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Treating Social Anxiety: Why Normal Social Interactions Might Not be Enough

Writer's picture: Ferdinando PalumboFerdinando Palumbo

By Ferdinando Palumbo, MSW, LCSW, Director, Northern NJ CBT www.NorthernNJCBT.com

Edited by Simi Lichtman, MSW, LCSW, Director,  Central Therapy www.centraltherapynj.com

Understanding Social Anxiety Disorder




 

I suspect that if I asked people to name the most important aspects of their lives, common themes would begin to emerge: friendships, romantic relationships, careers, and volunteering, among others. In any of these aspects of life, social anxiety has the potential to derail success. I would know—I myself suffered from social anxiety for many years.


Social Anxiety Disorder (SAD), also known as Social Phobia, is a serious, impactful condition that affects many people. SAD is a condition characterized by experiencing significant fear in one or more social settings. This fear must be disproportionate to the actual threat posed by the social interaction. The fear or avoidance of the fear must cause significant distress or get in the way of functioning for the person afflicted with SAD. Additionally, these symptoms must consistently be present for at least 6 months.


The Epidemiology and Effects of Untreated Social Anxiety


The precise number of individuals suffering from SAD is complex to calculate for several reasons. Still, population estimates from the National Comorbidity Survey (2017) suggest that approximately 12.1% of the US Population will meet diagnostic criteria for SAD in their lifetime. In general, when SAD goes untreated, symptoms typically get worse. Studies have shown high levels of Major Depression and Alcohol Use Disorder among individuals suffering from Social Anxiety Disorder.


Further complicating matters, large-scale epidemiological studies suggest that, on average, there is a 15–20-year lag from when these symptoms become problematic to when individuals first start receiving treatment.  What is interesting to me is that during this lag,  individuals suffering with SAD must be engaging in some sorts of social interaction. They likely go to school, work, family events, and potentially even social events.  As a practitioner of Exposure Therapy, who treats people with phobias by having them face their fears, I found myself wondering: Why does engaging in typical social interactions not decrease symptom severity of Social Anxiety Disorder? I believe the answers to this question has important implications for the treatment of SAD.


Why doesn’t normal social interaction seem to help individuals suffering from SAD?


Let’s start with a short overview of Exposure Therapy. There is some debate about why Exposure Therapy works for OCD, Anxiety Disorders (including SAD), and even PTSD, but it is indisputable that when people face their fears, they can substantially reduce the impact of their anxiety and PTSD symptoms. Himle (2015) argues that Exposure Therapy can be conceptualized through four theoretical lenses:

1.       The Habituation Model: Through repetition and with enough time, the person becomes more used to the avoided stimulus and less emotionally reactive to it . The anxiety decreases on its own and is replaced with a more calm emotion.  

2.       The Cognitive Model: Exposures are conceptualized as “behavioral experiments” that test out if the belief that leads to the fear is true. The behavioral experiments correct distorted, inaccurate beliefs; when the person has more accurate beliefs, they experience less distress.

3.       The Acceptance and Commitment Therapy (ACT) Model: The exposures facilitate learning that we can experience discomfort to accomplish the things that are important to us. In ACT this is called taking values based action.

4.       The Inhibitory Learning Model: We learn safety associations through many exposures that compete with previous fear associations. When we consistently face avoided stimuli, we learn to relate to the avoided stimuli differently and to be less afraid to experience distress. However, when we neglect to face the avoided stimuli, we end up slipping back into the fear association learning.


I posit that there two main reasons that typical social interactions of socially anxious individuals do not achieve what purposeful exposure therapy does: first, the use of safety behaviors that prevent people from facing feared outcomes and feelings of distress; Second, these typical social interactions not being frequent or long enough to assist in reducing the fear associated with socializing. We will examine these reasons in the subsequent paragraphs.

 

If we look at the Habituation Model, we can compare people with SAD to people who are afraid of needles and blood draws. When people have a needle or blood draw phobia, we see they rarely get better just from going to the doctor for regular visits. Why is this? At most, they get a couple of blood draws and a few vaccinations in a typical year, and each of these incidents doesn’t last very long. So while they are facing what they fear, it’s not frequently enough or for long enough time to experience less distress when faced with needles or blood draws. In fact, this short exposure can make people more afraid through a process we call “sensitization,” because they only experience a binary of intense distress before the needle or blood draw, followed by incredible relief when it’s over.


A similar problem is encountered for individuals with SAD. When they are forced to do a presentation in school-- provided they don’t escape it-- , they face their intense fear for a relatively short period of time. Because of this, they rarely have the experience of seeing their anxiety rise and decrease on its own. Instead, they experience intense anxiety followed by immediate relief of the presentation being completed, which ends up seeming to confirm the idea that presenting is terrible and not presenting is safer. In addition to these forced presentations being short, they are infrequent. In the Habituation and Inhibitory Learning Models of exposure therapy, repeated exposures, ideally with enough time to experience a different feeling of anxiety, are important in helping clients get better. Duration of time and number of times spent in challenging social situations are thus primary reasons that normal social interactions do not lead to a symptom reduction in individuals with social anxiety.

 

The second challenge to normal social interactions reducing symptom severity is what we Cognitive Behavioral Therapists call “safety behaviors,.” which is integral to all four models of exposure therapy. Safety behaviors are anything that a person does to reduce either their negative feeling or the likelihood of some perceived negative outcome occurring. Let’s look at the safety behaviors that are very common among individuals with SAD:

1.       Complete avoidance of social interaction and/or specific feared social interactions.

2.       Preparing/ planning social interactions to reduce the likelihood of making a perceived error.             

3.       Using recreational drugs or alcohol before, during, or after social interactions to reduce feelings of distress.

4.       Asking loved ones to complete social interactions, make phone calls, order at restaurants etc. Asking colleagues or classmates to present or facilitate meetings. Learn more about problematic accommodations of anxiety here.

5.       Leaving conversations quickly to reduce the likelihood of making a real or perceived social mistake.

Each of these safety behaviors prevents the person with social anxiety from fully experiencing their anxiety, but in doing so, also prevents them from learning that they can tolerate the discomfort and that making a social mistake is not a world-ending experience. In this way, the person with social anxiety ends up becoming more dependent upon safety behaviors and avoidance, and more fearful of making an error. If, however, they engaged more regularly in these normal tasks and took fewer precautions to avoid the seeming catastrophe of making a social mistake, they would be much more likely to benefit from these interactions. Because individuals with SAD tend to utilize these safety behaviors, any typical social interaction loses its chance of providing a true exposure for the individual.

Designing exposure therapy that works for social anxiety

What I would propose, and what we here at Northern NJ CBT do, is identify the precise fears of someone experiencing social anxiety and help them face those fears. In social anxiety this usually boils down to two categories: fear of being judged negatively or fear of inducing discomfort in others by breaking a social norm or having awkward social interactions. We want to tailor our client’s exposures to purposely and repeatedly make errors in a variety of settings so they can accept that they may look foolish or induce discomfort. Initially, we can anticipate that purposely making social mistakes will result in an increase in anxiety. However, if we can support someone in repeatedly making these errors, they not only become less distressed and more comfortable with experiencing distress, but they also get to test the notion that it’s intolerable to make social mistakes. Similarly, for someone whose social anxiety fears are primarily about creating awkwardness, we would pursue intentionally creating/ attempting to create the awkwardness they are fearing.

Let’s look at some examples of exposures we routinely use in the treatment of social anxiety :

1.       Making telephone calls to stores and asking routine questions.

2.       Making telephone calls to a store and asking a foolish question (e.g., asking why they aren’t open a particular day;, asking a jewelry store if they also happen to sell milk), then staying involved in a conversation.

3.       Walking backwards in public.

4.       Asking foolish questions in a store (e.g., asking the grocery store manager if they sell car tires).

5.               Asking follow up questions to the foolish questions (e.g. asking why the store doesn’t sell the product they don’t sell) then returning to normal conversation.

               

        

I would argue that, compared to less extreme exposures, these more extreme exposures ultimately challenge the original beliefs that it would be catastrophic to make a social mistake, cause discomfort in others, or receive unwanted social judgment from others. A recent TikTok trend embracing so-called "Rejection Therapy" uses similar principles to exposure therapy to encourage people to face their fears related to rejection and judgment using these more challenging and absurd methods.

If you experience social anxiety, you know firsthand how difficult it can be to get through a typical social interaction. You may recognize some of the safety behaviors that we listed above—and while those help in the short term, they have their own downsides. And now you may have a better understanding of why you haven’t been able to eradicate your social anxiety on your own.  If you are interested in conquering your social anxiety and challenging the beliefs related to social anxiety, contact us today!.


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