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6be1ba85d55e-1 | Do you wear certain clothes to hide “defects” that you perceive in your appearance? Do
you purposely end the presentation late so that there is no time for questions? Do you
use videos or slides during the presentation so the focus won’t be on you? Do you avoid
making eye contact with the audience? If you’re attending a party, do you purposely stay
close to someone you know well so that you won’t have to talk to other people? Do you
have a drink or two as soon as you get to the party so that your anxiety doesn’t get too
high? Do you offer to help in the kitchen so you won’t have to talk to the other guests?
Do you take frequent bathroom breaks to avoid being with everyone else? When you’re
talking to other guests at the party, do you ask the other person lots of questions to keep
the focus of the conversation off of you?
All of these are examples of subtle avoidance strategies that people sometimes use in
social situations. As discussed in chapter 1, these behaviors may decrease your anxiety
in the short term by helping you to feel safer. However, in the long term, they typically
have the effect of preventing your anxiety from decreasing naturally over time because | shyness_social.pdf |
431737d8b32d-0 | The Shyness & Social Anxiety Workbook
54they prevent you from learning that the situation can be safe and manageable even
without relying on subtle avoidance strategies. In the spaces that follow, list examples of
subtle avoidance or safety behaviors that you use to manage your anxiety in social situ -
ations. Because these behaviors may differ from situation to situation, there is space to
record these behaviors for up to five different social situations.
Social Situation Subtle Avoidance and Safety Behaviors
Comparing yourself to the “wrong” people. One of the ways in which we evaluate our -
selves is to make comparisons with other people. In school, we ask our classmates how
they did on their exams to get an idea of how our own work compares to that of others.
We are curious about our coworkers’ salaries, in part because having that information is
a way of knowing whether we are being paid fairly.
Research has consistently found that most people compare themselves to others
whom they perceive to be either similar to themselves or slightly better in a particular
dimension. For example, an average student is likely to compare his or her grades to
those of other average students or to slightly better-than-average students. Similarly, a
top athlete tends to compare his or her performance to other top athletes in order to
judge the quality of his or her own performance. This pattern of social comparison makes
sense because it is most likely to provide information you can use to gauge your own
performance. Comparing yourself to someone whom you perceive to be much better or
much worse than you in a particular dimension will provide information that isn’t espe -
cially relevant to you. For example, if you are a musician who plays mostly in local clubs, | shyness_social.pdf |
431737d8b32d-1 | it doesn’t make sense to compare your success to that of the most popular and successful
musicians in the world. Making such comparisons is likely to cause you to feel inadequate
because you will perceive that you can’t possibly compete with the best. | shyness_social.pdf |
5f324109e5d1-0 | Getting to Know Your Social Anxiety
55Research from our center (Antony et al. 2005) suggests that people who are
socially anxious make different types of social comparisons than do those who are less
anxious. Specifically, social anxiety is associated with a tendency to make more frequent
“upward” comparisons. In other words, people who are socially anxious are more likely
to compare themselves to people they perceive as better than they are. The tendency
to make upward comparisons increases the likelihood that an individual will feel worse
after making the comparison.
Can you think of recent examples of when you have compared yourself to someone
whom you perceived to be more attractive, more competent, less anxious, stronger, or
smarter than you are? Or, did you make an upward comparison on some other dimension?
How did you feel afterward? Do you often tend to compare yourself to people whom
you perceive to be ideal or perfect on a certain dimension, rather than people whom you
perceive to be typical or average? In the space below, describe an example of a time when
you compared yourself to someone who was much “better” than you in some way.
COULD YOU BENEFIT FROM IMPROVING YOUR “PEOPLE SKILLS”?
Everyone has times when they give off the wrong impression simply because they
didn’t know how to communicate a particular message to another person or group.
Generally, this is not a big problem unless it happens frequently or in situations where
there is a lot at stake.
In most cases, people who are socially anxious have fine social skills, though they tend
to assume that their social skills are much worse than they actually are. Furthermore, as
their anxiety decreases and they obtain more practice interacting with others in the situ - | shyness_social.pdf |
5f324109e5d1-1 | their anxiety decreases and they obtain more practice interacting with others in the situ -
ations that they fear, their skills tend to improve over time. Following are some examples
of areas where you may want to consider working on improving your skills. This may
prove to be particularly helpful for situations that you have tended to avoid over the
years and therefore may not have had the opportunity to learn some of the subtleties
of navigating your way through the situation. For example, if you have never dated, you
may need some practice before knowing how to ask someone out on a date to maximize
your chances of a positive response. As you read through the examples, try to identify
people skills that you may want to work on. There is space at the end of this section to
record your responses.
Assertiveness. Do you have difficulty being assertive? In other words, is it hard for you
to say no if someone asks you to do something that you don’t want to do? Is it difficult
to ask people to change their behavior if they are treating you unfairly or aren’t doing | shyness_social.pdf |
caf70013e07e-0 | The Shyness & Social Anxiety Workbook
56their share of the work? Most people sometimes find it difficult to deal directly and
assertively with situations like these. However, the more difficulty that you have in situ -
ations that call for assertive communication, the more you have to gain from learning
assertiveness skills.
Body language, tone of voice, and eye contact. Do you have difficulty making eye contact
with other people? Does your tone of voice or body language send the message that you
are not open to interacting with others? Behaviors that convey such messages may include
speaking very quietly or letting your voice drop off at the end of your sentences, standing
far away from other people when you’re talking with them, answering questions with very
short responses, and displaying a “closed” body posture (such as crossing your arms and
legs). Although you may use these behaviors to protect yourself in social situations, they
may actually have the opposite effect by turning others away. If you send the message to
others that you are unavailable, they will be more likely to leave you alone.
Conversation skills. Do you have difficulty knowing what to say when talking to people
at work or school? Is it hard to know how or when to end conversations? Do you find
it difficult to know where the fine line is between appropriate self-disclosure and talking
too much about yourself? Do you often offend other people with comments that you
make? If you have difficulty making small talk or engaging in casual conversations, you
may benefit by working on improving these skills.
Meeting new people. Do you have difficulty knowing what to say when you want to | shyness_social.pdf |
caf70013e07e-1 | initiate contact with new people? Do you have difficulty asking someone out on a date?
Are you at a loss for knowing how and where to meet new people? There are lots of
different places to meet new people and lots of tricks to making meeting people easier.
The first step is identifying whether this is an area that you would like to work on.
Presentation skills. Speaking effectively in public involves a number of complex skills
and behaviors. It’s not enough to be calm and confident. An effective speaker also knows
how to maintain the audience’s interest by using humor and effective audiovisual aids
and handouts, stimulating audience participation, and conveying an interest in the topic.
If you fear making presentations, part of overcoming your fear may include improving
your speaking skills.
In the space below, list any social or communication skills that you might like to
improve.
Social Skills That I Would Like to Develop or Improve | shyness_social.pdf |
f6a3039b46c8-0 | Getting to Know Your Social Anxiety
57HOW MUCH DOES YOUR SOCIAL ANXIETY BOTHER YOU OR
INTERFERE WITH YOUR LIFE?
As we discussed in chapter 1, social anxiety, shyness, and performance-related fears
are only a problem if they interfere with aspects of your functioning or if having the
fear is troublesome for you. So, as part of your self-assessment, it’s important for you to
determine which aspects of your fear trouble you and which don’t. Are there particular
situations for which you are most interested in overcoming your fear? For example, it
may be important for you to overcome your fear of socializing with friends but relatively
less important for you to overcome your fear of speaking in front of large groups if that
situation never arises.
In the space below, record (1) the ways in which your social anxiety interferes with
your functioning (including work or school, social life, relationships, hobbies and leisure
activities, home and family life), (2) the specific aspects of your social anxiety that
you most want to change, and (3) any aspects of your social anxiety that you are not
interested in working on.
Ways in Which Social Anxiety Interferes with My Life
Aspects of My Social Anxiety That I Want to Change
Aspects of My Social Anxiety That I Don’t Want to Change | shyness_social.pdf |
3b43af2dbb9c-0 | The Shyness & Social Anxiety Workbook
58 HOW AND WHEN DID YOUR SOCIAL ANXIETY BEGIN?
How old were you when you first had significant anxiety in social situations? What was
going on at that time in your life?
How old were you when you first noticed that your social anxiety began to interfere with
aspects of your life? What was going on at the time?
What has the course of your social anxiety been over the years? Has it improved, stayed
the same, or worsened? Are you aware of factors that may have caused it to change over
the years (for example, getting married or moving to a new neighborhood)?
Are there specific events that initially caused you to become more nervous in social
situations or made your social anxiety worsen? (Examples may include experiences such
as presentations that didn’t go well, being teased while growing up, or doing something
embarrassing or humiliating in public.) | shyness_social.pdf |
d2dbb5fa3323-0 | Getting to Know Your Social Anxiety
59DOES ANYONE ELSE IN YOUR FAMILY HAVE THIS PROBLEM?
Are you aware of anyone else in your family having problems with shyness, social anxiety,
or performance-related fears? If so, do you think that this had an influence on how you
feel in these situations? If yes, how?
ARE THERE ANY PHYSICAL CONDITIONS THAT CONTRIBUTE TO
YOUR SOCIAL ANXIETY?
For some individuals, certain physical or medical conditions may influence their
tendency to experience social anxiety. For example, people who stutter may be more
nervous when talking to others compared with people who don’t stutter. Often, their
fear is exclusively related to a concern that they will stutter and that others will notice.
Similarly, people suffering from other medical conditions (for example, shaking due
to Parkinson’s disease, having to move about in a wheelchair, not being able to write
neatly due to severe arthritis) may be self-conscious about having others observe their
symptoms.
Other people, although they may not be suffering from a medical condition, may
still have a greater tendency than others to have shaky hands, blush easily, or sweat
excessively, independent of their fears. For these individuals, these reactions tend to be
very intense and may often occur even outside of social situations and when they are not
particularly anxious. Although many people who experience these symptoms at such an
extreme level are not concerned about others noticing, for some, having these extreme
symptoms contributes to their social anxiety.
Do you suffer from any physical conditions or medical illnesses that add to your anxiety
around other people? If so, record the details below.
DIARIES | shyness_social.pdf |
d2dbb5fa3323-1 | around other people? If so, record the details below.
DIARIES
The diaries used to assess social anxiety are usually forms on which individuals record
their anxiety-related symptoms, including frequency of exposure to feared situations, | shyness_social.pdf |
ffeb88577031-0 | The Shyness & Social Anxiety Workbook
60anxiety levels (using a numeric scale such as 0 through 100), uncomfortable physical
sensations such as blushing or shaking, anxious thoughts and predictions (for instance,
“I will make a fool of myself during this presentation”), and anxious behaviors such as
avoidance and distraction. An example of such a diary is the Three Components of
Social Anxiety Monitoring Form, which you completed in chapter 1. Numerous other
forms and diaries are included throughout this book as well. They are designed to be
used while you try the specific treatment techniques described in later chapters.
BEHAVIORAL ASSESSMENTS
The most commonly used type of behavioral assessment for social anxiety is the
Behavioral Approach Test, or BAT. This assessment method involves physically entering
a feared situation and measuring your anxiety and associated symptoms. For example, if
you are afraid of public speaking, you might force yourself to speak at a staff meeting.
After the meeting, you can record the particulars of the situation (who else was there,
how long you spoke for, and so on), your fear level (for example, 80 out of 100), your
anxious thoughts (such as, “My words will come out all jumbled”), and whether you
engaged in any avoidance behaviors (like avoiding eye contact).
If it is too frightening to try this in a real-life situation, or if it is impossible to do
so for another reason, the assessment can be completed in the form of a role-play. In
a role-play, the person acts out the feared situation with the therapist or another indi -
vidual present, instead of being in the real situation. For example, if you are afraid of | shyness_social.pdf |
ffeb88577031-1 | job interviews, you might try to practice a job interview with another person (friend,
family member, or therapist) taking the role of the interviewer. Following the practice,
you would again record the particulars of the situation, your fear level, your anxious
thoughts, and your avoidance behaviors.
Therapists use behavioral assessments because they have several advantages over
traditional forms of assessment, such as interviews and questionnaires. First, they are
less likely to be influenced by people’s difficulties in remembering the details of their
fears. For example, some people may overestimate or underestimate their fear levels if
they are asked to describe their fear during past exposures to feared situations. Their
memories may be influenced by a particularly negative experience in a feared situation
and, as a result, they may report that their fear is actually higher than it typically is.
Also, people’s memories regarding their reactions in the situations they fear may be poor
simply because they typically avoid the fearful situation, making it difficult to know for
sure how they feel when they are exposed to the situation.
Another advantage of the behavioral approach test is that it allows the therapist and
the individual to directly observe anxious thoughts and behaviors that might otherwise
go unnoticed. It also allows the therapist to independently assess the extent to which the
client’s shaking, blushing, or sweating is actually noticeable to others. | shyness_social.pdf |
accb51b838f4-0 | Getting to Know Your Social Anxiety
61Can you think of a behavioral approach test or role-play that you can set up for
yourself? For example, if you are fearful of speaking up in a meeting, try doing it anyway.
Immediately after the meeting, record your physical symptoms, anxious thoughts, and
the avoidance behaviors that took place while you were conducting the practice. Did it
go better than you expected it to go? Was it worse? Was it about what you expected?
TROUBLESHOOTING
You may find that your self-assessment does not go as smoothly as you might like. Here
are some common problems that may arise during your self-assessment, as well as some
solutions, suggestions, and words of reassurance.
Problem: I didn’t know the answers to all the questions.
Solution: That’s to be expected. As you progress with the treatment, you will have
an opportunity to become better acquainted with your social anxiety.
Self-assessment is an ongoing process, and it’s not necessary to have all
the answers before you start to work on changing your social anxiety. In
fact, there may be some questions that you will never know the answers
to, and that’s okay. The purpose of this chapter is just to help you better
understand the areas that are causing you the most difficulty.
Problem: Answering these questions increased my anxiety.
Solution: This is quite common. Conducting a self-assessment forces you to pay
attention to the thoughts that contribute to your anxiety. This effect of
increased anxiety tends to be temporary. As you progress through the
treatment procedures discussed throughout this book, it is likely you
will find that focusing on the thoughts and feelings associated with your | shyness_social.pdf |
accb51b838f4-1 | will find that focusing on the thoughts and feelings associated with your
social anxiety will become less anxiety provoking.
Problem: My answers to these questions depend on many different variables, so I
find it difficult to come up with a response to certain questions.
Solution: This concern is often raised by people who are undergoing an assessment.
Questions are often difficult to answer because the responses depend
on so many different factors. For example, the question, “How fearful
are you of public speaking?” may depend on such things as the topic
of the presentation, the number of people in the audience, the lighting
in the room, the length of the presentation, how prepared you are, and
many other factors. We suggest that you handle difficult questions by
estimating your response based on a typical or average situation. So,
if your fear of public speaking ranges from 30 to 70 depending on the
situation, you could put down 50. If you prefer, you could just record
the range “30 to 70” which would be more precise. | shyness_social.pdf |
a8a1702e2e2b-0 | The Shyness & Social Anxiety Workbook
62After reading this chapter, you should have a better understanding of the nature of
your social anxiety. You should be more aware of the types of social situations that you
fear and avoid, the variables that affect your discomfort level, the physical sensations
that you experience when you are anxious, the thoughts and behaviors that contribute to
your fear, and the ways in which social anxiety interferes with your life. Understanding
these aspects of your social anxiety will help you to choose the best strategies for over -
coming your fear as you work your way through the rest of this book. | shyness_social.pdf |
2ad940b4c39d-0 | PART 2
How to Overcome Social
Anxiety and Enjoy Your Life | shyness_social.pdf |
37465d7fe6f3-0 | CHAPTER 4
Making a Plan for Change
This chapter will help you to consider the range of factors that are important for devel -
oping a treatment plan. These factors include deciding whether this is the best time for
you to work on your social anxiety, addressing the issue of motivation and readiness for
change, selecting treatment goals, trying to understand why treatment may or may not
have worked in the past, and understanding your current options for treatment.
IS NOW THE BEST TIME TO START
THIS PROGRAM?
In some ways, it may seem as if there is never a good time to begin a new project.
There are almost always competing demands that make it difficult to find free time or
extra energy to start something new. Work may be unusually busy, you may be getting
over a cold, or your children may be a handful right now. Although the time may not
be perfect, you will need to decide whether it is even a possibility for you to start this
program given your current life circumstances. Your chances of getting the most out of
this book will depend on your answering yes to the following questions:
UÊAre you motivated to become less shy or to decrease your social anxiety?
Is this something you really care about?
UÊAre you willing to feel even more anxious in the short term in order to feel
more comfortable in social and performance situations in the future? | shyness_social.pdf |
ada66023ed9c-0 | The Shyness & Social Anxiety Workbook
66UÊAre you able to put aside, at least to some extent, other major problems and
stresses in your life (things such as family problems or work stresses) so that
you can focus on learning to manage your social and performance anxiety?
UÊAre you able to set aside several blocks of time several days per week to
practice the techniques described in this book?
Hopefully, after carefully considering these questions, you will make a commitment
to work on overcoming your social anxiety. However, you may also decide that this
is not the best time for you to work on the problem and that you would rather wait
until your life situation changes. If that is the case, you may still find reading this book
helpful because it contains strategies that can be used from time to time, as you need
them. However, making big changes will require using the techniques described in this
book frequently and consistently. The next section will help you further as you decide
whether to work on your anxiety at this time.
MOTIVATION AND READINESS FOR CHANGE
Experts have identified five stages that people go through as they contemplate making
a change in behavior, such as quitting smoking, losing weight, or improving their work
habits (Prochaska, DiClemente, and Norcross 1992). The model describing these stages of
change is often referred to as the transtheoretical model of change. These five stages include:
1. Precontemplation . At this stage, people are unaware that they have a problem
or they have no intention of changing, either because they are unwilling to
change or they are convinced that change is impossible. An example would | shyness_social.pdf |
ada66023ed9c-1 | change or they are convinced that change is impossible. An example would
be someone who is very overweight and is convinced that nothing can be
done about it. (So why bother trying?)
2. Contemplation . At this stage, the individual intends to change sometime
soon (for example, in the next six months). The person is aware of the ben -
efits of changing but is also still focused on the possible costs. An example
is a smoker who’s thinking about quitting in a few months.
3. Preparation . At this stage, the person is ready to change in the near future
(for example, in the next month). The benefits of change are much more
obvious to the person than the costs of changing. An example is someone
who has decided to join a gym in a couple of weeks to become more fit.
4. Action . At this stage, the individual actually takes steps to change a problem
behavior. For example, an individual who feels depressed might start to see
a therapist for depression. | shyness_social.pdf |
c9ab5fce22c1-0 | Making a Plan for Change
675. Maintenance . At this stage, the individual has made the change and is taking
steps to prevent the problem behavior from returning. An example would be
an individual with a history of problem drinking who has now been sober for
six months and has stopped spending time with people who drink excessive
amounts of alcohol.
Although this model has been studied mostly in people who are working on chang -
ing health habits (for example, exercise, diet, substance abuse, improving medication
compliance), it can also be applied to your treatment for shyness and social anxiety. The
further along you are with respect to these stages of change, the more likely you will
be to benefit from the strategies described in this book. For example, if you are in the
action stage, you will likely get more out of this book than if you are at the precontem -
plation stage and have no intention of making any changes.
Of course, these stages overlap with one another, and deciding which stage you are
in is not always so clean cut. In fact, you may be at a different stage for different aspects
of your social anxiety. You may be convinced that it is completely impossible that you
will ever be able to date (precontemplation), but you may be thinking about working on
finding a better job over the next few months (contemplation). You may also have already
signed up for a night class so you can start to meet new friends (action). Fortunately, as
you make changes in some areas, you may discover that you become more ready to make
changes in other areas as well.
Success at changing your social anxiety will require that you are willing, able, and | shyness_social.pdf |
c9ab5fce22c1-1 | Success at changing your social anxiety will require that you are willing, able, and
ready to take action (Miller and Rollnick 2002). Being willing means that the change is
important to you, and that this is a change you want to make. Being able means that you
are confident in your ability to make the change (once you have been given the right
tools and strategies). Being ready means that this is a high priority for you, and that you
are prepared to put other priorities aside for now in order to get this done. Use the scale
below to rate the extent to which you are willing, able, and ready to make this change.
For each rating, you may use any number from 0 to 100.
0 10 20 30 40 50 60 70 80 90 100
Not
at AllA
LittleModerately Very
MuchCompletely
Willing (rate from 0 to 100)
Able (rate from 0 to 100)
Ready (rate from 0 to 100) | shyness_social.pdf |
69c80aa34c1c-0 | The Shyness & Social Anxiety Workbook
68COSTS AND BENEFITS OF OVERCOMING
YOUR ANXIETY
For the majority of people, the benefits of using the strategies described in this book
will far outweigh the costs. If you didn’t believe that, you probably wouldn’t be reading
this book. Still, you may have mixed feelings about changing, and therefore it may be
helpful to think about your reasons for change, as well as your reasons for not changing.
We will start with a discussion of the potential costs of change.
Costs of Overcoming Your Social Anxiety
In this section, we discuss the costs of changing. As you go through this section,
notice that these potential costs are mostly short-term inconveniences that are only
present while you are actively working on your anxiety. As your anxiety improves, these
costs will fade as well. Also, instead of thinking about these as costs, it is helpful to think
of them as challenges . After all, most of these costs are manageable, and there are often
possible solutions available to minimize their impact.
Costs of medication treatments. If you choose to use medications, you will have to
remember to take them regularly, and newer medications may be expensive, particularly
if they are not covered by your health plan. You may experience side effects. Depending
on the medication, side effects may include fatigue, headaches, changes in weight and
appetite, and changes in sexual functioning. Of course, as you will learn in chapter 5,
many of the side effects associated with medications are worst in the first few weeks,
improve over time, and are generally quite manageable. Side effects can also be mini -
mized by adjusting doses, changing medications, or stopping medications altogether. | shyness_social.pdf |
69c80aa34c1c-1 | mized by adjusting doses, changing medications, or stopping medications altogether.
Costs of psychological treatments. Psychological treatments, such as confronting the
situations that you fear, are also associated with costs. First, they are time-consuming.
To get the most out of exposure-based treatments, for example, you may need to prac -
tice for an hour or more, three to five days per week. Also, psychological treatments
can be expensive (especially in the short term), depending on your insurance coverage
and the fees charged by the therapist. In addition, conducting exposure practices will
probably make you feel anxious and uncomfortable, particularly at the start. Although
the exercises are designed so that the discomfort is usually manageable, at times your
fear may be intense. In addition to feeling uncomfortable, you may feel more tired, espe -
cially on days when you practice confronting situations that make you uncomfortable.
You also may feel irritable and perhaps even have anxiety-provoking dreams. Finally,
your improvement may not follow a smooth course. It is likely the changes will take
time and you may have periods (days, weeks, or even months) during which you feel as
though you’re slipping backward. For many people this is a normal part of the process | shyness_social.pdf |
8bb64f625400-0 | Making a Plan for Change
69of overcoming social anxiety. By continuing to use the strategies described in this book,
however, your anxiety should continue to improve over time.
Other possible costs of improving. Overcoming your anxiety may also have an impact
on other areas of your life. In most cases, the impact will be positive, but there may be
some costs associated with these changes as well. If you are in a long-term relationship,
you might find that your partner will need time to adjust to the changes you are making.
For example, as you become more comfortable socializing, you may be out more often
with friends or coworkers. If your partner is accustomed to having you around most of
the time, these changes may require some getting used to. It may be helpful to discuss
the changes that you are making openly with your partner, friends, and family members,
if appropriate. This will demonstrate to them that you are sensitive to how the improve -
ments in your social anxiety may affect them.
Can you think of other possible costs of overcoming your social anxiety, shyness, or
performance-related fears? If so, record them in the following space.
Benefits of Overcoming Your Social Anxiety
Fortunately, there are also benefits of overcoming your social anxiety. As we men -
tioned in the last section, the costs of overcoming your anxiety are usually just short-
term inconveniences. On the other hand, the benefits of change tend to be much more
long lasting. What this book challenges you to do is to decide whether you are willing to
tolerate some short-term pain, to achieve long-term gains. Examples of potential benefits
of overcoming your shyness and social anxiety include the following: | shyness_social.pdf |
8bb64f625400-1 | of overcoming your shyness and social anxiety include the following:
UÊLearning to feel more comfortable in feared social and performance
situations
UÊMeeting new friends
UÊImproving the quality of your relationships
UÊLearning to network more comfortably in situations related to your job or
career
UÊExpanding the possible options for what you can do in your leisure time | shyness_social.pdf |
54e140729a8e-0 | The Shyness & Social Anxiety Workbook
70UÊImproving your job prospects (for instance, realizing new opportunities to
get a promotion or to seek a higher-paying position)
UÊOpening up some opportunities for self-improvement by furthering your
education
UÊLearning to increase your enjoyment of life
UÊFeeling more confident
UÊIncreasing your ability to express yourself
UÊLearning strategies that you may be able to apply to other problems, such
as anger, depression, or a troubled relationship
Based on this list of examples, or others that you can identify, can you think of
benefits that would result from overcoming your social anxiety? Focus on benefits that
are based on your own internal values and goals (for example, “I want to have closer friend -
ships”), rather than the values and goals of others (for example, “My mother wants me
to make new friends”). Questions like the ones listed below can be useful as you identify
your own reasons for changing:
UÊHow would I like my life to be different in five years?
UÊWhat would be better about my life if I felt more comfortable in social
situation s?
UÊWhat type of person would I like to be, and how is my social anxiety pre -
venting me from being that type of person?
UÊWhat sorts of things do I miss about my life before social anxiety became
as big a problem as it is now?
Record your reasons for changing in the space below.
Now that you have had a chance to consider the costs and benefits of working on
your social anxiety, you are in a better position to make a commitment to working on | shyness_social.pdf |
54e140729a8e-1 | your social anxiety, you are in a better position to make a commitment to working on
overcoming your fears. Assuming that you have decided to go ahead as planned, the
remainder of this chapter will help you to consider the strategies best suited to your
individual needs. | shyness_social.pdf |
6e0074e02958-0 | Making a Plan for Change
71SETTING GOALS FOR CHANGE
Without setting specific goals or objectives, it will be impossible for you to evaluate
whether you’re making the changes that you hope to make. Goals can be described in a
number of different ways. First, goals can reflect either short-term or long-term changes that
you would like to accomplish. For example, if you have a fear of public speaking, a rea -
sonable one-week goal might be to ask a single question at a meeting at work, regardless
of how anxious you feel. A six-month goal might be to give a thirty-minute presentation
without feeling significant anxiety. As you go through the process of overcoming your
social anxiety, it is important to identify short-term goals (for example, what you want to
accomplish this week), medium-range goals (such as what you want to accomplish over
the next few months), and long-range goals (for instance, what you want to accomplish
over the next year or two).
Goals also can be described either as specific or general . A specific goal is more detailed
than a general one. Therefore, specific goals are often better suited for guiding you in
selecting appropriate treatment strategies, compared with general goals. Also, with spe -
cific goals, it is easier to measure whether your objectives are being met. Although it is
okay to have a few general goals, you also should try to generate as many specific goals
as possible. Examples of general and specific goals are listed below.
General Goal Specific Goal
To be more comfortable during
presentationsTo have my fear level during presentations at my | shyness_social.pdf |
6e0074e02958-1 | To be more comfortable during
presentationsTo have my fear level during presentations at my
weekly sales meetings decrease from a level of 100
out of 100 to a level of 40 out of 100
To ask someone on a date
sometimeTo ask John (or Jane) to have dinner with me by the
end of this month
To have more friends To meet at least three new friends by the end of this
year, with whom I can see movies or watch sports
To be comfortable in crowds To be able to walk through a crowded mall or on a
crowded street with my fear below a 30 or 40 out
of 100
To cope better with criticism To be able to tolerate negative feedback on my
annual performance review at work without becom -
ing very upset and while still paying attention to all
my positive achievements over the year
To ask questions in class To ask at least one question during each class over
the rest of this semester
To deal better with groups To be able to make small talk at a party while main -
taining eye contact and speaking loudly enough for
others to hear | shyness_social.pdf |
28dff71a6120-0 | The Shyness & Social Anxiety Workbook
72Now, think about what types of changes you would like to make. Specifically, think
about aspects of your social anxiety (anxious beliefs, situations that you avoid, and so
on) that you would like to change. Try to be realistic. Also, recognize that your goals
may change. For example, right now you may not need to make presentations in your
daily life. However, if you take a job that involves public speaking, your goals may have
to be revised later to reflect this change.
We have included space for you to record your goals for the next month as well as
your goals for one year from now. Of course, if you prefer, you may choose other time
periods. The main point to remember is that you may have different short-term and
long-term goals. Although some goals may be realistic targets for a year or two from
now, they may not be realistic goals for one week or one month from now.
One-Month Goals
1.
2.
3.
4.
5.
6.
7.
8.
9.
10. | shyness_social.pdf |
a60bccfa81de-0 | Making a Plan for Change
73One-Year Goals
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
REVIEWING PREVIOUS ATTEMPTS TO TREAT
YOUR SOCIAL ANXIETY
This section has two purposes. First, if you’ve tried to overcome your social anxiety in
the past, it will help you review the treatments that worked for you and those that were
not especially helpful. Second, this section will help you to identify possible reasons
why certain previous attempts to overcome your social anxiety were not useful, if this
was your experience. By identifying the reasons for previously successful and not-so-
successful treatment attempts, you will be able to make more educated decisions about
what types of strategies to try now. If a treatment has worked well in the past, you may
want to try it again. If you did not benefit from a particular treatment previously, you
may want to try something new. However, you should still consider giving a particular
treatment another try if you didn’t give it a fair chance the first time.
In the spaces that follow, check off any treatments that you have tried in the past.
Also, describe the treatment and record whether the outcome was helpful. | shyness_social.pdf |
783ea8c3345c-0 | The Shyness & Social Anxiety Workbook
74Record of Previous Treatments
Yes No Treatment
Medications
If yes, list drug names, duration of treatment, and maximum dosage
for each. Also, describe any side effects that you experienced and
whether or not each medication helped. Indicate if you took the
medication as prescribed.
Exposure to Feared Situations
If yes, describe the treatment (including frequency of exposures,
duration of treatment, types of situations practiced in, outcome).
Cognitive Therapy (This therapy is focused on teaching strategies for
changing anxious thinking; it usually includes completion of thought
records as a component.) If yes, describe the treatment (including
duration of treatment, outcome).
Skills Training (This might include assertiveness training or a public
speaking or communications course.) If yes, describe the treatment
or course content (including duration of treatment, outcome). | shyness_social.pdf |
9241d296ffff-0 | Making a Plan for Change
75
Insight-Oriented Therapy (This therapy is focused on early-childhood
experiences and on helping you to understand the deep causes
underlying a particular problem.) If yes, describe the treatment
(duration of treatment, outcome).
Supportive Therapy (In this fairly unstructured therapy, the client
describes experiences over the past week and the therapist offers
support and perhaps suggestions for solving problems that arise
from week to week.) If yes, describe the treatment (duration
of treatment, outcome).
Self-Help Book
If yes, describe the treatment. (For instance, what book/s did you
read? What approach did the book take? Did it help?) | shyness_social.pdf |
31092df4ddfb-0 | The Shyness & Social Anxiety Workbook
76Now that you have identified specific treatments you have tried in the past, the next
step is to understand why a treatment was ineffective or only partially effective, if that
was your experience. Listed below are some of the reasons why psychological treatments
and medications are occasionally not helpful.
Why Psychological Treatments Sometimes Don’t Help
UÊThe therapy is an ineffective treatment for social anxiety. Many types of
psychotherapy have never been studied for the treatment of social anxiety,
and others have been found to be of little benefit. (Cognitive behavioral
therapy is the best-studied approach and is well supported.)
UÊThe therapist is inexperienced either with the type of therapy being offered
or the treatment of shyness and social anxiety, in particular.
UÊThe frequency and intensity of exposure practices is too low. If you practice
exposure to social situations too infrequently, you will be less likely to see
the desired results.
UÊThe treatment does not last long enough. You may not have benefited from
previous therapy if you dropped out of treatment before positive results
could be seen.
UÊAn individual expects the treatment to be ineffective. There is evidence that
a person’s expectations can affect the outcome of psychotherapy (Safren,
Heimberg, and Juster 1997).
UÊThe person does not comply with the treatment. If you miss sessions, arrive
late for sessions, or don’t complete homework, therapy is less likely to be
effective.
UÊThere are other problems or stresses in the person’s life that interfere with
treatment (for example, severe depression, alcohol abuse, stressful job, | shyness_social.pdf |
31092df4ddfb-1 | treatment (for example, severe depression, alcohol abuse, stressful job,
marital problems, health issues).
Why Medications Sometimes Don’t Help
UÊIt is the wrong medication for the problem. Some medications have been
shown to be more effective than others for treating social anxiety (see
chapter 5). Furthermore, a medication that works for one person may not
be the best choice for someone else.
UÊThe medication dosage is not high enough.
UÊThe treatment does not last long enough. Some medications can take up to
six weeks to have an effect. Also, stopping certain medications too soon can
increase the chances of the anxiety coming back. | shyness_social.pdf |
81b09d1ccbf9-0 | Making a Plan for Change
77UÊAn individual expects the treatment to be ineffective. As with psychother -
apy, there is evidence that a person’s response to medication is affected by
his or her expectations.
UÊThe side effects are too unpleasant to tolerate.
UÊThe person is using drugs, drinking alcohol, or taking other medications
that influence the effects of the medication for social anxiety.
UÊThe person doesn’t comply with the treatment (for example, misses pills).
If you have tried to overcome your social anxiety in the past, but found treatment
to be ineffective or only partially effective, do you have any guesses about why it may
not have worked as well as you had hoped it would? Based on your previous experiences
with therapy or medication, are there strategies that you want to try again?
1.
2.
3.
Are there strategies that you definitely don’t think you should try again?
1.
2.
3.
PROVEN STRATEGIES FOR OVERCOMING
SOCIAL ANXIETY
There are hundreds of different approaches that people have used to overcome emo -
tional difficulties, behavior problems, and bad habits. Some of these approaches include
psychotherapy, medications, prayer, relaxation training, yoga, hypnosis, distraction,
drinking alcohol or using drugs, exercise, changing diet, reward and punishment, herbal
remedies, traditional remedies, acupuncture, education and reading about the problem,
past-life regression, and so forth. Furthermore, each of these methods can be subdivided
into even more categories. For example, there are many different types of psychotherapy | shyness_social.pdf |
81b09d1ccbf9-1 | into even more categories. For example, there are many different types of psychotherapy
and medications, some of which are more useful than others for a particular problem. | shyness_social.pdf |
094c7386b4dd-0 | The Shyness & Social Anxiety Workbook
78Given all of the different available options, it can be very difficult for a consumer to
select the best approach for overcoming a particular problem.
For most of the methods listed previously, there is almost no controlled research
examining their use in treating anxiety in general and social anxiety in particular. The
term controlled is used to describe studies in which the investigators have examined the
effects of a particular treatment while taking steps to ensure that any improvements that
occur are, in fact, due to the treatment, rather than to other factors. Note that a lack
of controlled research does not mean that a particular treatment is ineffective. It simply
means we just don’t know whether the treatment works or how well it works.
Even if someone seems to improve after using one of these methods, it can be dif -
ficult to know whether it was the treatment that had a beneficial effect or whether other
factors contributed to the change. For example, as we mentioned earlier, someone’s
expectations of improving during treatment can affect his or her improvement. Other
reasons why people might improve with a particular treatment may include the passage
of time. For some types of problems (such as depression), the symptoms may improve
naturally over time, regardless of whether the sufferer receives any specific treatments.
Changes in a person’s normal routines (for instance, a reduction of stress at work) also
can contribute to improvements over and above any treatment effects.
Properly controlled research can help to determine whether the effects of a treat -
ment are indeed due to the treatment rather than to other factors. One strategy used by
researchers is the inclusion of a control group. For example, research studies that examine | shyness_social.pdf |
094c7386b4dd-1 | researchers is the inclusion of a control group. For example, research studies that examine
the effects of a medication on a particular problem usually give a percentage of the individ -
uals in the study a placebo , which is, essentially, a pill that contains no real medication. This
group is called the placebo control group . Typically, neither the doctor nor the patient knows
whether the person is taking a placebo or the real medication until after the study ends.
The test of whether a medication is helpful depends on how well people who took
the medication respond compared with those who took the placebo. Including a placebo
control group allows the researcher to directly measure the effects of the medication over
and above the effects of the individual’s expectations about the treatment. Properly con -
ducted studies examining the effects of psychological treatments also include appropriate
control groups to aid in understanding why a particular treatment may appear to work.
In this book, we have chosen to focus on techniques that have been shown in con -
trolled research to be effective for helping people to overcome problems with social
anxiety, shyness, and performance-related fears. In other words, these techniques have
been shown to be effective compared with no treatment, placebo treatments, other forms
of psychotherapy, or other appropriate control groups. The techniques we will focus on
include two main groups of strategies: cognitive behavioral therapy and medications.
Cognitive Behavioral Therapy
Cognitive behavioral therapy, or CBT, includes a group of techniques that are usually
used together as a package. Numerous studies have shown that CBT is an effective | shyness_social.pdf |
3396ecdd3622-0 | Making a Plan for Change
79way of overcoming social anxiety (for reviews, see Antony and Rowa 2008; Rodebaugh,
Holaway, and Heimberg 2004). Cognitive behavioral therapy differs from other more
traditional forms of therapy in the following ways:
UÊCBT is directive. In other words, the therapist is actively involved in the
therapy and makes very specific suggestions.
UÊCBT’s focus is on changing a particular problem. Some other forms of therapy
focus on helping the individual develop insight into or understanding of the
deep-rooted causes of a problem but do not offer specific strategies for
overcoming the problem.
UÊCBT has a relatively brief duration. The typical course for social anxiety is
ten to twenty sessions.
UÊCBT focuses on current beliefs and behaviors, which are thought to be
responsible for maintaining the problem. Some traditional therapies tend to
focus more on early childhood experiences.
UÊIn CBT, the therapist and client are partners and work together during
treatment.
UÊIn CBT, the client chooses the goals for therapy, with input from the
therapist.
UÊCBT usually includes strategies for measuring progress so that treatment
techniques can be adjusted for maximum effectiveness.
UÊCBT involves changing beliefs and behaviors so that the client is able to
better manage anxiety and to navigate anxiety-provoking situations.
Cognitive behavioral therapy for social anxiety includes three main types of strat -
egies. Treatment almost always includes cognitive therapy and exposure to feared
situations. In addition, social-skills training is sometimes included.
COGNITIVE THERAPY
The term cognitive refers to anything having to do with assumptions, beliefs, predic - | shyness_social.pdf |
3396ecdd3622-1 | The term cognitive refers to anything having to do with assumptions, beliefs, predic -
tions, interpretations, visual imagery, memory, and other mental processes related to
thinking. The basic underlying assumption of cognitive therapy is that negative emotions
occur because people interpret situations in a negative or threatening way. For example,
people who are convinced that others will judge them in a negative way or who are
overly concerned about the opinions of others are bound to feel anxious or uncomfort -
able in certain social situations. Cognitive therapy teaches individuals to be more aware
of their negative thoughts and to replace them with less negative thoughts. People learn | shyness_social.pdf |
86c07e400738-0 | The Shyness & Social Anxiety Workbook
80to treat their beliefs as guesses about the way things may be, rather than as facts. They
are taught to examine the evidence supporting their anxious beliefs and to consider the
possibility that an alternative belief is true.
For example, if Henry is very hurt and angry because a friend didn’t return his call,
these negative feelings might stem from Henry’s belief that the friend doesn’t care about
him. In cognitive therapy, Henry would be taught to consider alternative explanations
for the friend’s behavior, including the possibility that the friend never received the
message, forgot to return the call, or is out of town. After all, there are many possible
reasons why a caring friend might not have returned Henry’s call quickly.
At the beginning of treatment, diaries are used to record anxious thoughts and to
counter them with more realistic predictions and interpretations. As people become
more comfortable with the methods of challenging their unrealistic negative beliefs, their
new ways of thinking become more automatic and the diaries are no longer needed.
People learn to manage their anxious thoughts before they get out of control. Cognitive
therapy techniques are described in detail in chapter 6.
EXPOSURE
Exposure involves gradually and repeatedly confronting feared situations until they
no longer trigger fear. In most cases, exposure is viewed as a necessary component of
CBT. In fact, exposure may be even more powerful than cognitive therapy as a way of
changing anxious negative thinking. By exposing yourself to situations you fear, you
will learn that the risk in these situations is minimal. Through direct experience, many
of your anxious predictions and beliefs will be proven incorrect. You will also learn
to better tolerate situations in which some of your beliefs actually may be true (for | shyness_social.pdf |
86c07e400738-1 | to better tolerate situations in which some of your beliefs actually may be true (for
example, when another person actually does judge you negatively). Finally, exposure will
provide you with an opportunity to practice your cognitive therapy skills and to improve
upon any social or communication skills that may be rusty from having avoided social
situations for so long. See chapters 7 through 9 for detailed instructions for designing
and implementing exposure exercises.
IMPROVING SOCIAL SKILLS
Social-skills training refers to the process of learning to improve the quality of your
communication as well as other social behaviors, so there will be an increased likelihood
of obtaining a positive response from others. Note that most people who are socially
anxious have better social skills than they think they do. In fact, formal social-skills train -
ing is often not included in CBT programs, and people undergoing the treatment still
respond quite well. Still, there is evidence that some people can benefit from learning a
few new techniques to become more assertive, make small talk more effectively, improve
their eye contact, and learn basic skills for dating or meeting new people. Chapter 10
describes strategies for improving social and communication skills. | shyness_social.pdf |
8d7e3fae0361-0 | Making a Plan for Change
81Medications
Numerous medications have been shown to be effective for treating social phobia
(Van Ameringen, Mancini, and Patterson, in press). Mostly, these include certain anti -
depressants that also target anxiety (such as paroxetine and venlafaxine) and certain
anti-anxiety drugs (for instance, clonazepam). Typically, medications are taken on a
daily basis. To varying degrees, all medications are associated with certain side effects.
However, for most people, these side effects are quite manageable and most tend to
decrease over time.
Other Treatments
There are a number of other therapies that have preliminary or limited research
support for treating social anxiety. Some of these treatments are quite new, and all of
them have only been investigated in one or more studies for social anxiety (most of
which are not controlled studies). Though it is too early to know if these therapies are as
effective as CBT and medications, here are some brief descriptions of these approaches:
MINDFULNESS TRAINING
Mindfulness training involves learning to focus on one’s present experiences (for
example, thoughts and feelings) without judging them or trying to change them and
without dwelling on the past or anticipating the future (see Orsillo and Roemer 2005).
Meditation is often a component of mindfulness training. Preliminary evidence sup -
ports the use of mindfulness for treating general worries (Roemer and Orsillo 2007)
and for preventing relapse in depression (Williams et al. 2007). Evidence from a recent
pilot study suggests that mindfulness training may be useful for treating social anxiety
(Bögels, Sijbers, and Voncken 2006).
ACCEPTANCE AND COMMITMENT THERAPY (ACT) | shyness_social.pdf |
8d7e3fae0361-1 | ACCEPTANCE AND COMMITMENT THERAPY (ACT)
ACT is a relatively new form of therapy that is related to mindfulness training in
that a goal of this treatment is to teach people to accept their experiences (includ -
ing emotions, thoughts, imagery, and other experiences) rather than trying to control,
fight, or change them (Hayes and Smith 2005). Mindfulness training is used as part of
ACT, but other strategies are used as well. In addition to acceptance, people receiving
ACT are also encouraged to make a commitment to live a life that is consistent with
their own values and goals, which typically involves changing behaviors. Though ACT
is often presented as an alternative to CBT, it actually overlaps with CBT quite a bit.
For example, ACT for anxiety and CBT for anxiety both use exposure as a component
(Eifert and Forsyth 2005). A preliminary, uncontrolled study suggests that ACT may
lead to reductions in social anxiety (Ossman et al. 2006). | shyness_social.pdf |
e39e5a95fd85-0 | The Shyness & Social Anxiety Workbook
82APPLIED RELAXATION TRAINING
Applied relaxation involves the combination of learning to relax the muscles of the
body with exposure to increasingly challenging situations. A few studies suggest that
applied muscle relaxation may be useful for social anxiety (Jerremalm, Johansson, and
Öst, 1980; Osberg 1981). However, it is difficult to know whether this approach is effec -
tive because of the relaxation component, the exposure to feared situations, or both.
There are no studies investigating whether relaxation training adds any benefit over and
above the effects of exposure alone.
INTERPERSONAL PSYCHOTHERAPY (IPT)
IPT is a brief therapy that focuses exclusively on interpersonal aspects of a person’s
problem, such as problems in the individual’s relationships with others. IPT has been
studied primarily in people who are depressed, and it’s been shown in a number of well-
controlled studies to be an effective treatment for depression, as well as certain other
problems (Weissman, Markowitz, and Klerman 2007). Because of the interpersonal focus
of IPT, some researchers have wondered whether it might also be effective for treating
social anxiety. A preliminary, uncontrolled study (Lipsitz et al. 1999) suggests that IPT
may be useful for treating social anxiety, though more research is needed.
CHOOSING AMONG TREATMENT OPTIONS
If you decide to try medications, you will probably need to get a prescription from a
physician—usually your family doctor or a psychiatrist. However, note that in some
states other professionals (for example, nurse practitioners) may be able to prescribe
medications. In fact, two states (New Mexico and Louisiana) now allow psychologists | shyness_social.pdf |
e39e5a95fd85-1 | medications. In fact, two states (New Mexico and Louisiana) now allow psychologists
with appropriate training to prescribe medications as well. For most people, a visit to
your family doctor is a good place to start if you are interested in trying medications.
He or she can make a referral to a psychiatrist or other professional if needed. If you
are interested in trying a psychological treatment such as CBT, you have the option of
trying to overcome the problem on your own or seeking professional help.
Self-Help or Professional Help?
For some people, a self-help approach such as that described in this book may be
sufficient. In fact, a study by Moore, Braddock, and Abramowitz (2007) found that
most people who used the first edition of this book achieved significant reduction in
their social anxiety, even without any additional therapy. However, for others, a self-help
book alone is not enough, and many people find that the added structure and support
provided by a therapist is important. If you decide to seek professional help, this book | shyness_social.pdf |
a35a1c4724e9-0 | Making a Plan for Change
83can still help to reinforce what you learn in therapy. An important part of CBT involves
educating the client (often using self-help readings) and encouraging the client to prac -
tice the various CBT techniques between sessions. In other words, CBT conducted with
a therapist often includes a self-help component. Combining a self-help book with your
therapy may even reduce the number of therapy sessions needed (Rapee et al. 2007).
For more information on finding a therapist, see the section on seeking professional help
that appears later in this chapter.
Cognitive Behavioral Therapy or Other Psychotherapy?
In almost all cases, we recommend cognitive therapy and exposure as the psycho -
logical treatment of choice for social phobia. Adding social-skills training to the program
may be useful for some individuals as well. As for other psychological therapies, although
they certainly have a place for treating certain types of problems, they are not sufficiently
proven when it comes to treating social phobia and other anxiety-related conditions.
Some people with whom we have worked have reported benefits from combining
CBT with another form of psychotherapy. In these cases, typically they have seen one
therapist for CBT and another for dealing with other issues (for example, marital prob -
lems, coping with childhood abuse). Although this approach sometimes works well, we
recommend that your two therapists stay in close contact with each other so that they
can ensure they are not giving you contradictory messages during therapy.
Medication or CBT?
A number of studies have investigated whether CBT, medications, or their combina -
tion work best (Antony and Rowa 2008). Although there are some differences across | shyness_social.pdf |
a35a1c4724e9-1 | studies, the overall pattern of findings has been that all three of these approaches are
about equally effective, at least in the short term. For example, in the largest study
conducted to date, CBT, fluoxetine (an antidepressant), and a combination of fluoxetine
and CBT were all found to be about equally effective and were all more effective than
placebo (Davidson et al. 2004).
Although these approaches are about equally effective in the short term, CBT tends
to be a more effective treatment than medications over the long term (Liebowitz et al.
1999). In other words, once all treatments have stopped, people who have been only
taking medications are more likely to experience a return of symptoms than people who
had CBT.
Also, just because these three approaches are about equally effective on average , that
doesn’t mean that they are equally likely to be effective for you . Some people seem to do
better with medications, whereas others seem to do best with CBT or a combination of
these approaches. The approach we usually recommend is to start with either CBT or
medication, and then introduce the other treatment after several months, if needed. | shyness_social.pdf |
851dc23ccd57-0 | The Shyness & Social Anxiety Workbook
84Group or Individual Therapy?
Cognitive behavioral therapy can be delivered either individually or in groups. Both
approaches work well. Although most studies have found group and individual thera -
pies for social anxiety to be about equally effective, some have found an advantage for
individual therapy (for a review, see Bieling, McCabe, and Antony 2006).
Regardless of which approach you choose, you should be aware of the advantages
and disadvantages of each. Group treatment gives people an opportunity to meet other
people with the same problem. This allows people to learn from the mistakes and suc -
cesses of others and reminds them that they are not the only ones suffering from this
problem. Group treatment also provides clients with opportunities to interact with other
individuals who can participate in exposure exercises and role-play practices. For example,
group members can be an audience during exposures that involve giving presentations.
The cost is another advantage of group therapy. Because you are sharing the thera -
pist’s time with other people, the cost per session is often lower than for individual
therapy. If you decide to enter group treatment for social anxiety, we recommend that
you try to find a group that focuses exclusively on anxiety problems, and ideally on
social anxiety (rather than a group that includes people who suffer from a wide range of
different problems). You are most likely to find a specialized social anxiety group at an
anxiety disorders specialty clinic.
Individual therapy also has advantages. First, it can be less scary than group therapy,
particularly at the beginning. As you can imagine, people with social phobia are often
quite terrified of starting group treatment, although anxiety about speaking in front | shyness_social.pdf |
851dc23ccd57-1 | quite terrified of starting group treatment, although anxiety about speaking in front
of the group usually diminishes after the first few weeks. Furthermore, with individual
therapy, you don’t have to share your time with other group members. And, because
there is more time to focus on you, the program can be individually tailored to suit your
personal needs. Individual therapy also has advantages from a scheduling perspective. If
you miss a session due to illness or vacation, usually you can just reschedule an individual
appointment. In contrast, if you miss a group session, catching up on the material that
you missed may be more complicated.
Whether you decide to seek group or individual treatment should depend on a
careful weighing of all of these factors. Keep in mind, however, that you may not have a
choice. Although the availability of CBT is increasing, this form of therapy is still hard
to find in some places, either in a group or individual format. We would like to empha -
size that, in choosing a therapy, the most important factor is finding a therapist who has
experience in providing CBT for social anxiety. Whether you choose group or individual
therapy should be a secondary issue, since both seem to work well.
THE IMPORTANCE OF REGULAR PRACTICE
Although simply reading about how to overcome social phobia may be helpful, to make
big changes in your social anxiety, it will be necessary for you to actually practice the | shyness_social.pdf |
09185e519c15-0 | Making a Plan for Change
85techniques described throughout this book. For example, you will get more out of
the cognitive strategies described in chapter 6 if you complete the monitoring forms
and diaries and frequently take advantage of opportunities to challenge your anxious
beliefs.
To get the most out of exposure practices, it will be important to enter feared
situations as frequently as possible and to stay in the feared situations until your fear
has decreased, or until you learn that your feared consequences don’t occur. Many of
your exposure practices can be conducted during the course of your everyday life (for
instance, having lunch with coworkers instead of eating alone), but other practices may
require you to set aside time just for the exposure exercises.
INCLUDING A HELPER OR CO-THERAPIST
It may be helpful to involve a helper or “co-therapist” in your treatment, for example,
a friend, coworker, or family member. Your helper can provide you with opportunities
to practice role-play exposures, such as presentations, simulated job interviews, making
small talk, or asking another person out on a date. In addition, he or she can provide you
with honest feedback about your performance and offer suggestions for improvement.
When choosing other people to help you out, we suggest that you select people
whom you trust. The person should be someone who is supportive and unlikely to
become frustrated or angry if things move slowly or if you are finding a particular situa -
tion difficult or anxiety provoking. If possible, your helper should read relevant sections
of this book so that he or she has a better understanding of the treatment and how it
works. If this is not practical, an alternative option would be to have you describe to your | shyness_social.pdf |
09185e519c15-1 | helper what his or her role will be during the practices.
DEALING WITH ADDITIONAL PROBLEMS
Many people who suffer from social anxiety also experience other problems, includ -
ing other anxiety disorders, depression, alcohol or drug use problems, and relationship
difficulties. In most cases, these other problems tend not to interfere with the treatment
of social anxiety. However, if you are currently suffering from problems in addition
to your shyness, there are two questions that you should consider. First, is your social
anxiety the most important problem to focus on currently? If not, you should probably
focus on the problem that is interfering the most with your life. For example, if your
depression is more severe than your social anxiety, it may be important to deal with your
depression first and then turn your attention to the social anxiety when your depression
is under control. Second, are your other problems so severe that they are likely to get in
the way of your social anxiety treatment? If so, you should work on the other problems
first. For example, if you are drinking alcohol so frequently that you’re unlikely to follow | shyness_social.pdf |
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86through with the exercises in this book, then dealing with your drinking before working
on your social anxiety is a good idea.
SEEKING PROFESSIONAL HELP
If you are interested in seeking professional help for your social anxiety, here are some
additional suggestions to keep in mind.
How to Find a Therapist or Doctor
One of the most difficult aspects of finding a therapist or doctor is knowing where
to look. A good place to begin is with your family doctor, who will likely be aware
of psychiatrists, psychologists, and anxiety specialty clinics in your area. You may also
want to call nearby hospitals and clinics to see if they have programs that offer either
CBT or medication for social anxiety. The Internet is also a great source of information
about treatment options in your area. Check with your insurance company about the
rules regarding coverage for treatment of psychological conditions. Your plan may have
restrictions regarding who you can see and the number of sessions that are covered.
Another way to find help is to contact a national organization that focuses either
on anxiety-related problems or CBT. For example, the Anxiety Disorders Association of
America (www.adaa.org) offers information about treatment options and self-help groups
across the United States and Canada (the ADAA has both consumer and professional
members). The Association for Behavioral and Cognitive Therapies (www.abct.org) is
a professional organization that also provides information on practitioners who treat
anxiety-related problems. Full contact information for these and other organizations is
provided in the resources section at the back of this book. You may also contact your
state psychological or psychiatric associations to get information about psychologists or
psychiatrists in your area. | shyness_social.pdf |
d52322d6f051-1 | psychiatrists in your area.
When choosing a professional, don’t be afraid to ask questions. Before making a
commitment, here are some issues that you should clarify:
UÊThe type of treatment being offered. For example, if you are interested in a
psychological treatment, you should ask whether the person is experienced
in providing CBT for social and performance anxiety.
UÊThe typical number of sessions recommended for treating this problem, rec -
ognizing that it is often difficult to know this before conducting a thorough
assessment. In many cases, ten to twenty sessions is enough.
UÊThe length of each session. One-hour sessions are typical, though longer
time periods are sometimes needed for exposure sessions. | shyness_social.pdf |
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87UÊThe frequency of sessions. Weekly sessions are typical.
UÊThe cost per session and preferred method of payment. Are the fees
flexible?
UÊThe location and setting. For example, is the treatment conducted in
a private office? A hospital? A university clinic? A community clinic? A
research center?
UÊThe availability of group vs. individual treatments for social anxiety. Either
approach is likely to help.
UÊWho provides the treatment? A psychologist? Psychiatrist? Psychology
student or psychiatric resident? How experienced is the person? Where
was he or she trained? If it is a student therapist, how closely is he or she
supervised? How experienced is the supervisor? Can you meet with the
supervisor if you wish?
Types of Professionals
If you are interested in receiving a psychological therapy, like CBT, your therapist
can be a psychologist, physician, nurse, social worker, or professional from any of a
number of other backgrounds. However, keep in mind that most practicing clinicians,
regardless of their background, do not have extensive experience in providing CBT
for anxiety-related problems. It is much more important that you find someone who is
familiar with treating social anxiety using cognitive and exposure-based treatments than
what degree the person has. Currently, psychologists are the most likely to have this
background, but other professionals are increasingly being trained in providing cognitive
and behavioral treatments.
Understanding the differences between types of therapists often can be confusing.
A brief description of some of the main professionals who often provide CBT and related
treatments follows:
Psychologist. In most places, psychologists who specialize in treating psychological dis - | shyness_social.pdf |
023c5a9dabd4-1 | Psychologist. In most places, psychologists who specialize in treating psychological dis -
orders usually have a doctoral degree in clinical or counseling psychology. Often, this
degree is a Ph.D. (which includes significant training in both research and in providing
clinical care), although it may also be a Psy.D. (indicating a primary training focus on
providing clinical services and relatively less emphasis on research) or an Ed.D. (indi -
cating training that stems from an educational psychology perspective). Typically, the
training of a psychologist includes an undergraduate bachelor’s degree (four years), fol -
lowed by an additional five to eight years of graduate training. In some states and prov -
inces, psychology practitioners with a master’s degree (usually two years of graduate
training) can also call themselves psychologists, whereas in other places, master’s level | shyness_social.pdf |
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88 clinicians are called by other terms (for example, psychological associate, psychothera -
pist, psychometrist).
Psychiatrist. A psychiatrist is a physician who has specialized in treating mental health
problems after completing four years of medical school. Typically, this specialty train -
ing includes a five-year residency and also may include additional fellowship training.
Psychiatrists are more likely than other types of professionals to understand and treat
anxiety from a biological perspective, although increasingly, psychiatric training pro -
grams are requiring training in CBT. Advantages of being treated by a psychiatrist over
other types of professionals include the opportunity to obtain medications in addition
to other forms of therapy, as well as the opportunity to be assessed by a physician who
is uniquely qualified to recognize medical conditions that may be contributing to the
problem.
Social worker. Social workers are trained to do many different things including helping
people to deal better with their relationships, solve their personal and family problems,
and learn to cope better with day-to-day stresses. They may help people to deal with
the stresses of inadequate housing, unemployment, lack of job skills, financial distress,
serious illness or disability, substance abuse, unwanted pregnancy, and other hardships.
Most social workers specialize, and some end up providing psychotherapy either in a
private practice or a hospital or agency setting. Although CBT is seldom a formal part
of social-work training programs, some social workers obtain specialized training in CBT
following their formal schooling.
Other professions. Professionals from a variety of other groups may be trained to
provide CBT or other forms of psychotherapy. These include some family physicians,
nurses, occupational therapists, clergy or other religious leaders, and even psychothera - | shyness_social.pdf |
eddaf7a1036f-1 | nurses, occupational therapists, clergy or other religious leaders, and even psychothera -
pists without any formal degree in a mental-health related field. As mentioned earlier,
it is more important to know whether the person you’re seeing has the experience and
expertise in treating social anxiety using strategies that have been proven to be useful
than whether the person is a nurse, family doctor, psychologist, psychiatrist, occupational
therapist, social worker, or a student in one of these fields.
FINAL QUESTIONS REGARDING TREATMENT
OF SOCIAL ANXIETY
Here are some answers to a few additional frequently asked questions.
How long does treatment take? As mentioned earlier, cognitive behavioral treatment
for social and performance anxiety typically takes between ten and twenty sessions.
Sometimes a person may make significant gains after just three or four sessions, par -
ticularly if the fear is very mild. Other times, treatment may last many months or even | shyness_social.pdf |
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89years. If you are being treated with medication (particularly antidepressants), it is usually
recommended that you stay on the medication for six months to a year or more before
slowly decreasing the dosage and eventually discontinuing the medication. If the symp -
toms return, it may be necessary to resume taking the medication or to try a different
form of treatment.
Are the effects of treatment long lasting? As we discussed earlier, the effects of CBT
tend to be relatively long lasting, although you may experience some bad days occasion -
ally. In contrast, stopping medication treatment suddenly is more likely to lead to a return
of the anxiety. You can protect against this to some degree by staying on the medication
for a longer period (perhaps at a reduced “maintenance” dosage) and by stopping the
medication very gradually. Also, stopping certain types of medications is more likely to
lead to a return of symptoms than stopping other medications, as reviewed in chapter
5. It is advisable to discuss reducing or stopping medication with the professional who is
prescribing it for you before you change the dose you’re taking.
Will you be completely “cured”? A small percentage of people who have significant
social anxiety are able to reach a point at which they rarely experience any social anxiety
at all. Similarly, a small percentage of people do not obtain any benefit from either
CBT or medications. For most people, however, the result of treatment is somewhere in
between these two extremes. It is realistic to expect that proper treatment is likely to
lead to a significant decrease in your social anxiety, avoidance behaviors, and impairment
of day-to-day life. However, it is also likely that there will remain some situations that | shyness_social.pdf |
36f0358cedf0-1 | will still be anxiety provoking, at least to some extent. This outcome may not seem too
bad if you remember that most people experience social and performance anxiety from
time to time.
What if you don’t like your therapist or doctor? Although it is unrealistic to expect
to be feeling better after only a few weeks, you should know after one or two meet -
ings whether you are comfortable working with your therapist or doctor. If you are not
pleased with how things are going, consider trying someone else. Within six to eight
weeks after beginning either CBT or medication, you should begin to see changes. If
changes have not occurred after two months, you should talk to your doctor or therapist
about the possible reasons for the lack of improvement and consider other treatment
options.
MEASURING CHANGE DURING TREATMENT
In chapter 3, we emphasized the importance of monitoring your progress throughout
your treatment program. We recommend that periodically (every few weeks) you reflect
on your progress by considering what types of changes you have made and what changes
remain to be accomplished. Depending on your progress, you may decide to revise your | shyness_social.pdf |
1c0ec08e2c4d-0 | The Shyness & Social Anxiety Workbook
90treatment plan. You may also decide to update your treatment goals. We recommend
that you occasionally complete some of the forms in chapter 3 as a way of assessing
whether your social anxiety is improving.
DEVELOPING A COMPREHENSIVE
TREATMENT PLAN
In chapters 1 and 2, you learned about the nature and causes of social anxiety. In chapter
3, you completed a thorough assessment of your own anxiety symptoms. Then, you
continued the self-assessment process throughout this chapter, as you reviewed your
previous attempts at treatment and developed your treatment goals. You are now ready
to develop a treatment plan. By now, you should have a good idea of what you need to
work on and whether you will try to overcome your social anxiety on your own or with
the help of a professional therapist or physician.
If you are considering trying medication, we recommend that you read chapter 5
next. Chapter 5 reviews the various medications that have been shown to be useful for
treating social and performance anxiety. If you are interested in trying cognitive behav -
ioral techniques, we suggest that you develop a treatment schedule for the next few
months. The following list is one example of such a schedule:
UÊIn the next week, read chapter 6 and begin to work on changing your neg -
ative thinking patterns. Chapter 6 includes a number of effective cogni -
tive strategies as well as diaries that you should complete several times per
week.
UÊContinue to practice the cognitive strategies for two to three weeks before
moving on to exposure-based techniques (chapters 7 through 9).
UÊWhen you are ready to begin exposure practices, begin reading chapters 7 | shyness_social.pdf |
1c0ec08e2c4d-1 | UÊWhen you are ready to begin exposure practices, begin reading chapters 7
and 8. As you read these chapters, you will have the opportunity to plan
exposures designed specifically for your own pattern of fear and avoidance.
We recommend that you practice the situational exposure strategies for five
or six weeks before moving on to chapter 9.
UÊAt the same time that you are practicing exposures, you should continue to
practice using the cognitive strategies that you will learn in chapter 6. By
using the cognitive strategies and practicing exposures to feared situations,
you should notice your fear beginning to decrease.
UÊAfter five or six weeks of practicing exposure to feared situations, read
chapter 9 to learn more about how to expose yourself to feared physical
sensations. If you are frightened of feeling certain sensations when you are
anxious, we recommend that you spend two to three weeks practicing the | shyness_social.pdf |
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91strategies described in chapter 9. At the same time, continue to practice the
cognitive and exposure techniques from the earlier chapters.
UÊIf there are social skills that you would like to improve, this will be the time
to use the exercises described in chapter 10. Again, we recommend that you
do not stop using the skills that you learned earlier, particularly the cogni -
tive and exposure-based strategies.
At this point, several months will have passed and your anxiety will be likely to have
improved significantly. We recommend that you read chapter 11 at this point, which
discusses ways of maintaining the gains you have made so far.
If you are curious and you want to read later sections in the book now, that’s fine.
However, it’s important that you go back and practice the strategies in each chapter
before moving on to the next set of techniques. These strategies are the building blocks
that eventually will lead to an improvement in your social anxiety.
After completing this chapter, a number of issues should be clearer to you. First, you
should have a better idea of whether this is the best time for you to work on overcoming
your social anxiety. Second, you should have formulated a number of treatment goals,
both for the short term and the long term. Finally, it is likely that you will have consid -
ered the various treatment options and identified your own treatment preferences. The
remaining chapters in this workbook provide more detailed instructions in how to take
advantage of particular strategies for managing social anxiety. | shyness_social.pdf |
8518308415f3-0 | CHAPTER 5
Medications for Social
Anxiety and Social
Anxiety Disorder
DECIDING TO TAKE MEDICATION
As discussed in earlier chapters, two approaches have been shown to be useful for over -
coming social anxiety: medications and cognitive behavioral therapy (CBT). Chapter 4
reviewed the key points to keep in mind when deciding whether to use drug treatments
to overcome your symptoms of social anxiety. Medications and CBT have been shown
to be about equally effective in the short term for treating social anxiety. Still, each
approach has advantages and disadvantages.
Advantages of Medications Compared with CBT
UÊMedications are often easier to get. Any physician (for example, family
doctor or psychiatrist) can prescribe medications, as can certain other pro -
fessionals. In contrast, therapists who have specialized training in providing
CBT are often more difficult to find. | shyness_social.pdf |
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94UÊDrug treatments are easy to use and don’t take up much time. You just need
to remember to take your pills. In contrast, CBT requires a lot of hard work
and can be time consuming.
UÊMedications often work more quickly than CBT. Depending on the type of
drug, changes in anxiety can be observed in as little as an hour for treat -
ment with anti-anxiety medications, and in as little as two to four weeks
for treatment with antidepressant medications. Typically, CBT takes several
weeks to months before significant changes take place.
UÊMedications are often less expensive in the short term. Visits to your doctor
can be infrequent once a stable dosage is reached. At that point, the only
cost is the medication itself. In contrast, CBT usually requires regular
visits to a therapist throughout the treatment and therefore can be costly,
especially if you have limited coverage through your health insurance.
Disadvantages of Medications Compared with CBT
UÊAnxiety is more likely to return after stopping medication than after stop -
ping CBT. In other words, the effects of CBT are often longer lasting.
UÊMedication may be more expensive than CBT over the long term. Because
medication is typically used for a longer period (often years), the costs are
likely to add up to more than the cost of CBT, which generally lasts only
several months.
UÊMany people experience side effects when taking medications. Although
these are usually manageable and improve after the first few weeks, some
people experience more severe side effects, making treatment with medica - | shyness_social.pdf |
b282e9f70e94-1 | people experience more severe side effects, making treatment with medica -
tion unpleasant or impossible. The main side effect of CBT is an increase
in anxiety during exposure to feared situations, and this anxiety resolves
quickly.
UÊMedications for social anxiety may interact with alcohol and with other
medications. They may also cause problems in people who have certain
medical illnesses. CBT does not interact in the same ways with alcohol,
medications, or medical illnesses.
UÊSome medications are difficult to stop taking because they may cause
uncomfortable symptoms during discontinuation. This is particularly a
problem with anti-anxiety medications, as well as with a few specific anti -
depressants. Medications with the potential for dependence should be dis -
continued slowly, under supervision from your doctor. In contrast, physical
dependence and withdrawal problems are not associated with CBT. | shyness_social.pdf |
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95UÊSome medications (in particular, monoamine oxidase inhibitors) require a
restricted diet. CBT does not require any food restrictions.
UÊMany medications must be either used with caution or avoided completely
during pregnancy or if you are breastfeeding. CBT can be used safely in
either of these situations.
In deciding whether to try medications, you should consult with your doctor. Keep
in mind, however, that your doctor’s advice regarding this issue is likely to be influenced
by his or her own expertise and preferences (for example, family doctors are often much
less familiar with research on CBT than with medication options). In reality, it’s very
difficult to predict who is most likely to respond to CBT or vs. medication, vs. a combi -
nation of these two approaches. We generally recommend that people try CBT initially,
if it is available, because the benefits tend to be longer lasting than those of medication.
In cases where CBT alone is not effective or is only partially effective, the addition of
medications can be considered.
CHOOSING AMONG MEDICATIONS
If you decide to try medications, there are two general classes of drugs that have been
found to be effective for social anxiety: antidepressant and anti-anxiety medications.
There is also evidence that beta-adrenergic blockers (also called “beta-blockers”) may
help with focused performance fears (for example, fears of public speaking), as well
as some preliminary research supporting the use of certain anticonvulsant medications
(these are drugs that are usually used to treat seizures). We will discuss each of these | shyness_social.pdf |
f5f56355ded7-1 | (these are drugs that are usually used to treat seizures). We will discuss each of these
approaches in this chapter, and we will also review what is known about the use of herbal
remedies for treating social anxiety.
When selecting among these medications, you and your doctor should take into
account the following factors:
UÊResearch findings on available medications . Treatment guidelines recently
published by the Canadian Psychiatric Association recommended antide -
pressant treatments as the first medications to try for social anxiety disor -
der, based on the most recent research (Swinson et al. 2006). In particular,
venlafaxine, escitalopram, fluvoxamine, paroxetine, and sertraline had been
investigated in the largest number of studies at the time the guidelines were
published. These medications are discussed later in this chapter.
UÊYour particular social anxiety symptoms . For example, although people
with focused performance fears (like public speaking or performing music)
may benefit from treatment with beta-blockers, people with more general -
ized forms of social anxiety tend not to benefit from these medications. | shyness_social.pdf |
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96UÊSide effect profile of the medication . For instance, if you’re already strug -
gling with your weight, you might want to choose a medication for which
weight gain is not a likely side effect.
UÊPrevious response to medications . If you or a family member has previously
responded to a particular medication, that drug might be a good option
for you to try now. On the other hand, if there is a drug that didn’t work
for you in the past (despite a long enough trial at an adequate dosage), this
might be a time to try something new.
UÊAdditional psychological disorders that are present . For example, if you
are experiencing depression, it might make more sense to try an antidepres -
sant than an anti-anxiety drug. The antidepressant would likely lead to an
improvement in both problems.
UÊCost . Older medications tend to be less expensive than newer medications,
often because older drugs are available in generic forms.
UÊInteractions with other medications and herbal remedies. If you are already
taking certain medications or herbal products, you should choose a drug
that will not interact with the products you are already taking.
UÊInteractions with certain foods . Medications such as phenelzine can be dan -
gerous if taken with certain foods (those containing tyramine, such as aged
cheese and draft beer). Other medications may also interact with foods.
For example, grapefruit juice appears to decrease the metabolism of certain
selective serotonin reuptake inhibitors (such as sertraline and fluvoxamine),
increasing the likelihood that they will accumulate in the body. | shyness_social.pdf |
796f0d9a6c3d-1 | increasing the likelihood that they will accumulate in the body.
UÊInteractions with medical conditions . If you have a particular medical con -
dition (for example, high blood pressure), you should choose a drug that will
not worsen the symptoms of your illness.
UÊSubstance-use issues . If you enjoy drinking alcohol or if you use other
drugs, you should choose a medication that is unlikely to interact with these
substances.
UÊDiscontinuation issues . Medications that leave the body quickly (in other
words, those with a short half-life) are more likely to cause withdrawal
symptoms and are often harder to discontinue. Therefore, drugs with a
longer half-life are usually easier to discontinue. If you and/or your doctor
are concerned about your ability to discontinue a medication, this should be
factored into your decision regarding which drug to take. (The term half-life
refers to the time that it takes for half of the amount of drug in your body | shyness_social.pdf |
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97to be metabolized or broken down. For example, a drug with a half-life of
twelve hours would be 50 percent broken down in twelve hours and 75
percent broken down after another twelve hours. Drugs with a longer half-
life are broken down more slowly, giving the body time to adjust to stopping
the drug).
STAGES IN MEDICATION TREATMENT
Treatment with medication involves the following five different stages:
1. The first stage is the assessment . During this phase, your doctor will ask you the
necessary questions to help choose the best medication for your needs.
2. The second stage is initiation of the drug . In most cases, medications are started
at relatively low dosages to give your body a chance to adapt gradually to
the new drug.
3. The third stage is dose escalation . During this stage of treatment, the dosage
is gradually increased until the individual’s symptoms start to improve. The
goal of dose escalation is to find the lowest dosage that is effective for a
particular person. Throughout the process, care is taken to minimize any
side effects that may be present.
4. The fourth stage is called maintenance . During maintenance, the individual
continues to take the medication for an extended period of time. For anti
depressants, it is usually recommended that treatment continue for at
least a year, minimizing the chances of symptoms returning following
discontinuation.
5. The fifth and final stage of medication treatment is discontinuation . Some time
after a person has improved on a medication, the individual may be encour -
aged to decrease the amount of the medication to assess whether he or she | shyness_social.pdf |
1d2645b00bb5-1 | aged to decrease the amount of the medication to assess whether he or she
is ready either to lower the dosage or to stop the medication completely. If a
person is also receiving CBT, it may be helpful to have regular CBT sessions
during the discontinuation phase. In some cases, your doctor may recom -
mend that you continue to take a medication that is working for you.
TREATMENT WITH ANTIDEPRESSANTS
Antidepressants are the most frequently recommended medications for social anxiety.
These drugs are called “antidepressants” because they were initially marketed for treating | shyness_social.pdf |
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98depression. However, don’t be fooled by their name. These drugs are useful for a wide
range of psychological problems, including social anxiety disorder. In fact, they appear to
work for this problem regardless of whether an individual is depressed. There are several
classes of antidepressant medications that are thought to be useful for treating social
phobia. Each of these is described in this section. In addition, a table of recommended
dosages is included at the end of this section.
Note that we also indicate which of these drugs is officially approved by the United
States Food and Drug Administration (FDA). Although FDA approval typically indicates
that a medication is safe and effective when used properly, there are many medications
that are safe and effective for social anxiety that are not approved by the FDA or regula -
tory bodies in other countries. This is because it is very expensive and time consuming
for pharmaceutical companies to obtain official FDA indications for their products, and
they therefore tend to limit the number of problems for which they apply for approval.
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are often the first choice for treating social phobia. In fact, the SSRI paroxetine
(Paxil) was the first drug to receive an FDA indication for treatment of social anxiety
disorder. Paroxetine is also available in a continuous release formula, marketed under
the name Paxil CR. Another SSRI that is FDA approved is sertraline (Zoloft). Although
only two SSRIs are officially approved for treating social anxiety disorder, there is no
evidence that either of these medications works any better or worse than most other | shyness_social.pdf |
873a3ab90ea7-1 | evidence that either of these medications works any better or worse than most other
SSRIs for this problem. In practice, any of the SSRIs can be used to treat problems with
social anxiety. Other SSRIs that have been found to be effective for social anxiety disor -
der include fluvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro in the
United States, Cipralex in Canada). Fluoxetine (Prozac) has been found to be effective
in some studies, but not others (Hedges et al. 2007; Swinson et al. 2006).
Although the side effects vary slightly across the SSRIs, some of the most common
ones include nausea, diarrhea, headache, sweating, increased anxiety, tremor, sexual dys -
function, weight gain, dry mouth, palpitations, chest pain, dizziness, twitching, constipa -
tion, increased appetite, fatigue, thirst, and insomnia. Don’t be discouraged by the long
list of side effects. Most people experience only a very small number of these, and some
individuals experience no side effects at all. Side effects are generally quite manageable.
They tend to be worse during the first few weeks of treatment and can be managed by
keeping the dosage low until the person becomes used to the medication. Certain side
effects (for example, medication-related weight gain and sexual dysfunction) tend not to
decrease over time, unless the drug is stopped or the dosage is decreased.
SSRIs typically take two to four weeks before they start working. They are believed
to work by altering serotonin levels in the brain. Serotonin is an example of a neurotransmitter ,
which is a chemical involved in the transmission of information from one brain cell to the | shyness_social.pdf |
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99next. Serotonin is thought to be involved in the regulation of emotion and other aspects
of psychological functioning.
Most SSRIs are relatively easy to discontinue, although paroxetine is more likely
than the others to cause withdrawal symptoms during discontinuation because it is
metabolized more quickly by the body. Therefore, paroxetine should be stopped more
gradually than the other SSRIs. Common withdrawal symptoms during discontinuation
of paroxetine include sleep disturbances, agitation, tremor, anxiety, nausea, diarrhea, dry
mouth, vomiting, sexual disturbances, and sweating.
Selective Serotonin and Norepinephrine Reuptake
Inhibitors (SNRIs)
Venlafaxine XR (Effexor XR) is currently the only available SNRI that has been
found in large studies to be effective for treating social anxiety disorder—in fact, it is
approved by the FDA for this purpose (the “XR” stands for “extended release”). Unlike
the SSRIs, venlafaxine acts both on the serotonin and norepinephrine neurotransmitter
systems, both of which appear to be related to problems with anxiety and depression.
A number of well-controlled studies suggest that venlafaxine is useful for treating social
phobia (Swinson et al. 2006), although, like the SSRIs, it takes several weeks to have
an effect. The most commonly reported side effects of venlafaxine include sweating,
nausea, constipation, loss of appetite, vomiting, sleepiness, dry mouth, dizziness, ner -
vousness, increased anxiety, and sexual disturbances. When discontinued too quickly,
the most common withdrawal symptoms include: sleep disturbances, dizziness, nervous - | shyness_social.pdf |
8c0b339512f7-1 | the most common withdrawal symptoms include: sleep disturbances, dizziness, nervous -
ness, dry mouth, anxiety, nausea, headache, sweating, and sexual problems. Duloxetine
(Cymbalta) is another recently introduced SNRI that has been shown to be useful for
depression and some forms of anxiety. However, with the exception of published case
studies (Crippa et al. 2007), this drug has not yet been studied for social anxiety, and it
is too early to recommend it for this problem.
Noradrenergic/Specific Serotonergic Antidepressants
(NaSSAs)
Currently, the only NaSSA available is a drug called mirtazapine (Remeron). Like
the SNRIs, mirtazapine works by affecting levels of both norepinephrine and sero -
tonin. This drug is newer than the other antidepressants discussed so far. Nevertheless,
some initial studies suggest that mirtazapine is an effective treatment for social anxiety
disorder (Muehlbacher et al. 2005; Van Veen, Van Vliet, and Westenberg 2002). The
most common side effects of mirtazapine include sleepiness, weight gain, dry mouth,
constipation, and blurred vision. | shyness_social.pdf |
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100Monoamine Oxidase Inhibitors (MAOIs)
MAOIs affect three neurotransmitter systems in the brain: serotonin, norepineph -
rine, and dopamine. The most studied MAOI for treating social phobia is phenelzine
(Nardil). This drug has consistently been found to alleviate the symptoms of social
phobia (Swinson et al. 2006). Like the other antidepressants, phenelzine takes several
weeks to have a therapeutic effect.
Despite their effectiveness, MAOIs are rarely used in clinical practice because of
necessary dietary restrictions and because the side effects tend to be worse than those
from other medications. When taking MAOIs, you must avoid foods containing a sub -
stance called tyramine. These include aged cheeses, meat extracts, overripe bananas,
sausage, tofu, soy sauce, draft beer, and many other foods. MAOIs are also dangerous
when combined with certain other medications, including SSRIs. The most commonly
reported side effects of MAOIs include dizziness, headache, drowsiness, sleep distur -
bances, fatigue, weakness, tremors, twitching, constipation, dry mouth, weight gain, low
blood pressure, and sexual disturbances.
Reversible Inhibitors of Monoamine Oxidase (RIMAs)
Reversible inhibitors of monoamine oxidase are a type of MAOI that tend to have
fewer side effects than traditional MAOIs. In addition, they are less likely than traditional
MAOIs to interact with other medications and with foods containing tyramine. The only
RIMA that is available is moclobemide (Manerix in Canada, Aurorix in several other | shyness_social.pdf |
28e7e9d1c50f-1 | countries), though this drug is not currently marketed in the United States. Findings
from studies on moclobemide for social anxiety disorder have been mixed. Early studies
found that this medication was helpful for treating social anxiety, whereas more recent
studies have found only modest effects. In some studies, moclobemide was no better
than placebo (Swinson et al. 2006).
The most commonly reported side effects for people taking moclobemide include
fatigue, constipation, low blood pressure, decreased sex drive, dry mouth, difficulties
ejaculating, insomnia, vertigo, and headache. Like the other antidepressants, moclobemide
takes several weeks to have a therapeutic effect. | shyness_social.pdf |
5f0abf8f9590-0 | Medications for Social Anxiety and Social Anxiety Disorder
101Dose Ranges for Antidepressants in the Treatment of Social Phobia
Generic Name Brand Name Therapeutic Dose Range (mg)*
SSRIs
citalopram Celexa 10–60
escitalopram Lexapro/Cipralex 10–20
fluoxetine Prozac 10–80
fluvoxamine Luvox 50–300
paroxetine Paxil 10–60
paroxetine CR Paxil CR 12.5–75
sertraline Zoloft 50–200
Other Antidepressants
mirtazapine Remeron 15–60
moclobemide Manerix/Aurorix 300–600
phenelzine Nardil 45–90
venlafaxine XR Effexor XR 75–375
*Dosages are based, in part, on recommendations by Bezchlibnyk-Butler, Jeffries, and Virani 2007.
TREATMENT WITH ANTI-ANXIETY MEDICATIONS
The most frequently prescribed anti-anxiety medications are the benzodiazepines. These
are sedatives that include drugs such as clonazepam (Klonapin in the USA; Rivotril
in Canada), alprazolam (Xanax), diazepam (Valium), and lorazepam (Ativan). To date,
only clonazepam and alprazolam have been investigated in controlled studies for the
treatment of social anxiety disorder (Swinson et al. 2006). Although neither is officially | shyness_social.pdf |
5f0abf8f9590-1 | approved by the FDA for treating social anxiety, both of these medications have been
found to be useful for this problem. The typical starting dose for alprazolam and clon -
azepam is .5 mg per day, with a maximum daily dose of 1.5 to 3 mg for alprazolam and
4 mg for clonazepam (Swinson et al. 2006).
When taken on a regular basis, these medications tend to be effective for treat -
ing social anxiety. The most common side effects include drowsiness, lightheadedness,
depression, headache, confusion, dizziness, unsteadiness, insomnia, and nervousness. | shyness_social.pdf |
3e34cdcb905d-0 | The Shyness & Social Anxiety Workbook
102These drugs may affect a person’s ability to drive safely and they tend to interact
strongly with alcohol. In addition, they should be used with caution by older people
because higher dosages have been associated with a greater likelihood of falling.
There are several advantages to taking benzodiazepines compared with antidepres -
sant medications. First, they work very quickly (within a half hour) and therefore can
be used on an “as needed” basis to deal with particularly stressful situations. They also
may be used during the first few weeks of antidepressant treatment, while the indi -
vidual waits for the antidepressant to take effect. In addition, the side effect profile of
benzodiazepines is quite different from that of antidepressants, and these drugs may be
more easily tolerated by some people.
Despite these benefits, benzodiazepines have fallen out of favor in recent years,
mostly because they can be difficult to discontinue. Stopping these drugs can cause
temporary (but sometimes intense) feelings of anxiety, arousal, and insomnia. In rare
cases, abrupt discontinuation can cause seizures. Given that discontinuation from these
medications can cause intense anxiety, it is not surprising that some individuals have
difficulty stopping these drugs. The symptoms of withdrawal can be minimized by dis -
continuing these drugs very gradually. Benzodiazepines are a potentially effective option
for treating social anxiety, particularly over brief periods. However, they are typically
not recommended as a first-line treatment (Swinson et al. 2006).
TREATMENT WITH BETA-ADRENERGIC BLOCKERS | shyness_social.pdf |
3e34cdcb905d-1 | TREATMENT WITH BETA-ADRENERGIC BLOCKERS
Beta-blockers are normally used for treating high blood pressure. In addition, they are
effective for decreasing some of the physical symptoms of fear such as palpitations and
shakiness. A number of early studies suggest that beta-blockers are useful for managing
intense fear in certain performance situations (Hartley et al. 1983; James, Burgoyne, and
Savage 1983). In particular, they are often used by actors, musicians, and other perform -
ers to manage stage fright. However, beta-blockers are ineffective for treating more
generalized forms of social anxiety and shyness. The most commonly used beta-blocker
for treating performance fears is propanolol (Inderal). This medication is normally taken
in a single dose of 5 to 10 mg, about twenty to thirty minutes before a performance.
ANTICONVULSANTS
Anticonvulsants are used to treat seizures, as well as pain, anxiety, and certain mood
problems. Recently, there have been a number of preliminary studies finding that certain
anticonvulsants such as gabapentin (Neurontin), pregabalin (Lyrica), and topiramate
(Topamax) may be useful for treating social anxiety disorder (Swinson et al. 2006). At
this point, however, it is too soon to recommend these treatments for social anxiety.
Additional research is needed. | shyness_social.pdf |
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103NATURAL AND HERBAL REMEDIES FOR
SOCIAL ANXIETY
In recent years, herbal preparations have become popular for treating a wide range of
health problems. For the treatment of anxiety and related problems, commonly used
herbal preparations include St.-John’s-wort, kava kava, inositol, Rescue Remedy, and
various other products. Generally, there have been very few studies on these products
in people with anxiety-based problems, and we are aware of only one study that has
specifically tested the effects of an herbal remedy for treating social anxiety disorder
(Kobak et al. 2005). In this study, 600 to 1800 mg per day of St.-John’s-wort (also known
as hypericum) was compared to an inactive placebo in forty people with social anxiety
disorder. No differences were found in the effectiveness of St.-John’s-wort vs. placebo,
despite the fact that some studies have found St.-John’s-wort to be an effective treatment
for depression.
In addition to the lack of studies on the effectiveness of herbal treatments, very little is
known about the safety of many of these remedies or the extent to which they interact
with conventional medications. Be sure to tell your doctor if you are taking any herbal
products, just in case there are any known interactions with medications you may also
be taking.
Although little is known about the effects of herbal treatments on social anxiety,
there are a few studies on the use of herbal products for other anxiety problems (Connor
and Vaishnavi, in press). Still, more studies are currently under way. In the coming years,
additional information regarding the safety, interactions, and effectiveness of these | shyness_social.pdf |
fcbd87bf9793-1 | additional information regarding the safety, interactions, and effectiveness of these
treatments will be available.
COMBINING MEDICATIONS
Your doctor may recommend combining several medications for treating your social
anxiety. In most cases, there is very little research on the benefits of combining differ -
ent medications. However, one combination that has been studied for the treatment of
anxiety is the combination of an antidepressant (for example, paroxetine) with a benzodi -
azepine (for example, clonazepam). Ideally, both drugs are started at the same time. The
benzodiazepine helps to keep the anxiety under control during the first few weeks while
the person waits for the antidepressant to start working. Then, once the antidepressant
kicks in, the benzodiazepine is discontinued gradually.
A limited number of studies have investigated whether it is useful to combine an
SSRI with a benzodiazepine. Whereas some studies of anxiety problems other than
social phobia suggest that this combination is useful for reducing anxiety symptoms
more quickly than an SSRI alone (Pollack et al. 2003), a study of people suffering from
social phobia did not find any added benefit of combining medications on the rate of
recovery (Seedat and Stein 2004). | shyness_social.pdf |
1ba869b98883-0 | The Shyness & Social Anxiety Workbook
104COMBINING MEDICATION WITH
PSYCHOLOGICAL TREATMENTS
Studies comparing medications to CBT have generally found both approaches to be very
effective for reducing anxiety. In addition, a number of researchers have begun to study
the benefits of combining CBT and medications (Antony and Rowa 2008). Overall, there
do not appear to be any consistent benefits of combining these treatments. That is,
medication, CBT, and a combination of these approaches all tend to be about equally
effective on average, based on the available evidence (for instance, Davidson et al. 2004).
However, that doesn’t mean that one approach or another is not likely to be more effec -
tive for any one person (including you). In other words, it is often the case that some
people do best with CBT, some do best with medication, and some do best with a com -
bined treatment. If you decide to try combining CBT with medication, it is helpful if
both treatments are delivered by the same person, or if the professionals providing you
with CBT and medication are in contact with one another. Treatment is most likely to
be helpful when multiple treatments are delivered in a coordinated fashion.
COMMON QUESTIONS ABOUT MEDICATION
Question: Is taking medication a sign of weakness?
Answer: Taking medication for social phobia is no more a sign of weakness than
taking medication for any other problem, such as physical illnesses like
high blood pressure.
Question: What level of improvement can I expect?
Answer: A small percentage of people obtain no benefit at all from medications
for social phobia. Another small group of people obtain almost com - | shyness_social.pdf |
1ba869b98883-1 | for social phobia. Another small group of people obtain almost com -
plete improvement. However, most people with social phobia experi -
ence moderate improvements with medications. They tend to feel less
anxious overall and are more comfortable in a broader range of situa -
tions. However, there may still be areas in which the social anxiety is a
problem for them.
Question: Are medications for social anxiety dangerous?
Answer: When taken as prescribed, medications for social phobia are gener -
ally safe. When side effects cause problems, as a rule they are easy to
manage by decreasing the dosage or switching to a different drug. | shyness_social.pdf |
19a3e36bc58f-0 | Medications for Social Anxiety and Social Anxiety Disorder
105Question: Is it dangerous for me to stop taking my medication?
Answer: Medications should always be stopped gradually and in close consul -
tation with your doctor. If done properly, discontinuation is generally
safe.
Question: What happens if my medication doesn’t work for me?
Answer: If your medication doesn’t work, it is important to first make sure you
have been taking it for a long enough time and at an adequate dose. If
your medication still is not effective despite an appropriate duration and
dosage, you may still benefit from trying a different medication or from
receiving CBT.
Question: How long should I try a medication before assuming that it isn’t going
to work?
Answer: Most antidepressants will start to have an effect within four to six weeks,
if not earlier. If you haven’t experienced any benefit after eight weeks
at a high enough dosage, it may be worth discussing the possibility of
trying a different treatment with your doctor.
Question: If I go off my medication and my anxiety returns, am I likely to benefit
again if I resume taking the same medication?
Answer: Often, when a previously effective medication is tried for a second time
(following a break), it will work again. However, sometimes a particular
medication is less effective the second time, in which case a different
medication may be prescribed.
In summary, medications can be an effective method of managing severe social
anxiety. Certain anti-anxiety medications (for example, clonazepam) and a number of
different antidepressants (for instance, paroxetine, venlafaxine) have consistently been | shyness_social.pdf |
19a3e36bc58f-1 | shown to help reduce symptoms of social anxiety. If you decide that you would like to
try medication, a first step is to contact your family doctor or psychiatrist. Your doctor
will be able to recommend a specific medication that is likely to work for you. | shyness_social.pdf |
c8b24f84701b-0 | CHAPTER 6
Changing Your Anxious
Thoughts and Expectations
The word cognition refers to the ways in which we process information, including experi -
ences such as thought, perception, interpretation, attention, memory, and knowledge.
The word cognitive is simply the adjectival form of the term cognition. For example,
cognitive science is the science concerned with the ways in which we think. Cognitive
therapy is a type of psychotherapy that is designed to alter negative and unrealistic beliefs,
thoughts, and interpretations.
This chapter provides an overview of strategies that have been shown to be useful for
decreasing social anxiety by changing negative or unrealistic patterns of thinking. Many
of the cognitive techniques and principles discussed in this book have been presented
and expanded upon elsewhere by authors such as Aaron T. Beck (Beck, Emery, and
Greenberg 1985), David Burns (1999), David M. Clark (Clark and Wells 1995), Richard
Heimberg (Heimberg and Becker 2002), Christine Padesky (Greenberger and Padesky
1995), and others. Over the years, strategies similar to those discussed in this chapter
have been adopted by the majority of therapists who practice cognitive therapy.
THE ORIGINS OF COGNITIVE THERAPY
Cognitive therapy was proposed in the 1960s and 1970s as an alternative to traditional
psychodynamic psychotherapies , which were the most prevalent forms of therapy at the time.
The original (and most influential), form of psychodynamic psychotherapy is psychoanaly -
sis, which Sigmund Freud developed in the early 1900s. Psychodynamic psychotherapies, | shyness_social.pdf |
8ee430af8410-0 | The Shyness & Social Anxiety Workbook
108including psychoanalysis, are concerned with helping individuals understand deep-rooted
unconscious conflicts that are presumed to cause or contribute to their psychological
problems. For example, Freud proposed that depression can occur as a response to
having unconscious aggressive thoughts or feelings toward a loved one. Because such
feelings are viewed as unacceptable by the individual, he or she is very motivated to
keep such thoughts and feelings outside of conscious awareness. According to Freud,
rather than allowing the aggressive thoughts to surface, the individual may turn those
angry feelings inward, leading to feelings of self-hatred and worthlessness, which are
often features of depression.
There are many newer forms of psychodynamic therapy (most psychodynamic psy -
chotherapists no longer accept all of Freud’s ideas), though the focus of these treatments
often remains on recounting early childhood experiences, interpreting unconscious expe -
rience (such as dreams), and helping individuals to understand the unconscious motiva -
tions for their behavior. Although psychodynamic psychotherapies remain popular, they
have gradually lost ground to other forms of therapy, including cognitive and behavioral
therapies. Some reasons for the decline of psychodynamic psychotherapies include the
relative lack of research supporting many of the underlying theoretical assumptions, as
well as a lack of research demonstrating the effectiveness of this form of treatment for
many specific problems, including social anxiety.
Despite these criticisms, psychoanalysis and the psychodynamic psychotherapies
have made considerable contributions to the understanding and treatment of psycho -
logical problems. For example, these were the first treatments based on the assumption
that simply talking to another person can lead to psychological changes. In addition, | shyness_social.pdf |
8ee430af8410-1 | that simply talking to another person can lead to psychological changes. In addition,
these treatments highlighted the importance of nonconscious information processing.
Although there is little evidence to prove the existence of many of the unconscious
motivations proposed by Freud, there is evidence that suggests people are frequently
unaware of the perceptions and interpretations that contribute to their understanding
of their environment. Finally, although many specific aspects of his theory were prob -
ably misguided, Freud highlighted the importance of early experience in determining
psychological functioning later in life.
The Birth of Cognitive Therapy
In the 1960s and 1970s, a number of psychologists and psychiatrists, disenchanted
with psychodynamic psychotherapies, began to explore other ways of helping their
patients and clients. Working independently, psychiatrist Aaron Beck (1963; 1964; 1967;
1976) and psychologists Albert Ellis (1962; 1989) and Donald Meichenbaum (1977) each
developed new forms of therapy based on the premise that people’s difficulties with
depression, anxiety, anger, and related problems stem from the ways in which they think
about themselves, their environment, and the future.
For example, fear was assumed to stem from a belief that a particular situation was
threatening or dangerous. Beck, Ellis, and Meichenbaum each developed treatments | shyness_social.pdf |
3f7b5a16812e-0 | Changing Your Anxious Thoughts and Expectations
109designed to help individuals recognize how their beliefs and assumptions contribute to
their negative emotions, and to overcome psychological suffering by changing these neg -
ative thoughts. Ellis called his form of treatment rational emotive therapy and later renamed
it rational emotive behavior therapy (REBT, 1993). Meichenbaum referred to his form of treat -
ment as cognitive-behavior modification (CBM). It was Aaron Beck, however, who first
used the term cognitive therapy to describe his treatment. Each of these three new treat -
ments was developed at about the same time, and they were quite similar with respect
to their underlying assumptions and some of the treatment strategies used.
Over the years, Beck’s form of treatment has become more popular and prominent
than either Ellis’s or Meichenbaum’s approaches. Furthermore, Beck’s cognitive therapy
has been subjected to more rigorous study than either REBT or CBM for the treatment
of social anxiety. Therefore, the methods discussed in this chapter are based on those
proposed by Beck and his collaborators, as well as others who adapted and expanded
upon Beck’s methods for treating social anxiety and related problems.
ASSUMPTIONS OF COGNITIVE THERAPY
FOR SOCIAL ANXIETY
Here are some of the basic assumptions of cognitive therapy, particularly as related to
the treatment of shyness, social anxiety, and performance fears.
1. Negative emotions are caused by negative interpretations and beliefs. People
who interpret a given situation in different ways are likely to experience dif -
ferent emotions. For example, imagine that a friend of yours has cancelled
a dinner date at the last minute without providing a reason. Below is a list
of possible emotional reactions you might have depending on your beliefs | shyness_social.pdf |
3f7b5a16812e-1 | of possible emotional reactions you might have depending on your beliefs
and interpretations.
Situation : Friend cancels dinner date at the last minute and gives no reason
Interpretation Emotion
“My friend has been hurt or is ill.” Anxiety or worry
“My friend isn’t treating me with the respect I deserve.” Anger
“My friend doesn’t care about me.” Sadness
“Thank goodness the dinner has been cancelled; I am
always so nervous when I have to eat with others.”Relief
“I guess something else came up. Everyone changes
plans from time to time, including me.”Neutral | shyness_social.pdf |
4a886aa07fe3-0 | The Shyness & Social Anxiety Workbook
1102. Anxiety and fear result when a person interprets a situation as threatening
or dangerous. Although fearful predictions and interpretations are sometimes
accurate, they are often exaggerated or inaccurate. Chapter 1 provided a list of
thoughts and assumptions that can contribute to social anxiety. These include
beliefs about one’s performance (such as, “People will think that I am an idiot”),
as well as beliefs about the anxiety itself (for instance, “It’s important for me
not to appear anxious in front of other people”). Beliefs such as these help to
maintain a person’s anxiety in social and performance situations.
3. You are the expert regarding your own thoughts and feelings. Unlike some
other forms of therapy, which assume that the therapist is the expert, cogni -
tive therapy assumes that the patient and therapist have unique areas of exper -
tise, and the best way to work on a problem is to take advantage of the skills
and expertise that each brings to the therapeutic situation. The therapist is
assumed to be an expert on the principles and methods of cognitive therapy.
The patient is assumed to be an expert regarding his or her own experi -
ences, assumptions, and beliefs. In most cases, the therapist and patient decide
together whether a particular belief is exaggerated or unrealistic, and together
they generate strategies for changing negative patterns of thinking.
4. The goal of cognitive therapy is to be able to think more realistically rather
than simply to think positively . There are occasions where your anxious beliefs
are realistic and are quite consistent with the actual threat in a given situa -
tion. In these cases, anxiety may be a good thing because it helps you stay
on guard and protect yourself from possible danger. For instance, being a bit | shyness_social.pdf |
4a886aa07fe3-1 | on guard and protect yourself from possible danger. For instance, being a bit
nervous while interacting with an authority figure (for example, your boss, a
police officer) may protect you from seeming overly confident, demanding,
or aggressive. Cognitive therapy focuses on situations where your beliefs,
predictions, and interpretations are exaggerated when compared with the
actual level of danger in the situation.
5. People naturally tend to seek out and pay attention to information that con -
firms their beliefs. In the case of social anxiety, people pay more atten -
tion and give more weight to evidence that others are judging them nega -
tively (such as a history of being teased in high school) than to evidence
that contradicts the anxious beliefs (for instance, a history of very positive
performance appraisals at work). Cognitive therapy aims to help people to
consider all the evidence before making any assumptions.
TYPES OF ANXIOUS THINKING
Anxious thinking begins and persists when people make incorrect assumptions about
what is likely to happen in a given situation, about the quality of their own performance, | shyness_social.pdf |
bf88131e8e1f-0 | Changing Your Anxious Thoughts and Expectations
111and about what other people are thinking of them. This section includes descriptions
of some of the most common styles of thinking that often seem to play a role in social
and performance anxiety. Note that there are additional examples of negative and exag -
gerated thinking that other authors have highlighted (see, for example, Burns 1999) that
we have chosen not to include in this section. In most cases, these were omitted either
because they were not especially relevant to social anxiety or because they were very
similar and overlapped considerably with those examples that we have included. In fact,
even the various thinking styles on this list overlap to some extent. As you may notice, a
particular anxious thought (something like, “Other people will think that I am boring”)
may easily fit into more than one category (probability overestimation, mind reading).
Probability Overestimations
A probability overestimation is a prediction that a person believes is likely to come true,
even though the actual likelihood is relatively low. For example, someone who is fearful of
giving presentations might predict that the next presentation is likely to go poorly, even
though her presentations usually go well. Similarly, a person who is nervous about dating
might assume that other people will find him unattractive, even though many people
have found him to be attractive in the past. If your thoughts are similar to those listed
below, you may have a tendency to overestimate the likelihood of negative events.
Examples of Probability Overestimations
UÊI will be overwhelmed with panic.
UÊEveryone at the party will think I’m stupid.
UÊMy presentation will be a disaster.
UÊI will never be in an intimate relationship again. | shyness_social.pdf |
bf88131e8e1f-1 | UÊI will never be in an intimate relationship again.
UÊI will have nothing to say if I phone my cousin.
UÊI will lose my job if I make a mistake.
UÊIf I go out, everyone will stare at me.
Can you think of recent instances when you assumed that things were going to work
out badly, without any evidence for that assumption? If so, list your own examples of
probability overestimations below: | shyness_social.pdf |
2137a48002ae-0 | The Shyness & Social Anxiety Workbook
112Mind Reading
Mind reading is actually just an example of a probability overestimation. It involves
making negative assumptions about what other people are thinking, particularly what
they might be thinking about you. If social anxiety is a problem for you, it is likely
that you assume that others think negatively about you. Although it is true that people
sometimes make negative judgments about others, the chances are that this occurs much
less often than you think. In many cases, your assumptions about what others are think -
ing are probably exaggerated or even completely untrue. Each of the following kinds of
thoughts represents mind reading:
Examples of Mind Reading
UÊPeople find me boring.
UÊMy boss will think I’m an idiot if he sees my hands shaking.
UÊWhen people look at me, they are thinking I am strange or weird.
UÊMost people see anxiety as a sign of weakness.
UÊMy friends think I am awkward or stupid when I lose my train of thought.
UÊPeople always know when I am feeling anxious.
Can you think of recent examples of times when you have made assumptions about
what other people are thinking about you? If so, list your own examples of mind reading
below:
Personalization
Personalization is the tendency to take more responsibility for a negative situation than
you should, rather than acknowledging all of the different factors that may have contrib -
uted to the situation. Here are some examples of personalization, followed by examples
of other factors that in reality may have contributed to the situation. | shyness_social.pdf |