W3/L3: Social Anxiety Disorder (SAD)
1. Introduction to Social Anxiety Disorder (SAD)
### Definition:
- Marked fear or anxiety in social situations where an individual may be scrutinized by others.
- Common in scenarios like public speaking, meeting new people, or being observed.
- Fear is disproportionate to the actual threat posed by the situation.
- The social situations are avoided or endured with intense anxiety.
- Causes significant distress or impairment in social, occupational, or other important areas of functioning.
- Duration: Fear, anxiety, or avoidance must persist for 6 months or more.
### Key Distinctions:
- SAD is different from shyness. Shyness may occur in certain situations, while SAD impacts daily life and doesn’t subside.
- Affects self-confidence, identity, and self-esteem, as well as relationships and work or school performance.
- Fear vs. Anxiety: Fear is a response to immediate threats; anxiety focuses on future possible threats.
- Common fears include:
- Embarrassment or humiliation in social interactions.
- Physical symptoms: Blushing, sweating, shaking.
- Cognitive symptoms: Worry about seeming boring, stupid, or strange.
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## 2. Prevalence and Onset
### Statistics:
- Lifetime prevalence: 12% (Kessler et al., 2005), based on surveys of over 10,000 adults.
- Women are more likely to report SAD.
- Children: In 2017, 0.8% of British children aged 5-19 were diagnosed with SAD, up from 0.32% in 1999.
- Girls are more likely to report SAD than boys.
- Lower prevalence is observed in collectivist societies.
### Outcomes:
- SAD is associated with a higher risk of:
- Substance misuse.
- Depression (Grant et al., 2005).
- Limited career prospects and relationship challenges (though not always).
- SAD is often comorbid with other psychological disorders.
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## 3. Diagnostic Criteria (DSM)
- Persistent, marked fear of one or more social or performance situations.
- Fear or avoidance behavior disrupts normal life.
- Minimum duration of symptoms: 6 months.
- Symptoms are not due to substance use, medications, or another diagnosis (e.g., panic disorder).
### Criteria for Children:
- Anxiety must occur in peer settings, not just with adults.
- Children may express fear by crying, tantrums, freezing, clinging, or failing to speak in social situations.
- Fear is out of proportion, considering the sociocultural context.
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## 4. Possible Causes of SAD
### 1. Genetic Factors:
- A meta-analysis of twin studies found a mean heritability of 0.65 (Beatty et al., 2002), suggesting a strong genetic component.
### 2. Early Environment:
- Parenting styles characterized by overprotection or modeling social avoidance can increase SAD risk.
### 3. Early Shaming Experiences:
- Parents or authority figures can amplify negative appraisals, contributing to the development of SAD.
### 4. Evolutionary Perspective:
- SAD can be seen as a protective strategy designed to prevent social rejection or exclusion.
- Based on group survival, where social cooperation is necessary for individual and group well-being.
- Affiliation System: Focuses on trust and cooperation to form bonds and relationships.
- Social Rank System: Monitors social status to regulate behavior and prevent costly group conflicts.
### Evolutionary Explanation:
- SAD is an overactive system that doesn’t stop once the threat is gone, leading to excessive monitoring of facial expressions, eye contact, and emotional responses.
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## 5. Cognitive-Behavioral Models of SAD
### 1. Heimberg’s Cognitive-Behavioral Model:
- Focuses on how SAD is maintained by the individual’s perception of constant social evaluation.
- Individuals assume others have high standards and judge them negatively.
- This perception leads to negative self-evaluation, worsening the anxiety and reinforcing avoidance behaviors.
### 2. Clark & Wells’ Cognitive Model (1995):
- Individuals with SAD often believe they have social skills deficits, even when they do not.
- Social situations are perceived as dangerous, triggering negative thoughts about one’s abilities (e.g., “I sound funny,” “People are laughing at me”).
- Individuals process themselves as if they are objects being scrutinized by others, which amplifies the anxiety.
- Safety behaviors (e.g., avoiding eye contact, playing with hands) are employed to cope with the anxiety, but these behaviors reinforce the negative self-appraisal.
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## 6. Treatment of SAD
### NICE Guidelines:
- Individual Cognitive Behavioral Therapy (CBT) is the preferred treatment for SAD, based on the cognitive models discussed.
- Treatment goals: Setting clear, measurable goals in collaboration with the patient.
- Psychoeducation: Explaining the nature of SAD and how cognitive and behavioral patterns contribute to maintaining the disorder.
### CBT Techniques:
1. Exercises: Demonstrate the negative effects of self-focus and safety behaviors.
2. Video-feedback: Helps correct distorted self-imagery, providing an objective view of how one appears in social situations.
3. Attention Training: Teaches individuals to focus on external stimuli instead of their internal anxiety.
4. Homework: Involves practicing attention training and facing social situations in a controlled manner.
5. Pre- and Post-Event Processing: Changing the way individuals appraise situations before and after they occur to reduce anticipatory anxiety and negative reflections.
6. Relapse Prevention: Preparing for potential setbacks to maintain progress.
### Effectiveness:
- CBT shows an effect size of 0.56, making it more effective than medication (effect size: 0.44).
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### Summary
- SAD is a chronic anxiety disorder centered around fear of social scrutiny and negative evaluation.
- The cognitive-behavioral models explain how negative self-perceptions and social evaluation contribute to maintaining SAD.
- Treatment primarily involves CBT, focusing on modifying negative thought patterns and behaviors through targeted interventions and psychoeducation.