Social Anxiety Disorder Notes

Social Anxiety Disorder

Learning Outcomes

  • Understand the prevalence of Social Anxiety Disorder.
  • Understand the diagnostic criteria for Social Anxiety Disorder.
  • Understand the causes of Social Anxiety Disorder.
  • Understand the cognitive model of Social Anxiety Disorder.
  • Understand how CBT for Social Anxiety Disorder works.
  • Understand how effective CBT for Social Anxiety Disorder is.

The Basics

  • Prevalence:
    • Varies from study to study.
    • Lifetime prevalence around 13% (Szuhany et al., 2022). Women are more likely to have it or acknowledge it.
    • Present in 0.8% of British 5-19 year olds in 2017 (files.digital.nhs.uk).
    • Up from 0.32% of British children aged 5-15 in 1999 (Ford et al., 2003). Girls more likely to report than boys.
  • Onset:
    • Theoretically, adolescence.
    • Often signs are present much younger.
  • Outcomes:
    • Risk of substance misuse (e.g., Turner et al., 2018).
    • Risk of depression (e.g., Koyuncu et al., 2019).

Diagnosis: DSM V

  • Marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or possible scrutiny by others.
  • Exposure evokes an immediate anxiety reaction.
  • The fear is irrational.
  • Feared situation is avoided.
  • Avoidance interferes with ‘normal’ life.
  • Minimum duration is 6 months.
  • Not better explained by another diagnosis.

What Causes Social Anxiety Disorder?

Can be explained on a number of overlapping, non-mutually exclusive levels.

  • Genes:
    • Genes have a part to play, but it's not the whole picture.
    • A meta-analysis of twin studies produced a mean heritability of 0.65 (Beatty et al., 2002).
  • Early Environment:
    • Some evidence suggests that early parenting styles characterized by overprotection and modeling of social avoidance can increase the risk (e.g., Yaffe, 2021).
    • Early Shaming Experiences (Eg Swee et al (2021))

The Cognitive Model of Social Anxiety

  • Social anxiety used to be treated using ‘social skills’ programs (and often still is, for children).
  • Newer models propose that social anxiety is not always a function of social skill deficits.

Cognitive Model of Social Anxiety (Clark & Wells, 1995)

  • People with social anxiety think that they have social skills deficits.
  • They often don’t; they just think that they do (Lots of papers by David Clark & colleagues).
  • These beliefs cause them to act and think in ways that maintain the anxiety.

Clark & Wells' Model

The model illustrates the following sequence:

  1. Social Situation: A social context that triggers anxiety.
  2. Activates Assumptions: Negative beliefs and assumptions about oneself in social situations (e.g., "I am boring," "I'm useless at small talk.").
  3. Perceived Social Danger: The interpretation of the social situation as dangerous or threatening due to activated assumptions.
  4. Processing of Self as a Social Object: Focusing attention on oneself and how one appears to others.
  5. Somatic & Cognitive Symptoms: Experiencing physical symptoms of anxiety (e.g., sweating, trembling) and cognitive symptoms (e.g., attentional biases, misinterpretation of ambiguous information).
  6. Safety Behaviors: Actions taken to prevent feared negative outcomes (e.g., avoiding eye contact).

Somatic and Cognitive Symptoms

  • Somatic symptoms of anxiety:
    • Sweating
    • Trembling
    • Butterflies in stomach
  • Cognitive symptoms:
    • Attentional biases
    • Misinterpretation of ambiguous information
Selective attention to socially threatening stimuli
  • The Dot Probe Design
Attentional Bias to Social Threat
  • Dot-Probe Task (e.g., Mansell & Clark 1999).
  • Studies using faces (not words) have shown tentative support for both vigilance and avoidance.
  • Little evidence for a causal role (at present).
Perspective Taking Rating Task
  • If you were looking at yourself as if through someone else’s eyes, you were using the observer perspective.
  • If you were looking out through your own eyes, then you were using the field perspective.
  • The observer perspective is more common in people with social anxiety disorder. It may be problematic because you don’t see what is really going on…you have to ‘make up’ what you think the audience saw:
    • This means you don’t have any real info on which to base your judgments of their performance, and so,
    • If you are anxious, you will use other information to base your judgment on. This is likely to be biased interoceptive info, such as you are feeling physically, and this is likely to lead to negative conclusions.

Safety Behaviors (Salkovskis, Clark, & Gelder, 1996)

These are behaviors that anxiety sufferers sometimes engage in because they believe that they will prevent some negative outcome.

  • But, they can make things worse:
    • Can make the person’s behavior appear unnatural.
    • Stops them finding out that the feared consequence wasn’t going to happen anyway.
    • Distracts the person, meaning that they don’t give the situation their full attention.
Examples of safety behaviors in social anxiety:
  • Grasping a glass tightly for fear of shaking and spilling it.
  • Avoiding eye contact for fear of seeing that people are bored/laughing at you.
  • Wearing thick, dark clothes to avoid showing sweat marks.

Before and after the Interaction

  • ‘Pre-Mortem’
    • Prior to entering a feared situation, social phobics review the likely run of events.
    • Recollection of past failures
    • This can lead to avoidance
  • ‘Post-Mortem’
    • Post-event processing (Rachman, Grüter- Andrew & Shafran, 2000).
    • Makes matters worse (Increases anxiety?)
    • Intrusive thoughts
    • Distorted Memories

CBT for Social Anxiety

  • Identify and modify assumptions.
  • Identify and modify safety behaviors.
  • Behavioral Experiments
    • Test out whether predicted catastrophes come true.
  • Dealing with the pre- and post-mortem.

Efficacy of Treatment for Social Anxiety

  • Mayo-Wilson et al (2014) meta-analysis
    • Medium effect of Individual CBT when compared to a placebo treatment (SMD=0.56SMD = 0.56).
    • Medium effect of Individual CBT when compared to psychodynamic psychotherapy (SMD=0.56SMD = 0.56).
    • Small-Medium effect of SSRIs/SNRIs when compared to pill placebo (SMD=0.44SMD = 0.44).

Efficacy of CBT for Social Anxiety for Children

  • Much less evidence for what works with children and adolescents, but Scaini et al (2016) managed a meta-analysis and found a long-term effect size of 1.18.
  • CBT probably better if focused on social anxiety, rather than on anxiety in general.

Further Reading

Core
  • Chapter Eight (Social Anxiety p199-218), from Field, M., & Cartwright-Hatton, S., (2015) Essential Abnormal and Clinical Psychology.
Secondary
  • NICE Guideline for the Treatment of Social Anxiety Disorder. http://guidance.nice.org.uk/CG159
  • Clark, D. (2011) Cognitive Therapy of Anxiety Disorders: Science and Practice.
  • “Quiet”. Susan Cain (2013).

References

  • Beatty, M. J., Heisel, A. D., Hall, A. E., Levine, T. R., & La France, B. H. (2002). What can we learn from the study of twins about genetic and environmental influences on interpersonal affiliation, aggressiveness, and social anxiety?: A meta-analytic study. Communication Monographs, 69(1), 1-18.
  • Clark, D. M., & Wells, A. (1995). A Cognitive Model of Social Phobia. In R. G. Heimberg & M. R. Liebowitz (Eds.), Social Phobia: Diagnosis, Assessment, and Treatment. New York: The Guilford Press.
  • Ford, T., Goodman, R., & Meltzer, H. (2003). The British Child and Adolescent Mental Health Survey: The Prevalence of DSM-IV Disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 42(10), 1203-1211.
  • Grant BF, Stinson FS, Hasin DS, Dawson DA, Chou SP, Ruan WJ, et al. Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. The Journal of clinical psychiatry. 2005 Oct;661123(Suppl. 10):1205-15.
  • Koyuncu, A., İnce, E., Ertekin, E., & Tükel, R. (2019). Comorbidity in social anxiety disorder: diagnostic and therapeutic challenges. Drugs in context, 8.
  • Mansell, W., Clark, D. M., Ehlers, A., & Chen, Y. P. (1999). Social Anxiety and Attention away from Emotional Faces. cognition and emotion, 13(6), 673-690.
  • Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A. E., & Pilling, S. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 1(5), 368- 376
  • Rachman, S., Gruter-Andrew, J., & Shafran, R. (2000). Post-event processing in social anxiety. Behaviour Research and Therapy, 38(6), 611–617.
  • Salkovskis, P. M., Clark, D. M., & Gelder, M. G. (1996). Cognition-behaviour links in the persistence of panic. Behaviour Research and Therapy, 34(5-6), 453–458.
  • Scaini, S., Belotti, R., Ogliari, A., & Battaglia, M. (2016). A comprehensive meta-analysis of cognitive-behavioral interventions for social anxiety disorder in children and adolescents. Journal of Anxiety Disorders, 42, 105-112.
  • Swee, M. B., Hudson, C. C., & Heimberg, R. G. (2021). Examining the relationship between shame and social anxiety disorder: A systematic review. Clinical psychology review, 90, 102088.
  • Szuhany, K. L., & Simon, N. M. (2022). Anxiety disorders: a review. Jama, 328(24), 2431-2445.
  • Turner, S., Mota, N., Bolton, J., & Sareen, J. (2018). Self‐medication with alcohol or drugs for mood and anxiety disorders: A narrative review of the epidemiological literature. Depression and anxiety, 35(9), 851-860.
  • Yaffe, Y. (2021). A narrative review of the relationship between parenting and anxiety disorders in children and adolescents. International Journal of Adolescence and Youth, 26(1), 449-459.
  • https://files.digital.nhs.uk/14/0E2282/MHCYP%202017%20Emotional%20Disorders.pdf