Cognitive CBT Management of Social Phobia
August 25, 2010 – 8:44 amThis article will look at social phobia, in comparison to anxiety disorders, and will also provide insights for the treatment of social phobias using cognitive behavioral therapy (CBT).
Question: Is it Social Phobia
or Social Anxiety D/O?
DSM-IV-TR Definition of Social Phobia
“A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing” (see diagnostic criteria, p. 456).
“Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.”
“The person recognizes that the fear is excessive or unreasonable.”
“The feared social or performance situations are avoided or else are endured with intense anxiety or distress.”
“The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.”
“The fear or avoidance is not due to the direct physiological effects of a substance or a general medical condition and is not better accounted for by another mental disorder.”
Classifications of Social Phobia
Generalized (undifferentiated): when fears include most social situations.
Differential Dx: Avoidant Personality D/O
- – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - – - – -
Specific (differentiated): when fears pertain to particular social situations (e.g., public speaking).
Differential Dx: Simple Phobias
Animal Natural Environment
Blood/Injection/Injury Situational
Social Anxiety Institute’s Definition of Social Anxiety D/O
“The fear of social situations and the interaction with other people that can automatically bring on feelings of self-consciousness, judgment, evaluation, and inferiority. The fear and anxiety of being judged and evaluated negatively by other people, leading to feelings of inadequacy, embarrassment, humiliation, and depression” (T. Richards, PhD, Med Dir)
Why Social Anxiety D/O?
Misunderstanding of term “social phobia.”
Misapplication of the term “phobia.”
Social anxiety d/o typically permeates all of a person’s life. E.g.: fear of social situations and events, not panic attacks.
Social anxiety and agoraphobia are distinct enough D/O’s to warrant separate classification.
So which is it …
Social Phobia or Social Anxiety D/O?
3 Components of Anxiety: Physiological
Palpitations
Tachycardia
Dizziness
Nausea
Smothering
Lump in throat
Shakiness
Blurred vision
Chills
Headaches
Depersonalization
Tightness or pain in chest
Tinnitus
Shortness of breath
Flushing/blushing
Diarrhea
Parathesias
3 Components of Anxiety: Behavioral
2 Distinct Parts
What someone does in an anxiety-provoking situation:
Shuffle feet, avoid eye contact, clinch fists, etc.
Avoidance:
Not doing something that is frightening, or
Doing it in a way that one stays away from the most frightening aspects of the anxiety-provoking situation.
3 Components of Anxiety: Cognitive
Specific thoughts
“I’ll look stupid”
“No one will like me”
“I’ll make a fool of myself”
Though Process – the selective rehearsal (or reliving) of the process involved in past anxiety-provoking situations, which may involve specific, “automatic” thoughts.
DSM-IV Differential Diagnosis for Social Phobia
Social Phobia must be differentiated from: Panic w/ agoraphobia
Agoraphobia w/o Hx of Panic, GAD, Specific Phobia In contrast to SP, the other condition:
Is typically not limited to social situations and is characterized by the initial onset of unexpected Panic Attacks.
Involves anxiety or avoidance that is not limited to situations that involve scrutiny by others.
DSM-IV Differential Diagnosis for Social Phobia
Social Phobia must be differentiated from: Sep Anxiety D/O
Pervasive Develop D/O, Schizoid PD
In contrast to SP, the other condition:
Is characterized by fears concerning sep from caretakers.
Is characterized by avoidance of social situations due to a lack of interest in relating to other individuals.
DSM-IV Differential Diagnosis for Social Phobia
Social Phobia must be differentiated from: Avoidant PD
In contrast to SP, the other condition:
Is conceptualized as a PD but may describe the same group of pxts as Social Phobia, Generalized type. For persons with Social Phobia, Generalized type, dx of Avoidant PD should be considered.
DSM-IV Differential Diagnosis for Social Phobia
Social Phobia must be differentiated from: Social anxiety & avoidance w/ other mental D/Os.
Non-pathological performance anxiety, stage fright, or shyness.
In contrast to SP, the other condition:
Is characterized by anxiety that occurs only during the course of the other mental d/o.
Lacks clinical significant impairment or marked distress.
Rationale for CBT
According to Dx criteria, Social Phobia is the fear of social interactions with others (usually strangers) or situations in which others may scrutinize or judge the behavior or actions of the person (e.g., embarrassment or humiliation). This fear(s) is based on two factors:
Past experience(s) repeating in the present
Interpretation of past & future experience(s)
While past experiences are not, in themselves, the focus of CBT, when past meets present or impacts, impedes, or influences the future, CBT can be very effective, especially when there is such a strong interpretive set.
Antecedent Event Bx Consequence
Bx is not based on AE, but on one’s interpretation of or belief about the AE.
Empirical Research
Originating with the publication of DSM-III, social phobia was conceptualized as anxiety in a single situation (akin to simple phobia), and socially anxious persons with a more generalized presentation received as Dx on Axis II of Avoidant PD (Craig, Heimberg, & Hope, 1992).
This was based on the premise that most social phobics experience anxiety in only one social situation. This premise has been challenged on empirical and conceptual grounds.
DSM-III-R modified social phobia to include a generalized subtype allowing for fear in most social situations.
DSM-IV-TR continues to maintain this subtype of social phobia.
Current researchers propose changing the name from Social Phobia to Social Anxiety Disorder, with two subtypes: generalized and specific.
1992a study (Holt, Heimberg & Hope): comparison & contrast of Avoidant PD and generalized subtype of Social Phobia.
Anxiety Disorders Interview – Revised (ADIS-R)
Clinician’s Severity Rating (CSR)
Personality Disorders Examination (PDE)
Liebowitz Social Phobia Scale (LSPS)
Social Avoidance & Distress Scale (SADS)
Fear of Negative Evaluation Scale (FNES)
Fear Questionnaire (FQ)
Social Interaction Anxiety Scale (SIAS)
Results:
Generalized SPs w/ or w/o APD and non-generalized SPs w/o APD can be distinguished on measure of phobic severity.
Generalized group shows earlier onset than non-generalized group.
Some difficulty in differentiating Generalized SPs and APD – further research needed to provide clinical distinctions b/t 2 groups.
1992b study (Herbert, Hope, & Bellack): distinction between Generalized Social Phobia and Avoidant Personality D/O.
Social Phobia Anxiety Inventory (SPAI)
Social Avoidance & Distress Scale (SADS)
State-Trait Anxiety Inventory – Trait (STAI-T)
Beck Depression Inventory (BDI)
Symptom Checklist 90 – Revised (SCL-90-R)
Fear of Negative Evaluation Scale (FNES)
Empirical Research
Results:
Discriminative examination of GSP and APD indicate high degree of comorbidity between 2 conditions.
All pxts who were diagnosed as APD also met DSM IV-TR criteria for GSP.
APD was associated with greater social anxiety and functional impairment, but no differences were found in social skills or impromptu speech performance.
Quantitative differences of same d/o that involve probable qualitative distinction based on degree of impairment.
1993 study (Chambless & Gillis): effectiveness of cognitive therapy of anxiety d/o’s, including social phobia.
Fear of Negative Evaluation Scale (FNES)
Irrational Beliefs Test (IBT)
Social Interaction Self-Statement Test (SISST)
Social Phobia subscale of Fear Questionnaire
Social Avoidance & Distress Scale (SADS)
Empirical Research
Results:
Consistently large pre-post effect sizes reflect substantial & significant within-group change.
Waiting list, supportive control group txt, CBT txt
FNES is best predictor of txt outcome due to:
Fear of scrutiny
Negative evaluation by others
1997 study (Safren, Heimberg, & Juster): Client’s expectations & their relationship to pretreatment symptomatology & outcome of CBGT for social phobia.
DSM-III-R or DSM-IV criteria based on clinical interview
Anxiety D/O Interview Schedule – Revised (ADIS-R)
Anxiety D/O Interview Schedule – DSM IV – Lifetime (ADIS-IV-L)
Empirical Research
Results:
CBGT, Heimberg protocol
Cognitive restructuring skills & exercises
Repeated exposure to simulations of feared situations in group
Related homework
Results to Treatment Questionnaire (RTQ)
Significant & consistent negative correlation with ADIS-R, Interaction fear (SIAS & LSAS), LSAS Performance subscale, BDI, and HRS-D.
CBT Protocol for Social Anxiety D/O
Developed by Hope, Heimberg, Juster, & Turk.
“Managing Social Anxiety: A Cognitive-Behavioral Therapy Approach,” 2000, TherapyWorks.
Client workbook consists of 14 lessons (chapters), 14-20 sessions.
CBT Protocol for Social Anxiety D/O – Lesson 1
Introduction to the program
Defining social anxiety D/O
How to use the manual
How this CBT protocol can help
How to get the most out of this program
Overview of the program
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 2
Understanding Social Anxiety D/O
3 components of social anxiety
Physiological
Cognitive
Behavioral
Interaction between the 3 components
Homework
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 3
Further information about Social Anxiety
Possible causes of SA
Genetics
Family environment
Important personal experiences
Dysfunctional thinking patterns
Mechanism of action – cognitive examples
Mechanism of action – physiological arousal
Mechanism of action – behavioral response
CBT Protocol for Social Anxiety D/O – Lesson 3 (Con’t)
Summary of development of social anxiety and dysfunctional beliefs.
FAQ, re: causes of SA & dysfunctional beliefs
CBT for SA
What’s involved
Systematic graduated exposure
Cognitive restructuring
Homework assignments
Homework & self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 4
Gathering situation-specific information
Fear & avoidance hierarchy
Brainstorming
Rank ordering the situations
Discovering dimensions that increase or decrease the situations
Rating each situation for fear & avoidance
SUDS: subjective units of discomfort scale
Avoidance ratings
Homework & self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 5
Identifying thoughts that cause anxiety
Homework review
Importance of thoughts
Relationship b/t events, thoughts, & feelings
Exploring client thoughts
How others may react to client thoughts
Automatic thoughts
Identifying ATs & the emotions they cause
Identifying client ATs & emotions they cause
Homework & self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 6
Tools to challenge client ATs
Defining thinking errors
All-or-nothing thinking Mental filter
Fortune telling Mind reading
Catastrophizing Overgeneralization
Disqualifying or Labeling
discounting the positive
Emotional reasoning “Should” or “Must” statements
Maladaptive thoughts
CBT Protocol for Social Anxiety D/O – Lesson 6 (Con’t)
Tools to challenge client ATs
Identifying thinking errors in client homework ATs
Challenging client ATs
Finding logical errors in client ATs
Combating ATs with rational responses
Homework
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 7
Exposure treatment
How exposure txt is helpful
First in-session exposure
Picking a situation
Cognitive restructuring
Working out the details of exposure situation
Setting achievable behavioral goal
Setting the goal of not being anxious
Importance of goal-setting
Completing the exposure
CBT Protocol for Social Anxiety D/O – Lesson 7 (Con’t)
Exposure treatment (con’t)
Do’s & don’ts of therapeutic exposure
Debriefing the exposure
Homework after first in-session exposure
Homework
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 8
Ongoing in-session and homework exposures
How to pick exposure situations
Easier before harder
Build into a sequence of exposures
Use exposures to challenge ATs
How cognitive restructuring changes as clients tackle different situations
Relationship between exposures, cognitive restructuring, & homework
CBT Protocol for Social Anxiety D/O – Lesson 8 (Con’t)
Ongoing in-session and homework exposures
Summary of the course of txt program
FAQs
Homework for the rest of the program
Weekly exposure homework
Self-monitoring homework
Making overcoming anxiety a new habit
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 9
Overcoming fears of doing things in front of others (like Powerpoint presentations)
“Original” social phobic behavior
Common ATs related to observational fear & how to handle these ATs
“My hand(s) will shake”
Uncovering & challenging the ATs
Setting reasonable behavior goals
In-session and homework exposure
CBT Protocol for Social Anxiety D/O – Lesson 9 (Con’t)
Overcoming fears of doing things in front of others
“I’ll make a mistake”
Uncovering & challenging the ATs
Setting reasonable behavior goals
In-session and homework exposure
Exposures for observational fears
Eating or drinking in front of others
Writing in front of others
Fear of making mistakes
Homework & self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 10
Big fears of small talk
Big impact of small talk
Small talk begins relationships
Social support networks
Examining client’s SSN
Common ATs for casual conversations
“I won’t know what to say”
“I’m not very good at making conversation”
Homework
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 11
Public speaking
Similar to lesson 9, but more specific & intensely anxiety provoking (specific phobia?)
#1 fear in USA
Identifying & challenging ATs
Setting achievable behavioral goals
In-session exposure
“Screening room” rehearsal (group txt)
Homework & self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 12
Advanced cognitive restructuring work
Addressing core beliefs
Searching for common themes in client ATs
Discovering client core beliefs
Peeling the onion
Not all core beliefs are hard to find
This is not about your past or how your mother treated you
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 13
Becoming your own coach: habituation & generalization
Progress checklist
How to continue the journey
New situations = new challenges
Reactions from others
You’re on your own, but I’ll be here
Self-assessment
CBT Protocol for Social Anxiety D/O – Lesson 14
Medication treatment for social anxiety
How medications affect the brain & reduce SA
SSRIs
MAOIs
Beta-adrenergic blockers
Benzodiazepines
General considerations concerning medication treatment for social anxiety
Treatment “cocktail”: therapy & medication
Self-assessment
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