Social Anxiety disorder
VEER KUMAR sat in the second row and listened as his team member Arun presented a new software module they had developed. Veer had done most of the work in developing this module. The team had wanted him to present it but he refused.
“I will make a fool of myself before the clients. I will not be able to answer questions. Please don’t force me,” he pleaded. A year ago, he had gone to make a presentation. He was anxious. As he was about to start, he felt giddy and felt his heart was pounding. His hands were shaking and his shirt became soaked with sweat. He fumbled and feared that he might collapse. Since then he has actively avoided any presentation or discussion with clients. Apart from being on stage, other situations too cause the same fear and bodily changes. He was scared to talk to his manager or any official.
Arun was now taking questions from the audience. As he wound up, many congratulated Arun for a good presentation. Veerkumar felt sad that he was not standing on the stage and receiving appreciation. He cursed his shyness.
Phobia is anxiety about a specific object, situation or activity and avoidance of these stimuli. The person avoids these to protect himself from anxiety.
The multiple fancy names for phobias are more an exercise in etymology than in Psychiatry. Psychiatrists divide phobias as Simple phobia, Social phobia and Agoraphobia. The last two retain their names in clinical use because they are more frequently seen.
A person with social phobia fears multiple social situations like public speaking, talking to a stranger, a person of opposite sex, a group, or a person of higher authority. Some fear writing in public (signing a cheque in a bank) and eating in public. They avoid all these situation/activities due to the fear of fumbling and being ridiculed/ teased. They are acutely aware of the opportunities they miss and many develop secondary depressive symptoms.
The best treatment for phobia is facing the feared object or putting oneself in the same anxiety-provoking situation or activity again and again. If someone has a phobia for getting into water, medicines or counselling alone is not going to help. The real treatment would be to actually get into the water. This can be done in a graded fashion. This is called Systemic desensitisation or in plain English, Graded exposure.
It is a delight to watch beginners’ swimming classes. Eight-year-old Lal is scared of the water. The swimming coach talked to him calmly and said, “You don’t have to get into the water. Sit on this chair and watch others playing”. Thirty minutes later, the coach asked, “Do you want to sit near the water and put your legs in the water?” Lal reluctantly agreed but soon started liking it.
The next day, as he was dipping his leg in the water, the coach asked, “Would you like to play in the shallow side, like that girl over there?” An hour later, his curiosity and the coach’s approach made him agree to move closer to the coach and the other children. The next day, though reluctant, he went through the coach’s instructions and in a week, started swimming. The coach was following Graded exposure.
The same principle can be applied in phobia. If the anxiety is severe, the person will not be willing for exposure. Anxiety can be brought down by medicines and/or by specific relaxation exercises, imagery, breathing exercises or yoga, before graded exposure is begun.
For example, if someone has phobia for dogs (to the extent of being homebound and avoiding dogs even in a picture), the graded exposure can be planned in the following manner: Looking at a photograph of a dog, touching the photograph, looking at a real dog in an enclosure from various distances, gradually coming closer, touching the dog with the help of another person and touching without help.
People with social phobia are afraid of multiple social situations. For them, the graded exposure is planned as follows. They are asked to List all the anxiety provoking stimuli and situations; Grade the severity of each situation in a scale of one-10. The least anxiety-provoking will be graded one and the most anxiety-provoking will be 10; Arrange the situations according to their severity; Start exposure with the least anxiety-provoking situations (those scored as one or two); Gradually work one’s way up.
Once the person persists in exposing himself to situations marked 1 or 2, the anxiety would gradually wane. This improves his confidence and motivates him to move to the next level of anxiety-provoking situations. With constant effort and encouragement, he will be able to overcome all his phobias.
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Different kinds of fear
Simple Phobia: Any animal, insect; Any inanimate activity; Height; Closed space; Flying; Taking an injection
Social Phobia: Public speaking; Speaking to a person of authority; Initiating conversation; Talking to a group; Writing or eating in public
Agoraphobia: Fear of crowded places such as mall, theatre, bus or train, crowded roads.
This article was first published in The Hindu on 28 May 2006