Social Anxiety Disorder

Social anxiety as trepidation and concern about social encounters is a very
common and distressing condition reported by as many as 40% of the general
population. Edelmann 1992

There is evidence that people with (SA) tend to believe that the way they
feel is the way in which they are perceived by others.

McEwan 1983


Social Anxiety Disorder (SA)

SA will usually involve excessive shyness and unease around strangers and
peers that becomes so extreme that it interferes with normal social development
and leads to isolation and depression. Sufferers tend to fear that people
are judging them in social situations; and even when they are aware that their
response is not logical their discomfort remains. This fear might be focused
on expected negative responses to physical symptoms such as shaking, sweating
and blushing; or possibly to their perceived ineptitude in conversation, bad
eye contact etc.; or even to the ‘fact’ that they feel sub-standard and expect
people to recognise this.  Where there is doubt about the validity of
these feelings, it might still be strong enough to cause handicap; perhaps
likened to the obsessive thinker who cannot tolerate even the smallest possibility
that his or her fears are genuine. That is, with SA, the most minute of chances
that judgment is being made might be enough to maintain the fear in a whole
range of social situations.

Using the word ‘shyness’ above does not mean that SA can be easily defined
in these terms as the SA sufferer’s version of the feeling may be to that
of a ‘normal’ person as a crippling migraine is to a slight tension headache. 
Shyness in general is not, of course, an illness or a neurosis.  It is
part of the personality for a great many people and does not need ‘treatment’. 
Some workers in this field find the whole idea of shyness as a significant
part of SA to be wrong and confusing; and being shy does not necessarily lead
to SA, which is itself a clinical disorder, not a personality trait. 
And it seems that many adults with SA were not particularly shy as children.

This might seem like ‘nit-picking’, but anything that encourages people
to see an anxiety disorder as of little consequence, or worse, as when shyness
is seen as its main characteristic; is destructive and puts one more hurdle
in the way of people with SA seeking help.

Social Anxiety Disorder is estimated to affect between 10% and 15% of subjects
in the community at some time in their lives.

J.C. Balleneger. M.D. et al

How it affects people
SA sufferers will, as mentioned above, persistently avoid situations where
they may be scrutinised or criticised by others  (or will stay in the
situation with dread) and will feel compelled to do this even though their
anxiety may be made worse by the knowledge that this is an excessive reaction.
They will avoid or dread situations like speaking in front of a class, eating
or writing in public and may overly fear blushing or vomiting or otherwise
embarrassing or humiliating themselves in front of people, perhaps leading
to a total avoidance of social situations. A vicious circle can build up of
anticipation leading to fearful thoughts about being judged or about the physical
symptoms of anxiety (shaking, sweating, blushing), or both, in the feared
situation.  This can lead to real or perceived poor performance, which,
in turn generates embarrassment and increased anticipating anxiety – and
so on.

Unlike ‘normal’ anxiety that anyone might experience when, for instance,
they have to give a speech, which tends to help in presentation and concentration
and then ease off, the person with an SA response will be experiencing sustained
anxiety that will get in the way of performance and might even stop it.

People with SA may be very sensitive to criticism and people not liking
them, and may feel inferior to others, have difficulty sticking up for themselves
and have very little sense of their own value as a person. People with SA
don’t tend to seek out a trusted companion to help them as is common with
agoraphobia and they don’t seem to have Panic Attacks while alone. And if
severe anxiety occurs in a situation that would be a problem for an agoraphobic,
the cause is likely to be different. For example, in a large shop, the SA
sufferer would be anxious about speaking to assistants or counting out money,
while the agoraphobic would be anxious about feeling physically trapped.

There is some discussion in research about the possibility of there being
more than one type of SA. This seems to be based on the number of different
situations that cause a person problems, and the severity of the disability
in these situations. This research suggests, understandably, that the less
situations there are, the less intensive the treatment necessary and the less
chance of other psychiatric conditions occurring with the SA. Research also
suggests that one in eight people may suffer from some form of SA during their
lifetime and that about 2% of the population will suffer from the more extreme
forms that cover a very wide range of social situations.

On the subject of having more than one disorder, research also suggests
that many sufferers do not recognise the SA disability, writing it off as
shyness, and tend to seek treatment for the disorder/s that occur alongside
it such as major depression.  In this way, the SA could be missed altogether
by the GP and inappropriate or insufficient treatment might then be offered.
Research also suggests that accompanying depression occurs in almost half
of SA cases; and that the depression starts, on average, after more than a
year of SA suffering. That is, the depression may occur as a response to the
SA. Onset of SA is usually between the ages of 14 and 20 with the average
age around 15. If it occurs before the age of 11, recovery may be more difficult.

If you feel that you, or a family member, might have SA, it has been suggested
that you ask the questions:

1.      Are you uncomfortable or embarrassed at
being the centre of attention?

2.      Do you find it hard to interact with people?

Answering ‘yes’ to both will not prove the existence of SA, but it would
then certainly  be worth exploring the possibility that it is present.

Social Anxiety Disorder appears to predispose individuals to the development
of other psychiatric disorders, most notable depression.  Some 70% to
80% of cases of social phobia are complicated by comorbid [being present at
the same time] conditions that increase the burden of disease.

J.C. Balleneger. M.D. et al

THE SYMPTOMS OF PANIC

– heart palpitations      – feeling sick

– chest pains              
– difficulty breathing

– dizziness                 
– ‘jelly legs’

– feeling ‘unreal’          
– intense sweating

– feeling faint               
– dry throat

– restricted or ‘fuzzy’ vision or hearing.

There is some disagreement in research about whether or not people with
SA panic, but it seems likely that someone with SA who has panic attacks
as defined in the Panic Disorder article on this site has this disorder as
well, rather than panic being part of  ‘normal’ SA.  People with
social problems may well have a big adrenaline rush when faced with a situation
they dread and experience extreme anxiety at this time, but this does not
have to be classical panic as in Panic Disorder; and people with SA do not
tend to dread panic or view the physical symptoms as evidence of a terminal
disease which happens with Panic Disorder sufferers.

 Also, while social problems can be part of agoraphobia, those with
SA will be seen to be different to agoraphobics in general as mentioned briefly
above. For example, agoraphobics in the Anxiety Care groups are often outgoing
and sociable, enjoying contact with others a great deal, including contact
with strangers. Many have defined themselves as ‘the life and soul of the
party’ before agoraphobia hit.  No SA sufferer would be able to say that.

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Treatment

This leads to a perennial problem with SA: seeking help.  Many people
with this problem would find working one-to-one with a therapist extremely
daunting and working within a group as virtually impossible.  Unfortunately,
group work is often the treatment of choice for neurosis within the NHS. 
Beside any therapeutic value this might offer, it is also a lot cheaper to
work with eight or ten people at a time than it is to work one-to-one, and
in these days of cost-effectiveness and the vast incidence of anxiety disorder
in the community, treatment has to fit the available resources. If group work
for SA is offered to you or to your child as the only way to obtain ‘talking
help’, it is essential to be realistic about the likelihood of this being
viable.  People desperately want to be free of their SA but sometimes
the price, at least currently, is too high.  Better to take some form
of medication and then attempt group work when and if this reduces symptoms,
than reinforce personal doubts and fears by not being able to maintain it
when ill-prepared.

Medication of various sorts is available for SA. In the past Beta Blockers,
Monoamine Oxidase Inhibitors (MAOI) and benzodiazepines have had their supporters. 
However, the current medication of choice is Selective Serotonin Reuptake
Inhibitors (SRI).  These are anti-depressants that have been found to
have a profound effect on anxiety.  They may take anything up to eight
weeks to become fully active and the side effects, if there are any, happen
before this. When a rapid response is required, it has been known for prescribing
physicians to offer a benzodiazepine as well as an SRI to make this waiting
time less difficult. Research suggests that not all the benzodiazepines are
equally effective on SA so the GP will need to do a little checking. Clonazepam
has been mentioned in some research as, possibly, the better choice here;
but it would not be sensible for any sufferer, or parent of a sufferer, to
demand a specific drug from their doctor.

However, with all medication, relapse is likely once the drug or drugs are
discontinued unless there is accompanying psychotherapy, or much personal
effort, that confronts thinking problems and any personal misperceptions about
life and people that has lead to this disorder in the first place. So at
best, medication will relieve symptoms while it is being taken. If there
are accompanying ‘thought problems’, ‘talking help’ such as Cognitive Behavioural
Therapy and/or social skills training would be advisable.  Assertiveness
training, exercise, relaxation or yoga, a reduction in the use of caffeine
and sugary snacks, a diet high in carbohydrates such as fruit and vegetables,
whole wheat bread and lean meat; have all been recommended too.

Prevalence rates for Social Anxiety Disorder (SA)…are estimated to be up
to 4% with boys and girls equally likely to develop it… Since children with
SA are usually quiet in school and do not exhibit behavioural problems, teachers
often do not recognize the disorder…What can complicate matters is that anxiety
disorders often run in families and children with SA may have a parent suffering
from the same disorder.  The parent may attempt to shield the child from
social situations, and that may confirm the child’s fears about social interaction…
The course of the disorder is chronic. In adolescence, these children are
at risk for substance dependence. Furthermore, there is continuity between
adolescent and adulthood SA.

(Karen Dineen Wagner, M.D. Ph.D)

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Avoidant Personality Disorder (APD)

There is a condition, not accepted as separate from SA by all professionals
in this field, called Avoidant Personality Disorder (APD). Within American
classifications, it seems that most people with APD fit the diagnostic requirements
for SA, but those with SA do not necessarily meet those for APD.  In
other words, APD might be seen as a more severe form of SA.

Work in this area suggests that those with APD might differ from the SA
sufferer in several ways. Conversation is one.  The person with social
problems will usually be careful to avoid long pauses while talking for fear
of appearing stupid, while the APD sufferer may speak slowly and with long
pauses, or very rapidly and may include rudeness or insults in his or her
speech to get their rejecting in first.  That is, to reject the listener
before he or she can, ‘do the inevitable’ and reject the APD sufferer. 
In this area, rejection, it also seems that the APD sufferer is constantly
on the alert for this and may, in social situations, be trying to monitor
the participants body language and attitude too: trying to process so much
incoming information that he or she loses track of what is actually being
said. In this conversational situation, the person with SA would probably
be so focused on how he or she was feeling that the interaction foundered
for this reason. There is research that suggests that shyness itself might
be in response to too much incoming stimulation where the person ‘shuts down’
out of sheer self-defence.  This might be because, in the shy person,
the body responds quicker than with ‘normal’ people, giving uncomfortable
chemical responses and cues that make it psychologically reasonable to avoid
such situations in the future where possible.

Within Anxiety Care, people with SA do not seem to have aggressive responses
or to become involved in ‘getting in first’ where rejection is concerned and,
as said, this is a difficult area for diagnosis.  If you or a family
member has negative social tendencies in this direction, further reading on
the subject of SA and AVP might be a good idea.  There is an interesting
site concerning APD on:

http://open-mind.org/SP/Articles/1c.htm

and a brief discussion of personality disorders in general on:

http://www.4degreez.co/misc/disorder_information2.html

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Vomiting, blushing and sphincteric problems
The SA may be focused on some particular thing, such as blushing, vomiting
or going to the toilet. Fear of vomiting (emetophobia) is often (though not
always) connected with social situations. Fear of vomiting can vary greatly.
Some people become panicky at the thought of vomiting, while others dose themsel­ves
with stomach medi­cine, barely eat, and avoid coming into con­tact
with anyone who might have a stomach disorder.

Blushing is also obviously connected with the presence of other people,
and this is also true of many cases of ‘sphincteric’ phobias (i.e. fears
related to urinating and defecating), though there are other aspects to this
condi­tion too.      It is because of the common
link that is often present that we have dealt with blushing, vomiting and
sphincteric phobias together with the broader condition of SA. These are
looked at in more detail below.

Nearly all emetophobics who are mothers report surviving pregnancy without
vomiting. So do 23% of non-emetophobics.

A.D.S

It is nearly impossible for a driver to become carsick.
A.D.S.

Nearly every case of emetophobia was triggered by a particularly traumatic
episode of vomiting that occurred between the ages of 6 and 10.

A.D.S.

People who fear others vomiting can get away from their phobic stimulus
simply by being alone. The phobic stimulus for emetophobics (i.e. their digestive
system) is always with them.

A.D.S.

The above quotes were taken from a fascinating and extensive website on
emetophobia that would be well worth visiting for anyone with a fear of vomiting,
or for readers who have a family member they suspect may have the disorder:

http://www.fortunecity.com/greenfield/dwellers/790/emetophobia.html

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Fear of vomiting (emetophobia)

Where a fear of vomiting is focused mainly on the sufferer being afraid
of embarrassing him- or herself in public, does not include fear of vomiting
in private, does not involve a hugely restricted diet or obsessional thoughts
about contact with others, the problem is probably an aspect of SA. 
When the problem is a daily misery, regardless of the situation, made worse
by the presence of others with illnesses and involves a heavily restricted
diet, it is probably a separate specific disorder: emetophobia.  However,
these are probabilities, not certainties and are really only useful as a guide
to understanding what other problems may occur during recovery work. 
That is, trying to overcome a fear of vomiting in a situation that may cause
high anxiety itself will make the techniques more difficult to apply. For
example, attempting a desensitisation programme for vomiting in a very busy
restaurant might aggravate a fear of being observed by strangers or of being
trapped if there is a social element to the disorder. Multiple fears sometimes
have to be approached as virtually separate disorders as far as recovery programmes
are concerned, and being unaware that a concurrent situation is causing anxiety
when attempting to counter emetophobia, can make it appear that the therapy
is not working.

The above-mentioned site mentions emetophobics who have a list of ‘danger’
foods, probably associated with the fear of food poisoning. This preoccupation
would not be of the sort common to people with eating disorders who are focused
on the affect rather than the type of food, although some anorexics might
be extremely preoccupied with food types.  Some people who have a fear
of vomiting, from Anxiety Care’s experience, are focused on the ‘gagging reflex’
where the texture of food in the mouth is very important rather than its
susceptibility to contamination; and a few have such a tendency to ‘heave’
that they will avoid anything that smells or looks as if it might induce this
response.  This will include other people vomiting and, often, animal
faeces and many strong smells.  The charity has also had contact with
emetophobics who view their problem as obsessional and who may also include
a fear of choking in the disorder.  In this case, anything that reminds
them of vomiting might be avoided including places where vomiting has been
seen, and they may stick to a very bland diet, even involving liquidized food
or baby food. None of those coming to Anxiety Care have had a content that
might be viewed as Social Anxiety Disorder, even when their lives were quite
restricted.  It can be seen from this, therefore, that a fear of vomiting
might be an aspect of many other disorders besides a separate phobic disorder.

The mentioned emetophobics site discusses many things that sufferers may
do; these include: very careful selection of unsealed food when shopping,
(fresh fruit etc.); meticulous kitchen hygiene; hand washing after visiting
a meat department; avoidance of eating from a buffet or salad bar in a restaurant
(perhaps avoidance of ‘danger’ restaurants for which they may have very idiosyncratic
criteria); eating an unbalanced diet; avoiding foods they ate before vomiting
even if they know the food was not the cause; sleeping with windows open to
‘kill viruses’; avoiding sick people; being unable to care for their sick
child or other family member; avoiding keeping pets for fear of catching something
from them (or seeing them vomit or defecate in some cases one must presume);
avoiding travel, particularly sea travel; avoiding pubs and parties where
people may get drunk (and vomit); avoiding high-risk careers (where they
perceive vomiting might be more likely); becoming obsessional about places
they have vomited, or utensils they were using, or clothes they were wearing,
or music they were listening to when vomiting occurred; and avoiding these
very stringently.

It seems likely that emetophobics find it very difficult to distinguish
between normal bodily gurgles and sensation and the imminence of nausea. 
Anyone who has suffered Panic Disorder will understand this, knowing how,
when one becomes sensitised to bodily responses that have brought on extremes
of anxiety and fear, the body and mind is super-ready to respond to the slightest
hint of them in the future.  The mentioned website also says that emetophobics
sometimes admit that what they perceive as nausea is not what ‘normal’ people
would mean by it. Figures discussed concerning a survey, show that emetophobics
tended to feel nausea (without vomiting) over seven times as often as non-phobics. 
This too would fit in with the above on Panic Disorder.  When extreme,
even something that is only vaguely similar to the feared event can trigger
a full-blown response.

This site also mentions that many emetophobics vomit very little, perhaps
a multiple of three to four times less than people who do not have this phobia. 
This might be because of a natural resistance to vomiting (which could have
made the problem a very unusual occurrence in childhood, unlike with most
children, and have lead to greater fear), or because of long self-training
against vomiting.  This site says: ‘Fully two-thirds of (emeto)phobics
say they don’t vomit until they decide to let it happen. Only 13% of non-phobics
say this, 59% of them saying they fight nausea but vomiting happens anyway.
28% of non-phobics don’t fight nausea at all, something only 5% of phobics
claim. Non-phobics on average let themselves vomit after feeling nauseated
for only twenty-one minutes. No emetophobic was willing to ‘give in’ in less
than two hours, and some claimed being willing to endure nausea for five days!’

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Children with emetophobia

The mentioned website discusses the following signs of this problem in children:

·         An obsession with
stomach feelings and upsets.  A sudden increase in this between ages
six and ten is noteworthy as is the response to (or absence of) vomiting at
this time.

·         Talking about vomiting
a lot with the parents.

·         Overreaction to
other people talking about vomiting.

·         Narrowing of food
choices.  Adolescents and adults seem to reduce their food varieties
very quickly after onset; younger children don’t.

Please remember that it is 100% normal for a child to avoid a food he or
she has vomited. Many people who are not emetophobics practice this the rest
of their lives.

…pickiness about food is a common trait in children.

A.D.S.

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Treatment

Unstructured exposure to vomiting doesn’t seem to work according to the
mentioned website and forcing someone with this problem to witness a person
vomiting, or making them vomit themselves would almost certainly be extremely
counter productive and, at least, put them off practical treatment altogether.

As with most recovery work that involves gradual exposure to the feared
situation, however, the attitude to vomiting is vital.  If the occurrence
is seen as a major disaster to be avoided then it will remain a problem however
often it occurs. If it is viewed as a chance to practise or something of
little consequence then exposure will probably work.  This site states
that few emetophobics take this option.

As anxiety is a ‘shrinking disorder’: always pressing against the boundaries
of one’s life and taking up as much space in it as possible, one option is
to do as Anxiety Care suggests with all phobias: draw a line across one’s
life now: ‘this is as bad as it gets. I may not be able to take any of my
life back for a while but it will not, under any circumstances, get worse.’ 

Once this has been done, the attitude of mind is different and plans can
be laid for taking some of that life back in the future, maybe very small
amounts at first. Even the smallest resistance can be useful because if the
phobic person has developed an attitude that is purely defensive, never resisting
the phobia in any way, it owns them. And, as with any defence, eventually
the attacker gets through it.  Being ready to ‘fight back’ even in the
mildest way, opens the person up to the possibility of getting past this problem,
or at least making it tolerable.  When situations stop being seen as
always potentially threatening and, instead, become more of a challenge, the
door is open to recovery.  This has worked many times within Anxiety
Care.  However, if this phobia is accompanied by other anxiety disorders,
or by depression, medication might be the best start, and if the sufferer
cannot conceive of resisting the phobia then some form of ‘talking treatment’
via a psychologist or other psychotherapist might be in order before practical
steps are considered.

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Fear of blushing (Erythrophobia)
Blushing is a very common symptom of SA. Some people naturally blush more
easily than others. This may be simply a physical charac­teristic like
having lighter or darker skin, but it can make these individuals more prone
to developing the phobia.  Within Anxiety Care, a client whose body (the
sympathetic nervous system) releases too many of the stress hormones that
generate a red face, has become totally fixed on the problem.  Prior
to this occurrence he did not appear to have social difficulties, but since
blushing has become a major part of his life he has begun to see it as reducing
his value as a man, even that it showed that he lacked masculinity. 
This has been particularly difficult in his chosen profession and encourages
him to dwell on the situation more and more. This tends to aggravate the problem,
make him more sensitive to any situation that may cause blushing, and make
its inappropriate occurrence more likely.

This is a perennial problem with anxiety disorder: ‘staining’.  Anxiety
Care encounters many people who are experiencing a spread of their disability
into areas that were not previously a problem.  This is understandable
as, when the body is made anxious or afraid, it searches for the occurrence
very carefully and anything that might lead to it.  Like the SA sufferer
who used only to dread going to work when he woke up on Monday morning, but
found that, gradually, his fear ‘stained’ back over Sunday night, Sunday afternoon
and into Saturday.  Eventually he began to experience the dread of Monday
work when he awoke on Saturday mornings.

Those with significant impairment often turn to drugs and alcohol.

Telaranta 2000.

Blushing of the cheeks and nose, and sometimes the forehead and neck, is
a natural emotional response that shows we are anxious or excited. (One charity
client with a very fair skin seemed to have the ability to blush throughout
her upper body). Some people tend to see its occurrence as a sign that their
emotions are on display and if they have doubts about their emotional stability
this would naturally cause problems.  This would be further aggravated
if the person concerned felt that his or her blushing gave away some ‘shameful’
secret about his or her value as a person, as described with the male client
above.

The treatment responses tend to cover the range mentioned previously. 
However, there is a surgical treatment, Endoscopic Thoracic Sypathectomy (ETS)
that has been used with success for excessive blushing where standard treatments
have failed. This began as a treatment for excessive sweating (Hyperhidrosis)
and surgeons then found that blushing was reduced too after this intervention. 
There is a good deal of information on the internet concerning this treatment
and it seems that people with sudden bursts of facial blushing, who have
a family member like it, and who also have some degree of Hyperhidrosis are
the ideal subjects.

This treatment involves certain nerve fibres in the chest that are thought
to be over responding and so generating the excessive blushing. ETS is inserting
a thin tube (a thoroscope) into the chest cavity and finding and cutting or
clamping these nerves at the second thoracic ganglion. This is thought to
reduce the fibres to normal levels of activity.  Surgery for a disorder
of this nature sounds alarming to many people, particularly any parent who
may be reading this to help a child; and this response would almost certainly
not be the first treatment of choice when approaching one’s GP, if, in fact,
it is even available on the NHS; but it has had its successes: up to 85% according
to some (American) statistics.

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Sphincteric phobias
Sphincteric phobias involve problems with urinating and defecating, the
former being more common. Sometimes the person affected is unable to perform
either function when other people are nearby – and ‘nearby’ might mean quite
a wide radius. Another form of the condition is feel­ing the need to
urinate or defecate many times when away from home. Both forms of sphincteric
phobia have a strong social content, and there is no appar­ent connection
with any sexual problems or phobias. However, it does seem that depressed
and very anxious people have a tendency towards constipation and this can
lead to becoming obsessed with the act of defecation.

Many people grew up with the belief that a daily bowel movement was imperative. 
This was probably in response to the medical profession’s opinion of a hundred
years ago that affected many of our grand parents and great-grand parents. 
Basically, people are different and the bowel will do what it has to do. 
Some children become afraid of bowel movements and contract the sphincter
to stop stools leaving their body. In some cases this can lead to involuntary
defecation, soiling oneself, which would only add to the fear. Anxiety Care
has no information on whether or not this situation occurs in older children.

A large proportion of people have problems with urinating in public lavatories,
particularly men, and few of these would see this as a social problem. It
is also common for young people to become somewhat obsessed in this area and,
as we all know, anxiety tends to generate the need to urinate and/or defecate.

This problem can be part of the extreme self-focus of adolescence or even
a touch of Body Dysmorphia (see Body Dysmorphic Disorder on this site). 
One teenage boy coming to Anxiety Care had a tendency to need to urinate very
often when anxious and had become very focused on emptying his bladder or
bowel before taking a journey, even a moderate journey. This condition was
not helped by the fact that he had always needed two or three bowel movements
in a normal day.  In line with many people he could not always work out
whether he needed to perform these functions when preparing to go out, or
if it was simply in his mind.  He then developed a mild obsession with
smells, using a great deal of deodorant and after shave and this lead to
his suspicion that he gave off a bad odour at times.  This then ‘naturally’
lead to him believing that, after urinating while out for the day, he had
soiled himself with urine and therefore smelt and had to go home before someone
detected it.

It might be inferred that this boy’s ‘bodily movements’ phobias had aspects
of other disorders. Anxiety Care has encountered a number of people with mild
obsessions and with full-blown Obsessive/compulsive Disorder who focus on
bowel movements, sometimes quite destructively.  This could not be realistically
linked to someone who fears being unable to find a place to urinate or defecate
in public places when this is needed.

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Coping strategies
One young woman who came to the charity had a number of buckets that she
colour coordinated with her clothing and took with her on car outings. This
is known as a coping strategy: something that gave her the confidence to go
out.  Another strategy suggested to sufferers has been to use incontinence
underwear, (available from pharmacies).  This ensures that the total
humiliation of soiling oneself does not occur and offers confidence to attempt
journeys and build up the series of memories of not needing to urinate or
defecate that is so important in overcoming this phobia.

The part of the brain that deals with anxiety does not have a lot of sense.
It understands only fear and cannot be talked out of giving its emotional
and chemical responses to what it perceives as dangerous situations. This
is a survival trait in our species as, if we could ignore danger signals,
we would not live very long.  The only real way to retrain this part
of the brain is to show it, over and over again, that the situation it believes
is dangerous isn’t.  And that means successfully entering the situation
many times. This does not mean that the original danger will be forgotten,
but it will be tempered with logic.  Like being able to touch the stove,
now cold, that burned you once.  You don’t forget it burned you, even
if you touch it hundreds of times afterwards when it is cold, with no pain.
The memory is there but it is just cautionary, it doesn’t interfere with life. 
So it has to be with bodily function phobias.

Any coping strategy that works, as long as it is seen as a temporary measure,
can be useful.  For people who believe only in facing their fear ‘head
on’ or who refuse to use coping techniques for other reasons, we tend to say
that if you break your leg and don’t use a crutch for a while in order to
walk, you are either being pig-headed or you are not that keen on walking.

A further coping technique, often seen in people who developed a disorder
very young, is denying the problem or dissociating themselves from it. 
Classically, this is seen in people who have been abused or neglected as young
children.  Here, the person they needed to rely on was, at least, not
a help and at worst, part of the cause.  The child, dependant on this
person, then had little choice but to ignore or deny their pain.  While
this might well have worked and was probably all that the child had available
at the time as far as coping went, it is not a good technique to take into
adulthood. Lessons learnt this young tend to stick and to become part of
our armoury of coping even though they don’t lend themselves to overcoming
anxiety problems in later life.  That is, denying or ignoring our pain
as adults just allows it to take a stranglehold.  So anyone who feels
that their ‘natural’ method of coping is in this area, must be brave enough
to look at it again and try to find techniques that acknowledge their disability.

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Causes of these and other anxiety disorders
It may, just may, be useful to know the ‘cause’ of one’s anxiety disorder,
but it isn’t vital unless this cause is part of an ongoing destructive lifestyle.
As with many phobias, the condi­tion is just one possible form that underlying
anxiety can take. The reasons why it has become focused on blushing, vomiting,
using public toilets or social situations may be quite acciden­tal. A
run of unpleasant ‘life events’ such as illness, death of a close relative,
marriage break-up, losing a job or bad depression may lie behind it (see ‘Transitions’
on this site).  And it is very common for people to try to find reasons
for any situation; this seems to be a trait of our species.  That is,
we are uncomfortable if we don’t understand things and any answer, even a
poor one, is often viewed as better than none at all. We are also prone to
be experts in retrospection.  That is, we look back and tell ourselves
that this ‘must’ have been why something happened; we ‘must’ have been feeling
this way or that way after a certain event, ignoring the fact that we might
have been very young at the time and virtually a different person. 
Simply, what humiliates or embarrasses us now might have had little effect
on our infant self. It is also common for people in western cultures to take
the Freudian route and look for sexual reasons or abuse in childhood. 
Some years ago a well known ‘agony aunt’ told a charity worker that a great
many young people contacting her simply assumed that, in line with the then
current ‘fad’, all their emotional problems were down to forgotten sexual
abuse in early childhood.

In short, one can grow old looking for ‘the reason’. It is not, therefore,
generally worth spending a lot of time and energy on this. The point is to
learn to control the anxiety disorder.

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Working out a self-exposure programme
People with phobias have become ’sensitised’ to produce the fear reaction
in situations that aren’t really dangerous. The best way to counter this is
by ‘desensitising’: training themselves to react correctly: This is done by
gradually exposing themselves to the things they fear, and experiencing the
anxiety it generates without running away, and so becoming less sensitive
to them as mentioned above.

The idea is simple, and it does not necessarily require the help of professionals,
but it calls for a fair amount of courage and deter­mination. The help
of family and friends can make self-treatment much easier to manage, and this
is also why many people prefer to join a self-help group where they can get
support from people in a similar situation.

Anyone who decides to try desensitisation needs to draw up a personal ‘exposure
programme’. This means working out what they can do now, deciding what they
want to be able to do at the end, and fitting as many gradual ‘exposure’ steps
in between as they need. The first step can be as simple as stay­ing in
a situation that can just be managed now, but for a little longer than before.

Obviously these anxieties take many different forms, and people are at many
different levels and may focus on many different fears. However, here are
some suggestions for how self-exposure could be handled.

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1. Social phobia and blushing phobia

When treating your phobia it is important to work out exactly what it really
consists of. For example, not just ‘parties’: what is it about parties that
frightens you? How many people make up a frightening number? How many strangers
need to be present for you to be frightened? Does the location, time of day,
age range of those present, or the temperature have a bearing? Once you have
worked out what is your ultimate horror, you can ‘pick and mix’ the least
threatening and begin to work out an exposure programme.

If your symptoms are hand tremors – rattling teacups, splashing wine from
a glass while serving, etc. – practise these actions in less threatening situations
like family gatherings. Use every opportunity to handle cups and glasses
in more threatening situations where you do not have to serve or otherwise
be the centre of attention. Perhaps you could keep a tissue to put between
the cup and the saucer to prevent rattles, or half fill the glass so that
it is less likely to spill.

If you find it impossible to drink in public, visit a cafe with a friend
when it is not busy and sit with a cup in front of you. Agree to take one
sip before leaving. If eating is the problem, break up a biscuit and slip
a piece into your mouth – try not to swallow it. Once ‘choking it down’ is
no longer the goal you will find that your body takes over and the biscuit
is swallowed quite naturally.

If you do not work out the combina­tion of fears that make up your phobia
you could waste time trying to overcome some­thing that is not a problem,
or give up in despair because you were not aware of some difficulty that was
making other things impo­ssibly hard.

Here is an example of how one person with fears of eating or drinking in
public went about designing a self-exposure pro­gramme for himself.

“First, you work out what you can do, and what you want to be able to do.
Are you sure that ‘what you can do’ is true? Is this just what you are relaxed
with, or what you can do with a little effort? You need to make sure it is
something that takes a little effort, but not something that raises your anxiety
a great deal.

            “Ask
yourself whether ‘what you want to be able to do’ is realistic. Would the
mem­bers of your family, or your friends, be able to do this? Setting
yourself an impossible target is pointless.

“Now fit in a number of realistic steps between your current capability
and your goal. For example, if you can eat a meal with two or three close
relatives, and drink tea with a somewhat larger group of friends, could you
increase the number of people with whom you can eat? In my case the work
programme, complete with some handy ‘cop­ing techniques’, went like this:

Can do:           Eat
a meal with mum and dad.

                       
Drink tea with uncle and aunt

                       
present too.

Step 1:            
Eat small piece of cake, with tea, while uncle and aunt are present. (Coping
tech­nique could be ‘remembering’ I have to set the video recor­der
in the other room, if this proves too much for me.)  Repeat this step
until I can manage it.

(Don’t use the same coping technique every time.)

Step 2:            
Join mum and dad, uncle and aunt for dessert. Come in late if

                       
necessary so that I don’t have to be present for the whole meal.

                       
(Coping technique could be me ‘hearing’ noise in the kitchen

 and going to investigate.)

Step 3:            
Join all four for a full meal.

                       
(Mum can be ready to say that I ate earlier,

 so they must excuse me only taking small portions.)

                       
Practise with larger and larger meals until I can manage a whole meal.

Step 4:            
Join mum and dad at uncle and

                       
aunt’s house for a meal. Prac­tise this, using coping techniques.

Step 5:            
Join all of them, plus cousins at their house for a meal. Practise,

                       
and use the various coping techni­ques if neces­sary.

Step 6:            
Go with mum and dad to a restaurant.

Step 7:            
Go with mum, dad, uncle and aunt to a restaurant.

Step 8:            
Go with all four plus cousins to a restaurant.

With support from his family, these steps worked very well, though having
to practise meant it took longer than he first expected. ‘Bad days’ were accepted,
and the parents did not insist that something once successfully completed
should be repeated every time. This Anxiety Care client is now quite confident
in company, even with strangers, as he did not rest content with that victory
but extended his recovery programme to include other family members, friends
and different situations.

Here are some further suggestions on facing up to SA, from an ar­ticle
by G Butler (1985).

1. Always respond to anxiety symptoms by approach rather than avoidance.

2. Remember where you are and don’t pre­tend to be elsewhere.

3. Greet people properly with eye contact.

4. Listen carefully to people and make a men­tal list of possible topics
of conversation.

5. Show that you want to speak: initiate conver­sation (asking questions
is easier, as it switches attention to the person expected to reply).

6. Speak up without mumbling.

7. Try to produce the symptoms of anxiety (if you sweat in company, move
away from the open window, wear an extra sweater, and accept hot food and
drink).

8. Tolerate some silences.

9. Wait for cues from others in deciding where to sit, when to pick up a
drink, and what to talk about.

10. Learn to tolerate criticism by introducing controversy deliberately
at an appropriate point.

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2. Fear of vomiting

If the fear is focused on certain foods, the steps could mean starting with
tiny amounts of the food and gradually building this up. Where it is a fear
of seeing someone vomit, they might involve resisting the urge to ask people
if they feel sick and gradually entering the situations where you have seen
people vomit in the past. Where the anxiety focuses on the stomach and possible
illness, the steps would start with staying longer in the situ­ations
where this anxiety occurs. It is import­ant to think carefully about the
anxiety and work out exactly what provokes it; then grad­ual steps to
deal with this can be worked out.

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3. Sphincteric phobias

Exposure steps for someone who cannot uri­nate when people are ‘close’
could involve drinking a good deal, refraining from urinat­ing in a ‘safe’
place, and then going into the situation which they normally fear, such as
a public lavatory or the house of an under­standing friend, and agreeing
not to leave the lavatory until urine has been passed – how­ever little.

Steps can also be based on having a helper, who will stand at first some
distance from the lavatory, then gradually come closer.

For some people, ‘fantasy’ exposure can be useful. This would mean finding
a ‘safe’ environment and waiting until urination became inevitable. Then the
person could try to imagine a stranger standing nearby. There could be gradual
steps here too: imagining the stranger closer and closer until it was possible
to imagine the stranger close by on entering the lavatory.

If the fear is of defecation as well as urination, then the desensitisation
might not work for both simultaneously, and separate sets of steps would be
needed. Fears about defecation can be more difficult to deal with, and extra
help, perhaps from a professional such as a clinical psychologist, might
be necessary.

When the problem is too frequent a need to urinate, steps might include
refraining from urinating for gradually longer periods, with these periods
carefully timed. When the condition is so severe that the person affected
refuses to leave their house, wearing incontinence pads and underwear may
give extra confidence during the early steps. These prac­tical aids can
soon be abandoned, and research shows that defecation frequency can be treated
in the same way.

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SOME HINTS FOR SELF-EXPOSURE WORK

– The first step in the programme can be very simple – perhaps staying in
a situation that can just be managed now, but for a little longer than before.

– The steps can be as large or as small as neces­sary, and big steps
can be broken down into smaller ones. However, it is important to make sure
that each step challenges the anxiety a little more than the last.

– Don’t be overwhelmed by the size of the task. As a rule, the steps become
steadily easier as you work through them.

– Don’t expect to be completely free from anxiety before you leave each
step and go onto the next – it will go completely in its own time as you
progress.

– Do the exercises as often as you can. You are trying to build up positive
memories to replace all the bad ones of being beaten by the phobia, and too
long a gap between efforts makes this more difficult.

– An hour or so of self-exposure work at a time and repeating this every
day is best. Waiting until you feel ‘strong’ or until you cannot avoid it
any longer is not a positive approach.

           

– Do enough at each step to increase your anxiety. You are trying to raise
the level of physical symptoms that you can manage, and where you are in control

– If it is possible to find someone to work with, who can talk to you calmly
and posi­tively while you are doing the steps (not over-sympathising or
endlessly asking how bad you are feeling) this can help.

– If you have a panic attack during your exposure work, try to remember
that the physical symptoms of panic will not do you any harm, and will always
ease off eventually, whether you run away from the situation or not. Many
people believe that a vague but terrible ‘something’ is going to happen to
them dur­ing a panic, and that they just manage to save themselves in
the nick of time by avoiding or escaping from the phobic situation. This is
not true.

– Relaxation techniques can be helpful in tackling the next step, and it
is easy to prac­tice relaxation in the privacy of your own home.

– If the steps you have chosen prove impossible, of if you are depressed
or have other severe anxiety problems, then professional help from a clinical
psychologist or psychia­trist may be needed. You can reach such pro­fessionals
through your GP; and in any case we recommend that you contact your GP and
talk to him or her about your disorder.

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Source material

A.D.S. ‘Frequently Asked Questions about Emetophobia’

Version 2.1 January 28, 2002

http://www.fortunecity.com/greenfield/dwellers/790/emetophobia.html

James C. Ballenger, et al, ‘Consensus Statement onSocial Anxiety Disorder
From the International Consensus Group on Depression and Anxiety’

www.psychitric.com/supplenet/59s117n8.htm

Tom Cremer, ‘Fear of Physiological Symptoms in Social Anxiety Disorder/Social
Phobia’ December 2000

www.angelfire.com/ab/ets/moula.html

Open Mind, ‘Avoidant Personality Disorder’

http://open-mind.org/SP/Articles/1c.htm

Thomas A. Richards, Ph.D, The Anxiety Network International, ‘What are the
Differences Between Panic Disorder and Social Anxiety Disorder (Social Phobia)?

http://www.anxietynetwork.com/diff.html