Hi

I work as a clinical psychologist in the NHS. I'm starting to produce some brief 'blueprints' for overcoming difficulties. This one is for social anxiety. hope you find it uesful. I've had to eddit it slightly as the models could not be pasted.

The nature and prevalence of social anxiety

In many ways social anxiety is similar to the normal experience of shyness that most people feel sometime or another. Social anxiety, however, is considered more severe because it interferes with a persons life to such an extent that they experience intense and excessive anxiety in social situations or they avoid social situations altogether. Some people with social anxiety find all social situations anxiety provoking whilst others find only particular activities such as talking in a group or signing a cheque provoke the unbearable levels of anxiety. Most people with social anxiety experience anticipatory and post event anxiety. Anticipatory anxiety is the anxiety associated with thinking about a forthcoming social event and post event anxiety is that which occurs following a social event where the person mulls over the event in their mind looking for social blunders.
Social anxiety is one of the most common anxiety disorders in the UK and is the third most common psychological problem in the US after depression and alcoholism. It is something that many people experience in a mild form but some people find themselves more seriously affected by it. Social anxiety is not well understood by the general public and is only recently being understood by medical and mental health care professionals. In fact, people with social anxiety are mislabeled with problems such as "schizophrenic", "manic-depressive", "clinically depressed", "panic disordered", and "personality disordered", among a host of other misdiagnoses. Social anxiety is not a sign of any more serious physical or mental illness, but it can be extremely uncomfortable.


Do I have social anxiety?
You would need a thorough clinical assessment to determine whether you have social anxiety, but if you identify with the statements below it is likely that you have some degree of social anxiety.

I worry about seeming foolish to others
I feel a strong feeling of fear in social situations that won’t go away
I am concerned about the opinions people have of me
I often worry that I will do or say the wrong things
I think I may act in way that will be embarrassing in front of others

Some people with social anxiety become frustrated and depressed with their situation believing that they will never be able to get better. For these people the depression may a result living with social anxiety and the depression lifts as they become more comfortable in social situations. For other people their depression is not just a consequence of the social anxiety. It is worth thinking about whether social anxiety is your primary difficulty in which case this ebook will hopeful prove useful. If the depression however, is more debilitating and not only related to the social anxiety then you may be better of tackling this first.



The cognitive behavioural model of social anxiety

Cognitive Behavioural therapy is based on research showing that emotional disorders are maintained by the way we think and behave.The cognitive model of social anxiety suggests that unhelpful thoughts occur that are themed around social failure and humiliation. These thoughts occur in social situations and result in self focused attention which can actually interfere with a person’s social performance. The self-focused attention feeds the belief that they are unable to perform adequately in social situations. The negative thoughts can occur before, during and after a social event and the pre and post negative thinking increases the fear of social performances.

Try and remember a recent occasion when you felt socially anxious and fill in the boxes below.

My thoughts were
Thoughts and talk funny & people will think I’m a fool


The negative picture of myself is

Image of self as a rigid red jibbering wreck

My avoidance or safety behaviours are

My physical symptoms are:

If you can’t remember a recent occasion or struggle to fill in the boxes then it might be helpful to keep a diary for a couple of weeks. Keep a diary of you thoughts, physical symptoms and avoidance or safety behaviours in different social settings.

Now look at the different components that maintain your social anxiety and see if you can understand how they interact. You want to be looking at the content of your anxious thoughts, how you think you looked and what behaviours you did in order to protect yourself. Try and understand how these components interact.


OK – so I kind of get the model, now what.

The next step is to approach the components as if you were a scientist and systematically test them out.

Looking at the model there a three main bits that we want to examine

1) Do you look as bad as you think you do?
2) Do your negative predictions actually happen?
3) Are your behaviours maintaining the problem?

1) Do you look as bad as you think you do?

Most people that struggle with social anxiety believe that they look worse than they really do in a social situation. This is problematic because it makes the person more fearful of a social situation.

You need to find out how you actually look rather than how you think you look. This can be tricky as it requires some kind of video recording device and ideally someone to film you. I realize that this may sound daunting to someone who suffers from social anxiety as being filmed is probably the last thing you want. It can be, however, really useful if you can do it.

One solution is to find someone supportive and ask them to film you doing something that you find anxiety provoking. It may also be possible to catch this footage on a mobile phone or you could even buy a cheap video camera. However you go about it you want to try and capture some footage of you interacting in an anxiety provoking social situation. The next step is to predict how you think you looked before analyzing the footage. Write down exactly how you think you appeared. For example if you think you were blushing writing down on a scale of one to ten just how much you think you blushed or even better find something that represents just how red you think you went. Try to make predictions about as many things as possible e.g. how much you think you blushed, how nervous you think you looked, how tight your mouth looked, how sweaty you looked. Next wait until your anxiety has reduced, playback the footage and rate all the observable features you can. Try to rate yourself as if you were somebody else rating you. It is also advantageous if you can get someone else to rate the recording as well.

Many people with social anxiety discover that they do not look as bad as they feel. If you have found this is the case you need to start replacing your distorted self image with a more realistic one. When you feel socially anxious and the anxious image is there in your mind try and remind yourself that you may be falling into the distorted self image trap. Remind yourself that ‘just because I feel this way it’s not the way I look’ or ‘I know I look better than I feel’ or ‘although anxiety feels terrible it’s not easy for other people to tell I’m anxious’ or ‘I probably don’t look as bad as I feel’, or ‘people aren’t really that concerned about how I look’.

As well as trying to replace your distorted self image with a more realistic one it can be helpful to try and s**t your attention from yourself to your environment. Try to look at other people and the surroundings, try counting the number of people in the room or look at what they are wearing. Look at different people and try and think whether they are having a nice day, what might be on their mind, or where they come from. The point is to try and shift your focus to other people and away from yourself.

2) Examine your thinking

When you feel anxious in social situations try and examine your thoughts. How are they making you feel? Are they accurate?.

Consider a situation in which you felt particularly anxious in a social situation. What kind of thoughts were you having just before the situation? During the situation? After the situation?. Did any of thoughts make you feel particularly scared or concerned? If so which ones?

Spotting anxiety provoking thoughts can be difficult at first as they might pass through your mind so habitually that you barely notice them. With a bit of practice, however, you will hopefully get quite skilled at spotting these unhelpful thoughts. Once you feel you can identify the thoughts the next step is to examine and challenge them. The aim is to examine these thoughts in a scientific manner rather than accept them as facts.

People with social anxiety have a habit of believing inaccurate thoughts and in particular they are falling for the trap of mind-reading, catastrophising and personalisng.

An example of mind reading is ‘he thinks I’m boring’. In this case you think you know what the other person is thinking, but in fact it’s just a guess and you are mind reading.

An example of of catastrophising is ‘everyone will laugh at me’. Again you don’t actually know this. How likely is it that absolutely everyone will laugh at you? How do you know?

An example of Personalising is ‘they are laughing, they must be laughing about something about me’. Once again, is this really true? How do you know? Perhaps they are laughing at something completely different, perhaps they are thinking of a joke they heard.

The basic principle is to challenge your thoughts rather than accept them as facts. What alternative explations are there? Are you catastrophising? Whats the worst thing that could happen?

The following example illustrates this unhelpful thinking. A person is asked to go to buy a drink from the bar. The first thing that pops into her mind is ‘They think I’m an idiot, because I look nervous’ – this makes her anxious and she tries to avoid going to the bar.

The girl is already making a number of thinking errors that are resulting in her becoming even more anxious.

  • How does she know the barman will think she’s an idiot?

  • Maybe the barman isn’t judging her or won’t even notice if she looks a bit nervous?

  • Maybe she feels worse than she looks?

  • Maybe the barman quite likes people who look a bit nervous, maybe it’s preferable to looking arrogant and cocky?

Hopefully you are starting to recognise that your thoughts are not facts and they need to be challenged. Sometimes you may think somebody thinks something, but you don’t actually know. You need to challenge you anxious thoughts rather than accept them as accurate statements as you might be viewing yourself unfairly and making yourself even more anxious. Why should you let these unfair thoughts dominate your life, they are just making you feel bad and you don’t really need to believe them. A tool that is often used in therapy is a thought diary. This is used to ‘catch’ anxious thoughts and evaluate them in a more balanced way to help you feel less anxious. It can take a bit of practice, but it has been shown to work in therapy.

An example simple thought diary is shown below.

Anxious thought
Balanced thought
I sound really stupid
Perhaps everyone does once in a while, even if I did it doesn’t mean I’m stupid


A more detailed (and probably more beneficial) thought diary is as follows

Situation
Mood
Anxious thought
Balanced thought
Re-rating of mood
Talking in a group
Nervous (90%)
I sound really stupid
Perhaps everyone does once in a while, even if I did it doesn’t mean I’m stupid
Nervous (60%)

3) Change the way you behave

The next step in treating social anxiety involves testing out predictions. This step takes courage as you are probably fairly convinced that your predictions are correct and your behaviour will result in humiliation. The truth, however, is that sometimes your predictions don’t come true and you’re probably worrying about something unnecessarily.

For example you might think ‘I will get so anxious I’ll panic and have to leave’ or ‘I’ll fumble my words and everyone will think I’m an idiot’. The problem is that these thoughts maintain the anxious state and without changing your behaviour you do not know whether this is the case or not. This is why changing the way you behave is so important. It is understandable that if you believe that something horrible will happen in a social situation then you want to protect yourself by not engaging in that activity. Indeed many people with social anxiety have felt humiliated in the past and do not want to be in that situation again. Whilst these protective behaviours seem sensible in the short term they maintain the belief that something awful would happen if you didn’t keep yourself safe in the future. What you need to due is stop doing these ‘safety behaviours’. Safety behaviours are any behaviours that you do in order to reduce the risk of being humiliated. They are a significant problem in social anxiety because they feed the belief that you need protection and that something would go wrong if you didn’t do them.

Most people with social anxiety have a whole range of safety behaviours many of which are quite subtle. People with social anxiety develop their own unique ways of protecting themselves so you will have to think carefully about the things you do in social situations that you believe keeps you safe.

Probably the most common ‘safety behaviour’ in social anxiety is avoidance. Avoidance of social situations prevents you from learning that they are probably not always as bad as you think. If a situation is avoided it feels even more difficult the next time you try and go to it.



Some examples of avoidance include:

  • Not going to places where you will meet a reared person or people
  • Not talking to someone you would like to talk to
  • Avoiding situations where you might be asked to speak

Some examples of more subtle safety include:

Trying not to draw attention to yourself
Saying very little
Keeping yourself busy so you don’t have to interact with anyone
Chewing gum because you believe it keeps your mouth lubricated
Rehearsing how or what to say
Checking things over in your mind first to ensure that they sound ok
Looking for a ‘safe’ person to stick with

Once you have identified your safety behaviours the next step is to give them up.

It is helpful to develop a ‘ladder’ for yourself with something at the bottom which causes some anxiety, but is bearable and increase in difficulty. You only need to move up a run on the ladder when you feel you have conquered the last one and you need to try and move up the ladder without using your safety behaviours. It’s ok to drop down a run and practice it a few times if you feel you’ve moved up the ladder too quickly. It’s worth remembering that many people feel anxious in social situations, it just doesn’t show.

Try this for yourself, make an anxiety ladder (an example of a ladder for someone that it afraid of speaking in front of a group is provided below)

  • say something to the supermarket checkout girl
  • make small talk with a neighbour
  • stay in a room with a group of people rather than trying to escape
  • look and listen to people in a group rather than paying attention to own feelings
  • ask a simple question in a group and try to listen for response rather than paying attention to how you feel
  • ask a longer question in a group and try to listen for response rather than paying attention to how you feel
  • ask a contentious or silly question in a group and try to listen for response rather than paying attention to how you feel

Once you have drawn up you ladder of increasingly difficult social activities you can start doing them. But the important bit is to do them without your safety behaviours. If you are clinging on to a safety behaviours you are maintaining the belief that something would go wrong if you didn’t.

Summary

The key strategies in coping with social anxiety include:

Try and understand how your thoughts, images and behavious influence the way you feel.

Find out how you really look in social situations and using this accurate image of yourself in social situations.

Challenging the negative habitual thinking that you’ve been doing

Facing your fears whilst dropping safety behaviours

Dealing with set backs

It’s likely that you will have good days and bad days and nobody overcomes social anxiety without experiencing a number of set backs. They key is not to give up when you experience a set back. It may be a case of two steps forward and one step back, but if you can keep going you have a good chance of feeling more and more comfortable in social situations.



Where can I get further help?

This ebook has provided you with a cognitive behavioural approach to understanding social anxiety. It is deliberately brief and it is hoped that you will derive some benefit from it. However, the model may be difficult to understand and the techniques are not easy to put into practice. It may be that treatment of your social anxiety requires therapy in which case you should ask your GP to refer you to a mental health professional. If you feel so distressed that you have thoughts of harming yourself then visit your doctor as soon as possible and explain how you feel

Available resources

In my opinion these are some of the best resources for understanding and managing social anxiety

Book: Overcoming social anxiety and shyness: A self-help guide using Cognitive Behavioural Techniques by Gillian Butler – published by Robinson London 1999

There is an accompanying workbook to the above book that is also very good and particularly useful if, like me, you find reading full books difficult.

There is an excellent CD collection by Dr Thomas A. Richards if you can afford it. It can be found here http://www.socialanxietyinstitute.org/audioseries.html




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