Lecture 3- social anxiety disorder Flashcards
describe the DSM for SAD
- marked fear or anx about 1+ social situs in which a person is exposed to possible scruitiny by others eg socila interactions and performing
- individual dears that he or she will act in a way that will be negatively evaluated by others
- social situ always provokes fear or anx
- social situs avoided or endured with intense fear or anxiety
- out of proportion to threat
- 6+ months
- fear , anx or avoidance is persistent and causes clinical distress or impairment to social functioning
prevelance for SAD
COMMON ANX DISORDER
- Furmark= lifetime prev of 7-13% in western countries
- wittchen 2011= 12 month prev 2.3% pop, 10.1 million, f/m= 2.1
rates vary across different levels of distress and impairment
why spike in mid teens
more independance
new alliances at school
puberty
shyness or SAD
Distinct from being shy (shyness is a relatively stable temperamental trait – an aspect of personality)
- Behaviours in SAD
o Exposure to feared social situation provokes anxiety
o May take the form of a panic attack
- Typical situations
o Public speaking (most common)
o Eating in public
o Writing while being watched
o Social interactions – making ‘small talk’ etc.
Symptoms of SAD
- anxious in socil situs
- physical (tremble, blush, sweat heart palpertations, fight flight mechanisms)
- cognitive (convinced others will notice nervousness, judged as weak )
- emotional (fearful, panicky)
- behavioural ( safety behaviours- hair covering face)
describe the arguement of SAD as a continuum
milder social anx->SAD = continuum
Discrete SAD -> generalised SAD -> generalised SAD + avoidant PD -> generalised SAD + >1 PDs
- This might represent a severity continuum (van Velzen, Emmelkamp, & Scholing, 2000, N = 90)
- Discrete= anxious about only one situation
o Eg public speaking
- Generalised
o More than one situ
give some evidence for biological aspects of SAD
- BRAIN STRUCTURE
hyperactivtity in the amygdala - unclear if a cause or correlation but deffs susceptible - GENETIC FACTORS
moderate exolanation of genes and family factors
may constitue a genetic vulnerability - DOES RESPOND TO MEDICATION
= supports model as meds effect it so must have some biological basis - Tillipors 2004
reviews studies shows sp has a neuroanatomical basis in highly sensitive fear network
amygdala and hippo region of prefrontal cortex ( alarm system)= general vulnerability to fearfullness
where is the alarm system of the brain
ghly sensitive fear network
amygdala and hippo region of prefrontal cortex
name some pharmacological treatments of SAD
Pharmacological treatments
o Beta blockers have been used
- Reduce effect of adrenaline in activating symptoms
o Benzodiazepines
- Some benzodiazepines show rapid effect
- But SAD requires long-term treatment and there are dependence issues with benzos
- Tranquilisers = temperory not a cure
- Risk of using it, only usually prescribe a week / two weeks’ worth
o Monoamine oxidase inhibitors (MAOIs)
- Can be effective, but unpopular due to dietary restrictions
- Many MAOIs not well tolerated due to physical side effects
- MAOIs Gastrointestinal problems and can cause high blood pressure
o Tricyclic antidepressants (TCA)
- Not generally used in social phobia
o Selective serotonin reuptake inhibitors (SSRI)
- Paroxetine most commonly used SSRI in social phobia
- Trials show significant improvement vs. placebo
- Reduced fear, anticipatory anxiety, and disability
- Improved social life and work
- Similar efficacy for other SSRIs
o Serotonin-norepinephrine reuptake inhibitors (SNRI)
- Venlafaxine also performs well in trials
- These forms of antidepressants have the additional benefit of being able to treat co-morbid depression and GAD at the same time
- Gives some support to the biological explanation for SAD
DESCRIBE THE behavioural arguement for SAD model
Behavioural models fairly strong as explanation (see Tillfors, 2004)
- SAD as learned behaviour
o Arises from classical conditioning
- Perceived social embarrassment or humiliation
- Being target of anger or criticism
o Generalised to all social situations
o Maintained by operant conditioning – negative reinforcement of avoidance of the feared social situation through temporary relief
- But not all people with phobias can identify a prior traumatic or aversive experience
- Though Ost & Hugdahl (1981) reported 58% of their SAD sample could identify a specific traumatic social event prior to developing SAD
describe the cognitive model of sad
Cognitive models strongly supported
o Socially phobic people expect others to negatively evaluate them
o Feel vulnerable around people that are perceived as threat
- Cognition has impact at the 3 levels of the cognitive model (core schema, attentional biases/biased information processing, NATs)
o Negative schema predict social failure
o Hypervigilant to body sensations in social situations
- Interferes with social interaction
o Negative automatic thoughts (NATs) about their social performance, what other people are thinking about them etc.
- Cognitive factors make social phobia very pervasive – the model hypothesises that these cognitive factors help maintain SAD
describe clarks model of cognitive SAD maintenance
lark and Wells (1995) proposed a cognitive model of the maintenance of social phobia
- The four maintenance processes highlighted are
o (a) increased self-focused attention and a linked decrease in observation of other people and their responses,
o (b) use of misleading internal information (feelings and images) to make excessively negative inferences about how one appears to others
o (c) extensive use of overt and covert safety behaviours, and
o (d) problematic pre- and post-event processing.
- Quoted from Clark et al., 2006
- Next week’s seminar focusses on this maintenance model
describe a behavioural (physiological ) treatment for SAD
Behavioural therapies (See Acarturk, Cuijpers, van Straten, & de Graaf, 2008 for a review of psychological treatments)
o Graduated exposure to social situations
- Evoke fear and learn that you can deal with it
- Symptoms will often reduce through extinction
- Therapy may include role-play in small groups to rehearse social encounters
- But purely behavioural interventions are used more with specific phobias than SAD
DESCRIBE COGNITIVE models for treating sad
Also use group sessions
o Practice feared social situation in front of other patients
o Block safety behaviours
- But also cognitively reappraise unhelpful, inaccurate thinking
o Challenge catastrophising thoughts and negative appraisals of self, appearance, performance
- Address Clark & Wells maintenance processes:
o (a) increased self-focused attention and a linked decrease in observation of other people and their responses,
o (b) use of misleading internal information (feelings and images) to make excessively negative inferences about how one appears to others
o (c) extensive use of overt and covert safety behaviours, and
o (d) problematic pre- and post-event processing
evaluate treatments for SAD
Unclear if adding cognitive intervention to exposure enhances outcome or not (see Acarturk et al., 2008)
o But, Clark et al., 2006: CT outperforms exposure + relaxation
- Group CBT: evidence of success (Blanco et al., 2010)
o CBT vs. phenelzine (MAOI) vs. placebo vs. CBT + phenelzine
o CBT + phenelzine more effective than the monotherapies
o Monotherapies more effective than placebo pill
o Less clear if there are differences between CBT and phenelzine
- Davidson et al. (2010): fluoxetine (SSRI), pill placebo, group CBT, CBT plus fluoxetine, and CBT plus pill placebo
o All active treatments had greater efficacy than pill placebo, but there were no differences among the active treatments
- Even adding CBT and drug together didn’t out perform drug individually
- Therefore have treatments, but don’t know which is best
- Psychological interventions (Meta analysis: Acarturk, Cuijpers, van Straten, & de Graaf, 2009)
- In general, psychological treatments produce significant improvements
- Most of the included studies used a combination of several of: exposure, cognitive restructuring, social skills training, applied relaxation
- No significant differences overall between studies that only utilised one of these approaches
- Treatment appears to be less effective for people with more severe SAD
