up create a "supportive space" that increases the client's commitment to his behavioral program; therefore, in behavioral therapy methods, frequent meetings with the therapist are essential. In each session, the therapist reviews the previous session's assignments and exercises, designs the next assignment and exercise in collaboration with the client, and, through role-playing in the therapy session, prepares the client to perform the exercise in the outside environment. Our behavioral assignments were gradually increased in this same way, and each session, depending on the client's readiness and agreement, the assignments progressed, while the medications were also busy exerting their effect. The result, as predicted, was that a few months later the patient was giving his class presentations, and of course he knew that to reduce the likelihood of symptom relapse, he had to continue the medication until his lifestyle changes were consolidated, and on the other hand, wherever he felt anxiety and wished to "avoid" and crawl into a corner, he must instead break his avoidance and speak up, because if he obeys his "avoidance," the scope of this avoidance will expand day by day. Of course, not all patients have the same conditions; for example, in a group of patients, the psychiatrist may realize that their escape from social situations is due to their "depression." In such cases, the psychiatrist treats the depression. In some cases, the therapist may also discover that the client is in close contact with a humiliating person, someone who takes away their self-confidence and intensifies their anxiety. Years ago, a woman came to me for treatment of a driving phobia. This woman had held a driver's license for years but avoided driving. When her treatment plan reached the point where she agreed to start practical driving exercises, her husband began to create obstacles. At first, the husband's obstruction took the form of frightening his wife about car accidents and their consequences, but when these threats proved ineffective, the husband started creating practical barriers; for example, he would take his wife's car keys with him or even sold his own car so he could use his wife's car to go to work and the car would not be at home! Some individuals who are interested in being in a position of dominance and authority make their close ones fearful and anxious in order to keep them dependent on themselves. Naturally, in such cases, systemic therapies like couple therapy must be combined with behavioral exercises; otherwise, the dominant person in the relationship will hinder the progress of treatment. Diagnosing and treating social anxiety is not always easy. Sometimes anxiety may be hidden behind grandiosity and even aggression. Years ago, I had a student who was indifferent to professors in class, would talk and laugh in his classmates' ears during the lesson, and adopted an aggressive tone and an arrogant look when speaking with professors, such that in initial encounters he appeared to be a narcissistic individual. Later, when I got closer to him, I realized he had high social anxiety, which he hid behind a mask of indifference, contempt, and mockery of others. In these cases, more complex and longer treatment is required, as it takes a long time for this person to come out from behind the mask, while their mocking tone and arrogant demeanor also interfere in the therapeutic relationship. Such individuals usually do not voluntarily step onto the path of treatment; rather, communication problems force them to seek help, while their accusing finger is pointed at others, whom they hold responsible for their communication problem.

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PDF file of the article Social Anxiety

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Social Anxiety

Dr. Mohammad Reza Sargolzaei – Psychiatrist

Source: Personal website of Dr. Mohammad Reza Sargolzaei

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