Recent Article in Irish Independent – by Shane Cochrane (12 August 2013)

AT A TIME when most of her peers were enjoying their first taste of independence, Laura was a prisoner.

“I lived in college accommodation with other students who loved to go out every night – drinking and partying. I hardly ever came out of my room, and when I did I was really scared of being asked to go out with them. I was so lonely and yet I was making excuses.

“I remember being asked to go to a barbecue on St Patrick’s Day. I told them I was going home. But really I stayed in bed all day crying. I was too scared to join them.”

Laura’s housemates had done nothing to make her fear them. They were just new people in a new environment, something that terrified Laura – and had done since childhood.

“In secondary school, I either spent my time in school among my friends where I felt safe, or at home on my own. I was fine until people started inviting me to places outside of school.

“I remember being at a friend’s birthday; her twin brother was there and I completely retreated into myself. Everyone was asking me if I was okay. No, I was not! But I didn’t know how to explain what was happening to me.”

When she was 19, Laura was diagnosed as having social anxiety disorder, a condition that is often perceived as an extreme form of shyness.

“At the core of social anxiety is a fear of being judged negatively and a fear of behaving in a manner that will lead to embarrassment, humiliation and ultimately rejection from others,” says Dr Alberto Blanco-Campal, Senior Clinical Psychologist at the Ladywell Centre, Louth County Hospital.

“While people with social anxiety have a strong desire to make a good impression on others and be liked and accepted, they hold very negative and rigid beliefs about their ability to achieve this. The crucial thing is that in most instances these negative beliefs are very out of line with the way things really are.”

Social anxiety disorder (SAD) was first recognised in 1980, and it’s believed that it affects up to 13pc of the population. The symptoms typically appear between the ages of 10 and 13. Left untreated, the disorder can cause other psychological conditions, such as depression, and can lead to substance and alcohol abuse.

In fact, it’s believed that much of the alcohol dependence in Ireland may be linked to social anxiety disorder. But, despite the severity of the symptoms, many sufferers wait years before seeking help.

According to research by Dr Kristy Dalrymple, a psychiatrist at Rhode IslandHospital in the United States, those with SAD endure their disabling symptoms for an average of four years before seeking help. She identifies two main reasons for this.

‘Due to the nature of the disorder, such individuals may wish to continue to avoid the anxiety rather than face it.

“As a result, these individuals may be less likely to seek treatment at all or less likely to voice these concerns to health professionals, thereby decreasing the likelihood that SAD would be detected.

“Owing to the early onset and chronicity of SAD, many individuals may also believe that these symptoms are part of their personality and therefore cannot be changed.”

Seeking help is just the first step; unfortunately, the symptoms of social anxiety disorder are not always recognised by GPs. Poor awareness of the condition may be partly to blame, but there are other factors that make diagnosing SAD difficult for doctors.

Odhran McCarthy is a senior clinical psychologist at Dublin’s Mater Hospital.

“Some patients find it difficult to accurately describe their symptoms. We also find that some patients focus on a secondary condition, such as depression. In these cases, depression is diagnosed and not the underlying social anxiety disorder.”

Without treatment, according to Dr Blanco-Campal, SAD “tends to run a chronic and unremitting course”. It won’t go away.

Laura describes her life with the disorder.

“I spend most of my time on my own. I have very few friends and I don’t go out very often. I drive because I hate public transport. I will not answer the phone unless I know who is calling.

“I often walk into a shop and if I cannot find what I’m looking for I’ll walk back out without asking for help. I’d rather leave without what I came for than ask the cashier. Small shops are worse; you get stared at.”

Not all social situations can be avoided, however. For events that must be endured, SAD sufferers develop what are known as safety seeking behaviours.

“This may take the form of rehearsing what they are going to say, avoiding eye contact, wearing excessive make-up to conceal blushing, talking very fast or pretending they are on the phone,” says Alberto.

While SAD sufferers may depend on these behaviours to help them cope with difficult social situations, Dr Blanco-Campal believes they may actually exacerbate the problem.

“The thing is that, far from being helpful, these safety-seeking behaviours perpetuate the problem by preventing the person from finding out that their negative predictions are very out of line with how things really are.”

Despite decades of research, no definitive cause for social anxiety disorder has been found. However, a number of consistent factors have been identified.

“Genetics play a modest but significant role in the development of social anxiety. Environmental factors are also important, such as the parent/child interaction,” says Dr Blanco-Campal. “Other critical experiences in the formative years, such as bullying, may also contribute to the development of social anxiety.”

For Laura, it seems that a combination of these factors was behind her experiences.

“A lot of it has to do with my upbringing, as well as being bullied in primary school by teachers. I’m dyslexic and it sometimes took me longer to grasp things.

“I was taunted by people I was told to trust,” she says. “When you hear words such as ‘you’re stupid,’ or ‘you’re an idiot,’ you believe them, and they become you.”

According to research by Golda Ginsburg at Johns Hopkins Children’s Centre, those at greatest risk of developing the disorder are the children of parents with social anxiety disorder.

She found that 65pc of children living with a parent with SAD already had the symptoms of an anxiety disorder. She believes that it’s how the parent interacts with their child that is behind this. Parents with SAD display a lack of warmth and affection for their children, and can be overly critical.

Given the potential long-term and far-reaching effects of the disorder, it’s important that it’s treated as early as possible. And it is treatable. Dr Blanco-Campal explains how to get help.

“The first thing to do is talk to your GP. Tell him or her that you always have to be at your best performance. Explain that you avoid social situations, or that you endure social situations.”

A number of different treatments are available for SAD, but cognitive behavioural therapy (CBT) appears to be very effective at providing long-term relief.

“CBT is not the only treatment, and it may not work for everyone, but it’s proven to be most effective,” says Alberto. “It’s the best validated treatment, with many studies supporting its efficacy.

“CBT helps the individual identify their unhelpful ways of thinking and behaving, and it helps the individual replace them with more helpful and realistic beliefs.”

Odhran McCarthy also uses CBT in his group treatment programme at the Mater Hospital. Given their aversion to social situations, getting SAD sufferers into group therapy can be a big ask, but it’s proving to be one of the most effective ways to treat the disorder.

It’s important to note that there is no magic fix for SAD. CBT takes effort and time; and some may need longer to see the benefits.

“Those who take longer to recover are those who have had the disorder longer, or those for whom the disorder has had a big impact on their lives. But they can still get to where they need to be,” says Odhran.

Laura has suffered with social anxiety disorder from childhood, and it has had a big impact on her life. She’s not cured – but she’s getting there. “I was 19 when I was diagnosed with social anxiety, and I can honestly say that my life has changed so much since then.

“I work in healthcare and that is the biggest joy in my life. I love helping people. I love being able to put a smile on someone’s face and – somehow – when I’m in my caring role, I have very little anxiety.”