Treatment for the more common anxiety-related disorders
Anxiety is the most common symptom of patients seeing a psychiatrist or a psychologist. About 5% to 8% of Americans each year are believed to have an anxiety disorder, about the same percentage have depression which often accompanies anxiety. Indeed, learning to cope with stress reduces the risk of depression. The major anxiety disorders are generalized anxiety, panic disorders, agoraphobia, and other specific phobias. Women are two or three times more likely to be diagnosed as being anxious than men are. We don't know why, perhaps because they admit fears more, see doctors more, get therapy more, have fewer rights and opportunities, are more abused and deserted, have to care for children alone and often work outside the home too, etc. Girls are also more prone to anxiety than boys, Blacks more than Whites, and the poor more than middle class.
You might think it is the busy executive who is most affected by stress. You'd be wrong. More likely to suffer from stress is the ordinary worker who is under heavy pressure to perform and has little control over decisions. Thus, the most influenced by stress is the factory worker, waiter, clerk-typist, data entry type who has fixed hours, limited breaks, rigid procedures, and little to say about conditions, solutions to problems, time off, lay offs, etc. Executives, business owners, managers, professionals may feel stressed but they are less affected by it. They are more motivated, more flexible, more challenged, and they can make decisions and run their own lives; this seems to be related to their being 2 to 4 times less likely (than the clerk) to become sick from the stress of their job. Still, in any job there are ways to relax (breaks, exercise at lunch, support from peers, calming fantasies, deep muscle relaxation, having hopeful positive thoughts, keeping a journal of your feelings, etc.).
An anxious person usually also has a history of associating with stress-related disorders, i.e. older relatives have been tense or fearful, poor social adjustment in the past, poor school adjustment (especially refusing to go to school after age 10), and general over-reactions to pressure or threats.
Panic attacks are thought of as being different from general anxiety; they respond to medicine differently. When the anxiety or panic is severe both medication and psychotherapy are advisable. I will briefly discuss a few of the anxiety-related psychological problems, such as worry, shyness, insomnia, burnout, phobias, panic attacks, obsessive-compulsive behavior, and psychosomatic disorders. There are others, such as Post-traumatic Stress Disorder, Dissociative States, and Multiple Personality, which usually require psychotherapy and so the details of treatment will not be discussed at length here. However, a considerable amount of general information about Dealing with Trauma has already been provided. If you have been traumatized, read this material and you will realize that several recent writers have provided help in understanding and getting over a traumatic experience.
Anxiety previews bad happenings; depression reviews bad happenings. Worry is anxiously anticipating that some awful, scary, unpleasant events are going to happen. Worry also involves trying to think of ways to avoid these unpleasant happenings (Borkovec, 1985). Worry is an unpleasant, upsetting activity that we'd like to stop but we can't; sometimes we can hardly think of anything else and can't sleep. Worrisome fretting is an effort to solve problems that results in our imagining more problems than solutions; thus, we never find a good place to stop worrying. The stream of worries goes like this: "I have to get that report done this weekend... what if the boss gets mad about what I said... if I lost my job it would be awful... I saw a homeless family on TV today... we should be saving more money... I wonder if my marriage would survive hard times... Oh, God, what if I couldn't take care of the kids..." Each little worry expands into a three hour, award winning movie or flows into an unending elaboration of other worries.
A chronic worrier estimates that he/she frets unconstructively like this for several hours a day! That's about 15% of our population! On the other hand, the non-worriers, about 30% of us, say they worry less than a hour and a half a day or benefit from their worries (planning). Borkovec says the chronic worrier thinks so much about possible troubles that he/she doesn't have the time to carefully and completely solve problems. The chronic worrier is more emotional in general (anxious, sad, angry, scared) than the non-worrier. They tend to be particularly afraid of being criticized and, thus, try to foresee every possible mistake. There are so many ways to go wrong--to make a mistake--that the worrying person may have great difficulty finding solutions to his/her very complex problems.
40% of our worries never happen; 30% are about pleasing everybody, an impossibility; 10% are about health, but we aren't doctors; 12% are "water over the dam;" thus, only 8% could be helpful.
-Thomas S. Kepler
There are several very good self-help books for worry--even Carnegie's book, "How to Stop Worrying and Start Living," with its common sense approach from the 1930's is still given high marks by readers. There is a 1999 audio edition available. I would recommend to the serious worrier three other books, Babior & Goldman (1996), Schiraldi (1996), and Copeland (1998). Copeland's book is a workbook; she has had years of experience with bipolar disorders. McKay, Fanning & Landis (1998) have produced a "Daily Relaxer Audio Cassette" for worriers.
Foa and Wilson (1991) have written an excellent, very thorough self-help book in this area. I've summarized it under "obsessions and compulsions" below. Also, see the next chapter for a discussion of perfectionistic worrying. Reading Goulding and Goulding (1989) and Craske, Barlow, and O'Leary (1992) should also be helpful. Mardus (1995) suggests ways of making worry work for you instead of wearing you down.
One of the more popular books about worry, at the moment, is by Hallowell (1998), a MD who has specialized for years in the ADHD area. Naturally, he brings a medicalized approach to worry and suggests several medications. He does also recognize that worriers have many ideas that lead to dread and insecurity, such as "I'm going to fail," "they may not like me," "I just know I'm going to make a mistake" and so on. For the cognitive aspects of worry, he recommends "techniques for retraining your brain," such as having positive thoughts, correcting wrong ideas, praying, using worry energy constructively, building friendships, following a daily schedule, listening to music, and others. It is easy reading; some reviewers even describe his suggestions as pop-psychology.
How can a worrier stop worrying excessively? Borkovec's approach is to try to get worrying under situational control, i.e. set aside a time (perhaps 1/2 hour each day) and a place to worry, and only worry there. To do this you also have to detect the onset of worrying and tell yourself to put it off until the appointed time and place. Thought stopping (chapter 11) or focusing your attention immediately back on the task at hand might help avoid the continuous worrying. Use the "worry period" to develop at least a crude plan (not the perfect plan) for current concerns. Writing your worries in a journal can help. A chronic worry becomes an obsession, so see the section below on obsessions and compulsions.
A reduction of the worrier's stress level might reduce the pressure to think, so any of the anxiety reduction techniques (relaxation, desensitization, inoculation) mentioned above might help. Clearly, decision-making and self-help planning would help the indecisive worrier cope and move on. Worries are often useless; this awful event that might happen, often doesn't happen. Thus, the worrier needs to use the cognitive methods cited above to straighten out his/her thinking, making it more realistic and stopping the "awfulizing" or "catastrophizing." Also, the worrier should be reminded that half of the formula for anxiety is self-doubt about being able to handle the expected crisis. Building self-confidence in coping with problems will reduce the unproductive fretting. Finally, one should always wonder if the worries serve some secret purpose, such as proving "I'm a good worried father" or distracting you from some deeper, more basic fear (better to focus on protecting my daughter from boys than to think about my own sexual problems with my wife).
Laboratory studies as well as clinical observations have shown that worriers under stress tend to over-estimate the degree of risk they face. If you think of more risks and threats, then your anxiety and worry levels go up. Worry is not a simple reaction, it is complex, including conditioned emotional reflexes possibly learned even in childhood, ingrained habits of responding, and cognitive processes that exaggerate the dangers ahead, set impossible or unrealistic standards, and reflect low self-confidence. So, a summary of how a worrier could possibly stop worrying excessively might include: directly countering the worrying behavior by relaxing in any one of several ways, by rewarding more confident and happy self-talk, by exercising, using massage, and thought-stopping, or by diverting attention with music, TV, reading, and socializing, and by practicing successfully facing stressful situations over and over again. One could also reduce worrying by changing one's thoughts, such as correcting unwarranted negative expectations, reducing tendencies to falsely view current situations negatively ("awfulizing"), giving up overly demanding perfectionistic standards ("I must always be right") and by correcting the refusal to accept the lawfulness of all behavior ("It's got to be different"). There are a lot more ways of reducing worries: one can learn new skills and problem-solving or decision-making methods, which can change things and strengthen the belief that one can cope with difficulties that might arise. Moreover, one might gain insight into his/her negativity, train oneself to be more optimistic, higher in self-esteem and self-efficacy, or perhaps even happier, and develop an inspiring life plan. Worry can be controlled but often not easily.
Shyness is very common and it can be very handicapping, but it does not gain you much sympathy. People often think you should "just get over it." Getting over it isn't easy. If you try to avoid being embarrassed and nervous by not interacting, you run the risk of being seen as snobbish, bored, unfriendly, or weak. How many of us are shy? Zimbardo, Pilkonis and Norwood (1975) found that 40% of college students considered themselves shy (by 2000 it is up to 48%). Another 40% had been shy in the past, bringing the total to 80%. Among young teenagers, 50-60% were shy. Most researchers agree that half or more of American adults are a little shy. Only 5% of us are not-at-all-shy. So, it is one of the most common human problems. Good discussions of shyness are by Carducci and Zimbardo (1995) or Carducci (2000).
We shy people find it hard to start a relationship. Sometimes others do reject us or avoid us because we are quiet and withdrawn...that rejection hurts. Occasionally, if the withdrawal or rejection seems unnecessarily cruel to us, we may get angry and start to feel superior and want revenge. Most of the time we just believe we are not very interesting and stay by ourselves. It is important to note, however, if we can break through the shyness barrier and develop a friendship, becoming close and intimate is usually not a problem (Carducci, 1999). We often long for intimacy and if we gain it with one or two people, we feel and do just fine.
The Diagnostic Manual divides social phobia into two types: generalized or nongeneralized (fear in certain social situations but not all). In addition, psychological tests of socially anxious college students have indicated two different basic kinds of problems with other people: (1) feeling anger, resentment and distrust with others and (2) being unassertive, submissive or overly nurturing with others. If you can identify your more common feelings while interacting, such as anger or submission, then perhaps further work on these problems, as well as social anxiety, would help you make the changes you want (Kachin, K. E., Newman, M. G. & Pincus, A. L., 2001).
There is also an important difference to note between shyness and introversion. Shyness involves a social nervousness, a lack of social skills, a harsh internal critic, and acute self-consciousness. An introvert may have social skills but simply prefers to be alone or with a few friends. It isn't always easy to tell from the outside if a person is shy or introverted. From the inside, there is a big difference.
Another important distinction is that almost all of us are a little "shy" in certain social situations, but that is different from serious chronic shyness in almost all situations. The 15%-25% who are chronically shy feel lonely, misunderstood, self-critical, and uncomfortable while interacting. They look nervous. They can't maintain eye contact. They are unassertive, have trouble thinking clearly and expressing themselves, are concerned about their "image," and, in fact, often give others bad impressions. It can, of course, be a serious problem--too bad we don't take it more seriously. One of the barriers to getting help is our shame about social nervousness--on average, it is 8 years before the person suffering shyness can tell a family member or a friend. Maybe because people respond with "get over it." The average delay in seeking treatment for shyness is 14 years!Perhaps we will in the future seek help earlier because of findings by Kagan (1989) discussed below.
First, one more distinction needs to be made. At the high end of the shyness continuum there is a diagnosis of "social anxiety." At times this label may include some of the chronically shy, but the diagnosis is usually reserved for the most distressed 3% or so (that is still 10 million Americans!). These people suffer grave consequences in life. They may find it impossible to go to work or to school. Interacting with others results in panic, racing heart, sweating arm pits, faces, and hands, "freezing" so that working together seems impossible, and so on, much like panic reactions and agoraphobia. These symptoms demand treatment. A good but somewhat academic discussion of "social anxiety" is by Leary & Kowalski (1995).
Jerome Kagan, researching child development for over 30 years, found only one trait that was fairly consistent from age 2 to 20; that was shyness. Other traits--aggression, dependency, competitiveness--change as we develop. But social inhibition remains so constant and is so similar from parent to child or in identical twins that Kagan concluded that shyness was, in part, genetically determined--a part of our inheritance, a part of our hardware. Shy (15% are "inhibited") children can apparently be identified as early as 2 to 4-months-old--and 50% of shy 2-year-olds are still extremely shy at 7 or 8. Placed in a strange situation, the extremely shy child of 2 or 3 is hyperactive, irritable, nervous, cries a lot, has a fast heart rate, etc. When forced to interact with strangers, he/she is inhibited, unresponsive to strangers, unwilling to take risks, and tense doing motor tasks. These shy children were also more likely to be colicky, allergy-prone infants, and by age 7 or 8 had more fears about speaking in class, going to camp, being in the dark, etc. Even 30 years later, shy children are different: shy boys marry later, are more apt to get divorced, enter careers later and do less well (Caspi, Elder & Bem, 1988). Shy girls are less likely to have careers when they grow up. Non-shy children (15% are "uninhibited") were sociable, fearless, and spontaneous with strangers. Shyness is likely to limit and reduce our joy of living; it may be with us a lifetime. Yet, we are not slaves to our genes.
Two thirds of us, including the shy, continue to think that shyness is caused by family experiences, overprotective or critical parents, abuse by peers, etc., i.e. by experience. Research assigns more blame to innate factors, which can be modified by experience. Hopefully, knowing that genes partly determine shyness will not discourage shy people or parents, teachers, and other helpers of shy kids. Clearly shyness can be changed because it does change over the years. It has been said "genes only set the stage, you get to write your life script." Sensitive, nurturing parents helped 40% of Kagan's inhibited children overcome their handicap by age 5 or 6. He advises parents to face the problem, protect the children from trauma, such as family fights, pushy older siblings, criticism or demands for excellence, etc., help them with social skills, and gently nudge them into social contacts. It is important that children know they are loved unconditionally, not just if they are "good." Seeing painfully shy children and adults as victims of their genes may help us be more sympathetic and spur the schools and helping professions to find better ways to cope with shyness. Shyness doesn't "just go away," explicit efforts are needed.
No one likes to be shy, so in their secret struggle with this problem almost all shy people try to "get over" the condition, often unsuccessfully (remember it is in our genes). To do this, they force themselves to interact, to think positively, and to relax while interacting by using drugs and alcohol. Some of these efforts are on the right track but aren't enough; the drinking/drugging may even harm. What will help?
Some of the mildly shy see the problem of nervousness very differently from the chronically shy (Zimbardo, Pilkonis & Norwood, 1975). Excessively shy people have a hapless view, "I look terrible, I say such dumb things, my nervousness is an obvious, awful, unavoidable problem," whereas the non-shy person, who is actually having similar and equal physiological stress reactions, is more hopeful and apt to say, "Some people or some situations make me uncomfortable, but that's OK, it's normal, I'll start a conversation anyway." That is a better way to look at your nervousness. So, if you get stressed out, stop putting yourself down, stop imagining everyone is scrutinizing just you and deftly finding from 30 feet all your faults. Keep on interacting. To further reduce these negative self-evaluations, some therapists simply provide shy people with successful experiences talking to people, i.e. in vivo desensitization (Haemmerlie & Montgomery, 1986). It works. Likewise, most of us have had the experience of becoming temporarily more outgoing and self-confident during or after certain experiences, such as a love relationship, being an athletic star, or doing very well in school. What we think and feel about ourselves, our self-esteem, influences our shyness and may come from observing our own behavior. In any case, adopting a hopeful, I-can-change-my-social-behavior way of thinking is important, then DO SOMETHING, like smiling and greeting people, making small talk, give a compliment, etc. (Glass & Shea, 1986).
What are some other things you can do about shyness? Learn social interaction skills, especially self-disclosure, assertiveness, and empathy responses. Gerald Phillips (1981) advocates teaching shy students practical speech communication skills, like in speech class, and forget about "therapy" for anxiety. Many other psychologists would do the opposite, namely, focus on relaxation and desensitizing the nervousness, and forget speech skills. Others would use cognitive methods (correcting negative thoughts, giving self-instructions, planning) and improve their self-concept by building self-confidence and self-esteem (all in chapter 14). Stop thinking how stupid you sound; stop wanting to be humorous, brilliant, and perfect. Stop focusing on how nervous you feel and focus on the other person, making them comfortable, helping them tell their story and share their feelings with you.
Almost all therapists would recommend lots of practice interacting by first imagining successful conversations with different people. Maybe you can role play with a friend. Then try out your new skills, talking to people at work, on the Internet, going out with friends, etc. Prepare things to say and ask in advance. Learn and think about current social/political issues, listen to the news, see movies, polish your opinions. Improve your listening skills. There are several good self-help books for shyness (Miller, 1996; McCullough, 1992; Marshall, 1994; Zimbardo & Radl, 1979; Zimbardo & Radl, 1981 and 1999; Powell, 1981; Gelinas, 1987; Cheek, 1989), but the best are Zimbardo (1987), Aron (1996 & 2000), Markway & Markway (2001), Burns (1985), and Carducci (1999). Also see the Conquering Shyness bibliography. It is better to DO SOMETHING, than to read lots of books.
Some studies have suggested that shyness is increasing in America. A few psychologists, including Zimbardo, have speculated that our increasing affluence and the increasing popularity of the Internet are responsible for the growth in shyness. What is the basis for these beliefs? Well, some think more wealth enables us to become self-sufficient and live alone with well furnished entertainment centers and expensive computers, i.e. live in isolation from others. But the same wealth enables us to have the time for friends and the means of going places and doing things with friends. Some with money choose to be alone, others want to be with their favorite people.
Zimbardo (an article, Shyness Breaks the Human Connection, on www.here2listen.com/public/topics/ on 2/19/2000) showed his biases when he wrote: "Technology further isolates within an illusion of interpersonal communication. We make acquaintances and lose friends by spending so many hours on email and in chat rooms, substituting emotional face-to-face contacts with information-based virtual contacts." A couple of the early studies supported this opinion that going online increases social distance or isolation and replaces deep, meaningful friendships with (what is assumed to be) shallow, fleeting, cyberspace interactions. However, about 55% of Internet users report that being online increases interpersonal connections and actually improves interactions with friends and family (a survey done by Pew Internet and reported by Aimee Balsey of the Badger Herald, U. Wisconsin, 6/30/2000). Certainly being online makes it easier and cheaper to stay in touch with old friends who are now far away. Good relationships can develop online; note the support groups and the marriages that start online.
It is obvious that humans have very different social needs--and some of us meet those needs within a close family or group of friends, perhaps face-to-face, perhaps by using new technology, perhaps by phone, perhaps for a few by writing each other. There are others of us who are content, even happy being alone (even though that is hard for the gregarious to realize, there is nothing wrong with that). What concerns me is the painfully shy who silently long for close relationships. For some of these people, the online chats, forums, lists, threaded discussions, etc. are an ideal way to start interacting more comfortably and, hopefully, learn to converse more easily with people face-to-face too. Indeed, King & Poulos (1998) have recommended that the seriously shy (Social Phobia and Avoidant Personality Disorder) consider joining one of the thousands of virtual communities as well as perhaps seeking online therapy by a professional.
There are a few Web sites that specialize in shyness: Overcoming Shyness, Cheek: How Shy?, Craig's Shyness Page, Yahoo! Shyness, Psych Central: Self-Esteem and Shyness, and Zimbardo is associated with several sites Shyness Clinic, and a bibliography at the Shyness Institute as well as his huge Positive Psychology Program. A crude test of Social Anxiety is offered by Queendom. You can also find many places to actually socialize online by looking earlier in this chapter at support groups. There are many newsgroups to consider, such as alt.support.shyness.
Zimbardo sees shyness, extreme or mild, as an enormous social problem. Some countries, such as China, do not raise nearly as many shy children as we do in the US. We must remember that in addition to genes, shyness is partly a result of societal pressure to be successful, to be beautiful, to be competitive and to impress others. These pressures don't have to be there. Our shyness or passivity may also be subtly encouraged by parents, schools, and society to insure that children are "manageable," obedient, submissive--kept in "their place." As a result, however, we--as children and adults--come to feel unimportant, powerless, ineffective, passive-dependent, and even defective, which increases our isolation from family, friends, neighbors, and perhaps from all humanity. Shyness reduces our sharing, caring, and loving one another. It increases our loneliness, being picked on, losses due to hesitation, and other social problems. That's serious. Let's help shy children (Zimbardo & Radl, 1981 and 1999).
Fortunately, exposure in vivo, social skills training, and cognitive techniques have all been shown to help social phobias. Actually a combination of cognitive group therapy followed by exposure in vivo seems to work best (Scholing & Emmelkamp, 1993). Why aren't these approaches used in school?