Steve was in his first year at university and since the beginning of his initial semester, his anxiety level had skyrocketed. He dreaded particular sessions where the lecturers would randomly pick on students to answer questions in a large class or in a smaller tutorial. It got to a point where he would literally freeze and was unable to concentrate on the lesson, sometimes missing large chunks of the lectures. On one occasion, when he thought that a lecturer had caught his eye and he was going to be picked to solve a problem for the class, he peed into his pants uncontrollably. He immediately got up and excused himself from the lecture hall, unfortunately drawing everyone’s attention to himself. The tutorial classes were his greatest challenge. In one of them, when he was chosen by the tutor, without prior notice, to lead a group discussion, he threw up. At other times, he was so tense with fear that his t-shirt would be soaked through with perspiration despite the air-conditioning, by the end of the tutorial, and his hands be trembling as he took notes. He gave up taking notes in his tutorials.
He had always been a shy boy when he was growing up, but having a perfectionist mother, who was suffering from what had appeared to be most likely OCD, did not help. Steve, the second of three boys, recalled that almost everything he did would be criticised as not good enough by his mother. It was humiliating to be incessantly compared to his other siblings and others, all the time. His shyness was also the butt of jokes by his classmates in elementary school and he was called stigmatising names throughout his school days. He never participated in any sports, as his schoolmates or teachers would always leave him out. His anxieties first began to surface in his early teens in the form of fears whenever he was picked on to answer questions in class by his teachers. These anxieties were mild compared to what he had been going through in university.
The underlying traits that predispose someone to social anxiety disorder or social phobia include behavioural inhibition and fear of negative appraisal by others. Childhood maltreatment and adversity are risk factors, although not necessarily the cause for it. The diagnostic criteria is indicative of a person who is provoked with a marked fear or anxiety in certain social situations, where he is exposed to possible scrutiny by others, and he fears being negatively evaluated. Usually, avoidance of these occasions if he had an option, would be normal. These fears are abnormal, considering the sociocultural context and his fear, anxiety and avoidance causes clinically significant distress or impairment in his social, occupational, or other important areas of functioning.
For Steve, to be called upon to address issues before other students was obviously phobic and disabling. Although it was not possible to engage his mother in his treatment, it took time to slowly change the way he thought about himself and others, and to reduce the level of his anxiety in social situations as a student and an adult.