U.S News
          Cover Story 6/21/99

          BY JOANNIE M. SCHROF AND STACEY SCHULTZ 



For millions of Americans, every day is a
struggle with debilitating shyness 


It is something of a miracle that Grace Dailey is sitting
in a restaurant in a coastal New Jersey town having an
ordinary lunch, at ease with her world. Her careful, tiny
bites of a tuna sandwich may seem unremarkable, but
they are in fact a milestone. Back in her grade school
cafeteria, she could only sip a bit to drink each day,
unable to eat while she imagined her classmates' eyes
boring into her. (Her high school teachers mistook her
anxiety about eating for anorexia.) Only in her 20s, when
panic attacks began to hit, did Dailey learn about the
condition called social anxiety disorder, also known as
"social phobia." But despite some success with
behavioral therapy and anxiety-reducing medication, the
32-year-old still struggles. "I would be a different person
in a different place if I didn't have to deal with this on a
daily basis," she says, frustration apparent in her
furrowed brow. 

Shyness is a nearly universal human trait. Most
everyone has bouts of it, and half of those surveyed
describe themselves as shy. Perhaps because it's so
widespread, and because it suggests vulnerability,
shyness is often an endearing trait: Princess Diana, for
example, won millions of admirers with her "Shy Di"
manner. The human species might not even exist if not
for an instinctive wariness of other creatures. In fact, the
ability to sense a threat and a desire to flee are lodged in
the most primitive regions of the brain. 

But at some life juncture, roughly 1 out of every 8 people
becomes so timid that encounters with others turn into a
source of over whelming dread. The heart races, palms
sweat, mouth goes dry, words vanish, thoughts become
cluttered, and an urge to escape takes over. This is the
face of social phobia, the third most common mental
disorder in the United States, be hind depression and
alcoholism. Like Woody Allen in the film Annie Hall,
some social phobics can barely utter a sentence without
obsessing over the impression they are making. Others
refuse to use public restrooms or talk on the telephone.
Sometimes they go mute in front of the boss or a
member of the opposite sex. At the extreme, they build
a hermitic life, avoiding contact with others (think of
young Laura in Tennessee Williams's Glass Menagerie
or the ghostly Boo in To Kill a Mockingbird). 

Though social anxiety's symptoms have been noted
since the time of Hippocrates, the disorder was a
nameless affliction until the late 1960s and didn't make
its way into psychiatry manuals until 1980. As it became
better known, patients previously thought to suffer panic
disorder were recognized as being anxious only in social
settings. A decade ago, 40 percent of people said they
were shy, but in today's "nation of strangers"–in which
computers and ATMs make face-to-face relations less
and less common–that number is nearing 50 percent.
Some psychologists are convinced that the Internet
culture, often favored by those who fear human
interaction, greases the slope from shyness down to
social anxiety. "If people were slightly shy to begin with,
they can now interact less and less," says Lynne
Henderson, a Stanford University researcher and director
of the Shyness Clinic in Menlo Park, Calif. "And that will
make the shyness much worse." 

Much worse–and, for drug companies, far more lucrative:
Recently, SmithKline Beecham won FDA approval to
market the antidepressant Paxil for social phobia,
leading to a raft of "public education campaigns"–on top
of those already put out by the National Institute of
Mental Health and the Anxiety Disorders Association of
America. This media blitz has raised concerns that
normally shy people will conclude they're social phobics
and seek medications for what is a complex, emotional
problem, or opt for such drugs merely as "lifestyle" aids
to win friends and influence people (story, Page 54). 

Hard-hitting. Social phobia hit Steve Fox so hard in
high school that girls made a sport of saying "hello" just
to watch him turn beet red. He refused to speak in class
and never dated; even walking in front of other people left
him with sweaty palms and gasping for air. By the time
Fox was 19, his father was concerned enough to find a
doctor, and a combination of medication and therapy has
helped him recover. Fox, now 23, recently gave a speech
in front of 1,700 people, and he is married to one of the
cheerleaders who used to tease him. 

Normal shyness and serious social phobia are clearly
different, but they are related. Emanuel Maidenberg,
associate director of UCLA's Social Phobia and
Performance Anxiety Clinic, says that shyness is to
social phobia what a fair complexion is to skin cancer.
"It's a predis posing factor but will only translate into
disease under certain circumstances," he says. "For
pale people, that might be 10,000 hours in the sun. For
shy people, it might be a string of embarrassing events."

Even though some people are born with a tendency
toward extreme shyness, biology is by no means
destiny. Harvard researcher Jerome Kagan has shown
that by 8 weeks of age, babies display innate shyness
or boldness. Roughly 1 in 5 will consistently be
frightened of and avoid anything or anyone new, while the
others welcome the unknown, reaching out to touch
strangers or to grab new objects. Yet, many shy babies
become gregarious 10-year-olds, and some outgoing
babies become shy, even socially phobic, adults. 

Life experiences can mold the brain to become more or
less shy over time. Through a process psychologists call
"contextual conditioning," the brain attaches a fear
"marker" to the details of a situation that causes trauma
(place, time of day, back ground music). So when a
child gets a disparaging tongue-lashing from a teacher,
the student will feel at least a bit nervous the next few
times he or she steps into that classroom. But
sometimes the brain is too good at making those
associations, says Maidenberg, and the anxiety grows
like a cancer, attaching itself to the act of entering any
classroom or talking to any teacher. 

The classic behavior of a child who does not know how
to handle these "daggers to the heart," says University
of Pennsylvania psychiatrist Moira Rynn, is to avoid any
attention at all. In fact, social phobia used to be known
as avoidant personality disorder. First, avoidant kids may
stop inviting friends over. Some will only speak to certain
people, usually their parents, a condition known as
"selective mutism". Others develop "school refusal." By
avoiding the very situations they need to learn the social
skills of adulthood, these children end up diminishing
their ability to cope. Not only can a parent who is highly
critical train a child to cower, but even the gentlest
parent can raise a fearful child. "If parents avoid social
situations or worry excessively about what the neighbors
think of them," says Richard Heimberg, director of the
Adult Anxiety Clinic at Temple University in Philadelphia,
"the message to a child is that the world is full of danger,
humiliation, and embarrassment." 

Social phobia affects about half of its victims by age 8,
and many others during adolescence, when social fears
are more pronounced. Others live with an undetected
problem that surfaces when facing a new public arena
(college, a new job) that overwhelms them. Grace
Dailey, who had man aged to suffer quietly through high
school, was seized with sudden panic attacks in her
she would race out of lecture halls, and she considered
dropping out. She did graduate, with the help of
thoughtful professors who let her take tests by herself
and who kept classroom doors open so that she didn't
feel so trapped. 

More women than men are thought to suffer social
anxiety, but because shyness and demureness are
smiled upon in females and less acceptable in males,
more men turn to professionals for help. Roland Bardon,
27, knew he needed to see a psychologist after
becoming too anxious to drive a car. "I worry about
making other drivers mad," he says. "When people
honk, that kind of criticism drives me crazy." He still
avoids taking the wheel whenever he can. 

Talking to strangers. It's Friday night at the Shyness
Clinic in Menlo Park, Calif., time for this week's social
phobia information session. But in the tiny room
decorated haphazardly with fake flowers, only one man
has shown up. The very nature of their disorder often
causes social phobics to hide, and revealing themselves
to a stranger is the last thing they want to do. Tonight's
newcomer put off coming for two months. Clinic patients
attend group meetings once a week, but some cannot
even bring themselves to show up at all. 

When the socially anxious do make it into clinics, they
usually start with a few months of cognitive behavioral
therapy. The cognitive element fights what psychiatrist
Isaac Tylim of the Maimonides Medical Center in
Brooklyn calls the intellectual core of social phobia: the
belief that others will pass negative judgments on you
and that unbearable humiliation will result. "I turn down
invitations to go to lunch with people I really admire, even
though I desperately want to go," says a Kentucky
housewife and mother of two girls who exhibit a similar
timidity. "I assume that as soon as we get together,
they'll regret having asked and want to get away from me
as soon as possible." These distortions cause an
emotional reaction that sends social phobics running
away from even the most promising friendships. Through
cognitive restructuring–a fancy term for replacing faulty
thoughts with realistic ones–many social phobics learn
to question the insidious fears that, no matter how
irrational, paralyze them in their everyday lives. 

Perhaps the most salient feature of social anxiety is
what is known as flooding: the sensation of being so
overwhelmed that panic sets in. Almost everyone feels
mild flooding at the podium during the first minute or so
of an important speech, but for most people the
discomfort soon subsides. A social phobic can suffer
such agony for more than an hour. But even in social
phobics, flooding will eventually subside, if only because
of sheer exhaustion. That is why behavioral therapists
coach social phobics to remain in terrifying situations
until the symptoms abate and it becomes clear that
nothing bad is going to happen. 

The first place that Melinda Stanley, professor of
behavioral sciences at the University of Texas-Houston
Health Science Center, takes many patients is the
elevator. Riding up and down, the patient practices
greeting and making small talk with fellow passengers.
"Sometimes it takes 10 or 15 rides, and sometimes it
takes all day," says Stanley, "but the phobic's heart will
eventually stop racing for fear of what the newcomer
might think of him or her." Eventually, the patients
progress to giving speeches in front of Stanley and an
audience of graduate-student volunteers. Other
therapists take social phobics through practice runs of
embarrassing situations, like walking through a hotel
lobby with toilet paper on their shoes or spilling a drink.
It's not unlike physical training, says Henderson. "Just
as our gym workouts get easier as time goes by, to stay
socially fit we must push ourselves to engage with
others until it is second nature." 

When a case is so severe that patients cannot even ride
an elevator with a therapist, drugs can enable the social
phobic to endure behavioral therapy. The perfect
medication has yet to be found. Antidepressants known
as monoamine oxidase inhibitors (MAOs) have been
used for over a decade, but they can cause side effects
such as fainting spells, heart palpitations, and blurred
vision, and users must follow strict diets excluding every
thing from coffee to cheese to red wine. Researchers
have experimented with Xanax, Valium, and other
tranquilizers but have had mixed success, not least
because those drugs can cause physical dependence.
Some sufferers try beta blockers, which are helpful for
surviving a speech or a party but use less as a long-term
therapeutic tool. 

Most popular now are the antidepressants known as
selective serotonin reuptake inhibitors (SSRIs), which
have fewer side effects than the old anxiety drugs.
"[Patients treated for depression] were spontaneously
reporting that they were losing their social anxiety,"
explains Murray Stein, director of the anxiety clinic at
the University of California-San Diego. Studies of the
SSRIs Paxil and Luvox show great improvement in about
half of social phobics, and studies now underway of
other new antidepressants, like Effexor and Serzone, are
also showing promise. But Henderson urges caution
amid the current hoopla over drugs, which she worries
are too often used as temporary crutches. "People tend
to relapse as soon as they get off the medication," she
warns, adding that research indicates that over the long
run, therapy might keep a person in better stead. Just as
troubling, says Tylim, is the message that only a drug
can save them. "These are people whose very problem is
a feeling of inadequacy, and the use of drugs can
exacerbate that." 

Because some social phobics have been out of the habit
of talking with others for so long, therapists often have to
help patients brush up on the most basic of social skills.
For example, it never dawns on many of the most shy
that they should introduce themselves to the person
standing in front of them. And they often are stuck in the
conversation-killing habit of answering questions with
one-word answers. "I had to learn that if someone
doesn't seem interested in the first sentence out of my
mouth, I should not just turn and walk away cold," says
Rick Robbins, a 31-year-old who was voted most shy of
his Indiana high school class and whose social anxiety
led him to drop out of college. 

Perhaps the most common thing social phobics have to
learn for the first time is to listen. "All kinds of alarm
bells and sirens are distracting to social phobics," says
Maid enberg. "So it is nearly impossible to hear what a
person standing 4 inches away is saying." In fact, it is
sometimes difficult for an extremely shy person to even
feign interest in a companion's words. "Social phobics
don't realize that most people in a room are not taking
much notice of them," says Tylim, who says that social
phobics in some ways crave the spotlight but fear that
humiliation will come from it. 

That's why Bernardo Carducci, author of Shyness and
director of the Shyness Research Institute at Indiana
University Southeast, is convinced that shifting the focus
away from the self is the most therapeutic thing a shy
person can do. "They desperately want to connect with
others," he says; otherwise, they would merely be
contented introverts or recluses who simply prefer their
own company. Carducci sends patients to soup
kitchens, hospitals, and nursing homes as a way of
escaping the tyranny of self-centeredness. "It works
because you get out there and start to see how shy
other people can be," says Rick Robbins. "And then you
don't feel so all alone, so different from every one else."
At first, he tried to pry himself out of his problem with
alcohol, what therapists dub "liquid extroversion." Then
he forced himself to go to social occasions, where he
would sit–miserable, silent, and sick to his stomach. If
anything, these kinds of efforts at beating shyness will
only aggravate the condition, because they are negative
experiences that reinforce the fear. 

Learning to cope. And because shyness is at least
partially genetic, researchers unanimously agree that it
is a mistake to try to become "unshy." Rather, the goal
is to take steps to function despite the pounding heart
and sweaty palms. Some do advance work for the tough
moments. "Be fore I go out, I come up with four or five
topics I would like to talk about," says Robbins. "Usually
by the third one I bring up, I find something in common
and forget about my nerves." Mark Goomishian, who has
trouble even signing a check in public, looks for social
arenas where he can be more himself, such as the local
coffee shop, where he meets others for regular games of
chess. "Because you don't have to talk during the
game," he says, "it's a socially anxious person's sport." 

In fact, many therapists say that if the socially phobic
could rein in their anxiety enough to function, they would
help make the world a better place. Many beloved figures
in history have suffered shyness, including Eleanor
Roosevelt, Robert Frost, and Albert Einstein. Shyness in
its milder forms is associated with traits such as greater
empathy, more acute perceptiveness, canny intuition,
and beneficent sensitivity. All qualities that are nothing
to be shy about. 

With Brendan I. Koerner and Danielle Svetcov in Menlo
Park, Calif. 

Phobias