Social Phobia Lecture Overview

1
Social PhobiaLecture Overview

• Nature and epidemiology
• Empirically-supported treatments
• Efficacy data
• Moderator variables
• Clinical tips in working with social anxiety
  clients
• Class discussion

2
Epidemiology of Social Phobia

• Defining features
• 1. Persistent fear (recognized as excessive or
  unreasonable) of at least 6 months duration of
  one or more social situations in which the person
  is exposed to possible scrutiny by others. The
  primary fear is one of negative evaluation by
  others.
• 2. Exposure almost always provokes anxiety or
  panic (situationally-bound or predisposed).
• 3. Situations are avoided or endured with
  significant distress.

3
Epidemiology of Social Phobia

• Defining features cont.
• 4. Marked impairment
• 5. Not better accounted for by a medical problem
  or other mental disorder

4
Epidemiology of Social Phobia

• Subtypes
• Generalized
• Specific

5
Epidemiology of Social Phobia

• Course
• Findings from Yonkers et al (2001)
• Only 38 percent of women and 32 percent of men
  experienced a complete remission during the
  eight-year study period
• Women were more likely to have concurrent
  agoraphobia, and men had a higher rate of
  comorbid substance use disorders
• Social phobia had a more chronic course among
  women who had low Global Assessment of
  Functioning scores and a history of suicide
  attempts at baseline than among men who had these
  characteristics.

6
Epidemiology of Social Phobia

• Prevalence

7
Prevalence of Anxiety Disorders
8
Epidemiology of Social Phobia

• Onset and course
• Early age of Onset (14.8 girls 16.3 boys)
• Chronic unremitting course

9
Epidemiology of Social Phobia

• Impairment/disability
• Significant interference in work and social
  functioning (Davidson et al, 1993)
• Inability to work, attend school, socialize, or
  marry are common in clinical samples (Liebowitz,
  1985)
• Most common co-existing anxiety disorder among
  alcoholics undergoing detoxification (Chambless
  et al, 1987)

10
Epidemiology of Social Phobia

• Comorbidity
• Simple phobia (59.0)
• Agoraphobia (44.9)
• Alcohol abuse (18.8)
• Depression (16.6)
• Based on (Schneier et al (1992)

11
Pharmacological Treatments for Social Phobia

• Standard MAOIs
• Selective reversible MAOIs
• Benzodiazepines
• Beta Blockers
• SSRIs

12
Effects of Sertraline
Van Ameringen, et al (2001). Am J Psychiatry
158275-281
13
Psychosocial Treatments for Social Phobia

• CBGT
• Exposure
• Cognitive therapy

14
Cognitive-Behavioral Group Treatment (CBGT)

• Potential advantages of group treatment
• Vicarious learning
• Fostering independence
• Learning through helping others
• Effects of sharing similar problems
• Public commitment
• Encouragement through others successes

15
Cognitive-Behavioral Group Treatment (CBGT)

• Procedural Components
• Education
• Exposure simulations
• Cognitive restructuring
• Home-based skill practice
• self-monitoring
• cognitive-restructuring
• in vivo exposure

16
Advantages of Exposure Simulations

• Exposure simulations are always available
• Exposure simulations can be scheduled in a
  graduated fashion
• Exposure simulations are more controllable
• Exposure simulations are moldable to the needs of
  the patient
• Exposure simulations occur under the observation
  of the therapist

17
Advantages of Exposure Simulations

• Exposure simulations are easily integrated with
  cognitive restructuring activities
• Exposure simulations are less easily avoided by
  patients
• Exposure simulations may facilitate compliance
  with homework assignments.

18
Examples of Common Exposure Simulations

• Initiating conversations
• Asking for a date
• Public speaking
• Writing in front of others
• Eating or drinking in front of others
• Working or playing while being observed

19
Examples of Common Exposure Simulations

• Assertion and interaction with authority figures
• Job interviews
• Joining ongoing conversations
• Making mistakes in front of others
• Expressing opinions
• Revealing personal information

20
Integrating Cognitive Restructuring and Exposures

• Prior to a simulated exposure
• Prompted thought recall
• Identify experienced or potential AT
• Identify cognitive distortion
• Dispute AT
• Develop rationale response to the AT
• Set appropriate goal for performance in the
  exposure simulation

21
Integrating Cognitive Restructuring and Exposures

• During an exposure simulation
• Patient gives SUDS ratings at one minute
  intervals
• Patient reads rational responses aloud when
  giving SUDS rating
• Patient uses rational responses as automatic
  thoughts occur

22
Integrating Cognitive Restructuring and Exposures

• After an exposure simulation
• Review the patients goal and assess goal
  attainment
• Review the occurrence of automatic thoughts
  listed before the exposure simulation
• Review and evaluate the use of rational responses
• Examine the occurrence of unexpected automatic
  thoughts and patients attempt to cope with them
• Examine the covariation between automatic
  thoughts, rational responses, and SUDS ratings

23
Summary of Homework Procedures

• Before attempting assignment
• Imagine yourself in the target situation
• Record AT on self-monitoring form
• Identify cognitive distortions
• Ask yourself which AT is most problematic
• Come up with the rational response for each AT

24
Summary of Homework Procedures

• While attempting the assignment
• Focus on the goals that you have set
• Tolerate whatever anxiety you experience to the
  best of your ability
• Use your rational responses to help control your
  anxiety
• Keep your eyes open and try to learn whatever you
  can from the assignment

25
Summary of Homework Procedures

• After attempting the assignment
• Set aside a period of cognitive debriefing
• Assess whether or not you made your goals
• Examined the list of automatic thought you
  recorded before the assignment
• Record automatic thoughts that occurred since you
  did the assignment
• Relax

26
CBGT Efficacy Data

• Heimberg et al, (1990)
• Heimberg et al. (1993)
• Gelernter et al. (1991)
• NIMH Multicenter Study Heimberg et al (1998)
• Lucas Telch (unpublished)

27
Heimberg et al (1990)
Data from Heimberg et al (1990). Cognitive
Therapy and Research, 14, 1-22.
28
Gelernter et al (1991)
Data from Gelernter et al (1991). Archives of
General Psychiatry, 48, 936-944.
29
NIMH Multicenter StudyPost-Treatment Findings
Data from Heimberg et al (1998). Archives of
General Psychiatry, 56, 1133-1141.
30
Heimberg et al (1998)Treatment-free Follow-up
31
Heimberg et al (1998)Treatment-free Follow-up
32
Lucas Telch (Unpublished)
33
Meta Analyses

• Fiske Chambless (1995)
• 21 studies (12 involving CBT and 9 involving
  exposure alone)
• CBT was no more effective than exposure
• Examined pre- to post effect sizes (uncontrolled)

34
Meta Analyses

• Taylor (1997)
• 49 studies divided into one of 5 classes of
  treatment (1) exposure, (2) CT without exposure
  (3) CT Exp (4) Social skills training and (5)
  Wait-list
• Trend for CT Exp to outperform the other
  treatments
• length of treatment predicted outcome and
  drop-outs
• Effects of treatment increased over the follow-up
  period

35
Moderators of Treatment Outcome

• Avoidant personality disorder
• Van Velzen et al (1997) -negative findings
• Lucas Telch (unpublished) positive findings
• Social Phobia Subtype
• Liebowitz et al (unpublished)
• Lucas Telch (unpublished)
• Client Expectancies (Safren Heimberg, 1997)
• Safety Behaviors (Wells et al, 1995)

36
Clinical Strategies in Treating Social Phobia

• Strategies aimed at correcting exaggerated
  estimates of social threat occurrence
• Education
• Downward arrow technique
• Pie chart with 100 objective judges
• Role reversal strategies
• Recorded feedback strategies
• Observation/participant modeling techniques
• In vivo exposure techniques
• Biological challenge techniques
• Fade Safety Behaviors as a way of facilitating
  disconfirmation of social threat

37
Clinical Strategies in Treating Social Phobia

• Strategies for correcting exaggerated estimates
  of social threat severity (Catastrophizing)
• Monitoring techniques
• Scaling technique
• Observation/participant modeling techniques
• In vivo techniques aimed at drawing attention to
  oneself
• Feigning Techniques
• Biological challenge techniques

38
Clinical Strategies in Treating Social Phobia

• Fading of safety behaviors as a way of
  facilitating disconfirmation of social threat
• Avoidance of eye contact
• Positioning oneself in an inconspicuous place in
  social/academic/work gatherings
• Alcohol/drugs
• Not speaking up in class or in meetings
• Making checks out in advance
• Keeping hands in pockets
• Excessive use of deodorant or A/C