People today might not actually be avoiding social interaction any more than they did in past decades, but they’re certainly more vocal about it. The rise of digital communication seems to be spawning a nation of indoor cats, all humble-bragging about how introverted they are and ordering their rides and groceries without ever talking to a human.
Sometimes reclusiveness can be a sign of something more serious, though. Social anxiety is one of the most common mental illnesses, but it’s still poorly understood outside of scientific circles. The good news is that it’s highly treatable, according to Stefan G. Hofmann, the director of the Social Anxiety Program at Boston University.
I recently talked with Hofmann about how social anxiety works and what people who feel socially anxious can do about it. An edited transcript of our conversation follows.
Olga Khazan: Why do people feel socially anxious when they go to parties, networking events, things like that?
Stefan Hofmann: People are social animals, and we have a strong desire to be part of a group and to be accepted by the group. Social anxiety is a result of the fear of a possibility that we will not be accepted by our peers. It's the fear of negative evaluation by others, and that is [part of] a very fundamental, biological need to be liked. That’s why we have social anxiety.
Khazan: Does everyone get socially anxious, or just certain people?
Hofmann: Well, it would be very abnormal not to be socially anxious. Social anxiety is a very normal stage that children go through, [along with] separation anxiety and stranger anxiety. These are actually very normal stages, and children who do not go through these stages, doctors do worry about those kids.
Later on, we obviously will still be uncomfortable in novel social situations, it’s quite normal. It becomes, obviously, a problem if we are too distressed. If it interferes with our lives and bothers us too much, then it becomes a problem, and then we would call it social anxiety disorder.
Khazan: How is social anxiety different from generalized anxiety? Is it more common than regular anxiety, or less severe? Where would you place social anxiety on the anxiety map?
Hofmann: In psychiatry we have a group of what we call anxiety disorders, and that includes social anxiety, generalized anxiety disorder, panic disorder, agoraphobia, specific phobias, and the like. Social anxiety disorder is the most common form among all the anxiety disorders. It actually is also ranked, in comparison to all the other mental disorders, as one of the most common disorders, next only to depression and substance use disorder. Thirteen out of 100 people meet criteria for social anxiety disorder [at some point in life].
Khazan: Is there any overlap between people who are generally anxious and people who have social anxiety?
Hofmann: Yeah, all the anxiety disorders are highly comorbid. Comorbidity means the coexistence of two or more problems in one individual. The most common problem for people with social anxiety disorder is actually depression. Then other forms of anxiety disorder, in particular generalized anxiety disorder and panic disorder. But this is true for almost all disorders—they are highly overlapping with each other. Which, by the way, causes problem for the psychiatric diagnosis, because we wouldn’t assume that there’s such a high overlap, but it does exist.
Khazan: How do you know if your level of social anxiety is considered disordered?
Hofmann: The definition of a mental disorder is that it causes either significant distress, and/or significant interference in one's life. So you might be able to perform normally during daily life, but you're terribly distressed around these social situations, such as meeting people, giving speeches, or doing things in front of people. It causes you such a level of distress that causes you to want to get help.
Or, there are people who kind of find their way around these problems, and they live lives that are fairly isolated. They might not marry, they might have very few friends, they might not go out for parties. In other words, they might not feel much distress because they’re living isolated lives, but at the same time they would like to be social. So they feel still an urgency to do something about it because they're not loners, but they just can't be around people because it's so distressing. Some people use substances like alcohol to medicate themselves.
Khazan: When you say they feel lots of distress, what kinds of things might they be feeling?
Hofmann: Often people will report panic attacks, anxiety attacks. They’ll report being struck by anxiety when they have to stand up in front of a group, that they show such strong anxiety that they can’t speak. Or they might escape out of the situation, run away, don’t go into interview situations, and the like.
Again, they might be missing out on many opportunities in life. They might not get married because not only are they scared of dating someone, but also going to their own wedding, etcetera. These are not just shy people—social anxiety disorder is not the same as shyness. People with social anxiety disorder have a real, significant problem that interferes with their lives.
Khazan: Has there been a rise in social anxiety, with social media and people interacting more through their computers?
Hofmann: It’s impossible to tell, because the definition of social anxiety disorder changes, and depending on how you define it, you'll get different rates of prevalence.
We do know, however, that there are interesting differences between cultures, which tells you a little bit about how society also shapes and influences that. We know that [some] Asian cultures, such as Japan and China, report social anxiety disorder less often. In more collectivist cultures, where the individual is not in the center, social anxiety disorder is less of a problem. In individualistic cultures, where it’s important that you are your own, unique person, in those cases social anxiety becomes more of a problem. So Western cultures report the higher prevalence rates of social anxiety disorder. Even within the U.S., Asians report lower rates, whites report the highest rates, and Hispanics and African Americans are in between. So that has to do with the setting, the cultural background, family relationships, and the like.
Khazan: What do patients with social anxiety disorder say when they describe how they feel, say, at a networking event?
Hofmann: Initially, they will dread the event, going there, they will worry excessively about the upcoming social event. They will be predicting that the worst thing will come true. And they will be extremely worried for a long period of time. Once you bring them into the situation, when they have to face whatever social challenge there is, they will then often report that they have no control over their anxiety. They believe that a mishap would have disastrous, long-lasting, irreversible consequences. They will report that they are not in control of their body, of their anxiety response, that others will see how anxious they are, and then they will try to avoid, to get out of the situation and escape.
Sometimes they try to use strategies that are more subtle, such as holding tight on a glass while they talk to someone so people don’t see them shake and tremble. They will maybe stare at the ground to avoid eye contact.
After the event, they will often engage in post-event rumination. Even in ambiguous situations that weren’t that bad, they will interpret them in a negative way, and identify weaknesses that they showed. This establishes a vicious cycle, and the next time they have to go into a similar situation, they expect that things will be even worse.
Khazan: What are some strategies that help alleviate symptoms or combat social anxiety when it starts creeping in?
Hofmann: What needs to happen is that people should face their anxiety. What we do is called cognitive behavioral therapy, a non-medication option which is more effective in the long term than medication treatment. You try to identify what kinds of thoughts people have in these situations, what sort of drives the anxiety.
Then you gradually challenge these maladaptive thinking patterns by asking people to engage in what we would call exposure practices, where they expose themselves to these situations repeatedly and for a long period of time so that they can realize that nothing bad is happing.
It is very effective. We have a response rate of at least 75 percent. Alternative treatments to CBT are medication—primarily with SSRIs.
Khazan: So what are some of the situations that you might send someone into? Like, “go give a speech?”
Hofmann: Initially, we use speaking in front of the rest of the group. In the seventh or eighth session, we go on to do more individualized exposure treatments, constructing something that we would call a “social mishap” exercise. We expose them to their worst-case scenario. For example, if someone is not engaging in any dating behaviors because they are concerned about being rejected, we would ask them to go to a restaurant and ask every woman at the table for her number. And obviously, he would get rejected a lot, and that's the purpose of it.
Khazan: That’s crazy! That sounds so intense. What do they say to the women?
Hofmann: We script it very clearly. We say, you’re going to go in there now, and say the following: “Hi, I like your face. Would you like to go out with me? Would you like to give me your number?” And she would obviously say, “No, go away, you freak,” or something, and that would be desirable. That would be perfect.
Or other examples might be, inconveniencing people, so let’s say go to a coffee shop and you spill your coffee and you say, “I'd like to have a new one.” Or you go to a book store and ask for a book on the joy of sex. You do something that is over the top that nobody likes to do, that violates their personal social norms and engages them in re-evaluating their maladaptive beliefs. And it’s very effective. It’s very successful. People speak to this treatment, they love it.
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