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Hello Dr. Robert!

First off, I would like to thank you for the great work you have been doing through your website.

I am 18 years old on my way to med school in Stockholm.

However there is one issue that has been slightly bothering me for quite a while now. I have always noticed that I tend to get very nervous in specific types of circumstances. For example I get very nervous when I am in public areas where there is a large amount of people. I have also realized that I think too much about what other people may or may not think about me to the point where I get nervous and anxious. This is specially irritating when for example I make a mistake in front of the class room and feel tormented and nervous later on. Most of the time  I feel like everything revolves around me that I am the centre of attention when as a matter of fact I am a simple person just the same as everyone else. I know that I should not feel like I am better or more special than everybody else but I just can't help it. As a child my parents used to praise me which boosted my self confidence a lot. I am not really sure if that has a direct correlation with my current situation.

 Your thoughts on this would be extremely helpful



ask dr-robert

Hello, K.A.--

Thanks for your kind comment about the website.

Social anxiety (which sometimes is called social phobia) is a common problem—in fact, it is one of the most frequent complaints which bring people into psychotherapy. According to Richards (2003), the prevalence of social anxiety which has reached a level serious enough to be considered an emotional disorder--what used to be called a neurosis—is somewhere between two and seven percent of the adult population of the U.S.

Now feeling nervous in certain social situations such as having to make a public presentation, or going out on a first date is normal, but when everyday situations produce a level of anxiety or ill-ease which interferes with normal functioning, then such anxiety has risen to the point of demanding diagnosis and treatment. The Diagnostic and Statistical Manual (DSM), which is a handbook of diagnostic categories used widely by psychiatrists and psychologists, has defined a set of diagnostic criteria for Social Anxiety Disorder (SAD) which include the following:

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I cannot judge from your brief letter if you meet these criteria or not. However, the teenage years are the usual time for the onset of social anxiety disorder, so you should consider them carefully to see if they apply. If they do seem descriptive of your experience, I would suggest getting some counseling help as soon as possible since anxiety disorders have a tendency to worsen with time if untreated.

Social Anxiety Disorder has both cognitive aspects and behavioral aspects as well, meaning that the sufferer is troubled by his or her own thoughts (such as believing, incorrectly, that you are always a center of attention), and also manifests behaviors which are abnormal and counterproductive, interfering with the freedom to function satisfactorily in ordinary life. One common behavioral aspect of SAD might occur in your case if your nervousness in crowded public areas caused you to avoid such places. This, you see, would hamper your ability to move freely through the world. If this avoidance went too far, you might then have to struggle not only with social anxiety, but also with agoraphobia, which is a fear and avoidance of public areas that sometimes becomes severe enough so that the sufferer cannot bear to leave home at all. I understand that your social anxiety has not developed into this kind of problem yet, but this is another reason why I suggest a professional evaluation and possible treatment. It is much easier to treat these kinds of problems before they become incapacitating.

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You mentioned having been praised lavishly by your parents. Sometimes too much praise can lead to narcissistic problems which might be one basis for the development of social anxiety—particularly the feature of feeling always the center of attention, or of being judged by others.

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Many parents believe that they are doing their children a favor when they offer a lot of praise, but this can go too far. After all, praise is a form of judgment (albeit seemingly a positive one), and if one can be judged positively, one can also be judged negatively. Not only does too much praise habituate the child to expect attention and judgment instead of simply being as he or she is, but this parentally cultivated need to be praised (to be a center of attention and comment) carries within itself a fear of not getting enough praise, or even of getting its opposite: harsh criticism. One can see easily how this fear could lead to social anxiety ("Am I doing the wrong thing? What will people think of me?"). Before the letters start arriving, please understand that I am not saying that parents should never praise their children, only that this should be done in a measured way, a realistic way, which will help to transform the child's innate narcissism into a healthy self-regard that will work well in the adult environment.

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Another possible factor in the development of SAD is genetic background. Studies of identical twins raised in different families show that, if one twin developed social anxiety disorder, then the other was between thirty and fifty percent more likely than average to develop the disorder too. This suggests that a factor other than the parental environment and other early experiences must be influential in the development of social anxiety. Other studies have followed people who as infants showed marked introversion or a fearful nature (probably present from birth), and these studies have shown that such infants are more likely than average to develop SAD later in life. Other possible factors may be having experienced a particularly embarrassing event—such as, for example, a total meltdown when called upon to speak in public—or having learned social avoidance from parents by imitation of their unease in social situations.

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Your mentioning Stockholm is suggestive too since SAD is more common in Scandinavia than in warmer, more southern countries, which has led to the hypothesis that the relative lack of easy interpersonal contact in winter months may favor the development of SAD.

As I said, you should think about getting some personalized psychotherapeutic help with this problem. In the meantime, I would suggest avoiding drugs and alcohol if you use any of those substances, since the period of withdrawal from them may exacerbate any symptoms of SAD.

Thanks for writing.

Be Well.

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