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Psychoses, Shyness and Social Phobia



Ruy Miranda
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An intriguing subject is the appearance of Shyness in people with certain types of psychoses. It is intriguing because, departing from the classical concept that psychoses represent a rupture in the self, with dissociation of the individual and reality, adverse judgments, supposedly made by others, should not alter the behavior of these people. However, in many kinds of psychoses, it does. This change presents certain peculiarities. Before commenting on how it occurs, I would like to briefly relate my personal experience with psychotics.

My experience with psychotics – At the beginning of my professional life, some forty-two years ago, I opted to work only as a psychotherapist. Nevertheless, the need to earn money to get me through the difficulties of starting a professional life, plus the long period of time it takes to build a reputation as psychotherapist, led me to take an civil service exam for a position as a psychiatrist in a public hospital for psychotics. During the course of my work there, I saw thousands, that’s right, thousands of patients who were diagnosed with either acute or chronic psychosis. Despite the limitations in the scope of psychiatric treatment at that time and the reduced number of psychotropics then available, which in addition to electroshock therapy were the only weapons at our disposal, I had the opportunity to follow the progress of hundreds of patients, inasmuch as if they were readmitted, they had to be treated by the same physician as before and, as such, I acquired extensive experience in the field.

On the other hand, in the area of private practice, I was sought after by family member of psychotics who wanted me to treat some patients in my office, using psychotherapy. Initially, I resisted the idea because, at that time, the only successful experiences in the psychotherapeutic treatment of psychotics were conducted by John Rosen and, even then, what he managed to do was remove the patients from being described as delirious, through his psychotherapeutic approach, and afterwards direct them to formal psychotherapy. However, after a few years, I agreed to see a patient and soon I was seeing others. My strategy was to treat them through psychotherapy while they continued receiving medication, on an outpatient basis, from their psychiatrists.

Surprises and disappointments – The first thing that surprised me was that these patients, in addition to the regimen of medication they received from their psychiatrists, initially immersed themselves in the therapy and attended the sessions regularly. However, they would suddenly stop coming without any apparent reason. One case that I found especially disappointing was that of a young man, close to thirty years of age, who seemed to be making good progress, then stopped coming to his sessions without notification, and reappeared again few days later. He then told me what had happened. His psychiatrist, believing that his psychotic signs and symptoms had improved significantly, suspended the medication, and quite suddenly, when he was out on the street again, he experienced intense visual and auditory hallucinations and delirious ideas of persecution, just like he had suffered before. He tried to resist, but the feeling of panic was so strong that he hailed a cab and went directly to a private psychiatric hospital to which he had been admitted several times when experiencing similar crises. There, he was attended by one of the doctors on duty and the young man pleaded to be admitted, given the medication needed to reduce his suffering, and, at the same, requested that his psychiatrist be contacted. Approximately two months after resuming his sessions with me, he quit therapy and, upon contacting his family by phone, I was informed that he refused to continue without giving a reason for his decision.

On this occasion, I began to question this type of work that I was doing in my office and decided not to treat psychotic patients anymore.

New efforts – Many years later, I gave into the appeals of a friend who asked me to see a relative with a history of admissions to psychiatric hospitals. This time, however, I decided that I, myself, would give the medication, simultaneously with the psychotherapy sessions. While seeing the patient once a week in my office, I closely followed the progress of the psychotic signs and symptoms and accordingly increased or decreased the doses of medication. The strategy worked. The patient didn’t quit therapy, made good progress, and was able to lead a productive life. It is not necessary here to describe the progress in detail. Afterwards, I accepted a few more psychosis cases and, today, I work with only one such patient. This experience in psychotherapy may be small in number, but it is large in terms of the quantity of observations it afforded me in that such work extends over of period of years. Among these observations, I noted that many previous behaviors prior to the psychosis, such as signs and symptoms of Shyness, continued to follow the individual after overcoming the signs and symptoms of psychosis. I did not observe anything like this during my work as a psychiatrist in the public hospital given that the excessive number of cases obliged me, and the other psychiatrists who worked there, to treat patients quickly.

Peculiarities of Shyness – I observed, in these experiences as a psychotherapist, that the previous Shyness was, at this new stage of life, distinguished by certain peculiarities that varied from case to case. For example, the fear of being adversely judged by other could be accompanied by catastrophic thoughts. Something like: “If people see that I am worse, everything will be destroyed. Therefore, I won’t go.”

By destruction, he might believe the family will become poor, that what is firmly standing will fall, that he won’t have further conditions to get along with others because of the humiliation he will suffer in this or that situation. Consequently, he postpones, for months, making a decision that is objectively simple. Thus, Shyness, which before the emergence of the psychosis was similar to that of others, takes on this catastrophic character.

Another observation is the flagrant discord between Shyness, its consequences, and reality. In one of the cases, the patient, having overcome the psychosis, became obsessive-compulsive (John Rosen said that all of his patients, after they were no longer diagnosed with psychosis, became obsessive-compulsive, at which point they were directed to formal psychotherapy. In my experience, this happened only in this patient.) If, on one hand, obsessive-compulsive behavior imposes sudden annoying and extravagant rituals, even in the presence of other people, on the other hand, outside of these crises, the patient feels ashamed and, to the extent possible, avoids talking to others, especially strangers, because he believes his voice was unpleasant. The strength of the compulsion was greater than the suffering caused by an adverse judgment with respect to his voice.

Social Phobia – Another peculiarity of these patients is that they do not develop Social Phobia. Even in those situations that might be catastrophic, whenever the patient was led voluntarily or involuntarily into threatening situations, once inside them, he was not seized by feelings of intense anxiety or panic. In fact, once in situation, he often felt comfortable and even actively interacted within the situation. Therefore, in my experience, psychotic patients do not develop classic Social Phobia, but rather may present behaviors typical of a previous Shyness. The Shyness process in these individuals undergoes some changes and goes on to present certain differences in relations to what it was.

Therefore, psychotic patients, after overcoming signs and symptoms of psychosis, may present Shyness and its components, whether dramatic or not, depending, it would seem, on the previous Shyness and the type of psychosis developed.



June, 2006

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This web site, the Social Anxiety Disorder and Shyness Directory and these articles contained on this web site are not solicitations, are not medical advice and are not intended as medical advice. This web site, the Social Anxiety Disorder and Shyness Directory and these articles are intended to provide only general, non-specific medical information and are not intended to cover all the issues related to the topics discussed. This web site, the Social Anxiety Disorder and Shyness Directory and these articles do not create any physician-client relationship between Ruy Miranda and you, and they do not replace the eventual relationship between you and your physician, psychologist, or other healthcare professional. This article’s author recommends no particular medication and does not represent the interests of any person, company or pharmaceutical laboratory.


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You may want to read other articles on Social Anxiety Disorder / Social Phobia and Shyness:

Basic Articles:

Self-Concept/Self- Actualization – Shyness Nucleus

Self-concept, Body Image, Self-depreciation and Shyness

Shyness and Social Anxiety Disorder: Neurophysiological Approach

Shyness Articles:

What Is Shyness? Fear, Anxiety, Anguish?

Questions and Answers on Shyness

Humiliation Stories, School Spankings: Examples of Shyness Causes

Social Anxiety Disorder Articles:

Social Anxiety Disorder: What It Is, The Anxiety Attack Symptoms

Social Anxiety Attacks: Incidence, Onset, History, Evolution

Social Phobia / Anxiety Disorder: Treatment

Social Phobia / Anxiety Disorder: Differential Diagnosis

Avoidant Personality Disorder

Medications in Social Phobia: Side Effects - Part 1

Antidepressants Tricyclics: Side Effects - Part 2

Metabolic Pathways Individual Differences and Medications Side Effects - Part 3

Genetic Changes: Medications Side Effects - Part 4

First Line Antidepressants - Side Effects - Part 5

Social Anxiety and Shyness Articles:

Panic Disorder, Shyness, Social Phobia - Differences

Why Self-Help in Shyness and Social Anxiety Disorder / Social Phobia Doesn’t Help You

Shyness and Social Anxiety Disorder:Medication Action

Facial Blushing, Redness of the Face, Ears and Neck

Psychoses, Shyness and Social Phobia


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