Psychotherapists’ Toolbox To Help Clients Live Happier Lives With Others
by Mike Tranter and Ana Lund
The term social anxiety has become part of everyday language, integral to the psychotherapy vernacular, so to speak. And for a good reason: most people can relate to that concept because most people have experienced some level of social anxiety in their lives. People who have social anxiety disorder or know someone who does, are aware of the vast difference between experiencing social anxiety in stressful situations and suffering from social anxiety disorder (SAD). The former refers to the discomfort that people feel around things like public speaking, job interviews, or maybe attending a party on their own. Social anxiety disorder is an acute and paralysing fear of everyday situations that involve others. Commonly diagnosed during adolescence and with a lifetime prevalence of between 13-18% [Goldin, Kessler, 2005], SAD can make mundane situations like going to the shop, talking on the phone or even walking down the street extremely daunting. Characterised by debilitating feelings of anxiety, panic, avoidance and withdrawal from most forms of social life, SAD is a truly incapacitating condition.
Whether you know someone who lives with SAD, are a mental health professional, are a curious scientific reader, or are affected by it yourself, you have found your way here because you want to learn more about social anxiety disorder. In this article, we are going to help demystify social anxiety disorder and explain why it is considerably different from the more generalised social anxiety. We will also break down SAD into seven simplified elements that you can address one by one, and get you up to speed with everything you need to know for creating a more manageable approach to dealing with social anxiety disorder.
Breaking Down The Social Anxiety
In our clinical work with clients affected by SAD, we've observed that while each person's story is unique, there are striking similarities in what triggers their hyperarousal, how they react to new situations, perceive themselves in the world, and what their coping strategies are. We have devised these shared patterns into seven elements: Predisposition, Fear of Novelty and Avoidance, Facial Expressions Display, Hyper-arousal, Blushing, Learned Helplessness, Shame/Self-Disgust.
Addressing each element individually, rather than as one giant complex disorder, can increase the chances of success in our approach to help tackle SAD. The idea is that once we address the above to a sufficient level, the experience of SAD for the client might become a pale shadow of the “monster” it used to be.
In theory, if we could borrow learnings from neuroscience to deepen our understanding of what occurs in the brain during SAD, then we may be able to more clearly define appropriate therapeutic actions. This does, however, come with a few caveats. Understanding brain activity in SAD patients has proven to be particularly challenging. Studies often use low patient numbers, different experimental tasks, and notoriously flakey MRI data [Yu, 2021]. Because of this, neuroscience has yet to reach a firm agreement on the brain regions consistently involved or how strong their influence is on the overall disorder. However, we have done our best to mention some of the brain regions commonly associated with SAD and have explained why understanding their involvement could benefit your work with social anxiety.
1.Predisposition
Definition When we say that someone has a genetic predisposition for something it means that their combination of genes makes them more likely to develop a certain trait in their life. The predisposition is not deterministic. Usually, the lifestyle and environment in which we are brought up play a role in determining whether this genetic tendency is actually going to manifest.
SAD context Humanistic or psychodynamic theories usually conceptualise SAD as stemming from a relational injury or an early trauma. But what if we were to think of SAD from a predisposition-driven perspective? Could this shift in perspective potentially offer new insights and approaches to helping clients with SAD?
Science Scientific studies tell us that in around 20-40% of SAD diagnoses [Hettema, 2021] there is a strong genetic association. For example, genes associated with the neurotransmitter serotonin, such as SLC6A4, have been strongly implicated, amongst others.
Toolbox Psychoeducation The idea is to explain to the client that social relationships may not come as easy for them, as they do for others. Clarify that this is not their fault. This is essential because the individuals suffering from SAD often blame themselves and feel embarrassed for not being “like everyone else”. Reframing social anxiety in a way that empowers the client to make sense of their experiences (such as explaining the concept of neurodiversity; how there are individual differences in how our brains work) can reduce self-loathing and self-criticism.
2. Fear of Novelty and Avoidance
Definition The fear of novelty causes a strong aversion to unfamiliar experiences.
SAD Context By definition, people with SAD fear new encounters and most social situations. Interestingly, for these clients the fear seems to extend to other new experiences, whether it is food, living situations, looking for a new job, watching an unfamiliar program or reading an unfamiliar genre of literature. Both the fear of social encounters and fear of novelty are compounded by a maladaptive coping strategy of avoidance.
Science Avoidance is a hindrance to both personal growth and overcoming fear. The fear of novelty and social situations would typically be encoded in the amygdala and associated structures (the Bed Nucleus of the Stria Terminalis, frontal cortex, and anterior cingulate cortex). This is demonstrated in studies where limiting the amygdala influence can decrease anxiety in novel social situations [Emery, 2012]. A recent meta-analysis (a statistically powerful review of all the relevant research data [Yu, 2021] has also reported heavy involvement of the fear circuit in SAD patients. One way by which a certain stimulus becomes less significant to the amygdala is when an alternate, less triggering experience, is created, related to the original stimulus. This extinction process does, however, require that a person confronts situations that are typically triggering for them.
Toolbox Systematic habituation (a close relative of systematic desensitisation) can be used to help the client transition from avoidance to being able to expose themselves to a triggering stimulus. It is a protocol, co-designed between the therapist and the client, to very gradually allow the introduction of new elements into the client’s life. We can find an example below.
3. Hyper-Arousal
Definition Hyper-arousal refers to a state of heightened physiological and psychological alertness in response to perceived threats or stressors. In this state, individuals may experience an increased heart rate, blood pressure, breathing, muscle tension, and a heightened alertness or vigilance.
Science The locus coeruleus, a region in the brain that supplies noradrenaline to the cortex, is essential in attention and arousal. The release of noradrenaline is well-correlated with arousal and, importantly, this system is affected by stress, suggesting that social anxiety could influence this system for states of hyperarousal. However, noradrenaline is not the only neurotransmitter that exerts a strong influence, dopamine and serotonin, in addition to hypothalamus release of histamine and orexins, exert a major influence on arousal and, indeed, sleep. Dysregulation of this system can also result in insomnia, a common symptom of hyperarousal.
Toolbox One effective way to limit hyperarousal is through regulating the breathing pace. Slow breathing has been shown to reduce amygdala activation. Breathing techniques such as “Box breathing” and “Oceanic breathing” are great examples. If you want to read a little more about the box breathing technique, take a look at our other article and video.
4. Blushing
Definition The rush of blood to the face creating a reddish appearance, often at times of high emotional stress such as embarrassment.
SAD Context Blushing is a strange phenomenon indeed, and the reasons why blushing has evolved as a human behaviour are not very clear. Charles Darwin famously proclaimed that blushing is “the most peculiar and the most human of all expressions”. Indeed, on the face of it, blushing seems like a paradox. When we are ashamed or embarrassed and want to hide away from the world, our own body, suddenly betrays us, we become red, and thus, make our distress noticeable to everyone, which, unfortunately, can amplify shame and embarrassment in a sort of feedback loop. People suffering from SAD commonly report excessive blushing, and can exacerbate avoidant behaviours and self-loathing.
Science Blushing results from the fight or flight response of the autonomic nervous system. Adrenaline is released, causing vasodilation (the widening of blood vessels) and the surface of the skin becomes flush with blood. The fear of blushing, called erythrophobia, can enhance the effect of blushing itself, as it places the person in a state of anxiety and vigilance which only serves to activate the fight or flight response further.
Toolbox A "Blushing Journal" is a detailed record of blushing events as they occur throughout the week, with the description of the situation, intensity of blushing 1-5, and general context of mood/tiredness. If a person keeps a well-maintained journal, therapy sessions can be used to identify patterns such as the specific type of situations that are most likely to produce intense blushing. This journaling technique has proven to be very effective in containing blushing when used with with our clients. Perhaps by getting to know one’s reasons and patterns of blushing in an intimate, detailed way, provides the client with more control. Assuming that some self-regulation or hyperarousal techniques are already available to the client (see the section on hyperarousal) knowing one’s pattern of blushing will allow one to be prepared to use those techniques in situations that are likely to cause blushing, preemptively halting blushing before it gets too much.
5. Facial expressions, smiling and the eye contact
SAD Context The perception of facial expressions is biased towards negativity for individuals with SAD. Due to their constant vigilance against social threats, SAD clients tend to smile minimally, rarely laugh spontaneously, and display constrained body language. When we display a reserved or unfriendly facial expression, people around us tend to mirror it, creating a vicious cycle.
Science The science behind body language, facial expressions, and eye contact is fascinating, if not a little exaggerated from TV and Film. While not every eye glance or arm movement means something significant, the brain does have specific areas dedicated to monitoring these aspects of human communication, so they must be important somehow. An area of the brain called the fusiform gyrus plays a critical role in understanding facial expressions and assigning social connotations to them. People suffering with SAD have shown an overactivation of the fusiform gyrus - amygdala - limbic system pathways compared to controls [Mizzi, 2022]. These regions are involved in monitoring facial expressions and regulating our emotions, and so it is likely that increased activity between them could potentially cause a person to remain in a constant state of hypervigilance to perceived social threats.
Toolbox The part of the toolbox is a simple one: learn to laugh together. Our suggestion is to bring humour into therapy sessions. Motivate clients to embrace the humour in programs they already love and recommend new funny shows to them. Make it a habit to smile together during greetings and goodbyes in each session. Smiling and laughing have the added benefit of boosting the mood and enhancing the therapeutic bond.
6. Learned Helplessness
Definition The giving up of any thought that a person can change the bad event about to happen, as there is nothing they can do to prevent it.
SAD Context The term was originally designated in laboratory research when a scenario was manufactured so that the participant could not escape or avoid shock. Nowadays, the term learned helplessness also encompasses humans who feel a sense of despair and feel unable to produce an adequate response to stressful situations. People with SAD often display passivity in the face of adversity and it is common to hear statements like:
“There is nothing I can do to change it.”
“It is too complicated for me to learn this.”
“I don’t think things are ever going to change for me.”
Science Learned helplessness represents a complex process within the neurochemical circuits of the brain. The neurotransmitter, serotonin, while not the only relevant transmitter, seems to exert a strong influence in this context. Serotonin is released throughout the brain, particularly in reward processing regions such as the striatum, and, amongst other things, plays a role in blocking our instinctive escape behaviour. Serotonin also activates the amygdala which likely increases the sense of fear and anxiety. What is important to note, is that laboratory research also shows that these neurochemical effects can last for days after the initial activation. Activation of frontal regions in the brain, such as the prefrontal cortex, orbitofrontal cortex, and anterior cingulate cortex (ACC), can produce a top-down control of the learned helplessness response by inhibiting serotonin activation.
Toolbox The type of activities that engage the anterior cingulate cortex and are easily integrated into everyday life often involve stepping out of our comfort zone or routine[Colcombe, Andrew Huberman Podcast]. For instance, activities like going for a short run (especially for non-runners) or extending one's workout routine by 10 minutes can stimulate this brain region. Similarly, cognitive tasks such as reading a few pages of a book (for non-avid readers) or learning a few words in a different language can have the same effect. Essentially, any new experience outside of one's usual interests and routine can serve this purpose. Abstaining from habits like eating dessert or refraining from watching a familiar TV show, achieves the same effect.
We refer to these tasks as "mini-challenges" and collaborate with clients to identify ones that would be suitable for them. Together, we establish a sequence for tackling these challenges, aiming to repeat each one daily for a week before progressing to the next task. This approach encourages cognitive and behavioural flexibility while actively engaging the anterior cingulate cortex.
7. Shame (and Self-Disgust)
Definition
Shame: especially the internalised shame that is not related to a specific event, is a self-conscious feeling characterised by a “deep-seated belief of inadequacy that feels permanent and irreversible and is accompanied by words, voices, and images” [Kaufman(Wikipedia)].
Self-Disgust: Describes the emotion of disgust when directed at one's own physical appearance, moral actions, and behaviours.
Description Shame and self-disgust are considered to serve a social conformity role, in that they promote acceptable behaviour by making a person aware of actions that would be considered unacceptable. But, in the context of SAD, shame and self-disgust are, no doubt, the most destructive, painful, and self-annihilating feelings that all of the clients carry with them. Shame and self-disgust are complex, self-conscious emotions, related to the notion of “self”. They only appear around two years of age, accompanied by the development of the notion of self in infants but can have a profound impact on us throughout our lives. For this section, let’s focus a little more on some of the brain structures involved and how meditation techniques may target specific regions to improve overall management of SAD.
Science While it is true that shame and self-disgust play a vital role in regulating human social behaviour, and that dysfunction of the emotional regulation around them can be particularly horrendous in people, neuroscience and psychology have paid little attention to the underlying causes. Some research suggests that changes in executive function (essentially, when the frontal cortex and other closely related regions support goal-directed behaviour) may be responsible. Others have reported that an area of the brain called the angular gyrus, involved in regulating beliefs in oneself, has much lower activation in SAD.Another area involved in feelings of shame and self-disgust is the insula. The insula plays diverse roles ranging from consciousness and self-awareness to empathy, taste, pain, hunger and fatigue. Interestingly, the insula is also important in social pain. Therefore, we can see shame almost as a feeling of social pain. The insula is also involved in the feeling of physical disgust, which we know shares some of the same neural pathways as moral and self disgust. New research has been exploring how meditation techniques such as mindfulness can influence the insula. Today, there is a robust body of research showing that regular meditators have several anatomic differences in their insula when compared with non-meditators and sustained, regular mindfulness may also lead to a greater capacity for compassion and self-compassion [Davidson].
Toolbox Regular mindfulness meditation practice, especially those focused on compassion.
The Social Anxiety Disorder Toolbox
While there are always multiple culprits (and complex circuit-level brain activity) for each of the SAD elements listed above, it is important to begin to tackle SAD from a simplified and clearer understanding. So this toolbox is not exhaustive, but it does provide a well-rounded approach to improving our understanding of social anxiety disorder and therapy outcomes.
Interested to read more of Mike's work? You can have a peek at what he is up to here.
References
Colcombe SJ, Erickson KI, Scalf PE, Kim JS, Prakash R, McAuley E, Elavsky S, Marquez DX, Hu L, Kramer AF. Aerobic exercise training increases brain volume in ageing humans. J Gerontol A Biol Sci Med Sci. 2006 Nov;61(11):1166-70
Davidson R, Goleman D. Altered States.
Andrew Huberman Podcast, How To Increase Your Willpower And Tenacity?
Fox SA, Hed H, Kalin M.D. A Translational Neuroscience Approach to Understanding the Development of Social Anxiety Disorder and its Pathophysiology 2014
Goldin PR, Manber T, Hakimi S, Canli T, Gross JJ. Neural bases of social anxiety disorder: emotional reactivity and cognitive regulation during social and physical threat. Arch Gen Psychiatry. 2009 Feb;66(2):170-80.
Kaufman, G. (1980). Shame: The Power of Caring. Cambridge, MA: Schenkman Publishing Company, p. 7, 33
Kessler RC, Chiu WT, Demler O, Merikangas KR, Walters EE. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005; 62:617–627.
Yu X, Ruan Y, Zhang Y, Wang J, Liu Y, Zhang J, Zhang L. Cognitive Neural Mechanism of Social Anxiety Disorder: A Meta-Analysis Based on fMRI Studies. Int J Environ Res Public Health. 2021 May 22;18(11):5556
Hettema JM, Neale MC, Kendler KS. A review and meta-analysis of the genetic epidemiology of anxiety disorders. Am J Psychiatry. 2001; 158:1568–1578.
Emery NJ, Capitanio JP, Mason WA, Machado CJ, Mendoza SP, Amaral DG. The effects of bilateral lesions of the amygdala on dyadic social interactions in rhesus monkeys (Macaca mulatta). Behav Neurosci. 2001; 115:515–544.
Mizzi S, Pedersen M, Lorenzetti V, Heinrichs M, Labuschagne I. Resting-state neuroimaging in social anxiety disorder: a systematic review. Mol Psychiatry. 2022 Jan;27(1):164-179
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