An article from Attention Magazine featuring Dr. Brown's new book Social Anxiety: Hidden Fears and Shame in Teens and Adults
Many teens and adults are a bit shy when they are meeting unfamiliar people or giving a talk or presentation for a class or a meeting. They wonder “does what I’m wearing look OK? Did what I just said sound OK?” For most teens and adults such worries are brief and trivial.
But for some individuals such worries are much more intense and much more persistently disturbing. They may start worrying long before the event and may have many persisting thoughts about how others might be critical of how they looked and what they said or didn’t say. Those worries may continue not just for a few minutes, but for several hours or even for days or weeks.
“Social Anxiety” is a diagnosis used to describe the problem of excessive chronic fears of being embarrassed or humiliated, seen by others as ridiculous or pathetic for how they look or what they said or how they were acting. Sometimes such fears start as soon as the person knows they might be exposed to such criticism, hours, days or weeks ahead of the dreaded event. And sometimes those fears of how others might be thinking about them persist long after any event or are chronically recurrent.
Sometimes the person with social anxiety is worried about how others whom they do not even know and are not interacting with might be thinking about them. They fear that others around them in a restaurant or a store may be thinking critically about them even where there is no actual interaction and when the others may not even be looking at them. This is not simple shyness!
One example is Sam, a handsome 35 year-old single man, who sought treatment because he lacked self-confidence and had chronic fears that when his parents eventually died, he would be unable to take care of himself.
Since early childhood Sam had always been extremely timid. He insisted on having his mother walk with him to school long after most of his peers walked to school in a group unaccompanied by any parent. When attending sleepover parties in middle school, he enjoyed participating in party activities, but he insisted on having one of his parents pick him up when all the other kids were getting ready to sleep over. He did not feel comfortable sleeping away from his parents.
Sam was a hardworking student who earned very good grades. Eventually he earned a degree from a college while he lived at home with his parents. His parents owned a retail store. He enjoyed working there part-time while he studied to earn a more advanced degree. However, he could not eat alone in a restaurant and did not feel comfortable going shopping for groceries or doing anything else by himself. He also felt unable to learn how to drive.
Eventually his parents bought Sam a condominium just a short walk from their home, but he continued to spend most of his time at their house. His parents recognized his fears and did not want to stress him. Sam sought treatment because he had been having frightening dreams about his parents both dying and him being alone, unable to take care of himself. He responded well to psychotherapy and prescribed medication. After six months of treatment Sam proudly reported that he had gone out and bought a pair of shoes without being accompanied by anyone. This was his first step in a long process.
The current diagnostic manual for psychiatry (DSM 5-TR) uses the term “social anxiety” to refer to the condition of persisting intense fear or anxiety about being severely embarrassed or humiliated in social situations where such fear is out of proportion to any actual threat (American Psychiatric Assn, 2022).
That definition picks up on what is often called “performance anxiety,” being anxious about giving a speech or playing an instrument; however that definition does not include the many ways that some people suffer from excessive fears of how others might be thinking about them, disapproving of who they are, how they are dressed, what they are doing or what they might be thinking, even when there may be no contact or even anticipated interactions with those persons in the present, the foreseeable future, or ever.
Usually those with social anxiety intensely try to avoid such situations. If avoidance is impossible, the person anticipates those situations with dread and endures them with intense fear and anxiety.
Who are these “others”? Those who suffer from social anxiety often describe their fears as related to what “others” may be thinking about them. Often those are anonymous others who just happen to be eating in the same restaurant, shopping in the same store, attending the same meeting, or walking near them on the street. Usually, but not always, these are people whom they do not know and with whom they are not likely to be interacting.
Yet, upon reflection, these unknown others may be representative of other people with whom the fearful person has had previous contact: classmates who ridiculed, bullies who humiliated, teachers who criticized, competitors who defeated them, parents, siblings or other relatives who shamed them. Most of us carry an unconscious collection of memories, an implicit bias from past experiences of embarrassment or shame that may readily be projected onto ambiguous moments in the present to create a potential threat that may not be realistic in the present situation or at all likely in the future.
In my experience as a clinical psychologist I have found that for many individuals, their social anxiety is based upon their assumptions about “What would my mother or father, wife or husband, son or daughter, close friend or pastor think if ever they were to find out about these thoughts or wishes I sometimes have had or about some of those actions in which I engaged in the past?”
That fear or shame felt by the person is usually based upon their own thoughts of what the “other” or “others” would be likely to feel, even if that other is not likely ever to find out about those secrets or perhaps cannot ever know because they are already deceased. For some persons, the “other” who might disapprove is an all-knowing God!
Social anxiety is not a rare problem. In the United States the lifetime prevalence of social anxiety for those between the ages of 13 and 17 years is 11% for females and 6% for males. The lifetime prevalence for American adults between the ages of 18 and 64 years is significantly higher and different in gender ratio: 14% for males and 11% for females (Kessler, R.C., Petrukhova, M., Sampson, N.A. et al., 2012).
Significant impairments often occur with social anxiety. These may include elevated rates of school dropout, increased unemployment, decreased sense of well-being , lower socioeconomic status, increased likelihood of remaining single or becoming divorced, and less participation in satisfying leisure activities.
Social anxiety may be helped by psychotherapy, family interventions and/or medication. However, despite these difficulties and impairments, only half of individuals with social anxiety ever seek treatment for it; those who do seek treatment for their social anxiety tend to do so only after 15 or 20 years of experiencing symptoms (DSM-5-TR, 2022, p 233).
This article, published in Attention Magazine, is an excerpt from the introduction of a new book by Thomas E. Brown, Ph.D. Social Anxiety: Hidden Fears and Shame in Teens and Adults, that will be published this summer by American Psychiatric Association Publishing. Dr. Brown is director of the Brown Clinic for Attention and Related Disorders in Manhattan Beach, CA. and is Clinical Professor of Psychiatry and Neuroscience at the University of California Riverside School of Medicine.