Lecture 6 - Social Anxiety Disorder

Question 1

Social Anxiety Disorder - Description, onset, course and prevalence

Answer 1

• Fear of social situations. Can be seen in conversational style (not assertive, too submissive, soft voice, no self-disclosure), body language (rigid posture, little eye contact, blushing), temperament (shy and withdrawn), occupational/social functioning (may seek employment with less social contact, delay moving out), medical (exacerbating tachycardia), substance use (self-medication), decreased wellbeing, employment, productivity, socioeconomic status, and quality of life (single/divorced, no children).
• Onset – by 11 in 50% of cases, 20 in 80% of cases. Median age of 13 yo in the US. Adult onset is rare, usually precipitated by a traumatic experience or transitioning between roles.
• Course – 30% experience spontaneous remission within a year, 50% within two years. 60% will have persistent symptoms without SAD specific treatment. Substance abuse, depression.
• Prevalence – most common anxiety disorder. 7% in US, 2-3% in Europe, 0.5-2% elsewhere. Similar rates for children and adolescence. Older adults decrease. 1.5-2 times higher in females, greater in adolescence. Males equal in clinical settings – higher male help-seeking.

Question 2

Social Anxiety Disorder - Aetiology

Answer 2

• Risk factors – childhood history of shyness, stressful or humiliating experience. Temperamental (behavioural inhibition, neuroticism); environmental (childhood mistreatment, psychosocial adversity); genetic and physiological factors (highly heritable predisposing traits).
• Feelings of embarrassment and shame are dominant. Intense anxiety elicits inhibitory behaviours and safety-seeking behaviours which can disrupt social performance and precipitate actual negative evaluations. Anxiety itself is a secondary threat, since they believe they must conceal it.
• Strong evidence of cognitive bias, strong evidence of biased interpretations. More research needed.

Question 3

Social Anxiety Disorder

Answer 3

• Social Phobia Inventory (SPIN) – 17 item self-report. Last week, 5 point Likert. 0-68 with 19 being a cutoff for adults with SAD. Good psychometrics.
• Liebowitz Social Anxiety Scale (LSAS) – 24 items, clinician administered or self-report. Each item for both fear provoke and level of interference/avoidance. 0-144, 60 as a likely cutoff. Social interaction and performance subscales. Good psychometrics for both clinician and self-report.
• Social Interaction Anxiety Scale (SIAS)/Social Phobia Scale (SBS) – 19/20 items, 5 point scale. Good psychometrics. Cut of 36/26 for clinical level. SIAS – anxiety

Question 4

Social Anxiety Disorder - Diagnosis (4)

Answer 4

• marked fear or anxiety about social situations in which the individual is exposed to possible scrutiny by others. Fears that they will act in a way or show anxiety symptoms that will be negatively evaluated. The social situations nearly always provoke fear or anxiety, and are avoided or endured with intense fear. The fear is out of proportion to the actual threat, and is persistent for at least 6 months. It must cause significant distress or impairment, and not be attributable to substances or part of another disorder. Specifier for performance only fear.
  
  • DSM-5 Changes – 6 month minimum only for under 18s. Do not need recognition from the individual that the fear is disproportionate.
  • Comorbidity – 69-89% have a comorbid disorder. Greater functional impairment, SAD precedes onset of other disorders. Early SAD onset has been associated with greater risk of MDD. 57% had an anxiety disorder - simple phobia, agoraphobia, GAD. 39% substance abuse. 37% had MDD. Secondary SAD had been found in ¼-1/2 individuals with PD, GAD, OCD, phobia, PTSD, MDD.
  • Differential diagnosis – agoraphobia (motivation), PD (basis for concern), GAD (focus of worry), Separation Anxiety Disorder (comfortable when attachment figure is present), Specific Phobia (not afraid when no stimulus), Selective Mutism (don’t fear when speaking is not required); MDD (fear of actions evoking negative evaluation); Body Dysmorphic Disorder (underlying beliefs); Delusional Disorder (good insight); Autism (have age-appropriate abilities); Personality Disorders (broader avoidance, more severe, dimensional).

Question 5

Social Anxiety Disorder - EBT (4)

Answer 5

• CBT Level 1, recognised as gold standard. Level II for self-help and psychodynamic, level III for IPT, level IV for ACT. Medication – SSRIs, SNRIs, D-Cycloserine for enhancement.
  
  • CBT – more effective than control. CBT better for relapse prevention than pharmacology. Individual > group > control. Exposure could be sufficient, or enhanced with cognitive therapy.
  • Reduce anticipatory anxiety (challenging threat bias and avoidance); counter excessive self-consciousness (exposure and redirecting attention); eliminating safety strategies; strengthen anxiety tolerance; reduce inhibition (social skills, realistic standards, balanced evaluation); eliminate post-event rumination (adaptive reappraisals); modify core beliefs (threat of negative self-evaluation.
  • Psychoeducation (3 phases of anxiety, models, explain their feelings in order to increase motivation to engage in exposure). Goal setting (costs and benefits, SMART goals – specific, measurable, attainable, reliable, timely, daily record of SUDS scores for social situations). Anxiety hierarchy (brainstorm a list of feared situations and rank them). Cognitive restructuring (low probability and decatastrophising, generating alternative thoughts, preparing for behavioural experiments). Exposure (practice shifting attention away, higher tolerance of anxiety, more realistic interpretations, disconfirming evidence, can use video roleplay). Targeting safety and inhibitory behaviours (needs to be conducted without these to prevent them seeing these as the cause of the experience). Applied relaxation training (could be used as a safety behaviour?). Social skills training (modelling and roleplay).

Question 6

Social Anxiety Disorder - Challenges (6)

• if you use safety behaviours they think that the anxiety dropped because they used the safety behaviours. Need to help them understand that the situation is not threatening.
  
  • Mindreading – they think that other people can read their minds. Use specific concrete predictions so that they cannot attribute it to something else. Get them to guess what you’re thinking so that it is clear that other people do not know what they are thinking. Ask their friends for direct feedback.
  • Self as a social object – attentional shift away from feeling constantly scrutinised. Challenge the images they have in their head.
  • Social skills deficit – be realistic. These may or may not be present.
  • Dealing with rejection – acting awkwardly and might be rejected. Specific predictions – normalising.
  • Client expectations – treatment won’t make them the life of the party. Opening yourself up to opportunities. Not about forcing them to be someone they’re not.