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Let's talk: A closer look at social anxiety disorder

Let's talk: A closer look at social anxiety disorder

Picture of Lee Adcock

Earlier this year, I shut down at the Association of Health Care Journalists conference in Denver.

For months my classmates and I been plotting what sessions to cover and which scientists and journalists we wanted to meet. We flew in from Georgia and set about mingling with the crowds, chatting with everyone and swapping business cards. This was my first major professional conference and so I attended six sessions a day, ate all the communal meals, edged in at strangers’ tables…

I broke down on the third day.

Something caught in my left eye and I pawed at it until it turned red, swelled nearly shut and oozed tears. By noon I felt so fatigued and miserable that I shuffled out of a lecture and huddled in the bathroom until my professor found me. She suggested that I sit out the next session, apply ice, and rest in my room for an hour or so. That helped.

What makes me crumble like this? I don’t know, but I have a hunch. I’m pretty sure I have a social phobia.


In September, a meta-analysis published in The Lancet Psychiatry reported that people with social anxiety disorder did better when treated with talk therapy than with drugs. The researchers examined results from 101 clinical trials, which included a total of 13,164 participants..

That’s great, but meta-analysis is a 1,000-foot view of something that is intensely personal for me. Since this article was published, I’ve talked to enough experts to learn that no one treatment works for everyone made anxious by socializing. And I’ve realized that social anxiety disorders range from mild (people like me, who balk only in certain settings) too intense (people who isolate themselves from any human contact).

Social anxiety disorder, or social phobia, is a consistent and vivid fear of certain situations that involve other people. A recent review claims that about 60,000 people in the United States have the disorder – but that only includes those who have been formally diagnosed. The National Institute of Mental Health places that figure at around 40 million.

Not all anxiety is harmful. If you’re hiking and come upon a rattlesnake on the trail, a brain structure called the amygdala sounds the alarm and spurs the heart to pump faster, allowing you to escape or react at once. If you come upon a second snake, the amygdala will swing into action even faster, a phenomenon that psychologists call normal adaptive anxiety. This can be a lifesaver. 

For some people, however, the amygdala overreacts in stressful situations that pose no real threat to life or limb. For people with a social phobia, talking with or performing in front of others triggers the same alarm as the sudden appearance of a snake.

For me, the people themselves aren’t the threat; anxiety grows when I feel judged and unwanted, and when the thought of being watched engulfs all others.

You might think that this fear only manifests only in the company of strangers, especially crowds of them. For me, that’s mostly true — I hardly know what to do with myself in a group bigger than six people. But even one-to-one encounters can be tricky.

I hang out often at the local record store – perhaps more often than I should – but whenever I approach the place, my heart flutters. I don’t know why. I’ve known someone who works there for over a year now, and we’ve spent hours together in and out of the shop; yet when I’m around him, sometimes my jaw locks shut. What do I say next? Do the other customers wonder why I’m here? Should I be somewhere else? This pressure builds and builds, and if I can’t say another word, I often shuffle off to the CD rack and organize the stacks until I cool down.

Social phobia isn’t just an embarrassment. For some it leads to substance abuse, depression or other anxieties. I hate beer and drugs, so I’m not worried about those. But depression ... that sounds very real.


There are three ways to treat anxiety: medications, talk therapy, or both.

Psychiatrists and other physicians typically prescribe some type of anti-depressant drug or an anti-anxiety medicine for people with significant anxiety problems. Sometimes a beta blocker is recommended to calm physical symptoms such as the racing heart and sweating that strike before a public speech. 

Benzodiazepines are the best-known class of anti-anxiety medicines, and clonazepam is the one most commonly prescribed for social phobia or generalized anxiety disorder. Their effects kick in quickly and people feel the effects right away.

Psychiatrists also prescribe selective serotonin-reuptake inhibitors (SSRIs), a class of drugs that were originally meant to treat depression, but which have helped many people with anxiety disorders. Well-known SSRIs such as fluoxetine and sertraline are often prescribed for people with social phobia. The meta-analysis published in the The Lancet Psychiatry found that SSRIs were one of the only medicines that outperformed placebos in clinical trials.

I tried one kind of benzodiazepine last year. I don’t remember which one, but I do remember taking a whole pill one morning and being barely able to drag myself up a flight of stairs a few hours later. That scared me.

Then, of course, there’s talk therapy. Of the various approaches using by psychologists and other clinicians, cognitive-behavioral therapy is the gold standard for social phobias and generalized anxiety. Our thoughts and actions are related, so it makes sense to address both.

CBT practitioners aim to change how an anxious patient thinks about situations that trigger extreme responses, and to develop skills for handling anxiety cues when they appear. Some therapists force their clients to confront their fears, others preach deep breathing and relaxation to calm panic, and some combine approaches. Regardless of the technique, though, the goal is always the same — to convince the amygdala that a public speech is not the same as a rattlesnake.

Many clinicians see medication as an important adjunct to psychotherapy. “It’s a destructive oversimplification to say that medicine cures mental health issues,” said social worker Brent Temple, a practicing therapist in Athens, Georgia. “What it does, though, is give people space to build the skills necessary to manage their symptoms.”

Boston psychologist David Barlow became famous — some would say infamous — for pioneering “exposure therapy” for severely anxious people. Barlow asked his clients to face their worst fears. The poet who dreaded public speaking recited his works to a distracted crowd. The woman who loathed flying took a round trip flight between Boston and New York. One client, who couldn’t stand being in cars, was told to drive on a wet road in the dark. This high-stakes kind of drama might scare off some, but by exposing themselves to the things that scared them most, many of Barlow’s clients learned how to deal with anxiety on their own

And see, that’s what I want to do.

I’m seeing a therapist-in-training at my university’s psychology clinic. We haven’t done anything serious yet — but he’s asked all sorts of questions and I’m spewing out words that I’ve never said to anyone before. Granted, my answers come only after long pauses, and with sharp jerks, as I screw and unscrew a ballpoint pen in my hands. Did I say too much? Am I explaining this right? What is he thinking? 

Everyone says the sessions get easier. Let’s hope so.

Photo by Sebastiaan ter Burg via Flickr.

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