Social Phobia’s Traumas and Treatments

When his self-described "worst episode" of anxiety lay hold of him on stage in 1994, Donny Osmond was no fledgling entertainer. The singer-actor had been in the public spotlight for more than 30 years--four of those, starting when he was just 18, as co-host of a popular variety program with his younger sister, Marie.

"Once the fear of embarrassing myself grabbed me," Osmond writes in his recent autobiography, Life Is Just What You Make It, "I couldn't get loose. It was as if a bizarre and terrifying unreality had replaced everything that was familiar and safe. I felt powerless to think or reason my way out of the panic."

At the time, Osmond was playing the lead character in the Andrew Lloyd Webber musical "Joseph and the Amazing Technicolor Dreamcoat." "… I kept trying to remember the words," he continues, "but they slipped through my fingers like mercury, defying me to try again. The harder I tried, the more elusive they became. The best I could do was to not black out, and I got through the show, barely, by telling myself repeatedly, 'Stay conscious, stay conscious.'"

This was not garden-variety stage fright, Osmond explains. The entertainer who had confidently mixed with such stars as Bob Hope, John Wayne, Andy Griffith, Lucille Ball, Danny Thomas, and Farrah Fawcett, and who had won two celebrity auto races by driving his cars at speeds of up to 150 miles an hour, had become afraid--not just of humiliating himself during his shows, but of being scrutinized off-stage, as well, while doing things as mundane as returning merchandise to the store for a refund. The fear, Osmond says in his book, stemmed from the possibility of not always being in control of what happened to him. His mind would race: "What will I do? What will people think? Will I look stupid?"

As Osmond discovered, the condition that caused his foreboding panics had a name: social phobia. Also called social anxiety disorder, social phobia is an extreme fear of public embarrassment and being judged by others. The condition affects as many as 13 of every 100 Americans at some point in their lives, according to the Anxiety Disorders Association of America, making it the third most common psychiatric condition after substance abuse and depression.

To control his condition, Osmond learned techniques to manage his fears by changing his thought patterns. While many people address their social phobia with such psychological therapy alone, many others find medication helpful, either alone or coupled with psychotherapy. In May, Paxil (paroxetine hydrochloride) became the first drug approved by the Food and Drug Administration specifically for treating social phobia.

Way Beyond Butterflies

Social phobia is far different from the run-of-the-mill nervousness associated with stressful situations. It's the intensity of the fear that distinguishes the condition from the almost inevitable butterflies that most people feel when they are about to give a speech or go to an interview or even a party.

When people with social phobia perceive that others will judge their "performance" in a certain situation, their bodies undergo physical changes, which typically include profuse sweating, rapid heartbeat, shortness of breath, faintness, and blushing.

"In the more severe cases, people can have a panic-like reaction and become so overwhelmed with anxiety that they feel completely disoriented," says Jerilyn Ross, president of the Anxiety Disorders Association of America and a psychotherapist who has treated thousands of patients with social phobia, including Osmond. "Your fight-or-flight alarm system that warns you when there's danger goes off at the wrong time. You literally feel like you're losing control, you're going to do something stupid to embarrass yourself, you're going to die."

Una McCann, M.D., an associate professor of psychiatry at the Johns Hopkins University School of Medicine and former head of the anxiety disorders unit at the National Institute of Mental Health, admits that when she started at NIMH, even she underestimated the life-altering impact that social phobia could have. "My initial reaction toward social phobia was probably typical of most people's," McCann says. "I thought, 'What's that? That's a disorder?' Because everybody experiences anxiety in some social situations, like public speaking, large crowds, or being the center of attention, it really seemed like a pseudo-disorder to me at first. Until I met some patients. Then, I suddenly realized how unbelievably debilitating social phobia can truly be."

For Marissa Turner, now 27 years old, even visiting her own aunt used to trigger panic-type symptoms. "It was pretty hair-raising," says Turner. "Standing on my aunt's doorstep, I'd be hyperventilating, shaking, and feeling hot when it wasn't hot outside. I'd feel like I wanted to turn around and run a mile. My throat would constrict, and it felt like if I opened my mouth to talk it wouldn't make a sound."

To avoid the frightening, panic-like reactions, people often rearrange their lives to sidestep their personal triggers rather than endure the intense anxiety. "What we're talking about is an anxiety so severe that a person is unable to function, either socially, academically or occupationally," explains Thomas Laughren, M.D., the team leader for FDA's psychiatric drug products group. "You hear of people who would turn down a promotion or quit their job rather than dealing with talking to groups of people. Other people are shut-ins because they fear being judged in almost any social interaction outside of their family."

It's not that these people are shy, necessarily. Turner, for example, craved social interaction. "I could list a million things I wanted to do, which my peers were doing, that I couldn't," Turner says. "I didn't date. I rarely went to parties, and when I did, I was very scared the whole time."

Turner's condition is referred to as "generalized" social phobia because her anxiety extended to a broad variety of settings. Some people with generalized social phobia become very anxious about activities as routine as eating in a restaurant, writing something down while someone is watching, or using a public restroom. As a group, those with generalized social phobia are less likely to graduate from high school and are more likely to rely on government financial assistance or have poverty-level salaries, McCann points out.

Other people have the more limited "specific" social phobia, meaning their fear is associated with just public speaking or another well-defined circumstance.

Combination of Causes

Scientists have not pinpointed the exact causes of social phobia, which tends to run in families and may affect women slightly more often than men. Studies suggest that both biological and psychological factors may contribute to the anxiety disorder.

Some scientists think social phobia is related to an imbalance of the brain chemical serotonin. Perhaps someone who is biologically predisposed to social phobia endures a triggering embarrassing event, Ross says. "I think we can all remember a time when we got up to talk, and the kids giggled because our skirt was up, or we forgot our line in a school play. At the moment it seemed like a traumatic experience, but for people who are biologically predisposed to social phobia, that experience can truly imprint itself on the brain as a traumatic event."

Many unproblematic years can pass between such an event and the phobia rearing its head, Ross says. Social phobia can appear any time in one's life, but typically shows up in the mid- to late-teens and can grow worse for a time after that, according to the Anxiety Disorders Association of America.

Turner has wrestled with her anxiety most of her life, but says that it "shot through the roof" as she neared adulthood. Like many fighting this war of nerves, Turner tried to self-medicate with alcohol. Without medical help, she says, she would have relied increasingly on drinking to get her through social situations. Turner did finally seek medical help, but not, she says, until she felt like she "couldn't cope with another day."

Addressing the Anxiety

Turner's doctor has prescribed the drug Paxil to ease the primary symptoms of her social phobia. This first drug approved by FDA for treating the condition is also approved to treat depression, obsessive compulsive disorder, and an anxiety condition called panic disorder. However, it is not approved for performance anxiety or shyness that does not rise to the level of social phobia.

Paxil is an effective treatment option for doctors to consider, says the agency's Laughren, who adds that many patients will see improvement but not be cured of their anxiety altogether.

Turner says it has made a "really big difference" in her life. "Since I've started taking Paxil, I've been on top of my anxiety."

People taking antidepressant drugs called "monoamine oxidase inhibitors" shouldn't take Paxil. The drug should be used with particular caution in some other patients, such as those who are pregnant or nursing or who have a history of seizures, mania (emotional highs associated with bipolar disorder), or certain other medical conditions.

Besides Paxil, doctors sometimes prescribe certain antidepressants or other drugs--beta blockers and benzodiazepines, for example--to try to control the anxiety symptoms associated with social phobia. While these drugs have not been approved by FDA specifically for treating social phobia, doctors can legally prescribe them if they feel a patient will benefit.

Some patients with social phobia opt for a nondrug treatment approach instead of, or in addition to, medication.

Philip Lawson (not his real name) is one of those who wanted to overcome his social anxiety without drugs. As an agent representing athletes, authors, and other public figures, the 24-year-old Lawson is required not only to meet individually with his clients and others, but also to give speeches. He relished doing presentations in college, but since graduating--during interviews and on his job as a talent representative--has battled an extreme fear of public speaking that's brought on white-knuckle anxiety attacks.

At first, Lawson didn't even want to accept that he had an anxiety disorder. "I'm the antithesis of someone you would expect to have a social problem. I planned my five-year high school reunion." The colleagues in whom he confided about his anxiety reacted with astonishment: "I don't believe it, you? Mister Outgoing Talk-to-Anybody?"

Yes, him, Lawson says. "When I had to give a presentation, I would either pretend to be unprepared or I'd say something really quick," he explains. "The anxiety grew into one-on-one meetings with people, where I would feel like I was completely on the spot. You always assume that all the attention is on you, like a spotlight."

Lawson's low point, he says, was when he called in sick to work because he had to give a speech. "I can either face this," he told himself, "or let it get worse and worse." Rather than allowing his condition to spiral downward, Lawson worked with a psychotherapist, individually and in group sessions, to learn to face down his irrational fears. He participated in a standard, two-pronged approach to treating social phobia called "cognitive-behavioral therapy."

The first part of cognitive-behavioral therapy--the "cognitive" aspect--tries to correct people's catastrophic perceptions of what others are thinking about them and what the real consequences are of a less-than-perfect performance. "Social phobia is a very self-focused illness," explains McCann. "You might think that people see you blushing and trembling, when really, many of them are thinking about what they're going to have for lunch."

To help people put things in perspective, a therapist may ask, "What is going to be the consequence if you do have a panic?" McCann's examples: "If you have a job interview and you blow it, so what? So you don't get that job. But it was good practice. So you do flub a sentence. What is the worst thing that can happen? Somebody might chuckle, maybe they'll rib you about it."

For Osmond, cognitive therapy reinforced what his wife, Debbie, had told him over and over: If he wasn't perfect, on-stage or off, people would like him nonetheless.

The "behavioral" aspect of therapy, typically undertaken at least partially in a group setting, gradually exposes people to the circumstances that can trigger their panic. It teaches them techniques to help them focus on the present reality rather than anticipating the imaginary dangers like "what if I lose control?" For example, people may learn to:

  • expect the fear and accept rather than fight it
  • focus on manageable things in the present--by paying attention to their breathing, for example, or counting backwards from 100 by threes, repeating an encouraging phrase to themselves ("What doesn't kill me makes me stronger," for instance), picturing themselves at the beach or another place they would like to be, or consciously rubbing their hand on a podium, chair, or other object.

By socializing or giving a speech surrounded by an empathetic group, people can practice using these techniques to cope in the unnerving situation and give their confidence a boost. Speaking groups like Toastmasters might not be a sufficiently nurturing first step for those with social phobia, stresses Ross, who does encourage patients to join such groups once they conquer their paralyzing fear. "Toastmasters teaches you how to give an effective speech and deal with the normal fears and jitters," she says, "but it doesn't teach you how to deal with the more pathological anxiety."

Behavioral therapy homework assignments can include making presentations in a real-life environment. "It's not just going for those 12 or so weeks," McCann says. "You have to go through a little pain and have the failures to get your improvements."

Osmond's "homework" included a trip with Ross to the local shopping center to buy, and the next day return, a shirt. At the mall, he tracked his panics on a scale of 1 to 10 while practicing his coping tricks. "Now, the entire time I was in the mall," he writes, "my panic never went down to 0, but anything under 5 or so, I could cope with."

To this day, Lawson isn't entirely without anxiety, either, but says the quality of his life has improved significantly. "I went from calling in sick to now at least being able to get up in front of a group of people. I'm able to have one-on-one meetings with people without feeling terribly nervous. I try not to take myself so seriously."

Combined with her Paxil treatment, cognitive behavioral therapy contributed to Turner's progress, too. Paxil, she says, "calmed my nerves and elevated my mood enough that I could use all the cognitive behavioral therapy techniques I'd learned."

Taking Control

Up to 80 percent of those treated for social phobia say they've gotten their anxiety under control, according to the Anxiety Disorders Association of America. Yet a recent study reveals that treatment delays of 10 years or more are common among adults with the condition. Some reasons people cited for not being in treatment: a fear of what others might think, a belief that the anxiety could be controlled without professional help, and uncertainty about where to go.

But despite such hesitations, medical experts and individual sufferers alike urge people to seek out help for this real and treatable condition. Turner: "The real me has been hidden for all these years. It's like a big, dark curtain was around me all that time, and I'm just now poking my head out. I want people to know they don't have to suffer. Life can be enjoyable."

As for Osmond, when his mind starts racing, he no longer thinks "what if I lose control?" Now, writes Osmond, he says to himself, "If I lose control, I know what to do."

Source: FDA Consumer Magazine
Date: November-December 1999
Author: Tamar Nordenberg, staff writer for FDA Consumer

Reviewed by athealth on February 7, 2014.