Clinical Psychology in Practice - Social Anxiety Disorder Study Notes

Clinical Case Analysis

  • Identify the following components:

    • Cognitions

    • Behaviours

    • Affect (emotional responses)

    • Physiology (bodily responses)

  • Identify evidence of functional impairment in daily life.

  • Identify informants who can contribute to the assessment.

What is SAD?

DSM-5 Diagnostic Criteria:

  1. Marked fear or anxiety about one or more social situations where individual may be under scrutiny by others.

    • Note: In children, anxiety must occur in peer settings, not just with adults.

  2. Social situations typically provoke fear or anxiety.

    • Note: In children, may express this via crying, tantrums, freezing, clinging, shrinking, or failing to speak.

  3. Fear or anxiety is disproportionate to the threat posed by the situation.

  4. Avoidance of social situations or endurance with intense anxiety.

  5. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  6. Persistent, lasting for 6 months or more.

Assessment: Structured Clinical Interviews

  • Semi-Structured Interview Guide (e.g. ADIS-5, SCID-5):

    • Often used in specialized clinics or research.

    • Provides valuable information for diagnosis but is time-consuming.

    • In children, informants may include both the child and parents.

Symptom Questionnaires

  • Important Note: Questionnaires alone are not diagnostic tools.

  • Tools and Their Functions:

    • Social Phobia Scale (SPS) and Social Interaction Anxiety Scale (SIAS) (Mattick & Clarke, 1998):

    • Assess fears of scrutiny during daily activities and fear of social interactions.

    • Cutoff Scores: 24 (SPS) and 34 (SIAS) may be used for screening but not diagnosis.

    • Liebowitz Social Anxiety Scale (Liebowitz, 1987):

    • A comprehensive scale for social anxiety evaluation.

Cognitive Questionnaires for Social Anxiety

  • Important Note: Questionnaires alone are not diagnostic tools.

  • Brief Fear of Negative Evaluation Scale (BFNE-II) (Carleton et al, 2007):

    • One of the most utilized scales for assessing dimensions of social-evaluative anxiety.

    • Updated versions have improved psychometrics from the original scale (Fear of Evaluation Scale, Watson and Friend, 1969).

    • Sample Items:

    • “I am afraid that others will think poorly of me.”

    • “I am often concerned about what others think of me.”

Reflective Questions for Therapists

Initial Considerations for Treatment Assessment:

  • How might social anxiety affect the therapeutic relationship?

  • Could symptoms of SAD hinder the client’s ability to engage with therapy, such as feelings of scrutiny?

  • Are safety behaviors being employed during therapy interactions?

  • Assess for comorbid conditions.

Treatment Options for SAD

  1. Individual CBT:

    • Specifically designed to manage social anxiety based on the Clark and Wells (1995) model and Heimberg model.

  2. Pharmacological Alternatives:

    • If clients decline CBT, discuss their reasons for this decision, address concerns, and consider offering selective serotonin reuptake inhibitors (SSRIs).

  3. Short-Term Psychodynamic Psychotherapy:

    • An alternative for adults declining both CBT and pharmacological interventions but less effective than CBT and other methods.

Influencing Factors for Treatment Offers:

  1. Patient/client choice, especially when multiple effective treatments exist.

    • Example Reference: Lindhiem et al. (2014) emphasized the impact of client preferences on treatment satisfaction and completion.

  2. Co-morbid conditions impact which issues should be addressed first.

  3. Client presentation (e.g., intellectual disabilities, suspected dementia) may influence treatment modality.

  4. Service provisions and available resources.

Cognitive Model of SAD (Clark & Wells, 1995; Clark, 2001)

Overview of Cognitive Model Assumptions:

  1. Assumptions Developed from Early Experiences:

    • Excessively high performance standards (e.g., “I must always be fluent/confident”).

    • Conditional beliefs concerning consequences of performance (e.g., “If I turn red, people will think I am weak”).

    • Unconditional negative beliefs about self (e.g., “I am unlikeable/boring/stupid”).

Self-Processing and Evaluation:

  • Individuals with SAD perceive a risk of negative evaluation by others, leading them to:

    • Shift their attention to self-monitoring (“processing the self as a social object”).

    • Gather internal information to infer how they appear to others and what they may think.

Symptoms and Safety Behaviours:

  • Experiencing perceived social danger/threat triggers somatic and cognitive symptoms (e.g., anxiety, sweating, difficulty breathing).

  • Safety behaviours can prevent the individual from confirming their fears and may inadvertently draw attention (e.g., speaking quietly due to fear of trembling voice).

Anticipatory Phase

  • The period preceding social events is marked by heightened anxiety and worry about potential outcomes.

  • Triggering cues include:

    • Invitations to social events, passing locations where events occur.

  • Higher anticipatory anxiety increases the likelihood of avoiding social events.

  • Pre-existing maladaptive self-schemas are activated, leading to:

    • Feelings of vulnerability and inadequacy in meeting expected standards.

    • Biased recollection of past social events, focusing on negative experiences of anxiety and embarrassment.

Post-Event Processing

  • Involves ruminating after an event, focusing on reconstructed versions of experiences.

  • This cognitive process plays a key role in maintaining social anxiety as one re-evaluates their performance.

Cultural Considerations in SAD

  • The presentation and experience of social anxiety may vary based on cultural factors.

  • Example:

    • Taijin kyofusho (TKS): Fears principally about interpersonal interactions and negative evaluation.

    • Offensive subtype involving thoughts about being flawed or inappropriate, leading to fears of offending others.

    • Aymat zibur: A specific fear in ultra-orthodox Jewish men relating to public speaking about religious matters.

Psychological Formulation

  • Idiosyncratic Formulation:

    • A psychological understanding of the individual's issues based on:

    • Personal history and traits.

    • Psychological theory/research.

    • Formulation should be a collaborative process with the client, addressing:

    • Thoughts, feelings, and behaviors related to anxious situations.

Clinical Formulation: Alex's Difficulties (Clark & Wells Model)

Analysis Components:

  • Social Situation: Attending a party.

  • Assumptions/Thoughts:

    • “I must make a good impression.”

    • “I need something interesting to talk about.”

    • “If I appear unconfident, others will think I am weak.”

  • Self-Focus and Image:

    • Concern about looking anxious/red in the face.

  • Symptom Manifestation:

    • Mind racing, flushed face, tachycardia.

  • Safety Behaviors:

    • Avoiding eye contact.

    • Speaking quietly or not at all.

    • Leaving social situations early.

Anticipatory and Post-Event Processing in Alex's Formulation

  • Anticipatory Phase:

    • Worries about upcoming events like parties or presentations.

  • Post-Event Processing:

    • Replay episode of party focusing on his anxiety and response capabilities.

Benefits of a Good Formulation

  • Assists clients in comprehending their difficulties.

  • Provides a clear treatment roadmap within the CBT framework.

Treatment Approach: CBT (Clark & Wells Model)

  • Recommendations:

    • Up to 14 sessions of 90 minutes.

    • Establish treatment goals.

    • Provide psychoeducation about SAD.

    • Incorporate behavioral experiments to demonstrate adverse effects of negative self-focus.

    • Use video feedback to correct misperceptions of self.

    • Train in externally focused self-attention techniques.

    • Address modification of pre/post-event processing areas.

    • Implement relapse prevention strategies.

Video/Audio Feedback: Methodology and Rationale

Aims of Video Feedback:

  1. To illustrate how individuals appear to others versus their self-image.

  2. To showcase safety behaviors and associated impacts on perceptions.

  3. To decrease self-focused attention and negative evaluations of social performance.

  4. Serve as a less anxious form of exposure within sessions.

Hypothesis Testing via Feedback

  • Models treatment strategies addressing focus on negative self-image.

Outcome of Video Feedback

  • Behavioral Experiment Findings:

    • Participants often find performance less detrimental than anticipated; e.g., Alex identified less blushing than expected.

    • Audience impressions typically varied with behaviors, highlighting perceptions differing from client fears.

Attention Training: Objectives and Execution

  • Aim: Shift focus of attention from self-perception to engagement with others during social interactions.

  • Practice Techniques:

    • Non-social (outside practice) including auditory or olfactory stimuli.

    • Social (in-situ practice) aiming to immerse in conversations and shift attention from self-monitoring to external observation.

Homework for Treatment

  • Implement behavioral experiments targeting core beliefs that drive SAD.

  • Example Experiment Record Sheet Components:

    • Target cognition and predictions.

    • Outcomes and lessons learned.

    • Rating beliefs and potential modifications.

    • Real-life testing engagement, dropping safety behaviors, and actual experience outcomes.

Evaluation of Treatment Efficacy

  • Study with 60 patients diagnosed with SAD assigned to:

    1. Cognitive therapy (CT)

    2. Fluoxetine plus self-exposure (FLU + SE)

    3. Placebo plus self-exposure (PLA + SE)

  • Findings:

    • CT demonstrated superiority in reducing social phobia compared to both FLU + SE and PLA + SE during mid-treatment and was found superior at a 12-month follow-up.

    • Minimal differences on general mood measures across treatments.