Social Anxiety & the Loneliness Epidemic

Preston: [00:00:00] So Margaret Welcome to the podcast. Welcome 

Margaret: you first. 

Preston: Wait, you're usually here, aren't you? 

Margaret: Well, in a sense. Do 

Preston: we even have a guest today? 

Margaret: Well, I'm not introducing this object. He's Mr. Dragon. 

Preston: And he's a character. This is 

Margaret: a problem. 

Preston: I hate it so much. He doesn't have any problems, except he gets a little nervous around people.

Hey, I'm Mr. Dragon. Is that your friend Margaret? Yes, it is Margaret. What if she doesn't like me? Um, Margaret's pretty nice. Usually. Hey, Margaret, do you want to introduce yourself to Mr. Dragon? 

Margaret: I refuse I refuse to compromise with you on this I do want to know have you picked that up since that last video you made with it?

Preston: No 

Margaret: Because that I think was your greatest hit. I'll 

Preston: drop the bit there were um, I think 

Margaret: that was your greatest video 

Preston: in the writer's room, there are a few discrepancies [00:01:00] about how we should approach teaching social anxiety and You know, the Muppet thing was kind of brute force, but I still wanted to give it a shot.

Margaret: It's plastic. Does it count as a Muppet if it's plastic? 

Preston: It's a hand puppet. 

Margaret: Why do you have it? Is my question. 

Preston: Because I saw it and I had to have it. 

Margaret: You're like, I needed Did you ever see the movie Big Daddy with, uh Uh, the like Sprouse twins was the little boy and Adam Sandler was like, but they had, they had to go to court and the little kid was super shy.

And so he got him these like sunglasses and he's like, no one can see you when you have these sunglasses on. That's you with that little plastic weird dress 

Preston: pretty much I'm, I'm invincible when I have it. 

Margaret: So Preston, what's today's episode about? Cause I didn't read anything. 

Preston: We're talking about social anxiety disorder and the male loneliness epidemic.

Margaret: The loneliness epidemic. You're like, that's what I said. 

Preston: Yes. 

Margaret: Yes, we are. 

Preston: And I think this is something that gets a lot of attention in pop psych and [00:02:00] everyone, I think I've seen a lot of people feel really empowered to comment on loneliness, but it's more complicated than that. And then it's tough because this kind of falls like many things into the spectrum of normal human behavior.

And there's a difference between having worry or nerves about meeting someone and then becoming totally disordered by how much you hate social interaction. 

Margaret: Right, right. Like when we first started. Making this podcast. I felt like it was very normal for you to be afraid of messing up when when you met me 

Preston: No, you're like I wasn't like worried at all how you felt, Toby, when I was like looking at my phone while you're like telling me something on a podcast, you think you think I would give you like my undivided attention, but like, honestly, I don't even care anymore.

Like, 

Margaret: okay, I have the 30 minutes before this though recorded. So I wouldn't, I wouldn't go say all 

Preston: that. That's true. Um, I, I remember, um, when we first met, I was always like trying to say the right thing. 

Margaret: I 

Preston: didn't want you to like, Be disappointed in [00:03:00] me because I was like, oh, you have this idea of who I am.

Margaret: Oh, yeah. Cause I followed you. I was your follower first. Yeah, 

Preston: exactly. I was like, this is my, 

Margaret: my God and my King. It's 

Preston: like very careful about using my words. I didn't know that. 

Margaret: It's interesting because to me it was like, I would have thought it would be the opposite where you're like, I'm, I'm the big man on campus, the virtual campus.

I'm, I'm that guy. I'm over here talking about Strega Nona and Taylor Swift to like 30, 000 people 

Preston: in your life. You want to talk about like, this might be a little bit of anxiety. Um, I don't know how pathologic this is, but I overanalyze interactions with fans so much. Like, I'll be waiting for an elevator and someone comes up to me.

They're like, Hey, you're Prezzo, right? I'm like, yeah. And they're like, dude, I'm a PA student. I love your stuff. You know, like, where are you going? Like, I'm going on my rotation. I'm like, Oh yeah, um, just hanging out. Like, I'll see you later. And then I'm like in the, in the interview, I'm like, stupid, stupid.

I'm like, you didn't ask him about himself, you know, nearly funny enough. I think you're like an aloof douchebag and all this stuff. And like, I'm just, I like want [00:04:00] them to feel like I come across genuine and then I thought I'm like, you know, it's funny. Like you think you get all this confidence from like having fame and notoriety, but it's just.

The monster just finds new, new things to sink its teeth into, you know, now I have new, you're about to just lift over the puppet 

Margaret: again. , you like the monster, , freaking monster because you're holding though. Um, yeah, no, it's interesting and I feel like. Social media plays such an interesting part in this question of loneliness, but talking today about loneliness and social anxiety disorder, because, like you're saying, this kind of connection of how easy is it for people to meet new people to interact with others to be seen or noticed, or, you know, the kind of sensitivity to embarrassment.

And I think it's something that gets talked about a lot online because of being, you know, um, Because of the pandemic and how that obviously all had to isolate and then it felt weird to come out of isolation. And then obviously like the loneliness part, we'll talk a little bit about more later, [00:05:00] but I liked the question that you came up for the icebreaker, 

Preston: which was, I liked it at first, but I don't like it.

What's, what's something so embarrassing that you still, that you did socially, you still think about today? 

Margaret: Um, yeah. Do you want me to go first? Cause I can, 

Preston: can you go first? Don't help me. So 

Margaret: this is going to speak to my like pathologic, like Catholic guilt of it all. Um, but. I remember there was this thing.

I was in third grade. We had these little like wooden chairs. We all sat in and we would move them during like there was a part of like English class every month where we would like put on a little play for like a week and we would move our chairs and do discussions. And I remember there was There was this thing in my third grade class that was like funny for a couple weeks of like trying to like pull out your friend's chairs when they try to sit on them and then they fall back and you all get a laugh and I tried to do it to one of my friends and I did it and she like hit her head.

She was fine. But I remember she and then she started [00:06:00] crying and I I don't know. I was like, felt so bad for her, but I also like, I think I started like a bad person. I still, I still get freaked out thinking about it. Prank gone 

Preston: wrong. 

Margaret: It could have gotten, well, it did go wrong and I was like, also, I was like, why are you so mean?

Like, what's wrong with you? Why did you do that? Like, what evil is in you? 

Preston: All the ways that like, Margaret abused herself is just like, this kind, supportive person. They're like, the opposite of that. 

Margaret: It's not true. 

Preston: You're everything you don't think you are. 

Margaret: This is what I knew about you. It's been true since the third grade.

So that's mine. And I still think about, I don't think anyone, I don't know the kinds of social anxiety as much as just like heinous guilt. 

Preston: Public shame. Yeah, 

Margaret: public shame and guilt. But yeah, this like, I don't know. I mean, that's 

Preston: what a lot of social anxiety is, right? Perceived disgust of others. 

Margaret: Yes. 

Preston: So it sounds like that's what you got.

Also 

Margaret: of God. That was a fun part of it. 

Preston: Yeah. God's always in the world. 

Margaret: Okay. Tell me yours that [00:07:00] you do not want to say. 

Preston: So I tell 

Margaret: our listeners, 

Preston: I was a sophomore in college and, um, I went to a military 

Margaret: 2021. 

Preston: Yeah. Um, I was in a military academy. So it was actually 2020. Oh no, no, that was med school. Uh, 2018.

Margaret: Um, 

Preston: yeah, so I was at military academy, which I mean to say it was like, I was thinking a little bit romantically stunted. Um, the ratio was like 75 percent dudes and 25 percent girls 

Margaret: college parties. 

Preston: Yeah, Air Force Academy did not party a lot. Um, 

Margaret: tracks 

Preston: and then like we were consistently ranked, um, like top 10 most attractive guys schools in the country.

So like of this, like small pool of girls, like I'm competing against like. Some of the hottest dudes I've ever seen, like, yeah, just like straight up specimens. These guys, they got their mustaches are better than mine. They're also like, do you want football players? They're going to be a fighter pilot. And then they're like engineers.

I'm just like, nice. [00:08:00] 

Margaret: And yet you've never introduced me to one of them. What's that? We'll come back to that. 

Preston: You know, that's, that's for the Patreon. That's 

Margaret: for the Patreon. So you're in school. We'll do 

Preston: speeding with Margaret and all my pilot friends. Action, style in action, problematic. , my avoidance confused, which we'll get into later.

Uh, so I'm sure we have 

Margaret: the same views. . 

Preston: Yeah. So, so the reason why I'm bringing all this up is that I like, kind of felt awkward about approaching girls. Mm-hmm . I like if you ever texted a girl, you kind of had to accept that she was probably talking to like six or seven other dudes. So I was like, honestly, I'm just gonna make it up as I go.

So like, we go out to Denver one night, we're like dancing in the, in like the clubs. We're like a group of dudes like all in our circle and there's like a group of girls over there and like one of them kind of like gives me the eyes, you know, like you're moving around the club and she kind of looks at you and then looks away and then looks back at you and then looks away and I was kind of like, oh, why she keep looking at me like, like, there's something on my face.

Like, did you have a staring problem? No, I wasn't that bad. But her [00:09:00] friend comes up and goes like, Well, you're gonna make a move or you're gonna like keep standing there all night and I was like, I was like, oh, like, nevermind. Like this is served to me on a platter. So my move was like, I saw this happen with like my friends who he kind of had like, he was like a funny guy who had these like platonic relationships with girls and he would like.

Instead of the girl twerking on him, he would like twerk on the girl and they'd be like, Oh, it's like, so it's like, it's sarcastic and flipped. It's funny. Like this guy's obviously like comfortable with his sexuality and stuff. And I was like, I think I'm going to twerk on her.

I started backing it up on her and then And then she started screaming and then all of her friends started screaming and then they just ran off And

I was just like 

Margaret: you said evacuate the dance floor [00:10:00] 

Preston: My friends were like it was like it was like yeah, but 

Margaret: how bad was it that you scared? 

Preston: I don't know. I like I think I'm you guys have really 

Margaret: been backing it up like no I have good hip 

Preston: mobility like I can I can isolate left cheek, right cheek. I can go back and forth if I need to.

So I don't think it was a skill issue. I just think it was like an appropriate context, I guess. I don't know. But anyways, like they, if they say the worst she can say is no, that's, that's incorrect. She can start screaming. All of her friends can start screaming. They can run out of the club. I, I still think about that.

Like, like, oh, when I think about that, you know, that's like probably social anxiety, like my worst social nightmare. 

Margaret: So when, sometime when we're in the same city, I'm going to be like, let's go out and we're going to do exposure therapy. I hate 

Preston: going to clubs. I only associate with negative experiences now.

Margaret: Wait, really? 

Preston: Yeah, like I genuinely dislike going to clubs. 

Margaret: Like, is this like all club, like all bar [00:11:00] dancing experience? No, 

Preston: I like, I have fun like dancing with my friends if it's like a big group or like kind of like a chill vibe. Club clubs, you know, like bottle service, dark rooms, strobe lights, something like that.

Margaret: That's fair. That's fair. It's very high sensory. Yeah. So what we got from our stories is I'm a bad person and Preston has committed a crime.

Hey, if 

Preston: serving on the dance floor is a crime, then lock me up. 

Margaret: That's true. They just weren't ready for it yet. Maybe you were too good at it and they were like, how did a professional get in here? 

Preston: Yeah. 

Margaret: Something to consider. Okay. Well. 

Preston: So. Margaret, Margaret, what is social anxiety? And who even cares about that stuff?

Like, why would I even care about social anxiety? Like, it clearly doesn't affect me. 

Margaret: Yes. Let's talk a little bit, I guess, about why this for this episode. Um, one thing, I mean, this is we obviously we film and prepare episodes earlier, but there was a trend on social media that Was something [00:12:00] like the rejection like challenge where people were going up to people and like being like I'm trying to get rejected a hundred times in whatever amount of days and then there was also like the stuff of, um, I'm going to say his name wrong, which is going to get Gen Z to flame me, but Timothee Chalamet, is that right?

I think you 

Preston: said it right. It's 

Margaret: like Timotee, technically, but whatever. Um, I feel like they would flame me more for saying it that way. Where it was like all of his things that have been on the internet. Have you seen this? Like the videos of him from like high school and college, it was like, 

Preston: he's like dancing and drag.

Margaret: Yeah, it was like, I know social anxiety hates to see him coming. Um, but I feel like it's also something like all of us experience anxiety. All of us experience social anxiety in some settings. And so I think it just, like, leads to an interesting conversation, especially as we talk about, like, the loneliness epidemic, as we talk about, like, how do people feel connected to each other in their communities, um, and, of course, the male loneliness.

Um, articles we've seen lately. So, 

Preston: like, why do people [00:13:00] distinguish, like, male loneliness from other types of loneliness? 

Margaret: Hmm. 

Preston: Like, why, like, why did males get this special brand of loneliness? 

Margaret: Guy. It's guy stuff. Um, dude's being bros. You know how it is. Um. I actually don't know. What do you think? 

Preston: Uh, yeah, so it's fascinating to me.

There's some surveys I've studied. I can't cite the statistics well, but Statistics. I think men are just less likely to have extensive friends once they enter their mid twenties. If you were to survey someone who spends a lot more time alone, um, a lot of like blue collar men will, they'd like literally go to work, come home, stay by themselves, go to work again the next day.

And that's just kind of it. They don't have a lot of like social outlets or, or gathering groups, like a third spaces they hang out with. So I think that like men are maybe more stoic about it. So that's why it's like gotten this own, like special type of brand. [00:14:00] 

Margaret: Yeah, I feel like from the like feminist perspective.

There's also and like not just feminist perspective as More women are thinking about like the 4b movement, which is I'm not gonna go into right now but like as it becomes both more okay, and also the discourse kind of and discord between men and women is present Politically right now, I think there's sort of less relationships to some extent and.

What happens when women are taking a step back for men and like, what role do women play in men's life, which is often a more emotional one than they're like male friendships, right? And so, like, I think, like, this gets into what they talk about in the loneliness, um, the 2023 document from the surgeon general that defined loneliness more as like a lack of kind of meaningful and regular connection.[00:15:00] 

Versus like solitude and that like different people obviously we know can have like different levels of connection that feels good and connected to them So they had he had defined in that document, which is like an 80 page thing for 2023 of loneliness as a subjective distressing Experience that results from perceived isolation or inadequate meaningful connections 

Preston: So it's not like fetishizing your solitude.

It's like a desire for connection and then 

Margaret: Not to be found that 

Preston: regularly. 

Margaret: Yeah. Yeah. Because solitude is like, and I think the poets actually talk about this a little bit better. Like this idea of, I think of like going on a wall. It's right now it's winter and it's very contemplative 

Preston: experience. 

Margaret: Yeah, it can be very beautiful, right?

And it can be connective, but That's different than this kind of overall lack of needs of connection and belonging being met 

Preston: like a despondent isolation. 

Margaret: Yes. Yeah. Yeah. Um, I wonder what you think [00:16:00] about like the connection between rising loneliness and if you think there might be a connection between that and.

We don't, I don't think we have studies on this yet in terms of data, but like higher levels of social anxiety. Cause I feel like that's talked about online a lot is like, especially over the last couple of years, people talking about like feeling like they almost don't have their social graces muscles as strong as they were before the pandemic.

Preston: Yeah. I think that based on everything I know about the brain, it makes a lot of sense to me. Um, I think most parts of our brain are in a lot of ways, user lose. I guess I would say Um, like the same way muscle groups are like if, if an astronaut goes to space where they're not walking against gravity every day, their muscles and bones atrophy.

And if you're not in a position where you're always just kind of recognizing social cues and social signals, even around like the water cooler or in the sidewalk or things like that, and you're just kind of, it's just you in a zoom call for hours at a time. It's [00:17:00] my hypothesis is almost like those parts of your brain that are attuned to like recognizing, responding to people's social cues.

Just kind of almost like atrophy, like, like they're out of the game a little bit and it takes a little bit to, like, recalibrate that. 

Margaret: Yeah. Yeah. No, I, I tend to, I, I feel like I share the same kind of theory, um, of it. It reminds me of, like, even thinking about, like, in medical school, like, When you would go from like a surgery rotation to like a clinical, like an internal medicine or a psych or one that had like an outpatient component where there was like, you didn't have to be at the hospital, you weren't standing as much like some of that is physical, some of it is like mental that it was like, oh, wow, this feels like a relief, whereas if you went from a similar specialty hours wise to the next one, it was like, oh, this is, yeah, but like the, Having so much reduced like more isolation, leading to like less exposure to the kind of friction of day to day life with [00:18:00] people, um, leads to that, that anxiety being higher, which we think about in social anxiety.

So, like, when we think about social anxiety disorder, um. I want to give you a few examples and ask you from your kind of thoughts and what you know about psychiatry and also as a human being, how you think this looks 

Preston: like a game show. This is a game show. 

Margaret: What was your favorite game show as a kid?

Preston: Jeopardy. 

Margaret: Jeopardy. Okay. I can't relate when I was prices, right? Also fear factor, which we won't get into. That was such a betrayal to me when I realized I was like, where did you go? I loved fear factor. 

Preston: Yeah, my. We watch Fear Factor, so my mom would make me watch Survivor and, um, Desperate Housewives, mostly.

Margaret: This explains so much about us, because I also watch Desperate Housewives at a young age. 

Preston: Okay, well, contestant number one is ready. Okay, contestant 

Margaret: number one, so we're gonna play, is, would you be concerned for a social anxiety disorder? Or you think it's normal or good or something [00:19:00] else. That's not a very catchy name.

I'm still workshopping that. 

Preston: Okay. 

Margaret: Um, okay. 

Preston: Welcome to do you think it's a social anxiety disorder? Or is it normal? Like, 

Margaret: today 

Preston: we have Preston. 

Margaret: Okay. Are you ready for scenario? Hey, 

Preston: Margaret. Happy to be here. 

Margaret: Hey, where are you from? Sorry. 

Preston: I'm from podcast land. Okay, let's go. 

Margaret: A contact. Um, you're actually AI. I don't know if the, the viewers know that, but okay, so you're walking alone through the woods.

You're, you know, you yourself, maybe you bring one of your cats along, you're walking along and you see a group of eighth graders, uh, also in the woods going on a hike. You walk by and they start pointing and laughing at you. And, but then it seems like they point and laugh at something else too that's similar and you hear them keep, they keep laughing and they walk past you and then it's a mile later [00:20:00] and you're thinking about it and you're wondering who's about it, but an hour later, you're back home making lunch and aren't really thinking about it all now, what would you make of that anxiety response to that situation?

Preston: So I, I would probably understand having this initial feeling of shame as someone points and laughs at me, but then as I'm able to kind of apply my social context cues, I wonder if they're eighth graders who laugh and make fun of everything and that I'm laughing at me probably isn't a reflection of anything I've done wrong, but rather their disposition towards the world 12 year olds.

So I would say This is a normal level of worry and not a reflection of pathology. 

Margaret: Yes. And the fact that an hour later you kind of moved on. Yeah. 

Preston: Uh, and then it didn't linger, 

Margaret: didn't linger, didn't make you change or do something different. Yes. Okay. I'm going to give you a second example. Are you ready?

Preston: Yep. 

Margaret: Okay, you [00:21:00] are at a party or club. Sorry, I didn't know your story, but you're at a party. Um, you are at a party, you just got there, and you were brought by your friend, who knows a bunch of people there. You don't know anyone besides one person who you did a rotation with at one point, um, in neurology.

You guys aren't that close, and so you don't go up to talk to them. Later, you're getting some snacks, you're getting a drink, and they're also there. They say, oh hey, how are you doing? But don't say your name. You talk for a couple minutes, and then they walk away, and you see them walk over and start looking at their phone.

For the rest of the party, You don't really connect with other people, and the next time your friend invites you to go to this, a similar group of people's party, you say no, and you think about that person. 

Preston: Does, does like the thought of having to have that intera like, what are my thoughts about that [00:22:00] interaction?

Do they still linger with me, even outside of the invitation to the party? 

Margaret: They linger, and you, they make you also not go to the next one. 

Preston: Because you're worried you're going to see that person. Yeah, do I, do I anticipate any, any judgments they might have about me? 

Margaret: Yeah, you think that they think you're very odd and also that you're a waste of time to talk to.

Preston: Yeah. So I would say we're now starting to enter the spectrum of social anxiety. And part of that is because we can see, first of all, disorder. So if I wanted to go to the party and I'm not going to the party, there's now an incongruence between my desires and my actions. So we are now seeing evidence of disorder caused from these social perceptions.

And then now kind of looking at that anxiety portion, Oh, I have seen a bunch of vague things. Social cues that could be due to anything. Maybe they're going over and checking their phone because their mom is in the [00:23:00] hospital and they're sick, or maybe there's kind of out of it that day, there are a million reasons why this person could be acting detached or vague around me.

And if I'm coming to the conclusion that they must think I'm odd or weird and they dislike me and I'm having trouble engaging with other like possible explanations. And my, my rigid hypothetical beliefs are now leading me to disrupt my social calendar. That's evidence of social anxiety. 

Margaret: Yeah, so the avoidance part of it, the perseverance of it and yeah, function change.

Okay, last, last 

Preston: one. Yeah, this is easy. I'm just really smart.

Margaret: Uh, the last one. Yes, I'm gonna I'm going to it. Those are those are both tests for effort. This is an actual Okay situation you are back in medical school you are studying in the library It is very quiet. Your friend comes up sits down with you and starts quietly [00:24:00] studying This is not unusual for the two of you later You get up and you go and have a little lunch break together and are talking And he tells you how he's been kind of struggling lately.

He's been pretty anxious. He's been feeling like he's not connecting with people. He's not sleeping as much. He also tells you that he feels like, quote, people are out to get him. When you ask what he means by that, he says he just feels like people have been acting weird or that they don't like him. When you push a little further after reassuring him of your friendship, he states that he feels like people are tampering with his tests and medical school 

Preston: is a social anxiety or what is this?

What would you ask? So when he starts talking about people tampering with him, I would start. So immediately ask about what he's seeing, like, Hey, what are signs of this tampering is happening? I'm just curious. So I don't know if you have that right ready or what are some examples he might have. 

Margaret: He says [00:25:00] that he feels like he saw, 

Preston: um, he 

Margaret: knows 

Preston: he saw.

Margaret: He feels like he, he know, he says he knows that he saw some strange, that the lighting was different in the lecture room that day. And that that was a sign that people, some people, someone kind of was messing with the 

Preston: electricity and that's probably why his scores have been worse. Yeah. Because they're, they're in the network.

Okay. So distinguishing this, um, from anxiety can be kind of challenging. And I think that, um, this is more consistent with something we call paranoia. And I won't think we'll dive into a lot of psychotic paranoia today, but an important difference is that this person is describing responses to stimuli and conclusions that they're making about it in the moment.

Like the lights are flickering, therefore someone's onto me. [00:26:00] And that other. Social situation is, um, worrying about like anticipated or like hypothetical scenarios. Like what if they don't like me and then seeing if you can reinforce that belief, 

Margaret: right? 

Preston: So while both of them may be vulnerable to confirmation bias, like I think people are tampering with my tests, therefore I'm going to interpret every kind of like weird electronic signal to be that versus I'm worried that people think I'm odd.

So I'm going to like, like no one says negative social. Yeah. Or like this person 

Margaret: used to sit there and now they don't and it's because I'm there. 

Preston: Response is the, the difference is like almost this bizarre interpretation of reality. The reality 

Margaret: testing being kind of different than maybe what most people would say.

Great. 

Preston: And then a lot of it is the, yeah, making connections between things that don't. 

Margaret: Yeah. Yeah. Like 

Preston: you would normally correlate that together. 

Margaret: that stops people who have paranoia [00:27:00] or who have illnesses that usually have the symptom of paranoia, like a lot of those people have comorbid anxiety as well.

And like, that's not uncommon. And so things never present as, as we say, patients don't read the textbook, uh, or don't read the DSM. 

Preston: And 

Margaret: so these things like drawing them out can be, can be difficult, like you were saying. Yeah. Yeah. Yeah. 

Preston: Yeah. And like functionally what they're both feeling is hyperactivity of their sympathetic nervous system.

So the feeling of fear that both the paranoid patient, the social anxiety patient feel is likely different to distinguish between them. The actual like visceral sensation itself, the intensity of it, the frequency is mean would be much different, 

Margaret: right? Yeah. So I guess what I just a little bit in general.

So we have a baseline to talk about a social anxiety of what the DSM calls it. So in the DSM five, which by the way, do you know when the DSM five came out? 

Preston: It's like 2012, right? 

Margaret: 2013. Yeah. So, and then [00:28:00] the, do you know, do you know anything about the history of the DSM besides just like general psych stuff?

This is where I shout out wash you. Uh, But I was, I was reading in a 2010 paper on the kind of like working group and evolution of how they define and kind of delineate social anxiety as an entity and the going from the DSM four to the DSM five. Um, and so I shouted out WashU because they were very involved with how the DSM three came into being.

One of those differences compared to the before, which I think is a relevant difference just in terms of how people refer to social anxiety, both clinically and then like pop culturally is the idea of like a social phobia versus like social anxiety disorder. Um, why do you think so? There's a change at one point.

It was called social phobia and the prior DSM, um, as in DSM three, not DSM four. What are your thoughts on why they might change it from like a phobia like social phobia to [00:29:00] social anxiety disorder 

Preston: super interesting? Um, let me see if I can articulate this. I I'm when I think about a phobia. I'm like focusing on like a singular object or scenario where someone just Repeatedly experiences fear so like arachnophobia.

For example, is this like disordered fear of spiders?

My fear of spiders is not based off of like hypothetical or maybe wrongful misinterpretations of spiders movements. It's just a almost unconditional response to spiders, period. So like social phobia would be like just fear of being around people, I guess, in that scenario. But like social anxiety isn't being afraid of people, it's being always worried about the judgments that people are making of you.

Margaret: Right. So I think that's like the 

Preston: direction, 

Margaret: I think they, so they wrote about this in the paper, like. The [00:30:00] phobias generally and elsewhere in the DSM are just, are more of this, like very tightly circumscribed, like fear of something specific, right? Like spiders. Um, whereas social anxiety tends to be more expansive than that, but this gets into the second point I was going to make that they also talk about in this paper, which is like, should there be specifiers?

Like, so how there's specifiers for, um, different illnesses, 

Preston: anxiety disorder, club type. Well, 

Margaret: there's like, should there be such a thing as generalized social anxiety disorder versus like, should like, you know, subsets of things like the type of relationship in 

Preston: the big bang theory, that guy, you can't talk to women, right?

Yeah. Yes. Like social anxiety disorder, opposite gender type. 

Margaret: Yeah, and so they came to the conclusion based on a number of things that I will not, I will not go bore you with right now, but at that point, it's, there is no generalized social anxiety disorder in the DSM 5, um, but so the conclusion was basically that, like, from a [00:31:00] clinical perspective and from a population based level, it didn't seem like it differentiated so much in terms of Pathology and function when it comes to like anxiety and social settings as like different subtypes.

1. E. It wasn't like this type of behavior or thing, but they were avoiding all of this was more similar in group compared to this as much as it clustered by severity, like how much and that it kind of they end up saying it as like a spectrum. And so I sort of think of it as like someone with social anxiety where they're only nervous They're only nervous, like in settings where they're meeting brand new people at like a certain type of environment, say the club, um, which can be disruptive to their life compared to people who are anxious and meeting anyone new and seeing people they already know at work, at home.

Preston: So it's on the same spectrum, but just at a different level of severity. 

Margaret: Yes. Um, the one, can you think of one that there may be [00:32:00] something of a different differentiator that was significant? Public 

Preston: speaking? 

Margaret: Yeah. So like performance anxiety. Mhm. Responsive, which changes how we treat things, right? Like if someone what do you think of that clinically is like a difference?

Like if I said this person has has full social anxiety disorder versus They have like public speaking, social anxiety or a phobia of like public speaking. 

Preston: Yeah, I think like public speaking falls more under the umbrella of like a social phobia because it's, it's a reproducible specific scenario where all eyes are on you and you're expected to do something and almost like agoraphobia where like you're just afraid of being in the marketplace functionally.

So. I think that, like, the way that's organized in the patient's mind is much different. 

Margaret: Yeah. One of the things I looked at was, like, that that might fall somewhere, like you're saying, between a phobia and a generalized thing. Because you can imagine someone who you think of as [00:33:00] having performance anxiety.

With speaking in front of like a group at work, let's say, but they worry about it constantly. They never stop worrying about it, even when it's not really coming up on their schedule. They wonder about it after about how people like interacted with them after their speech. And so, right, it expands and that I think would become more of this broader social anxiety disorder.

But it's what's common. I feel like a lot of people have is more that there's almost like there's no extinction of the fear. It's like not common enough. And so it's like they give a speech at work once every or twice every year and they have a lot of anxiety like the day before it. And then after it, they're glad to be done.

But that's kind of it 

Preston: like 6 months before or like you're yeah. You're reorganizing your entire like career trajectory over the potential of ever public speaking again, right? Yeah, and so you can see how much more severe it is 

Margaret: and what would you treat someone with just that like a patient who comes in is like I have this presentation coming at work and I always feel like I get sweaty and Anxious the day [00:34:00] before before I would 

Preston: say for panel would probably a good choice for them Oh, yeah, as long as it have asthma and yeah, the reason being is that it's Um, a good way to suppress release of, um, norepinephrine.

We actually have a lot of autonomic receptors that hang around in our temporal lobes that are amygdala. Um, but once they're activated, they bind to everything. So after you're already anxious, propanolol won't do much. It's a good, it's a good lock on the door, but it's not good at shutting the door or corralling everything back in.

In other scenarios, you may give something like a benzodiazepine, but if you want someone to be lucid and, uh, cogent for their presentation, I don't think a benzo would be a great choice because it would be sedating, which 

Margaret: not, not always the best vibe for a presentation. 

Preston: I mean, yeah, just trying to be chill.

So maybe on a plane or something, if all you have to do is sleep. 

Margaret: Yes. Yeah. And cause that, yeah, you're right. Like in terms of like more singular phobias. [00:35:00] And a couple other things I just want to say about social anxiety, general, um, is this kind of like, What people, oh, I'm moving to the side. Sorry. Uh, people think about as like kind of three baskets of symptoms that we think about with social anxiety because it's not just like, I'm nervous to go see my friends.

Um, but it's how they define it. Like in the paper in the DSM is this like marked fear anxiety about one or more social situations. In which it's possible to have one scrutiny by others. Um, so nervousness around social interactions, being observed or performing in front of others, or the kind of three buckets they give.

Um, and so I feel like one of the ones I didn't think about in reviewing this is like the being observed, um, which I did jokingly say when we started this podcast that this is my exposure therapy and I was like, no, hold on, [00:36:00] um, but yeah, so social interactions under scrutiny being observed or performing in front of others.

So that like sense of judgment, I wonder what you think. Social media adds to the sense of judgment or like level of thinking about other people thinking about you in the general population. 

Preston: I think that it takes that third bucket of like being perceived and it just like spams it. It's a multiplier beyond like our comprehension because I think a lot of humans are used to being in these tribes of like 40 people.

And social anxiety is probably great when like, you know, we're all in our like Caucasus mountain hunter gatherer tribes and somebody like trips that everyone kind of laughs at them and like, oh, I'll focus more on like, you know, keeping my balance. But I've survived the judgment of my peers. Now, if I do something stupid or I misspeak on a video and it goes viral, my brain can't comprehend.

Getting roasted by like [00:37:00] millions of people, like it's, it's like it goes outside of like what your brain can deal with and it just kind of goes on overload. 

Margaret: Yeah, yeah, yeah, I think like that's one of the reasons I've like avoided talking on tick tock is like the fear of nothing specific, but just that of like, and you know, fear to some extent, like, is it pathological to fear that?

Like it's such a weird setting to, to be like, okay, well maybe you should be afraid to speak in front of like, what, like, I don't know, is that normal human behavior or not? 

Preston: Yeah. I mean, like I, I do ridiculous stuff online all the time. Not that ridiculous, but I'm still afraid to go on live. I can't do it.

Margaret: Yeah. I've thought about it and I 

Preston: struggle because I just don't want, I Protect myself and the one barrier is that I have a chance to review the footage and record it and edit it before I post it going on live. I just can't. I can't pack it yet. 

Margaret: Yeah. [00:38:00] Yeah. 

Preston: Um, 

Margaret: well, it makes me think of like, what would a concept?

This is not a deal something, but like, what would parasocial anxiety look like? Like if that was a disorder of like, yeah, Difficulty connecting in social ways online, like anxiety about being perceived to be pathologic. That's not a real thing, but anxiety 

Preston: about being present by the crowd or something.

Yeah, that'd be interesting. 

Margaret: Yeah. And then I guess. A couple other things that it notes in this is just like, there's a lot of overlap, especially in like adolescents and kids thinking about like selective mutism, which is like children who don't talk in most situations besides like with a parent or like a trusted like sibling or friend.

Um, and there's a lot of overlap with that, though. It's not the same. So they're separate things. And then, um, thinking about. Avoidant personality, like style versus social anxiety disorder. Um, and they, they pull those apart because one of the things is that someone can be avoidant and withdrawn. And the thing they bring [00:39:00] up is kind of similar to this example with paranoia that like, that can kind of happen in psychotic disorders as well.

And so they didn't want to be like avoidant personality type and. Social anxiety is sort of the same collapse them into one thing because there can be kind of this difference. Yeah. 

Preston: So like the same type of behavior is achieved with kind of a different motivation. 

Margaret: Yes, and that that interiority or a different compulsion Yeah should make you think of different things Do you have anything to add in terms of like clinically what you like?

What kind of perks your ear when someone says something to you that makes you be like, huh? Maybe you need to be thinking about this for you and how I can help from this angle 

Preston: So when I'm interviewing patients, I I love to ask about what ifs Like, do you find your mind just saying, what if, what if, what if they're like, yes, they're worried about that.

And then when I'm trying to distinguish between something like generalized anxiety disorder and social anxiety, I say, um, like I, I'll ask people, how are they able to kind of get out of anxiety spiral? Because I think everyone who's had anxiety kind of knows what it's like to be caught in that loop that you can't pull yourself out [00:40:00] of.

Um, you know, for example, like if I can't fall asleep, then I'll be. We're tired tomorrow, so I'll do bad on my exam. So I just need to fall asleep. But now I'm not falling asleep. So it's making me more anxious, which is gonna be more awake. And so it's like there's a, it's like an Eddie that you get stuck in.

So when I asked someone when you finally break out of that Eddie or that kind of loop, does another thing just fill its place or does it kind of go away? 

Margaret: Yeah. And then a lot 

Preston: of times people with anxiety, they're like the second the leaves broken. Something else just shows up and then I kind of asked what the themes of those things and so sometimes it could be they go from worrying about their grades to all of a sudden worrying is my mom going to get hit by a car to do I have cancer to, um, you know, is, is the terrorist going to attack my city?

And that's more of like a generalized picture, but sometimes when I ask them about like the next thing, it's like I go from thinking my girlfriend hates me. So next thing I'm worried about, like if my small group, if it likes me and so they're the theme of like something always replacing the next thing they're worrying about stays [00:41:00] within the kind of guardrails of their like social environment.

So that kind of like prompts me a little bit. Then I kind of dive in and ask them, like, how do you read people? Like you have trouble reading people or do you guys feel like you can tell what people are thinking? 

Margaret: Yeah, well, I feel like that's like where an interesting thing with like depression versus versus social anxiety like in depression Depression can impact someone's like self worth and self esteem self evaluation and others to be more negative And so like we treat depression and social anxiety differently to some extent we use ssris for both but like the therapy might look different What do you think like Depression might sound like versus social anxiety in terms of that, like evaluation of what people think.

Preston: Yeah So they're both connected by um social being like socially withdrawn or social detachment So I would ask if you even feel like hanging out with people anymore And in both depression and social anxiety, the answer could be no [00:42:00] Which would you expect and then i'd just say why? And so someone with depression might say it's not worth it.

I just don't feel like going out of the house. I have no energy To even leave my bed. 

Margaret: I'm not, I wouldn't be fun to interact with. I don't care, 

Preston: like, what's the point of even hanging out with people anyways? We're all gonna die. And you're kinda like, that, like, when I hear like a statement like that, I'm like, whoa.

I feel like that 

Margaret: wouldn't be fun to, for people to even interact with anyway, is one that I think about depression 

Preston: too. Yeah, like I'm not worth spending time with. I'm, I'm so, I'm so worthless. There's nothing of value to me. 

Margaret: Mhm. 

Preston: That why would anyone even care? And then with social anxiety, sometimes if people have like more resistance to it, they'll say like, oh, I don't get anxious at parties.

I just hate parties. And so now I don't want to go to them and they're just a chore to me. So I'm like, so what do you do instead? Like, oh, I always try to like crochet or play video games with my friends or like, I'll do like things like one or two people. But like, There's not a big party person, you know, and then I kind of probe a little bit.

Like, why do you hate parties? [00:43:00] What about these things suck? And they're like, oh, they're loud. It's crowded. You know, everyone's always saying stuff. I'm like, do you find yourself just like worrying the whole party about what people are thinking of you? And that's like kind of a more specific question I'll ask.

And then. I would say about if I suspect social anxiety is 60 percent of the time. I get a yes to that. They're like, yeah, they're like, I can't freaking even like pick out what I want to wear. It's like, why would I spend 40 minutes picking on the outfit? Because I know everyone's going to judge me. I'm just not going to go 

Margaret: and it's like, it's totally cool if people don't like certain things, but I think that's like a constant thing in helping people with different anxiety disorders is helping them explore like Hey, you've lived with this disorder maybe for a long time, and maybe you, you know, it's genetic in some ways, so like, maybe your family also interacts in this way, but like, do you not like the club, or are you afraid the club doesn't like you, is like a very, two different things, and so helping them unlock that, I think that's a, a really good 

Preston: prompt.

Do you hate yourself so much that it's not worth going to the party, or do you hate the party [00:44:00] so much that you're remodeling your entire life around avoiding the party's going to hate 

Margaret: you? Yeah, yeah, exactly. I feel like there's that like future kind of worry oriented part of social anxiety, whereas depression is like, I'm not worth it.

And obviously these can overlap and have, you know, comorbidity as well. Um, but I think this also gets at What we're going to talk about after our break that Preston is going to talk a little bit about, which is that these disorders, like mental illness, not only can they be comorbid and happening at the same time, but they also all are located in our brains and have some shared neurocircuits.

And so we're going to talk a little bit about the neuroscience. 

Preston: Yeah. So I, I did some digging and then we'll come back in a little bit and see what I found to feel like a scientist for the day as we discuss social anxiety or just. Really feeling anxious around people.

Okay. So when I tried to take on the [00:45:00] task of exploring the nurse neuroscience behind social anxiety, it was a bit overwhelming to be honest. I think if you just type in. Social anxiety and brain function. You're going to like immediately find like a million papers and they get very dense into looking at resting state potentials of different neurocircuits things like that.

And a lot of these structures have a lot of the same problems. 

Margaret: Yeah, quick question just for myself and you know, listeners, but also myself. How would you simply explain like neurocircuitry as an approach to understanding? Okay. Like, because I think it's different than how we used to think about it, even like 30 years ago 

Preston: is so, um, I think an easy place to start is with just like the concept of a neural network and when you think of a neural network, I want you to think about basically an input and an output from a machine.

So let's say I press a button on a machine. [00:46:00] And it gives me a thumbs up. It's just like, that's it. There's a single node and that node says input button, press output, thumbs up. Now we have, let's make it a little more complicated than normal network. Let's add two nodes. Now we have one node that says input button, press thumbs up, but then maybe if it's two buttons, I press, then it's a thumbs down, very simple neural networks.

So now imagine that times 10 different nodes times 10, 000 different nodes. And then those nodes affect other networks and then. Some of the networks are actually nodes crossing each other, but functionally, it's always the same thing. Input a stimulus and you get a product coming out the other side. So like a neural network could be functioned around like me flipping my light switch or something like that.

So how that might work for our brains is different tasks or things that we want to achieve. We kind of categorize that, and then we test how. Our brain lights up when those things happen. So a [00:47:00] great example of this could be like when you visualize an object in space, we have a certain neural network that's responsible for looking at the color of an object and another one that looks at the shape of it.

So it turns out that if I'm watching on a screen and I look at the color green and I look at a square and I look at the color green, maybe this part of my brain lights up for green. And this part lights up for square. And then both light up for green square, 

Margaret: right? Right. 

Preston: So we can use that to say, like, okay, when I'm asking the brain to picture this thing, really concrete object with the polygon, I can see these things.

Now let's try to do the same thing, but for something like attention, it starts to get really complicated really fast because these are Abstract concepts and say, like, what about empathy? How do we measure empathy by, like, looking at someone's brain? So, 

Margaret: and you can, the research can look at any note [00:48:00] along the network.

Preston: Yeah. So we have these what's called a voxel, which is basically, um, a pixel in 3D space along the fMRI that kind of exists somewhere. And then each voxel is a certain size that has a certain level of activity. Can you say fMRI? 

Margaret: Okay. 

Preston: Oh, sorry. Functional magnetic resonance imaging. So, 

Margaret: which I feel like we talk a lot of, you see it a lot online or like an article in New York times or something.

And it's like f M. R. I. What does it mean to you when someone says f M. R. I. Versus M. R. I. Studies showed. 

Preston: Oh, yeah. So that's a great question. So, um, and then, yeah, for anyone who's not familiar with this, um, M. R. I. Is really just like a snapshot in time. Thank you. So it's think about like a single photograph that you're able to take.

And then I would think about fMRI almost like one of those like live photos that you can take on your iPhone where you can kind of like look at a snapshot of activity. The difference between them is that with functional, the F part of it, functional, [00:49:00] um, fMRI is that you're looking at how much blood flow is going to certain parts of the brain.

So when a, the hypothesis is that when a certain part of your brain is more active, it's going to need to burn more energy. And That means it needs ATP, so it's going to demand more oxygen, so it's going to suck more oxygen out of the red blood cells in your blood. So, it turns out that you have iron deep in your red blood cells, and when you actually dump that oxygen off, the hemoglobin, that part that carries iron in a red blood cell, it changes shape a little bit.

And that little bit of shape that's changed can be detected on the magnetic signal. And we follow those like really microscopic changes in magnetic signal to see, Oh, these parts of the brain have these different states of iron, which are associated with more oxygen and therefore different brain activity.

So that's kind of how we can go backwards and say there's more activity here. There are some flaws in that though, because just [00:50:00] because a part's using more blood or more oxygen doesn't always necessarily mean. It's more active than a lot of times. It is. 

Margaret: There can be issues 

Preston: with the sensitivity and specificity of fMRI.

So a lot of fMRI can come under scrutiny when it comes to using it for diagnosis, for example, which is why a lot of diagnosis is still performed clinically. It can be helpful if we like, No, this person's slam dunk has schizophrenia and now we want to look at how their brain works, but going the other way.

It's not too helpful. Gotcha. 

Margaret: Okay, that's helpful. That's helpful. It's also like, I feel like I haven't reviewed like what fMRIs process actually is in a couple of years. And so that was helpful to me. Yeah, like, Oh, yeah, I do that. That is ringing about. It's kind of just like, My brain, you know, automatically is like, yeah, fMRI.

This is what's happening vaguely, but that's a helpful review of 

Preston: it. So like, and a lot of times the way they do these studies is they do like a resting state function. So they just say, just chill out. We're just going to look at how your brain functions, and then they give you a task. And then they kind of see, [00:51:00] okay, we mapped all these nodes in your head while you're resting.

Now we're going to map all of them again while you're doing a task. And we're seeing which ones decrease in activity, which ones increase in activity. And from doing hundreds of those tests, we've been able to kind of conclude like, Oh, there are these like. Really complicated networks that maybe they're not related to anatomy necessarily, but it's a constellation that always lights up 

Margaret: like, for 

Preston: example, every time we tell someone to just chill out this network lights up and we say, Hey, focus on reading this network always lights up and we kind of sort of figure out that like.

There's a node that's responsible for daydreaming, like a set of nodes and a set of nodes are responsible for like paying attention to something and that's kind of how we started to like make these conclusions. 

Margaret: Well, I feel like this like it's a complicated idea, but this foundational kind of basic idea is why like so much stuff online adds to the confusion for like ourselves if we're not in this field and then also like patients where it's like.

Oh, like your cortisol is high. [00:52:00] That's why you're experiencing all these things. And it's like the, no, like maybe, maybe you do have that, but Right. This kind of understanding, this oversimplification, but then also like the same way people will be like, oh, cortisol does this, like, and that's why you feel this way and your brain, whatever.

There also is this kind of oversimplified sense. Mm-hmm . Or misinterpretation of 

Preston: the, of the research people. Complacently draw conclusions from it. Yeah. 

Margaret: But of like, no. Yes, but the, like, kind of thought that, like, it's different brain sections and each section does its own job instead of this kind of much more complicated and interesting overlapping networks.

Preston: Yeah. Um, a lot of it, like, feels more like a CPU and a graphics card and other things like the, the computer analogies and more, um, relevant to me as I learn more about the brain. 

Margaret: Yeah. 

Preston: So now kind of like taking this kind of understanding of like how we even try to try to look at the neuroscience of of disorders to specifically social anxiety.[00:53:00] 

And like I said, there was a lot that overwhelmed me when I first looked it up. So I kind of tried to divide it initially into two big buckets. So I was like, okay, let's just let's just look at the social part. So I was I was curious, like, how do we think about just. Interpreting someone's face 

Margaret: when 

Preston: you see them, like, how does our brain help us recognize things?

Because I'm sure you've heard of like the uncanny valley or something like that, where it's like everything in like the human mind is kind of programmed to recognize a face out of the crowd. And when we see something that looks like similar to a face, but not, it kind of makes us feel uncomfortable. It feels wrong.

Margaret: But what about when there's like, why does it make me feel happy when there's like an inanimate object that's like a little smiley face that's like, in my like morning coffee, there's like two bubbles in a line and it looks like a little smile. Why did, why do I like that? Is there something wrong with me Preston?

Probably 

Preston: because you know so certainly that it can't be a human. That's fair. That you can just, that you can just like reminisce. Proceed. Yeah. So when we think about the structures that affect that, um, there's the [00:54:00] temporal lobe and that houses your hippocampus, which is where you remember things. So obviously you want to remember a face.

You see one again. Then we have the frontal lobe that kind of works through the reasoning of all this input that we're getting. And then we have the amygdala, which is tightly related to fear and anxiety. And we'll get into that a little bit later. And then we have something called the fusiform face area.

So it turns out on the bottom side of the temporal cortex, there's a specific area that's like Really only responsible for recognizing faces. It's it's so that's actually an exception where there are dedicated parts. It's just turns out that recognizing faces is so important in human life that we're just like, you know what?

We're gonna set aside these resources just for that. You 

Margaret: get your own condo. 

Preston: Yeah. And. And so these things can be fooled in different ways, especially if you have strokes in different part of your, your um, temporal cortex. You may be able to recognize that someone's a human, but you just have no idea who they are.

So you can recognize [00:55:00] faces, but you can't name them. And so they're every anywhere in this network. Something can kind of get knocked out. But what we're interested in is how does this interpretation of someone's face lead us to be anticipated, anticipating judgment or always be worried that they're afraid of us.

So I kind of wanted to look into now, like how do we process anxiety in a lot of ways and. When you think about anxiety, you really just want to think about the sympathetic nervous system being activated. And so that's going to contain things like the hypothalamus, the cingulate gyrus, the basal ganglia, and then the amygdala, obviously.

So I think even like high school psychology, remember the first thing I learned was that the amygdala was in charge of like your fight or flight response or generating fear. And it was like fascinating for me to learn how much of a role it had and also in facial recognition and how close those two things work in that same network.

So now if we want to start like looking at 

Margaret: what, what do you mean how close they work together 

Preston: or like [00:56:00] what, what, what, what struck you about that? So basically what I'm saying is that we're running all these circuits at the same time. And so there's a circuit that's running fear, fear, fear, and it's hitting all these different nodes and it's passing through the amygdala and there's one that's running, recognize face, recognize face, recognize face, and that's also overlapping through the amygdala.

They're both, both of those circuits that have like separate functions are passing through the amygdala while they're doing their independent function. So I guess what I'm getting at is like, if wonder if there's something wrong with the amygdala, if it could have implications in both fields, that kind of makes sense.

And so I started looking at amygdala function on fMRI and social anxiety disorder very specifically. And there's, there's actually a lot of data that like really starts to dive into what happens to the amygdala. So I found a meta analysis that was going over it and what they found is that. Patients with social anxiety disorder have higher resting state activity in function of the amygdala.

It's just kind of [00:57:00] hyperactive. And so their perceptions of faces may be manipulated in some way. We can't make a neat conclusion from that, but their limbic system might be a little bit more active. Then they took the groups that had higher levels of baseline amygdala function and diagnosed social anxiety disorder and they presented them with different faces with kind of standardized expressions is something we do a lot in neuroscience tests.

So you have a face with like the standardized expression for fear or for happiness or for. Anger and you ask them to rate how much stress they had in response to those faces. And we also looked at their brain activity. And what we found is that compared to normal controls, people with social anxiety disorder had were more likely to have negative responses to neutral reactions and neutral faces from people and actually had.

Stronger, more visceral reactions to negative emotions. They, um, perceived and experienced the emotion discussed more intensely when looking at faces. 

Margaret: That's interesting. 

Preston: Another thing that was fascinating is that the [00:58:00] amygdala directly connects to, um, your insula. So it's kind of like right there in the middle.

That viscerally feel reactions to a lot of things. So yeah. One thing that the authors hypothesize was that the amygdala is functioning at a higher level, and it's actually causing that person to feel subjectively more distressed than another person, and also they are interpreting more neutral social responses negatively.

And it's funny to say all this stuff so scientifically when this is basically just parroting. That scenario that you talked about earlier where I see someone walk away on their phone and they're tired. 

Margaret: Yeah. Yeah. No, it's, it's so interesting. And I know from my reading and like the eating disorder world and like, and the trauma world, like one of the things, like the connection to like the insular cortex, it is an insular cortex, right?

Yep. Yeah. Is this like kind of body [00:59:00] awareness, body sensation, visceral sensation. And like when we're talking about like the performance Anxiety in particular, um, and what, what treats that versus your gut. Yeah. Yeah. 

Preston: It's a visceral sensation. 

Margaret: Yeah. So it's fascinating. 

Preston: Um, one thing that I was, I found really interesting when I was reading about this too, is that, um, the anterior cingulate gyrus came up a lot along with the insula and those are implicated a lot in both attention and also in ADHD.

So there's a section of ADHD where, um, people can have rejection sensitive dysphoria and, um, ADHD is also comorbid with anxiety. So that actually made me really curious about how quickly someone may come to conclusions about sensations that they're observing or how fast they make almost impulsive judgments from their environment could be like somehow playing a role in this like rejection sensitive dysphoria that we see in HD because Is Amygdala, the amygdala, the insula, the anterior cingulate cortex, [01:00:00] inferior temporal lobes, like they're all just like right there, you know, and so like anxiety doesn't have to walk far to, um, to start messing with ADHD.

And, and it's funny because like when I was learning in med school, I would tell patients, I'm like, yeah, like, ADHD is kind of like neighbors with anxiety. Like sometimes they hang out, sometimes they don't, we don't know. And then now when I'm like getting more teeny natty, kind of our neighbors. Yeah, that was maybe a little close.

They're like a centimeter 

Margaret: away. It 

Preston: was a lot closer than I thought. Yeah, and then they're always interacting with each other. 

Margaret: It's interesting to, to take that and ask, like, I think of like some of my patients with like ADHD and comorbid anxiety or ADHD that has things out, whatever, whatever you want to call it.

Right? Like the, if we take into it, the also the like lifelong neuroplasticity of the brain of like, is it? Is it comorbidity in this person or that person, or is it like the plasticity of the response to the environment with an ADHD brain that then sensitizes maybe the [01:01:00] network of the social anxiety or the rejection, right?

Like, how does this come into being? That is a whole rabbit hole. We could fall down, but it's it's so interesting. 

Preston: It really is. Yeah. So the next part that I want to talk about is, okay, now we've taken our pictures the best we can of how things go wrong. But what about if we can fix this? If we're trying to treat this?

So as we talked about earlier, we give SSRIs to treat social anxiety disorder, and I was really curious about changes in amygdala function with SSRIs. And there's actually some pretty interesting recent studies that have come out where they did fMRI Of signal changes of the amygdala in patients before and after taking SSRIs.

Margaret: Do you know how long they took this? Like, was it like, they took them for a month, a year? I think 

Preston: it was for 10 weeks. Nice. Okay. So they gave it a full trial. And then, so, for caveat, this study that I'm looking at right now has, um, five participants in it. So, the, the problem with a lot of these fMRI studies is that the numbers are [01:02:00] very low.

And so, the conclusions are always, this is promising data, but more research needs to be done. They're powered in some ways, yeah. Yeah, exactly. But there is some really interesting stuff that came through. So for this study specifically, they were actually looking at patients with depression. Um, it was only looking at the amygdala, but the amygdala has some implications of depression too.

So kind of, um, suspend your disbelief or, or, um, reservations about like only talking about social anxiety disorder. Remember that a lot of these anatomical functions are transdiagnostic and that we're just trying to like look at this function. So, so they looked at, you know, resting state amygdala functions.

Before and after they were given compliments, actually, so they would, um, put these patients in a room and say, you know, you look nice today. 

Margaret: I like your hat. 

Preston: Yeah, exactly. Yeah. And so what they found is that some patients, um, compared to normal controls didn't really respond. Well, it's a compliment at [01:03:00] all.

They had lower signals and those those were the depressed patients. And then they gave, um, the intervention group SSRIs, and they found that some responded to the SSRI and others didn't. And then when they looked at the signal change, so the responders almost reached the same signal responsiveness to a compliment as the healthy control.

And the non responder didn't. And this is taking the fMRI and looking directly at the amygdala and then just seeing how much does that signal change when I say something nice to this person. Yeah, 

Margaret: yeah. 

Preston: Because this is how much this person is perceiving like negative and positive things in their social environment.

So the other thing that they are able to find is that. Outside of these compliments they were giving people, when they were looking at the resting state function of the amygdala, it decreased when they gave SSRIs. So increasing serotonin was almost able to kind of temper the basal amygdala function. 

Margaret: And when you, when you say it's like the [01:04:00] resting level, it was like more elevated in those with depression, depression before the SSRI, which lowered the resting function.

Um, what is the significance of that? Because I think I hear it and it's like, oh, okay. If it's higher up, that's bad. Cause higher, like more activity means more anxiety. But I also know that there's like, you know, complexity to that in terms of like the rest, like if you think of. I don't know. You think of the complexities that we've started talking about culturally and scientifically about like dopaminergic signaling that like the delta is the thing that signals that more than the like.

Absolute level. So what do you think of that? I 

Preston: think we have to make some and I may be misinterpreting the what I'm reading here, but we are almost starting with the postulate that we've diagnosed this person with depression. Therefore, whatever state their amygdala is at is the state associated with depression, right?

Margaret: Okay, 

Preston: so their amygdala is hyperactive in this depressive state. And then we see this change with our therapy. We assume that changes in the right [01:05:00] direction because There are some disorders where it's hypoactive and then we see hyperactivity when we give the medication, for example, the, um, anterior cingulate cortex, the medial prefrontal cortex have hypoactivity AHD, but we stimulate that activity when we give, um, Adderall.

I think that we kind of have to assume what we know to be true and then 

Margaret: we're at the edge of the science and guess from there. 

Preston: Yeah, a lot of this is really just saying we're observing changes clinically and we're observing changes on the machine on the instrument. 

Margaret: Yeah, no, that's super interesting.

Preston: Kind of correlate. We're doing our best to apply the scientific method and draw conclusions based off of that. Yeah, so it's it's still like I said a long time before we can. Use this for diagnosis. I don't know if we ever will because in a future where you could go into a brain scan and they could say, according to your fMRI, you have social anxiety and you're like, [01:06:00] I don't feel like I have social anxiety.

You know, like I feel fine. Like I'm not going to gaslight you and force you to take an SSRI. But I think it's really interesting to say, Oh, we know this part of the brain affects how we view faces. We know this part of our brain affects how we feel anxiety, how we create these hypothetical situations.

And we know that when we give someone this pill, it makes them feel better. And now we can actually detect these different changes on an instrument showing us that like what we're doing is real. And we are like affecting the circuitry of the software of our brain functionally. 

Margaret: And I feel like, you know, like you said, it's so hard to like go into this research because it is the developing edge in a lot of ways in terms of like, there's not clinical guidelines that are like, this is how all psychiatrists or like neurologists should think about what these studies mean and implement this, right?

There's not a concrete answer, but I feel like showing people, you know, on this podcast and in general as like mental health professionals, like. [01:07:00] Okay, here's here's kind of a part of the edge of where we are, um, is so important because I think it's so misinterpreted so often, um, or oversimplified. So thank you for diving in and not making me do that work.

Preston: Of course. I mean, I love doing this stuff and it's helpful for me because I like being able to think, okay, like increasing this person's serotonin is going to help their medular function. But then also I need to talk to them to think about like Why they have such a rigid belief system that if they fail a test or if they don't look good at a party, their life is over because they've also have beliefs that are buried in there and their frontal lobe that's coming to certain conclusions is also influencing their amygdala.

So we don't have meds to fix your frontal lobe, but you can talk to a therapist who can help you reframe some of that. 

Margaret: And I think what we're going to spend the last couple minutes talking about is kind of the Therapy part, the medication part, you know, I think there's a lot of good guidance on SSRIs and kind of adjunct medications, but [01:08:00] we know.

For social anxiety disorder, that CBT is the goal is the gold standard from therapy, but that both are effective. And when we think broadly therapeutically in terms of like what responds well to certain subsets of therapy, a lot of the anxiety disorders do respond quite well to a structured therapy. So in this case, in social anxiety, the CBT kind of protocol for treating it.

Especially the behavioral part is probably the most active ingredient in the CBT for social anxiety, which again is true. And a lot of anxiety or phobia disorders. Um, so let's say. Let's say like from a therapeutic perspective, we started someone on a medication, but they're also getting therapy for social anxiety.

I feel like the things I would ask my patients about, like in the therapy setting is first information gathering like you talked about, right? So this asking about [01:09:00] like where, where are things first of all, not working the most for you because like they might be inhibited in this setting and this setting, but they really are coming because.

Yeah. They're coming to therapy and doing this work because it matters a whole hell of a lot to them that this part of their life doesn't feel right to them or doesn't feel isn't working with their family. It's causing issue. Um, so starting in a place that the patient cares about, I think in general is a good is a good thing.

Um, and then I feel like the first stage of therapy is a mixture of like psycho education around what we know. On a simple, like on a simpler level of how does this get maintained and how do we through kind of consistent exposure and risk and then preventing the response, right? Um, how do we help decrease that anxiety and the sensitization to the anxiety?

Um, I think that's the active ingredient for social anxiety, kind of cross therapy modality. I, you know, I, [01:10:00] myself am act and psychodynamically oriented and trained. And so, but I think when I look across CBT act, even sometimes psychodynamic or interpersonal work, it's pulling someone to the kind of emotionally salient thing over and over again until it's integrated and causes less of a stress response to some extent.

Preston: So when you say exposing some of the emotionally salient thing over, do you mean almost just kind of like desensitizing them to that, that hypothetical possibility or that belief? 

Margaret: Yes. 

Preston: Okay. 

Margaret: And not thinking of it as like the kind of like experiments you think about a 

Preston: worst case scenario. 

Margaret: Yeah. So that and again, I think the psycho ed part is an active ingredient in this as well of like, Okay.

A lot of, there's a lot of kind of like beliefs we can have, not just about ourselves, but also about like, how do our brains work? And I feel like one of the biggest things that changed me as a therapist positively in residency so far has been getting training at an OCD Institute and ERP specifically, and just [01:11:00] seeing the way.

Done well and done compassionately and with an understanding towards also like how mindfulness goes into it and how to pace it correctly for people being trauma informed, all those things, but seeing what it can do for people over time. And this was in like a residential setting where it was like they were doing exposures every day with like, um, a clinician on staff.

So when I say like in social anxiety, like, let's say you have someone, let's say you'd like a college student who actually they come to you. They're like, but you know, yeah. I'm, let's say you have someone who's like 25 year old, they're living in a city, they like, they're like, they come to you and they say, you know, I used to be a little bit anxious, but I was able to push through it before the pandemic happened.

And now, like, I want to be able to go to bars. I want to be able to go to concerts and I just get like, so anxious going with my friends and being around strangers. And I haven't been able to do it since COVID, like, it felt like something changed. One of the things that would have changed is the sensitization to the stimuli, right?

[01:12:00] Like. You didn't have it. And maybe if you're someone who kind of weren't socially anxious as often because you were forced in routine, then You were able to cope, but when it was covid and you were at home for a year and a half without any stimuli, kind of like we talked about the beginning of the episode, that ability and like the sensitivity to it is like the sensitivity is much higher and the ability feels like a whole lot more effortful and fearful.

Preston: Yeah, I think it's fascinating that desensitization is also a technique used in phobias. So we were talking about the difference between phobia and anxiety beginning, but now we're kind of coming back to similar treatments. So it's really just almost like deconditioning your fight or flight response to a stimulus, 

Margaret: right?

Well, and similar to like, it feels 

Preston: like Pavlovian almost. 

Margaret: Yeah Well, and I think adding that compassion and then adding the part of like exploring beliefs or the kind of cognitive component is important Especially I think so much of people so much of our identity comes from who we are in relation to others so if you have a long [01:13:00] history of or like a traumatic history or just a significant history of Having a really hard rejection feeling disconnected from people bullying any of these things or like not feeling connected in a certain setting like at work on talking about the narrative and schema around that cognitively in addition to doing the exposure work.

And adding these mindfulness and compassion components are all part of, you know, not being a pure behaviorist. I think in making the therapy, 

Preston: it's like the therapeutic physical exam. Um, I guess human, like all humans need to belong like full stop period. So just like how I need oxygen and food and water, I need to belong.

And so if my belongingness is thwarted for whatever reason or perceive I perceive it to be, that's going to cause Emotional injury. And so if it's you can teach someone to tolerate that emotional injury over and over again with [01:14:00] coping skills or exposing them to it. But like, is that emotional injury coming from true rejection?

Or is it almost like made up by these weird beliefs? So, you know, you're kind of teaching someone to tolerate the fist, but also realize that, like, maybe they're punching themselves at the same time. 

Margaret: And I'll say, like, I would never like have someone come to me on appointment three and we're working on social anxiety together and like, be like, okay, you know, that biggest thing you fear that you're horrified of doing.

We're not going to start there. Similar that you wouldn't probably have someone like it. Go. I know your marathon training right now, Preston, like be like, okay, it's time to do like sub six minute, 10 mile run right now. You wouldn't have someone start there and you would be likely to injure them. That would be irresponsible.

I think therapizing in some ways, uh, And so it is much more again, compassionate because we're also teaching people with social anxiety. Like they're often very critical of themselves. And so we don't want to re entrench that belief while doing exposures of like, you have to do [01:15:00] this perfectly or you're bad.

Preston: Yeah. Yeah. And. That's a great point you had about them being critical of themselves. A lot of, I guess, I was taking more like psychoanalytic lens to this is a projection. So they are judging themselves. They think they're worthless. And then they are perceiving that other people, they're projecting that judgment onto other people and saying like, they feel this way about me.

So a lot of it is almost like a maladaptive response to internalized feelings. Of worthlessness, 

Margaret: so I think, you know, we're reaching, we're probably at the end of time. So maybe we'll come back to more on loneliness, uh, in another episode, but I think we've talked about it at different points, like throughout this episode of how there can be this relationship and how we think about it coming into being, um, responding to meds, this kind of like anxiety and social settings response.

But I think there's a clear connection between. The loneliness epidemic and the way how do we think about the way out [01:16:00] of it for people like how do we think about loneliness is a something we talk to our patients about and there can be a many many reasons for loneliness that are not. I don't mean them as like, this is like, if we fix your personal thing, then you won't feel lonely.

There are a lot of structural and societal problems that contribute to the loneliness issue, but 

Preston: I was watching industry and it was HBO, like British succession, basically, but there was a line there by this character. Robert, he says there. There are a few things more lonely than being in a room with people that are supposed to love you and he was talking about his family, but I kind of brought up what we were talking about the beginning, which is loneliness as this subjective perceived distress for the unmet need of belonging.

And that's kind of what we're trying to find the antidote here. And then one sliver of that might be social anxiety, right? Because social anxiety leads to this unmet need of blog, but there are many things [01:17:00] that can contribute. So it's almost like we're trying to examine the loneliness epidemic through the lens of one of many different factors and pillars that can affect this, 

Margaret: right?

Yeah. Yeah, totally. I 

Preston: agree. And, and personally, like when I try to advise people on, um, how to counteract loneliness mm-hmm . Like I have a, I have a couple of therapy patients that, like, their prescription has been to like, find ways to reach community. 

Margaret: Yeah. And, 

Preston: um, I, I try to say like, okay, you know, what do you like to do and how do we find a way to do that thing around other people?

Right. Right. So like, if you liked soccer. Maybe instead of juggling your backyard try to join a league right or if you like running go to a run club Said and so I just kind of try to treat like community as another prescription in their behavioral activation. 

Margaret: Yeah 

Preston: Yeah, 

Margaret: well, I feel less lonely 

Preston: Okay [01:18:00] Thank you, 

Margaret: are you gonna say that mr.

Dragon 

Preston: feels a little less long too 

Margaret: Yeah, 

Preston: this was a good episode I enjoy talking about this yeah And if you're listening to the audience, I'm curious to, how did you guys feel about it? If we always want to hear what you think, if you have topics that you want us to dive into instead, you can always come and chat with us or just kind of drop us a message at our human content pod family.

We're on Instagram and TikTok at human content pods, or you can contact the team directly at howtobepatientpod. com. You can send us 

Margaret: a letter. Preston's address is I'll see it. 

Preston: I'm compulsively when I check these things. Thank you to everyone who's like leaving kind feedback and awesome reviews. If you've subscribed to my Instagram or other Patreon related things, we'll start dropping content there as well.

So I know subscribing to Preston's Instagram has been fruitless recently, but stuff is coming, I promise. Also, full videos will be available on our YouTube channel. Each week at It's Presro. So it's just all through my YouTube. Um, [01:19:00] and nothing else there. I think that's all the clerical stuff. So, now for the fun part.

You can't find me anywhere. We're your 

Margaret: hosts. 

Preston: Preston Roche. 

Margaret: Margaret Duncan. Did we say our last name? 

Preston: And our executive producers are me, Preston, Roche, Margaret Duncan, Will Flannery, Kristen Flannery, Aaron Corny, Rob Goldman, and Shanti Brooke. Our editor and engineer is Jason Portizzo. Our music is by Omer Benzvi.

To learn about our program disclaimer and ethics policy submission verification licensing terms and our HIPAA release terms, go to our website howtobepatientpod. com or reach out to us at howtobepatient at human content. com with any questions or concerns. How To Be Patient is a human content production.

Thank you for [01:20:00] watching. If you want to see more of us, or if you want to see this is Lilac, she's my cat. She's gonna be waving her hand at one of the floating boxes, which will lead to more episodes. Lilac Point to the other episodes. Lilac doesn't know what the internet is, but I swear they're there. They, they probably exist for real.

But in the meantime, I'm just gonna pet lilac and then I'm gonna go dance in the background.