Most of us are shy to some degree, but acute shyness is one of the most under-recognised mental health problems of the modern age, say some. So when is being shy an illness?
By Anna Buckley
BBC News Magazine
Walking down a busy high street with your cheeks painted like a clown isn't normal behaviour for most people. But it's precisely what is being prescribed for one group of people who desperately want to feel more normal.
People suffering from acute social embarrassment are encouraged to wear ridiculous amounts of blusher in public as part of their treatment at one hospital. It's an unlikely cure for a condition called social phobia.
The problem was first recognised as a mental health condition in 1980 and some professionals believe it's one of the most under-recognised and under-treated mental health problems of the modern age.
People can hide acute shyness
Others are uneasy about such statements, saying shyness is behaviour that falls within the normal part of human experience.
So when does shyness become a mental health problem? Social phobia is basically a fear, says the Royal College of Psychiatrists. The fear of social situations can be all-consuming and can even include contact with a person's immediate family. Sufferers describe the condition as "soul destroying".
Symptoms can sound less alarming than other mental health problems and are often perceived as less serious. But at its most serious social phobia can be debilitating and distressing, leaving people unable to carry out even the most normal daily activities.
Even something as simple as buying a newspaper can entirely obsess sufferer James. He gets anxious about what to say to the person serving him and then agonises afterwards about what he did or didn't say.
"People with social phobia tend to think that everyone can see they're anxious and embarrassed which in turn makes them feel even more anxious and embarrassed, but this is a rather exaggerated belief," says psychologist Professor David Clark.
A big problem with the condition is that it often goes undiagnosed.
"Social phobia is tragic and the tragedy is that it's relatively easily treated but most people don't get treatment," says Professor Ronald Kessler from Harvard Medical School.
"As a humane society we really should be thinking a lot more about it than we do."
Only 5% to 10% of people with social phobia in the UK currently get treatment for it, says Prof Clark.
"It's shocking when you consider the long lasting and devastating impact it can have on people and their families."
On top of this, it isn't likely to go away on its own. People are less likely to recover from it naturally than other mental health problems, says Prof Clark.
Studies over the last 12 years show only a third of people with social phobia recover without intervention, compared to a 95% natural recovery rate for depression and an 80% rate for panic disorders.
The condition can impact on every area of a sufferer's life.
"It's heartbreaking, it's so lonely," says sufferer Jayne. "Just being around people is horrible and when that includes your own family it's soul destroying."
It can influence people's decisions from an early age and sufferers often choose jobs which minimise their social contact, even if they would rather do something else.
"People with social phobia are much more likely to drop out of school early, because as soon as they can escape the crowded classroom they do," says Prof Kessler. "They're also much less likely to get promoted at work."
SOCIAL PHOBIA FACTS
It can be general or specific
Physical symptoms include heart palpations and shaking
Women are more likely to suffer it than men
Source: Royal College of Psychiatrists
The condition often results in alcohol and drug addiction later in life, as sufferers use excessive amounts of both to control their fears. They can also end up acutely depressed by their sense of isolation.
But while some health care professionals argue the condition is under-recognised, others worry the problem is psychiatry itself - labelling people who are just plain shy as having a mental illness.
"Social phobia is yet another example of normal behaviour being re-branded as an illness," says English professor Christopher Lane, author of Shyness: How Normal Behaviour Became a Sickness.
Professionals are also often at odds over how many people have it. The Royal College of Psychiatrists puts it at up to 2% of men and 3% of women in the UK. Some studies say 7% to 15% of people will be affected at some stage of their lifetime, but this includes those at the mildest end of the spectrum.
Prof Kessler estimates that 4% to 8% of people in the UK will suffer chronic anxiety at some time, while Prof Lane puts it at 1% to 2%.
Another battle is over how social phobia is described and treated. Pharmaceutical companies with big advertising budgets are keen to raise awareness of the condition and supply anti-depressants as a solution. But some remain unconvinced that powerful drugs should be used to treat shyness.
"For as long as social phobia is seen as medical problem people will favour a pharmaceutical treatment," says Prof Lane.
Children can have social phobia
The drug companies argue that playing down the disease and its impact does a huge disservice to patients and their families.
Randomised control trials show that while both anti-depressants and cognitive behavioural therapy (CBT) can help people with social phobia, therapy is more effective than medication in the longer term.
Which is why treatments such as going out looking like a clown have been developed. This method is part of a CBT programme specifically designed at Maudsley Hospital in London for people with social phobia.
Proving to these people they are not constantly being watched, no matter how ridiculous they look, is a powerful way of helping them to feel less self-conscious.
For them such methods may be embarrassing but it's a small price to pay if it helps them to overcome a phobia which, to date, has made their life a misery.
Some names have been changed in this article.
Am I normal: Social Phobia will be broadcast on Tuesday, 4 March at 2100 GMT on BBC Radio 4.
Add your comments on this story, using the form below.
Social Phobia has destroyed my life. I cannot stand meeting new people and walking into a room full of people causes me to almost have a breakdown. I have NEVER, EVER felt comfortable in any group and never feel like I fit in anywhere. It causes you to hate yourself. Your mind becomes blank and you panic if someone asks you a question. I wouldn't personally take drugs for it.
Have suffered from it all my life. I mostly get affected in larger social groups or discussions. One on one chats are fine, but more than three people in the group and I tend to freak out. It's news to me that it is "easily treated" though. As far as I am aware there is no treatment other than counselling. Anti-depressants certainly don't help with this condition, and if anything just make it worse.
I'd say I have social phobia but I don't consider myself to be ill - just at one extreme end of the confidence range. I'm far too shy to ever ask for help, even though my life is severely (self-)limited. I'd never go out with painted red cheeks in a million years. I can't be "cured" because I'm not ill, this is just the way I am and I'm no more "defective" or "ill" than the loud, confident extroverts at the other end of the spectrum.
Anon, Romney Marsh
I have suffered with social phobia for 10 years now. I can understand arguments for and against classifying social phobia as either a mental illness or as simply "the way" some people are, however this is not the fundammental issue. For those who suffer from this condition it can be completely disabling and a very real obstacle to living any kind of normal life. Similarly a cure is not as easy as either a pharmacuetical or psychological therapy approach. The sad and ironic fact is that the public medical services, from your registered GP to a department of psychiatry or psychology at a local NHS Trust requires that a patient present themselves for treatment. This is possibly one of the hardest things a person suffering with Social Phobia can be asked to do, as in itself it brings intense personal focus onto one's self, which is the last thing that most people with Social Phobia want to do. It is akin to asking a man with two broken legs to run to his local A&E department.
Richard Pearce, Lincoln UK
This is a problem i've had for many years. First time i've heard it given a name other than shyness or anxiety. I'm 67 now and have grown to live with it. I'm a bachelor, I discovered drink helped me to cope or handle social situations when in my 20s, it still helps now.
Bryan, Washington: UK
The world's gone mad - or at least Britain has. Every week there is a new "disorder" labelled and it sends more and more Daily Mail reading, ambulance chasing, paranoid hypochondriacs running to their over worked GPs. There is a spectrum of "shyness" in which we all must fit. We should encourage people to work on their confidence rather than to hide behind a label and blame that for their lack of social contact.
Jon Prew, Birmingham
Here we go again. Yes, shyness can be a problem in extreme cases, but shy people like myself have to learn to deal with it. This may not be easy but if they don't, they will not have a very happy life.
This is not an illness, just a state of being. Everyone has frailties of one kind or another and just get on with it.
I can see this will end up. Shyness will be catagorised as a disability and I can give up work and live off benefits for the rest of my life. Sounds good to me, bring it on!
Shyness and social phobia are in fact two separate problems. Shy people usually have no problem attending social events, but find it hard to engage with people one-on-one. Social phobics are often fine in one-on-one situations, but are afraid of social events.
Matthew Wintergreen, Coventry
I'm 21 years old and am now a fairly outgoing person who will chat to anyone. However in my early years at senior school between the ages of 13 and16 I somehow changed. I now believe it to be social phobia. I found it very difficult to talk to most people and if anyone asked me a question I would just go red and get really anxious and embarrassed, even if I knew the answer. Thinking that everyone was watching me go red would make me worse and I would actually start to panic/fidget and had to somehow make an excuse to get away from the situation. This would happen round my friends, teachers and any other person apart from family. It got to a point where I was scared to say anything and didn't want to be noticed at all. I'm not sure how I did it, but I managed to control my feelings of anxiety. I really had to concentrate and it took a long time, but I think I knew inside me that I had to sort this otherwise it's going to get worse. I now work as a recruitment officer in a
prison and deal with different people everyday. I am a very happy, confident person and I would now consider myself to be fully cured.
I can identify with this. I just didn't know "it" had a name until now. I find social situations intimidating and will go to any length to avoid them. I will drive alone rather than give a lift to a colleague. I've learned to live with it, but it is a very real problem.
I suffered from severe sociaphobia for several years but the cure for me was very good counselling. The debate about whether this is a true illness is irrelevant, the key word is "suffering". To ease another persons suffering should be the aim, not to question their legitimacy.
Mike Reynolds, London
I used to be crippled by shyness but now I teach English (fairly confidently) to dozens of students of all ages and abilities. I began to help myself by challenging myself to do things that were uncomfortable, beginning small. Avoidance of situations only reinforces the shyness. Now, when I'm teaching, I'm often astonished that I'm the same person! I try to maintain an awareness that most of the time people are thinking about how they are coming across and not about me at all, which is a huge relief. My advice to shy people is to show an interest in other people as it takes the emphasis off the self. Being shy is a fantastic tool for developing a good insight into fellow beings and their behaviours. The more introspective and self questioning the individual, the better they are equipped to be compassionate and sensitive to others in the long term, furthermore your understanding of the vulnerablity that some people are just doing a better job of hiding affords you a deeper insight and a more authentic confidence.
My wife developed this condition after post-natal depression. No social life left her marginalised and friendless. Feelings of inadequacy and "oh they won't want to see me, you go" became the norm following an invitation from friends. The condition remains although I had to leave, much to my regret, guilt and sadness.
Phil Weatherley, Bournemouth
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