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Shyness

What is shyness?

Professionals and laypersons alike use the term shy to describe persons who are hesitant to engage with others, preferring to be alone or with people they know well. They are less gregarious and less outgoing, especially with strangers or when they are expected to do something. Shyness is not necessarily an emotional disorder but rather is considered to be one type of temperament. Some people propose that shyness might be on a continuum, such that very shy people whose shyness negatively impacts their life are at one end of the continuum, and those at the other end are shy but it doesn't seriously affect their life. When shyness interferes significantly with the person's daily routine, occupational functioning, or social life, it is called Social Phobia.

What is Social Phobia?

According to the American Psychiatric Association, the essential feature of Social Phobia is "a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way . . . that will be humiliating or embarrassing."

Those with Social Phobia may fear only social interactions or specific performance situations, but they more typically fear both types. Commonly feared social interactions include initiating and maintaining conversations (especially with strangers or when more than one person is present), being assertive even when it is appropriate, talking with authority figures, or asking someone out socially. Those with Social Phobia report fearing their anxiety symptoms will be observed in such situations, revealing their inadequacy to the other person and leading to criticism or possible rejection. They may be afraid that they will have nothing to contribute to a conversation and others will get bored and want to leave their presence.

Performance situations typically feared by those with Social Phobia include eating, drinking, and writing in public. They may fear that their hands will tremble in these situations and others will interpret this as a sign of weakness or deficiency. By far the most feared performance situation is public speaking, which elicits tremendous fear of scrutiny despite adequate preparation. Other performance situations may involve writing papers that others are expected to read, performing on tests, participating in job interviews, or defending a proposal at work. When forced to perform, they anticipate that the presentation will be unacceptable. They fear they may suffer extremely severe anxiety symptoms or a panic attack, causing them to "go blank" so that they are unable to regain their composure and may have to stop their presentation.

The typical person with Social Phobia is afraid mainly of a single situation or a limited number of situations. The generalized subtype of Social Phobia refers to a fear of "most" social situations. People with Generalized Social Phobia may have few friends and are more likely to manifest deficits in social skills and to have severe social and work impairment.

How is Social Phobia treated?

Fortunately, effective treatment is available to those who are suffering from Social Phobia. Cognitive-behavior therapy (CBT) is considered the treatment of choice for this disorder. It combines cognitive restructuring, exposure, and social skills training. Cognitive restructuring explores the content of the person's thoughts about particular situations. The therapist uses a Socratic process of systematic inquiry to help clients evaluate their thoughts rationally rather than treating them as facts. This process weakens the causal link between cognitions and arousal (anxiety). Once irrational thought patterns are changed, exposure to the feared situation produces habituation with an accompanying reduction in anxiety. Exposure also breaks the chain of avoidance and provides opportunities for client to practice new skills and test old assumptions. Clients are given homework to increase exposure to feared situations outside the therapy sessions while using newly-learned cognitive skills. Cognitive restructuring and exposure are highly integrated, and can be administered in individual or group sessions.

In addition to cognitive-behavioral treatment, pharmacological treatment can be helpful. The most effective medicines are selective serotonin reuptake inhibitors (SSRIs) and benzodiazepines. According to a meta-analysis of research, CBT is the most effective treatment (ES=.74) followed by pharmacological treatment (ES=.62) (Gould, Buckminster, Pollack, et al, 1997, Clinical Psychology: Science and Practice, 4:291-306), American Psychological Association D12). Combined CBT and pharmacological is generally regarded as preferred.

Dr. Joyce Nash, PhD    (650) 329-1000