Are you socially anxious? What's the difference between social anxiety and being shy? That's what I'm discussing today. I'm also going to talk about how we treat social anxiety disorder. I'm Dr. Tracey Marks, a psychiatrist, and every Wednesday, I publish videos on mental health education and self-improvement. Social anxiety disorder causes a lot of shame for people and it can really interfere with your ordinary functioning. In 1980, with the DSM-3, it was called social phobia and it continued to be called this until the DSM-5 when the name changed to social anxiety disorder. This name takes into account the deeper fears that people have that go beyond just fearing social situations. Here's the official criteria: You fear social situations because you believe you may be judged, embarrassed, or humiliated. You avoid social situations that you know will make you anxious or you painfully endure them with a lot of anxiety. You have excessive anxiety that's out of proportion to the situation. This is important because there are some situations where you're going to have anxiety like taking a test or giving a speech. Even experienced speakers can still feel anxious when giving a speech. But are you hyperventilating, passing out, or vomiting before the event? These would be reactions that are over and above the usual heart racing or sweaty palms that you can get from a normal level of anxiety. Your anxiety or distress interferes with your daily living. Your fear or anxiety is not better explained by a medical condition, medication, or substance abuse. So what does this look like? A person who's extremely fearful of being humiliated, embarrassed, and rejected by others. You can be super preoccupied with offending or boring people. And this is different from being shy. Shyness is feeling anxious or reserved around people. Shy people usually aren't debilitated by their discomfort around others. Just to give you an idea of how granular this can look, here are some of the ways people with social anxiety can adjust their life. You can change the way you walk while people are looking. This can get so bad that you feel immobilized in public because your legs start feeling like jelly and you think you can't use them. If forced to go to a social situation, you ask a lot of questions to avoid needing to talk about yourself. Or you have a list of talking points ready to ask, even if they're not questions that fit well with that particular situation. With social anxiety, starting and maintaining conversation is extremely stressful. And this is how you can appear socially awkward. That awkwardness just reinforces your fear of having to interact with people. School can be atrocious because you can't escape. You're surrounded by critics who have no reason to hold back their judgments. They just let it rip. This is very different from the shy person who's uncomfortable around people. But with the shy person, they can usually overcome any resistances without as much pain as the person with social anxiety. How do we treat social anxiety? The standard treatments are medication and/or cognitive behavior therapy. The medications approved by the Food and Drug Administration for social anxiety are paroxetine, sertraline, fluvoxamine controlled release version, and venlafaxine. And these aren't the only medications we use though. There are other medications that have been shown to be helpful in research studies. These would be escitalopram, vilazodone, gabapentin, and pregabalin. A specific type of social anxiety is performance anxiety. This isn't just nervousness before a piano concert. This can affect your ability to speak in front of a group of people. And the trouble goes beyond worry that you're going to forget some of your talking points. This is a deeper level of fear and embarrassment or fear of being humiliated for just no real apparent reason. For performance anxiety, we will use a medication like propranolol. This is called a beta blocker because it blocks the beta adrenergic receptors in the heart, lungs, and blood vessels. Adrenergic is the same as adrenaline or epinephrine. When you block this response, you get a slower heart rate and an overall calming effect. So if you're someone who goes into a panic or starts stammering or flushing every time you need to speak in front of people, this is a medication that you can take prior to giving your talk to block that physical reaction. Aside from medication, there's cognitive restructuring and exposure therapy. Cognitive restructuring addresses and challenges your distorted thoughts about your fears. With exposure therapy, you're desensitizing yourself to the fearful situation by gradually exposing yourself to these situations in a way that they become less fearful for you. The more you avoid a situation, the more the fear just gets baked in. One way to do this is to build a fear ladder. First, you take an inventory of your fearful situations, and you may have several, but for each situation, you break down the situation into steps that go from somewhat scary to very scary. Here's an example. Let's say you fear going to small social gatherings where people do a lot of small talk, but it's something that you have to do for your job, so you can't avoid it. Here's how you can break this up and rank your fears from low to high. First, you set a reasonable goal to reach once you make it all the way up the ladder. In this case, it's to attend a meet and greet where you don't know anyone, and you have to have a conversation with at least three people. Here's how that ladder might look for you. Step one would be to look at a picture of people chatting at a party. Step two, say hello to the cashier at the store, then say hello to a stranger at the grocery store. This is a little different from saying hello to the cashier because if it's a store where you frequent, the cashier may be someone who's somewhat familiar to you, so that in theory would be a little less anxiety provoking than saying hello to a stranger at that same store or a different store. The next step would be to ask a stranger cashier something about themselves, so now you're getting more personal and it's the start of the small talk. Give a stranger a compliment while looking them in the eye. Ask a co-worker or classmate about their weekend. With this, can you see how the stakes are getting a little bit higher, why this might cause you more anxiety? Because now you're talking to someone that you're going to see again, so there's more risk of you embarrassing yourself or this whole situation humiliating you. The next step on the ladder would be to let yourself be in a group of people talking and then make eye contact with each person while they are talking. Next, join a conversation of people and then have something to say. And the last step would be to ask a stranger for their observations. Are you enjoying the hot weather we're having? You want to practice each step until you become comfortable with each one. You will feel anxious while you're doing this, but if you keep at it, the anxiety will level off. Then you move up the ladder until you get to the last step and feel less anxious. You want to practice these steps often, but you don't want to rush through either. Just keep doing each step until you feel more comfortable moving on to the next one. The number of steps that you have will vary depending on what it is you're trying to accomplish. Now you can do this on your own, but you may need help from a therapist to develop the steps of your ladder. A therapist trained in cognitive behavior therapy can also help combine the cognitive restructuring part with this. A typical course of CBT would be around 16 sessions. There are other methods that people will use like emotional freedom technique or tapping and also neurolinguistics programming or NLP. For some social skills training, take a look at this video that I did on how to talk so people listen.