It's Nobody's Fault

by Harold Koplewicz

  The MAOIs, especially Nardil, have been proven effective in treating adults with social phobia, but there are serious dietary restrictions attached to the MAOIs. When people taking MAOIs eat foods containing tyramine, a chemical found in aged cheese, red wine, beer, smoked fish, and aged meats, they may develop high blood pressure. Because of the difficulty in monitoring the diets of children and adolescents, this category of medication is rarely prescribed for them.

  The category of medication most commonly prescribed for type two social phobia (pathological performance anxiety and anxiety in specific situations) is the beta blockers, especially Inderal and Tenormin. Beta blockers, which were originally developed for the treatment of high blood pressure, block the peripheral physical symptoms of anxiety, such as palpitations, tremors, and sweating. Teenagers with severe test anxiety have been treated very successfully with Inderal. One child I treated, David, age 12, hated tests. He had headaches for a few days before an exam and would awake with a terrible stomachache on the morning of the test. During the test his hands would sweat and his heart would race, but his thoughts were sluggish. He said his mind would just go blank sometimes. David’s IQ was above average, and he knew the material, but he was nonetheless convinced that his teacher thought he was stupid. He just couldn’t control his thoughts when he sat down in front of a test. On a low dose of Inderal he was able to take tests comfortably.

  Beta blockers are usually taken an hour before any “performance,” including tests, and only on an as-needed basis. Few side effects are experienced by youngsters taking these medicines, but a child’s heart rate and blood pressure should be measured and an electrocardiogram done before he takes any beta blocker for the first time.

  Certain medicines work well for particular kinds of anxiety but not for others. For instance, Xanax tends to relieve anticipatory anxiety—it keeps a patient from worrying in advance—but it’s not recommended for performance anxiety, because it does tend to take away the edge that many performers say they need to do their best work. (“I want that sharpness,” a musician told me. “I want to be very clear-headed. I don’t want any cloudiness when I’m onstage.”) On the other hand, a small dose of Inderal can work wonders for performance anxiety. I treated a nine-year-old boy, a talented musician who could not perform. He’d get backstage and just freeze with panic. He’d sweat and feel light-headed. Eventually he developed a tremor. On a very low dose of Inderal taken an hour before a performance he became anxiety-free and was able to get up on stage and play, completely clear-headed. Not only does he feel less anxious, his teacher says he’s also playing better than ever.

  If a child begins a careful program of behavioral therapy at the same time he takes medication, there is a good chance that he won’t have to take the medicine for very long. A 12-year-old boy I treated took 20 milligrams of Prozac a day for only six weeks, during which time he worked hard with a psychologist on improving his social skills. We started the treatment in late May. By July 1 he was ready to go away to camp, without his medication. He needed a lot of encouragement arid a fair amount of coaching, but he did it. What’s more, his mother told me proudly, he made two friends the first day of camp.

  While we’re on the subject of medication, I should say that one of the major pitfalls associated with social phobia in adolescents is self-medication; these adolescents drink and take drugs to make themselves feel better. Many of them say that the only time they don’t feel horrible is when they drink or smoke marijuana. However, when they sober up, they feel even worse than before. What’s more, this self-medication inevitably escalates; as time passes, it takes more alcohol and more marijuana to get that loose, relaxed feeling.

  Behavior modification—learning how to act even after the medicine has been taken away—is the ultimate goal here. The social and coping skills that come naturally to most people must be consciously learned by children with social phobia, a process that requires time and a lot of effort. Most therapists begin by teaching the child some basic relaxation techniques to combat anxiety, especially deep breathing and progressive muscle relaxation. Visual imagery, the process by which a child pictures himself in a situation that scares him and then creates an image of himself working through it, is another basic treatment technique.

  Children being treated for social phobia are given assignments for behavioral changes, starting very small and working up to the big challenges. Parents are indispensable co-therapists in these efforts. “Okay. Talk to one person today. Just say hello,” a mother might say to her daughter on Monday morning. On Tuesday it would be, “That was great. Now today I want you to talk to two people. And smile when you say hello.” The assignments escalate, and the child is gradually exposed to more social situations and made to feel more confident. Small rewards for completed assignments will increase motivation. Stars, stickers, check marks on a calendar—all of these signs of success can be traded in for comic books, video rentals, half hours of television, or any other token or activity the child holds dear.

  Assignments are great, but it’s not enough to pat a child with social phobia on the head and send him out to have random conversations with the kids at school or the relatives at a family get-together. After all, children don’t have a lot of experience with idle chit-chat. Kids need to be coached, and they need to rehearse. “But what will I say? What should I talk about?” a child will want to know. Those are good questions. All of us, not just kids with social phobia, feel more relaxed if we know what’s coming next and what we’re supposed to do.

  I remember helping Henry, a six-year-old who had been in treatment for social phobia for a couple of months, get ready for a day he was truly dreading: Thanksgiving dinner with his large extended family. He had no idea what he was going to say to these people, and he was scared to death. I asked the parents to find out who would be sitting on either side of Henry. Then we came up with three questions he could ask each of his dinner partners. His assignment for the day was to ask those six questions and to answer any questions that were put to him. We even worked on answers to some of the more obvious questions: How is school? How old are you now? What do you want to be when you grow up? And finally, we rehearsed Henry’s good-bye and thanks to his grandmother. The little boy came through it beautifully. In fact, to hear his parents tell it, Henry’s social skills were a lot better than those of his aunts and uncles.

  It doesn’t always go that smoothly, of course. Henry wasn’t a terribly tough case. Children with especially severe social phobia will have to work long and hard before they dazzle the family over the turkey at Thanksgiving. Some never quite get there. It’s not unusual for kids to freeze when the moment of truth arrives. “I knew I was supposed to say something, but I couldn’t remember what,” one little girl said sadly. “It all just went out of my head.” But practice does make perfect, and with the right medication combined with good coaching and rehearsal, reasonable assignments, and a lot of parental support, a child will make progress. A change of scenery can make a big difference too. Kids with social phobia may be labeled at school or at camp or even at family gatherings—singled out as that “shy kid” or the one who “never says anything”—and labels are hard for anyone, especially children, to shake.

  Not surprisingly, group therapy sessions can be very useful for teaching social skills, since they replicate the social experience more closely than individual sessions do. One of the most interesting groups I know of was assembled by one of my colleagues, a psychologist. She invited three 11-year-old girls with social phobia to her office with the intention of doing some tests. What happened instead is that the girls somehow clicked. One of the girls was carrying a Baby-Sitters Club book, and the other two said they liked the series too. The next thing my colleague knew, they were talking among themselves, three preteens with social phobia. After discussion of the Baby-Sitters Club had been exhausted (none of them thought that the TV show was as good as the books), they needed coaching from the therapist. “Why don’t you tell us about
what happened when you went horseback riding?” she said to one. “Tell us about the new dress you got for your birthday,” she told another. “What kind of costume will you be wearing for Halloween?” she asked the third. The responses were quite lively, and the session went surprisingly smoothly. The girls really seemed to understand one another.

  When social phobia is treated promptly and aggressively, the prognosis is excellent. Left untreated, it may get worse, and it may have a negative impact on all important aspects of a child’s life: school, work, and play. In all likelihood later on it will affect his job choice and performance and will hinder his ability to have a romantic relationship. It will have a lasting effect on self-esteem and may well result in alcohol and drug abuse.

  PARENTING AND SOCIAL PHOBIA

  A few years ago I saw Michael, a very bright, handsome 18-year-old boy whose mother had died six months earlier after a long illness. It was a close family, and everyone took the mother’s death very hard. Michael was clearly in terrible pain. Every time his mother’s name up, he would start to cry, sometimes uncontrollably. The reason he finally came to me was that a few nights earlier, at a party with his friends, he got so upset that he went to the bathroom and started smashing his fist against the wall. “I was hitting the wall and crying about how much I miss my mother,” he told me.

  Michael had even more reason to miss his mother than his brothers and sisters did. Although it had never been diagnosed, Michael had social phobia—his symptoms were quite obvious even in our first session—and he had always been dependent on her for help in coping with the outside world. Probably without even being aware of it, the mother had coached Michael and rehearsed with him. “I used to talk to my mother about how I was nervous about going to parties, and she would give me ideas about how to act. I could tell her anything,” Michael said tearfully. She made his appointments, chose his classes, and helped him schedule every detail of his life, including what he would wear to any important social occasion. The idea of life without her was devastating.

  Behavior modification, with a strong emphasis on social skills training, calls for the informed assistance of the child’s mother and father—or trainers, as I like to think of them. Ideally Mom and Dad will help their child learn social skills by making assignments, coaching, and rehearsing. Parental intervention is not always possible, however. Some parents just aren’t temperamentally suited for the task of trainer. One type of parent who’s likely to have a problem is the kind who’s always asking kids for a progress report. “How did everything go? What did the teacher think of your paper? Did everyone like your new shirt? Did you make a lot of friends?” Those are not the sorts of questions that put a child with social phobia—who’s overly concerned about being scrutinized and evaluated to begin with—at his ease. There’s already far too much anxiety associated with his social performance.

  Other parents become too emotionally involved with a child’s social success and consequently apply more pressure than the kid can manage. The unspoken message here is that a child’s inability to handle himself in a social situation is a reflection on the parents. Such mothers and fathers inevitably communicate their disappointment or disapproval, and sometimes even their anger, to their child, and that only increases the poor kid’s anxiety. To be truly helpful, parents must take the matter of social skills training seriously but not so seriously that it makes the child more nervous than he already is. A parent’s goal should be to make a child feel more confident and secure. That may mean putting some emotional distance between parent and child.

  “You don’t understand. You have no idea what it’s like to be shy,” one of my patients with social phobia, a 10-year-old girl named Mary Ann, said to her father in my office one day. Mary Ann had a point. Her father, an extremely outgoing family lawyer, didn’t show the remotest signs of social phobia. Not even a cocktail party filled with strangers would scare this man. Of course, he wanted to understand and help his daughter, but trying to relate to a girl for whom the briefest conversation was a trial cannot have been easy for this natural extrovert. It’s not necessarily easy if the parent does understand what it’s like to be shy. I treated a little girl with selective mutism whose mother found the child’s disorder completely intolerable. She had no patience with it, and the child knew it. It turned out that Mom was painfully shy herself.

  No matter how empathetic parents are—and no matter how skilled at advising and coaching their kids—there are plenty of children who simply won’t let their parents be their trainers. They’ll take advice from a therapist or a teacher or a family friend, but not from their folks. There’s not a great deal parents can do when they meet this kind of resistance, except to insist that the child work with someone who knows what he’s doing. “Okay, if you don’t want to rehearse with Daddy and me, you have to talk to Aunt Laurie about it,” a mother might say. The child needs training, regardless of who the trainer is.

  A child’s school should be made aware that he’s being treated for social phobia. Many teachers can be very helpful in social skills training and other elements of behavioral therapy. If a teacher knows, for instance, that a child’s assignment is to speak out once a day in class, he can help the child achieve that goal—by calling on the child early in the class to get it over with, for instance, or not calling on him more than once a day until he shows marked improvement. Every little bit helps.

  CHAPTER 11

  Generalized Anxiety Disorder

  When nine-year-old Caitlin and her parents flew in from Chicago to see me, Caitlin had already been through more than her share of experiences with doctors. She’d been suffering from headaches and terrible stomachaches every day for months, and her parents had taken her to several specialists, most recently the neurologist who referred her to me. When I asked Caitlin what kinds of things she worried about, the floodgates opened. She worried about everything, she said—that she wasn’t playing the piano well enough, that her father was going to run out of money, that her hair didn’t look right, that she wouldn’t have any friends, that she wouldn’t do well in school. The neurologist said that Caitlin’s headaches were caused by tension.

  Larry, a sweet, serious little first-grader, came home with a handwritten note attached to his first report card. “Larry is a lovely boy. I just wish he would smile more than once a semester,” the teacher wrote. Larry’s parents knew exactly what the teacher was talking about. At six, their son took his academic life as seriously as a third-year law school student. From the moment he came home, he’d worry about doing his homework assignment, fretting about whether it was complete and correct. One recent morning he and his parents had the following exchange:

  “Where’s my homework?” Larry asked Mom.

  “Your homework’s in your knapsack. It’s all signed,” she answered.

  “You signed the homework? You’re not supposed to sign my homework. You’re supposed to sign my homework assignment book!”

  “Honey, it’s okay. I’m sure it will be fine.”

  “No, it won’t be fine.”

  “Okay. I’ll write a note to the teacher and explain that I didn’t know I was supposed to sign the assignment book.”

  “No, don’t write a note. You’re not supposed to write a note!”

  When he finally left for school, little Larry was not smiling.

  HIGH ANXIETY

  A five-year-old boy on his way to a classmate’s birthday party tells his father he’d really rather not go, thank you very much. When the father questions the child, he discovers that the boy is a little nervous about going to a house he’s never visited before. He also fears that the other kids might not want to play with him. The boy finally agrees to go to the party. Dad offers to stay at the party and keep his son company for a little while, but the boy turns the offer down. No, he’ll be fine, he says. And after a few minutes at the party, he is.

  Another sensitive five-year-old goes to a G-rated movie only to be faced with a PG-rated preview of a coming at
traction: a movie with monsters. As soon as the child hears the music of the preview, she turns to her mother and says, “This is going to be scary. I’m closing my eyes.” She sits with her eyes shut tight until the ominous background music stops. “I wasn’t scared,” the little girl said afterward, “but it was good I closed my eyes.”

  Both of the youngsters I have just described were experiencing anxiety that falls within normal limits. All kids worry about something at least some of the time. They’re afraid of storms, animals, strangers, loud noises, the dark. They fret about wearing the wrong clothes, taking tests, getting invited to parties, and choosing a college. They’re scared that other kids won’t like them. All of these anxieties are to be expected in a child’s normal development.

  What is not part of normal development is the brand of anxiety that Caitlin and Larry exhibit. Both children are suffering from generalized anxiety disorder, or GAD, which is defined in the textbooks as “pathological anxiety characterized by all-consuming worry and excessive or unrealistic anxiety about a number of events or activities occurring more days than not for a period of at least six months.” GAD should not be confused with a simple phobia, which is an illogical fear of a particular thing—cockroaches, snakes, pigeons, whatever. Until recently GAD had a different name in the textbooks: overanxious disorder.

  Most kids worry when they have to take a test. Children with GAD worry not just before a test but before, during, and after a test. Normal kids study, get nervous, take the test, and wait to get their grades. Children with GAD study, take the test, and then replay it over and over again in their minds, convinced that their performance wasn’t good enough. They’re the ones who are always asking in class, “What did you put for number 6?” or “I’m sure I failed.”