Psychotherapy for social anxiety disorder

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Psychotherapy for social anxiety disorder Author Stefan G Hofmann, PhD Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Oct 2013. | This topic last updated: Out 1, 2013. INTRODUCTION Social anxiety disorder (SAD) or social phobia is a mental disorder characterized by an intense fear of negative evaluation from others in social and/or performance situations. In severe cases, the disorder can follow a chronic, unremitting course, leading to substantial impairments in the affected individual [1]. The disorder has two subtypes: generalized and nongeneralized SAD. In generalized SAD, distressing fears are experienced in most social situations (eg, in conversations, meetings, parties, performances, and other interactions). In nongeneralized or circumscribed SAD, fears are limited to one or a few social situations, such as public speaking and performances This topic addresses psychotherapy for SAD. The epidemiology, pathogenesis, clinical manifestations, diagnosis, and pharmacotherapy for the disorder are discussed separately. (See "Pharmacotherapy for social anxiety disorder" and "Social anxiety disorder: Epidemiology, clinical manifestations, and diagnosis".) THEORETICAL FOUNDATION The most widely studied of contemporary psychological theories of social anxiety disorder (SAD) emphasize the role of cognitive processes in the generation and maintenance of social anxiety disorder in vulnerable people upon entry into, or anticipation of, a social situation [2-4]. These models are the bases for cognitive behavioral therapies (CBT) for SAD. An interpersonal model posits that SAD is primarily maintained by impaired and restricted interpersonal relations [5-8]. This model is the basis for interpersonal psychotherapy (IPT) for SAD. Cognitive-behavioral models A variety of cognitive models have been proposed to explain pathologic thought processes in SAD. One widely regarded cognitive-behavioral model assumes that individuals with social anxiety disorder (SAD) believe they are in danger of behaving in an inept and unacceptable fashion, and such behavior would have disastrous consequences in terms of loss of status, loss of worth, and interpersonal rejection [4]. When exposed to situations that might put them in such danger, they become increasingly vigilant for cues that would signal the realization of their fears. They closely attend to sources of potential negative scrutiny and environmental cues. As an example, a person with SAD who is asked to give a speech in front of people might scan the audience members for negative reactions to their speech. They maintain a negative view of how they appear to others and pay close attention to cognitive, behavioral, and affective cues related to the severity of their anxiety in the moment. Another model proposes several psychopathological processes that prevent individuals with SAD from disproving their maladaptive beliefs [2]. When individuals with SAD enter a social situation, they shift their attention to detailed monitoring and observation of themselves. This attentional shift produces an enhanced awareness of feared anxiety responses (eg, increase in heart rate and hot flushes) and interferes with processing their perceptions of other peoples behavior. Together with the perception of the physiological anxiety response, this information is then used to construct a negative self impression. Individuals with SAD engage in behaviors to reduce the risk of rejection and provide a sense of safety (eg, wearing dark clothes or a turtle neck to hide facial blushing). Such safety behaviors are subtle avoidance Section Editor Murray B Stein, MD, MPH Deputy Editor Richard Hermann, MD

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strategies that give the patient a sense of safety in fearful social situations. These behaviors might lead to a short-term decrease in anxiety. However, they contribute to the long-term maintenance of the problem because they prevent individuals with SAD from critically evaluating the outcomes they fear (eg, shaking uncontrollably) and other catastrophic beliefs. They show an anxiety-induced deficit in performance and overestimate how negatively other people evaluate their performance. Before and after a social event, individuals with SAD think about the situation in detail and primarily focus on past failures, negative images of themselves in the situation, and predictions of poor performance and rejection. These anxious feelings and negative self-perceptions are strongly encoded in memory because they are processed in such detail. A third model posits that individuals with SAD are apprehensive in social situations in part because they perceive a high standard or expectations for social performance [9]. They desire to make a particular impression on others but doubt that they will be able to do so, partly because they are unable to define goals or select specific, achievable behavioral strategies to reach those goals. These thoughts lead to a further increase in social apprehension and increased self-focused attention, which triggers a number of additional cognitive processes, including: They exaggerate the probability of a negative outcome of a social situation and overestimate the potential social costs. They perceive little control over their physiologic response to anxiety in social situations. They hold a negative view of themselves as social objects. They view their social skills as very poor or inadequate to master the social task. As a result, the individual with SAD anticipates social mishaps and engages in avoidance and/or safety behaviors followed by rumination after the event. This cycle feeds on itself, ultimately leading to the maintenance and exacerbation of the problem. In general, the three cognitive models of SAD show a considerable overlap. They primarily differ in their emphasis of certain components. Preliminary studies support the notion that changes in cognitions mediate changes in social anxiety [3,10,11]. However, the precise mechanism through which CBT acts on symptom change is not known. Attentional biases Attentional biases have been proposed to contribute significantly to the etiology and maintenance of anxiety disorders, including SAD. Consistent with the cognitive model, researchers have postulated that anxiety disorders are uniquely associated with a bias in the initial stimulus registration phase of cognitive processing [12]. In anxiety disorders, attention to threatening information is rapidly and automatically deployed. Although this shift toward threatening information is evolutionarily adaptive, it becomes problematic when it leads to hypervigilance to social and environmental queues, as is proposed to occur in social anxiety Interpersonal model Initially developed as a treatment for depression, interpersonal psychotherapy (IPT) has been adapted for use in SAD and other disorders [13,14]. IPT is based in psychodynamic theories and assumes that SAD is primarily maintained by problems related to role dispute (a prominent conflict within an important relationship) and role transition (a major life change such as marriage, divorce, the birth of a child, graduation, or retirement) [5-8]. As a consequence of such insecurity, interpersonal models propose that people with SAD develop a number of self-protective strategies that keep others unaware of the person's wishes and feelings (eg, individuals with SAD may avoid eye contact or avoid asking open-ended questions to limit the degree of social interaction). (See "Overview of psychotherapies".) Some self-protective strategies may make the person with SAD appear uninterested in others, which may lead others to feel rejected and subsequently to withdraw. This is called a self-perpetuating, interactional cycle, in which individuals unwittingly produce the very response they fear. Observation of their fear, avoidance, and failure to perform socially enhances patients role insecurity and sense of defectiveness, leading to maintenance of the problem. INDICATIONS Motivated patients with generalized SAD are generally good candidates for psychotherapy. Although SAD frequently co-occurs with other anxiety disorders, depression, and avoidant personality disorder, none of these comorbidities constitute a contraindication to psychotherapy. (See "Social anxiety disorder:

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Psychotherapy for social anxiety disorder

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Epidemiology, clinical manifestations, and diagnosis", section on 'Comorbidities'.) Studies suggest that different cultures (eg, certain racial/ethnic minority groups in the US) may express SAD differently, potentially requiring modification to methods for assessment and psychotherapy [15]. ASSESSMENT SAD is a heterogeneous diagnostic category, and individuals differ considerably in the factors that maintain the problem. Therefore, a treatment approach that is tailored to address the principal maintenance factors for each individual is likely to result in the greatest possible treatment benefits. Although it is not standard practice in contemporary therapy to tailor treatment based on the results of specific measures, clinicians are encouraged to carefully explore the core problems of each individual. INTERVENTIONS Cognitive behavioral therapy More recent cognitive behavioral therapy (CBT) protocols for SAD [16,17] are based on earlier protocols on CBT for SAD [18] and cognitive therapy for anxiety disorders [12]. Specific therapeutic strategies differ slightly, depending on the treatment protocol. However, common elements include psychoeducation, cognitive restructuring, and exposure practices. Group and individual CBT CBT has traditionally been administered for SAD by two therapists for a group of four to six patients in 12 weekly 2.5-hour sessions. More recent modifications of this format include individual treatment sessions lasting 60 minutes scheduled weekly for up to 15 weeks [19] Advantages of group CBT include the social support of the group and its utility in conducting exercises involving exposure to social situations. Individual CBT affords more therapeutic time and attention to the individual patient and allows for the targeting of specific cognitive factors that cannot be easily addressed in a group. The only study that has directly compared individual treatment and group therapy format for SAD showed an advantage for the individual format [19]. However, this result may be related to the difference in the direct therapist-patient contact time, which was greater in the individual treatment format than in the group format. CBT components Treatment is generally designed to encourage patients to: Understand the maladaptive nature of their concerns about social situations Identify specific thoughts and beliefs that are associated with social situations Conduct exposure tasks to challenge the maladaptive thoughts and beliefs The therapist acts as a coach, setting up the opportunities for learning and guiding accurate interpretations of current performance. As treatment progresses, longer term maintenance is promoted by helping patients become their own therapists by understanding and applying treatment strategies on their own. Such independent application of therapy skills is initiated by the therapist providing a model of the disorder. In the beginning sessions, patients are usually taught the CBT model as applied to SAD, and they are introduced to cognitive restructuring techniques. This includes identifying and challenging negative cognitions (maladaptive beliefs and automatic thoughts), observing the association between anxious mood and automatic thoughts, examining errors of logic, and formulating rational alternatives to these beliefs and thoughts. The newer generation of CBT approaches includes a number of refinements and innovations: Safety behaviors are identified and discouraged. These behaviors lead to a short-term reduction in discomfort in socially threatening situations, but can contribute to the long-term maintenance of the problem. An example is a patient who puts his or her hands in the pocket so that people cannot detect hand shaking. Despite providing a short-term reduction in anxiety, this avoidance strategy does not address underlying cognitions or effective and physiologic responses to the precipitating social situations. Video feedback is employed to correct distorted self-perception. As part of in-session exposure, patients are asked to predict in detail what they will see in the video and form an image of themselves in the social situation. They then watch the video from an observers point of view following completion of an exposure task. The tendency to focus on anxiety symptoms or negative cognitions in a fearful social situation can be

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Psychotherapy for social anxiety disorder

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retrained by encouraging individuals to direct their attention toward nonfearful aspects of the situation. Behavioral experiments are created in which the person purposefully creates social mishaps to experience and critically evaluate undesirable consequences (eg, walking around with toilet paper hanging out of the shirt, spilling water in a restaurant, asking a random woman on a street out on a date). People with SAD often ruminate over perceived or actual social mishaps. This post-event rumination can be effectively targeted by helping patients process negative social events more adaptively through guided questions (eg, How will your life change as a result of a particular social mishap?). Attention retraining Attention retraining is an intervention that modifies this attentional bias by training patients to attend to certain types of stimuli by using dot-probe detection tasks [20]. The dot-probe task involves simultaneously presenting two stimuli that vary in emotional content (eg, a threatening word and a neutral word) side-by-side on a computer screen, removing the stimuli, and then replacing one of the stimuli with a probe (ie, a neutral symbol, such as a dot or a line). The viewer is instructed to identify the presence of the probe as quickly as possible. It is assumed that participants will be faster at detecting a probe that replaces the stimulus to which the participant was attending before the probe appeared. As an example, a socially anxious viewer is typically faster at detecting a probe (eg, a dot) that replaces a threatening stimulus (eg, the word speech) than a non-threatening stimulus (eg, the word flower) because the viewers initial attention is captured by the threatening stimulus. In attention retraining paradigms, the connection between probes and non-threatening stimuli is strengthened, whereas the connection between probes and threatening stimuli is weakened. As an example, if probes are more likely to appear after the non-threatening than after the threatening stimuli, the viewer is encouraged to pay closer attention to the non-threatening than to the threatening stimuli without the viewers conscious awareness. Interpersonal psychotherapy Interpersonal psychotherapy (IPT) is a time-limited psychodynamically-based form of psychotherapy. Originally developed to treat grief and depression, IPT specifically targets interpersonal problems. IPT differs from CBT in several ways. Most importantly, IPT does not conceive of maladaptive cognitions as the primary target of treatment. Instead, conceiving of SAD as a medical illness, IPT focuses more on interpersonal role disputes, interpersonal deficits, and role transitions. A frequently used strategy is to encourage the patient to find ways of enlisting their partners support in their attempt to overcome social anxiety and to turn them into an ally [5,21,22]. The IPT model assumes that early adverse experiences and later peer experiences influence feelings and patterns within adult relationships. The IPT therapist, therefore, addresses past interpersonal difficulties as these inform the patients understanding of current problems. As an example, the IPT therapist may work with the patient on being more assertive in an upcoming visit with her/his parents if the IPT therapist views the patients past relationship with his/her parents to have contributed to the patients present interpersonal problems. EFFICACY Cognitive behavioral therapy A meta-analysis of randomized trials found CBT to be moderately efficacious for SAD compared to placebo control (OR = 4.21), with considerable variation in effect sizes across studies [23]. As an example, a randomized trial of 133 patients with SAD compared group CBT, phenelzine (a monoamine oxidase inhibitor used to treat SAD), a pill placebo, and an educational-supportive group therapy (serving as a psychological control intervention) [18]. After 12 weeks, a higher proportion of patients were assessed as responding to treatment in the groups receiving phenelzine (65 percent) and group CBT (58 percent) than pill placebo (33 percent) or the psychological control (27 percent). A randomized trial of 60 patients randomly assigned to CBT, fluoxetine and self-exposure, or placebo and self-exposure supported the efficacy of newer variations of CBT for SAD [16]. After 16 weeks of treatment, the group receiving CBT experienced a greater reduction of social anxiety than the groups receiving fluoxetine/self-exposure or placebo/self-exposure. Attention retraining The model underlying attention retraining has been supported by research studies in non-clinical samples. An example is an experiment that manipulated attention by training participants to attend to threatening words using a dot-probe task [24]. One group of participants was trained to attend to threatening words (ie, the probes always replaced the threatening words) while the other group was trained to attend to

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neutral words (ie, the probe always replaced the neutral words). Post-training, the participants in the threat group exhibited faster reaction times to probes replacing new threatening words. Additionally, post-training those participants in the threat group reported higher levels of negative mood and anxiety during a stressful task than participants in the neutral group, supporting the hypothesis of a causal relationship between attentional biases toward threat and a vulnerability to anxiety. Several randomized trials have found attentional retraining for individuals with SAD resulted in reduced attentional bias toward threat cues and reduced SAD symptoms [25-28]. Although these studies are encouraging, more research is necessary to examine this promising new intervention. Interpersonal psychotherapy Findings from clinical trials of interpersonal therapy (IPT) in SAD, compared to placebo or to another psychotherapy, have been mixed: A trial randomized 70 patients with SAD to receive 14 weekly, individual sessions of either IPT or supportive therapy (administered as a psychological control intervention) [8]. Patients in both groups experienced a reduction in symptoms, but IPT did not result in greater improvement than supportive therapy. 117 patients with SAD were randomly assigned to receive 16 individual sessions of either cognitive therapy (CT) or IPT, or to a wait list control group [29]. After 20 weeks of treatment, the proportion of patients who responded was 65.8 percent for CT, 42.1 percent for IPT, and 7.3 percent for the wait list control. CT performed better than IPT, and both treatments were superior to participation in the control group. Another randomized trial, lacking a placebo control, compared IPT to CBT in 80 residential patients with SAD [6]. Patients in both groups improved on the primary outcome measures, however, no differences were observed between therapies. COMPARING CBT AND MEDICATION Randomized trials comparing CBT to pharmacotherapy for SAD have not demonstrated superiority of one treatment over the other [30-32]. (See "Pharmacotherapy for social anxiety disorder", section on 'Treatment selection'.) COMBINING CBT AND MEDICATION Trials comparing the combination of CBT and antidepressant medication for SAD to either treatment individually have shown mixed results [31-35]. A promising approach is to enhance or hasten the effects of CBT with the partial N-methyl D-aspartate agonist d-cycloserine [36-38]. (See "Pharmacotherapy for social anxiety disorder", section on 'Combined psychological and pharmacological treatment'.) ADDITIONAL PRINCIPLES FOR CLINICAL MANAGEMENT Psychotherapy for SAD, as for any disorder, can only be effective if the therapeutic context and the therapeutic relationship between clinician and patient are adequate (ie, if the therapist shows the necessary empathy, warmth, and support). As with many other disorders, treatment is negatively affected if patients lack treatment motivation and are deficient in setting appropriate treatment goals. Motivational enhancement strategies can augment CBT techniques [39]. Furthermore, the therapeutic process, including problem identification, goal setting, and treatment planning should be conducted within the general guidelines of CBT [40]. Other reasons for nonresponse to CBT include cognitive errors that enhance social anxiety in response to actual or imagined social threat, and avoidance strategies (such as safety behaviors) that lead to the maintenance of social anxiety. Examples of such maladaptive strategies include obvious avoidance and safety behaviors but might also include distraction techniques if they serve the purpose to lessen the anxiety experience. The Liebowitz Social Anxiety Scale, developed for clinical research, can be useful for monitoring the patients response to treatment. It measures fear and avoidance in a variety of social situations as well as provides information about the type of feared and avoided situations [41]. The 24-item, clinicianadministered instrument can be used in the development of exposure exercises and homework assignments, and to assess the results. The scale has good psychometric properties [42] and has also been administered

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by patient self-report [43]. INFORMATION FOR PATIENTS UpToDate offers two types of patient education materials, The Basics and Beyond the Basics. The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon. Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on patient info and the keyword(s) of interest.) Basics topic (see "Patient information: Social anxiety disorder (The Basics)") SUMMARY AND RECOMMENDATIONS In cognitive-behavioral models for social anxiety disorder (SAD), maladaptive beliefs are important maintaining factors that are closely associated with anxious feelings, physiologic responses, and avoidance behaviors. (See 'Theoretical foundation' above.) Cognitive behavioral therapy (CBT) can vary by treatment protocol but typical components include psychoeducation, cognitive restructuring, and exposure practices. CBT is usually provided in group or individual therapy over approximately 12 weekly sessions. (See 'Interventions' above.) Cognitive restructuring involves identifying and challenging negative maladaptive beliefs and automatic thoughts, observing the association between anxious mood and automatic thoughts, examining errors of logic, and formulating rational alternatives to these beliefs and thoughts (See 'Interventions' above.) In exposure, patients are confronted with feared situations and asked to examine specific expectations that arise. For patients with generalized SAD, we recommend first-line treatment with either pharmacotherapy or CBT (Grade 1A). Randomized trials have found both modalities to be effective treatments for generalized SAD. Trials comparing combined treatment (pharmacotherapy and CBT) to either modality individually have not consistently shown combined treatment to be superior. This may be due to one or more reasons: a small number of trials, differences in effectiveness among the medications studied (SSRIs and MAOIs), or a small margin of benefit. Selection between pharmacotherapy and CBT should be based on patient preference and treatment availability. (See 'Combining CBT and medication' above and "Pharmacotherapy for social anxiety disorder".) Use of UpToDate is subject to the Subscription and License Agreement. Topic 14635 Version 10.0

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