You’re not going to hear the real story anywhere else. I guarantee you that. This is a deep dive into a complex subject, the reality of which remains very misunderstood. So let’s get clinical. Kendra, age 46, mother of two is a world-renowned physician who has headed numerous clinical trials and has saved many lives. She suffered from public speaking anxiety disorder. You may want to listen to her interview, which is on the podcast. It’s titled, world-renowned physician describes her cure from public speaking anxiety disorder. Mike, age 26, a college grad, spends most of his life in his room.
He doesn’t work. He’s socially paralyzed and spends over 100 hours a week with various technology dependencies. His parents walk on eggshells for fear of triggering his anger. This has resulted in long-term enabling of what has become an addiction to avoidance. While these two cases personify opposite ends of the functioning spectrum for social anxiety, both have dynamics in common. These are anxiety based on performance dynamics, dissociation, and a clinical cocktail of PTSD and OCD. I know that’s a lot. Karen’s perfectionism drove her public speaking anxiety in formal presentations.
Mike’s perfectionism manifested in his selective mutism where he believed he had to have the perfect thing to say in any interactive scenario. For example, he did have two gym buddies, but he wouldn’t go to the gym if they were not there. He described his primary fear. Someone may want to work their way onto the machine and might start a conversation with me. He was frozen by his selective mutism. Both Kendra and Mike had trauma in their reservoir. The reservoir is one’s conscious and unconscious past and present. Kendra’s trauma was a combination of excessive internal critical script training for perfectionism, something she referred to as halo alto syndrome, along with unresolved emotional content related to an aggressive male.
For over 25 years, she had disassociated from these. Mike’s trauma included a combination of peer rejection, developmental struggles with OCD, avoid of paternal nurturing, and overcompensatory maternal attempts at nurturing. What they do not have in common is initiative for their mental health. Kendra was lecturing around the world and was confused as to why her performance in his panic seemed to appear out of nowhere. She was highly motivated to fix the problem. Mike was agitated and overwhelmed upon any attempt to move out of his primitive lifestyle and limited comfort zone.
Initiative for Healing was a foreign concept as he was paralyzed by shame and embarrassment. He remained stuck based on his belief that he was born this way and nothing could be done about it. His parents’ conflict with each other and eggshell anxiety resulted in a long-term, deeply ingrained compulsion to avoid. So in a nutshell, what is social anxiety? Having well over 50,000 clinical hours under my belt since 1978, I’ll first tell you what it’s not. It’s not simply generalized anxiety with the word social thrown in front of it. This approach of lumping anxiety orders together all too often characterizes mental health marketing which sets the consumer and practitioner up for unrealistic expectations.
According to a November 1991 article in the Journal of Clinical Psychiatry, and I’m quoting now, social phobia is an emerging problem that is just beginning to receive attention and will be taking the limelight among anxiety disorders. What separates, and this is key, what separates social anxiety from other anxiety disorders is that it’s based on performance. That’s over 30 years ago. Major advances in technology have enabled interactive avoidance. Many studies show that texting has replaced talking as the most common form of communication. This may not mean much to a millennial or Gen Z, but it’s quite startling to me.
And it’s symptomatic of an epidemic of verbal communication avoidance and social skills deficits. In addition, COVID has been a tremendous enabler of avoidance. Okay, now we’re going to get clinical here with terms from the ICD-10, defined social anxiety as an anxiety disorder characterized by an intense irrational fear of one or more social or performance situations in which the individual believes that he or she will be scrutinized by others. The DSM currently defines social anxiety disorder as a persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others.
Clinical reality is that there are subsets on a wide range of functioning levels. While there are many manifestations of the disorder, there are two basic types, individuals with and without initiative. And this is the key to effective treatment is understanding this reality. I define social anxiety as an emotional and cognitive attack on personhood associated with autonomic hypersensitivity overload. Social anxiety goes to the core of self-esteem. The core dynamic of the pathology, the disease, is the inability to differentiate performance from personhood.
Social anxiety is the classic disease of resistance. Most sufferers will do anything to avoid introspection and interoception. Introspection is the examination of one’s mental and emotional processes. Interoception is our seventh sense. It’s the ability to be aware of internal sensations in the body, such as heart rate, respiration, temperature, pain, and more. It’s a collection of senses that can be conscious or subconscious. Resolving social anxiety is about channeling, psychophysiological. That’s mind-body energy. This energy is an internal phenomenon.
In three ways to better understand your emotion from Harvard Business Review, November 10, 2016, Susan David writes, and I quote, dealing effectively with emotions is a key leadership skill. Naming our emotions is an important first step in dealing with them effectively. But it’s harder than it sounds. Many of us struggle to identify exactly what we are feeling, and often the most obvious label isn’t the most accurate. This is a process of approaching one’s inner experiences in a mindful way rather than trying to suppress them. That is the key word, suppress. Let’s take this a step further. This is very powerful. The Latin word for emotion, emotere, e-m-o-t-e-r-e, is defined as energy and motion.
Those who suffer from social anxiety are in general detached from this internal energy. One of my patients, a 40-year-old scientist with performance anxiety and concurrent dysthymia, had the initiative to rate on a 1 to 10 scale the intensity of her specific emotions during her journaling. Kendra’s case is an example of specific performance anxiety. Like is an example of pervasive social phobia. When anxiety morphs into avoidance, it becomes a phobia. Both cases are examples of social anxiety. I received a call from the mother of a 26-year-old who was suffering from pervasive social phobia.
She said, I would like you to see my son. I said, I need to see the parents first. She responded, within dignity, why do you want to see us? He’s 26 years old. I responded, why are you making the phone call? The avoidance dependence dynamic is a complex dynamic which holds psychotherapist hostage. Think about it. The over 18-year-old is primitively functioning socially avoidant and overly dependent with no initiative for their mental health. In most cases, this person will want to have nothing to do with therapy. In the case where the over 18-year-old is in therapy, the usual pattern is that the parents are not involved.
This is due to a variety of reasons, including the 18-year-old will not want it. The therapist will not know how to facilitate parenting and family engagement, or the parents want nothing to do with treatment and have the attitude that the therapist should fix the adult child. Indeed, this is a confusing subject. For example, Susan had her first and only date at age 38. She maintained a low-level civil service job. Her only socialization was in a weekly special needs group. During her appearance with me on Oprah in 1988, Oprah said, I don’t understand.
Were your parents so much fun you wanted to hang out with them all the time? There is something drastically wrong with this formula. This is the reason in a case like this, it must be positioned as a family challenge. Treatment needs to be initiated by the caregivers who need to learn an empowering, non-enabling strategy. Thinking otherwise will be a poor investment as the pathology the disease of avoidance will accrue. Here’s where we may get a little controversial. A number of research articles, position, CBT, cognitive behavioral therapy as the gold standard for social anxiety.
All too often, the behavior therapies promise gold standard results in a short-term treatment framework for this problem. In my opinion, this marketing does not meet integrity standards. In fact, you can quote me on this, CBT research is a step above total BS. The research trivializes the disorder. In fact, many of my patients who have done well in treatment have said it’s the hardest thing I’ve ever done in my life. The bottom line is that everything starts with a thought, conscious or not, which leads to behavior.
This is an important component of CBT, obviously. Negotiating this dynamic is what CBT is all about. This makes a lot of sense. That said, leaving out the emotion physiology connection will have limited treatment results. My therapeutic formula includes four domains. Think of the an acronym FATE, F-A-T-E, FATE, function, physiology, A, action behavior, T, cognition thinking, E, emotion, emotere. Statistics are helpful to understand the prevalence of social anxiety, but they aren’t really completely adequate to define the condition which has attained epidemic proportions.
After all, it’s not a subject most sufferers are open to discussing because of shame and embarrassment. People with avoidant personalities are experts at avoiding. Perfectionists don’t want to admit non-perfectioning. My high-functioning achievers, like Kendra, with public speaking anxiety, will wait for the last possible moment to get help when their careers are threatened, often after decades of struggle. Patients with a profile like Mike only enter treatment if facilitated by caregivers. The Anxiety and Depression Association of America estimates that 15 million adults have social anxiety. This number swells when you consider stats such as the Chapman University Survey in 2019 that said 10.7% of Americans have public speaking phobia.
No excuse me. That goes up to 23.3%. Similarly, a 2001 Gallup poll found that 40% of adults have public speaking anxiety, but consider the following. Selective mutism, a very complex, interesting social anxiety disorder, is defined as a compulsive inability to speak in specific situations. This affects 0.47% to 0.76% of children. Hyperhidrosis, excessive sweating. This can lead to phobic avoidance. Many of my patients come to me specifically for fear of being noticeably nervous. Erythrophobia, blushing anxiety, affects 5% to 7% of Americans.
Avoidant personality disorder, a condition that occurs in 2.1% to 2.6% of people. You don’t find much information about resolution of avoidant personality disorder. That said, the co-author of my book Amy and the book’s work makes me nervous, is as close to a recovered avoidant personality as you can get, and she talks a lot in the book about how she achieved this. In addition, when considering special needs populations, the statistics regarding social anxiety grow immensely due to a multiplicity of processing challenges. So we’re talking about a complex clinical profile. There is extensive comorbidity associated with social anxiety.
This includes substance and technology overdependence, depression, and a variety of personality disorders. These commonly include avoidant, dependent, OCD, OCPD, which is obsessive compulsive personality disorder, which is perfectionism, along with many sprinkles of narcissism. These can morph into a complex clinical profile which often falls between the cracks of clinical profiling. I first discovered social anxiety in 1978 while working as a youth worker in a community center on the North Shore of Long Island. At the suggestion of a colleague who worked with the Girl Scouts, we started a socialization group for teens with learning disabilities.
Very interesting thing happened. After doing intake interviews, many of the participants never showed up for the group. Welcome to social anxiety. To really understand social anxiety, it’s important to understand dissociation. Dissociation is detaching from the mental processes of thoughts and emotions. It manifests in many forms. It’s a defense mechanism. One’s defense of positioning can be a compulsion or an addiction. Social anxiety suffers become very skilled at dissociating because they do not want to experience the pain of emotear. The result of this detachment is that repressed emotional energy morphs into the physical symptoms of anxiety and other comorbidity.
Kelly, age 32, lived independently in apparent funded condo. She worked at the counter at a local bakery. She socialized two times a year with coworkers. She never dated. Her favorite activity was watching the reruns of the Golden Girls. She dissociated by playing old radio songs in her head as she compulsively paced back and forth for hours as her primary evening activity. David, age 49, has eight children. He is very successful in commercial real estate. He’s a community organizer. He’s a philanthropist. He studies Talmud 20 hours per week. He’s always too busy for introspection as he is compulsively engaged in creating external processes.
Todd, age 45, had played semi-professional baseball and worked in commercial real estate. He was an imposing figure at 6-6. He had been struggling with public speaking anxiety for many years. At our first session he said to me, your book, Work Makes Me Nervous, was great. But don’t insult me by saying something about my past is related to anxiety. He was all in for technique but obviously resistant to core work. We were not compatible. Understanding the content in one’s reservoir is a necessary foundation for healing because that is where the unresolved emo-ter is.
Approximately 20 years ago I worked with Cindy. Cindy was a would-be singer and disco queen at age 45. Her role model was Madonna. She suffered from a stage fright before every performance. In addition, training was a challenge because of over-dependence on alcohol and cannabis. I knew of a physician, the late John Sarno, S-A-R-N-O-M-D, who treated back pain. I suggested she read his book Healing Back Pain, The Mind Body Connection. She skipped the book and went for an appointment. In the next appointment with me, she shared his study guide. Going to Sarno’s work was a milestone in my clinical journey. To dumb it down, Sarno’s work is based on the dynamic that repressed emotion is so powerful it inhibits the flow of oxygen, creating a condition he calls tension myositis syndrome.
The primary repressed emotions are rage, emotional pain, sadness, fear, and feelings of unworthiness in the unconscious mind. Now think of this. In essence, any physical symptom that does not have a biological etiology to it is a symptom of TMS. Social anxiety is very much a manifestation of TMS. The brilliance of Sarno’s work is how he organizes the content in one’s reservoir. The domains of the reservoir include number one childhood, number two self-imposed pressures based on personality traits, number three the pressures of life and four other emotions. A full reservoir means the brain must produce symptoms to protect from these feelings.
This causes the physical symptoms of anxiety. In the reservoir is trauma. There are three types of traumas, acute chronic and complex. An example of obvious trauma is Alana, age thirty-four, who works as an administrator in commercial shipping. She grew up in Ukraine. Both parents were alcoholics. Her father abused her mother physically and mentally. Her father abused her mentally and often forced her to buy vodka for him when he was comatose. Alana was responsible for getting them both into rehab to no avail. Her father’s friend tried to rape her. He grew up in a state of constant hyper-vigilance. A much less obvious example of trauma is Tim, age twenty-five. He grew up in a wealthy real estate family which was loving and supportive.
He could do no wrong. He was the golden child. Expectations were quite high. Over time the pressure to be perfect accrued. It drove his internal critical script into toxic territory with unrealistic expectations regarding perfection. This was his trauma. An example of acute trauma for Alana was when at age sixteen her father’s friend drove her into the woods and tried to rape her. An acute scenario for Tim was when he learned that he did not make the varsity baseball team in college after being a star in high school. Or insidious that acute trauma is the chronic ongoing nature of toxic influences in the complex way they impact self-esteem.
Experiencing a first panic attack is trauma. The post-panic ongoing struggle where obsessive rumination dominates becomes chronic and complex. The following is so important. When I quote, when the trauma is resolved there’s no more triggers. This statement by Dan Segal during a training seminar on interpersonal neurobiology really hit the mark. Crucial for healing is the core work of identifying target memories in one’s reservoir where the following were learned. Wave association to adrenaline, hyper-vigilance, over-adaptation to fear of judgment, and how personhood versus performance became at risk.
Attaching to this reservoir energy is foundational work for the clinical objective of self-regulation. It’s based on bringing emoteur emotional energy to a conscious level and crossing the bridge from the intellectual mind to the emotional. For example, Sean, age 50, a salesman was not convinced at all, like many of my patients, about reservoir relevance in his initial stage of treatment. In a breakthrough moment of introspection and interoception he was able to identify the same adrenaline energy when he and his siblings were lined up waiting for his mom to use or belt for corporal punishment as the same energy he experienced is anticipating speaking in public.
When the trauma in one’s reservoir merges with perfection, with the perfectionism of obsessive compulsive personality disorder, the result is the perfect formula for performance anxiety. You’re now going to need a visual for what I’m going to teach. If you’re so motivated, please go to my website, socialanxiety.com. On the top bar for self-help, scroll down to the egograph and keep it in front of you. The egograph is based on the psychology of transactional analysis developed by Eric Berne and others in the 60s. The concept of the egograph was developed by John M. Dusay.
In mind state terms it provides a visual of what baseline pathology and eventual resolution looks like. All mind states are important. There’s no such thing as a bad mind state. The issue is synergy and balance. Take a good look at it. The twin towers of the critical parent and adapted child provide a visual of the unresolved trauma. The towers represent a deeply ingrained mind tick. This is not a neurological tick, but a deeply ingrained psychophysiological reflex between the toxic critical script and over-adaptive self. As the excessive critical parent activates excessive adaptation, the mind tick is created.
Again, this is clinical stuff. As the adapted child learns to be hyper-vigilant about perceived threats, pressure on one’s nervous system accrues over time. The critical parent-adapted child interaction becomes a reflex that becomes quite ingrained and automatic. The formula for anxiety resolution and high performance is to nurture the natural child with a good dose of adult. The resolved egograph represents the objectives of treatment. While technique is certainly important, core work, which is based on introspection and interoception, is critical for true healing and what I reference as a high performance mind which means developing a proactive approach for health and happiness.
Both technique and core work need to be integrated for high performance. So let’s talk about technique. These three things. Journaling, surfing, and response prevention. Building on Sarno’s methodology, I integrated journaling into my work about 20 years ago. During this time, no patient has reached a quality state of therapeutic productivity without it. Journaling is the key technique for introspection and introception. That said, this has been a difficult crossfit process for many of my patients. Concept of paradox or opposite is very important here. Those who have embraced it have experienced a substantial boost for their learning curve.
Surfing is the primary technique for adrenaline control. There are four steps. Number one, realistic expectations. This means that fight or flight adrenaline will be present in challenging scenarios to different degrees. Like my hands get cold at the beginning of a presentation. You go with it or you fight it. Do not waste any time hoping adrenaline will not be there. This is a huge concept. If the critical script puts unrealistic expectations on the inner child like there should not be any energy present, the result will be strain and more adrenaline. Number two is the hardest. This is acceptance. This means going with the adrenaline instead of fighting it or trying to suppress it.
Do this with the interpretation that it’s your friend and source of energy. Number three, go with the wave. The surfer goes with the wave and harnesses its energy. Four, take one or two diaphragmatic breaths. Feels good. The breath is the most valuable tool available to control nervous system energy. Many social anxiety sufferers are challenged with OCD and OCD symptoms. Therefore exposure and response prevention encourages facing fears and letting obsessive thoughts occur without putting them right or neutralizing them with compulsions. To organize this technique as well as surfing, it’s important to create a hierarchy of anxiety at the beginning of treatment so that the patient can take on this challenge in a methodical manner.
Here are some basic thoughts on medicine. Obviously this subject could be the subject of many podcasts. This is basic thoughts on medicine. When I started my practice in 1978 utilizing biofeedback and counseling to treat stress-related disorders, a primary objective was to help without pharmacology. 45 years later, I’ve discovered that there are significantly empowering ways to integrate psychopharmacology into the treatment process. Lowering the mind tick on the egograph is the primary objective of medicine for social anxiety. Using these mind states creates neuroplasticity and more potential to nurture the natural child with a good dose of adult.
In cases where medicine is indicated, I encourage the patient to think of it as a metaphorical pregnancy, meaning to utilize it for nine months or longer, the goal of which is to wean off the medicine after therapeutic goals are achieved and sustained. That said, this can be complicated as many patients enter treatment having been on medicine long term and have no clue for any proactive therapeutic strategy. In addition, many patients who have positive results with medicine do not want to stop taking it. In 1988, shortly after I appeared on the Oprah Winfrey show, I was on the phone with the producer of the Sally Raphael show. The first thing he said was, you are on Oprah, we don’t want you.
Then he asked, why do you have a public relations firm? My response, I want to educate the world. The result was a wonderfully produced show that generated a few thousand phone calls. There was no internet. The bottom line is that the world still needs to be educated. I wish you high performance.
