Chapter 5 : Social Anxiety Disorder

Chapter 5: Social Anxiety Disorder

Deborah Roth Ledley

Brigette A. Erwin

Amanda S. Morrison

Richard G. Heimberg

Overview

Definition A marked or persistent fear of social or performance

situations

Social Anxiety Disorder = SAD; also known as Social Phobia• Generalized SAD: Individuals fear a range of situations • Specific SAD: Individuals have a more limited fear (e.g., public

speaking only)

DSM-5 Criteria for Social Anxiety Disorder (SAD)

(A) Fear or anxiety about social situations in which the individual may be exposed to scrutiny by othersExamples: Speaking in public, eating around other people, initiating a

conversation (B) Fear that one will say or do something or display anxiety, and that

this will illicit a negative reaction from others (C) Social situations almost always provoke fear or anxiety

Children may display clinging behaviors, crying, and/or tantrums (D) The individual will avoid the situations or endure them with extreme

anxiety or fear

6 month duration now for all ages Anxiety out of proportion to the actual danger or threat but does not

now have to be recognized by the individual as excessive or unreasonable

Epidemiology

Epidemiology• SAD is one of the most prevalent psychiatric disorders in the

United States (Kessler, Berglund et al., 2005; Kessler, Chiu, Demler, Merikangas, & Walters, 2005)

• Mean age of onset is 13-20 (Hazen & Stein, 1995)

• More common in women than men (Magee, Eaton, Wittchen, McGonagle, & Kessler, 1996)

• Although men take longer to seek treatment (Wang et al. 2007), they outnumber women in clinical samples (Chapman, Mannuzza, & Fyer, 1995; Stein, 1997)

• Importance of cultural factors: The cost of not pursuing treatment may be higher in men

Comorbidity

Most frequent comorbidity: Other anxiety disordersFor example, panic disorder, agoraphobia, PTSD

Depression Co-occurrence of depression and SAD is associated with greater

impairment (Erwin, Heimberg, Juster, & Mindlin, 2002)

Substance abuse Research suggests SAD could be a risk factor for alcohol

problemsIndividuals with comorbid SAD and alcohol dependence have

lower rates of treatment seeking (Schneier et al., 2010)

Avoidant Personality Disorder (APD)Those who meet criteria for generalized SAD and APD have

greater impairment

Genetic Underpinnings

It is unlikely that there is a specific “SAD gene”

Instead, researchers believe that an underlying trait like neuroticism is transmitted to an individual, and that this trait contributes to spectrums of psychopathology (Stein & Stein, 2008)

Neurobiological Underpinnings

Serotonin and dopamine are two neurotransmitters that have been frequently linked to SAD in the literature

Imaging studies have shown brain activation differences in the amygdala, uncus, and parahippocampal gyrus in response to angry and contemptuous faces among patients with generalized SAD compared to healthy controls (Stein et. al, 2002)

Psychosocial Dysfunction

Impaired Social FunctioningIndividuals with SAD have strained relationships, and

generally fewer relationships than individuals without the disorder

May have difficulty expressing emotions and beliefs in relationships

Deficits in Interpersonal Style

Individuals with SAD may engage in a “self-perpetuating interpersonal style” in which they enter interpersonal relationships expecting the worst, and then behave in ways that maintain their expectationsMay frequently display overt signs of anxietyMay emotionally distance themselves from their partnersWhen they do self-disclose, individuals with SAD have a

difficult time describing emotional experiences

Psychological Deficits

Attentional BiasSome studies show slower color-naming of social threat wordsSocial anxiety may be associated with cognitive avoidance of positive

materialExecutive control of attention appears to be impaired among

individuals with excessive anxiety Judgment and Interpretation Bias

Socially anxious individuals judge themselves more negatively than they judge others and also judge themselves more negatively than they are judged by others

Individuals with SAD overestimate the probability of negative outcomes and the cost of these outcomes

Imagery and Visual Memory BiasMany inconsistent findings in this area

Family Environment

Infant temperament and early attachment to parents are important early-life factors; insecure attachment patterns related to SAD in adulthood

Studies suggest parents of socially anxious individuals overemphasized the importance of a “perfect” impression

Recent meta-analysis suggests that parenting accounts for only 4% of the variance in social anxiety (McLeod, Wood, & Weisz, 2007)

Other detrimental familial factors: long-lasting separation from either parent, observing conflict between parents, and lack of a close relationship with an adult

Peer Environment

Children with SAD are more likely than non anxious children to have negative peer relations

The relationship between social anxiety and peer victimization appears to be bidirectionalRelational aggression is particularly important

Frequent teasing was associated with negative outcomes later in adulthood, including less comfort with intimacy and worry about abandonment Important to note that one cannot draw causal

conclusions from a correctional relationship, how teasing in childhood might play a role well into adulthood

Assessment of SAD: Clinical Interviews

Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID) – Patient Edition Advantage: Can be completed efficiently Disadvantage: Information gathered is not sufficiently

detailed for use in treatment planning Anxiety Disorder Interview Schedule for DSM-IV

Contains a lifetime version and a child/adolescent versionAdvantage: Contains many questions that go beyond DSM criteria (e.g., triggers for anxiety), which is useful for treatment planning

Disadvantage: Can take longer to administer

Assessment of SAD: Clinical Rating Scales

Liebowitz Social Anxiety Scale (LSAS)Most commonly used clinician-administered measure of

social anxiety 24 items, 11 pertaining to social interaction situations and

13 pertaining to performance situationsVery good tool for clinical treatment planning

Brief Social Phobia Scale (BSPS)18-item scale that assesses the symptoms of SAD that

patients experienced in the past weekThree scales: fear, avoidance, and physiological arousalHas been shown to be sensitive to medication-related

changes in social anxiety symptoms

Assessment of SAD: Self-Report Measures

Social Anxiety Interaction Scale (SIAS)Reliable and has high convergent validity with other

indices of social anxiety and avoidance Brief Fear of Negative Evaluation Scale (BFNE)

Strong psychometric properties in undergraduate and clinical samples

Social Phobia Inventory (SPS)Reliable and has high-convergent validity with other

indices of social anxiety and avoidance

Assessment of SAD: Self-Report Measures (cont.)

Social Phobia Inventory (SPIN)Good reliability, significant correlations with related

measures, and the ability to discriminate between clients with SAD and other anxiety disorders

Social Phobia and Anxiety Inventory (SPAI)Valid, reliable, good test-retest reliability, sensitive to

treatment-related changes

Monitoring Progress in Therapy

Social Anxiety Session Change Index (SASCI)Four-item scale that is completed prior to each treatment

session to assess the progress patient believes he or she has made since beginning treatment

Good internal consistencySensitive to symptom improvement Brief and easy to score

Additional measures can be administered For example, Beck Depression Inventory-II to monitor

depressive symptoms if depression is comorbid with SAD

Psychological Interventions: Cognitive Behavioral Therapy

Cognitive Behavioral TherapyExposure Helps patients face social and performance

situations in which they experience distress or which they prefer to avoid

Cognitive Restructuring Identify, evaluate, and re-frame dysfunctional thoughts so that the client learns to not expect failure in every social situation

Homework Assignments Given to patients so they can apply what they learn in therapy to real-life situations

Psychological Interventions

Cognitive Behavioral Group Therapy Several studies demonstrate CBGT’s efficacyMay be logistically difficult to implement Meta-analyses suggest that there is no difference

between group and individual treatment for SADCognitive Therapy (individual treatment)

Teaches clients to reduce safety behaviors and to shift attention externally rather than on the self

Goals: Help patients create more accurate information about how they are evaluated by others and reevaluate their distorted self-image

Pharmacological Intervention

Selective Serotonin Reuptake Inhibitors and Serotonin Norepinephrine Reuptake Inhibitors Moderate effect sizes, mild side effects, low risk of

overdose, most efficacious for the treatment of disorders comorbid with SAD

Benzodiazepines frequently prescribed on an as-needed basis for low frequency high-anxiety situations Can be problematic withdrawal effects

Monoamine Oxidase Inhibitors (MAOIs)Due to the side effects, used only as a last-resort treatment

when other medications have proven ineffective

Prevention of SAD

Norwegian Universal Prevention Program for Social Anxiety (NUPP-SA)Psychoeducation, cognitive restructuring, and a writing assignment

in which participants write about an aspect of social anxiety Intervention group had greater reduction in the incidence of SAD 1

year later than the control group FRIENDS Program

Teaches skills that are a part of a thoroughly researched protocol used to treat children with anxiety

Involves children, parents, therapists, and teachers Evaluations done by the protocol designers found the program to

be effective, but external evaluations of the program are not as positive

Future Clinical and Research Directions

It is important to evaluate how the various biases interact to maintain SAD

More research on disseminating SAD treatmentsIndividuals with generalized SAD are twice as likely to

report not seeking treatment The most empirically validated treatment strategies are

not always utilized by clinicians Important to publish treatment protocols that are

relatively easy to implement