CHAPTER 5
Medications for Social
Anxiety and Social
Anxiety Disorder
DECIDING TO TAKE MEDICATION
As discussed in earlier chapters, two approaches have been shown to be useful for over -
coming social anxiety: medications and cognitive behavioral therapy (CBT). Chapter 4
reviewed the key points to keep in mind when deciding whether to use drug treatments
to overcome your symptoms of social anxiety. Medications and CBT have been shown
to be about equally effective in the short term for treating social anxiety. Still, each
approach has advantages and disadvantages.
Advantages of Medications Compared with CBT
UÊMedications are often easier to get. Any physician (for example, family
doctor or psychiatrist) can prescribe medications, as can certain other pro -
fessionals. In contrast, therapists who have specialized training in providing
CBT are often more difﬁcult to ﬁnd.


The Shyness & Social Anxiety Workbook
94UÊDrug treatments are easy to use and don’t take up much time. You just need
to remember to take your pills. In contrast, CBT requires a lot of hard work
and can be time consuming.
UÊMedications often work more quickly than CBT. Depending on the type of
drug, changes in anxiety can be observed in as little as an hour for treat -
ment with anti-anxiety medications, and in as little as two to four weeks
for treatment with antidepressant medications. Typically, CBT takes several
weeks to months before signiﬁcant changes take place.
UÊMedications are often less expensive in the short term. Visits to your doctor
can be infrequent once a stable dosage is reached. At that point, the only
cost is the medication itself. In contrast, CBT usually requires regular
visits to a therapist throughout the treatment and therefore can be costly,
 especially if you have limited coverage through your health insurance.
Disadvantages of Medications Compared with CBT
UÊAnxiety is more likely to return after stopping medication than after stop -
ping CBT. In other words, the effects of CBT are often longer lasting.
UÊMedication may be more expensive than CBT over the long term. Because
medication is typically used for a longer period (often years), the costs are
likely to add up to more than the cost of CBT, which generally lasts only
several months.
UÊMany people experience side effects when taking medications. Although
these are usually manageable and improve after the ﬁrst few weeks, some
people experience more severe side effects, making treatment with medica -


people experience more severe side effects, making treatment with medica -
tion unpleasant or impossible. The main side effect of CBT is an increase
in anxiety during exposure to feared situations, and this anxiety resolves
quickly.
UÊMedications for social anxiety may interact with alcohol and with other
medications. They may also cause problems in people who have certain
medical illnesses. CBT does not interact in the same ways with alcohol,
medications, or medical illnesses.
UÊSome medications are difﬁcult to stop taking because they may cause
uncomfortable symptoms during discontinuation. This is particularly a
problem with anti-anxiety medications, as well as with a few speciﬁc anti -
depressants. Medications with the potential for dependence should be dis -
continued slowly, under supervision from your doctor. In contrast, physical
dependence and withdrawal problems are not associated with CBT.


Medications for Social Anxiety and Social Anxiety Disorder
95UÊSome medications (in particular, monoamine oxidase inhibitors) require a
restricted diet. CBT does not require any food restrictions.
UÊMany medications must be either used with caution or avoided completely
during pregnancy or if you are breastfeeding. CBT can be used safely in
either of these situations.
In deciding whether to try medications, you should consult with your doctor. Keep
in mind, however, that your doctor’s advice regarding this issue is likely to be inﬂuenced
by his or her own expertise and preferences (for example, family doctors are often much
less familiar with research on CBT than with medication options). In reality, it’s very
difﬁcult to predict who is most likely to respond to CBT or vs. medication, vs. a combi -
nation of these two approaches. We generally recommend that people try CBT initially,
if it is available, because the beneﬁts tend to be longer lasting than those of medication.
In cases where CBT alone is not effective or is only partially effective, the addition of
medications can be considered.
CHOOSING AMONG MEDICATIONS
If you decide to try medications, there are two general classes of drugs that have been
found to be effective for social anxiety: antidepressant and anti-anxiety medications.
There is also evidence that beta-adrenergic blockers (also called “beta-blockers”) may
help with focused performance fears (for example, fears of public speaking), as well
as some preliminary research supporting the use of certain anticonvulsant medications
(these are drugs that are usually used to treat seizures). We will discuss each of these


(these are drugs that are usually used to treat seizures). We will discuss each of these
approaches in this chapter, and we will also review what is known about the use of herbal
remedies for treating social anxiety.
When selecting among these medications, you and your doctor should take into
account the following factors:
UÊResearch ﬁndings on available medications . Treatment guidelines recently
published by the Canadian Psychiatric Association recommended antide -
pressant treatments as the ﬁrst medications to try for social anxiety disor -
der, based on the most recent research (Swinson et al. 2006). In particular,
venlafaxine, escitalopram, ﬂuvoxamine, paroxetine, and sertraline had been
investigated in the largest number of studies at the time the guidelines were
published. These medications are discussed later in this chapter.
UÊYour particular social anxiety symptoms . For example, although people
with focused performance fears (like public speaking or performing music)
may beneﬁt from treatment with beta-blockers, people with more general -
ized forms of social anxiety tend not to beneﬁt from these medications.


The Shyness & Social Anxiety Workbook
96UÊSide effect proﬁle of the medication . For instance, if you’re already strug -
gling with your weight, you might want to choose a medication for which
weight gain is not a likely side effect.
UÊPrevious response to medications . If you or a family member has previously
responded to a particular medication, that drug might be a good option
for you to try now. On the other hand, if there is a drug that didn’t work
for you in the past (despite a long enough trial at an adequate dosage), this
might be a time to try something new.
UÊAdditional psychological disorders that are present . For example, if you
are experiencing depression, it might make more sense to try an antidepres -
sant than an anti-anxiety drug. The antidepressant would likely lead to an
improvement in both problems.
UÊCost . Older medications tend to be less expensive than newer medications,
often because older drugs are available in generic forms.
UÊInteractions with other medications and herbal remedies.  If you are already
taking certain medications or herbal products, you should choose a drug
that will not interact with the products you are already taking.
UÊInteractions with certain foods . Medications such as phenelzine can be dan -
gerous if taken with certain foods (those containing tyramine, such as aged
cheese and draft beer). Other medications may also interact with foods.
For example, grapefruit juice appears to decrease the metabolism of certain
selective serotonin reuptake inhibitors (such as sertraline and ﬂuvoxamine),
increasing the likelihood that they will accumulate in the body.


increasing the likelihood that they will accumulate in the body.
UÊInteractions with medical conditions . If you have a particular medical con -
dition (for example, high blood pressure), you should choose a drug that will
not worsen the symptoms of your illness.
UÊSubstance-use issues . If you enjoy drinking alcohol or if you use other
drugs, you should choose a medication that is unlikely to interact with these
substances.
UÊDiscontinuation issues . Medications that leave the body quickly (in other
words, those with a short half-life) are more likely to cause withdrawal
symptoms and are often harder to discontinue. Therefore, drugs with a
longer half-life are usually easier to discontinue. If you and/or your doctor
are concerned about your ability to discontinue a medication, this should be
factored into your decision regarding which drug to take. (The term half-life
refers to the time that it takes for half of the amount of drug in your body


Medications for Social Anxiety and Social Anxiety Disorder
97to be metabolized or broken down. For example, a drug with a  half-life of
twelve hours would be 50 percent broken down in twelve hours and 75
percent broken down after another twelve hours. Drugs with a longer half-
life are broken down more slowly, giving the body time to adjust to stopping
the drug).
STAGES IN MEDICATION TREATMENT
Treatment with medication involves the following ﬁve different stages:
1. The ﬁrst stage is the assessment . During this phase, your doctor will ask you the
necessary questions to help choose the best medication for your needs.
2. The second stage is initiation of the drug . In most cases, medications are started
at relatively low dosages to give your body a chance to adapt gradually to
the new drug.
3. The third stage is dose escalation . During this stage of treatment, the dosage
is gradually increased until the individual’s symptoms start to improve. The
goal of dose escalation is to ﬁnd the lowest dosage that is effective for a
particular person. Throughout the process, care is taken to minimize any
side effects that may be present.
4. The fourth stage is called maintenance . During maintenance, the individual
continues to take the medication for an extended period of time. For anti
depressants, it is usually recommended that treatment continue for at
least a year, minimizing the chances of symptoms returning following
discontinuation.
5. The ﬁfth and ﬁnal stage of medication treatment is discontinuation . Some time
after a person has improved on a medication, the individual may be encour -
aged to decrease the amount of the medication to assess whether he or she


aged to decrease the amount of the medication to assess whether he or she
is ready either to lower the dosage or to stop the medication completely. If a
person is also receiving CBT, it may be helpful to have regular CBT sessions
during the discontinuation phase. In some cases, your doctor may recom -
mend that you continue to take a medication that is working for you.
TREATMENT WITH ANTIDEPRESSANTS
Antidepressants are the most frequently recommended medications for social anxiety.
These drugs are called “antidepressants” because they were initially marketed for treating


The Shyness & Social Anxiety Workbook
98depression. However, don’t be fooled by their name. These drugs are useful for a wide
range of psychological problems, including social anxiety disorder. In fact, they appear to
work for this problem regardless of whether an individual is depressed. There are several
classes of antidepressant medications that are thought to be useful for treating social
phobia. Each of these is described in this section. In addition, a table of  recommended
dosages is included at the end of this section.
Note that we also indicate which of these drugs is ofﬁcially approved by the United
States Food and Drug Administration (FDA). Although FDA approval typically indicates
that a medication is safe and effective when used properly, there are many medications
that are safe and effective for social anxiety that are not approved by the FDA or regula -
tory bodies in other countries. This is because it is very expensive and time consuming
for pharmaceutical companies to obtain ofﬁcial FDA indications for their products, and
they therefore tend to limit the number of problems for which they apply for approval.
Selective Serotonin Reuptake Inhibitors (SSRIs)
SSRIs are often the ﬁrst choice for treating social phobia. In fact, the SSRI paroxetine
(Paxil) was the ﬁrst drug to receive an FDA indication for treatment of social anxiety
disorder. Paroxetine is also available in a continuous release formula, marketed under
the name Paxil CR. Another SSRI that is FDA approved is sertraline (Zoloft). Although
only two SSRIs are ofﬁcially approved for treating social anxiety disorder, there is no
evidence that either of these medications works any better or worse than most other


evidence that either of these medications works any better or worse than most other
SSRIs for this problem. In practice, any of the SSRIs can be used to treat problems with
social anxiety. Other SSRIs that have been found to be effective for social anxiety disor -
der include ﬂuvoxamine (Luvox), citalopram (Celexa), and escitalopram (Lexapro in the
United States, Cipralex in Canada). Fluoxetine (Prozac) has been found to be effective
in some studies, but not others (Hedges et al. 2007; Swinson et al. 2006).
Although the side effects vary slightly across the SSRIs, some of the most common
ones include nausea, diarrhea, headache, sweating, increased anxiety, tremor, sexual dys -
function, weight gain, dry mouth, palpitations, chest pain, dizziness, twitching, constipa -
tion, increased appetite, fatigue, thirst, and insomnia. Don’t be discouraged by the long
list of side effects. Most people experience only a very small number of these, and some
individuals experience no side effects at all. Side effects are generally quite manageable.
They tend to be worse during the ﬁrst few weeks of treatment and can be managed by
keeping the dosage low until the person becomes used to the medication. Certain side
effects (for example, medication-related weight gain and sexual dysfunction) tend not to
decrease over time, unless the drug is stopped or the dosage is decreased.
SSRIs typically take two to four weeks before they start working. They are believed
to work by altering serotonin levels in the brain. Serotonin is an example of a neurotransmitter ,
which is a chemical involved in the transmission of information from one brain cell to the


Medications for Social Anxiety and Social Anxiety Disorder
99next. Serotonin is thought to be involved in the regulation of emotion and other aspects
of psychological functioning.
Most SSRIs are relatively easy to discontinue, although paroxetine is more likely
than the others to cause withdrawal symptoms during discontinuation because it is
metabolized more quickly by the body. Therefore, paroxetine should be stopped more
gradually than the other SSRIs. Common withdrawal symptoms during discontinuation
of paroxetine include sleep disturbances, agitation, tremor, anxiety, nausea, diarrhea, dry
mouth, vomiting, sexual disturbances, and sweating.
Selective Serotonin and Norepinephrine Reuptake
Inhibitors (SNRIs)
Venlafaxine XR (Effexor XR) is currently the only available SNRI that has been
found in large studies to be effective for treating social anxiety disorder—in fact, it is
approved by the FDA for this purpose (the “XR” stands for “extended release”). Unlike
the SSRIs, venlafaxine acts both on the serotonin and norepinephrine neurotransmitter
systems, both of which appear to be related to problems with anxiety and depression.
A number of well-controlled studies suggest that venlafaxine is useful for treating social
phobia (Swinson et al. 2006), although, like the SSRIs, it takes several weeks to have
an effect. The most commonly reported side effects of venlafaxine include sweating,
nausea, constipation, loss of appetite, vomiting, sleepiness, dry mouth, dizziness, ner -
vousness, increased anxiety, and sexual disturbances. When discontinued too quickly,
the most common withdrawal symptoms include: sleep disturbances, dizziness, nervous -


the most common withdrawal symptoms include: sleep disturbances, dizziness, nervous -
ness, dry mouth, anxiety, nausea, headache, sweating, and sexual problems. Duloxetine
(Cymbalta) is another recently introduced SNRI that has been shown to be useful for
depression and some forms of anxiety. However, with the exception of published case
studies (Crippa et al. 2007), this drug has not yet been studied for social anxiety, and it
is too early to recommend it for this problem.
Noradrenergic/Speciﬁc Serotonergic Antidepressants
(NaSSAs)
Currently, the only NaSSA available is a drug called mirtazapine (Remeron). Like
the SNRIs, mirtazapine works by affecting levels of both norepinephrine and sero -
tonin. This drug is newer than the other antidepressants discussed so far. Nevertheless,
some initial studies suggest that mirtazapine is an effective treatment for social anxiety
disorder (Muehlbacher et al. 2005; Van Veen, Van Vliet, and Westenberg 2002). The
most common side effects of mirtazapine include sleepiness, weight gain, dry mouth,
 constipation, and blurred vision.


The Shyness & Social Anxiety Workbook
100Monoamine Oxidase Inhibitors (MAOIs)
MAOIs affect three neurotransmitter systems in the brain: serotonin, norepineph -
rine, and dopamine. The most studied MAOI for treating social phobia is phenelzine
(Nardil). This drug has consistently been found to alleviate the symptoms of social
phobia (Swinson et al. 2006). Like the other antidepressants, phenelzine takes several
weeks to have a therapeutic effect.
Despite their effectiveness, MAOIs are rarely used in clinical practice because of
necessary dietary restrictions and because the side effects tend to be worse than those
from other medications. When taking MAOIs, you must avoid foods containing a sub -
stance called tyramine. These include aged cheeses, meat extracts, overripe bananas,
sausage, tofu, soy sauce, draft beer, and many other foods. MAOIs are also dangerous
when combined with certain other medications, including SSRIs. The most commonly
reported side effects of MAOIs include dizziness, headache, drowsiness, sleep distur -
bances, fatigue, weakness, tremors, twitching, constipation, dry mouth, weight gain, low
blood pressure, and sexual disturbances.
Reversible Inhibitors of Monoamine Oxidase (RIMAs)
Reversible inhibitors of monoamine oxidase are a type of MAOI that tend to have
fewer side effects than traditional MAOIs. In addition, they are less likely than traditional
MAOIs to interact with other medications and with foods containing tyramine. The only
RIMA that is available is moclobemide (Manerix in Canada, Aurorix in several other


countries), though this drug is not currently marketed in the United States. Findings
from studies on moclobemide for social anxiety disorder have been mixed. Early studies
found that this medication was helpful for treating social anxiety, whereas more recent
studies have found only modest effects. In some studies, moclobemide was no better
than placebo (Swinson et al. 2006).
The most commonly reported side effects for people taking moclobemide include
fatigue, constipation, low blood pressure, decreased sex drive, dry mouth, difﬁculties
ejaculating, insomnia, vertigo, and headache. Like the other antidepressants,  moclobemide
takes several weeks to have a therapeutic effect.


Medications for Social Anxiety and Social Anxiety Disorder
101Dose Ranges for Antidepressants in the Treatment of Social Phobia
Generic Name    Brand Name   Therapeutic Dose Range (mg)*
SSRIs
citalopram    Celexa   10–60
escitalopram    Lexapro/Cipralex   10–20
ﬂuoxetine    Prozac   10–80
ﬂuvoxamine    Luvox   50–300
paroxetine    Paxil  10–60
paroxetine CR    Paxil CR   12.5–75
sertraline    Zoloft   50–200
Other Antidepressants
mirtazapine    Remeron   15–60
moclobemide    Manerix/Aurorix   300–600
phenelzine    Nardil  45–90
venlafaxine XR    Effexor XR   75–375
*Dosages are based, in part, on recommendations by Bezchlibnyk-Butler, Jeffries, and Virani 2007.
TREATMENT WITH ANTI-ANXIETY MEDICATIONS
The most frequently prescribed anti-anxiety medications are the benzodiazepines. These
are sedatives that include drugs such as clonazepam (Klonapin in the USA; Rivotril
in Canada), alprazolam (Xanax), diazepam (Valium), and lorazepam (Ativan). To date,
only clonazepam and alprazolam have been investigated in controlled studies for the
treatment of social anxiety disorder (Swinson et al. 2006). Although neither is ofﬁcially


approved by the FDA for treating social anxiety, both of these medications have been
found to be useful for this problem. The typical starting dose for alprazolam and clon -
azepam is .5 mg per day, with a maximum daily dose of 1.5 to 3 mg for alprazolam and
4 mg for clonazepam (Swinson et al. 2006).
When taken on a regular basis, these medications tend to be effective for treat -
ing social anxiety. The most common side effects include drowsiness,  lightheadedness,
depression, headache, confusion, dizziness, unsteadiness, insomnia, and nervousness.


The Shyness & Social Anxiety Workbook
102These drugs may affect a person’s ability to drive safely and they tend to interact
strongly with alcohol. In addition, they should be used with caution by older people
because higher dosages have been associated with a greater likelihood of falling.
There are several advantages to taking benzodiazepines compared with antidepres -
sant medications. First, they work very quickly (within a half hour) and therefore can
be used on an “as needed” basis to deal with particularly stressful situations. They also
may be used during the ﬁrst few weeks of antidepressant treatment, while the indi -
vidual waits for the antidepressant to take effect. In addition, the side effect proﬁle of
 benzodiazepines is quite different from that of antidepressants, and these drugs may be
more easily tolerated by some people.
Despite these beneﬁts, benzodiazepines have fallen out of favor in recent years,
mostly because they can be difﬁcult to discontinue. Stopping these drugs can cause
temporary (but sometimes intense) feelings of anxiety, arousal, and insomnia. In rare
cases, abrupt discontinuation can cause seizures. Given that discontinuation from these
medications can cause intense anxiety, it is not surprising that some individuals have
difﬁculty stopping these drugs. The symptoms of withdrawal can be minimized by dis -
continuing these drugs very gradually. Benzodiazepines are a potentially effective option
for treating social anxiety, particularly over brief periods. However, they are typically
not recommended as a ﬁrst-line treatment (Swinson et al. 2006).
TREATMENT WITH BETA-ADRENERGIC BLOCKERS


TREATMENT WITH BETA-ADRENERGIC BLOCKERS
Beta-blockers are normally used for treating high blood pressure. In addition, they are
effective for decreasing some of the physical symptoms of fear such as palpitations and
shakiness. A number of early studies suggest that beta-blockers are useful for managing
intense fear in certain performance situations (Hartley et al. 1983; James, Burgoyne, and
Savage 1983). In particular, they are often used by actors, musicians, and other perform -
ers to manage stage fright. However, beta-blockers are ineffective for treating more
generalized forms of social anxiety and shyness. The most commonly used beta-blocker
for treating performance fears is propanolol (Inderal). This medication is normally taken
in a single dose of 5 to 10 mg, about twenty to thirty minutes before a performance.
ANTICONVULSANTS
Anticonvulsants are used to treat seizures, as well as pain, anxiety, and certain mood
problems. Recently, there have been a number of preliminary studies ﬁnding that certain
anticonvulsants such as gabapentin (Neurontin), pregabalin (Lyrica), and topiramate
(Topamax) may be useful for treating social anxiety disorder (Swinson et al. 2006). At
this point, however, it is too soon to recommend these treatments for social anxiety.
Additional research is needed.


Medications for Social Anxiety and Social Anxiety Disorder
103NATURAL AND HERBAL REMEDIES FOR
SOCIAL ANXIETY
In recent years, herbal preparations have become popular for treating a wide range of
health problems. For the treatment of anxiety and related problems, commonly used
herbal preparations include St.-John’s-wort, kava kava, inositol, Rescue Remedy, and
various other products. Generally, there have been very few studies on these products
in people with anxiety-based problems, and we are aware of only one study that has
speciﬁcally tested the effects of an herbal remedy for treating social anxiety disorder
(Kobak et al. 2005). In this study, 600 to 1800 mg per day of St.-John’s-wort (also known
as hypericum) was compared to an inactive placebo in forty people with social anxiety
disorder. No differences were found in the effectiveness of St.-John’s-wort vs. placebo,
despite the fact that some studies have found St.-John’s-wort to be an effective treatment
for depression.
In addition to the lack of studies on the effectiveness  of herbal treatments, very little is
known about the safety  of many of these remedies or the extent to which they interact
with conventional medications. Be sure to tell your doctor if you are taking any herbal
products, just in case there are any known interactions with medications you may also
be taking.
Although little is known about the effects of herbal treatments on social anxiety,
there are a few studies on the use of herbal products for other anxiety problems (Connor
and Vaishnavi, in press). Still, more studies are currently under way. In the coming years,
additional information regarding the safety, interactions, and effectiveness of these


additional information regarding the safety, interactions, and effectiveness of these
 treatments will be available.
COMBINING MEDICATIONS
Your doctor may recommend combining several medications for treating your social
anxiety. In most cases, there is very little research on the beneﬁts of combining differ -
ent medications. However, one combination that has been studied for the treatment of
anxiety is the combination of an antidepressant (for example, paroxetine) with a benzodi -
azepine (for example, clonazepam). Ideally, both drugs are started at the same time. The
benzodiazepine helps to keep the anxiety under control during the ﬁrst few weeks while
the person waits for the antidepressant to start working. Then, once the  antidepressant
kicks in, the benzodiazepine is discontinued gradually.
A limited number of studies have investigated whether it is useful to combine an
SSRI with a benzodiazepine. Whereas some studies of anxiety problems other than
social phobia suggest that this combination is useful for reducing anxiety symptoms
more quickly than an SSRI alone (Pollack et al. 2003), a study of people suffering from
social phobia did not ﬁnd any added beneﬁt of combining medications on the rate of
recovery (Seedat and Stein 2004).


The Shyness & Social Anxiety Workbook
104COMBINING MEDICATION WITH
PSYCHOLOGICAL TREATMENTS
Studies comparing medications to CBT have generally found both approaches to be very
effective for reducing anxiety. In addition, a number of researchers have begun to study
the beneﬁts of combining CBT and medications (Antony and Rowa 2008). Overall, there
do not appear to be any consistent beneﬁts of combining these treatments. That is,
medication, CBT, and a combination of these approaches all tend to be about equally
effective on average, based on the available evidence (for instance, Davidson et al. 2004).
However, that doesn’t mean that one approach or another is not likely to be more effec -
tive for any one person (including you). In other words, it is often the case that some
people do best with CBT, some do best with medication, and some do best with a com -
bined treatment. If you decide to try combining CBT with medication, it is helpful if
both treatments are delivered by the same person, or if the professionals providing you
with CBT and medication are in contact with one another. Treatment is most likely to
be helpful when multiple treatments are delivered in a coordinated fashion.
COMMON QUESTIONS ABOUT MEDICATION
Question:  Is taking medication a sign of weakness?
Answer:   Taking medication for social phobia is no more a sign of weakness than
taking medication for any other problem, such as physical illnesses like
high blood pressure.
Question:  What level of improvement can I expect?
Answer:   A small percentage of people obtain no beneﬁt at all from medications
for social phobia. Another small group of people obtain almost com -


for social phobia. Another small group of people obtain almost com -
plete improvement. However, most people with social phobia experi -
ence moderate improvements with medications. They tend to feel less
anxious overall and are more comfortable in a broader range of situa -
tions. However, there may still be areas in which the social anxiety is a
problem for them.
Question:  Are medications for social anxiety dangerous?
Answer:   When taken as prescribed, medications for social phobia are gener -
ally safe. When side effects cause problems, as a rule they are easy to
manage by decreasing the dosage or switching to a different drug.


Medications for Social Anxiety and Social Anxiety Disorder
105Question:  Is it dangerous for me to stop taking my medication?
Answer:   Medications should always be stopped gradually and in close consul -
tation with your doctor. If done properly, discontinuation is generally
safe.
Question:  What happens if my medication doesn’t work for me?
Answer:   If your medication doesn’t work, it is important to ﬁrst make sure you
have been taking it for a long enough time and at an adequate dose. If
your medication still is not effective despite an appropriate duration and
dosage, you may still beneﬁt from trying a different medication or from
receiving CBT.
Question:   How long should I try a medication before assuming that it isn’t going
to work?
Answer:   Most antidepressants will start to have an effect within four to six weeks,
if not earlier. If you haven’t experienced any beneﬁt after eight weeks
at a high enough dosage, it may be worth discussing the possibility of
trying a different treatment with your doctor.
Question:   If I go off my medication and my anxiety returns, am I likely to beneﬁt
again if I resume taking the same medication?
Answer:   Often, when a previously effective medication is tried for a second time
(following a break), it will work again. However, sometimes a particular
medication is less effective the second time, in which case a different
medication may be prescribed.
In summary, medications can be an effective method of managing severe social
anxiety. Certain anti-anxiety medications (for example, clonazepam) and a number of
different antidepressants (for instance, paroxetine, venlafaxine) have consistently been


shown to help reduce symptoms of social anxiety. If you decide that you would like to
try medication, a ﬁrst step is to contact your family doctor or psychiatrist. Your doctor
will be able to recommend a speciﬁc medication that is likely to work for you.


CHAPTER 6
Changing Your Anxious
Thoughts and Expectations
The word cognition  refers to the ways in which we process information, including experi -
ences such as thought, perception, interpretation, attention, memory, and knowledge.
The word cognitive  is simply the adjectival form of the term cognition. For example,
cognitive science is the science concerned with the ways in which we think. Cognitive
therapy  is a type of psychotherapy that is designed to alter negative and unrealistic beliefs,
thoughts, and interpretations.
This chapter provides an overview of strategies that have been shown to be useful for
decreasing social anxiety by changing negative or unrealistic patterns of thinking. Many
of the cognitive techniques and principles discussed in this book have been presented
and expanded upon elsewhere by authors such as Aaron T. Beck (Beck, Emery, and
Greenberg 1985), David Burns (1999), David M. Clark (Clark and Wells 1995), Richard
Heimberg (Heimberg and Becker 2002), Christine Padesky (Greenberger and Padesky
1995), and others. Over the years, strategies similar to those discussed in this chapter
have been adopted by the majority of therapists who practice cognitive therapy.
THE ORIGINS OF COGNITIVE THERAPY
Cognitive therapy was proposed in the 1960s and 1970s as an alternative to traditional
psychodynamic psychotherapies , which were the most prevalent forms of therapy at the time.
The original (and most inﬂuential), form of psychodynamic psychotherapy is psychoanaly -
sis, which Sigmund Freud developed in the early 1900s. Psychodynamic psychotherapies,


The Shyness & Social Anxiety Workbook
108including psychoanalysis, are concerned with helping individuals understand deep-rooted
unconscious conﬂicts that are presumed to cause or contribute to their psychological
problems. For example, Freud proposed that depression can occur as a response to
having unconscious aggressive thoughts or feelings toward a loved one. Because such
feelings are viewed as unacceptable by the individual, he or she is very motivated to
keep such thoughts and feelings outside of conscious awareness. According to Freud,
rather than allowing the aggressive thoughts to surface, the individual may turn those
angry feelings inward, leading to feelings of self-hatred and worthlessness, which are
often features of depression.
There are many newer forms of psychodynamic therapy (most psychodynamic psy -
chotherapists no longer accept all of Freud’s ideas), though the focus of these treatments
often remains on recounting early childhood experiences, interpreting unconscious expe -
rience (such as dreams), and helping individuals to understand the unconscious motiva -
tions for their behavior. Although psychodynamic psychotherapies remain popular, they
have gradually lost ground to other forms of therapy, including cognitive and behavioral
therapies. Some reasons for the decline of psychodynamic psychotherapies include the
relative lack of research supporting many of the underlying theoretical assumptions, as
well as a lack of research demonstrating the effectiveness of this form of treatment for
many speciﬁc problems, including social anxiety.
Despite these criticisms, psychoanalysis and the psychodynamic psychotherapies
have made considerable contributions to the understanding and treatment of psycho -
logical problems. For example, these were the ﬁrst treatments based on the assumption
that simply talking to another person can lead to psychological changes. In addition,


that simply talking to another person can lead to psychological changes. In addition,
these treatments highlighted the importance of nonconscious information processing.
Although there is little evidence to prove the existence of many of the unconscious
motivations proposed by Freud, there is evidence that suggests people are frequently
unaware of the perceptions and interpretations that contribute to their understanding
of their environment. Finally, although many speciﬁc aspects of his theory were prob -
ably misguided, Freud highlighted the importance of early experience in determining
 psychological functioning later in life.
The Birth of Cognitive Therapy
In the 1960s and 1970s, a number of psychologists and psychiatrists, disenchanted
with psychodynamic psychotherapies, began to explore other ways of helping their
patients and clients. Working independently, psychiatrist Aaron Beck (1963; 1964; 1967;
1976) and psychologists Albert Ellis (1962; 1989) and Donald Meichenbaum (1977) each
developed new forms of therapy based on the premise that people’s difﬁculties with
depression, anxiety, anger, and related problems stem from the ways in which they think
about themselves, their environment, and the future.
For example, fear was assumed to stem from a belief that a particular situation was
threatening or dangerous. Beck, Ellis, and Meichenbaum each developed treatments


Changing Your Anxious Thoughts and Expectations
109designed to help individuals recognize how their beliefs and assumptions contribute to
their negative emotions, and to overcome psychological suffering by changing these neg -
ative thoughts. Ellis called his form of treatment  rational emotive therapy  and later renamed
it rational emotive behavior therapy  (REBT, 1993). Meichenbaum referred to his form of treat -
ment as cognitive-behavior modiﬁcation (CBM). It was Aaron Beck, however, who ﬁrst
used the term cognitive therapy  to describe his treatment. Each of these three new treat -
ments was developed at about the same time, and they were quite similar with respect
to their underlying assumptions and some of the treatment strategies used.
Over the years, Beck’s form of treatment has become more popular and prominent
than either Ellis’s or Meichenbaum’s approaches. Furthermore, Beck’s cognitive therapy
has been subjected to more rigorous study than either REBT or CBM for the treatment
of social anxiety. Therefore, the methods discussed in this chapter are based on those
proposed by Beck and his collaborators, as well as others who adapted and expanded
upon Beck’s methods for treating social anxiety and related problems.
ASSUMPTIONS OF COGNITIVE THERAPY
FOR SOCIAL ANXIETY
Here are some of the basic assumptions of cognitive therapy, particularly as related to
the treatment of shyness, social anxiety, and performance fears.
1. Negative emotions are caused by negative interpretations and beliefs. People
who interpret a given situation in different ways are likely to experience dif -
ferent emotions. For example, imagine that a friend of yours has cancelled
a dinner date at the last minute without providing a reason. Below is a list
of possible emotional reactions you might have depending on your beliefs


of possible emotional reactions you might have depending on your beliefs
and interpretations.
Situation : Friend cancels dinner date at the last minute and gives no reason
Interpretation Emotion
“My friend has been hurt or is ill.” Anxiety or worry
“My friend isn’t treating me with the respect I deserve.” Anger
“My friend doesn’t care about me.” Sadness
“Thank goodness the dinner has been cancelled; I am
always so nervous when I have to eat with others.”Relief
“I guess something else came up. Everyone changes
plans from time to time, including me.”Neutral


The Shyness & Social Anxiety Workbook
1102. Anxiety and fear result when a person interprets a situation as threatening
or dangerous. Although fearful predictions and interpretations are sometimes
accurate, they are often exaggerated or inaccurate. Chapter 1 provided a list of
thoughts and assumptions that can contribute to social anxiety. These include
beliefs about one’s performance (such as, “People will think that I am an idiot”),
as well as beliefs about the anxiety itself (for instance, “It’s important for me
not to appear anxious in front of other people”). Beliefs such as these help to
maintain a person’s anxiety in social and performance situations.
3. You are the expert regarding your own thoughts and feelings. Unlike some
other forms of therapy, which assume that the therapist is the expert, cogni -
tive therapy assumes that the patient and therapist have unique areas of exper -
tise, and the best way to work on a problem is to take advantage of the skills
and expertise that each brings to the therapeutic situation. The therapist is
assumed to be an expert on the principles and methods of cognitive therapy.
The patient is assumed to be an expert regarding his or her own experi -
ences, assumptions, and beliefs. In most cases, the therapist and patient decide
together whether a particular belief is exaggerated or unrealistic, and together
they generate strategies for changing negative patterns of thinking.
4. The goal of cognitive therapy is to be able to think more realistically  rather
than simply to think positively . There are occasions where your anxious beliefs
are realistic and are quite consistent with the actual threat in a given situa -
tion. In these cases, anxiety may be a good thing because it helps you stay
on guard and protect yourself from possible danger. For instance, being a bit


on guard and protect yourself from possible danger. For instance, being a bit
nervous while interacting with an authority ﬁgure (for example, your boss, a
police ofﬁcer) may protect you from seeming overly conﬁdent, demanding,
or aggressive. Cognitive therapy focuses on situations where your beliefs,
predictions, and interpretations are exaggerated when compared with the
actual level of danger in the situation.
5. People naturally tend to seek out and pay attention to information that con -
ﬁrms their beliefs. In the case of social anxiety, people pay more atten -
tion and give more weight to evidence that others are judging them nega -
tively (such as a history of being teased in high school) than to evidence
that contradicts the anxious beliefs (for instance, a history of very positive
performance appraisals at work). Cognitive therapy aims to help people to
 consider all the evidence before making any assumptions.
TYPES OF ANXIOUS THINKING
Anxious thinking begins and persists when people make incorrect assumptions about
what is likely to happen in a given situation, about the quality of their own performance,


Changing Your Anxious Thoughts and Expectations
111and about what other people are thinking of them. This section includes descriptions
of some of the most common styles of thinking that often seem to play a role in social
and performance anxiety. Note that there are additional examples of negative and exag -
gerated thinking that other authors have highlighted (see, for example, Burns 1999) that
we have chosen not to include in this section. In most cases, these were omitted either
because they were not especially relevant to social anxiety or because they were very
similar and overlapped considerably with those examples that we have included. In fact,
even the various thinking styles on this list overlap to some extent. As you may notice, a
particular anxious thought (something like, “Other people will think that I am boring”)
may easily ﬁt into more than one category (probability overestimation, mind reading).
Probability Overestimations
A probability overestimation is a prediction that a person believes is likely to come true,
even though the actual likelihood is relatively low. For example, someone who is fearful of
giving presentations might predict that the next presentation is likely to go poorly, even
though her presentations usually go well. Similarly, a person who is nervous about dating
might assume that other people will ﬁnd him unattractive, even though many people
have found him to be attractive in the past. If your thoughts are similar to those listed
below, you may have a tendency to overestimate the likelihood of negative events.
Examples of Probability Overestimations
UÊI will be overwhelmed with panic.
UÊEveryone at the party will think I’m stupid.
UÊMy presentation will be a disaster.
UÊI will never be in an intimate relationship again.


UÊI will never be in an intimate relationship again.
UÊI will have nothing to say if I phone my cousin.
UÊI will lose my job if I make a mistake.
UÊIf I go out, everyone will stare at me.
Can you think of recent instances when you assumed that things were going to work
out badly, without any evidence for that assumption? If so, list your own examples of
probability overestimations below:


The Shyness & Social Anxiety Workbook
112Mind Reading
Mind reading  is actually just an example of a probability overestimation. It involves
making negative assumptions about what other people are thinking, particularly what
they might be thinking about you. If social anxiety is a problem for you, it is likely
that you assume that others think negatively about you. Although it is true that people
sometimes make negative judgments about others, the chances are that this occurs much
less often than you think. In many cases, your assumptions about what others are think -
ing are probably exaggerated or even completely untrue. Each of the following kinds of
thoughts represents mind reading:
Examples of Mind Reading
UÊPeople ﬁnd me boring.
UÊMy boss will think I’m an idiot if he sees my hands shaking.
UÊWhen people look at me, they are thinking I am strange or weird.
UÊMost people see anxiety as a sign of weakness.
UÊMy friends think I am awkward or stupid when I lose my train of thought.
UÊPeople always know when I am feeling anxious.
Can you think of recent examples of times when you have made assumptions about
what other people are thinking about you? If so, list your own examples of mind reading
below:
Personalization
Personalization  is the tendency to take more responsibility for a negative situation than
you should, rather than acknowledging all of the different factors that may have contrib -
uted to the situation. Here are some examples of personalization, followed by examples
of other factors that in reality may have contributed to the situation.


Changing Your Anxious Thoughts and Expectations
113Examples of Personalization In Reality
At a friend’s birthday party, I
was talking to another guest
and we ran out of things to
talk about very quickly. I think
the conversation ended so fast
because I am so boring and
can’t think of things to say.In reality, other factors that may have contrib -
uted to the situation include (1) the other person
couldn’t think of anything to talk about, (2) I had
nothing in common with the other guest, even
though neither of us is actually boring, and (3) it
is normal for many conversations at parties to end
fairly quickly. Nobody was at fault.
The fact that my boss got
angry at me for making a
mistake is proof that I am
incompetent.In reality, other factors that may have contrib -
uted to the situation include (1) my boss is always
getting angry at people, so I shouldn’t feel singled
out, (2) my boss’s expectations are too high (I
know that not every boss in the world would have
yelled at me for making a mistake; part of why my
boss became angry had to do with his own
expectations, rather than me making a mistake),
and (3) there are many reasons why people make
mistakes besides incompetence.
People were falling asleep
during my presentation,
proving once again that I am a
really boring speaker.In reality, other factors that may have contributed
to the situation include (1) the topic was somewhat
dry and would have been difﬁcult for any speaker
to make exciting, (2) the presentation was late in


to make exciting, (2) the presentation was late in
the day, and the audience was feeling tired, and (3)
it is normal for some people to feel bored at a talk;
other people probably found it interesting.
I was in an elevator and a
woman was looking at me. She
was probably thinking that I
looked strange.In reality, other factors that may have contributed
to the situation include (1) she was staring at me
because she liked the way I look or what I was
wearing, (2) she was looking in my direction but
wasn’t really looking at me (maybe she was staring
into space or daydreaming), and (3) she noticed
me but was thinking of other things.
Can you think of recent examples of times when you engaged in personalization? If so,
list your own examples of personalization in the space below:


The Shyness & Social Anxiety Workbook
114“Should” Statements
“Should” statements  are incorrect or exaggerated assumptions about the way things ought
to be. Statements that include words like “always,” “never,” “should,” and “must” are
often “should” statements. Sometimes, the tendency to use words such as these is a sign
of having overly rigid and perfectionistic expectations for yourself or for others. Here
are some examples:
Examples of “Should” Statements
UÊI should never feel nervous around other people.
UÊI must never let my anxiety show.
UÊI should never make mistakes.
UÊI must never inconvenience other people.
UÊOthers should never think badly about me.
UÊI ought never to do anything to draw attention to myself.
UÊOthers must never tease me or laugh at something that I have done.
UÊI should always be interesting and entertaining to others.
UÊI must do things perfectly so everything is just right.
In the space below, list examples from your own life of unreasonable expectations
(“shoulds”) that you hold for yourself or others:
Catastrophic Thinking
Catastrophic thinking  (also known as catastrophizing ) is the tendency to assume that if a
negative event were to occur, it would be absolutely terrible and unmanageable. From
time to time, we all make mistakes, offend others, or look foolish. One difference
between people who are socially anxious and those who are not particularly anxious is
how they deal with these unfortunate social events. People who have very little social
anxiety are often able to say to themselves, “Who cares what this person thinks? I have


the right to make a mistake from time to time.” Or, “I feel sorry that I upset that person,


Changing Your Anxious Thoughts and Expectations
115but everyone puts their foot in it at times.” In contrast, people who feel anxious around
others are more likely to think, “It would be a disaster to have others think badly of me.”
Below are more examples of catastrophic thinking:
Examples of Catastrophic Thinking
UÊIt would be terrible if my anxiety showed during my presentation.
UÊI would not be able to handle making a fool of myself.
UÊIt would be terrible to be unable to think of things to say during my date
on Saturday night.
UÊIf someone shows signs of not liking me, it feels like the end of the world.
UÊIt would be terrible to lose my train of thought during a presentation.
UÊIt would be a disaster if I blushed while answering a question in class.
In the space below, list examples of times when you have catastrophized or exaggerated
how bad a particular outcome would be if it actually were to occur:
All-or-Nothing Thinking
All-or-nothing thinking (also called black-and-white thinking ) is the tendency to judge any
performance that falls short of perfection as being completely unacceptable. People who
engage in this style of thinking tend to categorize their behavior as being either perfect
or awful, without acknowledging all of the possibilities that lie between these two
extremes. As with “should” statements, all-or-nothing thinking is associated with exces -
sive perfectionism and a tendency to hold unrealistic standards. Following are several
examples of all-or-nothing thinking:
Examples of All-or-Nothing Thinking
UÊIf I lose my train of thought even once, I will blow the entire presentation.
UÊEven one person thinking I look nervous is too many.


UÊEven one person thinking I look nervous is too many.
UÊIf I don’t get an A on my exam, my teacher will think I am stupid.


The Shyness & Social Anxiety Workbook
116UÊIt is unacceptable if my boss makes any negative comments or suggests even
one area for improvement during my annual performance review.
UÊShowing any signs of anxiety is almost as bad as falling completely apart.
In the space below, list examples of the times when you engaged in all-or-nothing
thinking:
Selective Attention and Memory
Selective attention is the tendency to pay more attention to certain types of information
than to other types. Selective memory is the tendency to remember certain types of informa -
tion more easily than other types. As discussed earlier, people are more likely to attend
to and remember information that is consistent with their beliefs. Therefore, people with
social anxiety are more likely than others to remember times when they were criticized
or teased by another person or when they performed poorly in a social situation. When
performing in social situations or interacting with others, individuals with social phobia
are more likely to notice people who appear to be bored or disapproving. Some other
examples of selective memory and attention are provided below:
Examples of Selective Attention and Memory
UÊIgnoring positive feedback from a teacher or boss (in other words, discount -
ing positive feedback as if it doesn’t matter), yet taking negative feedback
very seriously (for example, letting negative feedback ruin your day)
UÊFocusing on the one low grade on your report card and ignoring all the
high grades
UÊRemembering being teased in high school, while forgetting about the good
times spent with friends after school
UÊFocusing on audience members who seem bored during your presentation
and ignoring those in the crowd who appear to be enjoying your talk
UÊFocusing on the moment during a conversation when you stumbled over


UÊFocusing on the moment during a conversation when you stumbled over
your words and lost your train of thought, while ignoring the fact that the
rest of the conversation was fairly smooth


Changing Your Anxious Thoughts and Expectations
117Can you think of ways in which you selectively pay attention to events or information
that conﬁrm your anxious beliefs and selectively ignore information that is inconsistent
with those beliefs? In the space below, list examples of times when you have engaged in
selective attention or memory:
Negative Core Beliefs
In addition to paying attention to your negative thinking in particular situations that
trigger your anxiety, it may also be useful to become more aware of any deeper, more
central, and long-standing assumptions that contribute to your feelings of anxiety. These
assumptions are called core beliefs  and they can include negative assumptions that people
hold about themselves (for example, “I am incompetent”), other people (for instance,
“Other people cannot be trusted”), and the world (such as, “The world is a dangerous
place”). The more strongly held these core beliefs are, the more difﬁcult they may be
to change.
One technique for uncovering core beliefs involves continually asking about the
meaning of each fearful belief you have until the core beliefs underlying your anxious
interpretations are revealed. This process is illustrated in the following conversation
between Liam and his therapist:
Liam:   I am terriﬁed to ask my coworker Cindy out on a date.
Therapist:   What are you afraid might happen if you ask her out?
Liam:   Mostly, I’m afraid she will say no.
Therapist:   Why would that be a problem?
Liam:   If she rejects me, it will probably mean that she doesn’t ﬁnd me attractive.
Therapist:   What would be so bad about that?
Liam:   It will conﬁrm my own belief that I am unattractive.


Therapist  : What if that’s true?
Liam:    Well, if I really am unattractive, that means nobody will ever think I’m
attractive or want to date me. It would mean that I am unlovable.
Therapist:   What would be bad about being unlovable?


The Shyness & Social Anxiety Workbook
118Liam:   If I am unlovable, I am bound to be alone forever.
Therapist:    So, to summarize, you seem to be saying that (1) if another person turns
down your invitation for a date, it means that she ﬁnds you unattractive, (2)
if another person ﬁnds you unattractive, then everyone will ﬁnd you unat -
tractive, (3) being turned down for a date means that you are unlovable and
destined to be alone forever. Do you think of yourself as unlovable?
Liam:    I think I do. Part of me knows it isn’t true, but much of the time I just can’t
shake that belief.
HOW TO IDENTIFY YOUR ANXIOUS THOUGHTS
AND PREDICTIONS
In chapter 3, we discussed strategies for identifying your anxious thoughts. We suggest
that you review the relevant passages in chapter 3 on identifying anxious thoughts before
trying to use the techniques discussed in the remainder of this chapter. There is no point
trying to change your anxious beliefs unless you are clear about the content of these
beliefs. In addition to reviewing the anxious thoughts recorded in chapter 3, identify -
ing your anxious beliefs, predictions, and assumptions should be an ongoing process.
Whenever you ﬁnd yourself in an anxiety-provoking situation, try to identify the speciﬁc
thoughts and beliefs that contribute to your discomfort. In most cases, you can identify
your anxious predictions and assumptions by asking yourself a series of questions such
as the following:
UÊWhat am I afraid will happen in this situation?
UÊWhat do I fear that the other person will think about me?


UÊWhat do I fear that the other person will think about me?
UÊWhat will happen if my anxious thoughts are true?
Sometimes it may be difﬁcult to pinpoint your fearful thoughts. Chances are that
social anxiety has been a part of your life for so long that your negative thoughts are
well-rehearsed, very quick, and almost automatic (like habits). Also, the fact that you
probably avoid the situations you fear makes it that much more difﬁcult to remember
exactly what thoughts tend to occur when you are actually in the situation.
If you have difﬁculty identifying your anxious beliefs, we suggest that you try to
engage with the situations you fear and attempt to identify your assumptions and predic -
tions while you are still in the situation. With practice, it should get easier to recognize
your anxious beliefs. In fact, even if you are unable to identify the speciﬁc thoughts that
contribute to your anxiety, practicing being in the situation will likely lead to a decrease
in your fear, as discussed in chapters 7 and 8.


Changing Your Anxious Thoughts and Expectations
119STRATEGIES FOR CHANGING ANXIOUS THINKING
This section provides an overview of seven different techniques for changing the beliefs
and predictions that contribute to your social anxiety. These include (1) examining the
evidence for your beliefs, (2) challenging catastrophic thinking, (3) remembering your
strengths, (4) seeing yourself as others do, (5) examining the costs and beneﬁts of your
thoughts, (6) creating rational coping statements, and (7) conducting behavioral experi -
ments. Along with a description of each strategy, we include exercises to provide oppor -
tunities to try each technique. Near the end of the chapter, we offer some suggestions
for tying together all the pieces and for integrating the cognitive therapy techniques into
your larger treatment plan.
Examining the Evidence
The fact that you are anxious about being judged by others in a particular situation
doesn’t mean that your fearful predictions and thoughts are true. In fact, what we assume
others are thinking is often completely different than what other people actually think
of us. How many times have you heard someone say, “My hair looks awful” or “I am
such a loser” and thought to yourself that the individual was just ﬁne? If you are consis -
tently assuming you’re inferior in the eyes of others, you are probably exaggerating or
 misinterpreting other people’s reactions to your appearance, behavior, or performance.
The ﬁrst step toward changing your thoughts is to recognize that your beliefs are
not facts. Rather than assuming that your beliefs are true, it is important to treat your
anxious thoughts as guesses or hypotheses. By examining the evidence, you will be able
to assess the extent to which your beliefs are true. Remember, your natural tendency


to assess the extent to which your beliefs are true. Remember, your natural tendency
may be to seek out only information that conﬁrms your negative beliefs about yourself.
Examining the evidence involves trying to achieve a more balanced view by looking at all
the evidence, especially information that contradicts or disproves your anxious thoughts
and predictions.
In order to examine the evidence for your beliefs, we recommend you get into the
habit of asking yourself questions such as the following:
UÊHow do I know for sure that my prediction will come true?
UÊWhat does my past experience tell me about the likelihood of my thoughts
coming true?
UÊHave there been times when I have experienced anxious thoughts that
didn’t come true?
UÊAre there facts or statistics that can help me to decide whether my predic -
tion is likely to come true?


The Shyness & Social Anxiety Workbook
120UÊAre there other possible interpretations for this situation?
UÊHow might another person interpret this situation?
You may ﬁnd it useful to type these questions on a small index card and carry that
card as a reminder in your pocket or wallet. Essentially, examining the evidence involves
four basic steps: identifying your anxious beliefs, generating alternative beliefs, weigh -
ing the evidence supporting and contradicting your beliefs, and choosing more realistic
beliefs. Asking questions similar to those listed above will help you to identify alternative
beliefs and to evaluate the evidence concerning your anxious and alternative beliefs. An
illustration of how to use this strategy to combat a fear of shaking during a presentation
appears below:
Steps for Examining the Evidence
1. Identify the Anxious Thought
UÊThe audience will think I am incompetent if they see my hands shaking
during my talk.
2. Generate Alternative Beliefs
UÊNobody will notice my shaking.
UÊOnly a small number of people will notice my shaking.
UÊPeople who notice my shaking will think I am tired or that I have had
too much coffee.
UÊPeople who notice my shaking will think I am feeling a bit anxious.
UÊIt is normal to shake sometimes, so people will think nothing of it if they
notice my shaky hands.
3. Examine the Evidence
Evidence Supporting Your Anxious Belief
UÊI believe that my shaking is very extreme.
UÊA few people have commented on my shaky hands over the years.
UÊI tend to notice when other people shake.
Evidence Supporting Your Alternative Beliefs
UÊI know others with shaky hands, and people don’t seem to think they
are incompetent.


are incompetent.
UÊWhen I notice other people shaking, I don’t think they are incompetent.
UÊOften people seem not to have noticed me shaking when I asked them
if it was noticeable.


Changing Your Anxious Thoughts and Expectations
121UÊWhen people have noticed my shaking, they haven’t tended to treat me
differently.
UÊThe people in the audience know me well. I can’t imagine that their
opinions of me would change dramatically based on whether my hands
shook during a single presentation.
4. Choose a More Realistic Belief
UÊSome people may notice my shaky hands, but it’s unlikely that they will
think I’m incompetent.
The following form can be used as you begin to work on examining the evidence
supporting and contradicting your anxious beliefs. You may want to make copies of this
form so that you can continue to use it whenever you encounter a feared situation.


The Shyness & Social Anxiety Workbook
122Form for Examining the Evidence
Situation
Anxious Beliefs, Predictions, and Interpretations
Alternative (Non-Anxious) Beliefs, Predictions, and Interpretations
Evidence Supporting My Anxious Beliefs, Predictions, and Interpretations
Evidence Contradicting My Anxious Beliefs, Predictions, and Interpretations
Choosing a More Realistic Way of Thinking


Changing Your Anxious Thoughts and Expectations
123To further illustrate the process of examining the evidence, here is an example of a
discussion between Stephen and his therapist demonstrating how to ﬁrst identify anxious
beliefs and then challenge those beliefs based on your past experiences.
Therapist:   What are you afraid will happen if you attend your company picnic next
week?
Stephen:    I am nervous that I won’t be able to come up with anything to say to anyone.
Everyone else will be talking about their children. I’m not in a relationship,
and I have no kids, so I will have nothing in common with any of them.
Therapist:   How sure are you that you will have nothing to say?
Stephen:   Probably about 90 percent.
Therapist:   What that means is that nine out of ten times that you attend an event such
as this one, you have nothing to say. Is this really true? What happened at
last year’s company picnic?
Stephen:    When I ﬁrst arrived, it was difﬁcult. I stood off to the side and didn’t say
much to others. After a while, people started to include me in their conver -
sations and it got easier. I think it was especially difﬁcult last year because I
had just started at the company and didn’t know anyone very well.
Therapist:  Were you able to think of things to say?
Stephen:    At ﬁrst, I struggled. I think it was harder for me than it was for the others,
but I was able to think of a few things to talk about, especially later in the
afternoon.
Therapist:   Did everyone at last year’s picnic bring a partner or spouse? Did they all talk
about their children?


about their children?
Stephen:    No. In fact, there are a few other single people at work. Last year, lots of
people ended up talking about work.
Therapist:   Thinking back to last year’s company picnic, do you still think that you
won’t have anything to say at this year’s picnic?
Stephen:    Well, I may not be as talkative as some other people, but I suppose I will
probably ﬁnd something to talk about. Maybe it will be easier this year
because I’ve worked with these people for over a year, so I know them much
better.


The Shyness & Social Anxiety Workbook
124Challenging Catastrophic Thinking
Challenging catastrophic thinking requires shifting the focus of your thoughts from
how terrible a particular outcome would be to how you might manage or cope with
the situation if it were to occur. One of the most effective ways of overcoming your
 catastrophic thoughts is to ask yourself questions like the following:
UÊSo what?
UÊWhat if my fears actually come true?
UÊHow can I cope with            if it were to occur?
UÊWould              really be as terrible as I think?
UÊDoes this really matter in the big scheme of things?
UÊWill I care about this a month from now? A year from now?
In many cases, you will realize that even if your fear does come true, it won’t be the
end of the world. You will cope with the situation, and your discomfort will pass. Below
you will see a discussion between Aimee and her therapist illustrating how to use this
technique to challenge catastrophic thoughts related to asking someone out on a date.
Aimee:   I am terriﬁed of asking anyone out on a date for fear of rejection.
Therapist:   Is there a particular person whom you have considered asking out?
Aimee:    There is a guy in one of my classes. I’ve sat with him a few times. The class
ends just before lunch, so I’ve thought of asking him to have lunch with
me.
Therapist:    What’s stopping you? What do you think might happen if you ask him to
join you for lunch?
Aimee:    Mostly, I am afraid he won’t be interested in me. I will put him on the spot


and he’ll have to come up with an excuse for rejecting my offer. I’m afraid
he’ll think I’m stupid, or even worse, he’ll feel sorry for me.
Therapist:    As we’ve discussed previously, there are many different possible reactions
that he could have. Thinking you’re stupid or feeling sorry for you are just
two of many possibilities. Nevertheless, let’s assume for a moment that your
fears actually are true. What if he does think you are foolish and pathetic?
Aimee:   I don’t know. I hadn’t really thought beyond that. I would feel terrible.


Changing Your Anxious Thoughts and Expectations
125Therapist:   Would it mean that you really are pathetic and stupid?
Aimee:   I suppose not.
Therapist:    Would it mean that all other people also think you are stupid and
pathetic?
Aimee:   Not really.
Therapist:   Why not?
Aimee:    Well, his opinion doesn’t reﬂect that of other people. I know my friends
don’t think I’m pathetic. At least I hope not.
Therapist:   If you’re not stupid or pathetic, why else would he reject you?
Aimee:    Perhaps he might have other lunch plans. Or, maybe he already has a
girlfriend.
Therapist:    Those are both possibilities, but let’s come back to your original thoughts.
What if he really thinks you’re pathetic and that’s why he isn’t interested in
spending time with you?
Aimee:    I guess it wouldn’t matter. Over the past few weeks, I’ve come to recognize
that not everyone has to like me. Perhaps it would mean that we’re just not
a good match.
Therapist:    If he declines your offer for lunch, do you think you will be able to cope
with the feelings of rejection?
Aimee:    I think so. It will feel bad at ﬁrst, but I think I can stop myself from getting
too down on myself.
Overcoming catastrophic thinking also involves combating the tendencies to con -
centrate only on the immediate consequences of some negative experience (for example,
“People will think badly about me during my presentation”) and to forget that your
discomfort will pass after a short time. In reality, the consequences of making a mistake


discomfort will pass after a short time. In reality, the consequences of making a mistake
or of embarrassing yourself are usually minimal and almost never last very long. Even if
people notice that you have made a mistake or that you appear to be anxious, they are
likely to forget about it after a few minutes.
We have included a Decatastrophizing Form toward the end of this chapter to help
you challenge your catastrophic thoughts in social situations. The form includes three
columns. In the ﬁrst column, you should describe the situation that led you to feel
anxious. In the second column, describe your anxious thoughts and predictions. Now,
ask the questions provided in the previous bulleted list (such as, “So what?”) and record
your noncatastrophic responses in the third column. Following are some examples.


The Shyness & Social Anxiety Workbook
126Column 1 (Examples of Situations)
UÊGiving a presentation
UÊHaving difﬁculty thinking of things to say during a conversation
UÊAttending a party
UÊAsking someone out on a date
UÊWalking through a busy mall
Column 2 (Examples of Anxious Thoughts)
UÊ            will think I am stupid.
UÊMy hands will shake.
UÊI will look weak or incompetent.
UÊ            will feel sorry for me.
UÊMy anxiety will be noticed by              .
Column 3 (Examples of Noncatastrophic Responses)
UÊEven if             thinks I’m an idiot, it doesn’t mean I
really am one. His opinion doesn’t reﬂect that of everyone else.
UÊIt wouldn’t be the end of the world if             noticed
my anxiety. Everyone feels anxious from time to time.
UÊWho cares if my hands shake? I have the right to have shaky hands. Probably
no one will even notice. Even if they notice, they probably won’t care. My
boss has shaky hands and nobody seems to care.
UÊIf I am ridiculed or laughed at, it would be manageable. Most people get
teased and ridiculed from time to time. I certainly laugh at other people
sometimes. Other than the temporary discomfort or embarrassment, it
wouldn’t really matter in the big scheme of things.
Remembering Your Strengths
If you tend to focus on small mistakes and perceived ﬂaws in your personality or
appearance, you will likely continue to feel anxious. For example, if you assume that
everyone is judging you based on whether your hands shake, you are more likely to


Changing Your Anxious Thoughts and Expectations
127be nervous when your hands are shaking. Similarly, if you assume that everyone else
is criticizing you based on ten seconds during your presentation when you lost your
train of thought, you will probably continue to be nervous when giving presentations.
Although it is true that we all judge and criticize other people from time to time, it is
unlikely that people are noticing and judging the speciﬁc behaviors that you assume are
being criticized.
People’s judgments of one another are based on many different dimensions, includ -
ing appearance (for example, height, weight, hair color and style, facial features, cloth -
ing, shoes, and so on), intelligence (for instance, verbal abilities, problem-solving skills,
knowledge of trivia, and so on), competence (such as abilities to do one’s job well,
computer skills, ability to ﬁx things around the house), work habits (for example, ten -
dency to arrive on time, work hard, and not take overly long breaks), athletic abilities
(like the ability to play tennis, ﬁtness level, strength), creativity (for instance, musical
or artistic ability), health habits (such as diet, exercise, smoking, drinking), health status
(presence of medical problems), social status (type of home, income, type of job), mood
(happy, excited, sad, angry, fearful), and personality (generosity, empathy, conﬁdence,
 politeness, arrogance), to name just a few.
Most of us are far above average on some dimensions, far below average on some
other dimensions, and well within average range on most dimensions. The extent to
which a person criticizes you about a particular dimension probably depends on whether


which a person criticizes you about a particular dimension probably depends on whether
that person believes that particular domain is important. Although some people may
criticize you for appearing nervous, it’s likely that most people couldn’t care less. If you
assume others are focusing only on those dimensions in which you judge yourself to be
inferior, you will continue to feel anxious and fearful around other people.
Because your natural tendency may be to focus on those areas in which you feel you
don’t measure up to others, it may take some practice to recognize dimensions in which
you excel or in which you are similar to most other people. As a start, it may be helpful
to list some of your strengths in the space provided below.
Areas of Strength
Seeing Yourself as Others Do
One powerful method for challenging the overly harsh standards that you may hold
for yourself is to try to see anxiety-provoking situations through another person’s per -
spective. What if the tables were turned and a close friend came to you for advice and


The Shyness & Social Anxiety Workbook
128support after giving a presentation? What if your friend expressed many of the same
thoughts that you experience when you are in a feared social or performance situation?
What might you say?
For example, what if your friend said to you, “I totally blew my presentation. My
voice was trembling, and at one point I even lost my train of thought. I’m sure I looked
like a complete idiot.” How would you respond to your friend? Most likely you would say
something like, “You probably did better than you think. Even if you did look anxious,
people probably didn’t care.” Or, perhaps you would say something like, “I also feel very
anxious during presentations. It feels very uncomfortable in the moment, but eventually
it passes.”
It is often much easier to challenge someone else’s anxious thoughts than it is to
challenge your own. Therefore, we suggest that you try coping with your own anxious
thoughts by mentally “stepping out” of the situation for a moment. Imagine that it is
someone else (perhaps a close friend or family member) who is experiencing the anxiety.
What might you tell him or her? Taking the perspective of a close friend may help you
to challenge your own anxious thoughts.
Another helpful method of shifting perspectives is to imagine how you might judge
someone else who exhibits the same anxious behaviors that you do. For example, if you
are worried that others might criticize you if your voice become shaky, you might ask
yourself, “Am I critical of other people when I notice their voice shaking?” Most likely,
you would not assume someone else to be incompetent, stupid, or weak just because he
or she seems a bit shy or anxious in a particular situation. Well, the same is true of other


people. It is unlikely that they will make such harsh judgments of you, even if they do
notice that you’re anxious.
A third strategy for shifting perspectives is to ask yourself how someone who isn’t
anxious might interpret the situation you fear. For example, if you believe that it’s impor -
tant to avoid parties if there is any risk at all of looking anxious, you can ask yourself
how someone who isn’t anxious might view that situation. You can even imagine how
a particular person (for example, a friend, relative, spouse, or therapist) might view the
situation.
To summarize, shifting your perspectives involves asking yourself three types of
questions:
UÊWhat might I say to a close friend or relative who was having the same
thought as me?
UÊHow might I view someone else who was exhibiting the same behavior as
me (shaking, sweating, making a mistake, and so on)?
UÊHow might someone without an anxiety problem view this situation?


Changing Your Anxious Thoughts and Expectations
129Examining the Costs and Beneﬁts of Your Thoughts
As we have discussed throughout this chapter, anxious thoughts about social and per -
formance situations are often untrue. However, sometimes they may be true (at least par -
tially true) and still be a problem. In addition to establishing whether your thoughts are
true, it’s useful to consider whether your thoughts and behaviors are helping you. If they
are helpful, then they may be worth holding on to. If not, it may be time to let them go.
Almost everyone wants to make a good impression and probably no one would
choose to be thought of as incompetent, stupid, boring, or weak. In fact, many of the
anxiety-provoking beliefs held by individuals with excessive social anxiety are similar in
content to those held by people who don’t have problems with social anxiety. Beliefs
such as “It is important to be liked by other people” and “It is important to make a posi -
tive impression” are often helpful beliefs that most of us develop early in life. Making a
good impression on others helps us to develop friendships, get promoted at work, and
impress our teachers. In fact, many rewards in life depend on being able to inﬂuence
others in a positive way.
However, excessive social anxiety is usually associated with a tendency to be overly
concerned with the opinions of others—so much so that it interferes with your life and
may actually lead to a more negative impression on others, particularly if you avoid
important social events. The problem with the beliefs and thoughts associated with
social anxiety is not necessarily that they are untrue (although sometimes they are), but


social anxiety is not necessarily that they are untrue (although sometimes they are), but
rather that they are held in an exaggerated and inﬂexible way. For example, if the belief
“I should make a good impression on others” motivates you to do a good job at work,
that’s great. If, on the other hand, the same belief makes you feel paralyzed and unable
to get any work done, that’s a problem.
In addition to establishing the accuracy of your anxious beliefs and predictions, it
may also be helpful to consider whether your thoughts and behaviors are helping you.
Following is a form that you can use for this exercise. If you are unsure about whether
a particular anxiety-provoking thought is true or false, try examining the costs and ben -
eﬁts of constantly dwelling on the thought. How would the quality of your life improve
if you didn’t have the thought?
Describe Your Anxious Thought or Prediction
List the Beneﬁts of Having That Anxious Thought or Prediction


The Shyness & Social Anxiety Workbook
130List the Costs of Having That Anxious Thought or Prediction
Rational Coping Statements
At the height of your fear, it may be difﬁcult to challenge your anxious thoughts
using some of the techniques described in this chapter. You may ﬁnd that your attention
is completely focused on trying to get through the situation, and it may seem impossible
to think logically. Rational coping statements are relatively easy to use and don’t require
the same level of logical analysis as other techniques, such as examining the evidence
and evaluating the costs and beneﬁts of your anxious thoughts. Rational coping state -
ments are short “nonanxious” sentences that may help to combat your anxious thinking.
Examples include the following:
UÊIt would be manageable if             didn’t like me.
UÊIt’s okay to blush in front of others.
UÊPanic attacks are uncomfortable but not dangerous.
UÊIt is okay to look anxious during a presentation.
UÊPeople don’t seem to notice my shaky hands.
You may ﬁnd it helpful to write or type several coping statements on an index card
and carry the card with you as a reminder. When you are in an anxiety-provoking situ -
ation, you can take the card out of your wallet or purse and remind yourself of one or
more of these statements, thereby combating your anxious thoughts. Choose statements
that are most relevant to you. Also, choose statements that are believable. For example,
there is no point telling yourself, “I am not going to be anxious” if you always feel
anxious when giving speeches and you are about to give a speech. A more believable
alternative is, “It’s not the end of the world if I become anxious.”


alternative is, “It’s not the end of the world if I become anxious.”
In the following spaces, record ﬁve rational coping statements that are relevant to
your own particular anxious beliefs.
1.
2.
3.


Changing Your Anxious Thoughts and Expectations
1314.
5.
Behavioral Experiments
Cognitive therapy involves examining the validity of your beliefs and thoughts in
the same way that a scientist examines the validity of a scientiﬁc theory or hypothesis.
In fact, the experiment is the most powerful strategy scientists have to test their own
beliefs. In cognitive therapy for social anxiety, experiments involve challenging anxious
beliefs by setting up small behavioral tests to see whether a belief is in fact valid. Through
a series of repeated behavioral experiments, it is likely that you will disprove many of
the beliefs and predictions that contribute to your fear and anxiety. Some examples of
speciﬁc experiments that can be used to test the validity of various anxiety-provoking
thoughts are listed below.
Anxiety-Provoking Thought Example of Behavioral Experiment
It would be terrible to have my hand
shake while I hold a glass of water.Purposely shake your hand while you hold
a glass of water. For a true test of your
beliefs, let the water spill all over you!
Then see if it really is so terrible.
I will make a fool of myself at my job
interview tomorrow, so why bother going?Go to the job interview and see what
happens.
I can’t cope with being the center of
attention.Do something to draw attention to your -
self. For example, arrive to class late, drop
your keys, wear your shirt inside out, or
knock over some unbreakable items in a
supermarket.
It would be terrible to seem stupid or
incompetent.Line up at a store and after your items
have been rung up, explain to the cashier
that you have forgotten your money.


have been rung up, explain to the cashier
that you have forgotten your money.
I will be rejected if I ask a coworker to
have dinner with me.Invite your coworker for dinner and check
out his or her reaction.
When selecting possible experiments, try to choose practices in which you have
little to lose. For example, don’t tell your boss how much you hate him, just to see what
happens! Try to select experiments in which the worst that will happen is possible dis -
comfort or temporary embarrassment. Remember that the more social risks you take, the
more often they will pay off. Along the way, however, you will also experience rejection
from time to time. If you don’t take risks, you will never be rejected—but you will also


The Shyness & Social Anxiety Workbook
132never experience the beneﬁts of taking social risks, including improved relationships, a
better job, and other possible rewards.
In the spaces below, imagine and record some experiments you could try in order to
test out your particular anxious thoughts. In the ﬁrst column, write down your anxious
belief. In the second column, design a small experiment that will provide a good test of
whether your belief is true.
Anxious Thought      Behavioral Experiment

The next few chapters discuss strategies for confronting the very situations and
feelings that you fear. As you will see, exposure to feared situations is actually a type
of behavioral experiment. By repeatedly exposing yourself to situations that make you
anxious, you will learn that your fears often don’t materialize.
USING A THOUGHT RECORD OR
COGNITIVE DIARY
Throughout this chapter, we have included various forms and diaries to be used for
challenging anxious thoughts. In this section, we now provide a more general Social
Anxiety Thought Record that can be used whenever you experience anxiety in a social
situation. Unlike the other forms in this chapter, which are each designed for use with a
particular technique (examining the evidence, overcoming catastrophic thinking, and so
on), the Social Anxiety Thought Record is designed to be used with any of the cognitive
 strategies. At the end of this chapter is a blank form, as well as a completed sample.
It really doesn’t matter which form you use to record and change your thoughts. You
can use the forms provided in this chapter, or you can design your own. The diaries in
this chapter are only suggestions. The main point of these diaries is to get you into the


habit of paying attention to your thoughts and actively trying to change them. Once
the new patterns of thinking become second nature, it will no longer be necessary to
record your thoughts on paper. In the meantime, we recommend that you use some
type of diary or form several times per week after encountering feared social or perfor -
mance situations. The best times to complete the forms are either before entering the
 situation (as a way of preparing for the encounter) or immediately afterward (as a way of
 challenging any anxious thoughts that occurred while you were in the situation).


Changing Your Anxious Thoughts and Expectations
133Instructions for Completing the Social Anxiety
Thought Record
Column 1: Date and Time
Record the date and time.
Column 2: Situation
Describe the situation or trigger for your fear. Typical examples might include the
following:
UÊGave a presentation
UÊWent to a meeting
UÊPerson was watching me on the subway
UÊAte lunch with a coworker
UÊI was blushing
UÊMy hands shook in front of my boss
UÊWent to a party
UÊHad to do an oral book-report for class
UÊWas introduced to my sister’s new boyfriend
UÊWent on a blind date
Column 3: Anxiety-Provoking Thoughts and Predictions
In the third column, list any anxious thoughts that occur in response to the situa -
tion and triggers reported in column 2. Usually these thoughts will be predictions of
danger, embarrassment, and so on. Often these thoughts will be automatic or almost
unconscious. It will take practice to identify them. Try to come up with very speciﬁc
thoughts. A thought such as, “Something bad will happen” is too vague. Typical  examples
of  speciﬁc anxious thoughts include the following:
UÊPeople will notice my blushing and think I am strange
UÊPeople will notice that I am nervous
UÊI will make a fool of myself
UÊPeople will think I am stupid
UÊPeople will see me for the idiot I really am


The Shyness & Social Anxiety Workbook
134UÊPeople will think I’m ugly
UÊI will have to leave the situation
UÊI am incompetent and clumsy
UÊI need an alcoholic drink to feel comfortable
UÊPeople can always tell how I am feeling
UÊAnxiety is a sign of weakness
UÊI’ll be viewed as boring
UÊPeople will not like me
UÊI will have nothing to say
Column 4: Anxiety Before (0–100)
Rate your anxiety level before countering your anxiety-provoking thoughts. Use a 0
to 100 point scale, where 0 = no anxiety and 100 = extreme anxiety.
Column 5: Alternative Thoughts and Predictions
Record examples of alternative thoughts and predictions. For example, if you believe
that people will think you are strange if you blush, alternative predictions might include
such thoughts as (1) nobody will notice my blushing, (2) people who notice my blushing
will think I am hot or not feeling well, and (3) people who notice my blushing will think
nothing of it.
Column 6: Evidence and Realistic Conclusions
Consider the evidence for your anxiety-provoking thoughts as well as your alterna -
tive thoughts. For example, if you fear blushing, you might record your observations that
most people don’t mention that they notice your blushing, and that even when people
do notice that you are blushing, they still seem to enjoy your company and they still
treat you well. In this column, you should also record a realistic conclusion based on the
evidence. For example, you might record, “Many people don’t seem to notice my blush -


ing, and even when someone does notice it, there are no real consequences other than
my temporary embarrassment.”
Column 7: Anxiety After (0–100)
Rate your anxiety level after countering your anxiety-provoking thoughts. Use a 0
to 100 point scale, where 0 = no anxiety and 100 = extreme anxiety.


Changing Your Anxious Thoughts and Expectations
135INTEGRATING COGNITIVE STRATEGIES INTO
YOUR TREATMENT PLAN
The cognitive techniques described in this chapter are not meant to be used on their
own. Rather, they should be used as part of a comprehensive treatment plan that includes
exposure to feared situations. Exposure-based treatments are discussed in chapters 7
through 9. We recommend that you ﬁrst practice the cognitive techniques for a few
weeks before formally beginning exposure practices. Learning to manage your anxiety
by changing your thinking will help you when confronting the situations that you fear.
In addition to exposure and cognitive therapy, your treatment may also include medica -
tion (see chapter 5) and social-skills practices (see chapter 10), depending on your own
personal needs and preferences.
A WORD TO SIGNIFICANT OTHERS, FRIENDS,
AND FAMILY MEMBERS
If you are working with a loved one who is trying to overcome his or her social anxiety,
you can help him or her to change anxiety-provoking thoughts into more realistic
thoughts by engaging in calm, logical discussions about the situations he or she fears.
This process should always be done in a supportive way, and you should be careful
not to put your loved one down for having anxiety-provoking beliefs (after all, we all
have irrational thoughts from time to time). You should also be careful not to tell your
loved one what he or she should  be thinking. Rather, your loved one should draw his or
her own conclusions based on the evidence. Finally, remember that your role is to be
supportive—not to nag or pressure your loved one into making changes or to argue
about how to interpret anxiety-provoking situations. You and your loved one should


about how to interpret anxiety-provoking situations. You and your loved one should
discuss what role he or she would like you to have, and how you can best facilitate the
process of change.
TROUBLESHOOTING
Problem:  I have difﬁculty identifying my anxious thoughts.
Solution:   Ask yourself questions such as, “What might           think
about me?” and “What do I think will happen in this situation?” If, after
trying to answer these questions, you are still unable to identify your
anxious beliefs, try to detect your thoughts while you are actually in
the situation you fear. If you are unable to identify speciﬁc thoughts and
predictions, don’t worry. You can still beneﬁt from the exposure-based
strategies discussed in chapters 7 through 9.


The Shyness & Social Anxiety Workbook
136Problem:   I have difﬁculty believing the alternative, nonanxious, rational
thoughts.
Solution:   Sometimes the cognitive techniques seem superﬁcial when a person ﬁrst
starts to use them. Over time, the new nonanxious thoughts should
become more believable. If not, the exposure-based strategies (chap -
ters 7 through 9) are among the most powerful methods for changing
anxious thoughts and will likely help. Sometimes, changing thoughts
through ﬁrsthand experience in a feared situation is more effective than
trying to change thoughts by simply trying to think differently.
Problem:   When I am in a social situation, I am too anxious to think clearly, so I
can’t use the cognitive strategies.
Solution:   Try using the cognitive strategies before you enter the situation. If this
is not practical, try using them after you have been in the situation for
a while (your fear should decrease over time) or even after leaving the
situation.
Problem:   I can’t be bothered completing the monitoring forms. They are confus -
ing, and they take too long to complete.
Solution:   There are many different ways to learn the techniques described in
this chapter. The forms and diaries are designed to make the process
easier. However, if they are getting in the way of using the strategies,
try developing a simpler form (for example, you may want to use a two-
column form—with one column for recording your anxious thoughts
and another column for recording your new nonanxious thoughts).
Alternatively, you can even forget about the forms and diaries and
simply use the techniques in your head.


Changing Your Anxious Thoughts and Expectations
137A SUMMARY GUIDE TO CHALLENGING
THOUGHTS
This chapter includes a large number of suggestions and strategies for identifying and
changing your anxious thoughts. Now that you have had a chance to read through the
chapter and complete some of the exercises, we encourage you to continue using the
cognitive techniques to cope with your social and performance anxiety. Generally, using
the cognitive strategies will involve the following steps:
1. Identify your anxious thoughts, predictions, and interpretations.
2. Examine the validity of your anxious predictions using some of the tech -
niques described in this chapter (such as examining the evidence, taking the
perspective of others, examining the costs and beneﬁts of your thoughts,
conducting behavioral experiments). Are your predictions realistic? For
example, will others really think                 about
you?
3. Examine the validity of your catastrophic thoughts by asking the question,
“So what if my anxious thoughts are true?” For example, “What if a few
people in the audience really think my presentation is awful? How might I
cope with that?”
4. Use the Social Anxiety Thought Record to identify and challenge your
anxious thoughts on paper.


The Shyness & Social Anxiety Workbook
138
Decatastrophizing Form
Situation Anxious Thoughts and Predictions
(What do I think will happen?)Noncatastrophic Responses
(What if my thoughts come true?)


Changing Your Anxious Thoughts and Expectations
139Social Anxiety Thought Record
Date and
TimeSituationAnxiety-Provoking
Thoughts and
PredictionsAnxiety
Before
(0–100)Alternative Thoughts
and PredictionsEvidence and Realistic
ConclusionsAnxiety
After
(0–100)
© 2008 Martin M. Antony


The Shyness & Social Anxiety Workbook
140
Social Anxiety Thought Record—Completed Sample
Date and
TimeSituationAnxiety-Provoking
Thoughts and
PredictionsAnxiety
Before
(0–100)Alternative Thoughts
and PredictionsEvidence and Realistic
ConclusionsAnxiety
After
(0–100)
April 3,
2 PMMeeting at work I will say something stupid;
people will think I’m an idiot.90 I will say something intel -
ligent. I will say something
that is neither stupid nor
intelligent. Some people will
think I’m smart; some people
may think I am of average
intelligence. Whatever I
say won’t change what my
coworkers already think about
my intelligence.  My boss asked me to speak at the meeting,
so she must think I have something worth -
while to say. Everyone says stupid things
from time to time, and there is no reason to
think that I shouldn’t also say dumb things
sometimes. Nothing terrible will happen if I
say something stupid. Everyone in the room
already knows me. Even if someone thinks I
am stupid, it won’t be the end of the world.50
April 5,
7 PMEating dinner with
a friend; my hands
are shakingMy shaking hands will be
noticeable. My friend will
think that I am nervous and
will see that as a weakness.70 Maybe my friend won’t
notice my hands shaking.
Even if he notices, he may
not think it is due to anxiety.
Even if he thinks it is due to
anxiety, he may not see it as
a weakness.


anxiety, he may not see it as
a weakness.
 I have known my friend for years. He
knows that I get nervous sometimes, and he
still wants to spend time with me. He gets
nervous in situations that don’t bother me
(he is afraid of ﬂying). I have the right to
have shaky hands sometimes!
 45


Changing Your Anxious Thoughts and Expectations
141April 7,
3 PMReturning an item
to a storeThe cashier will think I’m
stupid for buying this item in
the ﬁrst place. I won’t be clear
when trying to explain what
I want to do. The cashier
won’t let me return the item,
and I won’t know how to
respond.70 The cashier will not think I
am stupid. I will be able to
explain what I want to do.
The cashier will allow me to
return the item. Even if I am
anxious, I will be able to cope
with this situation.I have returned items to stores before, and it
always seems to work out. Chances are that
it will work out this time, too. Returns are
allowed within 30 days, so I have the right
to return this item. Even if I seem nervous,
the cashier doesn’t have the right to turn
down my request. If I can’t think of the
right words, I can just take my time until
the words come to me.  20
© 2008 Martin M. Antony


CHAPTER 7
Confronting Your Fears
Through Exposure
Chapter 6 provided a detailed overview of cognitive strategies that have been shown to
be useful for changing anxious patterns of thinking. Almost all of the cognitive tech -
niques involve learning to think differently about social and performance situations by
(1) broadening the possible range of interpretations and beliefs that you can hold for a
particular social situation, and (2) considering all the evidence before assuming that a
speciﬁc thought is true.
This chapter provides an introduction to a number of techniques that are useful for
changing the behaviors that maintain your anxious beliefs and feelings. Essentially, these
strategies involve confronting your fears directly by exposing yourself to the situations
and the feelings that you currently fear and avoid. This chapter starts with a review of
the behaviors that contribute to social anxiety and a summary of the strategies that can
be used to change these behaviors. The remainder of the chapter provides more detailed
descriptions of the underlying principles of exposure and the best ways of conducting
exposure-based therapy.
Chapters 8 and 9 build directly on the content of this introductory chapter by provid -
ing more in-depth instructions for exposure to social situations (chapter 8) and exposure
to feared sensations (chapter 9). The exercises described in chapters 7 through 9 should
be used after you have had a chance to practice some of the cognitive methods described
in chapter 6. We recommend that you begin to learn about exposure by reading chapters
7 and 8 and that you practice the situational exposure exercises for at least three to ﬁve
weeks before moving on to chapter 9. Then, we suggest that you read chapter 9 and make
some attempts to expose yourself to feared sensations, if these exercises are relevant


some attempts to expose yourself to feared sensations, if these exercises are relevant
to you. As reviewed in chapter 9, exposure to physical sensations may be useful if you