Social anxiety disorder may be the most common phobia you've never heard of.
Franklin Schneier, a Columbia University psychiatrist who specializes in research on social anxiety, said it represents the extreme end of shyness, and is so debilitating that people who suffer from it often can't stay in school, hold down a job or form a meaningful relationship.
Social anxiety disorder affects about 6 percent of the U.S. population at some point in their lives, he said, or more than 17 million people, and because its main feature is severe worry over dealing with other people, that in itself can make it hard for sufferers to seek help.
But there is help available, he said, particularly in the form of cognitive behavioral therapy, or CBT, which can help people change their negative thoughts about themselves and what will happen to them in social situations.
In the case of social anxiety, the "B" in CBT is crucial -- reshaping people's behavior by getting them to undertake social homework assignments, whether it's attending a party or giving a public speech.
"People have got to put themselves in these situations," Dr. Schneier said. "Otherwise, you see people who have been in talk therapy for years and they haven't made any progress."
As with other phobias, the optimal therapy is "exposure" -- gradually putting yourself in the very situations that make you anxious. But for social anxiety, the challenge is greater than for many other simpler phobias.
"There is a more cognitive part of [the therapy] than say, treating a fear of dogs, where simply exposing yourself to dogs and realizing they won't bite you can help. In a social situation, you need to understand how your thinking feeds into your fears. Otherwise, you can walk away from it thinking 'What an idiot I was!' or 'That person hated me.' "
If a person is deathly afraid of public speaking, for instance, "he'll think 'I'll make a fool of myself and people will think I'm stupid and my voice will tremble.' "
In cognitive behavioral therapy, "we would try to question this a bit. Often there is a lot of evidence to show their fears are not so realistic. We can also help them develop substitute thoughts, such as the idea that they've got something useful to present to people, or even if they're anxious, they can still get their point across."
Besides cognitive behavior therapy, there is evidence that antidepressants, particularly the type known as SSRIs, also can help with social anxiety, Dr. Schneier said.
It often starts young
Another key feature of social anxiety phobia is that it often starts in late childhood or during the teen years.
Wendy Silverman, a child psychiatry professor at Yale University, has been working with children with anxiety disorders for years.
The dread these children face goes beyond the normal fears and social pangs that most children experience, she said, and starts to interfere with the normal activities of the children and their families.
"If families are not able to get their children to go to school, or the parents have not been able to sleep alone in their bed for a long, long time, that's when anxiety is starting to interfere. We're also concerned when children are not enjoying the things that most children experience joy from, such as playing with friends or being involved in activities outside of school."
She gives children tools to combat their fears that are similar to what Dr. Schneier uses with adults, but are geared to their developmental level.
A favorite intervention is giving them a STOP pen, a red ballpoint whose end is twisted into the familiar octagonal stop-sign shape. It reminds them to "stop" when they begin to experience anxiety and follow the reminders that go with each letter. The "S" stands for recognizing the things in their lives that scare them; the "T" teaches them they have thoughts that go with those feelings; the "O" reminds them they can have other thoughts that are not as frightening; and the "P" lets them remember they can praise themselves when they conquer their fears.
She uses incremental exposure therapy both with parents and children.
If a child has extreme fears at bedtime and he doesn't want to sleep alone, for instance, she will teach a parent to first sit on the edge of the bed, then in a chair in the room, then stand by the door, and then stand outside of the doorway, until gradually he can go to sleep when the parent is out of sight.
When children are too anxious to even go to the playground at recess, she said, the homework sequence for a frightened girl might be to play with a child who is younger, then play with kids her own age, then ask a younger child a question, and then ask an older child a question.
After children have carried out these experiments, she likes to "get them to deconstruct the experience, and usually they learn that what they were worried would happen didn't happen. You can't just tell a child some bad thing won't happen -- you have to go out and get the evidence yourself as a kid and be able to process that."
And tackling these issues early on is vital, she said, because these kinds of intense fears don't go away on their own.
How parents influence
Michael Crowley, a psychologist at Yale who works with her, said parents can sometimes inadvertently contribute to children's fears, especially if they are anxious themselves.
One of the worst things parents can do, he said, is to protect their children from all the situations that scare them.
"To the extent you allow avoidance, which parents often do, the chances of the child recovering from anxiety are going to be less," he said. In fact, children can almost become addicted to avoidance, he said.
"It's rewarding to escape or avoid the things that are distressing; it's called negative reinforcement. If I have a headache, I take an aspirin; if I have an itch, I scratch it. And if I'm an anxious person, I might make an excuse for why I can't give a speech or do some other activity."
If children don't learn how to master their anxiety, it can have serious consequences later in life.
"People then build their lives around avoiding things that make them uncomfortable," Columbia's Dr. Schneier said. "They may choose a career that puts them in a back room and not in the forefront. They may be the helper or confidante rather than the leader, even though they might be more competent than that.
"There is data to show some people with the phobia marry later or don't marry at all, and in a few cases, people are so fearful of having to seek out a new relationship that they cling to a bad one."
Whether the anxiety is afflicting children or adults, the basic approach of facing their fears in successful small steps remains the same.
"What these exposure treatments are doing is showing that you can tolerate this stress," said Wendy Silverman, the Yale psychologist. "If an anxious person goes through treatment, instead of saying, 'Oh no, I'm going to embarrass myself' or 'I'm going to faint,' they say 'This is what always happens and it's uncomfortable but I know nothing bad is going to happen' -- so it encourages a cue to cope rather than to escape."