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'A very designed life'

She's impeccably groomed, physically fit, professionally successful – and terrified of being exposed as an imposter. Group therapy patient Gail shows how she's finally learning to fight her social anxiety disorder: First, you make a list

From Saturday's Globe and Mail

It was in the year leading up to her 50th birthday that Gail “took stock” of her life and decided it was time. There was plenty to admire at her half-century mark. She and the man she had lived with for 12 years shared a comfortable home together. She had worked her way up to senior executive at one of the world's largest accounting firms. She was fit, a long-distance cyclist, as lean and strong as any woman half her age. She was an accomplished musician. She was well-read, trilingual, witty, articulate and pleasant, always pleasant. Not even her dear brother saw through the camouflage hiding the war within.

She pictures the enemy: a miniature, scowling version of herself – “the editor” – glued to her shoulder, delivering a relentless critique of every word that falls from her mouth, whether she is in an elevator with colleagues or chatting with a friend. It makes her rehearse and replay conversations. It makes her afraid of small talk and suspicious of silence. Three times she has turned down partnership offers at her Bay Street firm – too frightened of the social demands, the corporate functions, client lunches, cocktail parties, even the phone calls.

“There's a five-second lag and then it starts. … ‘Oh, Gail, that was stupid. … Oh, that was inappropriate! … Why did you say that?' ” It's like a radio that's always on, she says, sometimes with the volume turned up. “You feel sick to your stomach, never able to relax.”

The calm face she presents to the world is a fake, she says, born long ago, perhaps back when she was a lonely child of 6 or 7, her nose buried in the pages of Enid Blyton, and it arrived on the heels of a single thought: “If you really knew me, you wouldn't like me … at all.”

Gail calls it her “imposter syndrome.” The experts call it an anxiety disorder, a social phobia based on the extreme fear of making a bad impression. The effects can be so profound that the heart races, blood pressure soars, breathing becomes laboured and limbs tingle. Full-blown panic can set in like a heart attack. Gail had never sought treatment or taken medication for it. She believed she was alone with her demons. She was wrong.

Anxiety disorders are the most common form of mental illness. They strike as many as one in eight Canadians over the course of a lifetime, compared with one in 12 for major depression and one in 100 for schizophrenia.

Social anxiety, the extreme fear of negative evaluation, is the most prevalent form of the disorder. Up to 13 per cent of the population suffers from it, says psychiatrist Neil Rector, head of the anxiety disorders program at Toronto's Centre for Addiction and Mental Health (CAMH).

Yet social anxiety remains one of the least understood psychiatric conditions and, arguably, the most often ignored.

Shyness is, after all, a natural human characteristic and anxiety, the emotional trigger of the fight-or-flight response, an evolutionary necessity that has ensured survival of the species. Skeptics can see it as little more than chronic stage fright, an inconvenient reaction to contemporary society's high-performance demands.

“There is a tendency to dismiss anxiety disorders because everyone feels shy, everyone feels anxiety at one time or another,” says Dr. Rector, also an associate professor at the University of Toronto. But people with social anxiety disorder feel it more frequently and more severely, he says. “It is debilitating and seriously inhibits the quality of life.”

Dread of social scrutiny may not be as apparent as the depression that prevents a woman from leaving her bed, or the mutterings of a man with schizophrenia wandering down a city street. Yet the personal costs can be equally catastrophic.

In the worst cases, those afflicted hate to leave the house. They avoid eye contact, shaking hands, riding a bus or returning an item to the store. A smile unreturned can spark a panic attack. They miss opportunities for friendship, love, family and that most precious of gifts – peace of mind.

Untreated, many go on to substance abuse. Half become depressed. Only in 1980 were anxiety disorders removed as “neuroses” and given their own category in the Diagnostic and Statistical Manual III, the North American clinicians' guide to mental conditions. At first, doctors had narrowly defined social anxiety as the fear of social performance. But they eventually expanded it to include the marked distress brought on by everyday social interactions.

By the late nineties, the pharmaceutical industry was backing a public-awareness campaign that summed up the syndrome with a clever slogan – “Imagine being allergic to people.”

Gail certainly could. She likens her fears of social interaction to “hey” fever. “It's like having an off-the scale reaction to pollen. … You get that cotton mouth, sweaty palms, my ears ring, it's a really radical reaction.”

Still, most sufferers are too doubtful of their diagnosis to seek help.

“They've all suffered the stigma, thinking their disorder won't be taken seriously,” Dr. Rector says. People usually battle social anxiety for 15 to 25 years before receiving treatment. For Gail, it took more than four decades.

Last year, a few months after her milestone birthday, a psychiatrist at CAMH added her name to the waiting list of a 12-week program of cognitive behavioural therapy (CBT).

She was finally ready.

The first assignment

The Centre for Addiction and Mental Health sits on a busy corner in west Toronto, a grey concrete block built in the 1960s. Outside its entrance, loose knots of tired-looking men and women mill around in jeans and rumpled jackets, smoking cigarettes, oblivious to the steady stream of people flowing in and out.

On a May afternoon, Gail arrived in heels, perfectly coiffed, a briefcase swaying at her side. She had told everyone at the office that she had appointments that would keep her away for a couple of hours on Mondays. Telling the truth was out of the question. “Gossip fodder,” she calls it.

She rode the elevator to the sixth floor and stepped into the dim corridor that leads to group-therapy Room 618. (The hallway itself is a gauntlet for the anxious – signs posted to the doors along the way warn of “biohazardous materials,” “radiation” and “restricted access.”) Room 618, down at the end, is a tight, stuffy rectangle, with windows along two walls, a flip chart, and a board room table. Eleven patients were already there: six men, five women, aged mid-20s to 50s (names of all group members have been changed). Gail picked a seat at the far end, beside Sam, a young nurse with a shaved head and burly build that might suggest he was fearless.

It was session No. 2. Introductions had been made the previous week, confessions too, about their sweating and blushing and bouts of heavy breathing. But they said not a word to each other as they waited for Lance Hawley to reveal the agenda.

Dr. Hawley, a 34-year-old CAMH psychologist with a dry wit and a Johnny Cash ward-robe, had told them on their first day that they had taken a major step toward surmounting their fears by being there. CBT, particularly in group sessions, is the most effective treatment known for social anxiety, he had explained.

It wouldn't erase their fears, he said, but it would school them to understand, confront and overcome them. And, as with any class, there would be homework – they would be required to record and analyze their thought patterns, learn to counter them, and arrange “exposures” to the situations that make them anxious.

Eventually, they would be asked to do the unthinkable and deliberately draw negative attention to themselves – bump into a door, mispronounce words, spill a drink – in order to realize “the world doesn't end.”

“We've had people wet their armpits to make it look like they've been sweating profusely, or tuck toilet paper into their pants and walk around the office,” Dr. Hawley says.

For now, he and his assistant, Keegan Barker, a PhD student training at CAMH, began with the basics, describing their anxiety as a predictable cycle unleashed by social “triggers,” and asking the group to share theirs.

Sam said an invitation, or even the possibility of an invitation to a social event, was enough to set him off. Another man mentioned trips to the gym, where he has to face “other guys who are bigger.” For Gail, it's any “unstructured” conversation.

Her assistant recently took her to lunch, she said. “I mean that's a nice thing, right?” But the hour of small talk, she said, seemed to suck the moisture from her mouth and make her palms sweat.

Dr. Hawley explained the situations they cited “trigger” a flood of negative thoughts about their ability to cope with the interactions ahead. He described it as a chain reaction: The trigger fires up negative thoughts, which provoke physical symptoms that worsen as people become hyper-aware of their quickened breathing or pounding heartbeat.

“Do you see,” he said, “it's the thought process that kicks the anxiety into high gear?

“The physical symptoms you experience are the same feelings that arise when someone is coming at you with a knife. Adrenalin hits your body and that's what allows you to flee.”

When they can't flee, they find other ways, “safety behaviours” to limit the interaction, he said.

Betty, a middle-aged woman fond of twisting her long beads, said she eats her lunch in hiding instead of joining co-workers in the cafeteria, and copes better in winter when she can disappear into her coat. Sam simply declines invitations. Miran, a young woman with a ponytail, said she prepares lists of conversation topics for the dinners she attends with her husband's clients.

Gail relies on voice mail. When the number of a person who makes her particularly anxious pops up on her call display, she just doesn't pick up. Neither does she accept repeated invitations to give lectures on her area of expertise. She claims to have a condition that makes speaking difficult. “Well I can't say I want to stick my head in a toilet.”

Dr. Hawley said that for that week's assignment they would have to compile a list of 10 situations that trigger their fears. He told them to rank each one according to a scale known as “subjective units of distress,” or SUDs – with zero as totally relaxed and 100 as the highest level of distress ever experienced.

Up at the flip chart, marker in hand, Ms. Barker began jotting down a sample list with class input. Betty said riding the transit system at rush hour would be 70 SUDs, higher if she had to sit facing another passenger.

Tony, a beefy brunette in his mid-20s, said after-hours calls from the demanding clients at the luxury-car dealership where he works would rank at least 90. Gail gave the same score to speaking with a superior for 10 minutes.

Their first “exposures” to these sorts of situations – without fleeing or resorting to safety behaviours – would begin the following week, Dr. Hawley said. “This way you learn the consequences you fear do not come true. … The more you do it, and the longer you do it, and the frequency at which you do it, the better you will get at getting through it.

“What do you think?”

“I'm getting a headache,” Gail said.

Work-related triggers

Nine days after the session, Gail sat in an elegant cream outfit, sipping cranberry juice at Hy's Steakhouse, a lounge of dark wood and wing-backed chairs popular with the Bay Street suits. She wasn't there for happy hour. Gail had agreed to meet to share the story of her hidden, troubled life and the list of triggers she had worked on over the May long weekend.

“Just reading my list makes me anxious,” she said.

Gail hadn't set her sights on landing here, in “the towers” of Toronto's financial district. She worked in a bank after high school, then graduated from university with a degree in anthropology and linguistics. Fluent in French and Spanish, she ended up working on trade issues with a Latin American consulate in Toronto. In 1992, after the consulate relocated to Miami, an accounting firm hired her as a manager in its tax-advisory department. It was a workplace transition that pushed her anxiety to new levels.

After “working with Latinos, who did the merengue for colleagues' birthday parties and kept crates of rum in the office,” she suffered cubicle-culture shock in her new office – where priorities were set by colour-coded Post-it notes (pink means now, yellow means soon, green, whenever). There were even rules about plant height based on corporate hierarchy, she said (partners were entitled to the tallest vegetation).

“I felt really, really awful during that time, like a complete fraud, in a very demanding environment.”

She excelled all the same. In 1999, an even larger international accounting firm recruited her to a senior manage- ment position. But she still hadn't learned to manage her anxiety, and can't imagine accepting the repeated offers to become a partner.

“Being partner means networking, getting new business from clients, you have to take them to lunch, ball games, golf. I can't do that,” she says.

She told her bosses that she didn't believe her skills would be a good fit for the position and made “a vague reference to family demands.”

Besides, she said, partners are terribly stressed – she suspects an epidemic of anxiety and depression in “the towers” due to “the pressure on being able to keep up, work long hours, work weekends, attached to the BlackBerry.”

Not that anyone will admit it, she added. “No one will let anyone know about their mental health. … There's nothing to gain and a whole lot to lose.

“If you break your leg, everyone gets sympathy. But not for a broken spirit.”

Nearly all the situations Gail listed as her anxiety triggers were work-related. Several were enough to make anyone nervous – giving a presentation, leading a workshop, lunching with an argumentative managing partner.

But others were more surprising – phoning a friend “just to chat,” or playing cello within earshot of her partner, the man she has lived with for 12 years. The list ended with her ultimate goal – to attend the garden party given each summer by the president of the University of Toronto. At the moment, she said, even looking at the online pictures from last year's event made her anxious.

Difficult to say no

The third therapy session began with a handout and instructions for group members to evaluate their anxiety and signs of depression over the previous week.

Gail told the group that her irritability and agitation had increased. She blamed her workload, saying it can “get out of control.” Dr. Hawley said time management tends to be especially tricky for people with social anxiety because they find it difficult to say no.

Tony said he had managed to do exactly that in an im-promptu “exposure” when a client from the car dealership called him early on a Saturday morning.

“He said, ‘Hey, what are you doing?' and I said, ‘I'm in bed.' And he said, ‘I want you to change my battery.' ”

“And what did you say?” Dr. Hawley asked.

“I told him to fuck off,” Tony said.

The group was torn between shock and laughter.

“Maybe that was a bit too aggressive?” Dr. Hawley said.

“Yeah,” Tony agreed, “but it felt good.”

(As Dr. Hawley later explained, anger and anxiety often go together. While anxiety triggers the flight response in some, it provokes a fight response in others. Just that morning a woman from another group had ended up in a fistfight over a parking spot.)

Sam told the group that he had tried an exposure exercise the previous week. He had always had problems attending large social gatherings, but when a friend invited him to a keg party, he felt he “had to bite the bullet.”

His anxiety “was shooting through the roof” even before he arrived. He spent the two hours he stayed running from room to room, avoiding conversation.

He told the group that he had failed. The group disagreed.

“You could have gone and hid in the bathroom for two hours,” Gail said.

“Look,” Miran said, “it's a party – you went to a party!”

That week's information handout included a reading entitled “Big Fears of Small Talk.” It described why even trivial exchanges with a neighbour about the weather are key to forging social bonds.

Small talk sows the seeds of all close relationships, it said, and people with social anxiety cannot reshape their lives without it.

Ms. Barker once again passed out forms – this time asking the group to record the details of their upcoming exposures, how long they lasted, how they coped and their anxiety levels before, during and after.

Dr. Hawley suggested they complete five before the next session. “To get over your fear of heights, you can't just go up the CN Tower once,” he said. “You need to go up many times.”

To help them along, he ended the session by introducing the concept of “mindfulness,” a form of meditation. Everybody had to their close eyes and focus solely on the rhythm of their own breathing. They had to think about being “in the moment,” he said, instead of holding on to negative thoughts about themselves or what others might be thinking.

In his office later, Dr. Hawley explained that all the interventions are crafted to tear down the negative self-images built up over decades.

“Often they were bullied, or treated badly in childhood, they have a background that suggests it's wrong for you to stand out,” he said. “But they have become hyper-vigilant at observing others, watching, rehearsing, reading and finding ways to confirm their negative self-image.

“It's a very designed life.”

Roots in childhood

Anxiety disorders begin in childhood, studies show, hitting 50 per cent of sufferers before the age of 10 and 90 per cent before 20. It tends to run in families and scientists have found genes involved in the production of stress hormones may play a role.

Gail has little doubt about the roots of her disorder.

She grew up with her two younger brothers in a farming community in Southwestern Ontario. Her father was a pharmacist and her mother a homemaker. Her parents drove the kids to and from a distant school, leaving no opportunity to socialize with friends after class. They also lived quiet lives, she said.

“My brother recently said, ‘You know, I do not remember one person setting foot in that house who wasn't a grandparent or an uncle.' ” Gail used to tell her mother about the loneliness she felt and the teasing she faced, but her mother had grown up in the Depression, so poor her siblings had to be parcelled out to relatives. She showed little sympathy.

“I would say, so-and-so called me names, and pulled my hair … and she would say, ‘Oh, but her mother is such a nice person.' ” It's her mother's dismissive tone that “the editor” hurls at her most often. “My mother would say I had a childhood of luxury ... yet I felt like a reject on every social measure.”

Concerned by her lack of friends, a school guidance counsellor sent Gail to see a psychologist when she was 7. The psychologist, she said, told her she had to remember how her actions affect others. She thought she had done something terribly wrong. “It was a very unhappy time.”

By the age of 13, she had embarked on her “designed life.” Determined to be more like the popular kids, she got a $1.19-an-hour warehouse job with Canadian Tire to buy clothes. More often, she bought food, inviting school kids to McDonald's and always picking up the tab. “I bought friends and from that point on, I always had a job.

“For me, the overriding concern became getting people to like me.”

But the social discomfort never left, she said. “You become very good at reading other people and knowing how to emulate them and be accepted by them.

“There's a real price … because you are not true to yourself.”

In her late 20s, after devouring shelves of self-help books (“I have always gravitated to the agony section”), she diagnosed herself with social anxiety. She also learned then that she had likely suffered depression since she was 8 or 9. She recalled dark episodes that lasted more than two weeks at a time. “It's just like a heaviness, like all the sadness in the world comes and parks on your body … like having earplugs in your ears, or trying to see through a dirty window.”

Rewiring the brain

Evidence is mounting that anxiety disorders, like all mental illnesses, are diseases of the brain.

In new brain-imaging studies, Glenda MacQueen, associate professor of psychiatry at McMaster University in Hamilton and head of its mood-disorders program, has found that people with general and social anxiety who have never received drug or cognitive therapy have a smaller hippocampus compared with healthy control subjects.

The hippocampus, the seahorse-shaped structure best known for its role in memory, is also heavily involved in mood and controlling the body's response to stress. It speaks directly to the amygdala, the tiny brain region that triggers basic emotions such as fear, desire, anger and anxiety. But generally, Dr. MacQueen says, having been neglected in past decades as “neuroses,” anxiety disorders and their biological basis have been “quite poorly understood.”

Researchers, however, are finding that CBT seems to be the best way to treat social anxiety. Studies have found that cognitive therapy can alter a brain's physical structure. Some researchers suspect that by changing old thought patterns, CBT forces the brain to forge new pathways, firing and wiring different networks of neurons.

Dr. Hawley points out that while drugs may offer immediate relief, patients have a high rate of relapse if they rely on medication alone because they have not learned any new skills to cope.

“There is a bit of a danger that people can be overmedicated with anxiety,” he says. “And with CBT, we need to be able to feel anxiety, and to be aware of it and the reactions that cause it, to counter them.”

There's no question that CBT is in high demand: Gail waited six months for therapy.

Unlike the queues for cardiac care or cataracts, the waiting list for mental-health services is “the great untalked-about health issue,” she says.

With mental illness, without a private health plan, or a family doctor who will refer you to a psychiatrist covered by the Ontario Health Insurance Plan, she said, “the cost is prohibitive – $300 to $400 an hour is the going rate.”

To enter the CBT program at CAMH, Gail also had to pass a screening process to confirm the diagnosis.

Those assessments are in part to make sure people “can take responsibility for their care,” Dr. Rector says, “Can they come in weekly? ... Do their homework?”

Focus on the positive

Session 4 begins with complaints that five exposures is too much homework for one week. Who could be that social?

But they have made progress all the same. Miran has chatted with five coffee-shop and drugstore cashiers.

Sam has been alone for 15 minutes with a driver taking him to the shop where his car had been repaired and dared to make conversation.

“But he didn't engage, he just grunted, and said, ‘Yeah, yeah.'” His anxiety peaked toward panic as he assumed the driver was thinking, “Why is he even talking, saying all this stupid stuff?” But Sam talked himself down, tried “mindfulness” and focused on his breathing. “I got there smiling and that's never happened to me before.”

Gail also has successes to report. She has let fewer phone calls track through to voice mail and even forced herself to speak directly with a “dry as dust” colleague who tends to make her anxiety soar. She has also taken her administrative assistant for coffee. “In the beginning, I thought, she's going to think, ‘She's up to something, she's going to fire me.'… But we had a pleasant 20 minutes.” Back in the office, however, her anxiety “shot up.” Dr. Hawley asks if the assistant had said anything to her.

“Well, yes, she thanked me.”

Dr. Hawley raises his eyebrows: “Well that's pretty good, isn't it?” The goal, he tells the group, is to focus on positive feedback and realize that anxiety causes “cognitive distortions” – the falsehoods you tell yourself in its grip and the mistake of “thinking you know what the other person is thinking.”

Dr. Hawley notes that Sam's driver, for example, might have been distracted by things that had nothing at all to do with him.

Gail understands. How often had she mistaken silence for someone's disapproval – even with her partner, after all these years.

“We all have two lawyers,” Dr. Hawley tells them. “A prosecutor that says, ‘You suck and you're boring,' and then the defence, that says, ‘He's distracted by something else that has nothing to do with you.' ” They have to learn how to become their own advocates, Dr. Hawley says, to make the case that they are not being judged as negatively as their internal prosecutors would have them believe. As they continue their exposures, that will be next week's homework, he says, gathering evidence for their defence.

Determined to push on

Over the next six weeks, the group will step up their exposures to the high-anxiety triggers on their lists. They will learn to prevent relapses and meet again a month after the program ends. Dr. Hawley expects many of them will graduate to a life they might never have imagined.

“The research suggests that 75 per cent will report a clinically significant drop in their symptoms.”

“This works for me,” Gail says. “It's logical, it's structured. I just have to remember to slow down and remember what I've learned.”

She knows that it will never completely cure the anxiety that has haunted her for most of her life – she says the exposure-homework “feels like they're asking me to leap tall building in a single bound.”

But she is determined to push on. “I'd rather not have the editor on my shoulder, or the cotton mouth, or turn white,” she says. “I don't want the physical anxiety or the fear, the fear of what other people are thinking and the negative editorializing.”

She turns her head to the imaginary editor perched on her shoulder. “I give you the day off!

“Ah” – she catches herself – “am I making sense?”

Update: Follow up with Gail Andrews

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