Phobias

Summary

• Social anxiety disorder, also known as social phobia, is a fear of how others may react to you.
• It occurs in many kinds of social settings, including activities of everyday life.

Everyone with a phobia is afraid of something. Social anxiety disorder, also known as social phobia, is a fear of what may happen when you’re with other people. The National Institute on Mental Health (NIMH) defines it as “a persistent, intense, and chronic fear of being watched and judged by others and feeling embarrassed or humiliated by their actions.” In less scientific terms, it is a big fear that you will make a fool of yourself.

Social phobia is different from shyness or introversion. It can have a wide-ranging and bad effect on one’s life. The NIMH says people with social phobia:

• Are very nervous about being with other people and have a hard time talking to them, even though they wish they could
• Are very self-conscious in front of other people
• Are very afraid that other people will judge them
• Worry for days or weeks before an event where other people will be
• Stay away from places where there are other people
• Have a hard time making and keeping friends
• Blush, sweat or tremble around other people
• Feel nauseous or sick to their stomach when with other people

It is easy to see how social phobia can get in the way of work, school and friendships. It can make life hard in other ways. Some people with social phobia avoid eating in public for fear that they will choke or spill food. Others may not be able to use public toilets. Social phobia is often linked to other problems. One is depression. Another is drug use. Someone who dreads social situations may try to handle the fear with drugs or alcohol. Social phobia can also play a part in other phobias. A fear of flying might stem from a fear of being cooped up with strangers on a plane.

Social phobia tends to start early, in childhood or the teenage years. Young children can have it, and it can go unnoticed when it is confused with normal shyness. Psychologist Anne Marie Albano lists some warning signs of possible social phobia in children:

• Is a child uncomfortable speaking to teachers or peers?
• Does he avoid eye contact, mumble or speak quietly when addressed by other people?
• Does a child blush or tremble around other people?
• Does a young child cry or throw a tantrum when faced with new people?
• Does a child express a lot of worry about doing or saying something “stupid”?
• Does a child or teen complain of stomachaches and want to stay home from school, field trips or parties?
• Is she withdrawing from activities and wanting to spend more time at home?

Even high achievers can have social phobia. This was true of Ricky Williams, the Heisman Trophy-winning running back who went on to play for the New Orleans Saints. Williams played in front of thousands of spectators, but interacting with people close-up was a different story. He had trouble talking with reporters, fans and even his own daughter.

Williams sought help and his therapy worked. This points to another fact about social phobia—that it is treatable. Cognitive-behavioral therapy (CBT) is the usual approach. It works on two fronts, changing how one thinks and how one acts.

On the mental front, the goal is to change the thoughts that lead to fear. Someone with social phobia might believe people will think he’s stupid if he speaks up at a party. The reality is that they almost surely won’t, and the therapist will try to get him to see that point. Someone else may be afraid that people will notice her blushing or trembling. The therapy may teach her how to calm her worry symptoms. It might also show her that the symptoms are not as visible as she fears.

Another part of therapy is exposure—facing the social situations that cause fear. This is a step-by-step process. Someone who is afraid of speaking to a group of strangers may start by speaking to a small group of friends. After working through this first step, he will try a harder one. This might be talking to a larger group. It might be sharing more facts about himself. Or it may be talking with a group that has one or more strangers. This plan is well suited to group therapy. Along with exposure, a therapist may take some time to teach social skills such as making eye contact. Drugs for anxiety or depression can be a part of treatment for social phobia. They are not a substitute for CBT, but they can make the stages of therapy less stressful.

Resources

National institute of Mental Health

The Anxiety and Depression Association of America

The Anxiety and Phobia Workbook, 6th ed., by Edmund J. Bourne, New Harbinger Publications, 2015.

By Tom Gray

©2015-2019 Carelon Behavioral Health

Source: National Institute of Mental Health; Anxiety and Depression Association of America; Ronald M. Doctor, Ph.D., Emeritus Professor, California State University, Northridge; Simon Rego, Psy.D., Psychology Training Director, CBT Training Program Montefiore Medical Center, Bronx, NY. “When Young People Suffer Social Anxiety Disorder: What Parents Can Do,” by Anne Marie Albano, Ph.D., http://careforyourmind.org/when-young-people-suffer-social-anxiety-disorder-what-parents-can-do/

Reviewed by Charma D. Dudley, Ph.D., F.P.P.R., Associate Director of Behavioral Health Services, Beacon Health Options

Summary

• A phobia is a strong fear, coupled with avoidance, of certain situations and things.
• Unlike normal fears, phobias get in the way of living a normal life.
• Most phobias are treatable.

Fear is a normal emotion. It warns us of danger, keeps us from acting recklessly and helps us stay alive. But fear can be so strong that it stops serving its useful purpose and starts getting in the way of normal life. That’s when it crosses the line into phobia.

Take the fear of heights. Up to a point it is healthy. If you feel a bit nervous when perched on a high, exposed place, like the edge of a cliff, your brain and body are telling you to be careful. But if you turn down an offer for a job because the office is on the top floor of a high building, your fear is hurting you. It’s a phobia. You need help. You can’t fix the problem by dodging the thing you fear. If anything, that makes the phobia worse. Phobias can lead to sadness, drug use, social seclusion and even suicide.

Phobia types, from specific to social

Fear of heights, called acrophobia, is a specific phobia (or simple phobia). There are many of these. They range from fear of spiders and dogs to fear of flying and dental visits. In all these cases, the fear is about a certain situation or thing. It may not always be quite what it seems, though. Fear of flying may not be simply a fear of plane crashes. It may be a fear of close quarters, germs, or having to deal with strangers.

There are two other major phobia types: agoraphobia and social phobia. Agoraphobia means a fear of public gathering places or wide-open spaces. It is a fear of having panic attacks in public or when not able to get help. Those who have it avoid places where they feel unsafe if an attack occurs. They find it hard to be alone or to leave home without a close friend. This phobia can be very disabling, making it hard to hold down a job, travel or have normal relationships.

Social phobia is a fear of embarrassment around others, specifically when performing or interacting with others. It is what makes many people scared of speaking in public. Their fear is so strong that it gets in the way of work and relationships. People who have it avoid situations in which they see themselves being watched or judged. They might skip meetings at work. Or, if they can’t get out of social events, they may drink heavily to get through them. Social phobia can take specific forms, such as a fear of using public toilets. It is also known as social anxiety disorder.

Who has phobias, and why?

Phobias are a common problem. The National Institute of Mental Health (NIMH) says about 30 million American adults will have a specific phobia at some point in their lives. Nearly as many will have social phobia. About 3 million will have agoraphobia. Sadly, most phobias are not treated. The NIMH says about 32 percent of adults with specific phobia get help. Treatment rates for social phobia and agoraphobia are a bit higher: 40 percent and 46 percent.

Many live with a phobia for a long time before getting help. The Anxiety and Depression Association of America (ADAA) says 36 percent of people with social phobia have symptoms for 10 or more years before they get help.

Phobias tend to start in the teens or early adult years. The ADAA says social phobia is equally common in men and women. Twice as many women as men have specific phobias. Women also are twice as likely to have panic disorder, which often results in agoraphobia.

The cause of phobias is not clear. Phobias may start with an event, like being bitten by a dog. But often that’s not the case. Both genetics and upbringing may play a role. A shy child may start out with a fear of social situations; the child’s parents may add to that fear by being socially nervous themselves.

Treatments that work

In treating a phobia, the object is not to learn what started it but rather to change the behavior that keeps it going. For people with phobias, the key behavior is “avoidance of triggers that make them anxious,” says New York-based psychologist Simon Rego. This in fact heightens the phobia. The fear can also spread to other parts of life.

The good news about phobias is that there are ways to treat them. Most of these methods are forms of cognitive-behavioral therapy (CBT), which helps people learn new ways of thinking and acting in situations that cause fear. One common type of CBT for phobias is exposure therapy. This breaks down people’s fear by slowly increasing their contact with the things or situations that frighten them. For social phobia, this may start with speaking to a small group of close friends. Then, step-by-step, the group widens. For agoraphobia, it may start with walking out of the house to get the mail, then driving around the block. Drugs and relaxation therapy may also be used in treatment to ease anxiety.

Resources

The Anxiety and Phobia Workbook, 6th ed., by Edmund J. Bourne, New Harbinger Publications, 2015.

National Institute of Mental Health

Medline Plus, a website of the U.S. National Library of Medicine

The Mayo Clinic

By Tom Gray

©2015-2019 Carelon Behavioral Health

Source: National Institute of Mental Health; Anxiety and Depression Association of America; Simon Rego, Psy.D., Psychology Training Director, CBT Training Program Montefiore Medical Center, Bronx, NY; Ronald M. Doctor, Ph.D., Emeritus Professor, California State University, Northridge

Reviewed by Charma D. Dudley, Ph.D., F.P.P.R., Associate Director of Behavioral Health Services, Beacon Health Options

Summary

• Confront the fear.
• Confront the thought.
• Seek help when needed.

Phobias are fairly common, with many first appearing during childhood or adolescence. They can develop after a traumatic event or when a person makes an illogical association between a thought and a situation. For example: “I feel afraid of getting on this plane, so this plane must be dangerous.” Or phobias can develop for no reason at all.

Many children or teens voice these fears outright. Others might withdraw or show signs of a panic—sweating, trembling, rapid heartbeat, or shortness of breath. Some children develop chronic headaches or stomachaches in an attempt to avoid anxiety-making experiences. Others may have nightmares.

When fears start to interfere with daily life, then we need to teach our children how to cope. If your child is overly afraid, the first thing to do is listen. Let him express his feelings through talking, writing, or art. Parents can take other approaches to preventing or curbing irrational fears:

• Don’t dwell on the negatives. If a child is afraid of sharks, don’t let her watch a TV show or movie about sharks. Limit the amount of news children see and watch what you say when they’re present.
• Explain the situation in words he can understand, express your feelings honestly, and don’t be afraid to say, “I don’t know.”
• Teach your child relaxation exercises.
• Help her feel more in control by involving her in volunteer efforts or activities that build confidence.
• Be a role model. Children notice how you’re reacting.
• Never resort to teasing or ridicule.
• Point out when things work out well.
• Make sure your child is eating right, exercising, and getting enough sleep.

Experts agree that over-active imaginations lie at the root of most phobias. As such, most suggest two techniques:

1. Facing the fear through desensitization
2. Replacing the scary thoughts with realistic ones

Face the fear

If your child is afraid of tall buildings, start by looking at photos of them, read books about them, and talk about the many issues. If your child can handle it, get close to one. The thought is that through slow, repeated exposure a child will realize that he didn’t get hurt by looking at a skyscraper or being in one. This way takes patience and time. Don’t force a frightened child to do anything she doesn’t want to do. 

Face the thought

When we think scary thoughts, we wind up being scared. Help your child challenge the fearful thought. For example, if your child thinks, “This plane is going to crash,” tell him that this plane has taken off and returned safely each time it has flown. Bring up all the times people he knows have flown without incident. 

When to seek help

Err on the side of caution and seek help whenever you’re uncomfortable or when:

• Self-help efforts aren’t successful
• Fear is chronic and interrupts daily routines
• Physical symptoms of worry are severe or frequent
• Behavior changes for the worse

By Amy Fries

©2001-2021 Carelon Behavioral Health

Summary

• Social anxiety disorder is an illness; shyness is not.
• Many normal children are shy; even then, social phobia is different for them.
• Shyness, social phobia and introversion don’t necessarily go together.

Where is the line between social phobia and “normal”?

To start, some shyness is normal, especially in children. Even happy adults can be rattled by a high-pressure social situation. Think of a job interview with three or four people grilling you. Social anxiety at times like this is par for the course.

But too much social anxiety becomes a problem—it can be social anxiety disorder. It’s also known as social phobia. It may cause you misery. You can live happily with some shyness. You can’t live happily with social phobia.

Shyness is an emotional trait. It’s part of who you are. Most people who are shy as kids end up leading happy lives. But at a basic level their personality doesn’t change. They’re the same people. They just learn how to interact with others.

Social phobia is not part of a normal personality. Columbia University Psychologist Anne Marie Albano explains the difference in the case of children:

“Shyness is a temperament; it is not debilitating the way social anxiety disorder is. A shy child may take longer to warm up to a situation, but he eventually does. Also, a shy child engages with other kids, just at a different level of intensity than their peers. In contrast, children with social phobia will get very upset when they have to interact with people.”

A study by the National Institute of Mental Health makes a similar point. It suggests that, among teens, shyness and social phobia may not be linked. Using survey data, it found that 12 percent of those who saw themselves as shy met the criteria for social phobia. But a number of those not labeled shy—5 percent—also had social phobia.

Social phobia also is not tied to introversion. Introverts can be shy or have social phobia.

Introversion is a tendency toward self-reliance. So introverts can seem aloof. They tend not to be very outgoing in social settings. But that’s what they prefer. It doesn’t mean they’re shy. It doesn’t mean they have social phobia. Simon Rego, a psychologist with Montefiore Medical Center in New York, puts it this way: “If you’re happy living your life the way you want, that’s not a disorder.”

Resource

“When Young People Suffer Social Anxiety Disorder: What Parents Can Do” by Anne Marie Albano, Ph.D. Care for Your Mind, http://careforyourmind.org/when-young-people-suffer-social-anxiety-disorder-what-parents-can-do/

By Tom Gray

©2015-2019 Carelon Behavioral Health

Source: National Institute of Mental Health; Simon Rego, Psy.D., Psychology Training Director, CBT Training Program Montefiore Medical Center, Bronx, NY

Reviewed by Charma D. Dudley, Ph.D., F.P.P.R., Associate Director of Behavioral Health Services, Beacon Health Options

Summary

• It pays to seek help for phobias, which are treatable.
• Treatment methods include CBT and exposure therapy; drugs also play a role.

With phobias, help means hope. If fear gets in the way of living a normal life, the outlook is good if you get help.

Ron Doctor, psychologist and co-author of The A to Z of Phobias, Fears, and Anxieties, estimates that 85 percent of phobia cases are curable. That’s a better rate of success than for other common disorders.

The type of care will depend on the type of phobia you have. But in general, you can expect some form of cognitive-behavioral therapy (CBT) such as “exposure therapy.” Drugs may be used. Self-help is also part of the process.

People with phobias avoid situations or things that give them fear. Therapy helps them in two ways. First, it lets them face and master that fear. Second, it corrects the thinking that leads to irrational fears. It helps people align their thoughts more with objective reality.

While drugs don’t change the thinking behind phobias, they can calm anxiety. By doing so, they can make it simpler for people to face what they have been avoiding.

Here are the most common methods of treating phobias:

Exposure therapy. A phobia exists because your brain has “learned” falsely that something was a threat to you. That lesson has to be unlearned. One way to do this is to teach the brain not to react to phobia triggers. This is done by exposure therapy, which slowly exposes a person to the thing or situation causing fear. It often starts with a baby step. If you have a fear of flying, you may only drive around that airport at first. The object is to get close enough to a feared thing or situation to feel worry, and then to stay there until the fear passes.

In this way, you get closer and closer to the thing you fear until that fear is gone. Exposure therapy is the usual method to treat specific phobia, and it is important in treating other phobias as well.

Psychologist Edmund J. Bourne, in The Anxiety and Phobia Workbook, says exposure therapy has stages. The first is “coping exposure.” This is when you need support. It can be self-talk, deep breathing, a support person or a low dose of a tranquilizer. In the second phase, “full exposure,” you stop relying on support or coping methods. If your phobia is fear of flying, coping exposure might end when you can take a flight of an hour or more with support. You might then start full exposure by going to the airport without any of your coping aids. Then you might try a short flight, followed by a longer one.

Other CBT methods. Exposure therapy helps you master your fear. Other types of CBT help you get a handle on your thoughts. This is vital for phobias, which are fed by distorted thinking. People with social phobia, for instance, have an exaggerated belief that others are judging them. CBT helps them identify and fix such thoughts. CBT can also be used to lower the fear of fear itself. Someone who fears public speaking knows he will feel nervous at the podium. But he may overstate the effect of this fear. A therapist might help him see that the audience may not even notice, and that he will still be able to give his speech. CBT can attack social anxiety in another way as well—by teaching social skills.

CBT can teach how to handle symptoms such as panic attacks. It does this with exercises that bring on the symptoms and show how they are not as dire as they seem. This is a sort of “dry run” for real exposure. As psychologist Simon Rego puts it, “Once you no longer fear the panic symptoms, you can deal with the lingering fear of situations.”

Drugs. Medications can make therapy easier by lessening a phobia’s impact on the mind and body. Sedatives are useful against panic attacks, though they can be habit-forming and are best for short-term use. Examples are alprazolam (Xanax®) and clonazepam (Klonopin®). Beta blockers are another useful class of short-term drugs. They block the effects of adrenaline, such as a pounding heart and shaking voice. Lowering such stage-fright symptoms can help people with social anxiety get through stressful events.

Antidepressants are often used for phobias. Selective serotonin reuptake inhibitors (SSRIs) reduce panic attacks. They include paroxetine (Paxil®) and fluoxetine (Prozac®). Monoamine oxidase inhibitors (MAOIs) are helpful for social phobia. The National Institute of Mental Health (NIMH) warns that MAOIs can have dangerous side effects. It says they are “rarely used as a first line of treatment.”

Self-help. There is plenty of advice, online and in books, about how to tackle phobias on your own. But it may be impossible to face the task alone, especially at the start. The fear that makes you avoid something may simply be too strong. As Doctor explains, “When you’re in fear, the impulse is to escape.” To fight off that impulse, he says, you need “someone with you who is not afraid.” This person doesn’t have to be a therapist. She can be a friend who is at your side to comfort you.

At the same time, self-help is a key part of phobia therapy. In a sense, self-help is the goal of any therapy. The point is to enable you to stop dodging a given thing or situation and to face it by yourself. Also, self-help skills aid your care by helping you to relax and ease worry. These include deep breathing, meditation, self-talk, yoga and exercise. They are good for you, and you can do any of them on your own.

What friends and loved ones can do. Phobias and other anxiety disorders can put a strain on relationships. But there are ways that friends and loved ones can help. Here are some that the Anxiety and Depression Society of America (ADAA) lists on its website:

• Learn about the disorder.
• Encourage treatment.
• React positively to a healthy behavior, rather than criticizing irrational fear, avoidance, or rituals.
• Measure progress by improvement, not against some absolute standard.
• Help set specific goals that are realistic and can be approached one step at a time.
• Don’t think you know what your partner needs. Ask how you can help. Listen carefully to the response.
• Acknowledge that you don’t understand a panic attack or other form of irrational fear.
• Understand that knowing when to be patient and when to push can be challenging. Achieving a proper balance often requires trial and error.

By Tom Gray

©2015-2019 Carelon Behavioral Health

Source: National Institute of Mental Health; Anxiety and Depression Association of America; The Mayo Clinic; Simon Rego, Psy.D., Psychology Training Director, CBT Training Program Montefiore Medical Center, Bronx, NY; Ronald M. Doctor, Ph.D., Emeritus Professor, California State University, Northridge

Reviewed by Charma D. Dudley, Ph.D., F.P.P.R., Associate Director of Behavioral Health Services, Beacon Health Options