A new understanding of the link between social and performance anxiety and the lesser known Obsessive Compulsive Personality Disorder, which is often confused with Obsessive Compulsive Disorder, may hold the key to more effective treatment for millions of sufferers according to psychotherapist Jonathan Berent, L.C.S.W. “Toward a Clinical Understanding of Obsessive Compulsive Personality Disorder as Etiology of Social and Performance Anxiety” integrates a review of more than 20 peer-reviewed academic journal articles with extensive clinical observations. The paper includes a comparison chart that distinguishes between OCPD, OCD, and social anxiety. In addition, a pair of graphs, depicting transactional analysis-based mind states balance combines to enhance insight, and offers a pre and post treatment visual.
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I’m going to get directly to the point. If you are the parent or concerned person of a socially phobic avoidant and overly dependent adult, you are faced with a complex and daunting challenge. My goal for this podcast is to educate you to the clinical basics you need to understand if there is any chance of healing.
I once got a call from the mother of a 26- year- old who said, “My son stays in his room all day playing video games. He doesn’t work and has no real friends. I would like you to see him for therapy”. My response: “sure but I need to see the parents first”. Her response with significant indignation “Why do you want to see us he’s 26 years old.”
Welcome to the misunderstood world of social anxiety. What this well- intentioned mom was indirectly communicating was unawareness of the avoidance-dependence syndrome which has been at play for a long time for a 26- year- old to be so stuck. This mom is not alone. The mental health profession in general doesn’t get this.
Another mom, when starting treatment regarding her 30- year- old son who had been in his bedroom 99% of his time for the previous 2 years said, “I thought he was healing”.
I have worked with countless families with similar profiles.The content I’m teaching here is the result of about 45 years of clinical experience with thousands of patients of all ages and functioning levels.
To be very clear it’s important to know who you are getting advice from which brings us to the term “evidence based” as it applies to treatment. There are many variations of evidence in the clinical world ranging the gamut from credible to absurd. I submit to you the clinical evidence at www.socialanxiety.com; especially the free library of clinical interviews. I challenge any therapist or organization to come forward with more clinical evidence regarding social anxiety.
In 1988 after my appearance on Oprah I was on the phone with the producer of the Sally Jesse Raphael show. He started the conversation with an aggressive tone saying, “you were on Oprah we don’t want you”. But then added “why do you have a PR firm”. My response “I want to educate the world”. Thirty-five years later the world still needs to be educated about social anxiety as it is a complex challenge and the classic disease of resistance.
The core pathology or disease is the individual’s inability to differentiate personhood from performance and the concurrent deeply ingrained psycho-physiological or mind-body response which manifest with a variety of symptoms. Social anxiety has been grossly over-simplified by the behavioral therapies; especially CBT which often sets the potential consumer up for unrealistic expectations regarding treatment! I can assure you that while a behavioral strategy is needed deeper emotional work is needed for true healing!
One of my patients that I brought to the Saly Show was Arthur, a recovered social and school phobic. During an interchange with Sally, he said “If my parents knew what to do they would have done it”. You can listen to Arthur and many others who have given me permission to tell their story at socialanxiety.com area of concern social anxiety. The title of his interview is “School Phobia, Social Phobia, and Depression Cured-From School Refusal to Social Butterfly”.
On Oprah one of patients who participated was Susan. She had her first date at age 38. Sadly, it was her only date. Oprah was having a difficult time understanding her social avoidance and over-dependence on parents. At one point she asked, “Were your parents so much fun that you wanted to hang out with them all the time?” When Susan was 40 her mother passed. She wanted to jump into the grave with her. No one had taught her independence skills. Very sad!
Let’s cover some basics about social anxiety. First, understand that when anxiety leads to avoidance a phobia is present. Second, understand that the adult child eventually growing out of the problem after a sustained period of anxiety-driven avoidance and over-dependence is in the vast majority of cases a statistical oddity and a cognitive distortion, if not a delusion! As one of my patients said, “hope is not a strategy”. Third, if there is going to be positive change or any realistic hope for healing the parents need a game plan, a “map” to facilitate this change because the avoidant and dependent adult has no initiative for their mental health!
Social anxiety is a spectrum disorder. While there are many variations of this disorder there are two basic types of individuals who are afflicted: those with initiative for their mental health and those without initiative. At the high end of the spectrum are professionals of all kinds, entrepreneurs, executives, athletes, performing artists, who suffer from performance anxiety. Social anxiety is all about performance. That’s what separates it from other anxiety disorders. You may want to check out my podcast “Public Speaking Anxiety and Fear of Being Noticeably Nervous: Mind Surgery for high performers”. It’s at socialanxiety.com and most podcast outlets
So what is the 26 year old who doesn’t socialize and doesn’t work doing behind closed doors with all of their time? Enter a critical layer of over-dependence, technology and the internet. A little dramatic irony. One of my patients who came to treatment for public speaking anxiety was a brilliant developer of video games. He was the driving force behind a billion- dollar gaming company. He developed many of the video games that so many of my patients have been addicted to! In one of our sessions, he described the process of how the games are developed, the objective of which, through dopamine hits, was in essence to get the players hooked or addicted. Here’s the thing. So many socially anxious individuals are addicted to this technology at the expense of being able to access the neural pathways required for processing cognition and emotion; a necessity for true healing! As one such patient said, “the games are the only thing I can control!”
The adult child with social phobia who is stuck with avoidance is at the low end of the social anxiety functioning spectrum. They lack initiative for getting help and sadly they have learned to mistake happiness or contentment for the avoidance of discomfort and anxiety. That said, this profile has a spectrum also. For example, Tim age 19 experienced long term social anxiety and selective mutism which is a complex variation of OCD and manifests as a speaking phobia. His social skills were abhorrent. He frightened females with his affect. He was addicted to video games. He had no close friendships. However, he wanted to go to college and explore life away from parents. Compare this to Mitchell age 26 who had friends, and even a couple of girlfriends in his history. He was totally controlled by his addiction to avoidance and didn’t want to leave his house and his parents.
This is complicated stuff. My first book is entitled “Beyond Shyness: How to Conquer Social Anxieties.” It was released in 1992. Before contracting with Simon @ Schuster other publishers asked, “you are writing about shyness why are you writing about parents?” Well, if I didn’t understand the avoidant-dependent dynamic I would not have been able to develop a practice because the patients with no initiative never would have sought treatment.
Before arriving at the title “Beyond Shyness” I was playing with the title of “Between the Cracks”. This was in reference to the complex myriad of clinical diagnostics that are at play. Let’s go through the basics.
Two words dominate for clinical understanding: “pain” and “homeostasis”. The word “pain” is interchangeable with anxiety, depression, challenged self-esteem, and the possibility of several comorbid symptoms which can create a complex cocktail of dynamics. Your adult dependent is in a lot of pain! The most common co-morbid symptoms include substance dependence, OCD and OCPD which is perfectionism. Also common is dysthimia, a subset of depression. In my clinical practice I have also discovered a direct link between learning challenges and performance anxiety. In fact, that’s how I discovered social anxiety in 1978 while creating a socialization program for learning disabled teenagers. “Between the cracks” refers to a multiplicity of variables at play that do not fit rigid diagnostics.
A major component of the diagnostic formula is avoidant personality disorder. Do a little research on treatment for this and you won’t find too much. Afterall, the potential clients are busy avoiding. My Co-writer Amy describes her recovery from avoidance in our book “Work Makes Me Nervous”. This is rare content!
In my clinical work I discovered that avoidance can become a compulsion or in essence an addiction. This takes us to an addiction model. The gateway to addiction resolution is often via the influence of those who are over-depended on. Who and what are the sources of over-dependence and enabling for your socially phobic adult child?
Make a list, as extensive as possible organizing the ways your child is over-dependent on you. Dependency includes several categories: financial, emotional, practical problem solving, and social. Start your list now. If you ever choose to enter effective treatment you will need this list for a behavioral strategy. You will need to utilize your leverage to get your child’s attention.
Let’s go a little deeper:
The avoidant and dependent adult child with social phobia is in a lot of pain. To resolve pain, it has to be processed. The challenge is that the sufferer will do anything to detach or dissociate from the pain and resist therapeutic efforts which brings us to homeostasis. Homeostasis, from the Greek words for "same" and "steady," refers to any process that living things use to actively maintain stable conditions necessary for survival. The term was coined in 1930 by the physician Walter Cannon.
Andy was a straight A student at an Ivy League school who tragically succumbed to his pain via suicide. His family established the Andy Kukes Foundation it’s objective to develop awareness of this perplexing disorder. The foundation produced a state-of-the-art program geared to teach the mental health profession about social anxiety. “Social Anxiety: The Untold Story” is available via the website.
One quick story to make the point of a co-morbid dynamic driving social anxiety. When Andy was in his mid-twenties he was walking his dog and wanted to talk to a young woman who was walking her dog. He analyzed and analyzed to come up with the perfect thing to say and was paralyzed. He never talked to the woman. Here’s the clinical point. He believed there was such a perfect thing. His perfectionism his OCPD drove the pain!
The homeostasis for the adult child must be shifted for healing to occur. This is the most important concept in this podcast!
This is because the ingredients for homeostasis are what keeps the sufferer stuck… in stasis. This requires active parenting. For the sports enthusiast I use the metaphor of football and the quarterback. The QB drives the team. He may drop the ball, but he takes responsibility for creating motion and energy! If you don’t like this example, think of the pilot of the ship or plane. He or she is in control. You may not want to hear this. Parents need to quarterback or pilot for the stasis to shift. As previously stated, It would be a statistical oddity for the adult who has been stuck for years to actively implement mental health initiative. This may sound harsh but my assessment comes from a few hundred thousand hours of clinical experience. I remember one mother of a teenager with significant challenges say, “the real world is not as tough as Jonathan” Really!!! It’s imperative that parents get out of a defensive mind set and hypervigilance regarding anything that could upset the child! Walking on eggshells will get you nowhere other than stasis!
Consider please another dynamic here. Do you know the scientific definition of stress? Stress is not something up in the sky. It’s in all of us. The world’s foremost stress scientist Hans Selye defined stress as “physiological adaptation to change”. Take a good look at your child’s adaptation. Add to this the fact that the more things remain the same; stasis; the more the problem accrues and worsens with time. You put money in the bank to collect interest. The pathology…this means disease, of avoidance and social anxiety accrues with stasis. The disease collects interest. The Covid Pandemic has certainly played a major role in enabling “addiction to avoidance”!
Parents, caregivers…assess your time urgency. If the problem remains the same what will the impact be for you..for your child..for the family… in a year, 5-10-15 years? It’s imperative that you connect to this. Should you be considering estate planning for the handicapped?
It’s critical to engage the concept of nurturing. The operative definition is provide support-promote growth. This is a multi-dimensional concept. Many things go into nurturing. Many a loving well- intentioned parent has gotten this confused with rescuing. A great quote is “the role of the parents is to provide roots for security and wings to fly”. What’s missing here are the wings! Nurturing is not over protecting. Nurturing is not enabling! Nurturing is a process of empowerment! An ongoing supportive and empowering strategy needs to be sustained in order to nurture the child out of breakdown. At the risk of being upsetting if your adult child has been in stasis for significant time the reality is that you are running a hospital in your house without a professional staff!
Consider the nurturing deficit of growing up with no parents. Jim, having experienced panic about the thought of his public speaking class needed for college graduation-initiated treatment for his social anxiety when he was a senior in college. His mother died of alcoholism when he was in elementary school and his father died of cancer when he was a teenager. Josh is sensitive, intelligent, and attractive. He played basketball and football for his high school team. He had lost 100 pounds before starting therapy. His treatment focused on his building his nurturing self as he had been paralyzed by an internal critical script of self-loathing!
The primary obstacles to parental nurturing are confusion about the anxiety disorder itself and parenting anxiety. For example, the typical response of “we don’t know what to do” and “we fear pushing him or her further away”, and of course the fear of suicide rule with stasis.
These fears are all understandable. But please be clear the 26- year -old who has no social life, doesn’t work, or go to school, and is toxically dependent on video games and technology pursuits is already in breakdown mode. The goal is to facilitate the adult child out of the breakdown. This is a daunting challenge which requires organized parental intervention. This will require parents managing their own anxieties. This is a critical component of treatment.
It may be helpful for you to go to the website area of concern selective mutism and listen to the interview titled “Mom Resolves Break Your Heart Syndrome to Cure 5-year-old with Selective Mutism”.
This mom learned how to empower her daughter by not enabling avoidant behavior and nurturing emotional expression. To accomplish this mom herself needed a huge dose of self-nurturing and emotional management. She learned to channel distress into eustress which is the Greek word for good stress. When she was in the process of non-enabling which would trigger her daughters discomfort she experienced her own discomfort but learned to invest in the interpretation this was empowering!
This mom is one of the small minority of parents who seek help for socially anxious children at an early age as the saying “she’s just shy; don’t worry the child will grow out of the problem “still rules with social anxiety. As I said previously, social anxiety is the classic disease of resistance!
A few words on trauma. Trauma is a term used to describe the challenging emotional, mind-body, and functioning consequences of living through extreme distress. At play here are a combination of factors. The child’s social anxiety driven breakdown is the result of complex trauma of an invasive interpersonal nature that resulted in the inability to distinguish performance from personhood. The ongoing nature of stasis becomes chronic trauma for both caregivers and child.
Mark at age 16 had significant social anxiety and selective mutism. Now remember; selective mutism is a compulsion not to talk. One day he was boating with his father. It was just him and his dad alone. His father suddenly became quite ill and passed out. Christopher was able to call the coast guard and get help in this survival situation. What would your dependent do in a similar situation? Many parents have said to me about their socially avoidant children “you can’t force a person to be social”. Maybe, but you can influence or force a person to learn survival skills. After these skills are learned let the person decide if they want to be social.
Brenda’s parents initiated treatment when she was 23. This was two days after she left her first job after law school due to massive panic. She was significantly depressed and over-dependent on parents. At that time, she had a long- term toxic co-dependent relationship with a boyfriend and no other social life. Having made good progress with some consistent therapy, she now lives independently, makes 100k and is exploring her social identity. With all the progress therapeutically that she has made she says time is about “quelling the pain”. The pain of social anxiety runs quite deep as the social abandonment and bullying she experienced in younger years left an indelible imprint.
In fact, after the Columbine shooting in 1999 I had a few patients tell me “I understand why kids shoot up schools”! Not that these patients had the DNA for such a thing but their memories of bullying and struggle with being low on the social pecking order left them with unresolved rage.
Let’s get clinically technical. It’s important that parents understand what is taking place in the mind of the socially anxious dependent and avoidant adult so lets do a five minute course on mind states . I want to give you a visual. Go to socialanxiety.com and scroll down under self-help.
You may want to pause this for a moment…
You will see an ego-graph with the title public speaking anxiety unresolved and public speaking resolved. Public speaking is interchangeable with social anxiety. This before and after graph shows you what resolution for social anxiety looks like.
This graph comes from the psychology of transactional analysis. An understanding of mind states can go a long way in resolving social anxiety. All mind states are important. The issue at hand is synergy or balance. Look at the twin towers on the top graph. The excessive critical script with its messages of “be safe avoid”, “people will see who you really are”, “you will embarrass yourself” “you are not ok enough”, “you have nothing to say” etc. are examples of content which cause and drive social anxiety. The social anxiety itself is located in the right-hand tower, the adapted child, which is learned behavior and emotion. Your child may have been born with certain predispositions but social anxiety itself is a learned response.
Let’s go a little deeper. Look at the natural child mind state on the far left. This is genuine emotion, exploration, discovery, creativity, curiosity, sexuality. It’s one’s primitive self. Very importantly think of it as one’s truth of desire. When this desire is blocked; whether it’s educational pursuits, career development, relationship development, learning a skill, asking a question in class, taking a risk, the result becomes self-loathing and internalized emotion; not necessarily conscious anger and rage.
This causes a condition called Tension Myositis Syndrome. This term was coined by the late Dr John Sarno MD who was world famous for his work with back pain. His treatment was based on the dynamic that repressed emotion is so powerful it inhibits the flow of oxygen int the blood stream. This is the cause of all physical symptoms that do not have an organic etiology or cause to them. Social anxiety is a manifestation of TMS. The repressed natural child mind state is part of the root cause.
Stasis is an investment in TMS. It’s an investment in primitive functioning! Therefore, the clinical algorithm for healing requires caregivers introducing an updated strategy for “nurturing” to create a shift away from the twin towers which has become a deeply ingrained psycho-physiological or mind body response driven by an avoidant time economy! Think of the towers as a mind tic. Not a neurological tic but a very deeply ingrained mind-body reflex.
As you process the ego-graph understand that the therapeutic formula for social anxiety resolution is to nurture the natural child with a good dose of adult. The adult is one’s objective self. Think of it as an internal computer.
One of patients is a world renown cancer expert. She is an M.D. who entered treatment for her public speaking anxiety disorder. Obviously she is at the other end of the functioning spectrum from what we are addressing here. In the middle of a catharsis, she said to me and I quote “I’m realizing that my thoughts drive emotions and actions rather than allowing them to flow as if directed by something external”. This is a 45-year-old MD, mother of two. She experienced major dissociation. If such a high functioning individual can dissociate so deeply do you see the dissociation/disconnect in your dependent? This dissociation creates a back-up of emotional energy which recycles and drives anxiety and depression. This goes back to my reference to Tension Myositis Syndrome.
Let’s address the subject of medicine for moment. The purpose of pharmaceutical intervention is to lower the pain. Specifically, the purpose of medication is to lower the twin towers. This is necessary for the other mind states to grow. The issue becomes is there a proactive therapeutic strategy with the medicine or a passive approach? Mind state development can only occur via a proactive strategy. Passivity is an investment in stasis.
On the subject of substances for a moment.. Alcohol is the drug of choice for social anxiety because it lowers the twin towers. The problem is that it depresses the energy across the board in all the mind states. The same effect is true with video-game dependence. The effect of cannabis on social anxiety users runs the gamut from those who say it is very helpful to those where it induces anxiety, panic, paranoia, and depression. While many patients report a positive impact from cannabis the question becomes does it translate into proactive or passive energy and behavior?
These are subjects for another podcast.
Here are the clinical fundamentals for parents if you are considering a shift from stasis:
Understand the pain of social anxiety and the role of homeostasis.
Assess how there is disagreement with parenting technique and philosophy. The more parents are fragmented with parenting strategy the more enabling will take place. Not to over-simplify, but a typical scenario is one parent believes in setting limits and consequences and the other does not. One parent is aggressive, the other is passive, one parent is present the other is absent etc. This creates chaos. Learning and implementing a team approach is critical for any positive movement.
Let’s go back to Mitchel. At age 25 his OCPD driven perfectionism was running rampant creating a massive dose of image sickness. He avoided anything where he could be perceived as not perfect. He was dying of embarrassment! He was an attractive and intelligent young man raised in an affluent family. He struggled with learning disabilities at an early age which led to over- compensation from his mother who was a teacher. She did too much of the academic work for her son. He never learned independent academic skills and dropped out of college which created tremendous embarrassment and shame. In addition, a marriage conflict between parents impacted any cohesive parenting. The result stasis!!
Your bridge to challenging the pathology of avoidance is to first focus on attachment. The adult child has become an expert in detachment or dissociation. This means disconnecting both externally and internally from discomfort. Detachment is the doorway to avoidance. Attaching or connecting is based on caregivers learning to initiate, promote, and sustain communication rather than being disarmed by responses like “I don’t know”, “there is nothing to talk about”, “if you pressure me I will kill myself”, and an overall retreat into the inner sanctum of one’s room. Learning to connect and attach is an example the cross training of nurturing.
When met with resistance like “I’m going to kill myself”, aggression, withdrawal, or mutism it’s important to know your response or the detachment and avoidant pathology will rule! And what your bottom line is! This is where it’s important to nurture a new interpretation of discomfort. There is no way out of stasis without negotiating conflict.
As a means of monitoring your emotional reaction to shifting statsis….go slow. Pick a couple of things your dependent expects you to do for him or her and suggest they do it themselves. This could be asking them to do the shopping instead of you, setting up an appointment, communicating to someone instead of you. You can come up with numerous examples that would take the dependent out of their comfort zone. Again, this is just a beginning exercise to monitor your emotions as you challenge the avoidant comfort zone….nothing more. A process of parent initiated attachment communication is a pre-requisite to getting the child’s attention to address the issue which all too often is not present in stasis.
A component of a nurturing or empowering strategy for parents is realistic expectations. Resolution to the problem requires a lot of hard work. Think of it as mountain climbing. The purpose of this podcast was to provide basic information about the presenting pathology and to stimulate your thinking and emotion about the possibility of your nurturing a shift from stasis. When working with families with this challenge I try to get the parents ready to present to the adult child that there is a family problem or challenge rather than only the approach of you have a problem. Afterall for stasis to occur parents have their own anxieties and confusion about parenting. This indeed makes it a family challenge! It’s important to come out of the closet with this reality. My goal clinically is a bridge to individual treatment parallel to parents working on empowerment. This can only happen productively after a certain amount of shifting via parent-driven process.
I will end with this story. The last thing David wanted was to interact with me after his parents initiated treatment when he was 20. He was suffering from major and chronic social phobia, school phobia, and avoidant personality. He had no friends and was depressed. He went away to college and spent his first semester in his room isolated watching tv. This was before the internet I’ve been doing this for a long time. He never thought having a relationship with a woman was possible. He felt hopeless and helpless.. This was especially upsetting for his mom who was dean of a college. Flash forward, he received his Master’s Degree and was a supervisor in an educational setting. He got married. He had two children. One day years after he finished treatment I received a call from a family friend of his telling me that he died of cancer ..at a young age; leaving two young children and a wife. You can hear his interview, along with others who have given permission to tell their stories at socialanxiety.com “area of concern social anxiety” titled “”School Phobia, Avoidant Personality, Learning Disability: From School Refusal to Graduate Degree”.
What’s the moral of this story you might ask. I’ll answer with a question. Do you know what your most valuable asset is. It’s not your mortgage or your bank account. It’s time. Time is not elastic. It doesn’t stretch. You can borrow money. You can’t borrow time. Stasis is the enemy of time!
There is a wealth of information at www.socialanxiety.com. I hope this podcast has been helpful. I wish you good health!
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