So much more than shyness - understanding Social Anxiety

The work Christmas party is approaching. A person spends hours researching 'interesting' topics before attending. When they arrive they stay on the edge of the group and put so much effort into trying to remember these topics, and when to say them, they come across as aloof and end up saying very little. After failing to build any meaningful conversations they see this as confirmation they are boring and write-off future attempts at socialising with colleagues.

A woman in her 30s has a work presentation coming up. When thinking about it they get a strong sense of apprehension and remember a time when they stuttered in front of their whole year 3 class when asked a question, and were laughed at by their classmates. They cover their sides in text and also write an accompanying script which they practice reading over and over again so they know exactly what they are going to say. The evening before the presentation arrives they email their boss to say they are sick and cannot do it. They feel immediate relief before a sense of regret and then further fear thinking about when this will be rearranged for.

A teenager goes out with a group of friends. They have a good time but make a joke and are unsure whether others find it funny, despite some smiles. That night they cannot sleep as they replay this scenario over and over again and convince themselves that their friends thought they were stupid and unfunny, they conclude that this is unsurprising as they are generally unlikeable. The next day they cancel plans to avoid embarrassing themselves again.

Social anxiety poses a mystery when compared to other fears. If someone is scared of spiders it is common knowledge that a way to 'conquer' this phobia would be to spend time around them - starting with videos/pictures, imagining holding them, and perhaps working their way up in proximity and size; from holding smaller to larger creatures. Ultimately, they learn they can cope and their fears subside. Indeed, many of us can relate to this process of becoming used to things we were initially anxious about - ask anyone to compare their first day in a job to their tenth. Now, it is almost impossible to avoid socialising - yet people report their anxiety does not relent despite this 'exposure'. For some reason people are not 'getting used' to being in social situations in a way that might be expected.

The key to unlocking this mystery was proposed by psychologist David Clark and colleagues in 1995 when it was theorised that 'safety behaviours' - things done by someone to relieve their anxiety or try and prevent their fear happening, actually maintain social anxiety through both enhancing a sense of threat and preventing belief change when it comes to common fears: being boring, unlikable, inferior or weird.

Let me explain; as with so many anxiety related problems - the solution ends up becoming part of the problem. If we avoid parties or meeting new people whenever we can, then we never learn that we can cope, and that our beliefs about being boring, that we will appear nervous, or that we will be rejected, are never challenged. What's worse is our perceived solution ends up becoming a self-fulfilling prophecy. We may get short-term relief from avoiding that social occasion, but our absence may mean we appear uninterested in socialising and friends or colleagues may not bother to invite us next time around.

Avoidance is an obvious safety behaviour but others can be much more subtle and often hidden, explaining why for some socially anxious people socialising never seems to get an easier. No one can see us rehearsing what we are going to say, monitoring how we are coming across, or trying to picture how we appear to others. Sadly, what is noticeable to others is that we appear quiet or even rude; as we are so internally focused on our own performance we fail to follow the conversation. These behaviours both magnify our fear by acting as if our belief is true, whilst at the same time making it more likely to become reality.

Similarly, not talking about ourselves, keeping tight 'control' of our behaviour, or trying not to attract attention may both distract us from fully participating in a conversation and convey a sense we don't have much to say. Trying to conceal blushing, control shaking or prevent stuttering all create a greater sense of inward focus on these perceived social flaws, and we mistake this focus with the idea they are more noticeable to others. I may be aware of a slight tremor in my voice but this does not mean that everyone else is, and certainly not they are judging me in a negative way because of this. However, by focusing on these physical reactions we might increase our bodies 'fight' or 'flight' alarm response - once again inadvertently creating the very symptoms we are trying to hide. You are probably starting to see a pattern...

To be nervous before a presentation or anxious before meeting new people makes us human. When discussing social anxiety at a clinical level we are describing a highly disabling problem that has a significant impact on our lives; we may not go for that promotion because it involves more presentations or people managing, we may not meet our future partner because we are too scared of being judged, or we may let life pass us by because of the fear of being seen as anxious. Ultimately, this is a preventable tragedy and the good news is it is very treatable. Below are the stages this treatment may look like:

-Formulation - as with all psychological difficulties, an individualised formulation looking at the exact social fears someone has, and the things they do in response to these. It is also important to understand someone's history to get an insight into how their social fears were first formed.

-'Safety behaviour' Experiment - as safety behaviours provide short-term relief from anxiety they can be addictive and very hard to drop. Therefore some important work has to be done to allow someone to discover for themselves the role they play in maintaining social fears.

-Attention Training - a key maintaining factor in social anxiety is someones' attention is too inwardly focused; monitoring their own social performance at the expense of being present. Here, we view our attention as a muscle that can be trained and strengthened to focus on the present moment, so someone can learn that the scariest place by far is inside their head.

-Behavioural Experiments - the most powerful way to change a belief is to do something differently and discover what happens. Bespoke behavioral experiments are constructed with your psychologist to test out your specific beliefs to see if the worst does happen. These involve testing fears whilst dropping safety behaviours and may include anything from asking a stranger for directions to deliberately introducing a 'boring' topic of conversation. This is a powerful way of learning, and often the quickest way for someone to discover they have been holding on to catastrophic and unrealistic expectations of what may happen.

Social imagery rescripting - sometimes social anxiety can be linked to early events where someone felt humiliated. Common examples include being told off by a teacher in front of a class or bullied by peers. This can leave a sense of embarrassment and shame that can still resurface when the person approaches a social situation, despite this being years later and completely unrelated. Rescripting is a powerful method to update the meaning of this memory and keep the past in the past.

Work on rumination and worry - social anxiety is often enhanced by pre-event worry. People become very good at imagining worst case scenarios and the sense of anticipatory anxiety this creates is then mistaken for how we think the actual event will feel and becomes a powerful driver for avoidance or taking extra precautions. Similarly, people tend to get caught replaying the perceived 'worst moments' of social events once they have happened. These become distorted and again drive further avoidance or self-attack. Strategies to interrupt and change our relationship with worry/rumination are highly useful here.

It is estimated around 12% of people experience clinically significant social anxiety at some point in their lives. Often developing in the teenage years, it can create lifelong patterns of avoidance and missed opportunities if it is not treated. If you feel that social anxiety may be holding you back from reaching your potential, please get in touch for an assessment.

Doug Hobson is a Clinical Psychologist, Cognitive Behavioural Therapist and Senior Clinician working in NHS Talking Therapies and private practice.