Rebounding to Calm

I thought I’d address social anxiety on this site, as it is often experienced by those on the eating disorder spectrum, especially when they work towards recovery and are attempting to normalize all facets of their lives. 

 .Eddie: Flickr.com

.Eddie: Flickr.com

Conversation is Messy

Human conversations ebb and flow and hit a lot of snags all the time. The only difference between the 'socially awkward' and the 'seemingly smooth' is the amount of time they will devote to focusing on the snags and the level of importance they place on them in relation to their position within the social hierarchy. 

We all stick our feet in our mouths; we all go down the wrong path in conversations and have to back track (e.g. unequivocally stating you found a movie a complete dud only to discover that the person next to you actually worked on that movie in post-production); and we certainly all register micro-facial movements and feedback to our chatter through the facial expressions of those around us (with the possible exception of some on the autism spectrum).

Yet all these foibles and confusions are comparable to parenting outcomes—researchers have actually been able to determine that there only needs to be consistent and dependable attachment between the primary caregiver and the baby about a third of the time for the child to become securely attached and experience a comfortable development into adulthood. That's a whole slew of mistakes that parents can make and still have everything turn out okay.

The same is true for all human interactions I'm sure. Basically human beings are built for efficiency and not accuracy on all levels. Our brains are not computers—they make many more mistakes and jump to too many conclusions. But the sheer brilliance of such distributed and seemingly haphazard 'processing' enables us to experience a level creative thought that would be tough to mimic through computer processing of any kind.

Social awkwardness is likely an attention to accuracy that is counterproductive to the way in which all brains are optimized to work. Perhaps this kind of excessive attention is displayed in many circumstances for those with eating disorders because the amygdala, one of the emotional centers in the brain responsible for generating fear (the threat response), appears to be where the skewed threat responses to food (an eating disorder) 'reside'. 

For those on the eating disorder spectrum, getting everything right features prominently with food, exercise, hair, clothes, studies, career, relationships, social interactions...the drive to get it right is founded in the fear of getting it wrong.

Despite numerous examples that getting it wrong is not nearly as bad as the fear makes it out to be, the fear still gets fired up the next time as though the lesson of how relatively navigable mistakes are, is just never really learned. And once the avoidance kicks in to any stimuli that generates fear, then the whole fear cascade only gets worse, not better, when you cannot avoid the circumstances in question. 

People Notice

What people notice, for how long they notice and whether it impacts their opinions or not is where those with social anxiety tend to go into the weeds. 

In a society obsessed with thinness how does someone reconcile her efforts to restore weight and health?

We live in a society that has heavily conditioned all women to notice their own bodies and other women's bodies when it comes to weight gain. Yes, generally women are too polite to mention it. When women do mention it they are projecting their own anxieties—this will especially be true of close relatives and often mothers in particular.

Given that "Have you lost weight?" is considered a compliment in our messed up world, the presumption would be that "Have you gained weight?" would be a criticism and therefore rarely stated.

Men, despite heavy marketing directed at them as well, still experience a somewhat different reality. They tend to register proportion and shape. Given that women tend to have a womanly shape (and not a prepubescent boy-like shape) when they are heavier, weight gain tends to register for men but is seen as an increase in overall attractiveness.

Intimate partners (of all sexes) notice the marked improvements in mood and communication when their partners gain weight (assuming it is due to the cessation of dieting obviously). Again, with the exception of extremely status-focused and insecure partners, most enjoy seeing their partners gain weight because of its tremendous positive impact to the individual they love and the accompanying benefits to the relationship as a whole.

But in all these things, where it gets garbled is the skew that someone on the eating disorder will place on the fact that people notice their weight gain and what it all ultimately means.

The amount of time that anyone (including your mother) will actually spend registering your weight gain vs. the amount of time that you will expend thinking about their having registered your weight gain are two completely different things.

This is where the self-focus is problematic.

The eating disorder is likely a facet of an overall broad spectrum of anxiety conditions. Whether it is eating, obsessive compulsive disorder, phobias, panic attacks, generalized anxiety disorders and the like, the area of the brain impacted is the amygdala. As mentioned before, the amygdala is one of the emotional centers of the brain particularly responsible for the threat response and the generation of fear.

When the neurotransmitters in this area of the brain are influenced by the genotype that predisposes someone to anxiety, OCD, and/or eating disorders, then those neurotransmitters fire up to create a sense of imminent threat where objectively there is nothing there to fear. 

Collette Hirsch and her colleagues ran an interesting study with confident public speakers where they randomly split the group into three and each group was given either a positive self-image, negative self-image or control image to rehearse in advance of giving their speech. The negative self-image group felt more anxiety; believed they had performed less well; and had more negative thoughts during their speech. 1

These results suggest that negative self-talk shapes the experience, even for those who are normally unaffected, such that it can trigger fear and anxiety.

I bring up her study because clearly lessening social anxiety needs to include positive self-talk, but that is not all.

Social Anxiety Defined

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has recognized social anxiety disorder as a distinct disorder since 1980. But, as you know, I don’t put a lot of stock in that tome primarily because these conditions should not be framed through observable symptoms and behaviors alone. We have much more evidence to suggest that the distinctions applied in the DSM to identify one condition from another are not neurobiologically valid.

I ­prefer the Social Anxiety Network definition for social anxiety:

Social anxiety is the fear of social situations and the interaction with other people that can automatically bring on feelings of self-consciousness, judgment, evaluation, and inferiority.
Put another way, social anxiety is the fear and anxiety of being judged and evaluated negatively by other people, leading to feelings of inadequacy, embarrassment, humiliation, and depression.” 2

As with all anxiety conditions, all human beings experience these emotions. That is why it is the intensity, duration and the impact to quality of life that will subjectively determine whether someone needs intervention to re-establish an acceptable quality of life or whether it is merely a fleeting normal emotion.

Cue Responses

Numerous studies indicate that those with social anxiety are prone to either spend more time or less time paying attention to threat cues than non-anxious subjects. 3,4,5,6,7,8 That seems contradictory on the surface, but it is dependent on the threat cues used in these studies.

In real-life circumstances socially anxious individuals tended to spend less time than controls looking directly at an angry face and that would suggest a hierarchically submissive stance that is adopted to ensure one’s safety. However, in laboratory settings when faced with threat cues demonstrated by the use of images or words, then socially anxious people would spend more time than controls paying attention to the images or words that were deemed threatening.

It is now generally assumed that both attention towards and avoidance of threat cues play a part in the reinforcement of social anxiety. Basically if the threat is in-person and immediate, then there is an avoidance response, but if the threat is anticipated then there is an increased attention to that threat.

Borrowing heavily from the research of David Clark, the perseverance of social anxiety, despite the fact that all data reinforce the absence of negative outcomes, appears to be a multi-faceted process for those with social anxiety.

Spontaneous Negative Images

In addition to the reinforcements of either attending to or avoiding threat cues in abnormal ways, those with social anxiety also have spontaneous images occur that generate a warped observer-perspective that is actually the person’s own fears visualized rather than what an observer objectively registers:

For example, one of our patients who is a teacher was very anxious about asking questions of her colleagues in a coffee break. When she started to think about asking a question, she thought other people would think she was stupid and she started to feel tense round her lips. The tension then became converted into an observer-perspective, mental image in which she saw herself with a twisted and contorted face. When asked “what does that look like?” she replied “the village idiot” and at that moment she was absolutely convinced that her colleagues thought she was stupid.” 9

What Clark and his colleagues note is that the images are not updated and often date back to the onset of the social phobia, linked to memories of criticism, humiliation, bullying and other social events. 10 Once these spontaneous images arise, then the patient reduces her attention to the actual social situation at hand and this reinforces the fact that the images are never updated with newer and more accurate models.

Interoceptive Input Amplified and Distorted

Another aspect that reinforces social anxiety is the focus patients have on their own physical sensations that lead them to assume they look much more anxious than they actually appear to others.

This tendency is referred to as emotional reasoning. 11  If we look again at the above quote from the teacher she actually expresses emotional reasoning by translating the tenseness in her mouth that she identifies through her sense of interoception as being externally visible as a twisted, contorted and “village idiot” face.

Selective Memory

Not surprisingly those with social anxiety retrieve negative emotions more readily in situations of perceived threat than normal controls. This selective retrieval of negative memories that occurs specifically with the anticipation of social interactions is likely one of the key ingredients that push those with social anxiety to avoid social interactions of all kinds.

Harsh Self-Judgment Further Reinforces the Condition

In studies of those who experience trauma (car accidents and rape), almost everyone experiences post-traumatic stress disorder (PTSD) in the week following the incident (94%). However, the rate drops to 65% after one month and 47% after three months. 12

Clark and his colleagues have shown in studies that initial interpretations of PTSD symptoms have strong positive correlations with subsequent severity and persistence of PTSD. 13,14

Basically, people who interpret their initial intrusive thoughts, recollections and anxiety after a traumatic event as normal and understandable, are far less likely to develop persistent PTSD. Conversely, those with persistent PTSD will have initially experienced their symptoms as losing control, becoming neurotic and going insane.

Safety Behaviors

Safety behaviors are self-explanatory and they develop over time in an attempt to try to alleviate the anxiety and physiological discomfort associated with that anxiety.

Safety behaviors can exist at a level of superstition (e.g. knocking on wood when speaking of an event that you hope will occur in the future) and they can be taken to a level where an obsessional and compulsive loop is generated. At that point, the person is unable to feel “safe” unless and until the behaviors are performed perfectly.

At first glance you would assume that safety behaviors would have a moderating influence on social anxiety.

Let’s take an example of a woman with social anxiety with a variety of safety behaviors she has developed over time when she is unable to outright avoid a social engagement.

She will attend the event on an empty stomach. This is a safety behavior she has developed to avoid the possibility of feeling queasy and nauseous. She washes her hair with anti-dandruff shampoo although she does not have dandruff. She has developed this safety behavior because she does not want to inexplicably develop an itchy scalp at the event. She fears having to call attention to herself by needing to scratch her head in public. She will not eat anything at the event because she fears the possibility of being ridiculed if she ends up with food in her teeth. She always wears dark colors because her mother has told her she looks childish when she wears bright colors. The list goes on of course.

If the event seems to go well enough, then she attributes the success to her careful adherence of her safety behaviors. If there are any hitches that she perceives in her interactions at the event, then she will attribute the ‘failure’ to either the inadequate adherence to her safety behaviors or the necessity of adding to the safety behaviors to cover off new eventualities in future.

Not all safety behaviors are behaviors per se and many mental processes are involved: memorizations, pre-prepared topics of discussion, efforts to maintain certain facial expressions, etc.

Safety behaviors back fire on several levels for the person with social anxiety. Sometimes the behavior actually creates the symptom (or another equally anxiety-inducing symptom) that the patient fears.

For the woman who attends a party on an empty stomach and refuses to eat all evening, she may end up feeling queasy, nauseous and dizzy because she needs to eat and her blood sugar is low.

Having memorized comments and pre-prepared topics often involves a level of self-monitoring that makes the patient appear either preoccupied or disconnected. Unfortunately, other people often interpret these safety behaviors as a sign that the patient does not like them. This precipitates a cool response from those people that only reinforces the patient’s sense that she is being rejected, when in fact she started the entire cascade with her safety behaviors generating warped social cues.

It is a key facet of recovery from social anxiety that the patient cease all safety behaviors alongside the other techniques I discuss below. 

Chicago Art Department: Flickr.com
Chicago Art Department: Flickr.com

Anxiety Recap

Having social anxiety (in fact anxiety in general) encompasses:

  1. You have developed a heightened response to both identify and avoid threats.
  2. You have outdated and spontaneous images of social disaster that usually harken back many years to an incident of criticism or humiliation.
  3. You are hyper-aware of your physical sensations when you are anxious and you amplify greatly how much of your anxiety is visible to others.
  4. You have a knee-jerk response to pull up only negative memories if you are faced with any threat cue (e.g. you are told you have to attend a going away party at work).
  5. You have a very harsh self-assessment of how your initial response to an original incident (or incidents) of criticism or humiliation was a sign of losing control/being weak/being neurotic rather than a normal and understandable reaction to the very unpleasant experience of rejection.
  6. You have shifted from having a few superstitions to developing an entire roster of safety behaviors that you apply when you are unable to avoid circumstances your mind interprets as a threat. 

Learning and practicing self-compassion techniques are a valuable addition to the effort to rebound to calm that I am about to discuss in more detail.

Hit the Ground at Peace

Robert Sapolsky in his book Why Zebras Don’t Get Ulcers talks about the rebound to calm that was measured in Norwegian paratroopers in WWII and the observations on those studies are applicable to all types of anxiety, social anxiety included.

In WWII (typically Scandinavian in approach) the Norwegians measured everything to do with the training and development of their paratroopers. For conscripts, their first jump was sheer terror with the cortisol levels remaining high for up to 2 hours after the jump. However by jump 20 or so, the adrenalin hit as they left the plane and they were back to zero by the time they hit the ground. There was no release of glucocorticoids (cortisol) at all.

To backtrack for a moment, the stress response has two distinct features: 1) the release of adrenalin (epinephrine) almost immediately, and 2) if the threat that caused the stress response is maintained, then glucocorticoids are released in the body and these are longer-sustaining chemicals that shift many biological functions for longer periods of time.

Tellingly, the first jump was perceived as a significant threat not only prior and during, but also for a couple of hours afterwards. With practice, the paratroopers found the jumps exhilarating as they left the plane (with a commensurate release of adrenalin) but no longer experienced the jumps as threats that required a sustained stress response. The paratroopers were now rebounding to calm without any release of glucocorticoids.

Rebounding to calm can be generated in circumstances that feel like jumping out of a plane at 13,000 feet, but really just involve hanging out in someone's living room with a bunch of strangers.

Why is rebounding to calm necessary? Because social interactions need to be exhilarating, not death defying.

Having glucocorticoids swimming around in your system for hours on end is equivalent to the body’s ability to suppress your metabolic rate when you start dieting. These are life-saving capabilities your body uses but they are not used without some cost. Glucocorticoids rev up all kinds of biological functions that enable the body to attend to healing.

However, at some point that revving up starts to cause some damage. The same is true of metabolic suppression. Initially, it enables the body to conserve energy and support keeping you alive for longer. But eventually, there are just too many biological functions that have been put on hold for too long and things start to fall apart.

The reason the paratroopers could rebound to calm is that they had undergone many jumps with success (practice). However, let’s also recognize that they were updating their memories as they practiced and were not dealing with other aspects found in anxiety disorders such as intense interoception and extremely harsh self-assessments of their initial fear and responses early on in the training process.

It means that practicing to overcome social anxiety, by attending multiple social functions on a pretty continuous basis, will not be enough to hit the ground at peace because we have already established that there is no objective updating that happens for those with anxiety. So you have to learn to practice from a specific cheat sheet to address all the facets of social anxiety successfully.

Meta-Cognition

If you look at the above six facets of anxiety in the Anxiety Recap section, you will note that all six items are self-focused, and the observer-perspective that is discussed is actually projected fears and not objective outside input. Even when you receive objective outside input—perhaps your partner confirms to you that no one actually noticed whatever it was that was of particular concern—you are not able to update your perceptions so that the next time you are more aligned with what people really do and do not notice.

I mentioned earlier that what people notice, for how long they notice and whether it impacts their opinions or not, is where those with social anxiety tend to go into the weeds. In order to begin overcoming social anxiety we cannot start with objective outside or observer input because it will not be absorbed to update the internal experience. And so we begin, naturally enough, by being self-focused but in a new way.

Meta-cognition is the ability we have to think about thinking and feeling. We can experience those moments where we register that we are irritable, sad or bored and then think about the possible reasons why we might be in that particular mood at that particular moment. That is meta-cognition.

Registering that you are feeling fear rather than simply experiencing the fear with no thought makes a huge difference in detaching yourself from the panic.

Let’s take our poor teacher in Clark’s example above who becomes anxious about asking for a colleague’s opinion and immediately senses the muscles around her mouth becoming tense. If she applies meta-cognition right at that very moment, then it would read like this in her mind: “Hmm, I just noticed the muscles around my mouth and that means I am feeling anxiety about asking for her opinion.”

That really doesn’t seem very helpful does it? Yet by taking that moment to think about her feeling, our teacher is beginning the process to short-circuit the error loop.

2f06f-theerrorloop.png

The Error Loop

One of the most basic survival mechanisms we have in place is the orbito-frontal cortex to amygdala connection.

When the orbito-frontal cortex detects an error of any kind, it sends a message to the amygdala so that the amygdala can immediately muster the attention of the prefrontal cortex (the logic center) to determine what has to happen next.

When I say “error” I mean any aberration in what is expected. So this can be as varied as a rustle in the bushes, to an unexpected facial expression from a colleague, to internal signals of physical distress as well.

As the mess of the accompanying diagram shows, it is not a simple process. Our amygdala usually doesn’t wait for the logic center to make its determination and it keeps sending out signals to have the orbito-frontal cortex check again.

I prefer to describe these brain functions as muppets---seriously, it helps!

Meet Orbito-Frontal Cortex

Grover is a good stand in for the orbito-frontal cortex. He is sensitive to stimuli; he definitely rubbernecks quickly if anything appears threatening; and he is at the ready for any error that may show up in his line of sight.

When I was a child, he was my favorite muppet. He still is.

Let’s say your orbito-frontal cortex/Grover detects that someone you are talking to appears bored. Grover sends an immediate message to your amygdala…

Amygdala Panic Stations

Beaker represents your amygdala—the emotional center of your brain most responsible for a fear response.

As soon as Beaker gets the message from Grover, he makes his high pitched squeal and sends out broadcast messages to many areas of the brain to get you ready to high-tail it out of there, face the perceived threat, or try to neutralize the threat.

It is tough to get an excitable Beaker to stand-down. He insists that Grover keep his eye on the error at hand and he has managed to create an entire cascade of physiological changes that you definitely notice (racing heart beats, tenseness in major muscle groups…).

Beaker informs the prefrontal cortex that a decision needs to be made on how to proceed.

 
dcdce-beaker.png

The Lazy and Excuse-Ready Boss

As there is no suitable well-known muppet that I feel really represents the prefrontal cortex, we will simply have a generic boss-muppet instead.

The prefrontal cortex is very self-assured and also has little interest in actually working. Most of the time the Boss simply wants to shunt the entire mess that Beaker is squealing about over to the basal ganglia (you’ll meet him in a minute).

If the Boss keeps getting panicked messages from Beaker, he will reluctantly turn his attention to the issue.  If the Boss is able to convince Beaker that the situation is not a threat, then everything goes back to business as usual.

However, if at this point Grover and Beaker are now locked in a frenzy of Beaker squealing “Check again, is the threat still there?!” with Grover tensely responding with “Pretty sure the threat is still here, shall I check again?!!” then the Boss is generally ignored even if he has something of value to add.

This entire loop is extremely valuable when the threat is real—the house is on fire, the guy approaching you intends to mug you, etc.

However, Grover leaves it to Beaker to determine whether an error he has detected is actually a threat. And if Beaker is not inclined to trust the input of the Boss then that’s when something as mundane as the person in front of you appearing bored with your topic of conversation ends up as a threat equivalent to that of the house being on fire.

Basal Ganglia: How We Run Most of Our Lives

In the background, where no one really pays much attention, lives our Mr. Snuffleupagus (basal ganglia). When Grover and Beaker are quiet and the Boss is having a siesta (which he does a lot) then Mr. Snuffleupagus is running the entire show.

Ever drive home from work and realize you cannot recall whether the lights were green or red? That’s you on automatic pilot when Mr. Snuffleupagus actually ensures the lights are green while the rest of your brain is elsewhere.

291c5-mrsnuffleupagus.png

And while the Boss is always keen to shunt things to Mr. Snuffleupagus when Grover and Beaker are locked in a squealing match of checking the situation over and over, we are actually looking to get the Boss to step up rather than leave it to poor Mr. Snuffleupagus who is actually invisible to both Grover and Beaker in any case.

The only one of your muppets who can apply meta-cognition is the Boss, so your working towards alleviating anxiety is all about getting him to do his job.

Next week we will look at the exercises you can apply to strengthen your meta-cognition, update your memory banks, ease-up on the self-judgment and normalize your scale of what is noticed and whether it merits threat-status at all.

Next: REBOUNDING TO CALM—PART II


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2. www.social-anxietynetwork.com

3  Beck, Aron T., Gary Emery, and R. L. Greenberg. "Anxiety disorders and phobias: A cognitive approach." Basic, New York (1985): b58.

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10. Wild, Jennifer, Ann Hackmann, and David M. Clark. "When the present visits the past: Updating traumatic memories in social phobia." Journal of Behavior Therapy and Experimental Psychiatry 38, no. 4 (2007): 386-401.

11. Burns, David D. "The perfectionist’s script for self-defeat." Psychology today 14, no. 6 (1980): 34-52.

12. Rothbaum, Barbara Olasov, Edna B. Foa, David S. Riggs, Tamera Murdock, and William Walsh. "A prospective examination of post-traumatic stress disorder in rape victims." Journal of Traumatic stress 5, no. 3 (1992): 455-475.

13. Clark, David M., and Adrian Wells. "A cognitive model of social phobia." Social phobia: Diagnosis, assessment, and treatment 41, no. 68 (1995): 00022-3.

14. Ehlers, Anke, David M. Clark, Emma Dunmore, Lisa Jaycox, Elizabeth Meadows, and Edna B. Foa. "Predicting response to exposure treatment in PTSD: The role of mental defeat and alienation." Journal of traumatic stress 11, no. 3 (1998): 457-471.