Jim was a nice looking man in his mid-30’s. He could trace his shyness to boyhood and his social anxiety to his teenage years. He had married a girl he knew well from high school and had almost no other dating history. He and his wife, Lesley, had three children, two girls and a boy.
At our first meeting, Jim was very shy and averted his eyes from me, but he did shake hands, respond, and smile a genuine smile. A few minutes into our session and Jim was noticeably more relaxed. "I’ve suffered with this anxiety for as long as I can remember", he said. "Even in school, I was backward and didn’t know what to say. After I got married, my wife started taking over all of the daily, family responsibilities and I was more than glad to let her."
If there was an appointment to be made, Lesley made it. If there was a parent-teacher conference to go to, Lesley went to it. If Jim had something coming up, Lesley would make all the social arrangements. Even when the family ordered takeout food, it was Lesley who made the call. Jim was simply too afraid and shy.
Indeed, because of his wife, Jim was able to avoid almost all social responsibility -- except at his job. It was his job and its responsibilities that brought Jim into treatment.
Years earlier, Jim had worked at a small, locally-owned record and tape store, where he knew the owner and felt a part of the family. The business was slow and manageable and he never found himself on display in front of lines of people. Several years previously, however, the owner had sold his business to a national record chain, and Jim found himself a lower mid-range manager in a national corporation, a position he did not enjoy.
"When I have to call people up to tell them that their order is in," he said, "I know my voice is going to be weak and break, and I will be unable to get my words out. I’ll stumble around and choke up....then I’ll blurt out the rest of my message so fast I’m afraid they won’t understand me. Sometimes I have to repeat myself and that is excruciatingly embarrassing........"
Jim felt great humiliation and embarrassment about this afterwards: he couldn’t even make a telephone call to a stranger without getting extremely anxious and giving himself away. That was pretty bad! Then he would beat himself up. What was wrong with him? Why was he so timid and scared? No one else seemed to be like he was. He simply must be crazy! After a day full of this pressure, anxiety and negative thinking, Jim would leave work feeling fatigued, tired, and defeated.
Meanwhile, his wife, being naturally sociable and vocal, continually enabled Jim not to have to deal with any social situations. In restaurants, his wife always ordered. At home, she answered the telephone and made all the calls out. He would tell her things that needed to be done and she would do them.
He had no friends of his own, except for the couples his wife knew from her work. At times when he felt he simply had to go to these social events, Jim was very ill-at-ease, never knew what to say, and felt the silences that occurred in conversation were his fault for being so backward. He knew he made everyone else uncomfortable and ill-at-ease.
Of course, the worst part of all was the anticipatory anxiety Jim felt ahead of time – when he knew he had to perform, do something in public, or even make phone calls from work. The more time he had to worry and stew about these situations, the more anxious, fearful and uncomfortable he felt.
REMARKS: Jim presented a very typical case of generalized social phobia/social anxiety. His strong anticipation and belief that he wouldn’t do well at social interactions and in social events became a self-fulfilling prophecy, and his belief came true: he didn’t do well. The more nervous and anxious he got over a situation, and the more attention he paid to it, the more he could not perform well. This was a very negative paradox or "vicious cycle" that all people with social anxiety get stuck in. If your beliefs are strong that you will NOT do well, then it is likely you will not do well. Therefore, thoughts, beliefs, and emotions need to be changed.
The depression (technically "dysthymia") that comes about after the anxious event continued to fuel the fire. "I’ll never be able to deal with this," Jim would tell himself, thus constantly reinforcing the fact that he saw himself as a failure and a loser.
Unusual in this situation is that Jim’s wife remained loyal to him, understood his problem to some extent, and even seemed to enjoy her role as the family’s "social director". The more and more she did for Jim, the more and more he could avoid. It got so bad that Jim, who loved to listen to new albums and read new books -- could not even go to stores or to the library. He would tell his wife what to buy and she would buy it. She even kept track of when the library books were due and made sure she took them back on time.
This family situation is unusual because most people with social anxiety/social phobia have an extremely difficult time making and continuing personal relationships -- because of self-consciousness and the need for more privacy than most other people. In fact, social phobia ranks among one of the highest psychological disorders when it comes to failed relationships, divorce, and living alone.
TREATMENT for Jim consisted of the normal course of cognitive strategies so that he would relearn and rethink what he was doing to himself. He was cooperative from the beginning, and progressed nicely doing therapy. He took each of the practice handouts and spent time each day practicing. He made a "special time" for himself that his family respected and he used this place and time to practice the cognitive strategies his mind had to learn.
His biggest real-life fear, speaking to another person in public, was not really a speaking problem; it was an anxiety problem. There was nothing wrong with Jim’s voice, his reading ability, or his speaking ability. Jim was a bright man who had associated great anxiety around these social events in public situations.
The course of treatment here is NOT to practice! In fact, practicing would just draw attention to what Jim perceived was the problem: his voice, his awkwardness, his perceived inability to speak to others. Thus, it would reinforce the very behaviors we do not want to reinforce.
Instead, Jim worked on paradoxes. We deliberately goofed-up. We tried to make as many mistakes as possible. We injected humor into the situation and found that when he exaggerated his fears, he thought this was funny. Although more is involved than just this, the concept here is to de-stress the situation and enable the person to see it for what it is: NO BIG DEAL! If you make a mistake, SO WHAT? Everyone else does too!
Over the weeks, before group therapy began, Jim did a number of interesting things in public that began proving to him that he was NOT the center of attention, and it just didn’t matter if he made a mistake or two. After all, he was human just like everyone else. It’s this idea of perfectionism, of always having to "do your best" that must be broken down. Jim was human; humans make mistakes; so what? It was certainly nothing to get upset about. In fact, as time went by, it become even more funny and humorous, rather than humiliating or embarrassing.
After completion of the behavioral group therapy, Jim had an opportunity for advancement in his company, which he now felt comfortable to take. The promotion entailed holding weekly meetings in which he was in charge. He would have to do some public speaking and respond to his employees’ questions. By this time, Jim was feeling much more comfortable and much less anxious about the whole situation. "I think I’ll deliberately goof up," he joked to me before the start of his new job. "It would be interesting to see how everyone else responds."
To say that Jim did not have any anticipatory anxiety before taking this position or before making his weekly presentations would be inaccurate. The difference was now they were manageable. They were simply minor roadblocks that could be overcome. Jim’s thinking about social events and activities had changed a great deal since the first day I saw him in therapy.
I talked to Jim a few months ago and everything was going well. His responsibilities at work had increased slightly, but Jim now had the ability and beliefs to deal with them. He was much more confident and had a feeling of being in control. He was doing more around the house and his wife was a little surprised at his metamorphosis. Luckily, this did not change the marriage dynamics adversely, and the last time I talked with him, Jim had become a father again: another little boy.
"He’s the last," Jim said, laughing over the phone, "I can’t get too distracted. I’ve got too many speeches to give now."
definition of panic attacks. “A discrete period of intense fear or discomfort, starting
abruptly and reaching a peak within 10 minutes. May experience symptoms of palpitations, sweating, shaking or trembling, chest pain/discomfort, nausea, abdominal distress, dizziness, faintness, feeling unreal or detached from oneself,
fear or “going crazy” or losing control, fear of dyin
g, parethesias, chills or hot flashes, and sensation of shortn
ess of breathing or smothering”
(Varcarolis, 2011 p. 110). The admitting doctor ruled out everything physical which lead him to believe that there was something psychologically wrong. According to the DSM IV a patient needs four or more symptoms from the above list to receive this diagnosis (Mathyssek, 2012, p.1). G.G. had seven of the symptoms necessary to diagnose a person with panic attacks. One symptom G.G. is particularly concerned with is his difficultly remembering information. When a person is under severe stress it causes an increased production of glucocorticoids. If a person remains under stress for a period of time the glucocorticoids can cause structural damage to the hippocampus, which is responsible for memory (Peavy, 2009). G.G. had admitted to being under stress for a while now, which could have lead to some hippocampus damage and ultimately to why he is having trouble with his memory. G.G. is curious as to what caused him to have these panic attacks. As a nurse it is important to explain the different risk factors and triggers that made him more susceptible to panic attacks. It may also be pertinent to explain the different neurotransmitters and hormones that could be off balance because it could help him understand why he will take certain medications.