Dr Christian Jonathan Haverkampf M.D.
This article provides a brief overview of social anxiety and its treatment. There are several psychotherapeutic and psychopharmacological treatment options. Often, a combination of the two leads to superior results. Special emphasis is given to a communication-oriented approach. Since communication is the mechanism which is impaired, communication is also the instrument how the condition and the debilitating symptoms that come with it can be reversed.
Keywords: social anxiety, psychotherapy, communication, communication-focused therapy, psychiatry
Table of Contents
Social anxiety can be defined as nervousness in social situations. What is meant by ‘social situations’ is a situation where communication takes place among a number of people or in front of people. It is rarer that it affects people in one-on-one interactions. Some of it may be related to not having a sense of control or seeing the other person as judging and making this judgment personal and very important. Having a clearer sense of what is relevant and meaningful, a sense of purpose in interacting with oneself and others, usually facilitates communication. Social anxiety is a form of anxiety with the typical symptoms associated with anxiety, but at the same time it distinguishes itself from other forms of anxiety because it directly affects an individual’s ability to communicate with the world, which then also has an effect on internal communication patterns. (Haverkampf, 2013)
Individuals higher in social anxiety avert their gazes, show fewer facial expressions, and show difficulty with initiating and maintaining conversation. Trait social anxiety, the stable tendency to experience this nervousness, can be distinguished from state anxiety, the momentary response to a particular social stimulus. Nearly 90% of individuals report feeling a form of social anxiety (i.e., shyness) at some point in their lives. Half of the individuals with any social fears meet criteria for social anxiety disorder. The function of social anxiety is to increase arousal and attention to social interactions, inhibit unwanted social behavior, and motivate preparation for social situations such as performance situations.
Projecting one’s own thought into the other is a common mechanism which contributes to social anxiety. It means that one is, for example, critical of oneself and then sees this in the audience or other people. Everyone is than as critical of the own person as oneself. The brain is usually not good at tolerating the unknown, especially if the anxiety level is elevated anyhow. So, it develops theories about another’s thinking, motivations, intentions and feelings. However, the information it has about people who are strangers is very limited, so the own patterns of thoughts and feelings are used to make up for the unknown. Unfortunately, this leads to a situation where one is essentially communicating with a mirror image of oneself. If one has good thoughts about oneself, other people will also have positive thoughts about oneself. If one is very critical of oneself, other people are seen as no less critical of oneself.
Projection usually becomes much less of a problem, once one realizes that one is engaging in projection. However, it does take practice to prevent oneself from automatically engaging in projection.
Some disorders associated with the social anxiety spectrum include anxiety disorders, mood disorders, autism, eating disorders, and substance use disorders. Many of these conditions are caused by interference with communication with oneself and others, and cause interference with communication processes. Often, it is therefore possible to resolve the underlying issues of multiple conditions if one works at improving the patient’s understanding and use of communication processes.
Social anxiety disorder (SAD), also known as social phobia, is an anxiety disorder characterized by a significant amount of fear in one or more social situations causing considerable distress and impaired ability to function in at least some parts of daily life.  Social anxiety can impair important functions in life, such as finding a partner or a job or getting admitted to a college of one’s choice. Social anxiety strikes where individuals interact with their environment to get their needs, values and aspirations met. Communication is thus the mechanism that is impaired the most, but it is also the instrument which can be used to successfully treat social anxiety (Haverkampf, 2010b, 2013, 2015, 2018b).
Social anxiety can be triggered by perceived or actual scrutiny from others. This reflects either maladaptive internal or maladaptive communication patterns, or both. Communication patterns are the structured ways win which individuals exchange meaningful messages with each other. For example, if an individual with social anxiety receives a message from the other which conflicts with other information a communication pattern may lead to limit any signals that could reflect that rather than asking for clarification. Especially when it comes to selecting, encoding and decoding messages, maladaptive communication patterns, can lead to the breakdown of communication. If such experiences, which are to an already socially anxious person often catastrophic, accumulate, the result can be a further increase in social anxiety and yet more withdrawal. Focus on communication patterns in therapy can break this vicious cycle and lead to a recovery from even sever cases of social anxiety.
According to ICD-10 guidelines, the main diagnostic criteria of social anxiety disorder are
- fear of being the focus of attention, or fear of behaving in a way that will be embarrassing or humiliating
- avoidance and
- anxiety symptoms. 
Social anxiety is the most common anxiety disorder with up to 10% of people being affected at some point in their life. 
Social anxiety is quite common. 90% will have experienced an episode of social anxiety in their lives. However, if it occurs early and over a prolonged period of time, it can interfere with a person’s mate selection, school work, education and the job he or she chooses. This form of anxiety may be one of the most problematic ones, because of its potential to interfere with a person’s life. In several cases, social anxiety can be self-limiting, as people grow out of it, while in many others it can lead to social withdrawal and the constant feeling that one is missing out on life.
Social anxiety is a form of anxiety, and as such it is a feeling of uncertainty and a fear of the unknown. The feeling of uncertainty and a sense that something ‘bad’ could happen are closely related. A bad outcome is usually related to the sense of self, the integrity as a person in all its attributes. For example, in the case of social anxiety, a feared outcome could be rejection and the sense of not being god enough as a person. This is a hurt that goes right to the core of one’s self. Individuals with social anxiety often see their communication patterns as a direct expression of themselves rather than as a skill which can be experimented with to find ways of interacting with others that ultimately fit one’s personality and sense of self. Communication patterns with oneself and other are not rigid, but evolve over time. Unhelpful ones are discarded, while helpful ones are promoted. Since communication is the instrument by which people get their needs met, pursue what is valuable and meaningful to them, and fulfill their aspirations, having functional and adaptive communication patterns vis-à-vis oneself and vis-à-vis others is important to lead a happy and successful life. Unfortunately, those suffering from social anxiety interferes with the development of helpful communication patterns, and so, directly interferes with life itself.
Patients with social anxiety usually have a desire to communicate with other people and are interested in communication, but they often have a higher expectation of themselves to ‘get it right’. Whether it is that they feel they have more to lose from a social interaction or they have an elevated definition of what social success needs to be or what constitutes a failure, not engaging in communication with others decreases one’s communication skills and sense of success even further.
One of the reasons why often there is no self-correction is that communication is such a central, and powerful, element of living organisms. It is necessary for survival and thus lacks the constraints of other parts of life. If it does not work, the organism withdraws to avoid feeling worse. What should now take place is reflection and learning to make communication with oneself and others work. Unfortunately, for various reasons, this often does not happen.
Autoregulation is a process within many biological systems, resulting from an internal adaptive mechanism that works to adjust or mitigate that system’s response to stimuli. While most systems of the body show some degree of autoregulation, the brain also has to maintain the adjustment with and in the outside environment. By communicating with the outside world, we not only adjust to it but we can also change it so that we not only fit in better but can also meet our needs and aspirations by making it work for us.
Many processes in human communication and social interaction happen automatically. It does not mean that the concept of free will is invalidated (Haverkampf, 2018a), but that one would need to become aware of it to make changes to these interaction and communication patterns. In social anxiety it is particularly important to create more awareness and insight into communication and interaction patterns in therapy, which often leads almost automatically to a desire to make changes in the patient.
Communication is only an instrument, but its purpose is to maintain and ensure the survival of the individual, where survival does not only cover basic biological needs, but also the development of the person and a sense of self. External and inside communication not only helps the individual adjust to external circumstances, but it also allows a person to discover about the basic parameters, the own wishes, needs and aspirations. Social anxiety usually makes the external communication more difficult and anxiety prone. Given the link between external and internal communication (Haverkampf, 2010b, 2012c), this also leads to greater difficulties in shaping the internal communication structures which are needed to identify the basic parameters. An awareness of the own needs, wishes, values and aspirations is important to select paths in life and formulate goals, which are instrumental in building and maintaining motivation.
Having a purpose for communicating with oneself can facilitate the communication process. This, however, usually requires that one has relevance and meaning to oneself overall. This self-meaning can be raised by finding out about one’s wishes, needs, aspirations and values. Since they are inherent to oneself the whole sense of self-worth increases the more of them one discovers and explores. Internal communication is key to this discovery and exploration. As information about past interactions with others and oneself is released from memory together with other associated information, such as emotional signals, and the current communication and information processing patterns are observed, one can gain insight into the basic parameters. In therapy sessions with patients suffering from social anxiety it is thus crucial to also use insight into external communication patterns to improve internal communication, and vice versa.
While the symptoms of social anxiety disorder affect the external communication, their root is usually in maladaptive internal and external communication patterns which may have developed over time, be old communication patterns which were never reevaluated and adjusted or sudden new communication, for example, as a result of trauma.
The physical symptoms are the ones which are typical for anxiety. They are:
- excessive blushing
- excess sweating
While blushing can occur in many forms of anxiety, in the case of social anxiety there is an added vicious cycle as the person feels it is very visible to others, which causes even further anxiety and blushing.
Communication channels can be affected directly, such as the voice, which can lead to:
- stammering and
- rapid speech.
SAD is sometimes referred to as an “illness of lost opportunities” where “individuals make major life choices to accommodate their illness”.  To this one may add that a person suffering from SAD is usually hyperaware of any lost opportunities. While it is quite normal, that interactions with other people may not lead to the wished-for result in many cases, to someone suffering from SAD this just highlights the own ‘deficiency’ and that there is something ‘wrong’ with oneself. This can induce the vicious cycle of depressed thought patterns, negative self-image and social anxiety even more.
Many people with social anxiety are overly conscious of themselves in social situations, which makes these situations less fulfilling and successful than they could otherwise be. They focus heavily on the effect of their behaviors on other people. Often, they assume that people think negatively about them (mind reading) without any concrete evidence. Embarrassment, shame and even guilt often are felt, leading to a sense of loneliness and disconnection from the world.
Distorted thoughts are often self-defeating and inaccurate. Those with social phobia tend to interpret neutral or ambiguous conversations with a negative outlook, and many studies suggest that socially anxious individuals remember more negative memories than those less distressed. 
A previous negative social experience can be a trigger to social phobia.  perhaps particularly for individuals high in ‘interpersonal sensitivity’. An example of an instance may be that of a man at a social event walking up to a woman. If he is unable to say something within the first few seconds, he might become conscious of there being a problem, and then of himself. Even if she would like to help him, he may interpret her reaction of looking at him as indifference or even rejection for his inability to start a conversation. This cognitive thought propels further anxiety which compounds with further stuttering, sweating, and, potentially, a panic attack. The result is a negative memory of a social interaction which can then generalize into all interactions, and lead to social isolation and loneliness.
Physiological effects, similar to those in other anxiety disorders, are present in those with social anxiety.  Common mechanisms and symptoms underly all forms of anxiety. The reason is that the maladaptive internal and external communication patterns lead to communication failures which can, given particular memories and other information, trigger an anxiety reaction in the brain. (Haverkampf, 2018d) Since humans share basic biological structures for anxiety with each other and many animals, for example, in the form of the fight or flight response, the basic physiological responses are the same. Common symptoms can thus include:
- excessive sweating
- difficulty breathing
Walk disturbance may appear, especially when passing a group of people.
Blushing is commonly exhibited by individuals suffering from social phobia.  These visible symptoms further reinforce the anxiety in the presence of others.
Social anxiety is a result of maladaptive internal and external communication patterns. Most of these communication patterns are not conscious. There may be various reasons and factors why the system cannot autoregulate itself. Some may be biological, but many are a result of inadequate information, such as a string of hurtful experiences and an individual’s withdrawal from the world or looking for information about the world and oneself in the wrong places.
Studies suggest that genetics can play a part in combination with environmental factors. Generally, social anxiety begins at a specific point in an individual’s life. As the individual tries hard to counter the social anxieties, they often become even stronger. Eventually, mild social awkwardness can develop into symptoms of social anxiety or phobia. As the autoregulatory mechanisms no longer work effectively, the communication patterns cannot adapt and adjust. The person becomes afraid of communication processes, internally and externally, which inhibits them further. This may be due to different stages in the communication process, the selection of focus, and thus information, the decoding of information and meaning or the sending of meaningful information. A patient may for example try to control what she communicates to others out of fear that she may send the wrong information, such as the negative thoughts she has about herself. Or, someone may focus on distracting information, rather than on the central exchange of meaning within the interaction.
It is still not clear which proportion is inheritable, and which is learned. Studies of identical twins who were adopted into different families have indicated that, if one twin developed social anxiety disorder, then the other was between 30 percent and 50 percent more likely than average to also develop the disorder.  It may actually not be social anxiety that is heritable, but rather anxiety or depression in general.  The problem with many studies and theories in this area is that they work with social anxiety as a bundle of symptoms rather than looking at the causes of the condition and linking those to possible underlying biological variations. Whatever the underlying reasons are, however, the symptoms manifest because of how information flows and is being processed. (Haverkampf, 2012b, 2012a) This is how working with communication patterns in therapy can lower and eradicate symptoms that seem to be linked also to biological variations in components of the neuronal information transmission symptoms. (Haverkampf, 2018c)
There may be inheritable personality traits which can make a case of social anxiety more likely. Studies suggest that parents of those with social anxiety disorder tend to be more socially isolated themselves (Bruch and Heimberg, 1994; Caster et al., 1999), and shyness in adoptive parents is significantly correlated with shyness in adopted children (Daniels and Plomin, 1985). It has been shown that there is a two to threefold greater risk of having social phobia if a first-degree relative also has the disorder. However, learning and exposure to certain interaction patterns probably plays a very significant role. The presence of certain personality traits or other potentially predisposing factors does not mean one has to suffer from social anxiety disorder. An important variable consists of the communication patterns build and shape over time, beginning on the day they are born. These communication patterns need to be reassessed and changed over time so that they help an individual satisfy own needs, values and aspirations. However, if these adaptions do not happen or are inadequate, communication is becoming less helpful to the individual in satisfying needs and aspirations, which has an impact on well-being and quality of life.
Adolescents who were rated as having an insecure (anxious-ambivalent) attachment with their mother as infants were twice as likely to develop anxiety disorders by late adolescence,  including social phobia. Absent parents or an unpredictable parenting style can also contribute to problems in developing a healthy and complete self-image and security in human interactions. The mechanism is again in the communication patterns others and the person uses. Meaningful information leads to changes in communication patterns. So, depending on how a caretaker encodes and sends meaningful messages, and what these messages contain, the communication patterns the child uses can develop in more adaptive or maladaptive ways. Looking at the interaction between the caretaker and child over time, the dynamic that unfolds has an effect on both, but the impact on the developing communication patterns of the child will be greater as there are less past communication experiences. (Haverkampf, 2010a)
For around half of those diagnosed with social anxiety disorder, a specific traumatic or humiliating social event appears to be associated with the onset or worsening of the disorder.  Usually, these events have a significant objective or imagined interpersonal component and high expectations of how the individual is supposed to perform in the situation. It is easy to see how a combination of internal and external communication contributes to the development and maintenance of social anxiety. As negative, or even traumatic events are usually of an interpersonal nature, a resulting distrust in communication with others, or communication in general, lowers the autoregulatory efficacy of communication.
Shy adolescents or avoidant adults frequently report unpleasant experiences with peers  or childhood bullying or harassment. In one study, and children who were neglected by their peers reported higher social anxiety and fear of negative evaluation than other categories of children.  Unfortunately, social anxiety was also negatively correlated with social anxiety in the same study.
There is an unhelpful interaction between social anxiety and adverse behaviors by others which further increases the level of social anxiety, which maintains and worsens the vicious cycle between social anxiety, social withdrawal and increasingly negative self-image and self-esteem. Socially phobic children appear less likely to receive positive reactions from peers,  which would probably help the socially anxious child to break out of the vicious cycle. It is also commonly observed that anxious or inhibited children isolate themselves even more. 
People with social anxiety may not have lower social skills, but they often attach a greater importance to how the social interaction unfolds. It is actually quite often the case that an individual who is very sensitive to social cues may not be able to make this additional information work for himself or herself. Research has indicated the role negative beliefs play, which can be ‘core’ or ‘unconditional’ beliefs, such as “I am inept”, or ‘conditional’ beliefs, such as “If I show myself, I will be rejected”. Negative beliefs are thought to develop based on personality and adverse experiences and to be activated when the person feels under threat.  Social norms and expectations may play a role. For example, if extroversion is a desirable trait, being more introspective can put additional pressure on an individual.
One model  emphasizes the development of a distorted mental representation of the self and overestimates of the likelihood and consequences of negative evaluation, and of the performance standards that others have. Negatively biased memories of the past often seem to play a role, leading to anxiety before an interaction and unhelpful interpretations and ruminations after it.
Studies have highlighted the role of subtle avoidance and defensive factors and shown how attempts to avoid feared negative evaluations or use ‘safety behaviors’ (Clark & Wells, 1995) can make social interaction more difficult and the anxiety worse in the long run.
The neural foundations of social anxiety disorder have been studied extensively.   However, we are not much closer to translating the additional insight into recommendations for psychotherapeutic treatment. It is important to remember that the neural network is the level at which information is processed, which is magnitudes more detailed than conventional neurobiological studies which focus on morphologically distinct brain areas.
The amygdala, an area of the brain which is part of the limbic system, plays an important role in fear cognition, fear responses and emotional learning. It is apparently hyperactive when patients are shown threatening faces or confronted with frightening situations. The 2006 study found that patients with more severe social phobia showed a correlation with the increased response in the amygdala.  Individuals with social anxiety disorder have been found to have a hypersensitive amygdala, whether in relation to social threat cues, such as perceived negative evaluation by another person, angry or hostile faces, or while waiting to give a speech. 
The anterior cingulate cortex, which was already known to be involved in the experience of physical pain, also appears to be involved in the experience of ‘social pain’, for example perceiving group exclusion.  A 2007 meta-analysis also found that individuals with social anxiety had hyperactivation in the amygdala and insula areas which are frequently associated with fear and negative emotional processing. 
Individual variations in serotonin receptor can be inherited, which may also explain abnormalities in the binding and signal transmission within the serotonin neurotransmission system. Social anxiety disorder has indeed been correlated with reduced serotonin receptor binding.  A recent study reports increased serotonin transporter binding in psychotropic medication-naive patients with generalized social anxiety disorder. 
Sociability seems to be tied closely tied to dopamine neurotransmission.  Dopamine is a principal neurotransmitter in the reward system. It is produced by neurons of the ventral tegmental area and shuttled via a nerve tract to a deep portion of the brain called the nucleus accumbens. The stimulation of dopamine, and its subsequent release in the nucleus accumbens leads to feelings of pleasure, which supports survival-enhancing behaviors – such as eating, drinking, and mating. It is also the area of the brain most often implicated with drug addiction – drugs stimulate this pleasure center inappropriately. Stimulation of these areas also enhance remembrance of events leading up to the chemical’s release.
Elevated D2 receptor availability has been found in patients within the orbitofrontal and right dorsolateral prefrontal cortices. Variations in the extrastriatal dopamine system may thus be part of the mechanisms in social anxiety disorder.
While dopamine is more linked to attraction and feeling good in general, two neuropeptides, oxytocin and vasopressin, have been consistently linked with the neural regulation of sociability.
Psychotherapy is the first line of treatment, but medication can be a valuable support temporarily. Since social anxiety is a result of problems in internal and external communication, addressing these usually brings stable and long-lasting relief. Autoregulatory mechanisms, which help maintain better functioning, stabilize the therapeutic success over the long-term once this point has been reached. Since psychotherapy works with communication, it is in a good position to help patients who are afraid of communication processes with others. It usually takes some time to work, but the beneficial effect of psychotherapeutic approaches that focus on communication lasts in clinical practice often for a long time, as the patient in a way learns to become his or her own therapist.
Since changes in communication patterns affect a person’s interactions, they also bring about adjustments in the web of social life. Beneficial adjustments in the workplace or at home can help to further stabilize the changes the patient is making. There is thus not only a strong conceptual link between internal and external communication, but also a quite practical one. Due to an increase in the flow of meaningful information that is relevant to the patient, the improvements in internal and external communication patterns, make life in itself more meaningful to the patient, which also has a positive effect on any symptoms of mood and anxiety.
What exactly has the positive effect in the case of psychotherapy may not be that clear after all. Many schools of therapy, including cognitive behavioral therapy (CBT), claim that their techniques are the most effective ones. In the end, it may be the interaction between therapist and client, the therapeutic relationship, which contributes significantly to the success of the therapy.
A significant proportion of social anxiety may be learned. A series of bad experiences or an isolated life in childhood can contribute significantly to social anxiety early on and for decades to come. The fundamental question is whether a child learns to see and use communication with others as a valuable tool to get one’s needs and wants satisfied, or if communication is used by others to hurt and ostracize. CBT uses tools that can help to ‘re-learn’ what social interactions can be in a step-by-step approach. One drawback of CBT as compared to the more individualized, insight and emotion oriented approaches is that the effect may not be as long lasting (Haverkampf, 2017a), making ‘booster’ sessions at intervals necessary. There is also the problem that by learning new ways of thinking and behavior they may not be integrated as fully into the person’s concept of self and personality as when they are developed by him or her in a therapeutic interaction. The sense of ownership of the individual changes must be particularly low when manualized CBT therapies are used.
Psychodynamic psychotherapy (PPT) is more concerned with the reasons for the social anxiety in the first place. How one sees oneself determines how one sees others. Often, it can be observed that clients project their own expectations and fears into others and then interact with mirror images of their harshest critic, themselves. PPT is thus looking more at the underlying dynamics, while also paying attention to certain communication phenomena, such as transference, counter-transference and reflecting on how a patient talks about content. However, PPT does not focus directly on the communication patterns. It is more concerned with content. From a communication focused perspective, the causal sequence is seen differently as the content is a consequence of the communication patterns an individual uses.
Communication-Focused Therapy (CFT) was developed by the author for several mental health conditions (Haverkampf, 2017b, 2018b), such as anxiety and panic attacks (Haverkampf, 2017d), depression (Haverkampf, 2017f), ADHD (Haverkampf, 2017c), bipolar condition (Haverkampf, 2017e), psychosis (Haverkampf, 2017g), social anxiety (Haverkampf, 2017h), and more. It focuses on the internal and external communication patterns which cause and maintain the impairment. In the therapeutic setting, awareness is created for these communication patterns, they are observed, reflected on and experimented with. The result is to gain the insight needed to lower and eliminate the symptoms. It is extensively described by the author elsewhere. (Haverkampf, 2010b, 2017b, 2018b)
The serotonin reuptake inhibitors (SSRIs) have been helpful in the treatment of social anxiety in a number of cases. Paroxetine and sertraline are two SSRIs that have been confirmed by the FDA to treat social anxiety disorder. In a meta-analysis, Blanco et al. (2003) found phenelzine to produce the largest improvement in measures of social anxiety, with an overall controlled effect size (ES) of 1.02. However, phenelzine did not perform significantly better in their study than other medications, including the benzodiazepine clonazepam (ES=.97), the anti-convulsant gabapentin (ES=.78), the reversible inhibitor of monoamine oxidase-A brofaromine (ES=.66), and the SSRIs (ES=.65). Effect sizes for the SSRIs sertraline, fluvoxamine, and paroxetine ranging from .30 to 2.2 have been reported (Van der Linden et al., 2000). Well-tolerated, safer drugs like the SSRIs should be the first-line choice. Phenelzine with its potentially more dangerous side effect profile should be reserved only for cases where all other medication fails (Blanco et al., 2003). It is this author’s opinion that they should generally not be used, because in many cases where medication does not seem to work sufficiently or not at all, an effective psychotherapeutic treatment has been missing. And even if psychotherapy has been tried, as in the case of medication, rather than giving up on psychotherapy, one should switch to a different therapeutic approach, which frequently leads to additional positive effects.
Psychotherapy should not be weighed off against medication in the search for the ‘better therapy’. They both have their place and time, and it is important to keep in mind what either of them is used for.
Psychotherapy should always be considered as the long-term treatment that works on the underlying causes of social anxiety. There may be a biological predisposition, such as variations in neurotransmitter receptor sequences and three-dimensional conformations which affect the information transmission via the neurotransmitter-receptor system, but except for the severest cases the high plasticity of the brain can lead to major changes in the neuronal network given the right information. Working on internal and external communication, within the right environment and setting, can achieve fine-tuned changes, which a medication probably never can.
Medication is an option to support the patient until the therapy is fully working. It should also be considered in more severe cases where biological factors are just too strong to allow psychotherapy to work in the short- or medium-term. Still, even in cases of severe depression and even psychosis, with the right psychotherapy, medication could be tapered off over the long-term successfully.
Much of the research in this area has been done with cognitive-behavioral therapy as the studied psychotherapy form. There may be several reasons why this is the case. One reason could be that CBT due to its manualization may be easier compared with medication which often follows treatment algorithms. Another reason may be a result of timing, since CBT has been particularly prominent towards the end and the beginning of the millenniums where psychiatric medication, primarily in the form of the serotonin reuptake inhibitors (SSRIs), reached wide sectors of the population.
Gould et al.’s (1997) meta-analysis examined effect sizes of 24 controlled trials that evaluated either cognitive-behavioral or pharmacological treatments for social anxiety disorder. Both pharmacological and cognitive-behavioral treatments were superior to control conditions. These two approaches, however, were not significantly different from each other. Furthermore, CBT and medication had nearly equivalent rates of attrition at post-treatment and follow-up.
Fedoroff and Taylor (2001) found pharmacotherapies to be more effective than cognitive-behavioral treatments. SSRIs and benzodiazepines yielded the largest effect sizes, both performing better than control conditions but not significantly different from one another. In fact, benzodiazepines were found to perform better than the MAOIs and CBT (i.e., cognitive restructuring, cognitive restructuring plus exposure, and social skills training). However, the SSRIs were not significantly better than these treatments, nor were the MAOIs more effective than CBT. Pharmacotherapies appear to be somewhat more effective than cognitive-behavioral interventions in the short-term (Fedoroff & Taylor, 2001). Liebowitz et al. (1999) assessed the long-term outcome of clients receiving either phenelzine or CBGT and who met responder criteria after twelve weeks of treatment in the Heimberg et al. (1998) study. After a 6-month maintenance phase and an additional 6-month follow-up phase, half of the patients from the phenelzine group had relapsed, compared to only 17% of patietns who had received CBGT.
Blomoff et al. (2001) tested sertraline versus pill placebo, each in conjunction with either physician assisted exposure or non-directive encouragement and support, in a 22 design. At week 8, clients receiving sertraline plus exposure showed significantly more improvement than clients receiving pill placebo and supportive care. At week twelve, at which point the exposure therapy ended, all active treatments were superior to the placebo and non-directive encouragement condition, but there were no differences between active treatments. By week 24, sertraline was superior to pill placebo, and there was a trend for the exposure conditions to be superior to the support conditions. Exposure appeared to add somewhat to sertraline, at least in terms of efficiency (i.e., the combination treatment showed significant change earlier), but there were few significant differences between sertraline with and without exposure.
A one-year follow-up of clients in this study reported by Haug et al. (2003) showed that those who received exposure and supportive treatment continued to improve, whereas clients in the other conditions, including the combination treatment, failed to do so. In fact, there was some indication that clients who received sertraline with or without exposure deteriorated during the follow-up period, although all active treatment conditions were superior to placebo interventions alone. It may be that sertraline actually impeded the effects of exposure in the long run, even though the combination appeared more beneficial in the short term.
In many cases psychotherapy alone can be sufficient, while in some cases the added support from medication is needed. Medication by itself without psychotherapy is usually an inferior option because practically all symptoms in psychiatry are due to issues around internal, and often external flows of information. Only a communication-based therapy, which includes most flavors of psychotherapy, can bring about change here. However, adding the support of medication can be helpful in many situations. Medication, if it is used correctly, should not put a lid on things, but more distance from getting overwhelmed by anxiety can help to address issues and try some forms of exposure which would not be possible otherwise. In the case of social anxiety, working on communication patterns, unresolved issues from past experiences and trying stepwise exposure can all be supported with anxiolytic antidepressant medication in cases of more severe anxiety. Most studies exist on the combined use of medication and CBT. In studies of placebo-controlled discontinuation with paroxetine (Stein, Veriani, Hair, & Kumar, 2002; Stein et al., 1996) and sertraline (Walker et al., 2000), and in an uncontrolled discontinuation study with phenelzine (Liebowitz et al., 1999), relapse rates varied between 30% and 60%, but were consistently higher than relapse rates reported for group CBT (17%; Liebowitz et al., 1999).
Psychotherapy has traditionally been called the ‘talking cure’ because it uses interpersonal communication to achieve a positive effect in a patient. While it started out more or less as a one-way street from therapist to patient, particularly in early attempts with hypnosis. It is now seen as a process which affects both, the patient and the therapist. When both can reflect on its effect, this can translate into change in the patient. Communication is the exchange of meaningful information, and meaningful information, if it can be received, decoded, interpreted and translated into meaning within the information that is already there, is what directly induces change.
Communication-Focused Therapy (CFT) was developed by the author to focus more specifically on the communication process between patient and therapist. The central piece is that the sending and receiving of meaningful messages is at the heart of any change process. CBT, psychodynamic psychotherapy and IPT help because they define a format in which communication processes take place that can bring about change. However, thy do not work directly with the communication processes. CFT attempts to do so.
We engage constantly in communication. The cells in our bodies do so with each other using electrical current, molecules, vibrations or even electromagnetic waves. People communicate with each other also through a multitude of channels, which may on several technologies and intermediaries. It does not have to be an email. Spoken communication requires multiple signal translations from electrical and chemical transmission in the nervous system to mechanical transmission as the muscles and the air stream determine the motions of the vocal chords and then as sound waves travelling through the air, followed by various translations on the receiving end. At each end, in the sender and in the receiver, there is also a processing of information which relies on the highly complex networks of the nervous system. Communication, in short, happens everywhere all the time. It is an integral part of life.
Communication is an autoregulatory mechanism. It ensures that living organisms, including people, can adapt to their environment and live a life according to their interests, desires, values, and aspirations. This does not only require communicating with a salesperson, writing an exam paper or watching a movie, but also finding out more about oneself, psychologically and physically. Whether measuring one’s strength at the gym or engaging in self-talk, this self-exploration requires flows of relevant and meaningful information. Communication allows us to have a sense of self and a grasp of who we are and what we need and want in the world, but it has to be learned similar to our communication with other people.
If one suffers from social anxiety, this autoregulation seems to fail. One reason why it fails is because communication is such an important and basic process that there is nothing that could hierarchically control it and put a problem in it right. Only changes in communication can put a communication failure right. This is why a therapy that focuses on communication by identifying communication patterns and reflecting on them is in a good position to treat social anxiety.
Communication is important to be connected into the web of life. The exchange of meaningful messages helps one to get what one needs, wants and aspires to. This applies to communication with oneself and others. Finding out what one needs, wants and aspires to happens through communication with oneself. It requires openness and insight.
The feeling of being a part of ‘the whole thing’ is important to an individual, not just because the individual is part of a chain of generations. When one exchanges meaningful messages with others, oneself and the world around become meaningful to oneself. Losing a part of oneself or a loss of meaning, however, represents an existential threat, which can induce anxiety. This is how social anxiety and a loss in meaningful connectedness with others can lead to more anxiety. To an extent, this can be compensated for with meaningful communication with oneself, but for most this is not enough.
Social anxiety is often present from childhood. The fears already interfere with one’s development early on. Since some of the most experiences in a human life are the interpersonal ones, this can interfere with one’s personal development. As already mentioned, shyness is not a disorder, and a person may be happy about it. However, the potential loss to quality of life of social anxiety and shyness can be similar. Shy people often develop adaptive communication pathways, such as relying more heavily on the Internet and may be content with it. However, interpersonal communication is an important piece of change and of bringing about in the world, and without it some of this dynamic may be missed out on.
The ability to exchange and process meaningful messages also leads to a better connectedness with oneself and the world. Thus, if something interferes with communication it also reduces the ability to connect and to actually be connected. However, if some communication situations and channels do not work for the individual, this does not mean that this necessarily has to reduce connectedness. For example, if a person has difficulties with approaching a person in a public place eye-to-eye, an online platform may make it still possible to eventually go on a large number of dates. What helps here is that the available number of communication channels is reduced. Conversely, psychotherapy works best in person because the person ix experienced and experiences herself in full communication within the appropriate communication space. From gestures to voice, all communication channels can be used.
Often, there are already maladaptive communication patterns before, that cause the problems in the relationship or interpersonal interactions. These patterns can be analyzed and changed. Another important element is that communication can also take place on the inside of the individual. Individuals with social anxiety are often very critical of themselves, and this is what is then projected into others, who then appear critical of oneself. An important, and often helpful, step is to become aware of this.
The internal and external communication go hand in hand. Thought patterns that are used in one’s communication with oneself are usually also used in the communication with others. If there are doubts and fears in the communication with oneself, they often will also be present in one’s communication with others.
In life, one has to live with uncertainty. Uncertainty just means that there is no manual in the beginning and there are still unknowns which leave room for excitement and exploration. Life is a learning experience. An individual suffering from anxiety may have areas in life where she thrives on excitement, and other areas where images of worst case scenarios cause her to freeze when she just considers a change in action or any action at all. Uncertainty to someone suffering from anxiety seems to be bearable in some areas and avoided in others. Often, the areas where it is not tolerated feel meaningful only to the person suffering from anxiety.
Uncertainty in interpersonal situations can seem more daunting because in life we depend on interactions with other people to a large extent for our happiness and success. This applies to all areas in life, from the academic to the professional and the personal. A common cognitive mistake is to ‘jump ahead’ by already thinking about the future of a relationship when beginning an interaction with a person one has just met for the first time. The anxiety one is experiencing now while making small talk to the new contact is no longer only about the current playful finding out whether engaging further with this person can be a benefit, but about maintaining or losing the relationship one is projecting into the future in one’s mind as relevant and important. Social anxiety is largely based on this different experience of reality, that a thought about the future of the relationship is no longer a thought but an experienced reality, which one is afraid to lose. (Haverkampf, 2013) The uncertainty about the future of the relationship therefore assumes a new potentially threatening reality if one has to make it work before it has even begun yet.
Areas which people often feel anxious about are where there has been an issue with their interpersonal interactions in the past. Early traumata, like a disappearing or abusive parent, may be unresolved and cause emotional associations with certain communication situations and processes. The phenomena of transference and counter-transference, used in psychoanalytic psychotherapy to describe feelings and thoughts about another person which influence the interaction patterns and styles with that person, are examples which illustrate how content in memory can influence the communication patterns one uses with another person, which in turn determines largely the outcome of the interaction. Once these patterns become aware they can be adjusted so that they are more supportive of a person’s individual needs, Values and aspirations. As such they do not really represent communication deficits, but more so deficits of awareness.
‘Real’ communication deficits, such as speech or hearing impediments, may play a role in social anxiety, as could a tic or some other more biologically determined symptom. However, it is usually not one of these features which causes social anxiety, but how real or imagined feedback from other people is interpreted.
Anxiety can lead to avoidance, which in turn can attach even more anxiety to the situations or behaviors which are being avoided. In social situations, not interacting with others deprives the person of continuously updating and honing the skills and confidence of interacting with others. Avoidance can thus lead to an increase rather than a decrease in anxiety in the long-run.
Individuals suffering from social anxiety do not see less relevance in social interactions, but often even more. It is not necessarily seeing more meaning, though, but a different kind. In therapy an important part is to rediscover meaning, and find it in the things that are relevant to the patient. Relevant is anything that is close to his or her values, basic interests, aspirations, wants, wishes and desires.
However, someone with social anxiety may see the meaning in things differently from someone what does not suffer from it. Approaching someone of the opposite sex may be seen differently because of life experiences. Also, if different meaning is seen in it, the expectations can be different. Expectations that are so high that they are self-defeating can be a problem. However, to set expectations that are not too high and not too low mean having a view of reality that works for oneself.
An important step in therapy thus to make the person aware of how anxiety affects one’s thinking. Individuals from anxiety often focus differently from other individuals. There is often a focus on worst outcomes and strong fears which are caused by it. Underlying this are often strong emotions or conflicts which need to be defended against. The danger and uncertainty is quite frequently inside oneself, rather than on the outside. An individual with a fear of flying may be more afraid of not containing oneself and not being able to leave the plain than anything else. Anxiety is the fear of crashing psychologically and the feelings of a dreaded uncertainty about oneself and one’s emotional states.
Awareness means observing the own thought patterns and gaining insight into them. This requires being receptive to this information from oneself and the ability to reflect on it. Important is being able to perceive the flow of information between the parts of oneself, and the ability to let the information flow freely.
A free flow of information within oneself and with the environment is important to reduce the anxiety and physical symptoms associated with social anxiety. Often, such an openness has become difficult for people because of inadequate interaction patterns and a fear to change anything. In a therapeutic session, this can be changed in two ways. Interaction patterns can be experimented with in a therapeutic session and reflected upon. One objective should be to help the patient develop greater efficacy and confidence in his or her interactions with the environment.
If there have been adverse life experiences as a significant factor in the social anxiety, there can still be unresolved emotions underlying the anxiety. To resolve them means answering the hypothetical question, what one may have felt in the difficult situation, but then also seeing the strength that allowed one to pull through, which only becomes visible now. The goal is not necessarily to reconnect with only negative emotions form the past, but also the good ones, and emotions as a whole today.
If there is a disconnect, and emotional reconnection would be helpful, one should approach one’s feelings gradually. Especially in cases of social anxiety, it could be problematic trying this too fast. In any case, as internal and external communication go hand in hand, so do internal and external emotional connection. Someone who is disconnected from oneself will have a more difficult time to emotionally communicate with others or stay reflected and calm in situations where there is a potential for greater emotional communication, such as in romantic situations.
Social anxiety means potentially experiencing less of the world, although the higher sensitivity can at the same time let someone experience more. High sensitivity is not a bad, but the capability to perceive and experience more about oneself and the world. The important part is to make it work for one, rather than feeling constrained by it.
Various communication techniques can be helpful, not as an end in themselves, but to help the person have more confidence in oneself and to see communication not as something dangerous one needs to be guarded against, but as something that can help one meet one’s needs, wishes and expectations. Thus, the reason for communication techniques should be not an end in itself, but to increase one’s repertoire, ease and confidence in communicating with oneself and others.
Openness to others, a positive and welcoming attitude towards the messages of others and engaging in reflection on the interaction are some helpful approaches towards communication, but there are many others as well. Important is not to be deterred from the interaction when something unsuspected or disappointing happens, but to reflect on what it could mean, whether it is a message from outside or inside oneself. Genuinely new information is never meaningless and reflecting on it helps to gain more insight into the world. Social anxiety, on the other hand, is often a result of engaging with messages only superficially, rather than letting them resonate with oneself and determining what they might mean.
The main objective should be changes in the communication patterns which determine the exchange of meaningful information with oneself and the environment. Since information flow is conducted in communication patterns which are partly hardwired, but to a large degree learned in a heuristic fashion with conditioned learning, awareness, analysis and change of these communication patterns is crucial in bringing about change. Communication patterns and structures have been discussed in greater detail elsewhere (Haverkampf, 2018c).
To break through the vicious cycle of anxiety, in which emotions like fear and anxiety cause safety thoughts and behaviors, which in turn reinforce feelings of fear, loneliness, sadness, and so forth, it is helpful to focus on identifying what is meaningful and having more of it in life. Communication helps in identifying and finding meaning, either communication with oneself or with others. The exchange of messages is like a learning process in which meaning can be identified, found and accumulated. Through meaningful interactions one accumulates more meaning, more connectedness with oneself and the world and reduces the need for thoughts and behaviors which are triggered by fears, guilt, self-blame and other negative emotions. This also helps against depression and anxiety.
Insight and connectedness reduce anxiety. Openness and receptiveness to information and messages can lead there. This can be practiced in therapy and brought from there into everyday life. The sense of competence helps build confidence in dealing with oneself and the environment. Important is to connect with oneself to a level that there is greater insight into what is truly important to oneself.
Perceiving more meaning also makes interacting with others and oneself more meaningful. This has a positive effect on one’s interaction patterns, how and in which ways one relates to one’s environment and exchanges messages with it. People with social anxiety often see less in an interaction, although they often have a greater sensitivity and perceptiveness to see more. This has to do with a different focus on where to find a relevant and meaningful message in the interaction. For example, in an interaction with a romantic love interest, the socially anxious person may be too focused on signals and own thoughts about a possible rejection rather than on information from the other person that could help in getting to know that person.
Beyond food, drink, a roof over one’s head and basic safety, humans have values, needs and aspirations that drive much of what they are doing throughout their lives. We are not born to be Robinson Crusoes, and just like the fictional character, interpersonal interactions and communication in general is usually a core component of these needs, values and aspirations, and required to have them met. Communication keeps the engine running that brings about positive and lasting change in oneself and in the environment.
One of the most painful elements of social anxiety is that a person finds it more difficult to find the own needs met. It interferes with dating, in workplace situations or in academia. People suffering from this condition, do so in silence, which tends to make it even worse. To escape this vicious cycle, a new orientation towards the own values, needs and aspirations is needed. What helps to achieve this is through a better connectedness with oneself and others.
Living organisms have a need for communicating with themselves and others. This is needed to grow, innovate and propagate. Most of the human accomplishments in the arts, sciences and professions are based on the exchange of meaningful messages, communication. But communication is also to have one’s needs met and to survive in general. Even a hermit in the mountains needs to interact with his or her living mountain environment. People who enjoy nature usually do not want to shun communication, but focus on an exchange with a nonhuman environment. Communication is fundamental to life itself.
It often helps people with social anxiety and shyness to connect with and appreciate their need and joy in communicating. Once communication is seen as a potential source of joy rather than a necessary task, it can become much easier, as ‘I want’ replaces ‘I should’.
Communication is the vehicle of change. The instruments are meaningful messages which are generated and received by the people who take part in these interactions. In a therapeutic setting, keeping the mutual flow of information relevant and meaningful brings change in both people who take part in this process. The learning curve for the patient may be steeper in certain respects because he or she spends less time in this interaction style than a therapist.
In social anxiety, embracing change can be associated with anxiety, but it can also be liberating, because it means that there are no rigid rules one needs to adhere to other than those linked to the communication process itself, which has clear laws. Understanding these laws of communication, on the other hand, which humans subconsciously operate on and use as they accumulate experience in their interactions with others is important to be more confident in tolerating and working towards change. Basic communication concepts, such as what constitutes communication, how meaning is created, how information flows, and how communication processes are influenced, is usually not conscious, but reflecting on it and beginning to use it can be especially helpful to sensitive people, who quite frequently have experienced social at some point in their lives. One might say, that only those who do not care about people and themselves are entirely free from social anxiety.
It is not the number of social contacts which is relevant. Having a few good friends is often worth more than thousands of contacts in an online social network. However, this does not mean friends have to be always physically present. Meeting friends online also allows for communication, while close physical contact in an intimate relationship is to most people important on a regular basis.
Important is that the communication patterns, the frequency and the interaction style fit the needs, values and aspirations of the individual. People who are shy can be quite happy with the intensity and frequency of their interactions, those with social anxiety are usually not. It is thus important to help individuals with social anxiety discover what is important to them and how they want to live their ives.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. He is the author of several books and over a hundred articles. Dr Haverkampf has developed Communication-Focused Therapy® and written extensively about it. He also has advanced degrees in management and law. The author can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.ie and www.jonathanhaverkampf.com.
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