It's Nobody's Fault (21 page)

“I was really shy as a kid. I was one of those youngsters who’d hide behind my mother’s leg when my aunts came to visit.”

“I’m okay in most social situations, but I don’t really like them. I really have to push myself to talk to people.”

“I
hate
parties. I never know what to say. I couldn’t do it at all without a glass of wine.”

Everybody is shy some of the time. Meeting strangers, making a speech, being the guest of honor at a surprise party—those are not situations that most people consider relaxing. Some years ago it was reported that the three greatest fears of the American people are death, heights, and speaking in public. (In fact, speaking in public ranked higher than death!) Of course, some are more shy than others; they’re usually the ones standing behind the potted plant hoping no one will spot them or over by the bar having a third cocktail to loosen their tongue. Many people outgrow their shyness—by the time they’re too big to hide behind Mom’s leg when the aunts come to call, they don’t feel the need to do it anymore—but others continue to be uneasy in specific situations. Shyness is a perfectly natural response to events, especially in children and adolescents. As long as it isn’t excessive, as long as it doesn’t seriously interfere with a child’s ability to function, shyness is nothing to be particularly concerned about.

Obviously, Rebecca and Eric are
not
functioning very well. Both children are suffering from social phobia, an anxiety disorder characterized by the persistent fear of being scrutinized and judged by others and of doing or saying something that will be humiliating or embarrassing.
Some children become so concerned that people will be critical of them that they become unable to speak, drink, or eat in front of other people. Others are afraid to use public toilets, not because they worry about hygiene but because they worry about doing something that will make them look bad.

The key to this brain disorder is intense self-consciousness. Children with social phobia are basically afraid that they’re going to do something the wrong way and consequently look foolish to others. They don’t speak in class because they’re afraid they’ll get the answer wrong or say it in a voice that will sound strange. They don’t eat in public because they might spill their food or choke. They have trouble urinating in a public toilet if anyone is around. Children with social phobia believe that all these things (and many more) will make them seem stupid. They’re afraid that people will mock them for their inadequacies.

Children and adolescents with social phobia have not lost touch with reality. When confronted with the force of logic, these kids will readily acknowledge that their fears and anxieties don’t make a whole lot of sense. They know that they’re being “silly,” but they just can’t help themselves.

The numbers on garden-variety shyness are astronomically high, but true social phobia is thought to be uncommon among young people, affecting about 1 percent of the child and adolescent population. (Recent studies have found that social phobia affects as many as 12 percent of all adults.) The symptoms of social phobia are usually noticed in adolescence, especially the mid-teens, but we have good reason to think that adolescence is not when the symptoms actually begin. Teenagers with social phobia often report a long history of painful shyness or social inhibition, but until their teens, they were able to cope. With the increased demands and expectations of adolescence—part-time jobs, interviews for college, dating, and other social pressures—come the distress and dysfunction that bring these kids to psychiatrists’ offices. Even perfectly normal teenagers usually go through a patch of greater-than-average self-consciousness. Teenagers with social phobia go off the charts during these years.

Social phobia in very young children often is seen as a closely related disorder: selective mutism.

Lydia was an enchanting child—pretty, beautifully dressed, exceptionally bright. At the age of five she was already reading quite well. Her parents brought her to see me because most of the time Lydia did not speak. She
could
speak. She talked to her parents and to her brother a little, and once in a while she spoke to her grandparents. She read aloud. But otherwise she didn’t talk—even to respond to direct questions—and she never participated in sharing or “show and tell” at school. Neighbors, relatives, schoolmates, and teachers had been expressing their concern and their irritation. Her teacher was worried about passing her on from kindergarten to first grade.

At nine years old Alice had been going to school for several years, but she hardly ever talked. She had one friend to whom she’d occasionally whisper. When she had no other choice but to speak to her teacher, she would get up close and speak softly into her ear. Alice’s parents had been taking her for therapy for a couple of years. Every week for two years she’d go in and whisper to her therapist. The week before I saw Alice, the school had sent a letter home to the parents: “There’s a real problem with Alice,” it read. “We can’t really evaluate what she knows and what she doesn’t know. What’s even more important is that Alice is incredibly uncomfortable all of the time.”

A child’s failure to speak—called selective mutism—has many possible explanations. It could be perfectly normal shyness; many five-year-old kids aren’t crazy about chatting with strangers. It could be the result of a traumatic experience, such as physical or sexual abuse, but that connection is very rare. It might be caused by a problem with language; there is a higher than average incidence of selective mutism among children of non-English-speaking parents and among kids who have a developmental speech delay or a learning disability. Children who stutter sometimes decide not even to try to speak.

The most common cause of a child’s failure to speak is anxiety. Children who are selectively mute are, quite simply, too anxious and nervous to talk in front of others. For that and other reasons selective mutism (sometimes called
elective mutism)
may be regarded as a symptom, or at least a first cousin, of social phobia.

Social phobia is divided into two general types. Type one is
generalized
, an anxiety marked by the avoidance of most daily social interactions. Eric, the child hiding under his bed, described at the beginning of this chapter, has the symptoms of generalized social phobia. Just about anything that involves other people makes Eric anxious.

Type two social phobia is characterized by discomfort in and the avoidance of
specific
situations, such as speaking in public, using public lavatories, and eating, writing, or speaking in front of others. (This is a form of pathological performance anxiety.) With type two, the phobia isn’t generalized; in fact, there may be just one situation that brings on anxiety. A college student I treated a few years ago was normal except for his terrible fear of using a public bathroom. He eventually had to move out of the dorm and into his own apartment because of it. When we talked about it, all he could say by way of explanation was: “I’m afraid someone will walk in on me.” A junior high school girl was fine too except for her fear of being called on in class. “I have the feeling that I won’t know the answer and I’ll say something stupid,” she told me. She would rather take a zero in class participation than respond to her teacher.

Communicating with some of these troubled children, especially the young ones, can be quite a problem. The difficulties with the kids who are selectively mute are obvious; we’re lucky to get them to speak at all. I’ve interviewed a five-year-old who did nothing but grunt and moan in response to my questions. One of my colleagues is treating a little girl through her father; the father does all her talking for her. It’s not at all unusual for these youngsters to have appointments and not show up. When the time comes to interact with a new person, they just can’t do it. What’s more, the very young children who
do
show up and
do
speak are not skilled at articulating the distress and dysfunction associated with social phobia. We’re not likely to hear, for instance, any version of, “Doctor, I’m afraid to answer questions in class because I’ll be embarrassed and humiliated by my peers” from a child with social phobia until he’s well into adolescence, if then.

Even when the kids are in their teens and very smart, talking to them
is often like pulling teeth. I was treating a 16-year-old boy who was on the cusp of being a genius. He had a very high IQ, and he was a whiz at math and computers. Socially, however, he was completely lost; the only people he could converse with were his sister and his mother.

When kids are capable of communicating, they may not be willing to communicate; they’re reluctant to acknowledge, let alone describe the nature of, their symptoms. Many of them will dismiss symptoms as being nothing to worry about. An 18-year-old boy named Eugene was virtually dragged in to see me by his mother. He was finishing the first semester of his freshman year away at college, and his mother thought—correctly in my estimation—that he was having some serious problems. He’d been quiet and withdrawn his whole life, she told me in front of her son, but this year he’d gotten worse. All alone in his new school, Eugene hadn’t spoken to a soul in over a month.

For the first half-hour I couldn’t get any response out of Eugene at all. Eventually he told me, haltingly and with no eye contact: “I don’t know why my mother’s making such a big deal out of this. So I don’t speak in class. So I don’t talk to people. I just don’t have anything to say.”

Children later diagnosed with social phobia come to see me for three main reasons: they don’t speak, they don’t go to school, and they have no friends. In many cases these problems have existed for quite some time, but something has happened to make the situation intolerable. For example, one young woman’s social phobia caused her to drop out of college. First she dropped an American history class because she was asked to make an oral report. The moment she stood in front of the class, she started sweating and felt light-headed. After reading only three lines of her report she had to sit down; she was sure she was going to faint. Then she dropped biology because of the lab work; it meant interacting with other people, and she just couldn’t deal with it. She finally got so anxious that she dropped out of school completely. Other adolescents who have been suffering for some time may be brought in by their parents because they’ve started using drugs and alcohol to ease their anxiety. By the time they reach me, many young people with social phobia show symptoms of other related disorders. Studies show that some 50 percent of people with social phobia will have other anxiety disorders, and many others will eventually require treatment for depression.

Making a diagnosis of generalized social phobia is not always easy. Sifting through the underbrush of family troubles, extraneous symptoms, and other facts that occasionally clutter up the diagnostic landscape can be quite challenging, particularly if the child has been sick for some time. Penny, a 16-year-old high school senior, came to me because her homeroom teacher told the parents that there was a problem. Penny was acting strange in class—a little “nutty,” her parents called it. According to the teacher, she almost never spoke in class, but she would often giggle uncontrollably, sometimes so much that she disrupted the class. (It’s not unusual to hear complaints about the behavior or the attitude of children with social phobia. Many of them, especially the young ones, come off as rude and defiant.)

As I learned during our first visit, Penny had other symptoms as well: frequent urination, depressive complaints, and some anxieties. There were some conflicts at home too. Penny’s parents were in the process of getting a divorce, and her sister was quite ill. It took me some time to explore the issues of anxiety with Penny, distracted as I was by the family crises. But when I did get her to talk about what she was worried about, I discovered that she was a mass of fears and anxieties. Even getting on the school bus every morning scared her. “I’m nervous about saying hello to the bus driver,” she told me. “I might say it wrong and sound really stupid.”

Symptoms related to social phobia must be carefully assessed before a diagnosis is made. Taking a history from the child himself is only the beginning. Besides, we can’t always count on what the youngsters report, because they’re usually nervous about making a bad impression—one of the key factors in social phobia. We make it a point to get a detailed history from the child’s parents and teachers. Teachers are not always ideal sources of information either. Some children with social phobia are completely ignored by teachers. After all, they sit quietly—
very
quietly—in the back of the classroom, not bothering anybody. They appear shy or withdrawn, as if they’re watching the scene rather than participating in it. Sometimes they’re perceived as being stuck up or judgmental, but it’s fear that keeps them from taking part in the action. They don’t want
to say or do anything that will get them into trouble. The disruptive disorders are the ones that usually get a teacher’s attention.

In making a diagnosis for social phobia we have to rule out other diseases with similar symptoms, especially separation anxiety disorder (described in
Chapter 9
), obsessive compulsive disorder (
Chapter 8
), and generalized anxiety disorder (
Chapter 11
). Schizoid disorder must be ruled out as well. A teenager sits at the table at a large family holiday dinner. She doesn’t socialize with her cousins or the other guests and leaves the table as quickly as possible. The behavior could be that of an adolescent with schizoid disorder, a chronic condition that may start in late adolescence and is characterized by detachment and limited interest in others, or these could be the actions of someone with schizophrenia (
Chapter 16
). If the girl is silent and withdrawn because she’s convinced that she will say something stupid, she has social phobia. It’s important to note that people with schizoid disorder are not uncomfortable or anxious in social situations; they just have peculiar interactions. In the case of schizophrenia the youngster will be anxious and nonresponsive with everyone, while the girl with social phobia may be a chatterbox with her parents once the dinner guests go home.