Eric Hollander, M.D., is a professor of psychiatry at Mt. Sinai Medical School in New York City and lives in Westchester County. He is the co-author of the American Psychiatric Association's Textbook of Anxiety Disorders and has appeared on Dateline and the Today Show. Nicholas Bakalar is the author or co-author of eleven health books, including Understanding Teenage Depression. He lives in New York City.

Introduction: A "New" Disease?

PART ONE

1. Who Gets Social Anxiety, and Why?

(18)

2. Shyness, Phobia, Social Anxiety

(14)

3. Symptoms

(16)

4. More Than One Illness

(10)

5. Are You Sure It's Social Anxiety?

(12)

6. Children and Adolescents

(20)

PART TWO

7. On Your Own: Self-Tests for Shyness and Exercises to Help Overcome It

(24)

8. Finding the Best Treatment

117

(8)

9. Psychological Treatments for Social Anxiety

125

(26)

10. Pharmacological Treatments for Social Anxiety

151

(26)

11. Making Your Own Contribution to Clinical Research

177

(16)

Conclusion: Social Anxiety and the Brain-New Research

193

(12)

Resources

205

(6)

Scientific Bibliography

211

(10)

Acknowledgments

221

(2)

Index

223

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Excerpts

Coping with Social Anxiety

Part One

Who Gets Social Anxiety, and Why?

Some human characteristics are purely genetic. Eye color is one of them. No amount of "good" or "bad" parenting, no physical environment, north or south, hot or cold, will change the color of a baby's eyes. Others--the language we speak, for example--are purely environmental. There are no genes for speaking English, or French, or Navajo. But most human qualities, particularly those that have to do with behavioral and emotional traits, seem to lie somewhere in the messy middle--a complex combination of genetic and environmental factors that work together to make us what we are. It is often extremely difficult to say exactly what environment or genes contributes to a given characteristic, and so it is with social anxiety disorder (SAD). Much scientific effort has gone into trying to figure out how much the symptoms of social anxiety disorder can be attributed to our genes and how much can be attributed to our environment. While little is known definitively, researchers have developed considerable data that suggest at least some partial answers to this difficult question.

Childhood Trauma and Social Anxiety

Current estimates are that somewhere between 4 and 8 percent of adults suffer from SAD in any year, and that the percentage of people suffering from the disorder at some time in their lives is even higher. Such a rate makes social anxiety, after depression and alcoholism, the third most common psychiatric disorder. Knowing how many people suffer from a disease is, of course, not enough. We'd like to be able to predict which people are going to suffer from a given disease so that we can intervene early to prevent it. To do this, researchers look for risk factors--clues that suggest a disease is likely to occur. In the case of social anxiety (and many other psychiatric illnesses) one of the things they look for is developmental problems in childhood. If a particular kind of childhood problem leads to later social anxiety disorder, it is identified as a risk factor for the disorder, one of the contributing causes of a disease. This is what a team of Canadian researchers did in 2001 when they set about to examine the backgrounds of people with SAD. They depended for their data on a large health survey undertaken by the Ontario Ministry of Health.

The study found that certain childhood events are highly correlated with SAD later in life. Childhood sexual abuse, the lack of a close relationship with an adult, failure in early grades of school, and dropping out of high school were all associated with SAD. So were moving more than three times as a child, involvement with the juvenile justice system, and running away from home. Social class, on the other hand, had no bearing whatsoever on whether a person would suffer from the disorder. Being a firstborn male increased the risk for social anxiety; firstborn females experienced no such increased risk.

But things are never so simple. The authors of the study are careful to point out that these associations are not the same as causes. Itis perfectly plausible, for example, that a child who runs away from home is already suffering from a form of social anxiety, so that it isn't running away that caused social anxiety, but the social anxiety that caused the running away. The same problem might apply to any other of the risk factors identified. So the authors' correlations, accurate though they are, tell little about whether these childhood events actually cause social anxiety.

Childhood trauma seems to play a role in other closely related anxiety diseases as well. Panic disorder and generalized anxiety disorder have both been found to be significantly related to past childhood physical or sexual abuse--in fact, in some studies these disorders appear to be more closely related to such abuse than social anxiety disorder.

Childhood behavior, even when it isn't pathological, might also be a predictor of social anxiety disorder. I see some kids who seem naturally curious; they like to explore new environments, meet new people. Others are more withdrawn. Inhibited behavior--a consistent tendency in children to display fear and withdrawal in any new situation--gives me a hint that social anxiety will develop. A carefully designed study published in 2001 demonstrated that behavioral inhibition was associated with a higher risk for SAD as well as other anxiety disorders. (There was also some good news for shy kids: behavioral inhibition has a lower association with disruptive behavior.)

The next question is why childhood personality or behavior predicts social anxiety in adulthood, and the answer is not at all self-evident. Many feel that childhood experience makes people modify their attitudes about the world and the extent to which they fear it. Some speculate that childhood trauma actually causes biological changes in the brain that lead to social anxiety, and this finds some support in animal studies. By manipulating the environment of young macaque monkeys, and then testing their reactions to anxiety-provoking drugs later in life, researchers were able to show that astressful environment in juveniles was likely to produce anxious adults, and even actual permanent neuronal changes in the animals' brains caused by early experience.

The experiment worked like this. Two groups of five female macaques and their infants were the subjects. In the first group, mothers had easy access to their food rations. In the second group, mothers had to search for their food in a device that hid the rations under a pile of wood chips. This required considerable time--and considerable anxiety--in finding the food. Both groups of infants matured normally, but the second group were raised by anxious parents. Presumably this anxiety would affect their treatment of their infants.

When the infants were six months old, the researchers gave them anti-anxiety drugs. The infants raised by anxious mothers responded more to the drugs as measured by observations of their social behavior than did those raised by non-anxious parents. Apparently, anxious mothers had transmitted their anxiety to their children, even to the extent of causing biological changes that would result in a different response to anti-anxiety medicines.

But of course I treat people, not monkeys, and it has been almost impossible for researchers to connect a specific traumatic event in a person's life to the development of social anxiety disorder. A minority of patients report a specific event that they feel led to the development of their problem, but their reports are not always reliable. Often there is a long delay between the time a patient feels symptoms and the time he seeks help, and in the interval many traumatic events may have happened and been forgotten. It is probably true that traumatic events by themselves are unlikely to be the cause of social anxiety--significant proportions of people without social anxiety have experienced traumatic events, and some studies show as little as 15 percent of those with social anxiety can point to a specific traumatic event as the source of their problem.

Nevertheless, there are some suggestive findings about less dramatic or specific events. Constant rejection or bullying by peers, for example, may sensitize kids who are already at risk for social anxiety. One study found that "behavioral inhibition" in five- to twelve-year-olds (assessed by parents looking back at the past), long-lasting separation from parents, and a parental history of psychopathology were all associated with the incidence of social anxiety. Whether or not any of these things are actual causes of social anxiety, however, is another unanswered question.

Genes and Your Destiny

If it is differences in brain structure that cause a tendency to social anxiety, then it is clear that genetics may also play a part. Everyone notices that "the apple doesn't fall far from the tree," that not only physical appearance but also children's behavior tends to resemble that of their parents. But noticing such similarities is not the same as scientifically proving that they are inherited, and certainly far from proving exactly what the mechanism of inheritance is. The inheritance of physical traits--eye and hair color, height, weight, and so on--is complicated enough. When it comes to the inheritance of behavioral traits, the complexity increases enormously, and the uncertainties begin to multiply.

That shyness is inherited is not a new observation. In 1872, Charles Darwin publishedThe Expression of Emotion in Man and Animals,in which he asserted that shyness--or at least its physiological manifestation in blushing--was an inherited characteristic. He quotes the observations of a physician: "Even peculiarities in blushing seem to be inherited. Sir James Paget, whilst examining the spine of a girl, was struck at her singular manner of blushing; a big splash of red appeared first on one cheek, and then other splashes, variouslyscattered over the face and neck. He subsequently asked the mother whether her daughter always blushed in this peculiar manner; and was answered, 'Yes, she takes after me.' Sir J. Paget then perceived that by asking this question he had caused the mother to blush; and she exhibited the same peculiarity as her daughter." In 1890, William James, inThe Principles of Psychology,quoting Darwin approvingly, counted shyness as a basic human instinct.

SAD clearly runs in families. But to say that something "runs in the family" is not the same as saying it is carried in the genes. Sorting out what is genetic and what is environmental is the most difficult part of the problem. One way to do this is with twin studies. Since identical twins have exactly the same genes, differences in twins' behavior can, at least with greater justification than those between non-twins, be attributed to their environment. Most researchers agree that environment adds to whatever effect genes have--in other words, that the effect of genes is consistent no matter what the environment. If this is so, then the special case of identical twins who have been separated at birth and raised in different environments provides the ideal natural experiment to test such ideas: the genes are the same, only the environment is different. Such groups of identical twins have been studied to test all sorts of hypotheses about nature and nurture, among them the heritability of anxiety disorders.

Of course, even such an apparently perfect natural experiment has its complications and limitations. Events in a family may profoundly affect one twin while leaving the other untouched. Suppose, to take an extreme example, one twin is sexually abused by a parent while the other is not. Such an event could cause a predisposition to later psychiatric illness in the affected twin, but not in the other. Or suppose, less spectacularly, that each twin simply reacts in a different way to an event they both experience, one interpreting it as benign, the other as traumatic. Parents' frequent loud arguments with each other, for example, could be harmful or not, depending on each twin's interpretation of the meaning of these disputes.

Even twin studies sometimes contradict each other. For example, a 1992 study of 2,163 female twins concluded that 30 to 40 percent of the development of social phobia is genetically passed from parent to child. But then another study appeared to show that genetic contribution was minimal, and though some anxiety disorders seemed to be heritable, there was no difference in heritability of social anxiety between monozygotic (identical) and dizygotic (fraternal) twins. In other words, though there is some genetic component, it does not seem to be particularly strong.

More recent twin studies, conducted with more sophisticated methodologies, have shown a higher heritability of social anxiety. And they have shown that the most severe kinds of social anxiety are the most likely to run in families. Moreover, social anxiety was found to be more heritable than other kinds of anxiety disorders.

In addition to twin studies, there are studies that consider the families of people with social anxiety. It's pretty clear that having one parent with an anxiety disorder increases a child's risk of social anxiety, and that having two parents with an anxiety disorder increases it even further.

The handful of studies that specifically consider the heritability of social anxiety disorder (separate from other anxiety disorders) show that a person with a first-degree relative (a brother, sister, mother, or father) who has social anxiety is two to three times as likely to suffer from it as someone who has no such relative, and the heritability is greater for generalized social anxiety (the fear of most social situations) than for the specific form (the fear of only one or two social situations).

Parents and kids interact, whatever their genetic makeup, and different kids interact in different ways with the same parents. It's possible, for example, that a very shy and retiring child may inspire different behavior from his parents than his outgoing and sociable sibling. In such a case, parents and children work together to create two different environments for two different kinds of children. This,too, might be considered an effect of genes--the same genes that make a child shy also have an influence on his environment, in the sense that his shyness makes people interact with him in particular ways. Genetic predisposition affects environment; environment affects the expression of a genetic predisposition. One study made this stunningly clear, when researchers looked at adoptive parents of children whose biological parents suffered from substance abuse or antisocial personality. The researchers first showed that the bad behavior of the children was significantly related to the psychiatric diagnosis of their biological parents. This was interesting, but not surprising. But then they showed that children who behaved badly (presumably genetically induced behavior, since they had no contact with their biological parents) elicited less nurturance and more hostility from their adoptive parents. Thus the behavior of the adoptive parents was significantly influenced by the psychiatric status of the biological parents, even though they had never come into contact with each other! The biological parents' genes, in other words, had, insofar as their children inherited those genes, affected the behavior of the adoptive parents. The researchers were able to draw a direct line between the psychiatric status of the biological parents and the behavior of the adoptive parents. Sorting out nature and nurture, genes and environment can be a tortuous process.

Good Parents and Bad

How about poor parenting? Can that cause psychiatric illness? Maybe, but it's not easy to decide whether someone has had poor parenting. First, how do you define "poor parenting"? Why do the same parents have such apparently varying effects on siblings? How does a child's perceptions of his parents, accurate or not, affect psychopathology? Do parents engage in different kinds of child-rearingpractices depending on the personality of the child? How much of parenting style depends on the relationship between a particular child and the parents? How do you separate all the other influences, environmental and genetic, from the "parenting" factor? And, as I suggested above in discussing how children and parents interact, the behavior of the kids themselves can under some circumstances make parents "good" or "bad." Such complications make it very difficult to pin it on the parents, and when studies are undertaken that try to take all these problems into account, researchers, even those using carefully designed twin studies, can't definitively say that people's psychiatric distress is caused by having had unskilled parents.

This doesn't mean that parents have no influence, however. It seems to be true that people who suffer from social anxiety have children who are more likely to suffer from it, too. In a study published in 2000, researchers concluded that social anxiety in parents is definitely a risk factor for social anxiety in their children. The authors didn't draw any conclusions about whether this association was due to genetics or environment--they only asserted that it exists. They speculate, however, that if there are environmental factors involved, they might include a restricted opportunity to learn social skills among children of parents who don't demonstrate such skills themselves and can't teach them to their kids. Depression, alcohol use disorders, and other anxiety disorders in parents were also associated with the development of social anxiety in their offspring, although the authors admit that other studies seem to contradict this finding.

When the researchers eliminated from consideration the parents' psychiatric illnesses, they were left with one consistent factor: parental style as perceived by the child with social anxiety. Adolescents who felt their parents were either overprotective or very rejecting were more likely to have social anxiety than other kids.

You may be thinking, Well, so what? All kids have criticisms of their parents, and anyway, their recollections of the way their parentsbehaved often aren't that accurate. That's true, but other studies don't depend on kids' recollections of their parents' attitudes but on objective assessments of shy and non-shy mothers and children. One British study demonstrated that the mothers of shy children had considerably higher rates of anxiety disorders, especially social anxiety, than did the mothers of non-shy children. Again, the researchers didn't draw any conclusions about genetics or environment--they just stated what they found to be the case: that shy children are about seven times as likely as non-shy children to have mothers who suffer from social anxiety.

We'll have more to say about parenting in chapter 6, but I have to emphasize that I'm not an expert in parenting--nothing in my training in medical school or internship or residency qualifies me to be handing out advice about raising kids. I have kids of my own, and I think I've raised them well, but I'm not in the advice-dispensing business, especially in something as fraught with problems as bringing up children. With those warnings in mind, however, let me say this: parents who recognize themselves in the descriptions above may want to think about their own issues and how they might affect the behavior of their children. As you'll learn in reading this book, there is plenty that parents can do without running themselves down, feeling guilty, or blaming themselves for their kids' problems.

Men and Women

What part does gender play in social anxiety? Are women more susceptible than men? Probably not--the disorder affects women and men in roughly equal numbers. In general, women seek treatment for psychiatric disorders more frequently than men, but this isn't the case for social anxiety disorder. A greater percentage of men seek treatment for social anxiety than for any other anxiety disorder, andmost treatment programs reflect the epidemiology of the disease in the community--about half the patients are men. There are probably several reasons for this.

Shyness, acceptable and sometimes perhaps even encouraged in women, is incompatible with traditional male sex roles and very much discouraged in men. Men are expected to be dominant and self-confident, not reticent and retiring. Parents, especially fathers, often agree with this tradition, seeing shyness in their sons as much more of a problem than the same trait in their daughters. It may also be that being shy is more disruptive to the life of a man than of a woman, and that this is another reason why men are eager to seek help with the problem. Men are supposed to initiate sexual relationships, be ambitious in their careers, speak and act boldly. Those who don't, or can't, are likely to see this as a significant life problem. There is some justification for this point of view; for example, shy men marry, become parents, and enter a stable career later in life than their more outgoing peers.

Women, too, experience problems in their professional lives if they are extremely shy. They are, for example, less likely to continue working after marriage or return to work after childbirth than non-shy women. In certain specific situations, differences between men and women are sharper: men experience more severe fear in urinating in a public restroom than women; men find returning goods to a store harder than women do; women are more likely than men to fear speaking in public, being observed while working, talking to an authority, and being the center of attention. In anxiety provoked by social situations, such as going to a party, men and women are about equally matched. They're also equally matched in the anxiety provoked by many other kinds of situations: participating in small groups, drinking or eating in public places, meeting strangers, telephoning in public, resisting a high-pressure salesman, and taking a test, among others.

In general, men and women differ more in the degree of fear they feel than in the situations that make them fearful. Especially in work situations, women report greater levels of anxiety than men. In one study, where the average age of people with social phobia was thirty-five, half of the patients were unmarried. You might guess that since it is men who are usually the ones expected to be more assertive in romantic relationships that there would be fewer unmarried men than unmarried women in such a sample--but you would be wrong. Men and women were unmarried in equal numbers.

Social anxiety in men and women is accompanied at about the same rate by diagnoses of other mood and anxiety disorders despite the fact that such disorders are usually more prevalent among women. (I'll have more to say about this in chapter 4.)

Boys and Girls

If asked, most people would agree that girls are, in general, shyer than boys, and therefore they might guess that girls are more likely to suffer from social anxiety. I certainly have this feeling. But it's difficult to establish this common observation as a scientific fact. Using questionnaires, interviews, and reports from parents, some researchers tried to figure out if there were any differences among preadolescents. They didn't have much luck finding any--boys and girls seemed quite similar in this respect. Reading aloud in front of the class, performing musically or athletically, joining in on a conversation, speaking to adults, starting a conversation, and writing on the blackboard troubled boys and girls alike. They did note, however, that parents usually thought of their daughters as significantly more anxious than their sons, even though the kids rated themselves equally fearful. This may mean that girls express their anxiety more freely than boys, but it's difficult to say. (More about this in chapter 6.) Theresearchers looked at race as well, and found no significant difference between whites and African-Americans.

I see a lot of kids with social anxiety, and the picture they present is disturbing. They suffer substantial emotional distress and are significantly impaired in the ways they function with their families and peers. They are lonely and largely friendless, and they resist any involvement in extracurricular activities. Their anxiety has what psychiatrists call "somatic" aspects--that is, they suffer physical symptoms like headaches and stomachaches with greater frequency than their less anxious peers. And there is another sad aspect to their plight: because they are quiet and not disruptive, they don't attract the attention that kids get when they suffer from more obtrusive behavioral problems. They cause no trouble, except to themselves. They suffer in silence.

Culture and Illness

Social anxiety disorder exists not only in Western cultures but in others as well. In Japanese and other Eastern cultures, for example, a disorder calledtaijin kyofushois characterized by a fear of offending other people, which leads to pathological social avoidance. While this may not be exactly the same disorder as SAD, its symptoms overlap considerably with it, and it apparently responds to the same kinds of pharmacological treatments. Some believe that the underlying psychobiological mechanisms are the same in each disorder, and that culture determines the expression of the problem. People who suffer fromtaijin kyofushotypically worry about having an unpleasant body odor, stuttering, and blushing, and these concerns lead to a fear of and withdrawal from social interactions. Some have theorized that those who suffer fromtaijin kyofushoare more afraid of offending others than they are of embarrassing themselves, while socialanxiety disorder sufferers in the West typically consider embarrassing themselves the bigger threat.

How Many People Have Social Anxiety Disorder?

Several epidemiological studies have now been undertaken to try to establish the prevalence of SAD in the American population. There have been two large population-based studies of the prevalence of SAD, the Epidemiological Catchment Area (ECA) and the National Comorbidity Survey (NCS). These are both large multisite studies of the prevalence and incidence of psychiatric disorders in the United States. Results from the ECA showed a lifetime prevalence among women of 3.1 percent and among men of 2.0 percent. Some sites reported higher lifetime prevalence rates for the general population--the Duke University site, for example, found a rate of 3.8 percent. A 1992 European study found an almost identical prevalence rate. But then the first study using a structured diagnostic interview was carried out by the NCS in 1998. Using these more accurate diagnostic procedures, the results were radically different: the lifetime prevalence among women was 15.5 percent, and among men 11.1 percent. With this refined diagnostic technique, we get a more accurate picture of the prevalence of the disease.

All of the studies except this last one had used the definition of social anxiety from theDiagnostic and Statistical Manual'sthird edition. When the fourth edition, theDSM-IV,was published, it presented somewhat stricter criteria for making the diagnosis (see here). Using these criteria, a German study in 1998 concluded that SAD prevalence rates were 9.5 percent for females and 4.9 percent for males, an overall rate of 7.3 percent. In any case, most studies agree that even those individuals whose SAD is mild--that is, they meet only some of the criteria for diagnosing the disorder--couldstill benefit from treatment. No matter how you figure it, this is a large number of sufferers.

The Origins of Social Anxiety

Why does such irrational behavior as that associated with social anxiety arise in the first place? There are, loosely speaking, three different theories: neurobiological or evolutionary, behavioral, and cognitive. No strong argument supports one theory over the other two, and each has its logic, its supporting scientific evidence, and its proponents.

An evolutionary advantage may be conferred by a well-developed sense of fear that results in the life-preserving fight-or-flight reaction in the part of the nervous system not under conscious control, the sympathetic nervous system. Our ancestors who quickly reacted by running away from dangerous animals, for example, were the ones who survived to reproduce. Whatever genetic physiological mechanisms allowed them to do that survive in their offspring. In fact, psychophysiological research shows the similarity of this fight-or-flight reaction to that of people who are phobic about animals. In other words, those with animal phobias presumably react the same way as our predator-fearing ancestors. Since the young are most vulnerable to predators, these kinds of fears should arise very early in development, yet such is not the case with social anxiety, which arises in early adolescence or early adulthood after a person has had experience with social interactions. Proponents of an evolutionary theory respond to this objection by arguing that social fears might well have evolved as a response to the building of social hierarchies: those humans who properly understand their place in a social organization are more likely to survive and reproduce, so high anxiety about social relationships is an important survival mechanism.

Behaviorists see the development of social anxiety as an unconscious result of trauma: a child bitten by a dog develops a fear of dogs that is then irrationally applied to all dogs, whether they are a danger or not. Analogously, social anxiety results from a traumatic social experience, being humiliated, or being the object of anger or criticism on a specific occasion, which develops into an irrational fear of many or all social interactions. It is true that a large percentage of people suffering from SAD report a specific traumatic "conditioning experience." Often my patients will tell me of a specific event or events from long ago that they're sure is the root cause of their anxiety. There is at least some anecdotal evidence that witnessing another person being criticized or humiliated in a social situation might be a traumatic experience that could help cause social anxiety, and experiments with rhesus monkeys provide experimental evidence as well. The question of whether such trauma is a cause or an effect of social anxiety disorder in humans, however, remains unanswered.

There is also a cognitive model of the origins of social anxiety. Because some people lack social skills, the theory goes, they find little success in social situations. This causes them to expect bad outcomes, leading to negative thoughts about any future social interactions. These negative thoughts then cause psychological and physiological reactions that encourage avoidance of social interaction. Avoidance of social interaction limits the opportunity to practice social skills, the lack of practice perpetuates and reinforces the lack of skills, and the cycle continues. In this formulation, a person could enter the vicious cycle at any point and find himself spiraling toward social anxiety.

Whatever theory they offer for its origins, and whatever the epidemiological studies demonstrate about its extent, all researchersagree that social anxiety is a common disorder, and one that disrupts lives in serious ways. You, and those you love, are not alone, and we've learned many ways to help, both medical and psychological. Picking up this book is a good beginning.