Social Phobias - Social Anxiety Disorder and Paranoia

• Fear of situations in which one may be judged
• Fear of embarrassing or humiliating oneself
• Intense fear of interacting or talking with strangers
• Fear of others noticing that you look anxious
• Fear of physical symptoms that may embarrass you, such as blushing, sweating, shaking or shaky voice.
• Avoid doing things or talking to people for fear of embarrassment.
• Avoid situations where you could be the center of attention.
• Having anxiety in anticipation of a feared activity or event.
• Enduring a social situation with intense fear or anxiety
• After a social situation, spend time analyzing your performance and identifying flaws in your interactions.
• Expecting the worst possible consequences of a negative experience in a social situation.

• Blushing
• fast heartbeats
• Tremors
• Sweat
• Stomach pain or nausea
• Difficulty catching breath
• Dizziness or vertigo
• Feeling of mental emptiness
• muscle tension

In social phobia, the fear of not being good enough, funny enough or interesting enough in social situations often leads patients to perceive others as judging them harshly and this is especially true when a person is "convinced" that she is not interesting. Thus, the fear of blushing or making mistakes, etc., causes the patient to overregulate their physical reactions and obsessively focus on the possibility of others noticing their physical reactions. In such situations, people may get nervous about signing their name on official documents, some worry about sweating, blushing or making a mistake. The very attempt to control what cannot be by force leads to the loss of control that the person most fears.

One of the unusual paradoxes is that this phenomenon is more likely to occur in very obsessive people, most often those who fear that they are less than perfect. In such situations, the patient's obsessive attempt to control is actually the root of his problem and his phobic problem is compounded by the fact that he is so capable of trying to stop it. Digestion noises after lunch, shaking hands, blushing, etc. produce in the person a paranoid fear of receiving negative judgment from others. Avoidance of lunch or breakfast, excessive use of make-up or clothing to mask these reactions of fear, favor the extension of the problem to many areas of the person's life. For the socially paranoid individual, when the problem has taken on a pathological rigor, he can either adopt strict measures of avoidance of all social relations, or suffer the humiliation of being forced to cross them, which gives him the impression of a path strewn with pitfalls and failure each time. These experiences leave the person with an unpleasant "reality" in their mind that they are "really" incapable, weak or uninteresting.  

The systemic and circular view of human interaction, problem formation and maintenance is a main feature of our work. This process is perfectly illustrated by social phobia. That is, the very prophecy of the feared event leads to the event of that prophecy. The obsessive focus on physical reactions and the avoidance of any possibility of being rejected or criticized, leads them to appear and feel different. This phenomenon of self-fulfilling prophecy, which is the basis of most paranoid disorders, was proposed by the American sociologist Robert K. Merton. In 1948 he said it was "a supposition or prophecy which, by the mere fact of being spoken, brings about the occurrence of the thing prophesied, thus further confirming the truth of The prophecy". William Thomas also once said that "if men define certain situations as real, they are real in their consequences." In social relationships, if we truly expect a person to be cold or aloof, sociable or outgoing, they will tend to condition themselves to act that way. These social and personal expectations strongly influence the perception we have of ourselves and the effect can be both positive and negative. Those who expect to do well will often succeed better, those who expect to fail in life tend to fail more often. It is for this reason that we tend to avoid talking about social phobia and prefer to talk about paranoid disorder. However, the paranoid disorder can turn into a phobia due to the avoidance of the person and can eventually become a form of delusional paranoia.

A socially paranoid patient may be paranoid not only about the intentions of others, but also about their own abilities and the person's relationship to themselves. People who fall into this category constantly feel bad no matter what they do. Their permanent feeling of depression, following good or bad results in specific situations, leads them to think that they are "not good enough" and to lack confidence in their own abilities or resources. The seemingly simple and uncomplicated interventions we use in our therapy can have a seemingly magical effect. The effects of our first session, if effective, can transform the patient's disorder and thinking from the start. When patients hold a negative and paranoid view specifically focused on themselves and their relationship to themselves, they may exhibit fears of public speaking, giving presentations and job interviews and will develop, more than others, stalled performance or total avoidance in these situations.

Patients who continually feel judged and critically observed by others, express feelings of persecution, abuse, or feel like they are being misinterpreted. These patients end up harboring resentment, anger and rage towards their employers, colleagues, parents, friends and loved ones. They may experience an intense feeling of envy and jealousy towards their colleagues and neighbors and be consumed by anger, which may lead them either to avoid contact with others or, on the contrary, to seek to attack the alleged persecutor who essentially becomes the victim of the alleged victim. In this type of paranoia, the person defends himself against something that does not actually exist. In their minds, they see suspicious activity everywhere and believe that others may be plotting against them and begin to generate a logic of self-protection, believing their own beliefs and observations to be "proof" of their reality. Paranoid episodes of delirium are essentially an invented reality which produces a concrete effect leading the patient to defend himself against something which does not exist in reality and which he nevertheless sincerely believes exists.

So what is the difference between a healthy skepticism or doubt and a real disorder, which involves obsessive paranoia. We can see in this disorder, as in most pathologies, that there is a quantitative and rigid repetition of a behavior that qualitatively transforms it into something very different. Those who suspect and fear, without substantiated evidence, but on the basis of simple clues, real or presumed, may feel persecuted or threatened and may believe that these experiences or events emanate from fate, God, bad luck or fate. . This skeptical attitude towards life conditions the person to be genuinely afraid of living. These episodes can follow experiences of extreme hostility and they can be triggered by real or imagined events. These events can be real and sometimes are. Events such as rejection or relationship breakdown, bullying, or even a traumatic event can precipitate the outcome. These patients are always suspicious, always alert, always ready to defend themselves, and their prophecies are almost always negative. A paranoid patient has a high degree of certainty that his suspicions are correct, rational and entirely justified, he has little or no doubts. This reaction is quite typical of obsessive paranoia. It is precisely the level of doubt versus certainty that constitutes and distinguishes obsessive ideation from paranoid ideation. Certainty is the source of paranoid thinking, which converts subjective knowledge into objective and absolute truth for the paranoid.

Treatment usually depends on how much social phobia affects a person's ability to function in their daily life. The two most common types of treatment for social phobia are CB psychotherapy or medication, or both. In cognitive-behavioral therapy (discussed above), the patient learns to recognize and rationally change the negative thoughts they have about themselves and others. Cognitive-behavioral therapy can be conducted individually or in a group. CBT uses exposure-based therapy, gradually bringing the patient to face their fears through practice, it can be met with great resistance although gains are not always maintained. Patients can also participate in training or role play to practice social skills and gain comfort and confidence in their relationships with others, but many of these interventions can be very distressing and the patient often resists it.

Symptoms of social phobia can change over time. They can be exacerbated in case of stress or demands. Although avoiding situations that produce anxiety may help people feel better in the short term, the anxiety may persist in the long term if they do not seek treatment. Common daily experiences that can be difficult to bear with social phobia disorder include, for example:

During our strategic work with patients, we have observed these main ways in which people try, without success, to solve their problem and these are the mechanisms on which we must act in therapy for the treatment to be effective.

- Patients choose to react continuously by defending themselves before a perceived attack by avoidance or isolation;

- Some patients defend themselves by attacking, verbally or physically, their perceived persecutor;

Social phobia and paranoia

These fundamental and typical solutions above which support the structure of paranoid disorder and they are the avoidance attempt or excessive defense or anticipatory attack towards others. That is, the person overreacts to the slightest provocation or perceived criticism from others because of how they feel. The patient sees aggression or rejection everywhere. A number of social phobia interventions are described below and have proven to be very effective and efficient;

Paranoia

• The anthropologist's prescription - this is an intervention that asks the patient to go and observe the behavior of others in daily life and any concrete evidence of refusal by others towards him. This simple yet complex prescription shifts their focus from themselves to others and works by helping us to subtly challenge their thesis and rigid beliefs. It "opens a mental door" that we can open more and more as each session progresses, moving them from one belief to a new, more functional one with minimal effort and without the question directly.
• Angry letters - by prescribing the writing of angry letters, these patients are asked to express any negativity they may harbor toward other people without expressing it to others on the "hate" list ". This intervention helps to decant their emotion and manage their affect.

Social phobia

Allowing a small mistake, loss of control, or criticism - when the therapist asks the patient to allow a small mistake or loss of control, he is helping him to slowly dismantle his habitual attempts at control. With each session, he progresses from small to larger loss of control, until the disorder is completely resolved.

Worst Fantasy - As previously with all phobic disorders and as described above, this intervention allows the patient to control their phobic reactions to frightening situations.

The above interventions are based on blocking the usual attempts at a solution. In therapy, relating to these patients, especially the paranoid type, involves being able to fully accept their beliefs without them feeling that you are directly questioning them. We have to work by questioning their methods, but not their beliefs from the start. If the relationship is properly calibrated, the clinician can help the patient quickly restructure their perception and start living again. Again, the relationship must be tailored to the requirements of the problem to be solved. Paranoid individuals may seem controlled, cold or detached and we may appear unremarkable and risk losing their confidence if our body language is too open and warm in the initial stages, we need to control how we interact with these patients in the early stages therapy and slowly open up. We must ensure that the patient does not feel criticized or rejected in any way by our communication or our questions.

The treatment of phobias and paranoid disorders by the systemic approach is taught in the third year of the LACT course of the Clinician of the Relationship and in the clinical master of Giorgio Nardone .

• Monophobias, specific phobias and generalized phobias
• Diagnostic criteria for monophobias or specific phobias (DSM-5).
• List of the most common forms of monophobia.
• Dysfunctional solution attempts related monophobias, specific phobias and generalized phobia.
• The treatment of monophobias or specific phobias in brief strategic therapy (strategy, communication and therapeutic relationship).
• Explanation of the therapeutic maneuver "study your enemy".
• Explanation of the therapeutic maneuver "logbook".