The Lonely World of Social Phobia

by John Koenig

Imagine standing in the checkout line at your neighborhood supermarket. You are almost rigid with fear and a familiar feeling 
of impending disaster. Hesitantly you look around.  As you suspected,  all eyes are on you.  They can see right through you. 
Your vulnerability is as plain as if you wore a sign that said,  "I am afraid of you. I am different." The man behind you says something.  
You try to respond.  You try to say something. You try to say anything. No words actually come out. 'You stammer. 
He says, "What did you say?"  You know he must be sure that you are a complete fool. Your mind has gone blank.  
All you want is to be alone in your apartment.

    A nightmare? Well, sort of. It is a description of a typical incident in the life of a social phobic.

Social phobia is an irrational and excessive fear of other people. The Social Phobia Association estimates

that 7% of all Americans suffer from it. Shame and embarrassment are their most common emotions.

Severity ranges from discomfort to immobilization. Sometimes the phobia centers on people in particular situations

 or particular kinds of people. Large gatherings. Strangers. Authority figures. Dating situations. Other times it is 

more generalized extending to family members and other people supposedly close and non-threatening.

The social phobic feels as if he or she is being constantly judged, and found lacking.

How do social phobics cope? Often they respond in a very understandable way. They avoid any 

potentially threatening social interaction. They turn down invitations. They isolate. Often they lead lonely

lives of extreme avoidance and self-inflicted isolation.

All the Lonely People. Where do they all come from?

What causes social phobia? Probably a combination of an innate sensitivity and lack of emotional support

perhaps even oppression, in childhood.  Social phobia is a learned emotional response. Just as we learn to 

speak, ride a bike, read and handle the myriad challenges associated with life, we learn how to perceive

 ourselves in relation to other people. The social phobic defines him or herself as less than others. 

They see themselves as uniquely socially inept. They become preoccupied with what they regard as their defect.

And they endow others with an aura of exaggerated prestige. The problem stems from childhood and is aggravated

by the young social phobics experiences growing up into society. A painful self-fulfilling prophecy is acted out in a

series of reactivating, highly emotional encounters. These crystallize the sufferer's identification of himself as separate

 from and less than others.  These situations might be job interviews that go poorly, social situations such as parties,

 romances gone bad, or downright bullying.  These reinforce the social phobic's view of himself as "less than" others

and in danger of losing control of him or herself at a moment's notice. They come to see other people as threatening

and themselves as lacking any power for self-defense.  Falling apart in public is a common worry of socially phobic

people. They fear social situations where they will simply cease to function appropriately and make a fool out of

himself or herself. Unable to speak. Incapable of thought. Utterly humiliated. Destroyed. Paralyzed with fear. 

Often, they are also troubled by a mistaken belief that others can "see through them" to their fearful, vulnerable core.

Instead of going about their lives, social phobics may literally wish they could sink into the floor and disappear

from sight.  In a way, this is exactly what happens. The social phobic comes to dread a repetition of the feelings

of emotional devastation and, understandably, tries to avoid similar situations in the future. As with any phobia,

their life constricts to eliminate or minimize the possibility of the phobic situation.  Since the fear is of other people,

it can lead to as complete isolation as the social phobic can manage.  Their isolation reinforced the social phobic's 

belief that there is something fundamentally wrong with them. This leads to more avoidance and greater isolation.

The workplace and other situations where they are forced to interact are torturous. Any social activity that can be

avoided is. Yet, ironically, social phobics may be perceived of as "stuck up", "snobby" or "condescending" by people

who don't know that they keep their distance out of crippling fear.  Another irony is that social phobics tend to spend

an excessive time thinking about themselves. Their focus is turned inward instead of outward. 

Social phobia can be a crippling problem that effects every aspect of a person's life. Career. Social. Intimate relationships.  

It is a lonely world.

All the Lonely People. Where do they all belong?

The good news is that there is hope for the social phobic. Psychiatric medication and psychotherapy are both 

often effective in elevating the social phobic's suffering.  Psychiatric medication and a diagnosis of social phobia

are handled between you and your physician. The manufacturers of the anti-depressant Paxil present it as effective

in treating social phobia. They are drawing the public's attention to the existence of this phobia in a series

of television commercials.  But your doctor will have to be the one to prescribe any medication.

The other often effective treatment modality is cognitive behavior therapy. This is a psychotherapeutic approach

whose goal is to change thinking and behavior patterns that plague the social phobic.  A cognitive behavior therapist

guides the client to identify the self-defeating beliefs and thinking patterns that limit his or her life and to replace

these with positive, reality-based perspectives. The therapist then directs the client to reinforce this new thinking

with new behavior. You'll find that David Burns' book Feeling Good: the New Mood Therapy offers a great introduction 

to cognitive therapy.

    Hypnosis can add another dimension by implanting new thinking patterns as post-hypnotic suggestions. 

Hypnotic suggestions can help the client raise their self-image as they learn to see themselves as worthy, whole,

complete and equal to any and all whom they might meet. Hypnosis and visualization also allow the client to

"practice" new behaviors within the safety of a hypnotically induced sensation of relaxation and peacefulness.

In this way the client can gradually desensitize him or herself before reinforcing these ideas in real life. 

If this description of social phobia sounds even a little like your life, please do something about it.  This may

be more difficult than it sounds to the average reader. And many social phobics do not seek treatment. 

They assume this is just "the way they are."  But it is not. It is a learned response. This means it can

be unlearned and that is well worth the effort.  You are not alone. Help is available for the asking.  If you have

a family member or friend who seems to fit this description, you might urge them to take the step.

Sadly, support groups are few and far between. This is possibly due to nature of the phobia.  

If you are interested in starting one yourself, you should visit www.spnewsletter.com/frontdoor.html .'

This is the website of the Alliance for People with Social Phobia. They offer support for people including

starting and running support groups.  You might also try www.socialanxietysupport.com and

www.socialphobia.org  for information and support.

Social Phobia (Social Anxiety Disorder)

Social Phobia (Social Anxiety Disorder), affects some 4% of the population and is the most common anxiety disorder and the third most common psychiatric disorder (after Major Depressive and Dysthymic disorders). Social Anxiety Disorder (the preferred name for the condition), is characterized by an intense fear of situations - usually social or performance situations - where embarrassment may occur. People with the disorder are excessively self-consciousness, and are acutely aware of the physical signs of their anxiety. They have a persistent, intense, and chronic fear of being watched and judged by others and of being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work or school and other ordinary activities. While many people with social phobia recognize that their fears of being around people may be excessive or unreasonable, they suffer them nonetheless. They often worry for days or weeks, in advance of a dreaded situation. Social Phobia (Social Anxiety Disorder) was not established as an authentic psychiatric entity until 1980 when it appeared in the the American Psychiatric Association DSM III.

The onset of Social Anxiety Disorder (SAD) is usually in the teens. It may follow a pattern of social hesitation or shyness, or it may suddenly develop after a humiliating or disturbing experience in public. Social anxiety is often mistaken as shyness, but the two are not the same. Shy people can be very uneasy around others, but they don't experience the extreme anxiety in anticipating a social situation, and they don't necessarily avoid circumstances that make them feel self-conscious. In contrast, people with social anxiety aren't necessarily shy at all. They can be completely at ease with people most of the time, but particular situations, such as walking down an aisle in public or making a speech, can give them intense anxiety. Social phobia disrupts normal life, interfering with career or social relationships. For example, a worker can turn down a job promotion because he can't give public presentations. The dread of a social event can begin weeks in advance, and symptoms can be quite debilitating. Social anxiety is also different from Agoraphobia. Agoraphobia is a condition which develops when a person begins to avoid spaces or situations associated with anxiety or panic attacks. Typical "phobic situations" might include driving, shopping, crowded places, traveling, standing in line, being alone, meetings and social gatherings. [NOTE: As Agoraphobia almost always occurs with panic disorder, if you suffer from Agoraphobia please submit your rating in the RemedyFind Panic Disorder section.]

Both, women and men are equally likely to develop social anxiety. It usually begins in childhood or early adolescence, and there is some evidence that genetic factors are involved. Social anxiety often co-occurs with other anxiety disorders or depression. Substance abuse or dependence may develop in individuals who attempt to "self-medicate" their social phobia by drinking or using drugs. Social anxiety can be treated successfully with carefully targeted psychotherapy or medications.

SOCIAL PHOBIA

Published in Perpectives Magazine - January 2000

by Sarah Chana Radcliffe, M.Ed., C.Psych.Assoc.

Many people suffer silently with a devastating disorder - social phobia. Indeed, one out of twelve people - 8.2% of the population - are afflicted but almost none of them seek or receive treatment! The reason for this is two-fold: 1) this common disorder is rarely asked about during routine interviews in doctors' offices or even in psychiatric facilities and 2) sufferers tend to think of it as a "personality" thing rather than a mental health problem and they therefore don't come forward for treatment. The result is high costs for both individuals and society.

Social Phobia

By NIMH
Social phobia is an intense fear of becoming humiliated in social situations, specifically of embarrassing yourself in front of other people. It often runs in families and may be accompanied by depression or alcoholism. Social phobia often begins around early adolescence or even younger.

If you suffer from social phobia, you tend to think that other people are very competent in public and that you are not. Small mistakes you make may seem to you much more exaggerated than they really are.

Blushing itself may seem painfully embarrassing, and you feel as though all eyes are focused on you. You may be afraid of being with people other than those closest to you.

Or your fear may be more specific, such as feeling anxious about giving a speech, talking to a boss or other authority figure, or dating. The most common social phobia is a fear of public speaking.

Sometimes social phobia involves a general fear of social situations such as parties. More rarely it may involve a fear of using a public restroom, eating out, talking on the phone, or writing in the presence of other people, such as when signing a check.

Although this disorder is often thought of as shyness, the two are not the same. Shy people can be very uneasy around others, but they don't experience the extreme anxiety in anticipating a social situation, and they don't necessarily avoid circumstances that make them feel self-conscious.

In contrast, people with social phobia aren't necessarily shy at all. They can be completely at ease with people most of the time, but particular situations, such as walking down an aisle in public or making a speech, can give them intense anxiety.

Social phobia disrupts normal life, interfering with career or social relationships. For example, a worker can turn down a job promotion because he can't give public presentations. The dread of a social event can begin weeks in advance, and symptoms can be quite debilitating.

People with social phobia are aware that their feelings are irrational. Still, they experience a great deal of dread before facing the feared situation, and they may go out of their way to avoid it.

Even if they manage to confront what they fear, they usually feel very anxious beforehand and are intensely uncomfortable throughout. Afterwards, the unpleasant feelings may linger, as they worry about how they may have been judged or what others may have thought or observed about them.

About 80 percent of people who suffer from social phobia find relief from their symptoms when treated with cognitive-behavioral therapy or medications or a combination of the two. Therapy may involve learning to view social events differently; being exposed to a seemingly threatening social situation in such a way that it becomes easier to face; and learning anxiety-reducing techniques, social skills and relaxation techniques.

The medications that have proven effective include selective serotonin reuptake inhibitors, MAO inhibitors and high-potency benzodiazepines. People with a specific form of social phobia called performance phobia have been helped by drugs called beta-blockers. For example, musicians or others with this anxiety may be prescribed a beta-blocker for use on the day of a performance

The Social Phobia Group

What is Social Phobia?
Social Phobia is a fear that other people are thinking negatively about you. A person with Social Phobia worries about saying or doing something embarrassing, making mistakes, not looking right or not behaving as they think they should. The person also worries a lot about looking anxious or nervous, for example sweating, having a trembling voice, shaking or blushing.

Difficult situations include public speaking, parties, writing or signing ones name when other people are watching, standing in line, speaking on the phone with other people around, eating or drinking in public, using public toilets and travelling on public transport.

A person with Social Phobia either puts up with the feared situation with intense anxiety and discomfort, or just avoids it. Sometimes they use alcohol or drugs to help them relax in the difficult situation.

What is the impact of Social Phobia?
Social Phobia has an enormous impact on the person. Obviously self esteem, how much you respect and value yourself, is terribly affected. It’s difficult to feel positively about yourself if Social Phobia is limiting what you can and can’t do.

Avoiding situations such as those listed above can affect promotion at work, for example if you decide not to pursue or take a promotion because it may involve an interview, or having to present reports in a new position. Career choice can be determined based on avoiding feared situations. Performance at university may suffer if speaking up in tutorials is difficult. At times people leave university because it is just too difficult to attend tutorials or lectures. Developing friendships can be impossible if you can’t get out socially to meet people, or you’re too nervous when in a social situation to connect with people. Similarly developing intimate relationships can be very difficult if you just can’t get out to meet people, or can’t relax enough when with people. If you do have a close relationship there may be tension if you prefer to stay home because socialising is too difficult.

Social Phobia is very stressful to deal with, and it can seem to be an overwhelming problem. It’s not surprising then that 70 percent of people with Social Phobia develop depression. The feelings that come with depression, such as feeling very low, not enjoying anything, having little energy and motivation to do anything, compound the problems of Social Phobia. If you use alcohol, medications such as tranquillisers, or illegal drugs such as marijuana to cope, you can wind up with other problems as well.

How does Social Phobia develop?
It is likely that there’s more than one factor that contributes to the development of Social Phobia. It may be a combination of a person’s innate nature, or personality, and other factors such as family relationships and early friendships. It is also likely that the precise reasons for the development of this problem vary from person to person.

How do you treat Social Phobia?
The research suggests that Cognitive Behaviour Therapy or CBT is most useful to overcome Social Phobia. CBT has been around for approximately 50 years. Very simply, this type of therapy focuses on how a person’s thinking (cognition) influences their feelings and behaviour. For example, if you worry and go over and over an anticipated social situation you’re probably going to feel fearful about going along to the event, and may in fact decide not to go.

There are three important elements to manage Social Phobia:

1	Learn to control the anxiety and panic so that symptoms don’t become very distressing. This also involves learning how to tolerate anxiety symptoms and not try to hide them, learning helpful techniques to control symptoms, and building some regular relaxation into your lifestyle so that you can approach life in a more relaxed manner generally.
2	Examine and challenge things that you’re saying to yourself that aren’t helping you.
3	Gradually face the situations that you fear, or learn to be more relaxed in situations that at present you simply endure with great distress.

Individual work with a psychologist is helpful to learn to manage Social Phobia. Research also suggests that group work is very helpful. An obvious advantage of group work is the opportunity to meet and talk with other people who have similar difficulties. Group work is also important because it exposes you to what is a challenging situation, in a very supportive atmosphere

Social Phobia is an anxiety disorder characterized by an intense, persistent fear and avoidance of social situations. This extreme fear of being judged or embarrassed may put a life on hold. Those who suffer may avoid social situations at all costs or tolerate them with great discomfort.

During social situations, or even before them, patients may experience some or all of the following symptoms: Excessive sweating, trembling, blushing, experience a pounding heart beat, feelings of confusion or a desire to flee the situation.

Social Anxiety can affect every day decisions. Sufferers ask themselves, "what do I feel comfortable doing?" instead of "what do I want to do?" People with Social Phobia are at higher risk for depression, alcoholism and even suicide. Also, long term relationships and professional success are often drastically limited.

What is Social Phobia (Social Anxiety Disorder)?

Social phobia, also called social anxiety disorder, involves overwhelming anxiety and excessive self-consciousness in everyday social situations. People with social phobia have a persistent, intense, and chronic fear of being watched and judged by others and being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work or school, and other ordinary activities. While many people with social phobia recognize that their fear of being around people may be excessive or unreasonable, they are unable to overcome it. They often worry for days or weeks in advance of a dreaded situation.

Social phobia can be limited to only one type of situation- such as a fear of speaking in formal or informal situations, or eating, drinking, or writing in front of others-or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people. Social phobia can be very debilitating-it may even keep people from going to work or school on some days. Many people with this illness have a hard time making and keeping friends.

Physical symptoms often accompany the intense anxiety of social phobia and include blushing, profuse sweating, trembling, nausea, and difficulty talking. If you suffer from social phobia, you may be painfully embarrassed by these symptoms and feel as though all eyes are focused on you. You may be afraid of being with people other than your family.

People with social phobia are aware that their feelings are irrational. Even if they manage to confront what they fear, they usually feel very anxious beforehand and are intensely uncomfortable throughout. Afterward, the unpleasant feelings may linger, as they worry about how they may have been judged or what others may have thought or observed about them.

Social phobia affects about 5.3 million adult Americans.1 Women and men are equally likely to develop social phobia.10 The disorder usually begins in childhood or early adolescence,2 and there is some evidence that genetic factors are involved.11 Social phobia often co-occurs with other anxiety disorders or depression.2,4 Substance abuse or dependence may develop in individuals who attempt to "self-medicate" their social phobia by drinking or using drugs.4,5 Social phobia can be treated successfully with carefully targeted psychotherapy or medications.

Social phobia can severely disrupt normal life, interfering with school, work, or social relationships. The dread of a feared event can begin weeks in advance and be quite debilitating.

About Anxiety in Adults

What is Anxiety?

Anxiety is a common emotion that is needed to survive and is experienced by all people. Other words used to describe the emotion include fear, shyness, worry, nerves, or stressed. People differ in the extent and degree to which they experience anxiety and in the types of situations that produce anxiety. When an individual experiences anxiety to such an extent or in such situations that it reduces their enjoyment or functioning in life, they might consider seeking help.

Types of Anxiety Problems

When people have a problem with anxiety, it commonly takes one of several main forms. Of course it is important to note that anxious individuals often experience more than one of these forms of anxiety.

Social Fears

People who suffer what is often called social phobia or social anxiety disorder are typically highly shy. That is, they worry a great deal about what other people will think about them. As a result of these worries, they fear or even avoid social activities such as going on dates, attending meetings, giving talks, being assertive, and even writing or drinking in front of other people.

Generalised Anxiety

People who suffer from what is known as generalised anxiety disorder are characterised by high levels of worry. Typical areas of worry include family, health, career, finances and especially daily, minor events and hassles. For people with generalised anxiety, their worries seem to be out of control and take up a large part of their day.

Panic Disorder

People who suffer panic disorder experience a number of panic attacks. Panic attacks involve a sudden rush of fear together with many physical symptoms including palpitations, dizziness, breathlessness, and shakiness. In many cases, there is also a strong feeling that one is about to pass out or even die. Panic attacks may lead to further avoidance such as not wanting to go out without a partner, not wanting to catch public transport, or avoidance of trapped spaces such as cinemas, lecture halls, and being stuck in traffic. In these cases, panic disorder is said to be accompanied by agoraphobia.

Obsessive Compulsive Disorder

People with obsessive compulsive disorder usually experience fearful thoughts, images, or even urges, which run through their minds over and over again in a repeated pattern. Some common themes include thoughts about contamination and germs, images of losing control, feelings that things are not "just right", or thoughts about things not being in the right order or not being completed. These thoughts or urges often lead to particular actions that are repeated over and over and are aimed at preventing or undoing the beliefs. For example, people might wash themselves repeatedly, check repeatedly, or repeat certain signs or phrases.

Post-Traumatic Stress Disorder

From time to time, many people in our society will go through a traumatic, life-threatening event such as a rape, car accident, or natural disaster. Following these events, it is common to experience extreme distress, often lasting for some time. In most cases, this distress decreases with time. When the distress is especially high and does not seem to decrease over the expected time, it is oven referred to as a post-traumatic reaction. People who experience post-traumatic reactions often report quite marked symptoms such as a blank memory for the event, strong feelings of unreality, extreme jumpiness, and sleep difficulties.

Treatment for Anxiety Problems

The good news is that there are a number of very effective treatments now available for anxiety disorders. These include various medications and psychological treatments. Scientifically, the best-studied and most demonstrated techniques include medications such as tricyclic antidepressants and SSRIs and the psychological techniques often referred to as cognitive behavioural therapy (CBT).

At the Macquarie University Anxiety Research Unit we offer cognitive behavioural therapy for all of the anxiety disorders as well as for problems related to anxiety such as depression, relationship difficulties, or work-related problems. Our research-based programs are currently focussing on social anxiety and generalised anxiety. Further information on these programs can be obtained by clicking on the relevant heading at the top of this page. We also offer individual therapy for anxiety-related problems, that are not the focus of current research, from psychologists who are highly trained and specialised in delivery of treatments for anxiety. Further information on clinical services can be obtained by clicking here.

From Social Phobia To Social Skills

Very often discussions of social phobia lead nowwhere because nobody is asking the question: what can we focus on as a solution?

There are three powerful ways to make progress and take charge of social phobia.

1. Develop better social skills

When social phobia is not addressed by an effort to improve your social skills a downward spiral can take over - you feel anxious and you communicate poorly so you feel even more anxious.

Even the simple goal of working to improve social skills can go a long way towards improving your quality of life as long as you also take charge of your nerves.

2. Learn to deal with social anxiety

The anxiety that comes with social phobia can be managed to some degree by puttting time into meditation, relaxation exercise and visualization.

And yes these techniques do work as long as you use them daily. the best approach is to use one before you start your day and last thing before going to sleep in the evening.

3. Plan to improve social skill gradually

You can slowly but surely take charge of your social phobia issues by dedicating yourself to a step by step plan of action - aim to make small yet gradual improvements one day at a time. Think about it. Even a small progression from where you are now is worthwhile.

Social phobia can be managed to some degree when you start focuing on the positive i.e. how to improve your social skills and manage your anxiety.

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Tratamento Farmacológico: Fobia Social

Marcio Versiani
Ivan Figueira
Programa de Ansiedade e Depressão
Universidade Federal do Rio de Janeiro

18 Apr 1996

Indicações

Como no caso do Transtorno do Pânico o diagnóstico, por si só, de Fobia Social pelos critérios DSM-IV ou CID-10 não é uma indicação para o tratamento farmacológico. Mais importante do que o diagnóstico, de acordo com critérios científicos ou operacionais, é o julgamento clínico, escasso em ambos os sistemas. Os critérios diagnósticos para Fobia Social são menos operacionais do que aqueles do Transtorno do Pânico, o que dá mais liberdade ao clínico. O importante é saber se os sintomas são realmente incapacitantes, ou muito relevantes no sentido de perturbar a vida da pessoa.

A Fobia Social é também diferente do Transtorno do Pânico, da Depressão ou do Transtorno Obsessivo Compulsivo na medida em que compreende sintomas previsíveis em função de certas situações ou estímulos. Não é um transtorno contínuo, como na depressão ou algo que pode se manifestar a qualquer momento, sem aviso, como no Pânico.

Essas características são importantes para a indicação do tratamento farmacológico. As definições diagnósticas procuram, como de hábito, a sintomatologia mais evidente e mais fácil de ser detectada pelo clínico -- sintomas de ansiedade em situações sociais. Não se aprofundam, contudo, no interregno entre os estados de ansiedade que ocorrem nas situações sociais. Em outras palavras, como o indivíduo se sente no dia a dia, mesmo sem contacto com situações que induzem ansiedade. Esses períodos, os mais constantes da vida da pessoa é que são os alvos primordiais do tratamento farmacológico e/ou psicoterápico -- a qualidade de vida do paciente.

Na Fobia Social, subtipo Generalizada, a indicação do tratamento farmacológico é mais fácil, uma vez que o comprometimento da vida pessoal é amplo, e quase sempre, incapacitante. Já na Fobia Social, subtipo Circunscrita, a indicação é mais difícil. Exemplo: um cirurgião de renome, excelente profissional, com vida pessoal e familiar sem problemas, inclusive uma vida social particularmente rica e gratificante; que não consegue assinar cheques na frente de estranhos, principalmente travellerâs checks (aqueles que têm que ser assinados sob a observação atenta de um funcionário de uma loja ou de um banco). Quando tenta fazê-lo, treme, sente intensa ansiedade com sudorese, taquicardia e outros sintomas e a assinatura fica totalmente diferente. Contorna o problema com atitudes do tipo, assina cheques no consultório, depois enviados ao banco, em viagens sua esposa lida com os famigerados travellerâs checks, usa muito dinheiro em espécie para fazer compras. Ri de tudo isso e, aparentemente, não se incomoda com o problema. Não sente qualquer sintoma de ansiedade relevante durante as cirurgias que pratica. Tratamento farmacológico para um paciente como esse? Nem pensar. Dentre outros motivos porque os medicamentos interfeririam de modo sério em sua atuação como cirurgião.

Outro exemplo: uma senhora que não consegue assinar escrituras de imóveis, listas de votação em eleições ou outros documentos que julga serem muito importantes, na frente dos outros. Só consegue fazê-lo se tomar uma dose relativamente alta de um benzodiazepínico uma a duas horas antes. No mais sua vida é normal em todos os sentidos, inclusive com uma vida social ativa. De novo, é um caso no qual não se deve pensar em tratamento farmacológico contínuo. Não há evidência de tendência a abuso de drogas. Só usa os benzodiazepínicos nessas situações circunscritas, que não são frequentes.

Há casos peculiares, quando um sintoma apenas, perturba de modo considerável a vida do paciente e o tratamento farmacológico e/ou psicoterápico deve ser considerado. Um executivo que sofre de crises de sudorese intensa em diferentes tipos de contacto social, festas, reuniões de negócios, às vezes encontros casuais com pessoas na rua. A sudorese é tão intensa que as pessoas notam e fazem perguntas do tipo: "Está acontecendo alguma coisa. O Sr. está passando mal?" O que piora a intensidade e a duração da sudorese. Tentou diversas manobras para tentar evitar ou minimizar o problema : "Sofro de hipoglicemia e isso às vezes me acontece", em resposta aos comentários dos circunstantes. Mas não funcionam e até, eventualmente, complicam ainda mais a situação pois é bombardeado com outras perguntas e sugestões de médicos e tratamentos. Aí, então, a sudorese não cessa de aumentar. O sintoma, em virtude disso, passou a limitar consideravelmente a vida do paciente. O que mais deseja é ficar quieto em casa, livre da possibilidade de mais um vexame.

Na Fobia Social Generalizada a incapacitação é muito grande. O paciente fica extremamente limitado, quase não consegue realizar atos corriqueiros, que envolvam algum contacto social. Aí sim o tratamento farmacológico contínuo deve ser indicado. Sem se perder de vista a tradicional relação risco-benefício. Os efeitos indesejáveis dos medicamentos são consideráveis e perturbam a vida do paciente. Isso precisa ser contraposto aos benefícios do tratamento.

Para se aferir a gravidade de um caso três parâmetros devem ser investigados -- a frequência, a gravidade dos sintomas de ansiedade e suas consequências (o grau de evitação fóbica e o nível de incapacitação que tudo isso representa). Além disso, como a Fobia Social é um transtorno, em analogia com a alergia, dependente de estímulos externos para se manifestar -- o contexto de vida do paciente precisa ser também explorado. Em amostras clínicas de fóbicos sociais predominam homens ao contrário de pesquisas epidemiológicas quando são mais frequentes as mulheres. Uma explicação plausível para essa diferença seria que os homens são mais obrigatoriamente expostos a contactos sociais.

Na indicação do tratamento farmacológico essas diferenças entre contextos de vida têm importância. Surge aí a Dona de Casa que sofre de Fobia Social. Tem uma vida adaptada e aprovada pelo marido, mas evita festas, reuniões, contactos sociais em geral. Isso não resulta em maiores problemas. Nota-se, entretanto, um considerável nível de infelicidade. Intervir ou não em um caso como esse, com um medicamento, é uma questão difícil e que deve ser exaustivamente discutida com a paciente, e com sua família.

Nos casos extremos de gravidade a indicação do tratamento farmacológico é clara, principalmente quando a incapacitação profissional é muito acentuada. Pessoas que recusam ou não suportam progressões funcionais devido ao maior contato com pessoas. Pacientes que têm suas vidas familiares restringidas a um ponto quase intolerável. O caso, p.ex., que não pôde ir ao casamento do único filho. Há pacientes, e muitos, que vão restringindo seu âmbito de atuação e/ou atividades a um nível mínimo, apenas para garantir a sobrevivência. Se pudessem, viveriam em uma toca sem qualquer contacto interpessoal.

A Fobia Social é um transtorno crônico, sem grandes ou significativos períodos de remissão (Versiani). Esse é outro ponto a ser considerado na indicação do tratamento farmacológico. Maior cuidado ainda com a relação risco-benefício, em função da provável duração prolongada do tratamento contraposto à possibilidade de se mudar radicalmente a qualidade de vida de um indivíduo sofrendo de algo muito incapacitante.

Início do Tratamento e Escolha do Medicamento

O paciente que sofre de Fobia Social procura o médico muitos anos depois que seu transtorno começou (nem ele nem nós sabemos exatamente quando). Vem de uma trajetória por poucos tratamentos médicos (ao contrário do Transtorno do Pânico) e sem grandes esperanças em relação a possibilidades terapêuticas, medicamentosas ou psicoterápicas. Pensa que é assim, não está assim. Como desde o final da adolescência passou a sentir os sintomas e as dificuldades deles decorrentes não se considera um doente, mas alguém que é diferente. Seus familiares e amigos confirmam isso.

Estamos diante de um caso que é, de certa forma novo, na medicina e na psiquiatria (como a distimia, a depressão menor, vista como personalidade depressiva, até pouco tempo atrás). Cabe, então, esclarecer o paciente que pesquisas, relativamente recentes, indicam que seu problema pode ser tratado por métodos farmacológicos e/ou psicoterápicos. Como no Transtorno do Pânico, essa orientação vai ser recebida com muito entusiasmo e muitas dúvidas. Como um medicamento e/ou uma psicoterapia podem mudar minha maneira de ser?

A resposta do clínico é positiva, com os devidos cuidados. O medicamento pode, sim, mudar sua condição de vida -- abolir os sintomas de ansiedade e a evitação fóbica. Mas, com todas as precauções necessárias -- cuidadoso acompanhamento médico de efeitos indesejáveis ou de novos transtornos do comportamento. Como se verá neste capítulo a libertação do fóbico social nem sempre é uma benção.

Ensaios clínicos controlados, em comparações com Placebo, de modo duplo-cego, demonstraram que três medicamentos são eficazes no tratamento da Fobia Social: fenelzine (Nardil) (que não é disponível no Brasil), clonazepam (Rivotril) ou moclobemida (Aurorix). Em um ensaio aberto, durando um ano de seguimento, foi demonstrado que a tranilcipromina (Parnate) é, também, muito eficaz. A tranilcipromina é um Inibidor da Monoamino-Oxidase, semelhante em ações, ao fenelzine, e, portanto, os resultados dos estudos duplo-cego com o fenelzine podem ser extrapolados para o estudo aberto com a tranilcipromina, quanto à eficácia.

Esses medicamentos são os mais estudados no tratamento da Fobia Social. O que não significa que outros sejam ineficazes. É natural, que o tratamento inicial seja feito com eles, no presente. Não há dúvida quanto à eficácia dos Inibidores clássicos da monoamino-oxidase (fenelzine ou tranilcipromina), em seguida vêm o clonazepam e a moclobemida, o último um IMAO de segunda geração, sem os problemas dos anteriores (não induz crises hipertensivas em interações com queijo -- tiramina -- ou com medicamentos simpatomiméticos).

Outros medicamentos, especialmente, o grupo dos inibidores seletivos da recaptação da serotonina (ISRS) estão sendo estudados em ensaios controlados e representam tratamentos promissores. Outros benzodiazepínicos, além do clonazepam, o alprazolam (Frontal) e o bromazepam (Lexotan) tiveram sua eficácia comprovada em ensaios clínicos duplo-cego, contra placebo.

Apesar da eficácia comprovada em ensaios clínicos controlados contra placebo os IMAOs clássicos, especialmente o fenelzine ou o seu congênere a tranilcipromina (estudada em ensaio aberto de longa duração) não podem ser considerados tratamentos de primeira escolha para a Fobia Social. Isso porque podem induzir crises hipertensivas graves, com sequelas irreversíveis ou morte em função de interações com medicamentos ou substâncias simpatomiméticas (a reação induzida pela tiramina, p.ex., presente em queijos, principalmente os mais fermentados). Foi dito, quanto ao tratamento do Transtorno do Pânico, que esses medicamentos apesar de mais eficazes não são, também, os mais aconselhados. Na Fobia Social essa afirmação deve ser ainda mais enfatizada. Apesar de muito incapacitante a Fobia Social é muito mais crônica e os sintomas ocorrem, apenas, em determinadas situações, o que equivaleria a submeter o paciente, caso tomasse um desses medicamentos, a uma constante espada de Dêmocles, durante anos e anos, mesmo durante os períodos nos quais está assintomático.

No Programa de Ansiedade e Depressão do Instituto de Psiquiatria da Universidade Federal do Rio de Janeiro, os IMAOs clássicos, fenelzine ou tranilcipromina, são reservados para casos muito graves e resistentes a outros tratamentos : Depressão (principalmente a refratária) e Transtorno do Pânico, Fobia Social ou o Transtorno Obsessivo Compulsivo, que não respondem a tratamentos menos perigosos. Nesses casos os IMAOs clássicos são receitados, mas com cuidados especiais -- exaustiva orientação oral e por escrito das precauções em relação à dieta ou ao uso de outros medicamentos, explicação do que é a crise hipertensiva induzida por IMAOs, carregar no bolso ou na bolsa dois comprimidos de nifedipina (Adalat) 10 mg, um bloqueador de canal de cálcio, o melhor tratamento emergencial para a crise hipertensiva, a ser mastigado depois de seu início. Com tudo isso evitamos acidentes mais graves.

Os acidentes mais preocupantes são as crises hipertensivas espontâneas ou endógenas, descritas por Kline, que ocorrem sem motivo aparente. Hipóteses para explicar esse tipo de crise hipertensiva existem, o metabolismo bacteriano no intestino produzir tiramina. Ex: uma paciente atendida no Programa de Ansiedade e Depressão, às 12:00 hs., sem ter almoçado, depois de um café da manhã singelo, sem qualquer possibilidade simpatomimética (nenhum queijo, leite e café apenas), tomando tranilcipromina (Parnate), 30 mg/dia. Saiu da consulta, dirigindo seu carro, e no trajeto para casa sofreu de uma crise hipertensiva grave (mal estar total, cefaléia lascinante, tonteiras, dor na nuca). O carro mal parado gerou o atendimento de circunstantes que a levaram para o pronto socorro mais próximo. Pressão 24 máxima, 16 mínima, sem qualquer história prévia de hipertensão (pessoal ou familiar). Os médicos do pronto socorro receberam a orientação de dar nifedipina (Adalat) 20 mg sub-lingual, e o episódio hipertensivo foi resolvido, sem qualquer consequência, apenas com muita cefaléia no dia seguinte. Um episódio como esse é apavorante.

É uma pena, pois os IMAOs tradicionais são muito mais eficazes do que os outros medicamentos para o tratamento dos Transtornos Depressivos ou de Ansiedade.

Se levarmos em conta o que existe de informação, nos estudos controlados existentes, a ênfase na escolha do primeiro medicamento para o tratamento da Fobia Social recairá sobre benzodiazepínicos de alta potência -- clonazepam ou alprazolam ou em um IMAO reversível a moclobemida.

O clonazepam (Rivotril) foi o medicamento mais empregado no Programa de Ansiedade e Depressão da U.F.R.J. Já foram, ou estão sendo tratados, mais de trezentos casos de Fobia Social com esse medicamento. Essa escolha, que está sendo revista, como se verá neste capítulo, deveu-se a eficácia acentuada demonstrada em estudo aberto (Versiani) depois confirmada em estudo duplo-cego (Davidson), além de um perfil favorável de ações farmacológicas para um benzodiazepínico: meia vida longa, menor sedação, eventual efeito estimulante, e possível maior facilidade para descontinuação.

O tratamento é iniciado com 2 mg/dia divididos em duas tomadas, 1 mg no almoço e 1 mg ao deitar (meio comp. de 2 mg, duas vezes ao dia). Caso o paciente sinta sonolência muito intensa, durante o dia, pode ficar uma semana ou mais tempo, tomando apenas 1 mg ao deitar (meio comp. de 2 mg). Na medida em que a sonolência diurna vai desaparecendo (tolerância) a dose é aumentada para 3 mg/dia (meio comp. de 2 mg, de manhã, à tarde e ao deitar). A dose ideal do clonazepam, na Fobia Social situa-se entre 3 e 6 mg/dia. Três metades de comprimidos de 2 mg ou três comprimidos inteiros de 2 mg, tomados três vezes por dia.

O resultado terapêutico é muito rápido, mais até do que desejamos. Uma, duas, três semanas nesse esquema (com Rivotril), o paciente começa a dizer que é uma nova pessoa, está fazendo coisas que nunca fez, assina na frente dos outros, frequenta reuniões, almoça na presença de estranhos, conversa espontaneamente com todo mundo, fala para pequenos grupos, enfim sua vida mudou! O paciente fica maravilhado com a mudança e, aí já existe um perigo. Essa alteração muito célere de padrões de comportamento de mais de dez anos de duração, resulta numa ruptura que é notada pelos outros e nem sempre é aceita.

A melhora dos sintomas da Fobia Social é muito bem vinda pelo paciente. Ex: Uma funcionária de multinacional, uma mulher muito bonita, que vinha tendo vários problemas em função de seu transtorno, tanto na esfera pessoal quanto profissional, inclusive rejeitando promoções para não ter mais contactos com pessoas. No trabalho, os homens a abordavam, com frequência, com propostas do tipo -- você quer almoçar comigo? Após três semanas de Rivotril começou a reagir a essas propostas, que antes a incomodavam e humilhavam, com respostas como -- na realidade o que você pretende, almoçar ou outra coisa? E mais importante, olhando no olho do homem, algo que nunca havia feito antes. O resultado -- em duas semanas pararam de convidá-la para almoços.

Uma outra paciente tinha o problema, sério, de não poder assinar na presença de estranhos, especialmente cheques. Após duas semanas de Rivotril foi a um shopping center grande e, comprou mais de quarenta items, todos de valor pequeno, pagos com cheques. Fiz uma verdadeira farra, assinei cheques a valer, sem problemas, comprei até revistas com cheques, estou curada! A mesma paciente, professora de curso secundário, tinha enorme dificuldade em ir ao trabalho -- problema: assinar o ponto, quase sempre com alguém em volta. Como com os cheques a dificuldade se resolveu, rapidamente com o tratamento medicamentoso.

O executivo que se aposentou precocemente, aquele que não pôde ir ao casamento do único filho, depois de meses (três a quatro) de tratamento com Rivotril, reiniciou, lentamente, uma vida normal. Assumiu um novo emprego, começou a fazer compras, sair de casa, visitar amigos -- tudo com um novo gosto pela vida. Suas limitações eram tantas, anteriormente, que não conseguia explicar bem onde tinha melhorado. Não ficou deslumbrado com os efeitos do tratamento. Homem sério e muito cônscio de suas atuações, continuava a se preocupar com qualquer deslize na sua performance social. De qualquer modo, usufruiu de uma melhora muito considerável.

Com a moclobemida, a partir de estudo duplo-cego controlado (Versiani et al.) mais um grande estudo multicêntrico com muitos casos (Katschnig) obteve-se evidência de que o medicamento é eficaz no tratamento da Fobia Social. Menos do que com os inibidores clássicos da monoamino-oxidase (fenelzine), no primeiro estudo, mas com uma relação risco-benefício mais favorável. O estudo multicêntrico, com grande número de casos lidou com uma comparação com placebo, na qual a moclobemida, foi superior ao placebo em doses de 300 mg/dia ou de 600 mg/dia, e foi detectada uma curva dose resposta. Isto é, a dose de 600 mg/dia foi superior a de 300 mg, ambas superiores ao placebo, quanto à eficácia. Esse estudo feito com 578 pacientes, é o mais completo até o momento na Fobia Social. A curva dose-resposta é uma evidência das mais importantes, quanto à eficácia de um medicamento.

A moclobemida induz um efeito terapêutico bastante diferente daquele do clonazepam ou do alprazolam. Demora mais para se manifestar, dois, três meses, enquanto os benzodiazepínicos de alta potência agem em duas, três semanas. Além disso, o efeito terapêutico é suave, vai crescendo gradualmente, nada de de uma revolução súbita na vida da pessoa. Os efeitos positivos, são, contudo, significativos do ponto de vista clínico e até mais seguros pois há pouca toxicidade comportamental, poucas mudanças radicais de comportamento.

Ainda há poucas evidências quanto à eficácia dos Inibidores Seletivos da Recaptação da Serotonina no tratamento da Fobia Social. Estudos abertos sugerem a eficácia da fluoxetina e um estudo controlado com a fluvoxamina.

O que interessa ao clínico é que esses medicamentos novos -- nessa indicação (Fobia Social) -- não têm eficácia comprovada e demorarão a tê-la, em função das complexidades metodológicas envolvidas nesse tipo de pesquisa.

O que não deve impedi-lo (o clínico) de receitar esses medicamentos em um caso de Fobia Social. É um transtorno novo, quanto à pesquisa psiquiátrica ou tratamento farmacológico e, mesmo, quanto à terapia psicoterápica. Grave e incapacitante merece abordagens inovadoras, se bem que com todos os cuidados, para se evitar efeitos indesejáveis perigosos de medicamentos, e por quê não, também de psicoterapias.

A fluoxetina (Prozac), a paroxetina (Aropax) ou a sertralina (Zoloft), os inibidores seletivos da recaptação da serotonina (ISRS) podem ser eficazes no tratamento da Fobia Social e, como vantagem, têm um perfil de efeitos indesejáveis muito mais favorável do que aqueles do clonazepam ou dos IMAOs clássicos (fenelzine, tranilcipromina). Não são, contudo, medicamentos inócuos quanto a efeitos indesejáveis. Têm seu próprio perfil, talvez menos perigoso do que os anteriores, mas nem por isso menos incomodante.

A fluoxetina é iniciada com 20 mg pela manhã. A dose pode ser aumentada até 60 mg/dia (3 caps. pela manhã). A sertralina pode ser dada à noite, pois tem certo efeito sedativo, em doses de 50 a 200 mg/noite (1 a 4 comps. ao deitar). A paroxetina pode ser dada de manhã ou ao deitar, pois pode tanto perturbar o sono como favorecê-lo, em doses semelhantes às da fluoxetina, i.e., 20 a 60 mg/dia ou noite (1 a 3 comps. pela manhã ou à noite).

Agora a questão é qual desses medicamentos escolher em um determinado caso de Fobia Social? Os mais eficazes e de efeito mais rápido são o clonazepam ou a tranilcipromina, com todos os seus problemas, alguns já assinalados. Pelo caminho mais seguro, quanto à tolerância moclobemida ou os inibidores seletivos da recaptação da serotonina -- paroxetina, sertralina ou fluoxetina.

Entra aí o já citado julgamento clínico. Pode o paciente esperar duas, três, quatro semanas por alguma melhora significativa? Se positivo, melhores os medicamentos de segunda geração (RIMAS ou ISRS). Se não, começar com o clonazepam e, depois tentar mudar para um outro, dos acima. Se isso não for possível, por recidiva ou piora grave, continuar com o clonazepam.

Marcio Versiani
Ivan Figueira, ilvf@mi.montreal.com.br
Programa de Ansiedade e Depressão
Universidade Federal do Rio de Janeiro

Rua Visconde de Pirajá 407, sala 805
Rio de Janeiro, RJ
22410-003
Brasil

Marcio Versiani
Ivan Figueira
Anxiety and Depression Research Program
Federal University of Rio de Janeiro

16 May 1996

Indications

As if in the case of Panic Disorder, diagnosis per se, is not an indication for pharmacological treatment irrespective of DSM-IV or ICD-10 criteria. Much more important than all this is the clinical judgment which is frequently disregarded in these diagnostics' systems. The clinician needs to know if the patient is incapacitated and, therefore, is a candidate for a drug treatment.

Social Phobia is a different disorder from Panic Disorder, Depression or Obsessive Compulsive Disorder in the sense of it does involve symptoms which are predictable in certain situations or stimulated by some kinds of stimuli. It is not a continuous disorder, like in depression or something that can be manifested suddenly as in Panic Disorder.

These aspects are important for indications for pharmacological treatment. Diagnostic definitions look for, as a habit, for symptoms very easy to be detected by the clinician. This definitions, however, do not go deeper into the state persons live between this attacks of anxiety. In other words, one is looking for the best treatment for these people in these periods which are long lasting and are more important in their lives.

In Social Phobia, Generalized subtype, the indication for treatment is easy because there is a great life impairment and incapacitation. However, in Social Phobia circumscribed type the indication is more difficult. Example: a famous surgeon, excellent professional, with a personal life without problems and a social life particularly rich and gratifying; he can not sign a check in front of strangers, mainly travelerâs checks (those that have to be signed under the stringent attention of a clerk). When he try to do it, he shakes, feels a lot anxiety and sweating, heart racing and other symptoms and the signature can not be identified. He tries to surmount the problem with attitudes like signing the checks in the office, later send to the bank by his employees. During travels his wife deals with these terrible travelerâs checks, spending a lot of money in money to by things. He laughs about all these and, apparently, does not get disturbed about the problem. He does not suffer any sign or symptom of anxiety during the surgeries he practices. A pharmacological treatment for a patient like this? Never think about. Among other reasons because the medications would hamper his performance as a surgeon.

Another case -- a lady who can not sign transference of realstate or lists in election voting lists or other documents she deems important, in front of others. She does only do that when employing a high doses of benzodiazepines one or two hours before the act she has to perform. Overall she has a normal life in all senses, including an active social life. Again, this is not a case for a continuos pharmacological treatment. There is no evidence of a drug abuse. She only uses benzodiazepines in these circunscribeds situations which are not so frequently.

There are peculiar cases, when one symptom only, disturbs the life of the patient considerably and pharmacological treatment should be indicated. One executive who suffers from crises of intense sweating in different types of social contacts, parties, business meetings, causal encounters with people in the street. The sweating is so intense that people noted and start asking questions of the type "What are you feeling? Is there something wrong?" These attitudes from the other persons make the patient feel even worse and to sweat more. The patient tried diverse ways to avoid or minimize the problem: "I suffer from hypoglycemia and this happens to me occasionally." These maneuvers make things even worse because people start suggesting treatments, names of doctors and other hints. The sweating keeps getting worse. These symptom limits very considerable the life of the patient to the point that he started avoiding several situations, including important professional meetings.

In generalized Social Phobia the degree of impairment is very great. The patient becomes extremely limited, almost unable to carry out daily tasks that involve any social contact. In such cases the pharmacological treatment is clearly indicated.

To assess the severity of a case three parameters should be investigated -- the frequency, severity of the anxiety symptoms and their consequences (the degree of phobic avoidance and the degree of impairment that these all represent). In addition, Social Phobia is a disturbance, in analogy with allergy that is dependent of external stimuli to manifest. In clinical samples of social phobic men predominate contrary to epidemiological surveys when women are more frequent. One possible explanation for this difference would be that men are more obliged to be exposed to social contacts.

In the indication of the pharmacological treatment these differences between life circumstances have importance. Here one could cite the housewife who suffers from Social Phobia. She gets on an adapted life well approved by the husband, but she avoids parties, meetings, and social contacts in general. This does not result in major problems. However, one can note a significant degree of unhappiness in her. To intervene in a case as such is a difficult decision.

Social phobia is a chronic disorder without significant periods of remission (Versiani). This is another point to be considered in the indication of the pharmacological treatment. A lot of care relative to the risk/benefit ratio, due to the long duration of the drug treatment and the possibility of unwanted effect.

Starting the Treatment and Choosing the Medication

The patient who suffers from Social Phobia looks for the doctor many years after his symptoms started (neither he nor us do know exactly when the disorder began). He comes from a lot of suffering without medical treatment (contrary to the panic disorder patients) and without hope relative to improvement. He thinks that he is like this and not that he is in a different state from before. Since the end of adolescence he spend most of the time suffering from the social anxiety symptoms and from the many difficulties involved, he does not consider himself as an ill person but as someone who is different.

We are (doctors, mental health professionals) in these cases in front of a disorder that is rather new in medicine. The same occurred with chronic minor depression or depressive personality, now treated or diagnosed as a sub-form of depression (dysthymia). Like in these new disorders the patient with Social Phobia will receive an indication for pharmacological treatment or psychotherapy with a lot of enthusiasm and huge doubts. "How a treatment will change my way of being?"

Controlled clinical trials in comparisons with placebo, in a double blind fashion have demonstrated that three drugs are efficacious in the treatment of Social Phobia: phenelzine (Nardil), clonazepam (Klonopin) or moclobemide (Aurorix). In an open study, after one year of follow up it was also demonstrated that tranylcypromine (Parnate) is also very efficacious.

These drugs are the ones best studied in the treatment of Social Phobia. Something that does not mean that others are not efficacious. Methodological and practical reasons result in delays in the demonstration of the efficacy of other drugs.

Despite the efficacy of the traditional inhibitors of monoamine oxidase (MAOIs) (phenelzine or tranylcypromine) we do not use them any more as first choice drugs for the treatment of Social Phobia, especially because of the serious adverse events, the possibility of a very severe hypertensive crisis due to interactions with substances (cheese) or medications with sympathomimetic actions. Worse, these crises can occur without any reason (endogenous or spontaneous hypertensive crises, Kline).

Clonazepam (Klonopin) was the medication most widely employed in the Anxiety and Depression Program of Federal University of Rio de Janeiro in the treatment of Social Phobia. More than 300 cases have been treated with this drug. This choice, now, is being reviewed.

The treatment is initiated with 2 mg/day of clonazepam (Klonopin) divided in two doses 1 mg lunch and 1 mg bed time. If the patient gets very sleepy he can stay for one week or even more with 1 mg bed time only. As tolerance develops the dose is increased to 3 mg/day. The ideal dose of clonazepam in the treatment of Social Phobia stays between 3 and 6 mg/day divided in three doses a day, morning, afternoon and bed time.

The therapeutic effect of clonazepam are very rapid, more so than we desired. One, two, three weeks in this schedule the patient starts to say that he is a new person, is doing things that he has never done before, signs in the front of others, goes to meetings, lunches in front of strangers, talks spontaneously with everybody, gives a talk to groups of people, his life has changed! The patient is marveled with the change and in this there is a danger. This change in behavior, so rapid, may result in problems with others who do not accept it or do not understand what is going on.

This therapeutic improvement with clonazepam may result in what we call disinhibition. Two cases can illustrate this. A lawyer who bought a gun and started to mingle in criminal actions going on in the city of Rio de Janeiro -- without a history of personality problems or aggressive tendencies -- a possible fatal side effect. Or, the wife who was housebound due to Social Phobia and after taking the medication starts to call former boyfriends and go out with them.

As we stated earlier the second generation medications moclobemide and especially the serotonin selective receptors inhibitors (SSRIs) may be very efficacious in the treatment of Social Phobia. We do have several cases showing this. Fluoxetine (Prozac) or paroxetine (Aropax, Paxil) should be given in doses between 20 and 60 mg/day, the first in the morning, the second either in the morning or at bed time. The therapeutic effects tend to appear after three weeks of treatment and are very significant. The case we talked about, the man with sweating crises is taking paroxetine 40 mg bed time and is assymptomatic.

The SSRIs are not devoid of unwanted effects. Most disturbing are sexual inhibition and weight gain, specially in the long term treatment. At this moment these drugs should be the first choices in the treatment of Social Phobia.

Social phobia: issues in
assessment and management
by
Connor KM, Davidson JR, Sutherland S, Weisler R
Department of Psychiatry and Behavioral Sciences,
Duke University Medical Center,
Durham, North Carolina 27710, USA.
Epilepsia 1999; 40 Suppl 6:S60-5; discussion S73-4

ABSTRACT

Social phobia was initially classified with phobic anxiety states and was believed to be quite rare, but it is now gaining due recognition as a widespread and often crippling disorder. The boundaries of social phobia merge into traits of shyness and universal performance anxiety, with symptoms commonly appearing in the teenage years. If left untreated, social phobia is a remarkably persistent condition, leading to potentially lifelong impairment in social development and occupational functioning. It may also give rise to other co-morbid disorders, particularly dysthymia, depression, obsessive-compulsive disorder, other phobic disorders, and substance abuse. Over the years, social phobia has been all too frequently viewed as a somewhat trivial, minor form of psychiatric illness and has received little clinical attention. This erroneous perception is now giving way under the mounting evidence in support of the extensive morbidity and disability associated with social phobia and the probable role of genetic and environmental influences. Furthermore, data from multiple controlled clinical trials reveal that this is a treatable condition, responding to both psychosocial and pharmacologic interventions. Here we examine issues to consider in the differential diagnosis of social phobia, review the goals of treatment, and summarize evidence in support of the effectiveness of individual pharmacologic treatments.

Social phobia is an intense fear of becoming humiliated in social situations, specifically of embarrassing yourself in front of other people. It often runs in families and may be accompanied by depression or alcoholism. Social phobia often begins around early adolescence or even younger and can be a debilitating anxiety disorder.

If you suffer from social anxiety disorder, you tend to think that other people are very competent in public and that you are not. Small mistakes you make may seem to you much more exaggerated than they really are. Blushing itself may seem painfully embarrassing, and you feel as though all eyes are focused on you. You may be afraid of being with people other than those closest to you. Or your fear may be more specific, such as feeling anxious about giving a speech, talking to a boss or other authority figure, or dating. The most common social phobia is a fear of public speaking. Sometimes social phobia involves a general fear of social situations such as parties. More rarely it may involve a fear of using a public rest room, eating out, talking on the phone, or writing in the presence of other people, such as when signing a check.

Although this anxiety disorder is often thought of as shyness, the two are not the same. Shy people can be very uneasy around others, but they don't experience the extreme anxiety in anticipating a social situation, and they don't necessarily avoid circumstances that make them feel self-conscious In contrast, people with social phobia aren't necessarily shy at all. They can be completely at ease with people most of the time, but particular situations, such as walking down an aisle in public or making a speech, can give them intense anxiety. Social phobia disrupts normal life, interfering with career or social relationships. For example, a worker can turn down a job promotion because he can't give public presentations. The dread of a social event can begin weeks in advance, and symptoms can be quite debilitating.

People with social phobia aren't necessarily shy at all. They can be completely at ease with people most of the time, but in particular situations, they feel intense anxiety.

People with social phobia are aware that their feelings are irrational. Still, they experience a great deal of dread before facing the feared situation, and they may go out of their way to avoid it. Even if they manage to confront what they fear, they usually feel very anxious beforehand and are intensely uncomfortable throughout. Afterward, the unpleasant feelings may linger, as they worry about how they may have been judged or what others may have thought or observed about them.

About 80 percent of people who suffer from social phobia find relief from their symptoms when treated with cognitive-behavioral therapy or medications or a combination of the two. Therapy may involve learning to view social events differently; being exposed to a seemingly threatening social situation in such a way that it becomes easier to face; and learning anxiety reducing techniques, social skills, and relaxation techniques.

The medications for social anxiety disorder that have proven effective include antidepressants called MAO inhibitors. People with a specific form of social phobia called performance phobia have been helped by drugs called beta-blockers. For example, musicians or others with this anxiety may be prescribed a beta-blocker for use on the day of a performance.

Social phobia is the fear that in certain social situations, one will be criticized or judged negatively. The individual feels a great deal of anxiety, humiliation, embarrassment or even panic in social settings. One can have either specific or generalized social phobia. The most common specific social phobia is the fear of speaking in public. Individuals with generalized social phobia are anxious in almost all interpersonal situations. If the individual is going to be judged or graded on his performance in a public situation, the fear is greatly increased.

Many people get a minor case of the “jitters” before performing in public. For some, this mild anxiety actually enhances their performance. However, this anxious reaction is massively exaggerated in the individual with social phobia. While mild normal anxiety can actually enhance performance, excessive anxiety can severely impair performance.

An anxious episode may be associated with some or all of the symptoms of a panic attack. These might include sweaty palms, palpitations, rapid breathing, tremulousness and a sense of impending doom. Some individuals, particularly those with generalized social phobia may have chronic anxiety symptoms. Individuals with social phobia may turn down accelerated classes and after school activities because of their fears that these situations will lead to increased public scrutiny.

The individual with a specific social phobia feels anxious during the feared social situation and also when anticipating it. Some individuals may deal with their fear by arranging their lives so that they do not have to be in the feared situation. If the individual is successful at this, he or she does not appear to be impaired. Types of discrete social phobia may include:

Individuals with generalized social phobia are characterized as extremely shy. They often wish that they could be more socially active, but their anxiety prevents this. They often have insight into their difficulties. They often report that they have been shy most of their lives. They are sensitive to even minor perceived social rejection. Because they become so social isolated, they have greater academic, work and social impairment. They may crystallize into an avoidant personality disorder.

Social phobia is the third most common psychiatric disorder. (Depression—17.1% Alcoholism—14.1% Social phobia—13.3%. (Kessler et al 1994.) Onset is usually in childhood or adolescence. It tends to become chronic. It is often associated with depression, substance abuse and other anxiety disorders. The individual usually seeks treatment for one of the other disorders. Individuals with SP alone are less likely to seek treatment than people with no psychiatric disorder (Schneier et al 1992) Social phobia is vastly under-diagnosed. It is not as likely to be noticed in a classroom setting because these children are often quiet and generally do not manifest behavior problems. Children with SP often show up with physical complaints such as headaches and stomach aches. Parents may not noticed the anxiety if it is specific to situations outside the home. Additionally, since anxiety disorders often run in families, the parents may see the behavior as normal because they are the same way themselves. On the other hand, if the parent has some insight into his of her own childhood anxieties, he or she may bring the child into treatment so that the child will not have to experience the pain the parent experienced as a child.

Treatment: 

Psychotherapy: There is the most evidence for cognitive-behavioral psychotherapy. Since the child or adolescent is more dependent on his parents than an adult, the parents should have some adjunctive family therapy.

Both individual and group therapy are useful. The basic premise is that faulty assumptions contribute to the anxiety. The therapist helps the individual identify these thoughts and restructure them

• Identifying out automatic thoughts: “If I sound nervous when I present my paper, my teacher and classmates will ridicule me.” The patient then identifies his physiological and verbal responses to the thoughts. Finally he identifies the mood associated with the thoughts.
• Irrational beliefs that underlie automatic thoughts: 
  Emotional reasoning: “If I am nervous, then I must be performing terribly.”  
  All or nothing: Absolute statements that do not admit any partial success of gray areas. “I am a failure unless I make an A.” 
  Overgeneralization: One unfortunate event becomes evidence that nothing will go well. 
  Should thoughts: Insisting that an unchangeable reality must change in order for one to succeed. 
  Drawing unwarranted conclusions: Making connections between ideas that have no logical connection. 
  Catastrophizing: Taking a relatively small negative event to illogically drastic hypothetical conclusions. 
  Personalization: Believing that an event has special negative relationship to oneself. (“The whole group got a bad grade because my hands trembled during my part of the presentation”.) Selective negative focus: Only seeing the negative parts of an event and negating any positive ones.
• Challenge negative beliefs: Once the patient and therapist have identified and characterized the negative thoughts, the therapist should help the patient examine the lack of data supporting the beliefs and look for other explanations of what the patient sees.

Exposure: Create a hierarchy of feared situations and start to allow one to experience them. One starts with situations that only elicit a little anxiety and then gradually move up to more intense experiences. This must be done in reality, not just as visualization in the office.

Group therapy: This can be a powerful modality for individuals with social phobia. A patient may need to use individual therapy to prepare for group therapy. In the group patients can encourage each other and can try out new behaviors within the safety of the group. They can get immediate feedback that may refute their fears. Patients should not be forced to participate more actively than they wish.

Medication Treatment: 

Recent studies have shown that some of the SSRI medications can be helpful in the treatment of SP. Paroxetine (Paxil) sertraline (Zoloft) have been approved by the FDA for treatment of SP. Other medications that may be useful include ß blockers (propranolol, atenolol) Benzodiazepines (lorazepam, clonazepam) buspirone, and the MAO inhibitors (Parnate, Nardil.)  MAO Inhibitors are only rarely used in children and adolescents because one must go on dietary restrictions while taking them. SSRI and other antidepressant medications are going to now have special cautionary statements about the potential activation of suicidal thoughts. However the SSRI medications are still useful if monitored carefully.  

References: 

Kessler R.C. McGonagle, K.A. Zhao, S., Nelson, C.B., Hughes, M., Eshleman, S., Wittchen, H.U., and Kendler, K.S.(1994) Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Results from the National Comorbidity Survey. Archives of General Psychiatry, 51, 8-19. 

Kessler, R.C., Stein, M.B., Berglund, P. (1998) Social Phobia Subtypes in the National Comorbidity Survey. American Journal of Psychiatry, 155:5. 

Murray, B., Chartier, M.J., Hazen, A.L., Kozak, M.V.Tancer, M.E., Lander, S., Furer, P., Chutbaty, D., Walker, J.R.  A Direct Interview Family Study of Generalized Social Phobia. American Journal of Psychiatry, (1998) 155: 1. 

Pollack, M.H., Otto, M.W.Sabatino, S., Majcher, D., Worthington, J.J. McArdle, E.T., Rosenbaum, J.F. Relationship of Childhood Anxiety to Adult Panic Disorder: Correlates and Influence on Course. American Journal of Psychiatry. 153: 3.  

Schneier, F.R., Johnson, J., Hornig, C.., Liebowitz, M.R. and Weissman, M.M. (1992) Social Phobia: Comorbidity and morbidity in a epidemiologic sample. Archives of General Psychiatry, 49, 282-288.

Social Phobia

A persistent irrational fear of situations in which the person may be closely watched and judged by others, as in public speaking, eating, or using public facilities.

The patient strongly, repeatedly fears at least one social or performance situation that involves facing strangers or being watched by others. The patient specifically fears showing anxiety symptoms or behaving in some other way that will be embarrassing or humiliating.
   

The phobic stimulus almost always causes anxiety, which may be a cued or situationally predisposed panic attack.
    

The patient realizes that this fear is unreasonable or out of proportion.
   
The patient either avoids the situation or endures it with severe distress or anxiety.

Either there is marked distress about having the phobia or it markedly interferes with the patient's usual routines or social, job or personal functioning.

Under the age of 18, and have the symptoms for 6 months or longer.

The symptoms are not better explained by a different mental disorder, including Anxiety Disorders, Dysmorphic Disorder, Pervasive Developmental Disorder or Schizoid Personality Disorder.

The symptoms are not directly caused by a general medical condition or by substance use, including medications and drugs of abuse.

If the patient has another mental disorder or a general medical condition, the phobia is not related to it.

Specify whether Generalized. The patient fears most social situations.

Associated Features:

Depressed Mood.
Somatic/Sexual Dysfunction.
Addiction.
Anxious/Fearful/Dependent Personality.

Differential Diagnosis:

Some disorders have similar or even the same symptom. The clinician, therefore, in his diagnostic attempt, has to differentiate against the following disorders which he needs to rule out to establish a precise diagnosis.

Panic Disorder With Agoraphobia;
Agoraphobia Without History of Panic Disorder;
Separation Anxiety Disorder;
Generalized Anxiety Disorder;
Specific Phobia;
Pervasive Developmental Disorder;
Schizoid Personality Disorder;
Avoidant Personality Disorder;
Anxiety Disorder Not Otherwise Specified;
Performance Anxiety, Stage Fright, and Shyness.

Cause:
   

Social phobias are characterized by fear and avoidance of situations in which a person may be subject to the scrutiny of others. The fear may be complicated by a lack of social skills due to lack of practice or to a high level of anxiety. Everyday activities may generate anxiety, and the fears may be specific, such as using lifts, public restrooms or eating in public. The onset may occur in adolescence and be associated with parental over protectiveness or limited social opportunity. Males and females are affected equally with this disorder.

Treatment:
    

The goal of treatment is to help the person function effectively. The success of the treatment usually depends upon the severity of the phobia.

Counseling and Psychotherapy [ See Therapy Section ]:

Systematic desensitization is the preferred behavioral technique used to treat phobias. It based upon having the person relax, then imagine the components of the phobia, working from the least fearful to the most fearful. Gradual exposure to real life phobias has also been used with success to help people overcome their fears.

Social skills training may involve social contact in a group therapy situation to practice social skills. Role playing and modeling are techniques used to help the person gain comfort in relating to others in a social situation.

Pharmacotherapy [ See Psychopharmacology Section ] :

Antianxiety and antidepressive medications are sometimes used to help relieve the symptoms associated with phobias. Dependency on the medication is a possible side effect of this treatment.

Social Phobia

Social phobia is a disorder characterized by overwhelming anxiety and excessive self-consciousness in social situations. People with social phobia have a persistent, intense, and chronic fear of being scrutinized by others and of being embarrassed or humiliated by their own actions. Although it is common for many people to experience some anxiety before or during a public appearance, anxiety levels in people with social phobia can become so high that they begin to avoid social situations. While many people with social phobia recognize that the fear may be excessive or unreasonable, they are unable to overcome it. In addition, they often worry for days or weeks in advance of a dreaded situation.

Social phobia can be limited to only one type of situation (such as a fear of speaking in formal or informal situations, or eating, drinking, or writing in front of others) or, in its most severe form, may be so broad that a person experiences phobic symptoms in any social setting. Social phobia can be very debilitating - people with this illness often avoid forming or maintaining close relationships or they turn down chances to advance their careers. Some even become house-bound.

Physical symptoms often accompany the intense anxiety of social phobia. People with social phobia experience symptoms that include blushing, profuse sweating, trembling, and other symptoms of anxiety, including difficulty talking and nausea or other stomach discomfort. These visible symptoms heighten their fear of disapproval in social settings and the symptoms themselves can become an additional focus of fear. Fear of symptoms can create a vicious cycle: as people with social phobia worry about experiencing the symptoms, the greater their chances of developing the symptoms.

Social phobia often runs in families and may be accompanied by depression or alcoholism.

How Common Is Social Phobia?

• At least 3.7% of the U.S. population (approximately 5.3 million Americans) has social phobia in a given year.
  
• Social phobia occurs in women twice as often as in men, although a higher portion of men seek help for this particular disorder.
  
• The disorder typically begins in childhood or early adolescence and rarely develops after age 25.

What Causes Social Phobia?

Research to define causes of social phobia is ongoing.

• Some investigations implicate a small structure in the brain called the amygdala in the symptoms of social phobia. The amygdala is believed to be a central site in the brain that controls fear responses.

• Animal studies are adding to the evidence that suggests social phobia can be inherited. In fact, researchers supported by the National Institute of Mental Health (NIMH) recently identified the site of a gene in mice that affects learned fearfulness.

• One line of research is investigating a biochemical basis for the disorder. Scientists are exploring the idea that heightened sensitivity to disapproval may be physiologically or hormonally based.

• Other researchers are investigating the environment's influence on the development of social phobia. People with social phobia may acquire their fear from observing the behavior and consequences of others, a process called observational learning or social modeling.

What Treatments Are Available for Social Phobia?

Research supported by NIMH and other institutions has shown that there are two effective forms of treatment available for social phobia: certain medications and a specific form of short-term psychotherapy called cognitive-behavioral therapy. Medications include selective serotonin reuptake inhibitors (SSRIs), monoamine oxidase inhibitors (MAOIs), and high-potency benzodiazepenes. Some people with a form of social phobia called performance phobia have been helped by beta-blockers more commonly used to control high blood pressure.

Cognitive-behavior therapy is also very useful in treating social phobia. The central component of this treatment is exposure therapy, which involves helping patients gradually become more comfortable with situations that frighten them. The exposure process often involves three stages. The first involves introducing people to the feared situation. The second level is to increase the risk for disapproval in that situation so people build confidence that they can handle rejection or criticism. The third and final stage involves teaching people techniques to cope with disapproval. In this stage, people imagine their worst fear and are encouraged to develop constructive responses to their fear and perceived disapproval.

Cognitive-behavior therapy for social phobia also includes anxiety management training - for example, teaching people techniques such as deep breathing to control their levels of anxiety. Another important aspect of treatment is called cognitive restructuring, which involves helping individuals identify their misjudgments and develop more realistic expectations of the likelihood of danger in social situations.

Supportive therapy such as group therapy or couples or family therapy to educate significant others about the disorder is also helpful. Sometimes people with social phobia also benefit from social skills training.

What Other Illnesses Co-Occur with Social Phobia?

Social phobia can cause lowered self-esteem, depression, and in extreme situations, suicide attempts. To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to addiction.

Many people with social phobia may also develop other anxiety disorders. In particular, people with social phobia may become so anxious that they experience panic attacks (intense bursts of terror accompanied by physical symptoms) when in dreaded social situations. As more situational panic attacks occur, people with social phobia may take extreme measures to avoid situations in which they fear another panic attack may occur or in which help may not be immediately available.

This avoidance, similar to that in many panic disorder patients, may eventually develop into agoraphobia, an inability to go beyond known and safe surroundings because of intense fear and anxiety.

The content of this fact sheet was adapted from material published by the National Institute of Mental Health.

Social Phobia

What is social phobia?
Complications
Cognitive Behaviour Therapy
What drives social phobia?
Slow breathing
Changing the way you think
Facing your fears
Drug treatments

See also www.climate.tv for a patient education package for social phobia that your doctor can arrange for you for $10. It contains elements of the cognitive behaviour therapy in an illustrated story line to show you just what to do to recover. And pictures can speak louder than words

Did you know that the most common fear reported by people is fear of speaking in public or speaking in front of a group? Many people feel that butterflies-in-the-stomach sensation, have sweaty palms and a racing heart, or even feel like they will throw up if they have to speak in front of a group. But most of the time, people manage to do these things when they need to.

A little anxiety before you give the big speech or get on stage for the school play helps to pump you up for a great performance. But occasionally some people can't manage the intense anxiety they feel when facing certain social situations. For these people, responding to a question in class, giving a presentation, or even talking at the lunch table may cause a surge of anxiety that's excruciating. This anxiety condition is called social phobia.

What Is Social Phobia?
Social phobia (also sometimes called social anxiety) refers to an intense fear of being in social situations. The fear is so intense that someone with social phobia will avoid these situations whenever possible. And just like with other phobias, this fear is out of proportion to the actual danger that's present. Although many people fear being embarrassed in certain social situations, some people find it incredibly difficult to cope with this embarrassment. A person with social phobia is usually overrating the danger of embarrassment while underrating his or her ability to get through the situation.

Most people feel very self-conscious during their teenage years. All the physical and emotional changes that occur at this time in our lives can lead to shaky self-esteem. And people who feel a little less confident to begin with will be more sensitive to things that threaten their confidence during this time.

Many teens feel reluctant to be the focus of attention, especially those who are by nature a little more shy than some of their peers. And most find it stressful and anxiety provoking to ask someone on a date, talk in front of a group, or sit at a lunch table with people they don't know well. But most teens find a way to deal with this and can cope with making a few mistakes.

Social phobia is much more than just normal shyness or the awkward feelings most people have from time to time. Social phobia is shyness to the extreme, and this shyness is accompanied by anxiety that causes people to avoid doing things they might like to do or to avoid situations that might result in having to be with - or to talk with or in front of - others.

When someone is so extremely shy or so fearful about talking to others that he or she just doesn't talk in school, to certain people, or in certain social situations, that's a form of social phobia known as selective mutism. This term simply refers to not talking (being 'mute') in certain situations but not in others (selective). People who feel too anxious to talk because of social phobia or extreme shyness do have completely normal conversations with the people they're comfortable with (such as parents or siblings, or a best friend) or in certain places (like home). But other situations cause them such extreme discomfort that they may not be able to bring themselves to talk at all.

What Causes Social Phobia?
Certain teens are a bit more likely to have problems with anxiety. People whose parents or other close relatives have anxiety problems may be more likely to develop a problem with anxiety, too. This may be due to biological traits that family members have in common. Certain traits may affect the function of brain chemicals (neurotransmitters and certain stress hormones) that regulate mood states like anxiety, shyness, nervousness, and stress reactions.

Some people are born with a cautious personality style and have a tendency to be shy and sensitive to new situations. This may contribute to social phobia. Others may learn a cautious style depending on experiences they have, the way others react to them, or the behaviors they see in their parents and others. Low self-confidence and a lack of coping skills to manage normal stress can also play a role in social phobia. Those who tend to be worriers, perfectionists, and who have a hard time dealing with small mistakes may also be more likely to develop it.

Dealing With Social Phobia
Therapists can help people who have social phobia to develop coping skills to manage their anxiety. This involves understanding and adjusting thoughts and beliefs that help create the anxiety, learning and practicing social skills to increase confidence, and then slowly and gradually practicing these skills in real situations.

One element of the therapy might include learning relaxation techniques (such as breathing and muscle relaxation exercises). Behavioral rehearsal can be helpful as well, during which the therapist and the teen might role play certain situations, trying out new behaviors ahead of time. This can make it much easier and more automatic to put these behaviors into practice when the teen is faced with real situations.

A person might also learn to correct self-talk that is leading to anxiety by learning self-talk that is more positive and that promotes self-confidence and builds coping skills. The teen may be guided by a therapist to tune into how he's thinking about particular situations and to modify certain thoughts, especially worry thoughts.

Understanding Worry Thoughts and Self-Talk
Worry thoughts have particular qualities. They often are in the form of a question that begins "what if . . ." and tend to be negative rather than positive. Examples of worry thoughts include, "What if there's no one to sit with at lunch?" and "What if I fail the test?" Worry thoughts also tend to get worse and worse, until the person having them expects not just bad things, but the worst possible outcome.

When someone with social phobia thinks about a teacher calling on him or her, chances are that thoughts run through that person's mind like, "What if I say the wrong thing?" or "What if I make a mistake?" or "What if they laugh at me?" There may also be thoughts like: "I can't do it. It's too hard and too scary. I'll mess up. I'll get it wrong." Usually the self-talk makes the anxiety worse and worse and supports the person's pattern of avoiding the feared situations. The main messages people give themselves during this self-talk that is part of anxiety are "It's too scary," and "I'm not able to cope."

Therapists can help people identify and examine these thoughts. For example, students who worry about being called on in class might examine how likely it is that they'd actually give the wrong answer: If a student realizes he or she usually knows the right answer, then a mistake would be unlikely. Next the therapist can work on how a student can cope if he or she does make a mistake and how to replace worry thoughts with calm, reassuring ones when faced with stressful social situations. People might imagine what they'd say to a friend who needed reassurance, for example, and learn to think that way themselves.

For some teens, medications can be helpful as part of the treatment for social phobia. Certain medications that help to regulate the function of serotonin (a brain chemical that helps to transmit electrical messages having to do with mood) are sometimes used. Though medication doesn't solve the whole problem, it can reduce a person's anxiety so he can put into practice some of the techniques that are described above

Facts about Social Phobia

Social phobia, also called social anxiety, is a disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. People with social phobia have a persistent, intense, and chronic fear of being watched and judged by others and of being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work or school—and other ordinary activities. While many people with social phobia recognize that their fear of being around people may be excessive or unreasonable, they are unable to overcome it. They often worry for days or weeks in advance of a dreaded situation.

Social phobia can be limited to only one type of situation—such as a fear of speaking in formal or informal situations, or eating or drinking in front of others—or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people. Social phobia can be very debilitating—it may even keep people from going to work or school on some days. Many people with this illness have a hard time making and keeping friends.

Physical symptoms often accompany the intense anxiety of social phobia and include blushing, profuse sweating, trembling, and other symptoms of anxiety, including difficulty talking and nausea or other stomach discomfort. These visible symptoms heighten the fear of disapproval and the symptoms themselves can become an additional focus of fear. Fear of symptoms can create a vicious cycle: as people with social phobia worry about experiencing the symptoms, the greater their chances of developing the symptoms. Social phobia often runs in families and may be accompanied by depression or alcohol dependence.

How Common Is Social Phobia?

What Causes Social Phobia?

Research to define causes of social phobia is ongoing.

• Some investigations implicate a small structure in the brain called the amygdala in the symptoms of social phobia. The amygdala is believed to be a central site in the brain that controls fear responses.
• Animal studies are adding to the evidence that suggests social phobia can be inherited. In fact, researchers supported by the National Institute of Mental Health (NIMH) recently identified the site of a gene in mice that affects learned fearfulness.
• One line of research is investigating a biochemical basis for the disorder. Scientists are exploring the idea that heightened sensitivity to disapproval may be physiologically or hormonally based.
• Other researchers are investigating the environment's influence on the development of social phobia. People with social phobia may acquire their fear from observing the behavior and consequences of others, a process called observational learning or social modeling.

What Treatments Are Available for Social Phobia?

Research supported by NIMH and by industry has shown that there are two effective forms of treatment available for social phobia: certain medications and a specific form of short-term psychotherapy called cognitive-behavioral therapy. Medications include antidepressants such as selective serotonin reuptake inhibitors (SSRIs) and monoamine oxidase inhibitors (MAOIs), as well as drugs known as high-potency benzodiazepenes. Some people with a form of social phobia called performance phobia have been helped by beta-blockers, which are more commonly used to control high blood pressure.

Cognitive-behavior therapy is also very useful in treating social phobia. The central component of this treatment is exposure therapy, which involves helping patients gradually become more comfortable with situations that frighten them. The exposure process often involves three stages. The first involves introducing people to the feared situation. The second level is to increase the risk for disapproval in that situation so people build confidence that they can handle rejection or criticism. The third stage involves teaching people techniques to cope with disapproval. In this stage, people imagine their worst fear and are encouraged to develop constructive responses to their fear and perceived disapproval.

Cognitive-behavior therapy for social phobia also includes anxiety management training—for example, teaching people techniques such as deep breathing to control their levels of anxiety. Another important aspect of treatment is called cognitive restructuring, which involves helping individuals identify their misjudgments and develop more realistic expectations of the likelihood of danger in social situations.

Supportive therapy such as group therapy, or couples or family therapy to educate significant others about the disorder, is also helpful. Sometimes people with social phobia also benefit from social skills training.

What Other Illnesses Co-Occur With Social Phobia?

Social phobia can cause lowered self-esteem and depression. To try to reduce their anxiety and alleviate depression, people with social phobia may use alcohol or other drugs, which can lead to addiction. Some people with social phobia may also have other anxiety disorders, such as panic disorder and obsessive-compulsive disorder.

Publication No. OM-99 4171 (Revised)
Printed September 1999

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If you have questions regarding these guidelines and use of NIMH publications, please contact the NIMH Information Center at 1-866-615-6464 or at nimhinfo@nih.gov.

Social Phobia

What is Social Phobia

Social Phobia, or Social Anxiety Disorder, is an anxiety disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. Social phobia can be limited to only one type of situation?such as a fear of speaking in formal or informal situations, or eating or drinking in front of others?or, in its most severe form, may be so broad that a person experiences symptoms almost anytime they are around other people. more

Signs & Symptoms

People with social phobia have a persistent, intense, and chronic fear of being watched and judged by others and being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work or school, and other ordinary activities. Physical symptoms often accompany the intense anxiety of social phobia and include blushing, profuse sweating, trembling, nausea, and difficulty talking. more>>Treatment

Effective treatments for social phobia are available, and research is yielding new, improved therapies that can help most people with social phobia and other anxiety disorders lead productive, fulfilling lives. more>>

Getting Help

Locate mental health services in your area, affordable healthcare, NIMH clinical trials, and listings of professionals and organizations. more>>

آرامش ذهني

هر كه هستيد و هر كجا زندگي مي‌كنيد، آرامش را به زندگي خويش دعوت كنيد و آن را در ذهن خود جايگزين سازيد.اگر كلام و رفتار شما قرين آرامش باشد، بدون شك اين ويژگي به دنياي اطراف شما نيز سرايت خواهد كرد. بخاطر داشته باشيد براي رسيدن به اين وضعيت، لازم است برخي قابليت‌هاي ويژه را در خود پرورش دهيد و شرايط خاصي را در زندگي خويش ايجاد نمائيد. رعايت نكات زير مقدماتي است كه به شما كمك مي‌كند در اين مسير گام برداريد:

1) ياد بگيريد كه گاه مسايل را رها سازيد.

بدين معنا كه به هر مسئله‌اي دائما گره نخوريد. وقتي هميشه و همه جا در فكر مسايل خود هستيد و به مرور آنها مي‌پردازيد، در واقع هميشه بار اضافه‌اي را با خود حمل مي‌كنيد كه اين خود سبب ايجاد اضطراب و استرس در شما مي‌گردد. بياموزيد كه با يك ذهن رها و آزاد زندگي كنيد. اين امر به شما كمك مي‌كند كه به هر محرك كوچك و يا مانع جزئي آشفته نشويد.

2) به خود و خداي خود ايمان داشته باشيد.

اگر به خود و خداي خود ايمان داشته باشيد، به راحتي از عهده مشكلات زندگي برخواهيد آمد و ثابت قدم و مطمئن در راه رسيدن به اهداف خود گام خواهيد برداشت.

3) مثبت انديش باشيد.

اگر ديدگاه مثبت انديشي نداشته باشيد، همه چيز مي‌تواند بي‌فايده و بي‌ثمر باشد. داشتن نگرش مثبت و اميد، بهترين سلاح درمقابل ترس و اضطراب است.

4) نسبت به انتظارات و برنامه‌ريزيهاي خود واقع‌بين و منطقي باشيد.

توانائيهاي خود را در موقعيت‌هاي خاص بشناسيد و نسبت به عدم توانائيها و ضعف‌هاي خود واقع‌بين باشيد. هر چقدر نگرش شما نسبت به مسايل زندگي منطقي‌تر باشد، به آرامش بيشتري دست خواهيد يافت.

5) نسبت به انسان‌ها، عشق بي قيد و شرط خود را نثار كنيد.

شما مي‌توانيد از دوستان، هم اتاقي‌ها و كلاسيهاي خود شروع كنيد. ياد بگيريد كه آنها را بدون قيد و شرط دوست بداريد، در مقابل ضعف‌هاي آنها صبور باشيد و خطاها و اهمال كاريهايشان را ببخشيد. هر چقدر نسبت به ديگران بخشش بيشتري داشته باشيد احساس شادي و خرسندي بيشتر را تجربه خواهيد كرد.

6) معناي فداكاري را لمس كنيد.

دست بخشش داشته باشيد ولي انتظار بازگشت نداشته باشيد. ديگران را به شيوه خودشان خوشحال كنيد. به افراد بي‌پناه يتيم و فقير كمك كنيد. براي آنهايي كه خواهان ياري گرفتن از شما هستند پشت و پناه باشيد و بدون آنكه منتي بر آنها نهيد تكيه گاهشان باشيد، هر چقدر بيشتر ببخشائيد. از الزامات و قيد و بندها بيشتر رها خواهيد شد.

7) افكار خود را بازسازي كنيد.

در افكار و عقايد خويش نسبت به شخص خود، بازنگري كنيد. بياموزيد در مقابل خويشتن صبور باشيد و ارزشها، استعدادها و مهارت‌هاي خود را ارج نهيد. خود را بدون هيچ قيد و شرطي دوست بداريد. هر گونه ترس و ترديد غيرمنطقي كه در مورد خود داريد، كنار بگذاريد. اگر ديدگاه مثبت و سالمي را در مورد خود داشته باشيد ياد خواهيد گرفت كه خود را بدون قيد و شرط قبول داشته باشيد.

روش‌هاي رشد و تقويت اعتماد به نفس

بر توانائي‌هاي خود تكيه كنيد. براي هر كاري كه انجام مي‌دهيد ارزش قائل شويد و تمركز و توجه خود را معطوف كارهايي كه مي‌توانيد انجام بدهيد بنمائيد.

به خاطر تلاش‌هايي كه داريد، خودتان را تشويق كنيد. بيش از فكر كردن راجع به نتيجه كارهايتان روي توانائي‌هاي خود تمركز نمائيد چرا كه اين امر به شما كمك مي‌كند تا بتوانيد با محدوديت‌هاي اجتناب‌ناپذير زندگی خود کنار بيابيد.ريسك كنيد. با وقايع جديد به عنوان تجربه‌اي نو روبرو شويد و از برد و باخت نهراسيد. در صورتي كه اينگونه عمل كنيد امكانات جديدي براي شما فراهم مي‌شود و مي‌توانيد حس خويشتن‌پذيري را در خود تقويت نمائيد. جلوي پيشرفت شخصي خود را نگيريد.با خودتان صحبت كنيد. صحبت كردن با خود، بيشتر در زمينه مقابله با فرضيات مضر مطرح مي‌گردد. مي‌توانيد خودتان اينگونه فرض‌ها را تشخيص دهيد. آنگاه به خودتان بگوئيد: "اين افكار را رها كن و فرضيات منطقي‌تري را جايگزين آن كن" براي مثال وقتيكامل انجام دهي فقط بايد سعي و تلاش كني كه آن را خوب انجام دهي" اين افكار به شما اجازه مي‌دهد كه خودتان را قبول داشته باشيد و براي پيشرفت تلاش كنيد.

خودتان را ارزيابي كنيد. ياد بگيريد كه اين ارزيابي را مستقلاً انجام دهيد. به خاطر جلوگيي از احساس ناراحتي در خود، روي نقطه نظرات ديگران تأكيد ننمائيد. تمركز اصلي شما بايد روي احساسات خودتان در مورد رفتار، كار و ساير جنبه‌هاي زندگي‌تان باشد. اين كارها باعث قوي‌تر شدن احساس مثبت در مورد خودتان شده و از اينكه اختيارتان را بدست ديگران دهيد جلوگيري به عمل مي‌آورد.

تنهايي

تغيير و تحولات در دوره دانشگاه، مجموعه متنوعي از احساسات را در دانشجويان به وجود مي‌آورد. علاوه بر احساس هيجان و انتظار، احساس تنهايي نيز ممكن است وجود داشته باشد. تنهايي لزوماً به معناي تنها بودن نيست، ممكن است مدت‌هاي طولاني تنها باشيم و به هيچ وجه احساس تنهايي نكنيم. بررسي نحوه تجربه  :تنهايي در افراد ديگر، بهترين راه براي درك تنهايي است. در شرايط زير ممكن است احساس تنهايي كنيدوقتي تنهاييد و راهي براي تنها نبودن به نظرتان نمي‌رسد.

به نظرتان مي‌آيد كه دلبستگي‌هاي پيشين را نداريد.

با تغييراتي در زندگي خود روبروييد، محل تحصيل، شهر يا شغل جديد و يا تغييراتي از اين قبيل.

   به نظرتان مي‌آيد كه هيچ كس در زندگيتان نيست كه بتوانيد

احساسات و تجارب خود را با او در ميان بگذاريد.

خود را غيرقابل قبول، دوست‌نداشتني و بي‌ارزش درك مي‌كنيد، حتي اگر ديگران چنين دركي از شما نداشته  باشند.

 درك نادرست درباره تنهايي

تنهايي ممكن است به علت معنايي كه از آن براي خود مي‌كنيد، عميق‌تر شود. بويژه دانشجويان آماده درك‌هاي نادرست زير درباره تنهايي هستند:

تنهايي نشانه ضعف يا عدم بلوغ است.

اگر تنها هستم به دليل اين است كه اشكالي در من وجود دارد . اين سال‌ها بايد بهترين‌ سالهاي زندگي من باشد.

من تنها كسي هستم كه چنين احساسي دارم.

     اگر اين درك‌هاي نادرست را باور كنيد، ممكن است به اين نتيجه برسيد كه تنهايي نتيجه نقصي در شخصيت شماست. پژوهشها نشان مي‌دهد كه دانشجوياني كه تصور مي‌كنند تنهايي نقص است مستعد مشكلات زيرند:مشكلات عميق‌تر در پذيرفتن خطرهاي اجتماعي، ابراز خود،‌آغاز روابط اجتماعي،‌معرفي خود به ديگران، مشاركت در گروهها و لذت بردن از زندگي.

مهارت كمتر در خود آشكارسازي، پاسخ دهي كمتر به ديگران، تمايل بيشتر به اينكه با بدبيني و بدگماني به درگيري‌هاي اجتماعي وارد شوند.

احتمال بيشتر در ارزيابي منفي از خود و ديگران و تمايل بيشتر به انتظار طرد از جانب ديگران.

دانشجويان تنها اغلب از احساس افسردگي، خشم، ترس و سوء درك شكايت دارند. آنان ممكن است به شدت از خود انتقاد كنند، فوق‌العاده حساس يانسبت به خوددلسوز باشند، يا ممكن است از ديگران ايراد بگيرندو آنان را مقصر بدانند. وقتي اين مسائل روي مي‌دهد، دانشجويان تنها غالباً دست به اقداماتي مي‌زنند كه اين احساس را در آنان پايدار مي‌سازد براي مثال، بعضي از دانشجويان دلسرد مي‌شوند، ميل و انگيزه خود را براي درگير شدن در موقعيت‌هاي جديد از دست مي‌دهند و خود را از مردم و فعاليت‌ها كنار مي‌كشند.

 برخي ديگر، براي مقابله با تنهايي، خود را به سرعت و عميقاً با مردم وفعاليت‌ها درگير مي‌كنند بدون آنكه نتايج اين درگيري را ارزيابي ‌كنند. اين افراد ممكن است بعدها خود را با روابط نامناسب يا تعهدات بي‌شمار نسبت به فعاليت‌هاي آموزشي يا فوق برنامه روبرو ببينند.

براي مقابله با احساس تنهايي چه بايد كرد.

به جاي آنكه احساس تنهايي را نقص يا ويژگي شخصيتي غيرقابل تغيير بدانيم، بايد بپذيريم كه احساس تنهايي قابل تغيير است. هم‌چنين مهم است كه بدانيم احساس تنهايي تجربه‌اي همگاني است . براساس نتايج يك پژوهش يك چهارم همه بزرگسالان حداقل چند هفته احساس تنهايي رنج آوري را تجربه كرده‌اند و بروز آن در ميان نوجوانان و دانشجويان حتي بيش از اين است. احساس تنهايي به خودي خود نه پايدار است و نه بد. در عوض، احساس تنهايي را بايد نشانه يا علامت نيازهاي مهمي دانست كه برآورد نشده‌اند.

وقتي نيازهاي مهم برآورده نشده باشند، شما يا هركس ديگري بايد دست به كار شويد. با تعيين اينكه كدام نيازها در شرايط ويژه شما برآورده نشده است شروع كنيد. احساس تنهايي شما مكن است ناشي از نيازهاي متعددي باشد. ممكن است ناشي از نياز به گسترش دوستي با محفلي از دوستان يا با يك دوست ويژه باشد. ممكن است نتيجه نياز به يادگيري انجام امور براي خودتان، بدون دوستان باشد. يا مكمن است ناشي از نياز به داشتن احساس بهتر درباره خود يا نياز به ارتباط بيشتر با خود باشد.

گسترش دوستي‌ها

راه‌هاي متعددي براي برآورده ساختن نياز به دوستي وجود دارد. راه‌هاي زير را ملاحظه كنيد:

به خود يادآوري كنيد كه تنهايي شما هميشگي نيست.در انجام امور معمولي و روزانه خود، به دنبال راه‌هايي براي برقراري ارتباط با مردم باشيد مثلاً مي‌توانيد:

با ديگران غذا بخوريد.

در كلاس در كنار افراد جديد بنشينيد.

براي مطالعه يا انجام تكاليف خود يك همراه پيدا كنيد.

خود را در موقعيت‌هاي جديدي قرار دهيد تا افراد جديد را ملاقات كنيد در فعاليت‌هايي شركت كنيد كه واقعاً به آنها علاقه‌ داريد. در اين صورت احتمال بيشتري وجوددارد كه با افراد مورد علاقه خود ملاقات كنيد؛ افرادي كه علايق مشتركي با آنها داريد.

      از امكانات دانشگاهي استفاده كنيد. سازمان‌ها و فعاليت‌هاي دانشگاهي را شناسايي كنيد.

براي مثال باشگاه‌ها، مراكز مذهبي، كانون‌هاي فرهنگي و ورزشي، مشاغل نيمه وقت و كارهاي داوطلبانه.

درباره برنامه‌ها از كسي كه بيش از شما در دانشگاه بوده است بپرسيد.

روي رشد مهارت‌هاي اجتماعي خود كار كنيد. روي شناخت ديگران و اجازه دادن به آنان كه شما را بشناسند، تمرين كنيد.

براساس روابط پيشين، روي افراد جديد قضاوت نكنيد. در عوض، سعي كنيد هر فرد را از زاويه جديدي بنگيرد.

دوستي‌هاي صميمانه معمولاً بتدريج رشد مي‌يابند به طوري كه افراد ياد مي‌گيرند احساسات دروني خود را با هم در ميان بگذارند.

     از شتاب در دوستي هاي صميمانه خودداري كنيد. از ديگران نيز چنين توقعي نداشته باشيد. بگذاريد دوستي  صميمانه روند طبيعي خود را طي كند.

به جاي آنكه معتقد باشيد كه فقط رابطه دوستانه با يك نفر مي‌تواند تنهايي شما را پايان بخشد براي همه دوستي‌هاي خود و ويژگي‌هاي منحصر به فرد هر يك از آنها ارزش قائل شويد.

رشد خود

خود را به صورت كل ببينيد. فقط به اين دليل كه نياز شما به دوستي يا معاشرت برآورده نشده، نيازهاي ديگر خود را ناديده نگيريد.

تغذيه خوب، تمرين‌هاي درسي منظم و خواب كافي را دنبال كنيد. نگذاريد كه تحصيلات، سرگرمي‌ها و ساير علايق به حال خود رها شوند.

      از اوقات تنهايي براي شناخت خود بهره ببريد. اوقات تنهايي را فرصتي براي رشد، استقلال و آموزش براي   رسيدگي به نيازهاي عاطفي خود بدانيد. در اوقات تنهايي مي‌توانيد جنبه‌هاي مختلفي از خود را رشد بدهيد.

به جاي آنكه فقط وقتي با ديگران هستيد زندگي كنيد، از اوقات تنهايي خود لذت ببريد. از برخورد منفعلانه با موقعيت‌ها پرهيز كنيد.

 مطمئن باشيد كه راه‌هاي مبتكرانه و لذت‌بخش فراواني براي بهره‌گيري از اوقات تنهايي وجود دارد.

در صورت امكان، از آنچه كه در گذشته از آن لذت برده‌ايد استفاده كنيد تا راه لذت بردن از اوقات تنهايي خود را انتخاب كنيد.

    وسائلي را كه مي‌توانيد از آنها براي پر كردن اوقات تنهايي خود استفاده كنيد مانند (كتاب‌ها،معماها يا موزيك) را در دسترس خود نگه داريد.

    راه‌هاي به تنهايي انجام دادن فعاليت‌هاي جمعي را كشف كنيد مثلاً (سينما رفتن) . نظر خود را درباره فعاليت، از پيش تعيين نكنيد.

 ذهن خود را باز بگذاريد. به طور خلاصه، صرف نظر از اينكه چه احساس بدي مي‌كنيد، خود را فردي تنها تعريف

نكنيد. وقتي توجه و انرژي خود را به نيازهايي كه معمولاً مي‌توانيد برآورده كنيد متمركز سازيد، وقتي ياد بگيريد

راه‌هاي جديدي براي برآورده كردن نيازهاي خود بيابيد، تنهايي كاهش مي‌يابيد يا حتي از بين مي‌رود. منتظر نمائيد

تا احساستان شما را به پيش براند، حركت كنيد. احساسات خوب بالاخره خود را به شما خواهند رساند.

نياز به ياري بيشتر

اگر پس از انجام اين توصيه‌ها، مشكل تنهايي هنوز باقي است، مي‌توانيد در فكر كمك‌هاي بيشتر باشيد. در اين باره، مشاوره‌هاي

مطالعه بهتر، يادگيري بهتر

گر چه خواندن، يكي از اجزاي اصلي مطالعه است اما مطالعه فقط شامل خواندن متون درسي نيست. مطالعه فرآيندي هدفمند است كه براي رسيدن به مقصود و منظور معيني تدارك ديده مي‌شود. مطالعه متون درسي مراحل گوناگوني دارد كه با توجه به موضوع و ماده درسي مي‌تواند متفاوت باشد. به عنوان مثال مطالعه براي موفقيت در امتحان معادلات ديفرانسيل با  گروهي و فردي يا حضور در كلاس‌هاي آزاد پيشنهاد مي‌شود.

مطالعه براي موفقيت در امتحان درس معارف تفاوت دارد. بنابراين اولين نكته‌اي كه در اين زمينه بايد مورد توجه قرار گيرد اين است كه براي هر ماده درسي روش مناسب مطالعه خاص آن درس را به كار ببريم. روش مناسب مطالعه، روشي است كه دانشجو را قادر سازد به آن سطح يادگيري كه براي موفقيت در ماده درسي لازم است، دست يابد.

مطالعه خود را براساس انتظارات استاد تنظيم نمائيد. مطالعه شما بايد به گونه‌اي باشد كه شما بتوانيد در زمان لازم به اهداف از پيش تعيين شده دست يابيد.

به طور كلي خواندن شفاهي به تنهايي روش كارآمدي براي مطالعه هدفمند نمي‌باشد؛ سعي كنيد در زمان مطالعه از يادداشت برداري،خلاصه نويسي و فهرست‌نويسي دروس استفاده نماييد.

نخست مواد و موضوعاتي را كه در كتاب درسي آمده است، به منظور كسب يك انديشه كلي بررسي كنيد. اين نگاه كلي بايد شامل يادداشت كردن فصول، بخش‌ها و عناوين هر فصل باشد.

دومين گام در مطالعه، خواندن گسترده مطالب هر فصل مي‌باشد. فنون زيادي ممكن است در اينجا به كار آيند كه خلاصه نويسي در هنگام مطالعه يكي از بهترين راهكارهاي افزايش يادسپاري است.

خلاصه نويسي:

   براي ايجاد ساختمان ذهني، بهتر است كه رابطه ميان تز اصلي، نكات اصلي و جزئيات را به صورت يك طرح يا يك شكل مجسم كنيد.

  براي مثلاً، مطالب را مي‌توان به صورت طرح شاخه‌اي، هرمي، شعاعي و يا سلولي تهيه كرد. تهيه خلاصه‌اي از مطالب درسي اين امكان را به خواننده مي‌دهد كه به يك نقشه و كليد براي فهم مطالب دست يابد.خلاصه، مروري بر مطالبي است كه خوانده‌ايد. در واقع بيان مجددي است از نكات اصلي به زبان خود شما. يك خلاصه نه تنها بايد شامل نكات اصلي باشد بلكه بايد بيان كننده روابط ميان نكات اصلي و دلايل مؤلف در ارتباط دادن اين نكات باشد و به طور منطقي نكات اصلي را به تز اصلي ربط دهد.خلاصه‌ها به سه منظور زير نوشته مي‌شود:

آنها نوعي وارسي از درك و فهم شما هستند.

آنها كار مرور كردن را آسان‌تر مي‌سازند.

     آنها نگهداري مطالب را در حافظه تقويت مي‌كنند. شواهد نشان مي‌دهند كه يادآوري مطالب پس از يك مدت طولاني، بدون خلاصه كردن گاه به گاهي آنها ميسر نيست.

سومين گام در مطالعه ارزشيابي از ميزان يادگيري است. بدون ارزشيابي از ميزان يادگيري هر گونه مطالعه‌اي بي‌فايده است. براي انجام اين كار، در حالي كه مطالعه مي‌كنيد سئوالاتي را روي يك صفحه سفيد يادداشت نمائيد و بعد از اتمام مطالعه سعي كنيد به اين سؤالات پاسخ دهيد. در صورتي كه نتوانستيد به بيشتر سئوالات پاسخ دهيد. نياز به تكرار و تمرين بيشتري داريد.

اگر جواب را مي‌دانيد ولي قادر نيستند كه آن را با عبارات منطقي و منظمي بيان نمائيد، از اين پس بايستي مطالب را با تسلط بيشتري ياد بگيريد.

    قدرت و توانايي شرح كامل پاسخ، بهترين دليل بر فراگيري كامل است و بهترين وسيله براي تسلط بر اضطراب امتحانات مي‌باشد.

آه آرام بخش

آه كشيدن و خميازه در خلال روز نشان آن است كه شما اكسيژن كافي در اختيار نداريد. آه اندكي از تنش شما را رها مي‌سازد و مي‌توان با انجام آن خود را آرام كرد. صاف بنشينيد يا بايستيد.

آهي عميق بكشيد. در حين اينكه هوا را به شتاب از ريه‌تان بيرون مي‌فرستيد، صداي رهايي عميق از تنش را بشنويد. بگذاريد هواي تازه به طور طبيعي وارد ريه‌تان شود. اين كار را هشت تا دوازده بار انجام دهيد و تا وقتي كه احساس مي‌كنيد بدان احتياج داريد، ادامه دهيد و احساس آرميدگي را تجربه كنيد.

چند توصيه ساده براي رفع مسأله بي‌خوابي

1ـ از نوشيدن قهوه. چاي يا كاكائو خصوصاً به هنگام عصر و از مصرف نوشابه‌هاي كافئين‌دار به هنگام عصر و شب خودداري كنيد.

2ـ از 2 الي 3 ساعت قبل از خواب، فعاليت‌هاي شديد را متوقف سازيد.

3ـ از چرت زدن و خواب بين روز خودداري كنيد.

4ـ هرگز قبل از خواب مبادرت به خوردن ننمائيد.

5ـ سعي كنيد هر شب رأس ساعت مشخصي به رختخواب برويد.

6ـ محل خواب خود را در مكاني آرام، به دور از هر گونه نور و صدا برگزينيد.

     7ـ سعي كنيد به هنگام رفتن به رختخواب، هر گونه فكر و خيالي را از ذهن خود پاك كنيد. نگراني‌هاي شغلي، عاطفي، مالي، بيماري و تحصيلي از عوامل اصلي بروز بي‌خوابي هستند مي‌توانيد قبل از خواب با نوشتن مسائل روز خود، آنها را از ذهن به كاغذ منتقل كرده و افكار خود را رها سازيد.

نوشيدن يك ليوان شير گرم به عنوان عامل كمك دهنده توصيه شده است.

8ـ به خاطر داشته باشيد كه رختخواب، رختخواب است. آن را به محل مطالعه، دفتر كار و يا كتابخانه مبدل نسازيد. بدين ترتيب عادت خواهيد كرد كه به هنگام رفتن به رختخواب فقط بخوابيد.

9ـ دعا و نيايش قبل از خواب نيز تأثير بسيار مثبتي دارد.

    10ـ مي‌توانيد زمان قبل از خواب را به خواندن كتاب، ماساژ اعضاي بدن، لم دادن در يك صندلي راحتي و يا حمام آبگرم اختصاص دهيد.

11ـ نوشيدن يك ليوان شير گرم به عنوان يك عامل كمك كننده توصيه شده است.

12ـ و بالاخره هنگامي كه به رختخواب رفتيد، در آن بمانيد. در صورتي كه دچار بي‌خوابي شديد، از برخواستن مجدد و دست زدن به هر گونه فعاليت فيزيكي يا فكري حتماً بپرهيزيد، زيرا در آن صورت تنها بيداري و هشياري شما تشديد مي‌شود نه خواب آلودگي شما.

13ـ اما اگر با وجود رعايت توصيه‌هاي فوق باز هم دچار بي‌‌خوابي شديد، حتماً‌ به پزشك متخصص (روان‌پزشك) مراجعه نمائيد.

What is a social phobia

A phobia is basically a fear. We all have fears about things such as heights and spiders but, for most of us, they do not interfere with the way we lead our lives. These fears are only called phobias when they interfere with things we would otherwise enjoy or do easily.

Many of us get worried before meeting new people, but we find that once we are with them, we can cope and even enjoy the situation. However, some of us become very anxious about these situations. At best, we cannot enjoy them and, at worst, we may have to avoid them altogether. This is what doctors and psychologists call social phobia.

This leaflet describes what it feels like to have a social phobia, how you can help yourself, and what other kinds of help are available.

There are two main sorts of social phobia.

Social Phobia

Social phobia, also called social anxiety, is a disorder characterized by overwhelming anxiety and excessive self-consciousness in everyday social situations. People with social phobia have a persistent, intense, and chronic fear of being watched and judged by others and of being embarrassed or humiliated by their own actions. Their fear may be so severe that it interferes with work or school - and other ordinary activities. While many people with social phobia recognize that their fear of being around people may be excessive or unreasonable, they are unable to overcome it. They often worry for days or weeks in advance of a dreaded situation

((راه هاي كسب قدرت))

 براي همه انسانها دستيابي به قدرت با احساس لذت بخشي همراه است.هيچكس نمي خواهد كه بعنوان فردي ضعيف و ناتوان در جامعه زندگي كند.از سوي ديگر دستيابي به قدرت براي همگان، امري ساده نيست و بعضي ها براي كسب قدرت راه هاي نادرستي را انتخاب مي كنند كه از آنها چهره خشن و نامطلوبي را به تصوير مي كشد.

در طول تاريخ زندگي بشر، هميشه افرادي بوده اند كه دوروبر پادشاهان، امپراطورها، رهبران و ملكه هابه دنبال كسب قدرت بودند. آنها براي اين تكاپو مجبور بودند كه به اربابان خود خدمت كنند، ولي در اين وادي بسياري از آنها مورد غضب ساير اطرافيان قرارگرفته وخطرات شديدي را متحمل مي شدندكه بعضاً به از دست دادن جانشان منتهي مي شد.از اين رو آنها براي دستيابي به قدرت مجبور بودند كه بصورت پنهاني به كوشش خود ادامه دهند.در بازي قدرت حتي افراد بسيار ماهر مجبورند كه خود را در برابر حسادت زيردستان خود محافظت نمايند چون هر لحظه بيم آن مي رفت كه آنها او را از صحنه خارج كنند.

در طول تاريخ افراد موفق دريافته اند كه همه برنامه هاي خود را در امر كسب قدرت »به طور غيرمستقيم« اجرا نمايند و اگر بخواهند ساير حريفان خود را از صحنه كنار بزنند بايد به گفته ناپلئون »دستان آهنين خود را در دستكش هاي مخملي نهاده و شيرين ترين لبخندها را بر لب داشته باشند«آنها با »اغواگري«،»فريبندگي« و روشهاي پنهاني هميشه در چند مسير به پيش مي تاختند. زندگي در صحنه هاي پررقابت »قدرت« فقط يك بازي پايان ناپذير است كه به »تفكر تاكتيكي« و حوصله بسيار نياز دارد.

امروزه هر قدمي را كه براي كسب قدرت برمي داريم، بايستي رنگ و بوي تمدن، آزادي خواهي، عدالت، جامعه پسند و جوانمردانه داشته باشد.

در اين بازي جسورانه اگر طوري عمل نمائيم كه در نظر رقباي ما، كاري ساختگي جلوه نمايد بزودي توسط آنها از صحنه خارج خواهيم شد و دوره اقتدارمان خيلي زود به سرخواهد رسيد.

در صحنه قدرت، افراد موفق كساني هستند كه با القاي باورهايي به ديگران آنها را همسو با اهداف خودشان به حركت وادارند. شما مي توانيد ديگران را بدون آنكه خودشان متوجه شوند به خود وابسته نماييد و اين يكي از رموز موفقيت شما در دنياي كنوني خواهد بود.

بسياري از مردم اظهار مي كنند كه جستجوي راه هايي براي قدرت از تفكرات شيطاني، قديمي و غير متمدن است.ولي اگر با دقت بيشتري به اعمالشان در جامعه توجه نماييد در ميابيد كه خود آنها از ماهرترين افراد براي كسب قدرت در جامعه شما به شمار مي آيند و هم اكنون هم افراد قدرتمندي هستند.

اين افراد ظاهراً اينطور وانمود مي كنند كه در صحنه قدرت، آدمي ضعيف و ناتوان هستند و علاقه اي به اين كار ندارند. ولي اين كار نمايشي بيش نيست و جزو سياستهاي مؤثر است كه بيشتر آنها براي كسب قدرت از آنها بهره مي برند.

بعضي از مردم عقيده دارند كه در جامعه بايستي با همگان صرفنظر از شرايط و قدرتشان بطور يكسان برخورد شود ولي خود اين تفكر نيز يك بازي سياسي بيش نيست چونكه افراد بشر هر كدام نقاط ضعف و قدرت خاص خودشان را دارند كه برخورداري مساوي از امكانات جامعه بدون در نظر گرفتن لياقتهاي آنها كاري غير عادلانه است.

بيشتر افرادي كه اين شعار را در جامعه اشاعه مي دهند، بدشان نمي آيد كه در كسب قدرت از ديگران پيشي بگيرند.دسته اي از افراد جامعه دوست دارند كه با صداقت و درستكاري و رك گويي به زندگي ادامه دهند ولي بايستي گفت كه صداقت و راستگويي آنها ممكن است براي بسياري از همتايان آنها مضر و خطرناك بوده و ممكن است دردسرهاي زيادي برايشان ايجاد نمايد.

بايد بدانيد هر چقدر هم راستگو وصديق باشيد، ديگران فكر مي كنند كه در پشت گفته هايتان حتماً اهدافي نهفته است كه قطعاً به سود خودتان خواهد بود.راستي چرا اينطور است؟

چون در صحنه قدرت افراد بيشماري  بوده اند كه از لغت »صداقت« و »جوانمردي« براي فريب و اغواي ديگران سود برده اند.

آنها براي كسب قدرت، خود را در برابر ديدگاه سايرين، فردي صديق، درستكار و خيرانديش معرفي كرده اند.»تظاهر به صداقت و راستي« خود روشي مرسوم براي دستيابي به قدرت است.

نكته ديگر اينكه ، حتي معصوم ترين افراد جامعه هم به دنبال راهي براي گذران بهتر زندگي خود هستند.حتي كودكان هم از روي غريزه خود به ترفندهايي دست مي زنند كه شرايط زندگي خود را در  خانواده و محيط اطراف خود بهتر نمايند.

لذا باز هم مي گوييم »آنهايي كه خود را در جامعه فردي صديق و مترقي و درستكار معرفي مي كنند، ممكن است بسياري از صفات نيك فوق را نداشته باشند«

حال كه ما در اين دوره زندگي مي كنيم، چاره اي جز اين نداريم كه در ابن بازي قدرت شركت نماييم.

هر فردي در اين جامعه در هر درجه تحصيلي، شغلي و مهارتي كه باشد، بايستي براي گذران زندگي خود و خانواده اش در اين بازي شركت كند و چاره اي جز اين ندارد.

دنياي كنوني، چون بارگاهي است كه همگان در آن به دنبال كسب قدرتي براي خود مي باشند.بي قدرتي و هر آنچه كه سبب اين امر مي شود پديده هايي نفرت انگيز هستند.

بنابراين بجاي قلم فرسايي درباره مضرات قدرت طلبي، بهتر است خودتان طعم قدرت را بچشيد.

مطمئن باشيد در اين دنيا كسي نيست كه به دنبال كسب قدرت نباشد.

هر چقدر بهتر در راه كسب قدرت پيشرفت كنيد، دوستان بهتر، زندگي بهتر، همسر بهتر و شخصيت مقبول تري نصيبتان خواهد شد.

شما مي توانيد كاري كنيد تا ديگران درباره خودشان احساس بهتري داشته باشند و مايه دلخوشي آنها شويد، آنهااز اين طريق به شما وابسته شده و خواهان حضور شما در جمع خود خواهند شد.

حال كه از بازي قدرت نمي توانيد فرار كنيد، بهتر است در اين بازي جزو بهترين ها باشيد.

يادگيري (( بازي قدرت))

براي آموختن بازي قدرت، بايد با ديد خاصي به جهان اطراف خود بنگريد.قبل از همه بايد احساسات خود را كنترل نماييد.

پاسخ احساسي به شرايط موجود، همچون سدي است كه مانع دست يابي ما به قدرت مي شود. اين حركت اشتباه تاوان بسيار سنگيني دارد كه خيلي بيشتر از لذت روحي آن است.

احساسات سبب تيرگي شعورتان مي شوند و اگر شما نتوانيد شرايط اطراف خود را به وضوح ببينيد، نمي توانيد خود را در برابر آنها نموده و آنها را تحت كنترل خود درآوريد.

»عصبانيت« مخرب ترين پاسخ روحي است، چون از جمله احساساتي است كه بيشتر از احساسات ديگر چشمتان را به روي وقايع مهم زندگي تان مي بندد. اگر عصباني باشيد نمي توانيد شرايط اطراف را تحت كنترل خود درآوريد و ديگر اينكه بهانه اي در دست حريف خود خواهيد داد.

به گفته يكي از بزرگان علم سياست:

»اگر مي خواهيد دشمني را كه به شما آسيب رسانده از دور خارج كنيد، بهتر است به جاي نشان دادن عصبانيت خود به او، با او از در دوستي وارد شويد«

»عشق« و »تاثيرپذيري« نيز از موارد بازدارنده در امر كسب قدرت مي باشند. اين عوامل چشم شما را براي ديدن حقايق كور مي كنند و سبب مي شوند كه بسياري از خطرات از ديد شما دور بمانند.

البته شما قادر نيستيد عاشق نشويد، ولي بايد دقت كنيد كه در وضعيت مناسبي، عشق خود را ابراز نموده و مهمتر از همه اينكه، عشق نبايد اهداف و طرح هاي شما را تحت تاثير قرار دهد.

»كنترل احساسات« به اين معني است كه شما قادر باشيد خود را از اين زمان جدا نموده و به گذشته و آينده بيانديشيد. براي مقابله بهتر با خطرات احتمالي، شما بايد در آن واحد بتوانيد به گذشته و آينده خود بيانديشيد.

هيچ چيزي نبايد شما را غافلگير كند.خوش بيني در بعضي موارد كار ساده لوحان است.هيچ چيزي نبايد شما را غافلگير كند و شما بايد قادر باشيد كه هر واقعه اي را از قبل پيشگويي كنيد.

هر چه افق ديد شما وسيعتر باشد، قدم هاي مفيدتري خواهيد برداشت و به قدرت بيشتري خواهيد رسيد.در نگاه خود به گذشته لازم نيست كه از تلخي و ناكامي هاي خودتان ياد كنيد.اين كار اثر منفي در كار شما خواهد داشت.فراموشي موهبتي است كه مي توانيد به موقع از آن بهره مند شويد و اين ناكامي ها و تلخي ها را به فراموشي بسپاريد.

بايد يدانيم كه هدف اصلي از يادآوري گذشته، آموزش است.ما براي اين به تاريخ مراجعه مي كنيم كه از گذشتگان خود عبرت بگيريم.در بسياري از وقايع تاريخي، درسهاي باارزشي نهفته است.

از اين رو با نگاهي به گذشته مي توانيد با ديد روشنتري به دوروبر و دوستان خود بنگريد.تاريخ گذشتگان دانشگاهي پرارزش است كه درسهاي آن براي طالبان قدرت بسيار حياتي است، چون از تجربيات انسانها سخن مي گويد.

اگر به گذشته خود مي نگريد، با نگاهي به اشتباهات خود اين كار را شروع كنيد. به مواردي فكر كنيد كه بيشتر از همه سبب به عقب انداختن شما شده است.لازم نيست با ديد احساسي به گذشته خود بنگريد.

پس از آنكه به اشتباهات قبلي خود پي برديد، بايد به خود بگوئيد:

»من ديگر اين اشتباه را تكرار نخواهم كرد«.

»من ديگر به اين دام نخواهم افتاد«.

 اگر بتوانيد با اين روش خودتان را ارزيابي كنيد، خواهيد آموخت كه چگونه آن عوامل مخرب را از سر راهتان برداريد.اين همان مهارتي است كه در تمام عمر به دنبال آن بوديد.

در صحنه بازي قدرت بايد هنر پيشه خوبي باشيد، بايد بياموزيد كه در شرايط مختلف، ماسكهاي گوناگوني را به چهره بزنيد و كوله باري از ترفندهاي اغوا كننده به همراه داشته باشيد.

در نظر شما نبايد اغواي ديگران امري غير اخلاقي و ناپسند باشد. در تمام روابط بين انسانها، درجات مختلفي از فريبندگي نهفته است و همين خصيصه است كه انسان را از حيوانات متمايز مي كند.در اساطير يونان باستان و ساير مكاتب، هميشه عواملي اغواگر بوده اند كه سبب تغييرات مهمي در سرنوشت يك قوم شده اند.

در اين برهه از زمان افراد مختلف، لغت اغواگري را در پوششي از لغات آبرومندانه تر پنهان مي كنند. آنها از هدايت، خيرانديشي، نيكبختي و نصيحتهاي سودمند به جاي لغت اغواگري استفاده مي كنند ولي بايستي گفت كه در نهايت قصدشان اين است كه ديگران را به راه دلخواه خودشان متمايل كنند و در نهايت به قدرت بيشتري برسند.

در دنياي كنوني، اغواگري و فريبندگي الزاماً به صورت يكي از هنرهاي مؤثر روابط انساني و به عنوان قوي ترين سلاح در بازي قدرت در جوامع انساني مي باشد.

براي مهارت در هنر اغواگري بايد ياد بگيريد كه در هر لحظه چهره اي مناسب را از خود ارائه دهيد، بايد بتوانيد مقاصد خود را تا آنجا كه ممكن است از ديگران پوشيده نگهداريد و ياد بگيريد كه چگونه از ديگران براي پيشبرد اهداف خود بهره ببريد.

شما با بازي با چهره هاي ساختگي خود در صحنه قدرت، با هنرمندانه ترين روش، بازي را به نفع خود خاتمه خواهيد داد ولي براي استفاده از اين سلاح بايد درسهاي خود را به خوبي فرا بگيريد.

چرا كه اگر نتوانيد اين بازي را تا آخر به پيش بريد، خودتان به دام خواهيد افتاد.پس بايد در قدم اول فردي صبور باشيد.

»صبر« شما را از اقدام به كارهاي مخرب محافظت مي كند.

»صبوري« نيز مانند »كنترل احساسات« يك مهارت است كه به خودي خود به آن نمي رسيد و بايستي آن را فرا بگيريد.

به قول پيشينيان »صبر يك عطيه خداوندي براي كساني است كه بجز وقت چيز ديگري ندارند.«

از طرف ديگر، بي صبري سبب مي شود كه شما را انساني ضعيف نشان دهد.

»قدرت« يك نوع بازي است و نمي تواند زياد تكرار شود.در بازي شما نمي توانيد حريفتان را از روي مقصودش بشناسيد، بلكه بايد به تأثير عملكردهاي آن توجه نماييد.

شما بايد اهداف و قدرت حريفانتان را از روي آنچه كه حس مي كنيد و »مي بينيد« ارزيابي كنيد.

زندگي در اين جهان به يك بازي براي قدرت تبديل شده است.حريفتان روبروي شما مي نشيند، هر دوي شما مثل آدمهاي مبادي آداب و متمدن و با فرهنگ برخورد مي كنيد. با يك هدف، بازي خود را آغاز مي كنيد و با آرامش تمام به حريفتان مي نگريد. بايد به چشمانتان بياموزيد كه نتايج هر حركتي از سوي حريفتان را ارزيابي نمايند. نبايستي تحت هيچ شرايطي كنترل خود را از دست دهيد.

نيمي از مهارت شما در بازي قدرت مربوط به كارهايي است كه نبايستي انجام دهيد. براي كسب اين مهارت شما بايد ببينيد كه  »بهاي انجام هر كاري تا چه حد است.«

به قول » نيچه «:

بعضي وقتها، ارزش يك چيز بر اين اساس نيست كه چه چيزهايي را مي توان با آن به دست آورد، بلكه بر آن اساس است كه چه بهايي بايد براي آن بپردازيم.

شما ممكن است به يك هدف ارزشمند برسيد ولي بايد بدانيد كه بهاي آن چقدر است؟

اين موضوع را بايد در همه موارد در مواقعي كه با ديگران همكاري مي كنيد و يا در مواقعي كه به ياري ديگران مي شتابيد در نظر داشته باشيد.

نكته پاياني در بازي قدرت اين است كه شما زمان كوتاهي را در اختيار داريد و انرژي شما نيز محدود است. بهتر است زمان ارزشمند خود و يا قدرت فكري خود را در كارهايي كه مربوط به شما نمي شوند صرف نكنيد، چون بهاي اين كار براي شما گران تمام خواهد شد. 

آگاهي از نشانه هاي قبل از خودکشي بسيار مهم است . چون اگر اين نشانه ها را در فردي متوجه شديم به سادگي از کنار آن نگذريم بلکه با دقت ، مواظب و مراقب وي باشيم و در صورت لزوم او را براي مصاحبه رواني آماده کنيم و يا موضوع را با يک مشاور متخصص مطرح و راهنمايي لازم را دريافت نماييم، و يا براي اقدامات پيشگيرانه و درمان ، آنچه را که لازم است انجام دهيم . مهم ترين نشانه هاي قبل از خودکشي عبارت اند از :

1- معمولاً فرد در فکر پايان دادن به زندگي خود است ؛ اغلب در فکر فرو مي رود ؛ نسبت به خود و زندگي واطرافيان بي توجه و بي تفاوت مي گردد.

2- فردي که مي خواهد خودکشي کند، گاهي در صحبت هاي خود به اين نکته اشاره مي کند و يا اظهار مي دارد که در آينده ممکن است حضور نداشته باشد ( با بيان جملاتي مثل اين که " اگر من در بين شما نباشم شما چه خواهيد کرد"؟ )

3- آنچه را که اغلب دوست داشته و مورد علاقه او بوده است و براي به دست آوردن آن تلاش فراوان و زحمت زيادي کشيده ، به ديگران مي بخشد.

4- ابزار يا وسيله اي را براي انجام خودکشي موفق مي خرد و ممکن است به طرق گوناگون آن را از ديگران پنهان نمايد ؛ به طوري که اگر ديگران آن وسيله را ببينند تعجب خواهند کرد و اگر از وي پرسيده شود که آن وسيله را براي چه منظوري خريده است با دلايلي ساختگي خواهد گفت براي انجام کاري خاص آن وسيله را خريده است.

5- اکثراً از احساس نارضايتي خود از زندگي و بي وفايي ها سخن مي گويد و در همين زمينه به آن چه که از دست داده اشاره مي کند مانند: از دست دادن اعتماد به نفس ، از دست دادن دوستان ، از دست دادن کار و...

6- گاهي مقدار زيادي دارو جمع آوري مي کند.

7- تغيير رفتار و شخصيت فردي که مي خواهد خودکشي کند واضح و مشخص است، به گونه اي که نزديکان و اطرافيان متوجه اين تغيير رفتار و شخصيت وي مي گردند.

8- در مواردي که فرد تصميم جدي براي خودکشي مي گيرد، شديداً افسرده مي شود و به طور کاملاً مشخصي سست و کم انرژي مي شود.

9- به فعاليت هاي روزمره اجتماعي، تحصيلي، کاري خود بي توجه مي شود ؛ به طوري که گاهي ديگران چنين فکر مي کنند که اين فرد خود را لوس کرده است.

10- درمورد مرگ و زندگي بعد از مرگ زياد صحبت مي کند.

11- از دوستان و خانواده کناره گيري مي کند.

همانگونه که اشاره گرديد اين حالات را بايد جدي گرفت و حتي وي را در بيمارستان بستري کرد ، و تحت نظر و مراقبت هاي لازم قرار داد.

چه چيزي به بحران خودكشي منجر مي شود؟

يك بحران خودكشي معمولاً توسط يك تجربه آسيب زا و يا مجموعه اي از تجارب كه احساس ارزشمندي شخص را پايمال مي كنند, ايجاد مي شود. اين تجارب شامل يك فقدان اساسي, ناكامي در نيل به اهداف شخصي و يا مشكلات شخصي دراز مدت مي باشند. زماني كه نظام مقابله اي شخص قادر به رويارويي با تجارب منفي زندگي نباشد, افسردگي و يأس ناشي از آن مي تواند شخص را به افكار خودكشي آسيب پذير نمايد.

 احساسات شخص خودكشي كننده

عموماً شخص در معرض خودكشي به دليل احساس بيگانگي از تعاملات اجتماعي كناره گيري مي كند. او در پس انبوه جمعيت احساس انزوا و تنهايي مي نمايد. نيروي لازم براي عملكردهاي روزانه كاهش مي يابد. احساس خستگي و نوسانات خلقي ايجاد مي شوند. خواب, خوراك و عادات مراقبت از خود از نظم معمول خارج مي گردند. شخص ممكن است بدليل سخت و غير قابل تحمل بودن الزامات زندگي از خوردن خودداري كند, در خواب مشكل داشته باشد, كلاس درس يا كار خود را فراموش كند و از آرايش ظاهري خود غفلت نمايد. عواطف خشم, آسيب و غمگيني احساس نااميدي و درماندگي فرد را در بر مي گيرد.

شيوه هاي مواجهه با افكار خودكشي

در زير چند راهبرد جهت مواجهه با معماي بحران خودكشي ذكر شده است. نكته كليدي براي پيشرفت از طريق اين حالت, برقرار كردن رابطه با يك شخص و مشاركت در يافتن راههاي جايگزين جهت (توجيه) زندگي (زنده ماندن) است.

        1)    ترسها، ناكامي ها و نگراني هاي خود را با والدين, دوست, همسر, استاد, مشاور يا يك روحاني در ميان بگذاريد. اگر شما راه حلي براي مشكلات نداريد به اين معني نيست كه براي آن مشكلات ديگر هيچ راه حلي وجود ندارد. ابراز افكار و احساساتتان آغاز كننده فرايندي است كه از طريق آن نيرو, اميد و احساس ارزشمندي مجدداً ايجاد شده و به كشف راه حل هاي ديگر جهت حل و فصل بحران منجر مي گردد. اگر افكار خودكشي پيش از چند روز طول كشيد, كمك حرفه اي و تخصصي الزامي خواهد بود.

        2)   آنچه را كه موجب ناراحتي شما مي شود بطور مشخص بنويسيد. علاوه بر اين, چگونگي رويارويي تان با مشكلات را معين كنيد. با مشخص كردن آنچه جهت مقابله با يك موضوع خاص انجام مي دهيد, دريچه ذهن خود را براي راه حلهاي ديگر باز مي گذاريد.

        3)       افكار مثبت را جايگزين افكار منفي كنيد. اگر شما بطور دائمي درباره نقائص, تقصيرها و بدبياري هاي زندگي خود تعمق و تفكر نمائيد، خود پنداره و نگرشي منفي در مورد آينده را دروني خواهيد كرد. تمركز بر اسنادها, توانايي ها و مشاركت هاي شخصي مثبت, نگرشي متعادل در  مورد خود و توانايي هايتان ايجاد خواهد كرد. در بعضي اوقات جهت ايجاد احساس بهتر با خودتان حرف بزنيد. 

        4)     كساني را كه در صورت كشتن خودتان زندگي آنها آسيب خواهد ديد, مشخص كنيد. تعيين اينكه آيا كسي در زندگي خود به شما نيازمند است, كاري سخت است. بهرحال, ما همه در شبكه هاي اجتماعي درگير هستيم و در هر لحظه از زمان شخصي وجود دارد كه رابطه اي معني دار با شما داشته باشد. در نظر داشته باشيد كه شما به حساب مي آئيد (براي ديگران مهم هستيد), ارزشمنديد و استحقاق اين را داريد كه چيزها را بهتر سازيد.

  زندگي در دوره هايي از زمان سخت مي گردد, همه فراز و نشيب دارند. يك بخش از خوبي زندگي در اين است كه شما اميدواريد فردا بهتر از ديروز خواهد بود.

  اگر شما از افسردگي, نااميدي و افكار خودكشي در رنج هستيد, مطمئن باشيد كه مراجعه به متخصصين بهداشت رواني براي شما بسيار كمك كننده خواهد بود.

پيشگيري از خودكشي!؟چرا مردم خودكشي مي كنند؟

خصوصيت مشترك ما بين افرادي كه اقدام به خودكشي مي كنند داشتن اين باور است كه خود كشي تنها راه حل غلبه بر احساسات غير قابل تحمل است .كشش خودكشي دراين است كه نهايتا به اين احساسات غيرقابل تحمل خاتمه مي دهد .درتراژدي خودكشي ،آشفتگي ومشكلات عاطفي به حدي شديد مي گردند كه فرد را دريافتن راه- هاي مختلف حل مشكل خود ناتوان مي سازند. رحالي كه راه حل‌هاي ديگري نيز وجود دارند.

همه ما درطول زندگي احساس تنهائي ،افسردگي ،بي كسي ونا اميدي را تجربه مي -كنيم .مرگ يكي از اعضاي خانواده وشكست دربرقراري ارتباط از جمله مواردي هستند كه اعتماد به نفس ما را تحت تأثير قرارداده احساس بي ارزشي را در ما  بوجود مي -آورند.ورشكستگي‌هاي اقتصادي نيز از جمله مشكلات عمده‌اي هستند كه بعضي از ما در طول زندگي كم و بيش با آن مواجه مي‌گرديم.  از آنجائي كه ساختار هيجاني هر شخص منحصر به فرد مي باشد هركدام ازما در شرايط مختلف پاسخهاي متفاوتي مي‌دهيم .

درتشخيص  اين كه آيا واقعا ٌفردي قصد خودكشي دارد لازم است اين موقعيت بحراني ،از ديدفردمورد ارزيابي قرارگيرد، چرا كه ممكن است موضوعي كه از ديد شما از اهميت كمي برخوردار است بنظر شخص ديگر بسيار مهم باشد ويا واقعه اي كه شما براي آن اهميتي قائل نمي‌شويد براي شخص ديگر بسيار ناراحت كننده و مهم تلقي گردد.

بدون توجه به ماهيت بحران ،اگر كسي احساس مي كند كه ديگر تحمل مشكلات را ندارد خطر اقدام به خودكشي ،به عنوان راه حل جذاب براي وي وجود دارد.

    علائم خطر

حداقل 70 درصد كساني كه اقدام به خودكشي مي‌كنند قبل از اقدام ،به گونه‌اي قصد خودشان را نشان مي‌دهند .آگاهي از اين نشانه‌ها وحاد بودن مشكلات فرد ميتواند د ر پيشگيري از چنين تراژديهايي كمك كننده باشد. اگر شما فردي  را مي شناسيد كه در برقراري يك ارتباط هدفمند ويا رسيدن به اهداف از پيش تعيين شده درموقعيت پراسترسي قرار دارد و يا حتي به دليل شكست درامتحان دچار مشكل مي‌باشد لازم است درصدد يافتن ساير علائم بحران برآئيد.

بسياري از افراد غالبا با ابراز جملاتي همچون « دلم مي خواهد خودم را بكشم   »يا  « نمي دانم چه مدت ديگر مي توانم اين فشارها ومشكلات را تحمل كنم » ،يا اينكه «من قرص‌هايم را براي روزي نگهداشته‌ام كه كارها واقعا بدتر گردد» يا« اخيرا طوري رانندگي مي كنم گوئي واقعا برايم اهميت نداردچه اتفاقي برايم پيش بيايد.» ديگران را مستقيما از برنامه خود كشي خود مطلع ميگردانند.بطور كلي وجود احساس افسردگي ، ابراز درماندگي ،تنهايي ونا اميدي شديد مي تواند بيانگر افكار منجر به خودكشي درفرد باشد.گوش دادن به صحبتهاي فرد كه نشانة درخواست كمك از طرف اوست حائز اهميت بسياري است چرا كه معمولا اين گونه صحبتها تلاش نا اميدانه فرد جهت برقراري ارتباط ، دريافت كمك و درك مشكلاتش توسط ديگران مي باشد.

بيشتر اوقات دررفتار بيروني افرادي كه به فكر خودكشي مي افتند تغييراتي ديده مي‌شود آنها ممكن است با بخشيدن اموال قيمتي خود ومرتب كردن كارهايشان خود را براي مرگ آماده كنند .آنها همچنين ممكن است از اطرافيان خود كناره گيري نموده الگوي خواب و خوراك خود را تغيير دهند ويا علاقه‌أشان را نسبت به فعاليتها يا ارتباطات  گذشته‌اشان از دست بدهند.

چنين تغييرات ناگهاني وشديد مي تواند به عنوان زنگ خطر تلقي گردد چرا كه با اين تغييرات فرد خود را درموقعيتي مي بيند كه بزودي مشكلاتش تمام خواهد شد و به آرامش دست خواهد يافت .

       باورهاي غلط وحقايقي راجع به خودكشي

 باور غلط : فرد بايد ديوانه باشد كه حتي فكر خودكشي به سرش بزند .

       حقيقت : بيشتر مردم گاهگاهي درطول زندگي خود درمورد خودكشي فكر كرده‌اند. بسياري از افرادي كه خودكشي مي‌كنند ويا اقدام به خود كشي حقيقت : اغلب مواقع عكس قضيه درست است ،كساني كه اقدام‌هاي قبلي خودكشي داشته‌اند بيشتر در معرض خطر خودكشي قرار دارند.براي بعضي از اين افراد، خودكشي دردفعات دوم  و سوم آسانتر مي‌باشد.

   باور غلط :كساني كه قصد جدي خودكشي دارند هيچ كاري را نمي‌توان براي آنها انجام داد .

     حقيقت :بيشتر بحرانها ي منجر به خودكشي ،محدود به زمان بوده و براساس افكار مبهم صورت گر فته‌لند .كساني كه اقدام به خودكشي مي‌كنند به نحوي قصد فرار از مشكلات را دارند .درحالي كه آنها مي‌بايد مستقيما با مشكلات برخورد نموده تا بتوانند راه حلهاي ديگري را بيابند .راه حلهايي كه با كمك افراد علاقمند به آنها درطول بحران مطرح شده و با حمايت آنها اين افراد قادر خواهند بود دقيق تر راجع به مسائل فكر كنند.

   باور غلط: صحبت راجع به خودكشي مي تواند ايده خودكشي را در فرد بوجود آورد.

    حقيقت :بحران و آشفتگي‌هاي هيجاني ناشي از آن ،فكر راجع  به خود كشي را در ذهن فرد مستعد ايجاد نموده است .علاقمندي وصحبت مستقيم راجع به خودكشي ،اين اجازه را به فرد مي‌دهد فشار يا ناراحتي صحبت دربارة مشكلات خود را تجربه نمايد كه اين امر مي‌تواند منجر به كاهش اضطراب در وي گردد.اين گونه صحبتها همچنين باعث مي‌شود فردي كه قصد خودكشي دارد كمتر احساس تنهايي يا انزوا داشته واحتمالا براي وي تسكين دهنده نيز باشد.

چگونه ميتوان به فردي كه قصد خودكشي دارد كمك نمود:

اغلب خودكشي ها را مي توان با اقدام‌هاي بجا و مناسب در مورد افراد در معرض بحران پيشگيري نمود. اگر فردي راكه قصد خودكشي دارد مي شناسيد لازم است اقدامات زير را انجام دهيد :

        خونسرد باشيد:دربيشتر موارد عجله‌اي دركار نيست .بنشينيد و واقعا به صحبتهاي فرد گوش فرا دهيد وضمن درك،حمايتهاي عاطفي خود را در مورد وي اعمال نمائيد.

   بطور مستقيم راجع به خودكشي بحث نمائيد. بيشتر افراد راجع به مرگ و مردن احساسات مبهمي داشته و آماده دريافت هرنوع كمكي هستند . از صحبت يا سؤال مستقيم راجع به خودكشي ،ترس و وحشتي بخود راه ندهيد.

    فرد را به استفاده از روش‌هاي حل مسئله واقدامات مثبت تشويق وترغيب نمائيد بخاطر داشته باشيد فردي كه در موقعيت بحران عاطفي قرار دارد نمي تواند منطقي ودقيق فكر كند. اورا از هر گونه اقدام جدي وتصميمات غير قابل برگشت درموقعيت بحران باز داريد وراجع به تغييرات مثبتي كه اميد به زندگي را در وي افزايش مي دهد بحث وگفتگو نمائيد.

      از ديگر افراد كمك بگيريد.عليرغم اينكه شما قصد كمك را داريد،سعي نكنيد با ايفاي نقش مشاور تمام مسئوليت را خود برعهده بگيريد .درجستجوي افرادي كه بتوانند در زمينه‌هاي تخصصي به شما كمك كنند برآييد ،حتي اگر به قيمت از بين رفتن اعتماد او به شما شود.اجازه دهيد فرد مشكل دار بفهمد كه شما براي وي اهميت قائليد ونسبت به او چنان علاقمنديد كه قصد گرفتن كمك از ديگران جهت رفع مشكلات وي را داريد.

 اطلاعات ارائه شده را مي توان چنين خلاصه نمودكه:

بحران منجر به خودكشي موقتي است .غير قابل تحمل ترين دردها و ناراحتي ها نيز مي توانند تحمل گردند .كمك هميشه در دسترس شماست .

      كرده‌اند افراد با هوشي بوده‌اند كه در موقعيت بحران ، انتظار بيش از حدي از خود داشته وموقتا دچار آشفتگي وپريشاني احوال شده‌اند .

       باور غلط : كسا ني كه يك بار اقدام جدي براي خودكشي داشته‌لند رغبتي براي اقدام مجدد ندارند .

تعريف نوجواني

روانشناسان در زمينه تعريف نوجواني اتفاق نظر ندارند، اما به طور کلي مي توان گفت که نوجواني دوره اي است بين کودکي و بزرگسالي که طول مدت آن بر حسب فرهنگها و محيطهاي مختلف، متفاوت است و حدوداً از ١١ تا ٢٠ سالگي ادامه دارد.

ويژگيهاي دوره نوجواني

بتدريج که دوره کودکي پشت سر گذاشته مي شود و فرد وارد دوره نوجواني مي شود، در ارتباط خود با والدين، مربيان و اطرافيان بازنگري مي کند. در نتيجه اين بازنگري و بازسازي روابط، فرد نوجوان در رفتار و نگرش خود نيز بررسي هايي انجام مي دهد و ارتباط جديدي را به عنوان يک نوجوان با ديگران برقرار مي کند، زيرا در دوره کودکي، معمولاً تفکر کودک قالبي بوده و مطيع دستوارت ديگران است، در حالي که در اين دوره به دليل افزايش سطح آگاهي، شناخت و رشد تفکر مي تواند به طور انتزاعي فکر کند و استدلال داشته باشد و باورها و ارزشهاي موجود در خانواده و جامعه را با استفاده از توان جديد خود، بازسازي نمايد.

نوجواني، دوره انتقال از کودکي به بزرگسالي است که در همه زمينه ها بروز مي نمايد: رفتارهاي کودکانه را بتدريج از دست مي دهد، خواهان استتقلال است، مي خواهد همه چيز را خود تجربه کند، افکار انقلابي دارد، طغيانگر است، تمايل به تنهايي دارد، رابطه با همسالان براي او ارزش بسياري دارد و در برابر دستورات بزرگسالان مقاومت  مي کند.

نوجواني، دوره نوسان بين عواطف است، يعني در عين حال که شاد است احساس افسردگي مي کند، گاهي اوقات رفتار خشن و گاه رفتاري ملايم دارد.

نوجواني، دوره نوسان رفتاري نيز هست، يعني نوجوان مدام در حالت رفت و برگشت بين حالات کودکي و نوجواني است. با توجه به شناختي که از خود، تواناييها، شرايط و امکانات کسب نموده، خواستار رفتار بزرگسالانه است، در حالي که تجربه لازم را ندارد.

ميرننونش شش ويژگي را براي دوره نوجواني مطرح مي کند :

1-رشد سازمان عصبي: نوجوان با ورود به دوره نوجواني، به بازسازي در افکار و عقايد خود مي پردازد و اين امر نشان مي دهد که بايد از نظر سيستم عصبي به ظرفيت بالايي دست يافته باشد.

2-رشد جسماني

3-رشد اندام جنسي

4-رشد احساس خود که همان بازسازي ارزشها: نگرشها و باورها مي باشد.

5-کسب موقعيت بزرگسالي: نوجواني، دوره تمرين و کسب مهارتهاي بزرگسالان است.

6-رشد کنترل رفتار خود: نوجوان خواستار تغيير رفتاري است ، يعني نمي خواهد رفتار کودکانه داشته باشد و سعي مي کند از رفتار بزرگسالان الگو برداري کند. او همچنين خواستار اين است که بر رفتارهاي خود کنترل کافي داشته باشد ( بر خلاف دوره کودکي که فرد بر رفتار خود کنترل ندارد) .

به طور کلي مي توان گفت که دوره نوجواني، حدفاصل بين کودکي و جواني يا دوره انتقال از کودکي به بزرگسالي است و اين انتقال در تمامي زمينه هاي رفتاري، اخلاقي، عاطفي و اجتماعي صورت مي گيرد و فرد خواستار تغيير حالات و خلق و خوي کودکانه است. در عين حال، گاهي برگشت به دوران کودکي نيز وجود دارد و فرد به حفظ حالات کودکانه خود تمايل دارد، اما خواستار ورود به دوره بزرگسالي که داراي مسووليت پذيري، استقلال، کنجکاوي، پيشرفت و سازندگي مي باشد نيز هست.

" استانلي هاي "، پدر روانشناسي نوجواني و بلوغ ، دوره نوجواني را دوره فشار و طوفان مي داند. همانگونه که طوفان به يکباره و بدون خبر، اثرات شديد و مخربي به جاي مي گذارد، دوره نوجواني نيز به طور ناگهاني با بلوغ شروع مي شود و اثرات شديدي بر رفتار و حالات نوجوان به جاي مي گذارد. والدين بايد نوجوان را پذيرفته و او را هدايت کنند تا بتواند به درستي اين انتقال را انجام دهد.

اطلاق واژه فشار و طوفان به دليل افزايش اطلاعات سياسي، تحصيلي، جنسي، اجتماعي، افزايش توانمنديهاي مختلف فرد و تغيير حالات رواني – عاطفي و رفتاري نوجوان مي باشد که موجب تنش در نوجوان مي گردد. تنش در نوجوان به اين دليل است که تمايل دارد رفتاري همانند بزرگسالان داشته باشد، مسووليت هاي بزرگسالان را بپذيرد، در حالي که هنوز تجربه کافي براي انجام اين امور کسب نکرده است ، زيرا در دوره کودکي با مسأله اي مواجه نمي شده، فعاليت و مهارتي انجام نمي داده و والدين، مسائل کارهاي او را حل مي کردند و انجام مي دادند.

بنابراين، فرد در دوره نوجواني در عين استقلال و کم تجربگي، نياز به کسب مهارتهاي مختلف دارد و در اين راستا، والدين و مربيان بايد هدايت و راهنمايي وي را به عهده بگيرند.

دوره نوجواني به عنوان پلي بين کودکي و بزرگسالي است. در واقع، ظرفيتهاي شناختي و آگاهانه نوجوان اين پل را ساخته و او را وارد دنياي بزرگسالي که خواستار مسووليت پذيري، اجتماعي شدن و همسر گزيني است، مي کند.

بنابراين، چون بين رفتارهاي کودکانه و بزرگسالانه نوسان دارد، گاهي به دليل محبت و توجه اطرافيان در دوره کودکي و دلهره و نگرانيهاي فعلي خود، تمايل به نشان دادن رفتارهاي کودکانه دارد و در نتيجه دچار تعارض مي شود. اين تعارض از ويژگيهاي رفتار کودکانه و لذت مسووليت پذيري و رفتارهاي بزرگسالانه ناشي مي شود و براي رفع تعارض، نوجوان نيازمند آموزش و راهنمايي اطرافيان است.

والدين نيز نقش مهمي در حل تعارضات نوجوان بعهده دارند. آنها بايد بدانند که نوجوانان نياز به فاصله گرفتن از آنها دارند، نيازمند برقراري ارتباط با همسالان هستند، در عين حال نياز، به اطمينان نسبت به والدين دارند و راهنمايي هاي آنها را مي پذيرند. اينها در صورتي امکان پذير است که والدين بتوانند اعتماد فرزندان خود را جلب نموده و در يک فضاي اطمينان متقابل، بتوانند مسائل خود را حل نمايند.