SOCIAL ANXIETY DISORDER (SAD)

SOCIAL ANXIETY DISORDER

Occurs when individuals develop a persistent fear of situations that are social or performance-focused and believe that they will behave in an anxious and embarrassing manner

  • Exposure to social situations provokes anxiety, the individual knows this fear is generally unwarranted, but they avoid these situations or endure them with distress. This results in a negative impact on their life, which endures for at least six months

  • A defining feature of SAD is the struggle to develop realistic perceptions of themselves in the eyes of others, or in the case of “social slip-ups” a balanced appraisal of the consequences

  • Consequently, they are primed to feel very anxious, and motivated to use strategies to prevent exposure and its painful social consequences

COURSE AND COMORBIDITY

  • Onset in adolescence to age 25

  • Course is chronic and unlikely to resolve without treatment

  • Has comorbidity rates between 61-81% (Fehm and Wittchen, 2004)

    • Of those who present with SAD, 61% also meet the criteria for Avoidant Personality Disorder (APD; Sanderson et al., 1994)

    • SAD more likely to occur alongside substance use, odds of using alcohol and cannabis 4-6x higher for SAD sufferers (Buckner et al., 2008)

    • Level of co-morbidity also predicts degree of socio-occupational impairment

RISK FACTORS

  • Familial Psychopathology (Bandelow et al., 2004)

  • Maternal Stress: related to behavioural inhibition by the age of 9

  • Behavioural Inhibition: 7x increase in risk for SAD, 10x risk of developing SAD two years later

  • Memories of Social Trauma: imagery in SAD linked with historical social trauma, embarrassment or humiliation. (Hackmann, Clark & McManus, 2000) Report high levels of social trauma before adolescent onset of SAD. High levels of PTS symptoms in this group

  • Repetitive Negative Thinking: Considered a transdiagnostic risk factor for various anxiety and depressive disorders (Newman et al., 2017; Newman et al., 2013)

  • Contrast Avoidance: A sensitivity to sharp changes in emotion, particularly increase in negative and decrease in positive emotion. Worry increases anxiety but inhibits surges of negative affect when during stressful events

FUNCTIONAL IMPACT

Psychological Impact

  • Untreated SAD is a powerful risk factor for subsequent substance use and MDD episodes (Buckner et al., 2008)

  • Shame and stigma were the main reason for not presenting for treatment (Goetter et al., 2020)

Educational Impact

  • Earlier onset of social anxiety can undermine scholastic achievement, heightening the risk of dropping out early and leaving with poorer qualifications

  • Sadly, this factor would put sufferers in the strata for higher prevalence of SAD due to socio-economic status (Kessler et al., 2005)

ECONOMIC

  • People with SAD were earning 10% less than the normal, non-clinical population (Katzelnick et al., 2001)

OCCUPATIONAL

  • SAD is associated with increased volume of sick leave and decreased productivity when in employment

SOCIAL

  • Those suffering with SAD have fewer friends and struggle to maintain these relationships. Compared to the normal population, they are less likely to have children, less likely to get married and more likely to get divorced

COGNITIVE MODEL

  • There is a preoccupation with the threat of being revealed as socially unacceptable, either through behaviour or anxious presentation, leading to negative evaluation and rejection

  • doubt their ability to make positive impressions amplifying the distressing event of social unacceptability

  • Negative bias for ambiguous social situations, catastrophic interpretations of mildly negatives, and neutral interpretation of positive ones

Stressful Event

  • When a socially anxious person enters a social situation, this activates core beliefs, assumptions and rules for social performance

Beliefs and Biases

  • These set the conditions for perceiving a social danger, which takes the form of negative automatic thoughts

Hyperarousal Symptoms

  • This generates anxiety symptoms

Safety Behaviours

  • This activates safety behaviours to protect oneself from the perceived threats

  • These behaviours are also experienced as socially threatening since they may be visible and odd to others, increasing anxiety further

Self Focused Attention

  • Attention is directed onto bodily events that might trigger feared outcomes. Sensations then determine how they look to others

  • Internal sensations of anxiety are appraised as visible, leading the individual to assume others are as acutely aware as they are

  • These sensations are then translated into spontaneous imagery, however this is not what other people witness

Implications

  • Self Focused Attention increases belief in anxiety visibility, motivating safety behaviours which generate the reactions they wish to avoid

  • This reinforcing self focused attention decreasing attention to social cues and disrupts social performance

  • Confirmatory experience is internally-generated and disconfirming experience from the social element remains unnoticed, resulting in significant anxiety-reinforcing distortions in perception

SAFETY BEHAVIOUR

  • Safety-seeking behaviours serve the function of protecting the anxious individual from the threat they perceive (Kennerly et al., 2017)

    • safety behaviours intended to prevent predicted catastrophe and selectively attend to stimuli perceived as threatening. however, these behaviours have negative social impact and prevent disconfirmation of this preoccupation with danger

    • short-term safety behaviours provide relief, long-term have unintended side effects

    • prevents the underlying belief from being disconfirmed, and failure of the threat to emerge attribute to safety effects rather than invalidate them

COGNITIVE FACTORS

Pre Event Processing

  • Often worry for long periods in anticipation of stressful and problematic social encounters

  • involves planning safety behaviours in the face of predicted catastrophes

  • this pre-event worry and processing activates the negative self image

Post Event Processing

  • after the event is endured with distress, the individual ruminates about their performance and the social context

  • but, they were focused on themselves and their own self-image during the event, so nothing new is learned, and the beliefs are inadvertently confirmed

  • this reinforces negative self-image, catastrophe predictions, and the anticipated need for the safety-behaviours and self-focus

SELF-FOCUSED ATTENTION

  • create distorted self-referent images from the perceptive of their observers. this increases anxiety and impairs judgement of anxiety visibility and social performance (Clark & Ahmad, 1998; Hackmann et al., 1998)

  • process social cues less but biased toward detecting negative facial cues in observers, neglecting other cues (Winton, Clark & Edelmann, 1995)

  • Hirch et al, 2003

    • SAD patients conversed with a stranger, once while maintaining negative self-imagery, and then counterbalanced with a neutral image

    • Negative Image Condition: greater anxiety, anxiety rated as more visible, and performance underrated compared to observer

      • these results support the hypothesis that negative self-imagery plays a causal and maintaining role in SAD

CBT FOR SAD TREATMENT COMPONENT

Exposure Therapy

  • Early studies show poorer outcomes of exposure alone for SAD (Butler et al., 1984)

Meta-Analysis

  • Cognitive Therapy with exposure for SAD was superior to control and placebo at both port-treatment and follow-up (Taylor, 1996)

Systematic Review and Meta-Analysis

  • Studies for SAD indicate cognitive therapy was moderately affective and end of treatment, moderately effective at 1-6 month follow-up, and mildly effective at 6-12 month follow up. Shows CBT effective for SAD, but gains are sometimes gradually lost overtime

  • Virtual reality therapy and cognitive behavioural therapy were equally effective for performance-scenario focused SAD (Wong et al., 2023)

Behavioural Experiments

  • Increase / decrease self-focused attention

  • Increase external focus

  • Increase / decrease use of safety behaviours

  • Document and discuss the effect of these exercises on the following:

    • Subjective sense of self-consciousness

    • Subjective sense of anxiety

    • The observed self as experienced in the imagery of felt sense

Substitute Imagery

  • Substituting the self-focused imagery for more neutral images has been shown to reduces anxiety in social anxiety disorder (Hirsch et al., 2003)

  • Creating a change in this domain will allow Jack to see the role that observer-perspective imagery plays in maintaining social anxiety

Imagery Rescripting

  • The spontaneous imagery experienced by the socially anxious is thought to be thematically linked with historical social trauma, embarrassment or humiliation (Hackmann et al., 2000)