Session Four (Social Anxiety Disorder)

Question 1

What is the central fear of social anxiety disorder?

Answer 1

Fear of scrutiny by others, fear that you’ll do something embarrassing and this will result in a negative evaluation by others?

Question 2

How do the fears in SAD affect the person’s behaviour?

Answer 2

SAD has marked avoidance/coping behaviours to manage the anxiety. Often this includes avoiding certain situations such as parties, public speaking, dating, eating out…

Question 3

What are ‘safety behaviours’, what detrimental affects can they have and give some examples?

Answer 3

Behaviours or strategies a person with SAD employs to minimise the feared catastrophe. This includes internal, mental processes.

They can have a paradoxical effect of worsening the person’s social skills/drawing attention to their social performance.

Examples including avoiding eye contact or being on your phone the whole time.

Question 4

Describe the prevalence and onset of SAD?

Answer 4

Prevalence: Most common anxiety disorder, 12.1% lifetime prevalence

Onset: Very early, 50% of cases by age 11, 80% by age 20.

Question 5

How do you distinguish “shyness” from “SAD”?

Answer 5

Very closely linked, especially in childhood with children often treated as just “shy” who actually have SAD.

Likely exist on a continuum, but a key difference is shyness generally only plays up when meeting strangers, SAD can make people anxious meeting friends they’ve known for years.

Question 6

What are the common co-morbidities of patients with SAD?

Answer 6

• Major depression
• Panic disorder/agoraphobia
• OCD
• Autism
• Body dysmorphic disorder

Question 7

What are the main negative impacts of SAD on a person’s life, long term?

Answer 7

• Significant personal impairment.
• Economic burden (secondary to academic under performance, inability to put self forward at work, depression/alcohol use down the line)
• Significant risk factor for the development of Depression and Substance abuse

Question 8

Why do SAD patients generally seek help later than other forms of anxiety?

Answer 8

• Getting help involves a lot of personal contact, and often face to face CBT, which may be too scary for the patient.
• Generally the resources that can help people are hard to get onto.

Question 9

What evidence exists to support the claim that SAD is a developmental condition?

Answer 9

It has an abnormally early age of onset (50% by age 11 and 90% by age 23) compared to other disorders such as GAD and depression.

This highlights the need for early intervention.

Question 10

What changes in sociability are seen during adolescence?

Answer 10

In their teen years, people transition into secondary school and begin to spend more time with their peers and less time with their family. From an evolutionary perspective this makes sense as we need to form our own social ties as we enter our reproductive window.

Question 11

What do the social tie strength studies tell us about how social skills develop across adolescence?

Answer 11

Heyes (2015)

METHOD:

• Students were asked to fill out a social strength questionnaire, rating how close they were to their classmates.
• This created scores for how much they liked each of their classmates and how much their classmates liked them (social tie strength)
• But also allowed the two values to be compared (reciprocation of social tie strength)
• The researchers then gave the students 100 pennies and asked them to allocate the money based on who they liked most.

FINDINGS:

• In young adolescents, social tie strength alone predicted how much they invested in their classmates
• However in older adolescents, reciprocation also impacted how much they invested
• This suggests that older adolescents are able to recognise when peers place more or less value on their relationship than they do.

CONCLUSION: Theory of mind and social inference skills continue to develop in adolescence.

Question 12

What is the Theory of Mind and why is it important in adolescence?

Answer 12

The ability to understand that other people have a mind separate to yours, with their own beliefs, knowledge, desires, emotions etc.. that differ from yours.

Allow us to navigate the more complex social situations that begin to arise as we enter our teenage years.

Question 13

Social Tie Strength studies suggest that social inference skills and ToM continues to develop throughout adolescence, what might be driving these changes?

Answer 13

Neuro-Cognitive changes. Sebastian (2011)

FMRI study looked into how adults and teenagers’ brains responded to various tasks, involving either Affective ToM (deducing emotions) Cognitive ToM (deducing intentions and beliefs) or Physical Causality (control).

Found group differences in BOLD response in the Ventro-Medial Pre-Frontal Cortex when looking at AToM vs PC. Adults and teens both deactivated to the PC questions, but only adults deactivated to the AToM.

This suggests that teens and adults’ brains function differently when presented with a task based on social understanding.

Question 14

FMRI studies show that adolescents’ brains respond differently to adults to social situations, what effect could this have on their relationships with their peers?

Answer 14

Could distort peer importance, making making valuation by friends seem more important and humiliation seem like a bigger deal.

Again, Sebastian (2011)
This is supported by the Cyber Ball task, where you ‘play’ a computer game with two virtual friends, who eventually start playing with themselves and not you. Both Young Adolescents and Mature adolescents reported greater feelings of Ostracism and less feelings of Inclusion. This shows that younger people react more emotionally to interactions with their peers.

Question 15

What does the Car Crash game study tell us about the link between adolescence, peer influence and risk taking behaviours?

Answer 15

Gardner (2005)

Teenagers and adults were asked to play a game where you drove a car towards a wall and had to break it just before you ran into it. They first played the game solo then with peers in the room, researchers looked for differences in risk taking behaviour based on peer influence.

Study found that by themselves; teens, YAs and adults all drove safely. When peers were introduced, adults maintained their safe driving, but both YAs and adolescents began to show risky behaviours. This effect was significantly more marked in the younger teens.

Suggests adolescents are more likely to be influenced by their peers into committing risky behaviour.

Question 16

Can the greater influence of peer evaluation seen in teenagers have a positive effect on their decision making?

Answer 16

Studies suggest it can.

Pre-adolescents (10-12) and adolescents (14-16) were asked to perform a odd-one-out recognition task, by themselves and then in collaboration with a peer. Found that when working together they scored better, and this “Collective Benefit” actually increased as the adolescent aged.

This suggests that older adolescents are able to influence each other into making better decisions together.

Question 17

In short, what changes are seen in adolescence and what is the potential link to the development of SAD?

Answer 17

Teens show:

• Improvements in social understanding (ToM development)
• Probably underpinned by a mix of changes in their brain, and their environment (secondary school, increased time with peers)
• Show heightened awareness and sensitivity to peer feedback and presence.

While these changes are essential to the development of social skills, they also bring out a vulnerability that in at-risk teens can lead to social anxiety

Question 18

What evidence is there to suggest a genetic influence of SAD?

Answer 18

Stein (2008)

• Family studies; 10x more likely among first degree relatives, Kids of parents with SAD are more likely to develop a number of anxiety disorders.
• Twin studies; Estimates a 48% heritability link
• Candidate gene studies; Some candidate genes have been suggested, mostly to do with Serotonin activity in the brain. Effects have not yet been replicated so unclear.
• Temperaments; Some distinct temperaments/styles of behaviour seen in babies have been linked to the later development of SAD. Largely to do with how the baby responds to novel stimuli (behavioural inhibition)

Question 19

What does the term “Behavioural Inhibition” mean?

Answer 19

Behavioural inhibition (BI) relates to the tendency to experience distress and to withdraw from unfamiliar situations, people, or environments. It is a trait observed in some babies linked to the later development of SAD.

Question 20

Describe how Behaviourally Inhibited babies respond to new stimuli?

Answer 20

• Extreme distress to over stimulation by a something novel or unfamiliar (e.g. a mobile).
• Withdraw and become clingy with caregiver when shown new stimulus or unfamiliar people. Was very vigilant and wary of surroundings.
• Inhibit their behaviour in the face of novel stimuli, ceased playing.
• Evidence suggest they show neurobiological features as well; High heart rates generally with an increase in novel situations, Raised cortisol levels (N.B. this might just be in those who are poorly attached as well as BI)
• EEG shows greater right frontal asymmetry (this is associated with withdrawal and avoidance behaviour)
• Increased amygdala activation to novel or emotional stimuli

Question 21

What does the Highfield-Becker study (2007) tell us about the link between BI and later development of SAD?

Answer 21

• Investigated wether BI in preschool children predicted psych problems in childhood.
• 215 children aged 21 months to 6 years were measured at baseline and once again at 9 years old.
• Found BI could predict Social anxiety, but no other disorders.
• Kids with BI (22%) were twice as likely as those without (11%) to develop Social anxiety.
• Concluded that there IS a temperamental antecedent of social anxiety seen in middle childhood, and that this could be a good way of identifying kids for early intervention

Question 22

What is the Amygdala responsible for and how could this relate to SAD?

Answer 22

Amygdala has a role in emotion processing.

Adults and adolescents with SAD showed greater response in the amygdala to fearful faces in a simple gender discrimination task. This suggests a link between hyperactive emotion processing and SAD.

Question 23

What does the Spielberg study (2015) tell us about the link between the Amygdala and SAD?

Answer 23

• Aimed to investigate wether there is a difference in brain activation between socially anxious and non-socially anxious individuals when anticipating peer interactions.
• 42 patients aged 8-17
• Placed in an fMRI and asked to perform a chat room task, evaluate how much they want to talk with a peer and then hear back how much the peer wants to talk with them
• Found that those with SAD showed greater amygdala activation during this anticipation stage.
• Furthermore, SAD Ps showed stronger co-activation between the Amygdala and the Ventrolateral PFC and the Anterior Cingulate Cortex. Unclear what these greater activations mean, but suggests SAD brains respond very differently when placed in a socially stressful situation.
• Interestingly, wether the social interaction was positive or negative had no influence on activation, appears to be a general response.

Question 24

What evidence is there to suggest a Social Learning Component to SAD?

Answer 24

Van Zalk et al (2011):

• Social ties strength test
• Found that people with SAD had fewer friends and were rated lower by others in their peer group.
• Found they were likely to form closer ties with other socially anxious individuals.
• Followed them up over time, found that people with SAD who were close to other SAD people tended to get worse over time.
• This suggests that people with SAD are more likely to hang out with each other AND can worsen each others symptoms over time.

Question 25

What does the Murray study (2008) tell us about the link between Social Learning and the development of SAD?

Answer 25

• Aimed to investigate the link between maternal social anxiety behaviour and the development of child fear and avoidance responses.
• 79 SAD mothers vs 77 Controls. Infants were investigated at 10 and 14 months.
• Infants were subjected to a strange situation-like scenario, where the stranger would come in and first talk to the mother before talking to them.
• Researchers measured first maternal stranger response, then infant response AND how mother interacts with child as it meets stranger.
• Found SAD mothers were less engaged with the stranger and less encouraging of their child engaging with them
• Found infants of SAD mums were more avoidant at 14 months, BUT only if also BI.
• Concluded there was a degree of transmission of anxiety, possibly though modelling of parental behaviour and in response to parental management of the child’s behaviour (in children with the BI vulnerability traits).

ISSUE: Does this only work for mothers? What about fathers with SAD?

Question 26

To summarise, across the entire body of evidence, what potential influences for social anxiety development have been found?

Answer 26

• Genetics (family, twin, specific gene studies) which might manifest itself as….
• Behavioural Inhibition (temperament/genetic vulnerability)
• Neurobiological differences (amygdala, hyperactivity, altered amygdala-PFC connection)
• Learned or Environmental effect (friends who also have SA, as well as parents)

Question 27

What two processes are central to the maintenance of a person’s SAD?

Answer 27

• Poor social skills, often caused by them focusing on themselves and away from others.
• Distorted cognitions, convincing themselves they aren’t liked or that if they spend time with people they will eventually do something socially humiliating.

Question 28

Describe the evidence for the effect of poor social skills on the maintenance of SAD?

Answer 28

• Socially anxious youths experience more social rejection
• Socially anxious youth perform worse on social cognitive tasks, especially tests that require putting oneself in the shoes of another to answer questions (e.g. the shelf and object trial). This suggest a decreased understanding of others.
• Social skills training is used routinely as an adjunct treatment for SAD, with positive results
• Patients with social communication difficulties often report social anxiety

Question 29

Describe the role of Distorted Cognitions on SAD behaviour?

Answer 29

People with SAD believe they will:
- behave in an unacceptable, embarrassing or humiliating way…
…and that…
- this will lead to rejection, to loss of worth or status, or will lead them to fail in achieving their important life goals

Question 30

What are the two models for the Cognitive behaviours seen in SAD?

Answer 30

• Clark and Wells (1995)
• Rapee and Heimberg (1997)

Both models exist to try and explain the cognitive processes that happen in a person with SAD that leads to their anxiety and control behaviour.

R&H is essentially the same as C&W but with more additional steps, both worth revising.

Question 31

Briefly describe the Clark and Wells (1995) model for SAD?

Answer 31

• Patient is in a Social Situation (e.g. talking to someone)
• This activates their Assumptions (e.g. if I speak ill babble or say something stupid, and they’ll think I’m a freak)
• This creates Anxiety (high HR, shaking…) while also leading to Self-Focused Attention (e.g. images of your lip quivering, no words coming out)
• This Self-Focused Attention contributes to and worsens their Assumptions.
• So the patient brings in Safety Behaviours (e.g. rehearsing what they’re going to say) to control the SFA, and hopefully avoid their Assumptions
• (the irony of this being that often the SBs actually make the person seem more robotic and weird that they’d have otherwise looked)

Question 32

Summarise the key maintaining factors of SAD?

Answer 32

Social phobia persists due to:

• Shift to internal focus of attention and use of internal information to infer how one appears to others.
• Safety behaviours (including avoidance)
• Anticipatory and post event processing
• Negative self images

Question 33

What is the evidence for anxiety causing a shift towards an internal focus?

Answer 33

Mansell (2003) showed that people who reported high speech anxiety showed attentional bias towards internal stimuli vs external stimuli on a probe test.

Question 34

What is the purpose of safety behaviours and what is the impact they actually end up having?

Answer 34

Safety behaviours are intended to prevent catastrophe but actually:

• Prevent assumptions from being discomforted (e.g. through practicing)
• Increased self focus (e.g. checking)
• Can actually cause feared symptoms (e.g. sweating and mental blanks)
• Reduce actual social functioning, make you appear unfriendly or withdrawn
• Can draw attention to feared behaviours (e.g. blushing) and to the person (e.g. speaking quietly)

Question 35

What are anticipatory and post event processing?

Answer 35

Behaviours shown by people with SAD, the tendency to worry in advance or ruminate after the event. Based on images the person has created about themselves. Selective retrieval of past failures.

Question 36

Explain the influence of negative self images on people with SAD?

Answer 36

NSIs are early memories of adverse social events which lead to excessively negative images of their social selves activated in social situations. Normally date from onset of social phobia and become recurrent.

Holding a negative image of oneself in mind when talking to a stranger can lead to anxiety, the use of safety behaviours, and can affect social performance.

Question 37

What treatment options are commonly used for SAD?

Answer 37

1st Line = CBT (highly effective, far more so than an SSRI alone. N.B. Not so effective in children with SAD)

2nd Line = An SSRI (normally Sertraline) paired with a short course of psychodynamic psychotherapy adapted for SAD

3rd Line = Alternative SSRI or SNRI