Where is the line between the shyness and awkwardness that many of us feel in unfamiliar circumstances or new social surroundings, and social anxiety as a disorder? What methods of treatment does cognitive behavioral therapy use? Clinical psychologist Denis Moskovchenko answers our questions.
Psychologies: Where is the line between personality trait and disease?
Денис Московченко: If we are talking about patients who suffer from social anxiety disorder, then the first thing they differ in is constant anxiety, constant shyness, a feeling of embarrassment that does not go away. For the average person, social awkwardness is a one-off situation that they think about and then forget about.
Most patients with social anxiety are constantly thinking about it, constantly analyzing situations. For them, social awkwardness is a way of being. That is, they live with this idea, they think about it all the time. Ordinary people may conclude, “I won’t do that again”; “Maybe I should change my behavior.” When we experience awkwardness, shyness, as a rule, they will be our motivators to change. For patients with social anxiety disorder, awkwardness becomes an occasion for self-blame and rumination, but they do not change their behavior.
Но это значит, что они испытывают неприятные эмоции почти каждый день, даже в обычных для нас обстоятельствах?
Yes. If we are talking about generalized social anxiety, then there is a severe form of anxiety. Yes, these people are constantly focused on evaluating their behavior. Where I did something wrong, how people will look at me, suddenly I can’t hold back my emotions, suddenly I blush, suddenly I have nothing to say. And this happens regularly. These patients really suffer from it.
Are there many such people with pronounced social anxiety?
I can only cite foreign statistics, unfortunately: approximately 13% of all mental disorders, quite a lot. This is the most common disorder among others: panic disorder, generalized anxiety, post-traumatic stress…
And what does science know about why this disorder occurs? Is it connected (as we say about 90% of everything in the world) with childhood or is it connected with the type of personality, type of character, with some physiological characteristics, with personal history?
There are a number of psychological factors that cause social anxiety. Firstly, this is the lack of emotional support, closeness from relatives. Constant criticism from others, criticism of social skills, talk about how you are not able to do something, you do not succeed, you will never be able to behave normally, make friends … This is one field.
School is the first competitive environment where you have to show yourself in social terms. Insecure children who do not have sufficient social skills fall into the vulnerability zone there.
Другое поле — моделирование или научение, когда ребенок видит, как ведут себя взрослые. Например, отец постоянно критикует окружающих, обвиняет их, и у меня возникает постоянный страх, что я тоже сделаю что-то неловко, неудачно, и меня будут обвинять.
Another factor is bullying at school. Probably all of us have experienced bullying in one way or another.
Now the teenage environment is quite aggressive. School is the first competitive environment where you have to show yourself in social terms. Insecure children who do not have sufficient social skills, who grew up with grandparents in a refined, comfortable environment, find themselves in school, fall into a vulnerability zone.
And then it affects their future life?
Yes, if they don’t get enough emotional feedback from their parents. Parents can say, “It’s okay,” they can help you deal with this social environment, they can teach you how to stand up for yourself. Patients with social anxiety often have childhood memories: I am alone, no one supports me, no one helps me, they turn away from me …
So any social situation becomes disturbing?
She becomes dangerous. How does an anxiety disorder work? If it is not treated, nothing is done with it, it spreads (generalizes) to other areas of life. Social anxiety is a combined disorder, it combines with others: with the use of psychotropic substances, with a high suicidal risk.
In your observation, does social anxiety increase in society, or is it about always the same percentage of the population? Or some circumstances of modern life, more information, more communication, provoke social anxiety?
Я думаю, в отношении классических форм социальной тревоги ничего не изменилось. Как был страх выступления, так он и встречается. Особенно это касается людей гуманитарных знаний, у тех же психологов — студентов, которым приходится выступать на научной конференции, где-то еще. Но при этом пациенты стали более осведомленными. Они читают книжки, они понимают, что у них социальная тревога. Популяризация современной и, в частности, когнитивно-поведенческой литературы помогает пациентам понять, что творится у них в голове.
We interviewed social anxiety specialist Stephen Huffman, where he talks about the main treatment for social anxiety – the exposure method. Can you say a few words about this?
Ключевая идея лечения социальных расстройств — если чего-то боишься, встань лицом к лицу со своим страхом. Face to face. Это действительно один из уникальных методов, когда мы сопровождаем пациента в то, что он боится больше всего. Мы видим его страхи, его опасения, видим, как он дрожит, но постепенно становится все сильнее и сильнее, более раскованным.
The key idea in the treatment of social disorders is that if you are afraid of something, face your fear. face to face
This method helps the patient to learn not at the level of the head, not when we sit in the office and talk, discuss something (there is such a form of therapy as cognitive work, during which we refute dysfunctional, automatic thoughts). Exposure allows you to learn at the level of behavior, at an implicit, implicit level, due to the fact that the brain itself begins to understand: this situation is not dangerous.
The approach is similar to a vaccine: we vaccinate a person with a weakened vaccine so that he is resistant to a real disease.
Yes Yes. A person sees that in reality everything is not so scary: “People will not criticize me, people will not blame me, they will not throw stones at me.” And if they show interest, then this interest will be more positive. This changes the perception of the situation.
And does it always work? There are no such patients who are so afraid that even in such homeopathic doses they cannot decide?
Мы говорим о социальной тревоге? Если да, то это задача терапевта — сделать так, чтобы этот пациент пришел к идее экспозиции, медленно, постепенно, через сократические вопросы, когда мы взвешиваем все аргументы за, аргументы против, ищем объяснения… Такой интеллектуальный подход. Да, пациенту будет страшно. Да, он будет испытывать стресс. Но мы с ним рядом, мы его сопровождаем, и он идет в этот страх.
А какие есть еще эффективные методы работы с тревожным расстройством?
Тревожное расстройство само по себе неоднозначно. И есть множество вещей, с которыми экспозиция не работает. Она действительно дает мощный эффект, чтобы человек почувствовал себя увереннее в социальных ситуациях. Но у него остаются правила долженствования, очень жесткие стандарты социального взаимодействия.
Например, чтобы поддерживать общение, нужно постоянно говорить, нельзя выдерживать паузы: «если я буду выдерживать паузу, то другой человек подумает про меня, что я скучный и неинтересный». Тогда нужна работа с автоматическими мыслями: мы через поиск альтернативных объяснений, через опровержение этих мыслей постепенно подводим пациента к тому, что эти жесткие правила могут быть опровергнуты, что можно вести себя иначе.
Психологическая особенность людей с социальной тревогой — заранее рисовать себе образ того, как они будут выглядеть. Они видят себя со стороны, оценивают и критикуют
Another aspect is such a complex and elusive thing as the perception of oneself in a social situation. Most patients with social anxiety, and this is their feature, draw an image of what they will look like in advance. I’ll ask you a question: if you imagine yourself in a social situation, how do you see yourself?
In what sense: from outside or from within?
Yes.
Rather from within.
Here! This is a sign that you do not have an anxiety disorder. Patients with social anxiety process themselves, see themselves from the outside, evaluate and criticize. This is their psychological feature. There are many techniques that allow you to switch the focus of attention: what they could focus on when, for example, they give a speech. Finally, the third type of work is related to cognitive errors. One of the cognitive errors is self-blame: patients often criticize themselves a lot for social awkwardness …
In situations where others might not even notice what happened.
Often we ask the patient: whose voice is this? Who is speaking? Who told you this? What is the inner critic? Where did he come from? Often these are dad, mom, parental patterns. And we teach the patient to be more compassionate towards themselves.
The interview was recorded for the joint project of Psychologies magazine and radio “Culture” “Status: in a relationship” in February 2017.
About the expert:
Denis Moskovchenko – clinical psychologist, candidate of psychological sciences, member of the Department of Clinical Psychology, Moscow State University of Medicine and Dentistry named after Evdokimov.