Social Anxiety Disorder (SAD)

Focus on identifying cognitions, behaviour, affect, and physiology that relate to the clinical case.
Identify any evidence of functional impairment associated with the disorder.
Identify informants close to the patient.

Profile: 17-year-old high school student recently relocated.
Symptoms/Behaviours:
- Appeared cautious and unsure during therapy.
- Avoided eye contact and spoke softly.
- Admitted difficulty connecting with classmates and avoided meeting anyone new.
- Shared issues with mandatory oral presentations, causing significant anxiety (e.g., trembling, difficulty breathing).
- Refusal to attend school; absence of 1-2 full school days per week.
- Reported a positive relationship with mother and sisters, a strained relationship with stepfather.

Mother's Insights:
- Alex was well-behaved until three years ago post-parental separation, deterioration noted recently.
- Claims of maintaining friendships contradicted by parents; Alex mainly spends time alone and wished to be homeschooled.
- Teachers noted his academic potential but described him as shy and withdrawn, avoiding social engagements and teamwork.

Therapy Progress:
- Alex expressed overwhelming anxiety, particularly about being noticed for physical symptoms like blushing.
- Concern that peers would view him as abnormal or weak; struggled with first impressions leading to anticipatory anxiety around social events such as parties.
- Account of anxiety visualization: felt heart racing, mind racing, and fear of blushing, leading to perceived judgment from others.

Responses to Anxiety:
- Experiencing heart pounding worsened his fear of embarrassment, leading to attempts to hide his anxiety by looking down.
- Post-party memory: felt exposed, judged; decision to leave early reinforced beliefs about social situations being overwhelming.

Marked fear/anxiety about one or more social situations where potential scrutiny is present (in children, anxiety must occur in peer settings).
Social situations almost always provoke fear/anxiety (in children, expressed through crying, tantrums, freezing, clinging, or talking less).
Fear/anxiety is disproportionate to actual threat.
Social situations are avoided or endured with intense anxiety.
Causes clinically significant distress/impairment in social or occupational functioning.
Persistent duration typically lasts for 6 months or more.

Methods Used: Semi-structured interview guides (e.g., ADIS-5, SCID-5) commonly employed for DSM-5 diagnostics, particularly in specialist clinics.
- Provide extensive information for guiding diagnosis but are time-consuming.
- In paediatric assessments, informants can be children and/or parents.

Note: Questionnaires alone are not diagnostic tools.
Instruments:
- Social Phobia Scale (SPS) and Social Interaction Anxiety Scale (SIAS) assess scrutiny fears in everyday activities.
- Examples of Items:
  - SPS: "I become anxious if I have to write in front of other people."
  - SIAS: "I get nervous if I have to speak with someone in authority."
- Cutoff scores: 24 (SPS) and 34 (SIAS) may be useful for screening.
- Liebowitz Social Anxiety Scale (1987) mentioned for comprehensive assessment.

Purpose: Assess dimensions of social-evaluative anxiety.
Instrument: Brief Fear of Negative Evaluation Scale (BFNE-II) measures cognitive components of social anxiety.
- Example Items:
- "I am afraid that others will think poorly of me."
- "I am often worried about what others think of me."
- Versions have evolved to improve psychometric properties since the original scale.

Consider how social anxiety might affect the therapeutic relationship.
Symptoms of SAD could hinder a client's ability to engage if feeling scrutinized.
Assess for safety behaviours during interactions.
Consider potential comorbid conditions impacting therapy.

Individual CBT models specifically created for SAD (based on Clark & Wells model).
For clients preferring pharmacological interventions:
- Discuss reasons for declines in CBT and address concerns.
- SSRIs are recommended if proceeding with medication.
For clients declining both CBT and pharmacological options:
- Short-term psychodynamic psychotherapy may be considered, though its efficacy is lower compared to CBT and pharmacological interventions.

Patient/Client Choice: Influences satisfaction and completion of treatment (Lindhiem et al., 2014).
Co-morbidity: Consideration of which issues to prioritize initially.
Client Presentation: Special considerations for disabilities or suspected dementia.
Service Provision: Availability and access to different treatment modalities.

Proposes that individuals with SAD develop assumptions based on early experiences, evident in:
1. High Performance Standards: E.g., "I must always be fluent/confident."
2. Conditional Beliefs: E.g., "If I blush, others will think I am weak."
3. Unconditional Negative Self-Beliefs: E.g., "I am unlikable/boring/stupid."

Individuals at risk of negative evaluation focus on self-monitoring ('processing the self as a social object').
They use self-monitoring information to infer impressions others have of them.

Results in somatic and cognitive symptoms such as:
1. Palpitations, sweating, difficulty breathing.
2. Safety Behaviors: Actions taken to avoid perceived negative outcomes that unwittingly reinforce fears.

Leading up to a social event; increased anxiety related to potential outcomes.
Negative self-schemas activate pre-existing concerns about social performance, leading to biased recollections of past events.

Involves ruminating on the event afterwards, fostering maintenance of social anxiety through distorted recollections of performance.

Cultural Variations: Expression and experience of SAD can vary significantly.
Taijin Kyofusho: Emphasizes fears of offending others.
Aymat Zibur: Notable fear primarily reported among ultra-Orthodox Jewish men relating to specific religious interactions.

Recap of Key Topics Covered:
1. Definition of SAD.
2. Cognitive model explaining SAD symptoms, assessment, formulation, and treatment interventions.

Clark, D. M., Ehlers, A., McManus, F., Hackmann, A., Fennell, M., Campbell, H., Flower, T., Davenport, C., & Louis, B. (2003). Cognitive therapy versus fluoxetine in generalized social phobia: a randomized placebo-controlled trial. Journal of Consulting and Clinical Psychology, 71(6), 1058-1067.
Clark, D. M., Wells, A. (1995). A cognitive model of social phobia. In: Heimberg, R. G., Liebowitz, M. R., Hope, D. A., & Schneier, F. R. (Eds.), Social Phobia: Diagnosis, assessment and treatment (pp. 69-93). New York: Guilford Press.
Lindhiem, O., Bennett, C. B., Trentacosta, C. J., & McLear, C. (2014). Client preferences affect treatment satisfaction, completion, and clinical outcome: a meta-analysis. Clinical Psychology Review, 34(6), 506–517.
Mayo-Wilson, E., Dias, S., Mavranezouli, I., Kew, K., Clark, D. M., Ades, A., & Pilling, P. (2014). Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis. The Lancet Psychiatry, 5, 368-376.