Anxiety: A Very Short Introduction - Daniel Freeman, Jason Freeman 2012
The psychology of social phobia
When it comes to understanding the psychological processes involved in producing and maintaining the disorder, however, the picture is much clearer.
The most influential model of these processes was developed in the 1990s by the UK clinical psychologists David Clark and Adrian Wells. We’ll illustrate it using a fictional case study.
Alice is a thirty-year-old copywriter in an advertising agency. She is required to give regular presentations of her work to colleagues and clients. Alice has never enjoyed this aspect of her role, but over the last couple of years her anxiety has increased to such an intensity that she wonders whether she may have to switch careers. Sure that she is going to make a fool of herself, she can’t sleep the night before a presentation. Alice is tempted to avoid the situation entirely by phoning in sick. During the presentation itself, all she can think about is how awful she feels, and how ridiculous she must look to her audience. If anyone compliments her on the presentation, she presumes their praise is motivated by irony or, even worse, pity.
Let’s explore Alice’s social phobia using the Clark and Wells model. Although she is unaware of them, Alice has carried with her since adolescence a number of unhelpful assumptions about herself and other people. These assumptions developed after Alice had moved to a new school where she found it difficult to make friends. She desperately wants to create a good impression, but deep down — and despite all evidence to the contrary — believes she is unattractive and inarticulate.
Not only does Alice underrate her own qualities, she exaggerates those of the people she meets, presuming that they possess all the confidence and ability she feels she lacks. And she expects other people to notice — and remember — even the smallest problem in her performance. Only perfection will do.
Almost everyone experiences a degree of nervousness when giving a presentation, but Alice’s unconscious assumptions mean that the situation seems much more threatening to her than it really is. She has been worrying about the presentation for days. Now the moment has arrived, the danger of making a fool of herself seems greater than ever. Negative automatic thoughts flood her mind: ’I can’t do this. I have to get out of here. I feel sick. Everyone knows I’m a fraud.’ Predictably, her anxiety skyrockets.
This anxiety manifests itself in three ways.
First are physiological symptoms: sweating, blushing, trembling, difficulty concentrating. Alice is quick to notice these bodily changes. Rather than accepting them as normal in stressful situations, she worries that her anxiety is spiralling out of control and that it will be evident to her audience — which only increases her anxiety.
Alice’s worry about the physical signs of anxiety, and her acute sensitivity to them, is typical of people with social phobia. In fact, researchers have found that merely telling someone that they are undergoing an intense physiological reaction — even if it is untrue — can have a profound effect on the person’s thinking. In one study, students were asked to have a conversation with a stranger. Those who were led to believe that a sensor had detected blushing, trembling, sweating, and an increase in their heart rate reported feeling more anxious, claimed to have experienced more physical signs of that anxiety, and believed that they’d made a worse impression than those who hadn’t been given such information. They behaved, in other words, like people with social phobia.
Next, and crucially, Alice finds herself imagining how she must look to her audience. She sees a babbling, trembling, incoherent wreck. Not only does the image bear no relation to reality, it’s so vivid that she doesn’t check to see how her audience is actually responding. Instead she looks inwards for an indication of how things are going.
People with social phobia are much more likely than other people to experience images in social situations, and those images are both more negative and more likely to be from an observer’s viewpoint. Research has shown that simply asking people to think of a negative rather than positive self-image leads to greater anxiety — both felt by the individual and evident to an observer. It also causes people to believe they’ve performed poorly in a social situation.
Finally, Alice adopts a number of safety behaviours — actions she believes will help her get through her ordeal (see p. 26). She overlearns her speech; quickens her presentation of it; avoids looking at her audience; and tries to think of happy times, such as her recent holiday.
But, in fact, these strategies don’t help Alice. Like all safety behaviours, they prevent her from discovering that her anxiety is excessive: when she successfully makes it through to the end of the presentation, Alice credits her safety behaviours rather than her own ability to tackle a stressful task. Moreover, these behaviours — just like the self-images and physical symptoms of anxiety — pull her attention inwards and away from the task in hand, potentially hampering her performance. And they can be noticed by her audience. For all her distraction, Alice’s ability to spot a quizzical look or wandering attention is razor-sharp. And when she does, her anxiety ratchets up yet another notch.
(Interestingly, the idea that people with social phobia are hypersensitive to criticism has been confirmed by neurological studies. When researchers ask individuals to read negative remarks about themselves, those with social phobia — but not those without — show significantly increased levels of activity in the amygdala, the brain’s ’emotional computer’ (see p. 30), and in the medial prefrontal cortex, which plays a crucial role in thinking about the self.)
Alice’s anxiety doesn’t diminish much at the end of her presentation. Because, just like so many people with social phobia, she endlessly mulls over her performance (Clark and Wells call this a ’postmortem’). And the more she dwells on the presentation, the worse she feels it was — and the more intensely she fears the next one.
The Clark and Wells model is often reproduced in textbooks as a sort of flow diagram. In fact, it might equally well be represented as a series of vicious circles, each of them both triggering and increasing the person’s anxiety. With therapy, the cycle of social phobia can be broken. Left untreated, it can feel like being trapped within the gears of an unrelenting and remorseless machine.