Challenging 'Extreme' Shyness

It starts out just fine. You get invited to a party. You plan what you're going to wear, dream about whom you might meet. Then the big night arrives and, wham, the excitement sputters into nervousness. You stand around awkwardly, nurse a drink and ogle the chatty people around you. You feel shy.

You're not as alone as you think. Just about everyone is timid at some point, and plenty of people--almost half the population--qualify as shy most of the time. But what if every human encounter made you blush, tremble or perspire? What if your mind whirred incessantly with self-doubt ("I'm so stupid," "I sound like a moron")? What if an obsession about what others were thinking kept you from keeping a job, even getting married? You may be suffering from social anxiety disorder, a diagnosable mental-health condition.

Most Americans, and even many doctors, have never heard of social anxiety disorder, yet it affects more than 5 million Americans, according to the National Institute of Mental Health. Drug companies, eager to expand their markets, are now spotlighting the disorder--and advertising medications to treat it. This spring, Miami Dolphins running back Ricky Williams, diagnosed in 2001 and treated with the anti-depressant Paxil, kicked off a nationwide awareness campaign, funded by manufacturer GlaxoSmithKline. In the quick-fix society we live in, it's hard not to be skeptical: is inhibition a certifiable psychological problem? For clinicians who treat the problem, the answer is yes. "We see people whose lives have been trashed because of social anxiety disorder," says Richard Heimberg, head of the Adult Anxiety Clinic at Philadelphia's Temple University. "It's a horrid part of their existence."

Social anxiety disorder is more than just a bad case of shyness. Intense and unremitting, it can make people feel worthless and powerless to move forward in their lives. Like almost every other human condition, the disorder appears to be triggered by a complex mix of genes (it runs in families) and environment, which could include growing up with anxious parents or relentless teasing by classmates--no one knows for sure. Technology is now helping to pinpoint changes in socially anxious brains. Using MRI scans, Dr. Murray Stein, of the University of California, San Diego, found that when people with the disorder are shown pictures of angry faces, their amygdala--the brain's fear center--lights up with more activity than it does in people without the condition. Now Stein is looking deeper to see if the amygdala itself is overreacting or if the problem starts even earlier in the processing of fear.

Brain circuitry matters little to Jonathan Wonnell, 34, who has spent much of his life avoiding social interaction. Quiet as a child, Wonnell isolated himself in high school--dating was out of the question. When his sisters threw a surprise birthday party for him, he froze in fear, incapable of enjoying the fun. "It was horrible," he says. Socializing still sets off a flurry of symptoms: his chest gets tight, he shifts his weight back and forth, he worries profoundly about being judged. "Inside, I'm just burning with anxiety," he says. Cognitive-behavioral therapy has been proved to help sufferers battle their demons--and it's helping Wonnell come out of his shell. In group meetings, participants speak in front of others, then talk about what they feared ("Everybody saw me blush") versus reality ("Nobody noticed"). Therapists ask patients to do homework in the real world, too, like asking someone out on a date. "People with social anxiety disorder have distorted thinking," says Jerilyn Ross, head of the Anxiety Disorders Association of America. "We're challenging their worst fears."

Medications are helping some patients as well. Earlier this year, two antidepressants, Effexor and Zoloft, were approved for social anxiety disorder, joining Paxil, which hit the market in 1999. Other drugs, including Lexapro, may follow. Unlike therapy, though, relapse can be an issue once treatment stops. And the pills raise a critical question: could medicating social anxiety disorder lead to pathologizing normal shyness? "In an extroverted and drug-happy culture," says Wellesley College psychologist Jonathan Cheek, "the drugs are falling into fertile fields."

For now, though, specialists are more focused on getting help to those who need it. Social anxiety disorder, destructive on its own, can lead to depression and substance abuse. The key is to seek out and treat those who truly suffer--and let shy people enrich the world just as they are.