Psychiatry & Psychotherapy Podcast - Social Anxiety with Dr. Cummings

Episode Date: February 9, 2023

In this episode, Dr. Cummings joins the podcast to discuss and give tips on overcoming social anxiety disorder. Individuals with social anxiety disorder tend to avoid important events and activities, such as classes, meetings, or public speaking. The disorder is essentially the fear of rejection by a group one would like to be part of. This is different from shyness because of the intensity and pervasiveness of the symptoms. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome back to the podcast. I am joined today with Dr. Michael Cummings. He is going to be talking with me today about social anxiety disorder. And we will get into probably some of the things going on that lead to social anxiety disorder. Genetics, neurobiology, brain stuff along with treatments. And I'm looking forward to this discussion. Yes, indeed. And I'm happy to be back to be talking about this. We sometimes don't seem to focus enough on the anxiety disorders. As a group, they are the most common type of psychiatric disorder, but they receive less attention in general than things like major depression and schizophrenia and bipolar illness. And of course, social anxiety disorder is one of those disorders. The prevalence numbers I found in the U.S. population seem to range from around 8 to 12% of people at some point meet criteria for social anxiety disorder, a little more prevalent in women, a four to three ratio, women to men. And indeed, the core of the illness is either fear of being scrutinized or fear of performance, which indeed those often go hand in hand. can be very disabling for some people in terms of preventing them from being able to do things in their life that they would like to do, but they are too anxious to pursue them. Yeah. So there's something, it's like the anxiety rises to a level in which they stop doing the things that they might enjoy or may need to do because of social aspects. And with children, specifically, it's around other children, that they,

they will have the increased fear. And if it's just around adults, that it's not considered social anxiety for children, but if it's around other children, then it could be considered social anxiety. Yes. And indeed, you know, people who have looked at this in terms of,

in terms of its evolutionary history, clearly human beings benefit greatly from being a member of a group, we're not highly effective at doing things all by ourselves. And in many ways, a lot of those theorists have hypothesized that social anxiety disorder really comes out of a fear of being rejected by the group that one would like to belong to, which of course makes sense. All of us need other people, need social connections, and to some extent, anxiety, over being accepted or rejected, of course, is a normal part of life. The people who suffer from social anxiety disorder, though, as you point out,

their anxiety rises to the level that it begins to inhibit their behavior. They begin to be unable to make social approaches. Yeah, they start to avoid important events and activities, such as classes and meetings. And then as they progress, they may be less likely to have meaningful relationships like getting married. And then as they progress, it's like the more they avoid, the more it kind of reinforces the anxiety. Yes, indeed. The people I've treated with this often start with a relatively,

modest amount of fear about a particular activity or performance. But the more they avoid it, the bigger, the danger of that activity becomes in their mind to the point where it reaches proportions well beyond what is realistic. Yeah. So, you know, I think this is an important topic to go through. and I know in the podcast we've talked a lot about schizophrenia and psychosis, and then I was looking through our episodes we've done together, and I was like, you know, we really haven't covered anxiety that much.

And so I think this year we'll try to cover some of the different anxiety disorders, and this will be the first one in that series. Yeah, indeed. And I think that's good because people, as I said, psychiatry tends not to pay enough attention to this area. It's also important to take a look at because, of course, DSM-5 kind of reformulated the class of anxiety disorders. They removed obsessive-compulsive disorder and post-traumatic stress disorder from the anxiety disorder categories and put them in their own category.

And they added separation, anxiety, and selective mutism to the anxiety disorders, along with generalized anxiety disorder, specific phobias, and social anxiety disorder, as well as panic disorder. And it's an interesting group of disorders to discuss and think about. And so I think from that standpoint, it'll be good over this year to talk about the anxiety disorders. Yeah, so I think are there any other sort of diagnostic questions that you might ask to pull out if someone has social anxiety disorder or things that you might hear in the history that make you think that they might have social anxiety disorder? Yeah, the question I often start with, and it's a paraphrase of a question that occurs in the schedule for affective disorders and schizophrenia, I usually start. by asking the person if there are any situations that make them anxious enough that they avoid them. Rather than starting with, you know, are you nervous, are you anxious?

You know, is there anything that makes you uncomfortable enough that you avoid it? And then I'll give them example, things like public speaking or performing in public or going to a gathering where there are a lot of of strangers. And, you know, that usually then starts the conversation about the disorder and its symptoms. And it opens the door and allows the patient then to talk about what they may be avoiding in their life. Because what I'm trying to get a sense of is how avoidant has this anxiety made them? Because that's really the crux of the disorder is that the anxiety is bad enough that people avoid things in their life. And then, of course, you always ask about the common comorbid conditions.

The anxiety disorders very commonly co-occur with episodes of depression. may also, people may at times have a primary anxiety disorder, but occasionally they'll have collateral anxiety disorders as well, such as panic or, you know, now agoraphobia has become its own disorder in DSM-5. You could consider agoraphobia is sort of the extreme end of social anxiety disorder in some ways. As well as, I always ask people about simple phobias. Are there specific objects or creatures or things that they are so fearful of that they avoid them at all cost. So over time, you can get a nice overview of the person's anxiety. Because in terms of the underlying physiology, you know, us as a species, we're not huge, big predators with sharp teeth and claws.

and consequently we spent a lot of time avoiding predators that were bigger than we were. And it paid to be aware of our environment and to have some degree of anxiety or fear to drive vigilance. And for us, that's mostly the lateral and inferior portions of the amygdala and the temporal lobes, along with the temporal poles are in many ways in sort of charge of looking at the environment and looking for danger. That is then routed through the hippocampus

and paraphypochampal complex and also then involves ascending circuitry to the anterior cingulate gyrus and the prefrontal cortex. That sort of then completes the loop with communication back down to the amygdala

about whether what it has perceived is really dangerous or not. So in many ways, all of the anxiety disorders that are now in this group in the DSM-5 share that same circuitry with variations, basically.

Yeah. I was looking at a paper that reviewed a bunch of the resting state MRIs. Mizzy et al-2020. what they found was very similar to what you were saying there, that there's this increase in connectivity between the amygdala and the prefrontal cortex, which plays a significant role in controlling attention to salient stimuli and emotional regulation

with the presence of this. So imagine your, if this is charged up, you may be, you know, having increased attention to more things. Anything about the amygdala and the prefrontal cortex and how they interact that comes to your mind? Yeah, in the healthy person. I mean, obviously, you know, again,

thinking about our ancestors, it's useful to know whether that set of stripes that just walked by in the tall grass was a tiger or not. And it's good to figure that out before you become lunch. and in part the amygdala sort of serves as the monitor is something dangerous. The anterior cingulate in the prefrontal cortex, both direct attention and then the prefrontal cortex is the part that makes a judgment about, well, is this thing really dangerous or not?

If not, it can then inhibit the activity of the amygdala. when that's not inhibited, the anxiety can grow to the point that it sets off the classic fight-flight response. And indeed, that's the physical science and symptoms of the anxiety disorders, including social anxiety disorder. Go along with that, increased blushing, increased sweating, tremor, increased heart rate, blood pressure. those are all essentially arousal symptoms for the sympathetic nervous system as being overdriven at that point yeah and so you get this you get this hyper alertness this like danger danger danger which you know maybe has a survival advantage in a lot of situations and you know like thousands of years ago maybe it would have had quite a different survival advantage than today, it's to think of your anxiety as less of

an enemy and more of like a little buddy, you know, a buddy that's trying to keep you safe. And it's like, you know, part of the treatment, I think that's effective in psychotherapy is, is can you, instead of avoiding the anxiety and listening to it to the point of avoiding what you're afraid of can you like have compassion for that part of yourself that's you know your little buddy that's over aroused over concerned like that may be kept you safe early on developmentally even and can you have compassion for that side of yourself yeah indeed very much so and that's you know the the two psychotherapies that have been most evidence supported for uh for social anxiety disorder are cognitive behavioral therapy, which works on just that, rethinking the

anxiety and essentially, in part, converting it from something the person finds onerous and difficult to reconceptualizing their anxiety as a useful monitoring of the environment. And also then, though testing, you know, is this situation really dangerous or not? And, you know, over time, sort of retraining their anxiety,

if you will, not to be quite so apt to respond to things that are non-dangerous. The other therapy that's been highly and widely used for a long time, of course, is exposure therapies,

behavioral therapy, in which the person is exposed to the fearful object or situation in a graduated manner so that they can master the anxiety. In a way, it's an alternate approach to essentially training those anxiety centers not to be overly responsive and non-dangerous situations. Yeah, I was looking at this data to prepare for this, and there's one study in particular that looked at cognitive behavioral therapy versus more of a psychodynamic approach. And they were pretty similar,

maybe the cognitive behavioral therapy a little bit better. I'll put those in the notes if you want to look at that study. And then there was another, there's other studies looking at like acceptance commitment therapy versus cognitive behavioral therapy.

Pretty similar. A slightly different approach in the acceptance commitment therapy, they may, you know, look at your values and utilize those, those values as part of the treatment, but also then more of a mindfulness approach to the anxiety, looking at it and being curious about it, maybe not trying to like cognitively attack it like in a CBT model,

but, you know, can you just like more appreciate it? And what I've seen from CBT versus acceptance commitment therapy is maybe the acceptance commitment therapy is better for if there's personality disorder stuff as well, but very similar outcomes in most psychotherapies, which means most psychotherapies can be helpful. Yes, indeed. Which is an important point because, you know, given the prevalence of social anxiety disorder, well, the stated prevalence is probably an underestimate because a lot of people with milder social anxiety disorder, don't ever seek treatment.

And unfortunately for them, that winds up robbing them from being able to do or enjoy things as much as they should. So certainly people should be encouraged to pursue treatment for this. If people are out there listening and they have anxiety that's sufficient to make them avoid things in their life, they really should consider therapy to overcome that, because otherwise they're just denying themselves part of their own life. But I think that one of the common sort of pathways that I see is you have a kid who starts to get anxious and will start to want to withdraw from social interactions. And at times the parents like co-op this, and they're like, oh, okay, I'll pull you out of school,

and I'll homeschool you. And so then the kid for four or five years is homeschool. And it's like progressively more and more avoidance. And then at some point the parent is like, wow, I need, maybe I need to get some professional help for this. And so sometimes it's like five or six years down the road when you get a good history that this person has suffered without now normal development. relationships. And so it's kind of like they're rebooting later in life. And that's where,

you know, I see some of these patients. And yeah, any thoughts on that? Yeah, I think that's something parents need to be especially careful about. Certainly, I think every child has some degree of avoidance. I mean, everything provokes a little bit of anxiety when it's brand new. Those people, though, who do withdraw and, become essentially isolated. The patients like that that I've treated have a very difficult time later in life when

you can't be homeschooled forever because if you progress in school of entry, you're going to have to go to either high school or college. And without the social interactions growing up and the development of social skills that they need, they have a very rough time when they try to venture out into the world.

To the point that some of them essentially have a very difficult time functioning in such settings because they haven't had practice. They haven't dealt with either being accepted or rejected. And consequently, they're not emotionally and intellectually prepared for those things. Yeah. One aspect, you know, the DSM, when they usually describe things, they don't talk about what's really going on in the inner,

like in the inside of someone. but often what I find in these patients is they have a very strong, negative narrative about how people are viewing them. And about how much shame they have based off of these narratives. And so, like tying this back to the neurobiology in this one study,

they were looking at the fusiform gyrus and how they look at faces. and how there may be actually a mischaracterization of people's faces, which may be seeing more negative emotions out of people, which are not necessarily intended to be directed at them. And so you have these people who can be very competent in a domain of their life. Maybe they're a lawyer or a doctor, yet because of the negative attribution of what other people are thinking,

thinking or feeling towards them, it just cripples them socially. Yes. Indeed, there have been a number of such studies where they show individuals a series of faces, many of which are neutral, and indeed people with social anxiety disorder attribute anger or hostility or other negative emotions to faces that were intended to be neutral in character and that people without social anxiety disorder do interpret as neutral. And that fits, there's an over-attribution of, oh, I'm being scrutinized, I'm being judged. They've even tracked that down to things like people with social anxiety disorder characterize their own blushing as much more severe than it actually is when it's being measured objectively by temperature change. You know, the thermometer says their blushing is mild.

They see it as, oh, my God, I've turned to bright red like a lobster. So there's a misinterpretation of their own anxiety. And to some extent, particularly in the performance-related version of social anxiety disorder, because they are sweating a little more and they have a little bit of tremor, they, in essence, then become anxious about being anxious. and it becomes a very vicious positive feedback loop for them. Right. So imagine now this very sensitive to other people's experience of them,

someone who has heightened sensitivities to that, now trying to seek care by a psychiatrist or therapist. Now, you are the therapist or psychiatrist listening to this, and imagine that they will think that you are thinking critically of them or that you are thinking something maybe that maybe disgust or shame evoking, you know, inside of them. And so this is where I think maybe the transference work

or just being aware of the interpersonal, being aware of the here and now can actually allow you to put words to this if it comes up and then move through it so they can actually stay in treatment. Yes, indeed. And, you know, the other thing, is when people have been on this path for a while,

which many of them have by the time they come to treatment, although we haven't devoted nearly as much research effort to pharmacologic approaches for anxiety disorders as we should, there are a number of pharmacological agents that can help reduce anxiety to a manageable level so that the person can then be more effectively available for psychotherapy. You know, that's a theme you've heard me say before that the role of medication in many of these disorders

is to make the person available or more available for psychosocial treatments. Yeah, I think both of us have this balanced view. There's going to be people who listen to our podcast, and I know there are that are pure psychopharmacologists. They imagine that most of what they do is psychopharm. and, you know, those people who have patients who are just on medication, they need to continually find ways to educate their patients on the importance of doing the work, you know, psychologically, psychotherapy-wise. And then we have listeners as well who are like, you know, they go to conferences and

they hear about the evils of big pharma and they're very anti-psychiatry colleagues. And those people need to be informed, like, well, if the anxiety gets to a point where it's so, high that, you know, the patient can't do any behavioral experiments. They can't, they can't venture out. Or, you know, it's like they can't even take the first steps. Or even the work in sessions is like, it's very, very hard to access what you need to access. That's when medications can have an important role. So. Yeah, very much so. And certainly for social anxiety disorder, the SSRI antidepressants and the SNRI antidepressants have been the mainstays of treatment for a number of years now in terms of evidence-based treatments. People have gotten interested, and of course before that, at least for short-term use, benzodiazepines have been used, although those have a lot of potential problems in terms of tolerance, risk of abuse, or dependence, withdrawal.

And then, you know, more recently, beyond the antidepressants and the benzodiazepines, people have gotten interested in a variety of molecules in terms of potential approaches to reducing anxiety. Not a great deal of research has been done, not enough. But people have started looking at things like cannabidial, one of the two psychoactive components of, marijuana, cannabis. You know, they're two, Delta 9, THC is what makes people high, and then in some cases makes them paranoid. You know, on that one in particular,

I looked, there was a 2002 study called cannabodial enhancement of exposure therapy and treatment of refractory patients with social anxiety disorder and panic disorder with agoraphobia, randomized control trial. and they found, and this is, in the first clinical trial examining CBD cannabodial as an adjunctive therapy and anxiety source, CBD did not improve treatment outcomes. So that was, I don't know if you've read other things that make you more hopeful. I've read that study, and I think the, you know, it's this.

point there needs to be more research in this area the interest largely came from animal studies where things like the elevated maze test was better tolerated by mice who had cannabidial on board so essentially it's an animal proxy for anxiety but again this is an area I think that needs much more research there there was also a I believe a 2019 study, which actually used cannabidiol as an adjunctive treatment in individuals of schizophrenia. Interestingly, they found in them it did have a not huge, but significant effect on reducing both psychotic symptoms and anxiety.

Yeah, I've seen some positive stuff for schizophrenia. That's interesting to me. I think this is an area where there needs to be more research so that perhaps we have a better understanding of how the endogenous cannabinoid system interacts with the amygdala in terms of modulating its activity and see if there are specific circumstances and amounts and doses that might be useful in some people. We don't know that yet, so I'm certainly not recommending cannabidial for current treatment of anxiety disorders. People have also looked at the neurohormone oxytocin, which, Again, clearly in animal studies reduces anxiety like behavior. And in humans, it's been tested well enough to know that it promotes social interactions,

essentially increases trust in some animal species like voles, pair bonding. Again, needs much more research, though, in terms of, could it be a potentially useful treatment for anxiety, disorders. Yeah. This is sort of my soapbox of, you know, we need to pay more attention to this area and do more research. I think one article that I really enjoyed reading and gave me a lot of insight into the treatment of social anxiety was this article I set you, Dr. Cummings, on a randomized clinical trial by Frick et al, 2021, in which 27 patients with social anxiety disorder were divided into two groups.

One group was verbally told that they were going to receive the effective drug lexapro. While the other group was told that they were going to receive a non-effective neurokind in one reseparable. receptor antagonist that would have the same side effects as lexapro but none of its benefits and so in reality though this was a deception study in reality both groups were given lexapro 20 milligrams and the idea was that they would look at did the expectancy of having

the real treatment change the dopamine and serotonin levels as measured by PET scans with radio tracers, and would the expectancy change the outcomes like a greater decrease in social anxiety? Okay, so the findings were in this study that the individuals that were told that they were receiving the real medication, Remember, both groups were actually receiving the real medication, etatalopram lexapro. But specifically, the individuals that were told that they were receiving eschatalopram lexpro and were receiving eschatalabram lexpro, that group had significantly lower dopamine transporter binding by the radio tracer in the striatal and thalamic brain, meaning the actual dopamine in the brain was releasing slower from those dopamine transporters

leading to better outcomes due to expectancy. So let me put this another way. The radio tracer in the PET scan was trying to bind to the dopamine receptors. And in the group that received the lexapro and was expecting a good outcome, their brains had more dopamine naturally binding to those receptors. And so the radio tracer could not bind to those receptors as well. Okay. And they believed that this expectancy actually led to the good outcome

that the group that thought that they were receiving the real medication had a larger effect size and decrease in social anxiety symptoms. The effect size was pretty significant in the group that thought that they were receiving the active medication. It was 2.3. In the group that thought that they were receiving a placebo, but were in reality receiving esotalopram as well, it was 0.93. So both of them did well, but the group with the expectancy did. a lot better. And it had to do with increased dopamine being released. Okay. And just a side note in this study, when they looked at serotonin changes, they didn't see any difference between the two groups.

Probably because, you know, they had a serotonin re-uptake inhibitor. So there was an actual change being caused by the medication that was leading to pretty equal things going on in both groups. Overall, the study highlighted to me the significance of expectancy and belief and how treatment is highly influenced by the faith one has in a given treatment. Any thought on the power? I mean, it seems like there's such a power of placebo in this study in the way that they showed it. there was and indeed that's been one of the issues in anxiety disorder research for a long time has been that

there is often a fairly high placebo response rate and those where a placebo is used even you know just taking a socially anxious person and putting them in a research study where the the staff of the study are supportive and friendly that in and of itself can sometimes alter the results. So that in some ways it makes anxiety disorders more difficult to study from a pharmacological perspective because you have to be very careful not to assume that it's the pharmacology of the drug that is indeed changing things. anything that is reassuring such as

oh, I'm taking a medication that will help me be less anxious that thought in and of itself indeed may make the individual less anxious. What do you think about the... Okay, so in defense of medications, like both groups had a decrease in the symptoms. Yes. It's just that the group that thought

that they were taking an actual substance had a bigger drop, right? And so even taking what they thought was the placebo, in this case, an active control, decreased the social anxiety levels. And to a place that may have clinical relevance, too, in my mind, it's like, okay, you know, if your score is coming in at 80 and now they're down to around 60, the other group is started out at 80 and now it's down to 40, but that's still a significant drop out of a 100, you know, where maybe they're able to better tolerate therapy. But anyways, so I'm kind of thinking out loud, like, I'm not saying that we shouldn't think of medication as, you know, as a treatment. And I definitely would consider it a treatment.

Just that there's something about anxiety in particular where the expectancy actually is changing the brain. Yes. Well, and indeed, in some ways, we've come. back to the issue that, you know, the amygdala, hippocampus, anterior, singular, prefrontal cortex circuit, is there basically to monitor whether you're safe or not? And if you, indeed are having the thought that you're safe, well, that in and of itself changes the activity of that circuit. Yeah. And so if you think you're safe because you're taking a medication,

that changes potentially your reactivity just by the thought, like, okay, I'm proactively doing something for myself. I'm taking a medication, and this is going to help me. Yes, indeed. Which can be very useful. That's one reason. And children, for example, sometimes having a transitional object for a new social situation can be very helpful.

I had one young patient who, as long as he had his special marble in his pocket, he was much more comfortable at school. Now, I have, you know, that glass marble was not directly doing anything to his brain itself, but his feeling reassured by having this familiar, comfortable object in his pocket altered his anxiety response and in some ways a pill can do the same thing I think sometimes we underappreciate that medications always have two components one the

actual pharmacology of the medication and two be it positive or negative the person's attitude toward taking the medication right and their attitude towards you as the one that gave them the medication, I think, is powerful as well. Because if they trust you and if you've given them more possibly than medication through psychotherapy, the medication has in and of itself like a bigger impact and a different meaning than maybe someone who feels very disagreeable towards their provider. Yes. Yeah.

medications can have an element of being transitional objects or gifts from somebody who cares about them. Yeah. Yeah. I think the other, you know, with like, I think we should talk a little bit more, maybe even about the behavioral aspects of, like, how you might, like, decrease someone's behavioral, or, you know, through a behavioral approach, how might you progressively decrease someone's anxiety? like let's say they're anxious about going to school what kind of thoughts do you have around what you might recommend as a progression towards that most and I'm not a behavioral therapist I'll say that at front what I have learned from the behavioral therapists I've worked with though is the first step is to more clearly identify what

specific elements of going to school provoke anxiety, and then to break those down into a hierarchy from that which produces only a mild anxiety response all the way up to the thing that would essentially would make the person want to flee in terror. And then starting at the very low end with manageable anxiety, essentially either in imagination, exposing the person to the, you know, the low end of the list in terms of what provokes anxiety

and helping them work through that by repeated exposure until it no longer makes them anxious and then moving up a rung on the letter, if you will, until they can get all the way up to the point of actually, you know, conquering the thing that originally would have made them flee in terror. And that core approach seems to be highly effective. when it's being done by a, you know, a resourceful and talented behavioral therapist. Because I've seen people conquer fears with everything from indeed social anxiety disorder, where the person was able eventually to do the thing that they were initially feared so much they were avoiding it. to simple phobias where people might be, say, afraid of a lizard.

And they start with imagery and they finally get them up to the point where they can actually hold a real lizard in their hand and not be panicked by it. There's a couple common things that I get where we could look at this and give it some examples. Like one would be dating. I've met a lot of people who have a lot of anxiety around dating. let's say you're a guy in your 30s and you have not dated for years and years, right? And like just the even thought of approaching a girl and ask her out on a date is like very anxiety provoking. And so, you know, I like that approach that you talked about where it's like, okay, what are the 10 aspects? Can we break it down even further, right, dating itself into like 10 aspects?

Which of these 10 is the most anxiety provoking of the least anxiety provoking? Yeah. Yeah, creating a hierarchy so that you can start with the least anxiety provoking, and the person can then work their way up. Yeah. Yeah, and then how do you, like, you know, essentially give homework, and then they're running an experiment of sorts with, like, trying to do this thing, this feared task,

starting with the lowest on the spectrum, you know. And if doing it is too much, then starting with their imagination and imagining this, you know, writing out a story or, you know, imagining their head, and then progressively moving through it to where they're able to do and practice it, you know. And I think as well, I like this sort of the acceptance commitment therapy stuff where it's like, can you, one, come back to your values, like why you would. why you might value building a meaningful relationship. And then two, in the midst of the anxiety, can you notice it mindfully and appreciate it and not necessarily judge it or be critical of it,

but almost see the adaptive potential and see it as instead of like a monster, see it as like, you know, a little buddy, a little friend who's trying, who's been trying to help you, protect you, right? Now, it's so idiosyncratic with each individual, right, because there's trauma that often people have with dating or there's trauma, people have interpersonally that can kind of cloud things. So it's not always... Yeah, each person's experiences will greatly shape what it is that provokes an anxiety response for them. although there are some fairly common ones uh you know i'm always amused uh i think the i think it's the new york times publishes every year a list of things that people fear the most and public

speaking is always up near the top uh in fact it not uncommonly outranks dying so uh so indeed uh that's one of those things that a lot of people have a bit of uh fear about. Yeah, once in a while I'll ask someone to be on a podcast, and I get this, there's this like look that comes over their face of like, you want me to kill myself. Is that what you want? I'm like, no, you'll be having a conversation with me.

No one will be in the room, but me and you. It's like, yeah, but you'll be recording us. Are you recording us now? If you're recording us now, I need to know. Yes. Well, again, it comes back down to what we initially touched on. I think for many people with social anxiety disorder is that it's that fear of being scrutinized and judged. And of course, when you're doing something like public speaking, you're intentionally, typically standing up in front of a group of people and, you know, saying something and you're drawing attention to yourself intentionally.

Well, you know, that's a perfect setup for being scrutinized. Oh my gosh, absolutely. it's so it's there I mean there's a lot of things with public speaking I think also with like there's a group of people

like in the audience and it's like there's something about a bunch of eyes looking at you which evokes like a strong danger response right it's like historically

it's a very dangerous situation to have that many eyes on you maybe or something you know yes you don't know if the eyes are or not. And I think it evokes that kind of response, you know, because indeed, if you go back far enough, whether you were accepted or rejected by a group could be a life and death circumstance.

And so, indeed, having a lot of people stare at you, I suspect reawakens what amount to some very deeply buried species memories in terms of why are all these people looking at me? Is this dangerous? Yeah. And like, for those of you are listening, you're like, oh, you know, here's Dr. Cummings and Dr. Peter talking about talking in front of people. And, you know, of course they've never struggled with talking in front of people. But I remember, like, sitting on my podcasting gear for, like, a couple years and, like, recording some episodes, but then being so overly critical of myself. and what I had recorded that, it just never got released. So it's like I feel like there has been a behavioral process that I've been involved.

I don't know if you felt that yourself with being on here or public speaking in general. Not so much for the podcast because by the time we started doing this, I had been doing public speaking for a long, long time. But I do remember initially it was very difficult. And you always worry about, oh, you're going to say something wrong or make a faux pa. At some point, the turning point for me was when I figured out that in general, the audience is on your side. Because, frankly, if you're the person up there talking, they're identifying with you, and frankly, they're to some extent happy. It's not them.

Yeah. Oh, man. And, you know, if you are clearly enjoying it and talking, not at them, but talking with them, it becomes a much more collaborative collegial experience, even if there are hundreds of them and only one of you. Yeah. Yeah, I think I tell myself, like, if someone, the nice thing is to not have people forced to listen.

Like, if people find something about myself or yourself, like, it makes them so upset that they can't listen, then they'll stop listening. listening. They'll listen to something else. And so if they continue to listen, it's often because they've self-selected to continue to listen. So I much prefer to talk to people who choose to listen. And yeah. Well, I think for the person with social anxiety disorder, when they can reach the point where they realize that by and large, people are much more accepting of other people than the person with and anxiety disorder realizes,

you know, because they're imagining this person's scrutinizing me, they're hostile, they think I'm disgusting, despicable, very seldom are people that negative.

People, I often think, people are usually thinking about themselves in social contexts, where it's like, maybe they're not critical of you, maybe they're critical of themselves as well.

and so like your perception is that they may be anxious about or they may be critical. Your perception is they may be critical of you, whereas they may be sitting there critical of themselves thinking about how you're thinking critically of them as well. So it could be like, I think that's more common than the other way around. Yeah, then you have dueling anxiety, yes. But yeah. And I think, indeed, when people can overcome that to the point of realizing that, no, people are not that hostile, it can help them then be more willing to take the risk to perform in public or talk in public or meet people or, you know, eat in public, all of the various forms that social anxiety can take. Yeah. I find that the here and now work of the psychotherapy and the transference and, you know,

getting them to talk about if they feel like you're thinking of them critically or between sessions, they often will, patients sometimes will think like you are thinking critically of them. And then just getting them to put that towards an empathizing with the distress of it is so powerful because over time they'll internalize someone who cares about them, who is not thinking critically of them, who they can, and then through that, they may be able to judge other people's interactions with them more accurately as well. So, for example, like, let's say a patient has had parents who are very critical of them, and so they internalize this critical internal voice.

Maybe that helped them exceed in many domains of life. Maybe they got through medical school because they were constantly berating themselves thinking they weren't doing. good enough, you know, and then they get into their professional life, but then they struggle interpersonally because they are constantly thinking that people are thinking negatively of them. So then they go into therapy and let's say they are able to put that to words with the therapist and find out session by session that the therapist is not thinking critically of them and has empathy for them and compassion for them. And then it's like it can change on some fundamental level, their internal experience.

of how people view them in attachment relationships afterwards. And it also can make the treatment a lot of fun because when they're coming, instead of that anxiety is replaced eventually with gratitude in my experience, if we're able to navigate this well. Very much so. Yeah. Well, I want to make sure we hit all the things that you wanted to talk about this.

Is there anything else kind of floating around in your mind that you definitely wanted to get to. I did want to just mentioned one of the, and I would encourage people to read it, one of the papers I sent to you was a 2020 review of current pharmacological agents for treatment of anxiety.

It's an excellent paper that summarizes a lot of data, puts it into nice tables, and basically points out where the data currently is in terms of what's been supported, what hasn't. and talks about the pros and cons of each class of medication.

So for those of our colleagues who are contemplating using medications to treat social anxiety disorder, that is an excellent paper to get a good overview of the pharmacology in this area in one paper, I think it's seven or eight pages long. So it's a nice, concise source of data. Do they talk as well about how long people need to be treated on certain medications? Like on SSRIs, I think one of the common misunderstandings is like, how long do you need to be treated before it's effective? Well, before it's effective, usually you see onset of some pharmacologic effects within a few weeks.

There is actually a portion of the paper that looks at duration of treatment with pharmacology. and essentially it ranged from a low of around six months to a high of around two years. Because again, the point of the pharmacology was essentially to assist the person in engaging in therapy. Wait. How long? Six months to two years. Two years. Okay, because, so they're finding specifically for this type of issue.

prolonged treatment may be more helpful because it keeps them, it gets them back into life more, and then that getting back into life maybe gives them a behavioral exposure in and of itself, right? Yes, and then eventually they don't need the medication anymore. Now, the other use of medications is very transient, very temporary, which can be the two medications that have shown up mostly in that context are short-acting benzodiazepines, a person has to do something they know is going to be very stressful, what they really need to do it. Benzodiazepine, either single dose or a few doses can help them through such a period. For performance anxiety, particularly where they're going to be doing something where they're talking, they're singing, they're playing an instrument or something, or they're doing an oral exam,

low-dose beta blocker propranol can be very useful. But again, it's usually a one-time dose just for that thing that is going to provoke a lot of anxiety. Yeah, I really have found good success in test anxiety, specifically

with propanolol. I think... At one time in my past, I used to be a board exam. for a while when psychiatry still had an oral board. And indeed, I am aware that a number of the people who were taking that board were, had taken 10 milligrams of propranol before presenting. And indeed, in some cases, I told people who were going to take the board that they should,

because in helping them practice, it was clear that otherwise their anxiety was going to impair their ability to complete the test successfully. Yeah, that's good. I think the other of, well, I don't know if we'll have time to get to this, but just one other thought I had was, like, let's say you wanted to launch your own practice or go out on your own, go venture out in the world of being a therapist or psychiatrist on your own and you're in some sort of, like, group or something. If you think about it like a behavioral experiment or think about it as like one of those things

that you could possibly look at, you know, write down what are the 10 things, aspects of it, or more, what's the most anxiety provoking, what's the least anxiety provoking? And you could kind of create a behavioral journey and maybe get some therapy as well to overcome that. You know, you can apply this to anything, which is nice. Oh, yes. Yes, very much so. You can apply to any fear, anything that you feel like you need to do, but maybe it's just like it feels overwhelming to do it, whether that's like... Yeah, the behavioral hierarchy approach has a lot of utility.

And even beyond people who are dealing maybe with anxiety, if you're just contemplating a new activity, like going out and building a private practice, if you make a hierarchy of, well, what things do I know I can do that I clearly have mastery over? What am I going to struggle with? what's going to be a challenge. And if you put those in a hierarchy,

you can indeed work your way up and stand a much better chance of being successful because you're much less likely to become overwhelmed during this process. Yeah. So great. This was a good. This is a good discussion.

Thank you so much, Dr. Cummings, for coming on. I know people really appreciate you. I get messages quite often of people's thankfulness that you're willing to come on and share your knowledge. So I want to reiterate that to you. Oh, well, thanks. I appreciate doing this. I kind of enjoy it.

As I said, I've gotten over my fear of talking. So in fact, yeah. I think I may have reached that point where the trick is to get me to stop. Oh, no, no, no. I think retirement is like doing what you love and doing more of it. You know? So it's like, it's like, yeah, cut out the 50% of things that you just despise doing and see if you can just lean into those things that you love. So I'm glad this is one of those things that you love because... Yes, indeed. People love listening to you.

Well, thanks. All right, take care. You too. Bye-bye.