So You're Feeling Anxious?

One of the challenges of social anxiety is that it feels like you’re the only one experiencing it. But that’s not true. In fact, rates of social anxiety are high and growing in the United States. But Dr. Charissa Chamorro, clinical psychologist and Assistant Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai, explains that there are things you can do to feel better.

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Transcript

Stephen Calabria: [00:00:00] From the Mount Sinai Health System in New York City, this is Road to Resilience, a podcast about facing adversity. I'm your host, Stephen Calabria, Mount Sinai's Director of Podcasting.

On this episode, and with the holidays upon us, we're tackling a subject many of us are all too familiar with: anxiety. To help us understand what anxiety is, what causes it, and how it can be managed, we're joined by Charissa Chamorro, PhD.

Dr. Chamorro is a clinical psychologist and Assistant Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai.

Among other things, she breaks down how social media may contribute to feelings of anxiety and how the holidays present unique challenges to those coping with its effects. We're honored to welcome Dr. Charissa Chamorro to the show.

Dr. Charissa Chamorro, welcome to Road to Resilience. 

Charissa Chamorro: Thank you, Stephen. I'm so excited to be here. 

Stephen Calabria: So how do you define anxiety, specifically Social anxiety disorder?

Charissa Chamorro: [00:01:00] Social anxiety disorder is a mental health condition where a person experiences really intense fear or anxiety about social situations, and it may be talking to a coworker, it may be going to a party.

It could be public speaking, but the fear and the anxiety is so strong and so intense that it leads to impairment or great distress in a person's life.

Stephen Calabria: Is there an evolutionary explanation for anxiety and what separates just normal anxiety from determining that it's a disorder? 

Charissa Chamorro: We know that anxiety has been around forever and it makes sense that there's an evolutionary component to it. And in fact, in my clinical practice and my work with patients, I really love to highlight how there is a protective factor to anxiety.

And even beyond that, there are real benefits to anxiety. Many years ago, this might manifest as people being anxious [00:02:00] about not being able to eat. So then that would motivate them to go out and find food. Or not wanting to be caught by a predator.

But in more modern society, it often shows up for people in terms of being anxious about things that are important. So often, I will emphasize the strengths of anxiety, in that people who have anxiety are often very conscientious.

They're very motivated to do things. They're often very high achieving, and so we can see that there are benefits and evolutionary benefits to anxiety, and so I think it's really important for people to embrace those benefits.

What differentiates anxiety that is beneficial from a disorder is, I'll keep it very simple, really two things. We look for persistence over time and significant distress or impairment. So that means it's getting in the way of your life in some way.

Relationships, achievement, jobs. In some way, it is [00:03:00] getting in the way of your life.

Stephen Calabria: Many people confuse social anxiety with just shyness. There isn't really a clinical term for shyness, but what sets social anxiety disorder apart? 

Charissa Chamorro: Yes, this is a common mix up. We think of shyness as more of a personality trait. Something like temperament. And you might see this even in babies or toddlers, that some little kids are just a little more slow to warm up.

And other kids are out there playing with all the other kids. And so, we do think about shyness as being something that's more innate, persistent over time. But the real key distinguishing factor is that it doesn't cause the person distress.

So a person who is shy may accept that as part of their personality and say that is just part of who they are and it doesn't cause them distress. And they'd rather go to a party and speak to one person in a corner rather than work the room. And that's okay.

So we think of [00:04:00] shyness as being more of a personality trait that does not cause distress. And social anxiety disorder, in contrast, is something that is often perceived as being more intense and more distressing, and again, it's causing some type of impairment.

If you are experiencing intense fear or shame or, some type of impairment, inability to engage fully in your life and it is getting in the way, then you're more likely to seek treatment. 

Stephen Calabria: You've also written about the concept of rumination in the context of social anxiety disorder. Can you talk a little bit about that and who, I mean who doesn't feel that way about certain things in their past? Everybody ruminates, right? 

Charissa Chamorro: Absolutely. And this is one of those things where people can really identify with the experience of doing something that they thought was embarrassing and then thinking about it and replaying that moment and then maybe replaying the conversation and how I should have [00:05:00] said it or how I could have sounded better.

And that is a normal human experience. And actually, what I wanna also highlight is that with many mental health issues, we often find that they are common experiences that most people have at some point in their lives.

And what distinguishes that from something that we would recommend treatment for, again, is the amount of distress and impairment, and also often the length of time someone's experiencing it.

So for rumination, for example, it's normal to replay conversations and to think about things. And if we think about it there's some benefit to that.

We were talking about the benefit to anxiety, but if you are engaged in an experience and you think it didn't go well, and then later you rehearse that and you think about it and you identify where things might have gone wrong or they could have gone better, and then you use that as a way to problem solve and perform better in the future, then that's beneficial and that's something that could be seen as resilient.

The difference is what we see in social anxiety [00:06:00] disorder. This thing that, the fancy term we call post-event rumination where people. Get stuck in a cycle of replaying the moment over and over again. And that is coupled with intense feelings of shame or embarrassment.

And I will have people sometimes report to me that they can't focus on anything else. They can't even watch a TV show because they are so stuck in ruminating about the experience, and also the real deep feelings of shame and embarrassment that go along with that.

So that is a real distinguishing factor between normal rumination. Is it productive? Are you able to have empathy and compassion for yourself about it? Or are you falling into a spiral that's coupled with feelings of shame and embarrassment, and it's really not going anywhere? 

Stephen Calabria: At what point was social anxiety, specifically also Social anxiety disorder, even recognized? Is it a relatively new phenomenon? 

Charissa Chamorro: That is a great question. For a little history [00:07:00] lesson, there's a manual, we're referencing the term diagnosis, the term disorder, and that's because psychologists, psychiatrists, and mental health clinicians have a manual called the DSM, it's now, and the fifth iteration, DSM five, the Diagnostic and Statistical Manual.

And that is where we have all of our diagnostic terms. Social anxiety disorder was not recognized as a distinct issue until the 1980s, and that is when the DSM three came out. And in the eighties, there was a big cultural shift in mental health treatment towards more of a medical model.

So before that, if people are familiar with, like with Freudian terms, anxiety was referred to more as neurosis. And then in the eighties with the DSM three, we saw more of a shift to symptoms and categorization of symptoms and relating that to specific disorders.

And yes, it was relatively new. It was in the 1980s and actually it was termed social [00:08:00] phobia and it was really distinct to performance related experiences.

And then about 15 years later in the DSM four, in 1994, they broadened that description and the term social anxiety disorder came out. So it was in the DSM four in 1994 where this term finally gained recognition for what it is now. 

Stephen Calabria: With social anxiety and its accompanying disorder, having been so relatively new in our medical understanding, can we discuss the generational aspect? Is social anxiety more prevalent now than it was in previous generations? 

Charissa Chamorro: This research is really emerging because it is something that we're seeing. In younger generations. And the answer is yes. In emerging research, we are seeing higher rates of anxiety and higher rates of social anxiety.

And there are some theories, we don't know exactly why, but there are some theories out there.

And one [00:09:00] of the theories is that particularly in Gen Z, we have a generation who are digital natives, which means they have grown up in the digital space with social media and they may be more likely to engage in social comparison because that is just part of their life. That is part of how they they grew up.

And so it's thought that perhaps younger generations are, because they're more involved in social media use, they are more sensitive to social comparison, they're more sensitive to feedback and they have more anxiety about how they're perceived both online and in person, and we are also seeing fewer opportunities to engage in person in real interaction because people have the opportunity to engage through screens.

And so there's some thought also that the lack of in-person interaction may also be contributing to feelings of social awkwardness or increased feelings of social [00:10:00] anxiety. 

Stephen Calabria: Why? Because people are not exercising those muscles as much as they otherwise would had they not had the phones. 

Charissa Chamorro: Right. So it's very different for two kids to have a conversation in person than for them to be typing out in the chat room of a video game. Those are two very different ways of connecting. 

Stephen Calabria: Now, while this younger generation may exhibit higher signs of anxiety, are there higher rates of anxiety generally now in society? And from that, can we just now assume we are an anxious society? 

Charissa Chamorro: There are definitely many reasons to be anxious nowadays and the answer's a little complicated. There has always been anxiety and rates of anxiety have been relatively consistent in recent years. Generalized anxiety, I will say.

Where we have seen increases in anxiety is in social anxiety. And interestingly, the rates of anxiety do appear to be different [00:11:00] culturally. But for social anxiety and not general anxiety.

So most people are really surprised to hear that rates of social anxiety are higher than rates of generalized anxiety, almost double, and that rates of generalized anxiety tend to be pretty similar in the US when compared to global rates, but social anxiety rates are more than double in the US than they are when we compare those to global statistics.

Are we just an anxious society now? There are lots of things to be anxious about. I think we are living in a time with unique pressure. We all collectively just survived the global pandemic.

There's political polarization, there's climate anxiety, and there's 24 7 social media exposure. So there are a lot more reasons for people to be anxious, but there's also better detection and more research and less stigma around reporting anxiety.

So all of those things contribute to the higher rates that we're seeing. 

Stephen Calabria: The collapse of communal [00:12:00] activities in America and the lack of community, we've seen over and over again, on this program especially, can contribute to feelings of aloneness if people don't feel like anyone has their back and they're in it all by themselves.

That's something a lot of folks could feel very anxious about. 

Charissa Chamorro: Absolutely. And another cultural factor is that in the United States, we are living in a very individualistic society, and so personalities where people are achievement oriented and they are leaders and they are outgoing and they are for themselves, those things are really prized.

And that is different than in more collectivist cultures, where we see the sense of community and being a team player and maybe being a quiet contributor are things that are prized more highly.

And so that may also be contributing to higher rates and social anxiety.

Stephen Calabria: We see [00:13:00] this phenomenon of social anxiety even among people that seem to hide it very well, like a professional musician who still gets crippling stage fright, or someone whose job is public speaking and they may appear to be really good at it, but inside they're absolutely terrified.

Charissa Chamorro: Absolutely and many people are surprised to hear what you just shared, is that there are many people who choose professions where they have to perform in front of others, and yet they experience intense fear and distress around those performances.

So it is actually very common and I have worked with artists and people who have to engage in public speaking as part of their career. And fortunately it is treatable. And we do have strategies and treatments that work. 

Stephen Calabria: Regardless of whether the person works in the public sphere or not, what does life typically look like for someone struggling with untreated social anxiety? And what are the risks if it's left unaddressed? 

Charissa Chamorro: Someone [00:14:00] experiencing intense social anxiety will often avoid important opportunities. They may not go to their friend's party because they just can't tolerate being in that big social situation.

They may skip a job interview because that one-on-one. Conversation feels too anxiety provoking for them. They may miss out on their kids' game because they know there's going to be an after party and they feel like they can't be there for that.

So it often looks like missed opportunities. And embarrassment about that and regret. Or if the person is very high functioning, they may be able to actually engage in all these activities, but they experience intense distress, anxiety, and often the post-event rumination that we were talking about, but also anticipation of the events, as well.

So there's anxiety during the experience, but also before and after. So, left [00:15:00] untreated, not only can the anxiety become worse, especially if there's avoidance, because we know that avoidance, although it feels good in the moment, 'cause you're avoiding the thing that makes you feel anxious, it actually reinforces the anxiety because the next time you have to go to the big thing, you didn't do it last time and you felt better.

So you never got the opportunity to learn that if you actually did the thing you were scared of, you'd be okay. If people avoid, it actually makes it more intense. And yet when it's left untreated, there may be more and more avoidance, more missed opportunities, and then that exacerbates feelings of shame and regret.

It can lead to poor mood symptoms of depression. There's a cascade of things that can occur if it's left untreated. 

Stephen Calabria: We're officially in the holiday season. Is there any evidence, first of all, that social anxiety heightens during the holidays?

Charissa Chamorro: While there's limited direct research on social anxiety, specifically during the [00:16:00] holidays, there has been research on seasonal social stress and event related anxiety and holiday related distress.

And so all of this suggests that people with preexisting anxiety and preexisting social anxiety are more vulnerable to symptom spikes during holidays, and it makes sense. There's many reasons for this.

There are more social events, so there's more opportunities for people to feel triggered. Anticipatory anxiety is a huge part of social anxiety, so if you know there are going to be more social events, you're going to spend more time experiencing anticipatory anxiety.

There's also an increased exposure to social comparison. So you're on your social media feed, you're seeing other people at parties and doing other social things and looking great doing it.

And that can also trigger feelings of shame and embarrassment because you may be struggling with that. And then finally, there are heightened cultural and familial expectations that you're gonna show up to all these things, whether it's hard for you or not.

Stephen Calabria: It's also not [00:17:00] just the people you're comparing yourself to on social media. It's the comparisons that are happening around the dinner table with people that you haven't seen in 20 years, and the anticipatory anxiety of that.

And just having to be thrust into a situation that is largely outside of your control, where a lot of these roles have been set in stone for a generation or longer, that of course is going to lead to some trepidation, if not anxiety.

Charissa Chamorro: Absolutely. Absolutely. And it's really important for people, even if this is just your first stepping stone in facing this to remember that you don't have to feel confident to be courageous.

Just take the first step and do the best that you can and remember that is enough. So if there are comparisons around the Thanksgiving table and it's not making you feel good about yourself, let it [00:18:00] go, filter it out, that's okay.

You don't have to live up to anybody else's expectations and just showing up is enough. Oftentimes people with social anxiety have a real fear of performance and that they are not gonna do it.

And so one of the strategies in treatment is to practice letting go of the desire to be perfect and to accept that everyone has flaws and you are enough just as you are.

Stephen Calabria: Now, when a person typically seeks out treatment for social anxiety, is there a common tipping point that led them to do that often? 

Charissa Chamorro: It often happens when there's some type of missed opportunity, or it might be realizing that anxiety is really holding them back and maybe it's holding them back in their profession, or they feel that they are missing out on important relationships so they're not able to date because social anxiety is getting in the way.

But it's usually either some [00:19:00] distinct experience where they felt really, really anxious and like it was unmanageable and they were not able to do something that was important to them or that more generally, it's getting in the way of them engaging in their life.

Stephen Calabria: In resilience, we talk a lot about facing fear, and you've already talked about how social anxiety can be dealt with, if not in some cases overcome. What are the most effective strategies or treatments you've typically used to help people reclaim their lives? 

Charissa Chamorro: CBT, cognitive behavioral therapy, is the gold standard treatment for social anxiety disorder and what that looks like is, we work on the cognitive piece, the thoughts that contribute to anxiety, and then there's also a behavioral piece and oftentimes it should always actually incorporate exposure to the situations that are causing anxiety for the person.

But it's really important that treatment incorporate [00:20:00] all of these things and also what I was discussing before, which is a greater acceptance of who you are. Often people with social anxiety have very negative self beliefs about their difficulty socializing.

And I always emphasize that it's okay to have different social needs. You're not coming to treatment to be a more outgoing person. You are coming to treatment to learn, to manage your anxiety so you can engage more fully in life and you can connect with others and feel good about it.

So key components of CBT are identifying the thoughts that are getting in the way. What are you saying to yourself? Are those thoughts helpful or can we generate other ways to think about yourself and these situations?

Cognitive reappraisal, so thinking about the situation and maybe examining if your estimation of the danger or risk in that situation may be an overestimation, because we often find that is the case in social anxiety disorder.

People with social anxiety disorder often [00:21:00] fear that something really terrible is going to happen in a social situation. So that might be, I have to speak up in a meeting and right before I have to speak, I start to get really anxious and I'm sweating and I have a stomach ache, and then I start to play out some catastrophic episode in my mind that is, I completely go blank. I can't say anything. I'm visibly sweating.

Everyone questions my ability to do my job. All of a sudden, I'm not gonna have any friends at work. I'm gonna get fired. So it can go really into a spiral. And oftentimes when people do that, when in treatment, when you work on it and you have people identify that's where they're going with this, they're able to say, yeah, I know it's an overestimate.

Like, I know I'm blowing it out of proportion, but I can't seem to stop doing it. And so what we're gonna do is identify what some of those scenarios are that come up over and over again and how can we dial it back and work through it and help the brain rehearse a more [00:22:00] balanced perspective when entering these situations.

Stephen Calabria: Is that, would you say, the most common social fear that you come across, is speaking up in meetings? What are the ones that are the most often vocalized? 

Charissa Chamorro: That is one of them, But I would say going to parties is another really big one where people with social anxiety disorder may be okay one-on-one, but going to a party is so hard because they don't know people.

They may feel more like they're on display and being scrutinized. But certainly speaking up in a meeting, 'cause again, then you are the only person who is speaking. And younger people, 'cause I also work with teenagers, this comes up as fear of speaking up in class.

So for a teen who, or a college student who's having challenges with social anxiety disorder, one of our behavioral experiments may be to make it a goal to speak up just once during class.

And we might start with just once a week during class and you can identify the [00:23:00] exact subject you're gonna talk about and you only have to say a sentence, but that we want people to challenge themselves to do the things that they are scared to do. 

Stephen Calabria: Many listeners may know someone, a child, a partner, or a friend with social anxiety. How can loved ones offer support without pushing too hard? 

Charissa Chamorro: It's really important to validate a person's feelings and to empathize with them. So even if it may not make sense to you why your partner is so anxious about going to the party, validating that you see that they're struggling with it is really important.

It might just be I see this as really hard for you, rather than minimizing it, which would look like, oh, come on, it's just a party, you know everyone. So it's really important to validate people's feelings.

Offer gentle encouragement and suggest small steps rather than big ones. So that may be how about we go to the party for an hour and if, and after an hour if you've had enough, we'll leave [00:24:00] rather than saying, we're gonna go and you are going to perform the speech at my best friend's wedding.

So we want to really encourage small steps, not big, huge leaps. It's also important to avoid pressure or shaming, for example, just stop being anxious.

That feels really shaming to a person with anxiety and offer to help them access professional help if that's something that. You believe would be helpful for them, and that would just be maybe bringing it up so that it doesn't feel stigmatizing.

I think it's also really helpful when people hear real time specific feedback and encouragement. So oftentimes people with social anxiety may feel self-conscious about their social skills.

And if you love somebody and you know they're socially anxious and you also know that they're really funny and smart and you love talking to them, you can offer that feedback and say " Hey, I, you just, you have such a great sense of [00:25:00] humor. I love it when when you share stories."

Providing that specific feedback can be really helpful and really encouraging. 

Stephen Calabria: And not telling people just to chill out because that never, ever works.

Charissa Chamorro: Never say, just chill out. 

Stephen Calabria: Right. If you could offer one piece of encouragement to someone listening right now who feels trapped by social anxiety, maybe they might have to endure an insufferable relative at Thanksgiving or some other holiday dinner, and they're not sure how to get through the experience of being around their family at the holidays, what would you say to this person? 

Charissa Chamorro: You are already enough, even in silence. Even if you feel awkward and strange, you don't have to be perfect. You just have to be yourself. And you also don't have to be confident to be brave.

Just by [00:26:00] being there, you are putting yourself forward, and that's enough, and that relative that is annoying you or the dinner table that just feels so overcrowded with people and opinions, tho those people don't get to define you.

Even if they're your family. You showing up, that is already a win and you are not alone. Every moment that you choose connection over avoidance, you are retraining your brain, you are building resilience, and you are reclaiming your freedom.

Stephen Calabria: If someone wanted more information on social anxiety and perhaps even how to treat their own social anxiety, what should they do? 

Charissa Chamorro: As a clinical psychologist, I am going to suggest that you find a clinical psychologist to help you because having a partner in treatment is so incredibly empowering and helpful, and I think it's important for people to also know that when [00:27:00] people enter CBT treatment for anxiety or social anxiety, this type of therapy isn't the type where you show up and you just talk, and that can be very helpful and healing, but this is the type of treatment where it's a partnership.

It's a coaching relationship where you are going into this relationship to be seen and be heard and be coached and given strategies to really be your best self. So I would encourage finding a psychologist or a local mental health provider who specializes in CBT for social anxiety.

Stephen Calabria: Dr. Charissa Chamorro, thank you so much for being on Road to Resilience.

Charissa Chamorro: Thank you so much, Stephen. It was wonderful to be here. 

Stephen Calabria: Thanks again to Dr. Charissa Chamorro for her time and expertise. That's all for this episode of Road to Resilience. If you enjoyed it, please rate, review, and subscribe to our podcast on your favorite podcast platform.

Want to get in touch with the show or suggest an idea for a future episode? Email us at podcasts at Mount sinai.org.

Road to Resilience is a production of the Mount [00:28:00] Sinai Health System. It's produced by me, Stephen Calabria, and our executive producer, Lucia Lee. From all of us here at Mount Sinai, thanks for listening and we'll catch you next time.