Social Anxiety Disorder (Social Phobia)

Criterion A

Marked fear or anxiety about one or more social situations in which the individual is exposed to possible scrutiny by others. Examples include social interactions (e.g. having a conversation, meeting unfamiliar people), being observed (e.g. eating or drinking), and performing in front of others (e.g. giving a speech)

Criterion B

The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will be humiliating or embarrassing; will lead to rejection or offend others)

Criterion C

The social situation almost always provokes fear or anxiety

Criterion D

The social situations are avoided or endured with intense fear or anxiety

Criterion E

The fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context

Criterion F

The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more

Criterion G

The fear, anxiety, or avoidance causes clinically significant distress or impairment in social, occupational, or other areas of functioning

Criterion H

The fear, anxiety, or avoidance is not attributable to the physiological effects of a substance (e.g., drug abuse, medication) or another medical condition

Criterion I

The fear, anxiety, or avoidance is not better explained by the symptoms of another mental disorder, such as, panic disorder, body dysmorphic disorder, or autism spectrum disorder

Criterion J

If another medical condition is present (e.g., Parkinson’s disease, obesity, disfigurement from burns or injury) is present the fear, anxiety, or avoidance is clearly unrelated or is excessive

Who gets SAD?

• Adolescent onset

• 8% yearly prevalence, 1% point prevalence

• 3:1 female

Biological Theory

• Genetics: phobia per se probably not heritable component

• Non-specific propensity for anxiety

Biochemical Treatments: Benzodiazepines

• Benzodiazepines (Xanax, Valium)

• GABA ergic, stimulate GABA receptors

• You get amped up, GABA brings you back down

• Developed as safer option to barbituates

• Ones tolerance to them increases fairly rapidly, poor withdrawal- rebound anxiety

• Alcohol is GABA ergic and has similar effects to benzodiazepines, drinking calm nerves

Biochemical Treatments: MAO Inhibitors

Same side effects as depression, unpleasant side effects

Biochemical Treatments: SSRI’s

No current evidence for serotonin deficiency

5-HT1a agonists (BuSpar)

Best as an adjunctive treatment for other meds.

How well do medications work?

• 50-60% of people respond relatively well

• People with phobias/social anxiety report feeling slightly less anxious in these situations

Psychodynamic Theory

• Poorly resolved oedipus complex- more so related to phobias

• Castration anxiety displaced onto innocent object

Psychodynamic Treatment

• Standard psychoanalysis

• Goal: identify what caused anxiety to be displaced onto what you are afraid of

• Poor outcomes- worse than medications, 30-40% get better

Behavioral Theory

• Development of phobia

• Direct exposure

• Panic attack in specific situation

• Observational/informational

• Want to tell story of where things come from, but doesn’t make much of a difference

• Phobias classically conditioned, maintained by avoidance of phobic object or situation

• Have to be in-contact with phobic object without the unconditioned stimulus

Behavioral Treatment: Mower’s two-factor model

1) Acquistion (classical conditioning)

2) Avoidance (through negative reinforcement)

• Everytime you think about something, you get scared so you try to avoid it (negative reinforcement)

Behavioral Treatment

Exposure to phobic object/situation

Systematic Desensitization

Counterconditioning, replace anxiety with physiologically incompatible response

Systematic Desensitization Step 1

Train people how to create a relaxation response

• Progressive muscle relaxation

Systematic Desensitization Step 2

Walking through hierarchy of things that you fear regarding phobic objects

• Work through one phobic object at a time, start at lowest level

Systematic Desensitization Step 3

Put them together

• Sit with phobic object/situation while doing relaxation, work through hierarchy until you get scared, start over

Graduated exposure

Inhibitory learning model, sit with stimulus until anxiety dissipates

• In contact with items with hierarchy

Flooding

Skip hierarchy all together, go straight to top

• Works just as well as graduated exposure, but less likely for people to come back

How well does it work?

80-85% of people learn to tolerate phobic phobic object

• Medication is considered a form of avoidance

Applied tension technique

Modification of graduated exposure, clench all major muscles and don’t release, keeps blood pressure from dropping, clench all major muscles and don’t release, keeps blood pressure from dropping

Combined treatments

Logic of combining standard medical treatments with behavior therapy, found to be unhelpful when put the two together and work at cross purposes

• Medication reduces anxiety, but the goal is to extinguish it

D-Cycloserine

• Antibiotic typically used to treat tuberculois

• Partial glutamate agonist: used as adjunct to exposure

• Used shortly before an exposure session, memory of success you had last time is a little stronger, decreases time needed

• Significantly more effective than non-augmented exposure