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Social Anxiety Disorder: When Fear Leads to Isolation

Susan J. O'Grady, PhD - Blogs
By Susan J. O'Grady, PhDClinical psychologistAugust 30, 2018
From the WebMD Archives

We all want to feel liked and accepted. It’s what leads us to seek and maintain relationships, and it allows us to fully develop who we are in the world. But for people with social anxiety disorder (SAD), the ability to engage fully in life can take a drastic detour.

Social anxiety–also called social phobia–causes people to become anxious doing things that many of us would take for granted, such as being observed while eating a meal, meeting strangers, or speaking in front of people. The fear is of being judged negatively. Almost any social situation can provoke thoughts like, “They’ll think I don’t measure up” and “If I make even the smallest mistake, people will reject me.”

Of course, it’s instinctive, even protective, to dodge what we fear. But when fear is out of proportion to an actual threat, such as going to dinner with a co-worker, avoidance will only make our fear grow larger.

And we can’t overcome over fears if we hide from them. People with SAD avoid social opportunities and any circumstance that might make them experience the uncomfortable “flight or fight” response. But the very situations that they’re avoiding are their best chance to build the social skills that would help put them more at ease.

Because SAD affects every facet of someone’s life – relationships, school, work – it can lead to other forms of anxiety, as well as substance dependence and major depression.

I have seen this many time with clients who come to therapy because of anxiety or depression. Take Ryan, 26, who came to therapy with symptoms of depression that made it hard to complete a college class or look for a job. He was isolated, lonely, and felt worthless. But as we talked, it became clear that depression was not his primary problem; rather, it was severe social anxiety. Ryan’s anxiety caused him to stay home and play video games or watch TV. He dropped out of classes if he was expected to give an oral report, work in teams, or if class participation was part of the grade. He was depressed because life was passing him by.

The Self-Fulfilling Prophecy of Social Comparison

People with SAD internalize the negative judgments that they imagine others have of them and see themselves as inferior to other people. Unfortunately, when someone sees themselves as being undesirable to be around, the people around them pick up on this message and the statement becomes a self-fulfilling prophecy. Visibly anxious people often have a very difficult time making a positive impression when meeting new people, which can reinforce the negative cycle and lower self-esteem to the point of hopelessness, causing depression.

They also tend to elaborate their beliefs by creating a narrative or story about how they’ll mess up and people won’t like them. This might lead them to interpret events and information in a way that confirms that story, so that social signals that are actually neutral are misperceived as actual threats, raising anxiety further. All of this can create a snowball effect.

The Snowballing Effect of Social Avoidance

In Ryan’s case, as a child he developed stomachaches and felt sick when it was time for school. His parents took him to many specialists. Over the course of several years, Ryan had his appendix removed and his gallbladder taken out, but his stomach aches persisted, and he was eventually home schooled. Family therapy was never suggested to Ryan’s parents who thought they were protecting him by letting him stay home. Unwittingly though, they were aiding him in learning to cope with difficult emotions by avoidance.

Instead of finishing high school with his class, Ryan got a GED. His life became more and more constricted as anxiety generalized to other things—he never learned to drive, so his ability to seek out relationships was further impacted.

Treating SAD

Luckily, effective therapies exist for social anxiety disorder. Some of the most effective include:

  • Cognitive-behavioral therapy (CBT) and the relatively new CBT-R, which combines CBT with relational therapy which helps by reducing subtle avoidance/safety behavior and challenging negative self-beliefs.
  • Graduated exposure and relaxation training therapy (GEAR) used to develop an individualized hierarchy of anxiety-provoking social scenarios and then learning relaxation techniques for each fearful situation.
  • Mindfulness-based programs such as mindfulness-based cognitive therapy (MBCT) and the newer mindfulness-based emotional balance therapy (MBEB) that helps with emotional regulation. These techniques help people learn to tolerate difficult and uncomfortable feelings through acceptance, which leads to better coping.

Some doctors recommend anti-depressants in addition to the above non-drug therapies – speak to your doctor to find out what’s best for you.

Ryan was overwhelmed when he entered therapy, but at the conclusion of our work together he had entered community college and was working part-time in a local coffee shop. We used a combination of exposure therapy, mindfulness-based cognitive and emotional balance therapy, and group instruction to learn about and change avoidance behaviors. And, thanks to Uber, he is able to get around and hopes to tackle his anxiety about driving.

Note: If you are a parent of a child who shows signs of SAD, early treatment is important. Please seek help from a therapist.

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About the Author
Susan J. O'Grady, PhD

Dr. Susan J. O’Grady is a clinical psychologist in the San Francisco Bay Area providing psychotherapy and consultation for adults, couples, and teenagers. She has advanced training in marriage counseling and sex therapy and is credentialed in mindfulness-based interventions focusing on anxiety, depression, sleep problems, and emotional balance. In addition to her clinical practice, Dr. O’Grady writes on topics related to the psychology of living well at www.drsusanogrady.com.

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