The terrible irony of social phobia is that one of the things people suffering from it fear most is having their anxiety exposed—which is precisely what the symptoms of this anxiety serve to do. Social phobics worry that their interpersonal awkwardness or the physical manifestations of anxiety—their blushing and shaking and stammering and sweating—will somehow reveal them to be weak or incompetent. So they get nervous, and then they stammer or blush, which makes them more nervous, which makes them stammer and blush more, which propels them into a vicious cycle of increasing anxiety and deteriorating performance.
Blushing is infernal in this regard. The first case study of erythrophobia (the fear of blushing in public) was published in 1846 by a German physician who described a twenty-one-year-old medical student driven to suicide by shame over his uncontrolled blushing. A few years later, Darwin would dedicate a full chapter of The Expression of the Emotions in Man and Animals to his theory of blushing, observing how at the moment of most wanting to hide one’s anxiety, blushing betrays it. “It is not a simple act of reflecting on our own appearance but the thinking of others thinking of us which excites a blush,” Darwin wrote. “It is notorious that nothing makes a shy person blush so much as any remark, however slight, on his personal appearance.”
Darwin was right: I’ve had colleagues prone to nervous blushing, and nothing makes them glow redder than to have their blushing publicly remarked upon. Before her wedding, one such colleague tried multiple combinations of drug treatments, and even contemplated surgery, in hopes of sparing herself what she believed would be intolerable humiliation. (Every year thousands of nervous blushers undergo an endoscopic transthoracic sympathectomy, which involves destroying the ganglion of a sympathetic nerve located near the rib cage.) I, who am fortunate not to count blushing among one of my regular nervous symptoms, observe her and think how silly she is to believe that blushing at her wedding would be humiliating. And then I think how ashamed I was of sweating and trembling at my own wedding and wonder if I am not any less silly than she.
Shame, perhaps, is the operative emotion here—the engine that underlies both the anxiety and the blushing. In 1839, Thomas Burgess, a British physician, argued in The Physiology or Mechanism of Blushing that God had designed blushing so that “the soul might have sovereign power of displaying in the cheeks the various internal emotions of the moral feelings.” Blushing, he wrote, can “serve as a check on ourselves, and as a sign to others that [we’re] violating rules which ought to be held sacred.” For Burgess as for Darwin, blushing is physiological evidence of both our self-consciousness and our sociability—a manifestation of not only our awareness of ourselves but our sensitivity to how others perceive us.
Later work by Darwin, as well as by modern evolutionary biologists, posits that blushing is not only a signal from our bodies to ourselves that we’re committing some kind of shameful social transgression (you can feel yourself blush by the warming of your skin) but also a signal to others that we are feeling modest and self-conscious. It’s a way of showing social deference to higher-ranking members of the species—and it is, as Burgess would have it, a check on our antisocial impulses, keeping us from deviating from prevailing social norms. Social anxiety and the blushing it produces can be evolutionarily adaptive—the behavior it promotes can preserve social comity and can keep us from being ostracized from the tribe.
Though social anxiety disorder as an official diagnosis is relatively new in the history of psychiatry—it was born in 1980, when the disease was one of the new anxiety disorders carved out of the old Freudian neuroses by the third edition of the DSM—the syndrome it describes is age-old, and the symptoms are consistent from age to age.a Writing in 1901, Paul Hartenberg, a French novelist and psychiatrist, described a syndrome whose constellation of physical and emotional symptoms corresponds remarkably to the DSM-V definition of social anxiety disorder. The social phobic (timide) fears other people, lacks self-confidence, and eschews social interactions, Hartenberg wrote in Les timides et la timidité. In anticipation of social situations, Hartenberg’s social phobic experiences physical symptoms such as a racing heart, chills, hyperventilation, sweating, nausea, vomiting, diarrhea, trembling, difficulty speaking, choking, and shortness of breath, plus a dulling of the senses and “mental confusion.” The social phobic also always feels ashamed. Hartenberg even anticipates the modern distinction between people who feel anxious in all social situations and those who experience anxiety only before public performances—a particularized emotional experience he called trac, which he described as afflicting many academics, musicians, and actors before a lecture or performance. (This experience, Hartenberg writes, is like vertigo or seasickness—it descends suddenly, often without warning.)
Yet despite what seems to be the consistency in descriptions of social anxiety across the millennia, the diagnosis of social anxiety disorder remains controversial in some quarters. Even after the syndrome was formally inscribed in the DSM in 1980, diagnoses of social phobia remained rare for a number of years. Western psychotherapists tended to see it as a predominantly “Asian disorder”—a condition that flourished in the “shame-based cultures” (as anthropologists describe them) of Japan and South Korea, where correct social behavior is highly valued. (In Japanese psychiatry, a condition called Taijin-Kyofu-Sho, roughly comparable to what we call social anxiety disorder, has long been one of the most frequent diagnoses.) A cross-cultural comparison conducted in 1994 suggested that the relative prevalence of social phobia symptoms in Japan could be related to “the socially promoted show of shame among Japanese people.” Japanese society itself, the lead researcher of the survey argued, could be considered “pseudo-sociophobic” because feelings and behaviors that in the West would be considered psychiatric symptoms—excessive shame, avoidance of eye contact, elaborate displays of deference—are cultural norms in Japan.b
In the United States, social anxiety disorder found an early champion in Michael Liebowitz, a psychiatrist at Columbia University who had served on the DSM subcommittee that brought the disease into official existence. In 1985, Liebowitz published an article in the Archives of General Psychiatry called “Social Anxiety—the Neglected Disorder,” in which he argued that the disease was woefully underdiagnosed and undertreated.c After the article appeared, research on social phobia began to accrete slowly. As recently as 1994, the term “social anxiety disorder” had appeared only fifty times in the popular press; five years later, it had appeared hundreds of thousands of times. What accounts for the disorder’s colonization of the popular imagination? Largely this single event: the Food and Drug Administration’s approval of Paxil for the treatment of social anxiety disorder in 1999.d SmithKline Beecham quickly launched a multimillion-dollar advertising campaign aimed at both psychiatrists and the general public.
“Imagine you were allergic to people,” went the text of one widely distributed Paxil ad. “You blush, sweat, shake—even find it hard to breathe. That’s what social anxiety disorder feels like.” Propelled by the sudden cultural currency of the disease—that same ad claimed that “over ten million Americans” were suffering from social anxiety disorder—prescriptions of Paxil exploded. The drug passed Prozac and Zoloft to become the nation’s best-selling SSRI antidepressant medication.
Before 1980, no one had ever been diagnosed with social anxiety disorder; twenty years later, studies were estimating that some ten million to twenty million Americans qualified for the diagnosis. Today, the official statistics from the National Institute of Mental Health say that more than 10 percent of Americans will suffer from social anxiety disorder at some point in their lifetimes—and that some 30 percent of these people will suffer acute forms of it. (Studies in reputable medical journals present similar statistics.)
No wonder there’s controversy: from zero patients to tens of millions of them in the course of less than twenty years. It’s easy to lay out the cynical plot: A squishy new psychiatric diagnosis is invented; initially very few patients are de
emed to be ill with it. Then a drug is approved to treat it. Suddenly diagnoses explode. The pharmaceutical industry reaps billions of dollars in profit.
Moreover, these critics say, there’s another name for the syndrome ostensibly afflicting those with social anxiety disorder. It’s called shyness, a common temperamental disposition that should hardly be considered a mental illness. In 2007, Christopher Lane, a professor of English at Northwestern University, published a book-length version of this argument, Shyness: How Normal Behavior Became a Sickness, claiming that psychiatrists, in cahoots with the pharmaceutical industry, had succeeded in pathologizing an ordinary character trait.e
On the one hand, the sudden explosion in diagnoses of social anxiety disorder surely does speak to the power of the pharmaceutical industry’s marketing efforts to manufacture demand for a product. Besides, some quotient of nervousness about social interactions is normal. How many of us don’t feel some discomfort at the prospect of having to make small talk with strangers at a party? Who doesn’t feel some measure of anxiety at having to perform in public or to be judged by an audience? Such anxiety is healthy, even adaptive. To define such discomfort as something that needs to be treated with pills is to medicalize what is merely human. All of which lends weight to the idea of social anxiety disorder as nothing more than a profit-seeking concoction of the pharmaceutical industry.
On the other hand, I can tell you, both from extensive research and from firsthand experience, that as convincing as the case made by Lane and his fellow antipharma critics can be, the distress felt by some social phobics is real and intense. Are there some “normally” shy people, not mentally ill or in need of psychiatric attention, who get swept up in the broad diagnostic category of social anxiety disorder, which has been swollen by the profit-seeking imperatives of the drug companies? Surely. But are there also socially anxious people who can legitimately benefit from medication and other forms of psychiatric treatment—who in some cases are saved by medication from alcoholism, despair, and suicide? I think there are.
A few years ago, the magazine I work for published an essay about the challenges of being an introvert. Not long after that, this letter arrived at my office:
I just read your article on introversion. A year ago my 26-year-old son bemoaned the fact he was an introvert. I assured him he was fine, we are all quiet introverts in our family. Three months ago he left us a note, bought a shotgun, and killed himself. In his note he said he wasn’t wired right.… He felt anxious and awkward around people and he couldn’t go on.… He was smart, gentle and very educated. He had just started an internship dealing with the public and I think it pushed him over the edge. I wish he had said something before he bought the gun. It seems he thought it was his only option. This was a guy who got nervous before getting his blood drawn. You can’t imagine how horrible it has been.
One study has found that up to 23 percent of patients diagnosed with social anxiety disorder attempt suicide at some point. Who wants to argue that they are just shy or that a drug that might have mitigated their suffering was purely a play for profit?
No passion so effectively robs the mind of acting and reasoning as fear.
—EDMUND BURKE, A Philosophical Inquiry into the Origin of Our Ideas of the Sublime and Beautiful (1756)
As best I can recall, my performance anxiety blossomed when I was eleven. Before then, I had made presentations in class and in front of school assemblies and had experienced only nervous excitement. So I was blindsided when, standing onstage in the starring role in my sixth-grade class’s holiday performance of Saint George and the Dragon, I suddenly found I could not speak.
It was an evening in mid-December, and the auditorium was filled with a few dozen parents, siblings, and teachers. I remember standing backstage beforehand, awaiting my cue to enter stage left, and feeling only mildly nervous. Though it’s hard for me to imagine now, I think I was even enjoying myself, looking forward to the attention I would receive as star of the play. But when I walked to center stage and looked out into the auditorium to see all those eyes upon me, my chest constricted.f After a few seconds, I found myself in the grip of both physical and emotional panic, and I could barely speak. I eked out a few quavering lines with a diminishing voice—and then arrived at a point where I could make no more words emerge. I stopped, midsentence, feeling that I was about to vomit. A few agonizing seconds of silence ticked by until my friend Peter, who was playing my valet, bailed me out by saying his next line.g This surely seemed to the audience like a non sequitur, but it moved the scene to its conclusion and mercifully got me off the stage. By my next scene, the physical symptoms of my anxiety had abated a little; at the end of the play I slew the dragon as directed. Afterward, people said they had liked my fight scene, and (out of politeness, I was sure) nobody remarked on my first scene, where it must have looked, at best, like I had forgotten my line or, at worst, like I had frozen in terror.
A trapdoor opened beneath me that night. After that, public performances were never the same. At the time, I was singing in a professional boys’ choir that appeared in churches and auditoriums all over New England. Concerts were torture. I was not one of the better singers, so I never had solos; I was just one of twenty-four prepubescent boys standing anonymously onstage. But every moment was misery. I’d hold my score in front of my face so the audience couldn’t see me and mouth the words silently. I’d have that horrible choking feeling, and my stomach would hurt, and I would fear that if I made any sound, I’d vomit.h
I quit the choir, but I couldn’t completely avoid public performances—especially as my anxieties worsened and my definition of public got broader. The next year, I was making a presentation in Mr. Hunt’s seventh-grade science class. True to my phobic preoccupations, I had chosen to do a report on the biology of food poisoning. Standing at the front of the class, I became overwhelmed by dizziness and nausea. I made it only a few halting sentences into my presentation before pausing and then squeaking plaintively, “I don’t feel well.” Mr. Hunt told me to go sit down. “Maybe he’s got food poisoning!” a classmate joked. Everyone laughed while I burned with humiliation.
A couple of years later, I won a junior tennis tournament at a local club. Afterward, there was a luncheon banquet, where trophies were to be given out. All that was required of me was to walk onto the dais when my name was called, shake the hand of the tournament director, smile for the camera, and walk off the dais again. I wouldn’t even have to speak.
But as the tournament organizers proceeded down through the different age groups, I started to tremble and sweat. The prospect of having all those eyes upon me was terrifying—I was sure I would humiliate myself in some indeterminate way. Several minutes before my name was announced, I slipped out the back door and ran down to a basement restroom to hide, emerging only several hours later, when I was sure the luncheon had ended. (This sort of extreme avoidant behavior is common among social phobics. I once came across a report in the clinical literature of a woman who, feigning illness, skipped a company banquet where she was to be given an award for outstanding performance, because the prospect of being the center of attention made her so nervous. After she missed the dinner, a small group of colleagues planned a more intimate reception in her honor. She quit her job rather than attend.)
Once, in college, I applied for a fellowship that required me to sit for an interview with a committee of half a dozen faculty members, most of whom I was already friendly with. We bantered easily before the official proceedings began. But when the interview started and they asked me the first formal question, my chest constricted and I could make no sound emerge from my trachea. I sat there, mouth silently gaping open and then shutting like some kind of fish or suckling mammal. When finally I was able to get my voice to work, I excused myself and scurried out, feeling the committee’s befuddled eyes on my back, and that was that.
The problem, alas, has persisted into adulthood. There have been humiliating minor catastrophes (walking offstage
midsentence during public presentations) and scores of near misses (television shows where I’ve felt the chest constriction begin; lectures and interviews where the room started to swim, nausea rose in my gullet, and my voice diminished to a sickly warble). Somehow, in many of those near-miss instances, I’ve managed to fight through and continue. But in all these situations, even when they’re apparently going well, I feel I am living on the razor’s edge between success and failure, adulation and humiliation—between justifying my existence and revealing my unworthiness to be alive.
People are not disturbed by things but by the view they take of them.
—EPICTETUS, “ON ANXIETY” (FIRST CENTURY A.D.)
Why does my body betray me in these situations?
Performance anxiety is not some ethereal feeling but rather a vivid mental state with concrete physical aspects that are measurable in a laboratory: accelerated heart rate, heart palpitations, increased levels of epinephrine and norepinephrine in the bloodstream, decreased gastric motility, and elevated blood pressure. Almost everyone experiences a measurable autonomic nervous response while performing in public: most people register a two- to threefold increase in the level of norepinephrine in their bloodstream at the beginning of a lecture, a rush of adrenaline that can improve performance—but in social phobics this autonomic response tends to be more acute, and it translates into debilitating physical symptoms and emotional distress. Studies at the University of Wisconsin have found that in the run-up to a speech, socially anxious individuals show high activation of their right cerebral hemispheres, which seems to interfere with both their logical processing and their verbal abilities—the sort of brain freeze that young Gandhi experienced in the courtroom. The experience of struggling to think or speak clearly in moments of social stress has clear biological substrates.
My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind Page 13