3.4- Adolescent Social Anxiety Disorder (Medication)

Case 3 - Treatment Goals and Planning: (pp. 37-44)

Answer: B. Fear of negative evaluation in social or performance situations

Explanation: SAD is defined by intense fear of being negatively judged or embarrassed in social/performance situations (e.g., speaking, eating, playing music). Panic disorder involves unexpected attacks (A), OCD is intrusive thoughts/compulsions (C), and GAD involves broad worry (D).

Which of the following is most characteristic of Social Anxiety Disorder (SAD) as seen in Bonnie’s case?

A. Recurrent unexpected panic attacks not linked to specific triggers
B. Fear of negative evaluation in social or performance situations
C. Repeated intrusive thoughts about contamination
D. Persistent worry about multiple life circumstances

Answer: C. To facilitate natural opportunities for social exposure

Explanation: Small groups allow SAD patients to face feared social situations (e.g., introducing themselves, eating in front of others, performing). While group therapy can reduce costs (A), it typically reduces rather than increases therapist attention (B). Dropout can still occur (D).

What was the primary purpose of delivering Bonnie’s CBT program in a group format?

A. To reduce treatment costs for the clinic
B. To allow more personalized therapist attention
C. To facilitate natural opportunities for social exposure
D. To avoid the risk of treatment dropout

Answer: B. Brainstorming evidence for and against her prediction

Explanation: Cognitive restructuring teaches patients to treat anxious thoughts as guesses, then gather evidence to test them. Systematic desensitization (A) is a gradual exposure method, flooding (C) is intense exposure, and modeling (D) belongs to social skills training.

Bonnie initially believed she could not order pizza over the phone. The cognitive technique used to challenge this belief involved:

A. Systematic desensitization
B. Brainstorming evidence for and against her prediction
C. Flooding her with feared situations
D. Modeling appropriate behavior

Answer: B. SAD leads to social isolation and negative self-beliefs, which can contribute to depression

Explanation: Avoidance and low social reinforcement increase risk for depressive symptoms. While neurotransmitters are involved (A), they aren’t identical causes. Depression doesn’t directly cause SAD (C), and the co-occurrence is common but not universal (D).

Why is Social Anxiety Disorder (SAD) often comorbid with depression, as in Bonnie’s case?

A. Both disorders are caused by identical neurotransmitter imbalances
B. SAD leads to social isolation and negative self-beliefs, which can contribute to depression
C. Depression directly causes SAD
D. SAD and depression always co-occur in adolescence

Answer: B. Avoidance may prevent learning and practicing social skills

Explanation: Not every patient has social skill deficits, but avoidance often limits opportunities to learn them. Social skills training complements (not replaces) cognitive restructuring and exposure.

In Bonnie’s treatment, social skills training was included because:

A. All individuals with SAD have major social skill deficits
B. Avoidance may prevent learning and practicing social skills
C. It is more effective than cognitive restructuring
D. It eliminates the need for exposure therapy

Answer: B. Anxiety lasting longer than 6 months and causing impairment

Explanation: DSM-5 requires symptoms persisting ≥6 months with significant distress or functional impairment. Normal shyness (A, C, D) does not meet diagnostic threshold unless persistent and impairing.

Which of the following criteria distinguishes normal shyness from a DSM-5 diagnosis of SAD?

A. Fear of speaking in public
B. Anxiety lasting longer than 6 months and causing impairment
C. Avoiding parties due to nervousness
D. Feeling anxious when meeting new people

Answer: A. Patients in the combined condition show greater improvement that lasts at follow-up

Explanation: Research (e.g., Mattick & Peters, 1988) shows both exposure and combined methods help, but combined approaches yield more durable and stronger outcomes.

Which finding best supports the superiority of CBT with exposure plus cognitive restructuring over exposure alone?

A. Patients in the combined condition show greater improvement that lasts at follow-up
B. Patients in exposure-only conditions always relapse
C. Exposure-only treatments are considered ineffective for SAD
D. Cognitive restructuring alone is always sufficient for SAD

Answer: C. 13 years

Explanation: Kessler et al. (2005) found that SAD often begins in childhood or adolescence, with a median onset of 13 years.

According to epidemiological research, what is the median age of onset for SAD?

A. 7 years
B. 10 years
C. 13 years
D. 18 years

Answer: B. Females

Explanation: Unlike most anxiety and mood disorders where females predominate strongly, in SAD the difference is only slight (Magee et al., 1996).

Which group is slightly more likely to have SAD, based on large community surveys?

A. Males
B. Females
C. Children under 10
D. Married individuals

Answer: B. Being single, younger, and lower socioeconomic status

Explanation: SAD is more common in younger individuals (18–29), those with lower education, single status, and lower socioeconomic backgrounds (Magee et al., 1996).

Which factor is most consistently associated with a higher prevalence of SAD?

A. Higher education and stable employment
B. Being single, younger, and lower socioeconomic status
C. Strong family support and community ties
D. Living in rural areas with fewer social demands

Answer: B. Around 20% of SAD patients also meet criteria for a mood disorder

Explanation: SAD frequently co-occurs with depression and other anxiety disorders. About 1 in 5 cases also meet criteria for a mood disorder (Ruscio et al., 2007).

Which of the following is TRUE regarding the comorbidity of SAD?

A. SAD rarely co-occurs with other psychiatric disorders
B. Around 20% of SAD patients also meet criteria for a mood disorder
C. SAD is never diagnosed alongside panic disorder
D. SAD always develops after depression

Answer: B. It fails to address core maintaining factors such as avoidance and cognitive distortions

Explanation: Many SAD patients don’t actually lack skills but rather avoid situations or distort risk. Therefore, social skills training must be combined with CBT strategies (Heimberg & Magee, 2014).

Why is social skills training alone considered inadequate as a treatment for SAD?

A. All SAD patients already have excellent social skills
B. It fails to address core maintaining factors such as avoidance and cognitive distortions
C. It cannot be conducted in group settings
D. It is less credible to patients than supportive therapy

Answer: B. Placebo patients improved significantly but relapsed by 6-month follow-up

Explanation: Supportive therapy improved symptoms due to nonspecific effects (attention, credibility), but CBT patients had stronger, longer-lasting improvements.

In Heimberg et al. (1990), what did the placebo group (educational-supportive therapy) reveal about treatment effects?

A. Placebo patients showed no improvement at all
B. Placebo patients improved significantly but relapsed by 6-month follow-up
C. Placebo patients improved more than CBT patients
D. Placebo therapy prevented relapse better than CBT

Answer: B. Both were effective, but relapse was more common after medication

Explanation: Both CBT and phenelzine produced strong results, but CBT showed longer-lasting effects after treatment ended.

What did Heimberg et al. (1998) find when comparing phenelzine (a monoamine oxidase inhibitor) to CBT for SAD?

A. CBT was effective, phenelzine was not
B. Both were effective, but relapse was more common after medication
C. Phenelzine was superior to CBT at all follow-ups
D. Neither was effective compared to placebo

Answer: B. Cognitive therapy was superior short-term and long-term

Explanation: At posttreatment and 12-month follow-up, cognitive therapy outperformed fluoxetine. Gains were maintained at 5-year follow-up (Mortberg et al., 2011).
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- Prozac (fluoxetine) is an SSRI.

- Prozac is the brand name (or trade name) owned by the company that is used commonly by the people.

- Fluoxetine is the official, standard, medical, and scientific name that is used by health care professionals

In Clark et al. (2003), how did cognitive therapy compare to fluoxetine (Prozac) for SAD?

A. Fluoxetine was superior both short- and long-term
B. Cognitive therapy was superior short-term and long-term
C. Both were equally effective, with no differences
D. Combination therapy was significantly better than either alone

Answer: B. Patients learn skills they can continue applying after treatment

Explanation: Unlike medication, CBT equips patients with cognitive and behavioral strategies that remain useful long after therapy ends.

Which of the following BEST explains why CBT is considered advantageous over medication alone for SAD?

A. CBT cures SAD permanently
B. Patients learn skills they can continue applying after treatment
C. Medication is always less effective in the short term
D. CBT avoids nonspecific factors such as expectancy effects

Answer: B. Patients fearing only a limited set of situations (performance type)

Explanation: Some evidence suggests CBT is particularly effective for circumscribed fears (e.g., public speaking), though Clark et al. (2003) challenged this idea.

Which type of SAD patient may benefit the most from cognitive-behavioral therapy according to some researchers?

A. Patients with generalized anxiety disorder
B. Patients fearing only a limited set of situations (performance type)
C. Patients with psychotic symptoms
D. Patients with severe bipolar disorder

Answer: B. Adding family-based treatment involving parents

Explanation: Family-based CBT (e.g., Kendall et al., 2008) integrates parents into the process, improving outcomes for adolescents with SAD.

Which innovation has made CBT for SAD more effective in adolescents?

A. Using only medication in combination with therapy
B. Adding family-based treatment involving parents
C. Eliminating exposure therapy for younger patients
D. Using shorter, purely didactic group lectures

Answer: B) To allow patients to confront social situations within the group

Explanation: A small group provides opportunities for in-session exposure to social interactions, a core part of SAD treatment.
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Note for Group Therapy: The primary goals of this first meeting were to have each of the group members introduce themselves, establish the ground rules for the group (e.g., importance of attendance, participation, and completion of between-sessions homework), and provide a rationale for the techniques to be covered over the next 15 sessions.

Why was Bonnie’s treatment program intentionally delivered in a small-group format?

A) To reduce treatment costs
B) To allow patients to confront social situations within the group
C) To reduce therapist workload
D) To compare CBT to medication

Answer: B) To identify and correct skill deficits through modeling, rehearsal, and feedback

Explanation: Social skills training is educational: it identifies deficits, models appropriate behaviors, and provides rehearsal/feedback until responses are natural.

Which of the following best describes the purpose of social skills training in SAD treatment?

A) To eliminate all anxiety in social situations
B) To identify and correct skill deficits through modeling, rehearsal, and feedback
C) To replace cognitive restructuring
D) To increase avoidance behaviors

Answer: B) It tested whether CBT worked beyond nonspecific treatment factors such as credibility and attention

Explanation: Supportive therapy served as a credible placebo to rule out nonspecific factors, showing that CBT’s benefits extend beyond placebo effects.

In Heimberg et al.’s (1990) controlled study, what was the significance of using an educational-supportive therapy group as a comparison condition?

A) It was meant to be a weaker form of CBT
B) It tested whether CBT worked beyond nonspecific treatment factors such as credibility and attention
C) It was designed to test medication effects
D) It provided long-term follow-up data only

Answer: B) The combination was no better than CBT or fluoxetine alone

Explanation: Findings showed no added benefit of combining CBT and fluoxetine compared to each treatment individually.
——————————————————————————————-

- Prozac (fluoxetine) is an SSRI.

- Prozac is the brand name (or trade name) owned by the company that is used commonly by the people.

- Fluoxetine is the official, standard, medical, and scientific name that is used by health care professionals

According to Davidson, Foa, & Huppert (2004), what was found when CBT was combined with fluoxetine for SAD?

A) The combination was significantly superior to each treatment alone
B) The combination was no better than CBT or fluoxetine alone
C) The combination caused more relapses than either treatment alone
D) The combination worked only for performance-type SAD

Answer: D) All of the above

Explanation: Avoidance, negative cognitions, and hopelessness are shared features, making individuals with SAD vulnerable to depression

Which of the following features of SAD overlaps with risk factors for depression, helping explain their frequent comorbidity?

A) Situational avoidance and social withdrawal
B) Distorted thoughts predicting negative outcomes
C) Feelings of hopelessness and low self-esteem
D) All of the above

Answer: B) Built-in exposure opportunities with peers

Explanation: Group therapy provides naturalistic opportunities for exposure and peer feedback, which are valuable in treating social fears.

Which of the following is an advantage of group therapy over individual therapy for SAD?

A) Greater anonymity
B) Built-in exposure opportunities with peers
C) Lower effectiveness
D) Less therapist involvement

• SAD and depression share overlapping features such as social withdrawal, avoidance of rewarding activities, negative self-evaluation, and hopelessness.

• Constant fear of judgment and avoidance of social opportunities can reduce social support and lead to isolation, which is a major risk factor for depression.

• Cognitive distortions (e.g., overestimating negative outcomes, harsh self-criticism) also increase vulnerability to depression.

As in the case of Bonnie, many persons experience mood disorders (e.g., major depression) during the course of their SAD. Why do you think this is the case? What features of SAD are similar to the features and possible risk factors of depression?

• Fear of social judgment and evaluation is a near-universal human concern, making SAD more likely to develop.

• Genetic vulnerability, temperamental shyness/behavioral inhibition in childhood, negative social experiences (e.g., bullying, rejection), and overprotective parenting are important risk factors.

• Cultural pressures (e.g., emphasis on performance or public image) may also contribute to its high prevalence.

Like panic disorder, SAD is very prevalent in the general population. Why do you think this is the case? What factors do you believe are the most important causes of SAD?

• Normal social anxiety is mild, temporary, and doesn’t significantly impair functioning.

• A DSM-5 SAD diagnosis requires that anxiety is persistent (6 months or more), excessive compared to cultural norms, and leads to avoidance or clinically significant impairment in social, academic, or occupational functioning.

• Key difference: intensity + interference with daily life.

Some degree of shyness or social anxiety is found in most individuals. What do you think separates normal social anxiety from a DSM-5 diagnosis of SAD?

• Advantages: Built-in exposure to peers, opportunities for social skills rehearsal, feedback from multiple sources, normalization of experiences (“I’m not alone”), cost-effectiveness.

• Disadvantages: Less individualized attention, some patients may feel too anxious to participate, group dynamics may be uncomfortable, confidentiality concerns.

Bonnie received group treatment for her social anxiety. What are the advantages and disadvantages of group treatment (versus individual treatment) as an intervention for SAD?