A common feature associated with post traumatic stress disorder is social discomfort. As you are aware, social discomfort is not a discrete psychiatric diagnosis. It does, however, cause significant distress for many of your patients suffering from PTSD. And in severe cases, it makes recovering from PTSD more difficult leading to continued social, interpersonal and occupational deficits.
There are a number of symptoms and behaviors associated with social discomfort. Most notably, the person displays a consistent pattern of social anxiety or apprehension when around others.
The person also exhibits a hypersensitivity to disapproval or criticism by others. In essence, not only is the person uncomfortable in public settings, but is worried about being harshly judged by others. This presentation goes beyond basic shyness. Many of our patients have shyness tendencies.
In PTSD patients with social discomfort, the discomfort is more distressing and disruptive than shyness. And it’s often times related to the previous trauma. For example, a combat veteran who was ambushed during a large demonstration in the streets of Iraq may feel uncomfortable being around large and noisy crowds (e.g., sporting events, concerts).
A person experiencing extreme social discomfort associated with PTSD may have no close friends or social support system outside immediate family.
They may avoid situations that require interpersonal contact, worry about doing something foolish in public and are overly concerned that they will not live up to the expectations of others. This behavior can obviously lead to withdrawal and isolation. As a result, in addition to battling with the “classic” PTSD symptoms, your patient may also develop depression and begin to use substances or use them at an increasing frequency and amount.
The various symptoms associated with social discomfort vary from person to person. Common physical symptoms include a racing heart, sweating, dry mouth, muscle tension and shakiness in the body and voice.
These symptoms are often serious enough to where those around the person can tell something is wrong. Common behavioral symptoms, as noted above, include withdrawal and isolation, avoidance of people and places and self-medication.
How to Help
The first step in helping your patients gain control of social discomfort associated with PTSD is effectively treating the PTSD. For most patients, successfully treating the trauma will bring about relief from the social discomfort. However, it is important to keep in mind that even when a patient no longer meets criteria for PTSD, some degree of social anxiety can continue.
The most effective treatments for PTSD include various cognitive and behavioral psychotherapies such as Prolonged Exposure (PE) and Cognitive Processing Therapy (CPT). There is strong research support for both PE and CPT. In some cases, success rates have topped 80 percent.
Other commonly used and effective treatments for PTSD include Eye Movement Desensitization and Reprocessing and Stress Inoculation Therapy. Medication can be helpful, but is generally less effective than talk therapy. Medication is most helpful for those patients with extreme agitation, acute panic episodes and sleep disturbances. However, the positive effects of medication disappear once the medication(s) is stopped.
In those individuals who continue to experience social discomfort following successful treatment of PTSD, more targeted interventions are warranted.
One simple approach is education. Understanding how the cycle of social anxiety and avoidance works is key to recovery. At times, we tend to overlook this important aspect of treatment. I think this is mainly because we assume our patients already know the information or we feel it is too “basic” for us and that we should focus on more in-depth techniques.
Learning to manage one’s self-talk is also critical. Anxious people tend to generate quite a bit of self-defeating, one-sided conversations. Identifying, challenging, and replacing biased, fearful self-talk with reality-based, positive self-talk is important. This task can be difficult, but with some hard work, most people can reconfigure how they speak to themselves.
And consistent with the getting back on the horse if you fall adage, for your patients who struggle with social discomfort, it’s important to “force” them to go to the mall, hang out with friends, or take in a ball game. The longer they can stay in these types of situations, the more their anxiety will decrease over time.
Social discomfort does not have to keep your patients from enjoying life. Getting back to basics and providing adequate and evidence-based treatments is all you need to do in order to get them back in the game.
*This article was adapted from a previous article written by Dr. Moore for his column “Kevlar for the Mind.”
Uncomfortable student photo available from Shutterstock