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It is something of a miracle that Grace Dailey is sitting in a restaurant in a coastal New Jersey town having an ordinary lunch, at ease with her world. Her careful, tiny bites of a tuna sandwich may seem unremarkable, but they are in fact a milestone. Back in her grade school cafeteria, she could only sip a bit to drink each day, unable to eat while she imagined her classmates' eyes boring into her. (Her high school teachers mistook her anxiety about eating for anorexia.) Only in her 20s, when panic attacks began to hit, did Dailey learn about the condition called social anxiety disorder, also known as "social phobia." But despite some success with behavioral therapy and anxiety-reducing medication, the 32-year-old still struggles. "I would be a different person in a different place if I didn't have to deal with this on a daily basis," she says, frustration apparent in her furrowed brow.
Shyness is a nearly universal human trait. Most everyone has bouts of it, and half of those surveyed describe themselves as shy. Perhaps because it's so widespread, and because it suggests vulnerability, shyness is often an endearing trait: Princess Diana, for example, won millions of admirers with her "Shy Di" manner. The human species might not even exist if not for an instinctive wariness of other creatures. In fact, the ability to sense a threat and a desire to flee are lodged in the most primitive regions of the brain.
But at some life juncture, roughly 1 out of every 8 people becomes so timid that encounters with others turn into a source of over whelming dread. The heart races, palms sweat, mouth goes dry, words vanish, thoughts become cluttered, and an urge to escape takes over. This is the face of social phobia, the third most common mental disorder in the United States, be hind depression and alcoholism. Like Woody Allen in the film Annie Hall, some social phobics can barely utter a sentence without obsessing over the impression they are making. Others refuse to use public restrooms or talk on the telephone. Sometimes they go mute in front of the boss or a member of the opposite sex. At the extreme, they build a hermitic life, avoiding contact with others (think of young Laura in Tennessee Williams's Glass Menagerie or the ghostly Boo in To Kill a Mockingbird).
Though social anxiety's symptoms have been noted since the time of Hippocrates, the disorder was a nameless affliction until the late 1960s and didn't make its way into psychiatry manuals until 1980. As it became better known, patients previously thought to suffer panic disorder were recognized as being anxious only in social settings. A decade ago, 40 percent of people said they were shy, but in today's "nation of strangers"?in which computers and ATMs make face-to-face relations less and less common?that number is nearing 50 percent. Some psychologists are convinced that the Internet culture, often favored by those who fear human interaction, greases the slope from shyness down to social anxiety. "If people were slightly shy to begin with, they can now interact less and less," says Lynne Henderson, a Stanford University researcher and director of the Shyness Clinic in Menlo Park, Calif. "And that will make the shyness much worse."
Much worse?and, for drug companies, far more lucrative: Recently, SmithKline Beecham won FDA approval to market the antidepressant Paxil for social phobia, leading to a raft of "public education campaigns"?on top of those already put out by the National Institute of Mental Health and the Anxiety Disorders Association of America. This media blitz has raised concerns that normally shy people will conclude they're social phobics and seek medications for what is a complex, emotional problem, or opt for such drugs merely as "lifestyle" aids to win friends and influence people (story, Page 54).
Hard-hitting. Social phobia hit Steve Fox so hard in high school that girls made a sport of saying "hello" just to watch him turn beet red. He refused to speak in class and never dated; even walking in front of other people left him with sweaty palms and gasping for air. By the time Fox was 19, his father was concerned enough to find a doctor, and a combination of medication and therapy has helped him recover. Fox, now 23, recently gave a speech in front of 1,700 people, and he is married to one of the cheerleaders who used to tease him.
Normal shyness and serious social phobia are clearly different, but they are related. Emanuel Maidenberg, associate director of UCLA's Social Phobia and Performance Anxiety Clinic, says that shyness is to social phobia what a fair complexion is to skin cancer. "It's a predis posing factor but will only translate into disease under certain circumstances," he says. "For pale people, that might be 10,000 hours in the sun. For shy people, it might be a string of embarrassing events."
Even though some people are born with a tendency toward extreme shyness, biology is by no means destiny. Harvard researcher Jerome Kagan has shown that by 8 weeks of age, babies display innate shyness or boldness. Roughly 1 in 5 will consistently be frightened of and avoid anything or anyone new, while the others welcome the unknown, reaching out to touch strangers or to grab new objects. Yet, many shy babies become gregarious 10-year-olds, and some outgoing babies become shy, even socially phobic, adults.
Life experiences can mold the brain to become more or less shy over time. Through a process psychologists call "contextual conditioning," the brain attaches a fear "marker" to the details of a situation that causes trauma (place, time of day, back ground music). So when a child gets a disparaging tongue-lashing from a teacher, the student will feel at least a bit nervous the next few times he or she steps into that classroom. But sometimes the brain is too good at making those associations, says Maidenberg, and the anxiety grows like a cancer, attaching itself to the act of entering any classroom or talking to any teacher.
The classic behavior of a child who does not know how to handle these "daggers to the heart," says University of Pennsylvania psychiatrist Moira Rynn, is to avoid any attention at all. In fact, social phobia used to be known as avoidant personality disorder. First, avoidant kids may stop inviting friends over. Some will only speak to certain people, usually their parents, a condition known as "selective mutism". Others develop "school refusal." By avoiding the very situations they need to learn the social skills of adulthood, these children end up diminishing their ability to cope. Not only can a parent who is highly critical train a child to cower, but even the gentlest parent can raise a fearful child. "If parents avoid social situations or worry excessively about what the neighbors think of them," says Richard Heimberg, director of the Adult Anxiety Clinic at Temple University in Philadelphia, "the message to a child is that the world is full of danger, humiliation, and embarrassment."
Social phobia affects about half of its victims by age 8, and many others during adolescence, when social fears are more pronounced. Others live with an undetected problem that surfaces when facing a new public arena (college, a new job) that overwhelms them. Grace Dailey, who had man aged to suffer quietly through high school, was seized with sudden panic attacks in her college classes. The episodes were so distressing that she would race out of lecture halls, and she considered dropping out. She did graduate, with the help of thoughtful professors who let her take tests by herself and who kept classroom doors open so that she didn't feel so trapped.
More women than men are thought to suffer social anxiety, but because shyness and demureness are smiled upon in females and less acceptable in males, more men turn to professionals for help. Roland Bardon, 27, knew he needed to see a psychologist after becoming too anxious to drive a car. "I worry about making other drivers mad," he says. "When people honk, that kind of criticism drives me crazy." He still avoids taking the wheel whenever he can.
Talking to strangers. It's Friday night at the Shyness Clinic in Menlo Park, Calif., time for this week's social phobia information session. But in the tiny room decorated haphazardly with fake flowers, only one man has shown up. The very nature of their disorder often causes social phobics to hide, and revealing themselves to a stranger is the last thing they want to do. Tonight's newcomer put off coming for two months. Clinic patients attend group meetings once a week, but some cannot even bring themselves to show up at all.
When the socially anxious do make it into clinics, they usually start with a few months of cognitive behavioral therapy. The cognitive element fights what psychiatrist Isaac Tylim of the Maimonides Medical Center in Brooklyn calls the intellectual core of social phobia: the belief that others will pass negative judgments on you and that unbearable humiliation will result. "I turn down invitations to go to lunch with people I really admire, even though I desperately want to go," says a Kentucky housewife and mother of two girls who exhibit a similar timidity. "I assume that as soon as we get together, they'll regret having asked and want to get away from me as soon as possible." These distortions cause an emotional reaction that sends social phobics running away from even the most promising friendships. Through cognitive restructuring?a fancy term for replacing faulty thoughts with realistic ones?many social phobics learn to question the insidious fears that, no matter how irrational, paralyze them in their everyday lives.
Perhaps the most salient feature of social anxiety is what is known as flooding: the sensation of being so overwhelmed that panic sets in. Almost everyone feels mild flooding at the podium during the first minute or so of an important speech, but for most people the discomfort soon subsides. A social phobic can suffer such agony for more than an hour. But even in social phobics, flooding will eventually subside, if only because of sheer exhaustion. That is why behavioral therapists coach social pho bics to remain in terrifying situations until the symptoms abate and it becomes clear that nothing bad is going to happen.
The first place that Melinda Stanley, professor of behavioral sciences at the University of Texas-Houston Health Science Center, takes many patients is the elevator. Riding up and down, the patient practices greeting and making small talk with fellow passengers. "Sometimes it takes 10 or 15 rides, and sometimes it takes all day," says Stanley, "but the phobic's heart will eventually stop racing for fear of what the newcomer might think of him or her." Eventually, the patients progress to giving speeches in front of Stanley and an audience of graduate-student volunteers. Other therapists take social phobics through practice runs of embarrassing situations, like walking through a hotel lobby with toilet paper on their shoes or spilling a drink. It's not unlike physical training, says Henderson. "Just as our gym workouts get easier as time goes by, to stay socially fit we must push ourselves to engage with others until it is second nature."
When a case is so severe that patients cannot even ride an elevator with a therapist, drugs can enable the social phobic to endure behavioral therapy. The perfect medication has yet to be found. Antidepressants known as monoamine oxidase inhibitors (MAOs) have been used for over a decade, but they can cause side effects such as fainting spells, heart palpitations, and blurred vision, and users must follow strict diets excluding every thing from coffee to cheese to red wine. Researchers have experimented with Xanax, Valium, and other tranquilizers but have had mixed success, not least because those drugs can cause physical dependence. Some sufferers try beta blockers, which are helpful for surviving a speech or a party but use less as a long-term therapeutic tool.
Most popular now are the antidepressants known as selective serotonin reuptake inhibitors (SSRIs), which have fewer side effects than the old anxiety drugs. "[Patients treated for depression] were spontaneously reporting that they were losing their social anxiety," explains Murray Stein, director of the anxiety clinic at the University of California-San Diego. Studies of the SSRIs Paxil and Luvox show great improvement in about half of social phobics, and studies now underway of other new antidepressants, like Effexor and Serzone, are also showing promise. But Henderson urges caution amid the current hoopla over drugs, which she worries are too often used as temporary crutches. "People tend to relapse as soon as they get off the medication," she warns, adding that research indicates that over the long run, therapy might keep a person in better stead. Just as troubling, says Tylim, is the message that only a drug can save them. "These are people whose very problem is a feeling of inadequacy, and the use of drugs can exacerbate that."
Because some social phobics have been out of the habit of talking with others for so long, therapists often have to help patients brush up on the most basic of social skills. For example, it never dawns on many of the most shy that they should introduce themselves to the person standing in front of them. And they often are stuck in the conversation-killing habit of answering questions with one-word answers. "I had to learn that if someone doesn't seem interested in the first sentence out of my mouth, I should not just turn and walk away cold," says Rick Robbins, a 31-year-old who was voted most shy of his Indiana high school class and whose social anxiety led him to drop out of college.
Perhaps the most common thing social phobics have to learn for the first time is to listen. "All kinds of alarm bells and sirens are distracting to social phobics," says Maid enberg. "So it is nearly impossible to hear what a person standing 4 inches away is saying." In fact, it is sometimes difficult for an extremely shy person to even feign interest in a companion's words. "Social phobics don't realize that most people in a room are not taking much notice of them," says Tylim, who says that social phobics in some ways crave the spotlight but fear that humiliation will come from it.
That's why Bernardo Carducci, author of Shyness and director of the Shyness Research Institute at Indiana University Southeast, is convinced that shifting the focus away from the self is the most therapeutic thing a shy person can do. "They desperately want to connect with others," he says; otherwise, they would merely be contented introverts or recluses who simply prefer their own company. Carducci sends patients to soup kitchens, hospitals, and nursing homes as a way of escaping the tyranny of self-centeredness. "It works because you get out there and start to see how shy other people can be," says Rick Robbins. "And then you don't feel so all alone, so different from every one else." At first, he tried to pry himself out of his problem with alcohol, what therapists dub "liquid extroversion." Then he forced himself to go to social occasions, where he would sit?miserable, silent, and sick to his stomach. If anything, these kinds of efforts at beating shyness will only aggravate the condition, because they are negative experiences that reinforce the fear.
Learning to cope. And because shyness is at least partially genetic, researchers unanimously agree that it is a mistake to try to become "unshy." Rather, the goal is to take steps to function despite the pounding heart and sweaty palms. Some do advance work for the tough moments. "Be fore I go out, I come up with four or five topics I would like to talk about," says Robbins. "Usually by the third one I bring up, I find something in common and forget about my nerves." Mark Goomishian, who has trouble even signing a check in public, looks for social arenas where he can be more himself, such as the local coffee shop, where he meets others for regular games of chess. "Because you don't have to talk during the game," he says, "it's a socially anxious person's sport."
In fact, many therapists say that if the socially phobic could rein in their anxiety enough to function, they would help make the world a better place. Many beloved figures in history have suffered shyness, including Eleanor Roosevelt, Robert Frost, and Albert Einstein. Shyness in its milder forms is associated with traits such as greater empathy, more acute perceptiveness, canny intuition, and beneficent sensitivity. All qualities that are nothing to be shy about.
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