Cognitive Behavioral Treatment of Social Anxiety Disorder

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Cognitive Behavioral Treatment of Social Anxiety
Disorder

• The original version of these slides was provided
  by
• Michael W. Otto, Ph.D.with support from NIMH
  Excellence in Training Award at the Center for
  Anxiety and Related Disorders at Boston
  University
• (R25 MH08478)

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Use of this Slide Set

• Presentation information is listed in the notes
  section below the slide (in PowerPoint normal
  viewing mode).
• A bibliography for this slide set is provided
  below in the note section for this slide.
• References are also provided in note sections for
  select subsequent slides.

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Social Anxiety Disorder (Social Phobia)

• With an incidence of 13, it is the most common
  of the anxiety disorders
• The course tends to be chronic and debilitating
  (delaying achievement and interfering with
  relationships for more severe cases)
• More women than men receive the diagnosis, but
  men are slightly more likely to seek treatment
• Depression is frequently comorbid

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Onset

• Average age of onset is 16 years
• Behaviorally inhibited children are at increased
  risk for the disorder
• Most patients describe an insidious onset
• Occasionally patients will describe specific
  humiliation episodes linked to onset
• Regardless of onset, CBT tends to focus on the
  self-perpetuating patterns that help maintain the
  disorder

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Core Patterns In Social Phobia

• Self-focused attention
• Negative self-evaluation
• Anxious apprehension
• Avoidance and escape
• Behavioral disruption of normal functioning
• Skills deficits

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Negative Expectations

• They will reject me
• I will be found out as incompetent
• They will think Im weird
• I cant even do the simplest things
• I had better not blow it again
• I cant (dont know how to) do this
• I will tremble and my boss will fire me
• If they see how anxious I am, they will think Im
  crazy
• I will stumble over my words and be unable to
  continue

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Consequences Of Negative Expectations
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The Amplification of Anxiety About Symptoms or
Minor Errors

• Anxiety
• Failure
• Shame

Anxiety Minor Mistakes
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Amplifying Cognitions
Being Different Rejection Anxiety
Failure Errors Blowing it
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Perceived Failure
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Next Time

• I hope I dont mess up (again)!

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Targets For Treatment

• Correction of dysfunctional cognitions
• Correction of social cost estimates and
  failure-focused attention
• Modification of performance
• decreasing avoidance
• improve skills
• eliminating safety cues
• Modification of evaluation of performance

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Common CBT Interventions

• Information
• Cognitive restructuring
• Exposure
• Social skills training
• Relaxation training

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Cognitive Restructuring

• Identify truth about cognitions they dont have
  to be true to affect emotions
• Learn about common biases in thoughts
• Treat thoughts as guesses or hypotheses about
  the world
• Apply more accurate and adaptive thoughts
  according to experience / logic

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Exposure Goals

• Provide a chance to learn social situations are
  safe (that goals are often met despite anxiety
  and that catastrophic outcomes do not occur)
• Provides a chance to learn that the assumed
  social costs of errors are lower than expected
• Provides a chance to re-direct attention to
  others rather than the self

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Heimbergs CBGT for Social Anxiety

• Identify dysfunctional cognition
• (what are you thinking when)
• Identify cognitive error (e.g., all or nothing
  thinking style)
• Identify a more functional cognition (restate
  during exposure)
• Review objective performance after completion of
  the exposure

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• I was nervous, but I did OK

Maybe I can do this.
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Exposure Interventions

• Provide rationale for confronting feared
  situations
• Establish a hierarchy of feared situations
• Provide accurate expectations
• Set objective goals for social performance
• Reduce use of safety behaviors
• Notice what others are doing (to interrupt
  self-focused attention)
• Attend to the disconfirmation of fears (what was
  learned from the exposure?)

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Social Mishap Exposures

• Specifically target concerns over social errors
• For this exposure, specific social mishaps are
  programmed the patient is to examine the actual
  outcome of such mishaps,
• Stand outside a well-known location and ask for
  directions to that location
• Rent a DVD, then immediately return it stating,
  I forgot I dont own a DVD player

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Attending to What is Learned

• Even though I am anxious, I meet my goals
• My anxiety is brief the payoffs of persisting
  socially are large
• Errors are not a catastrophe
• Social mishaps are common and ok
• Being different is not being bad

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Attending to What is Learned Social Cost

• 3 group design (90 randomized patients)
• CBT
• Exposure without cognitive restructuring
• Wait-list control
• CBT Exposure gt Wait-list
• Estimated social cost mediated treatment changes
  in both active treatment conditions
• Hofmann, 2004, JCCP,
  72, 393-399

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Outcome Studies for Social Anxiety
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2009 Meta-Analysis of Psychological Treatments

• 24 comparisons of CBT to a control condition
• Effect size of d .708
• Strong effects on depression as well as social
  anxiety
• Over follow-up periods of 4 to 18 months, there
  was evidence of continued treatment gains

Acarturk et al. (2009) Psychol Med, 392, 241-254.
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Within-Group Meta-Analysis Of Treatment Elements
Taylor S. (1996), J Behav Ther Exp Psychiatry,
27, 1-9.
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Treatment Acceptability (dropout rates)

• Table 1. Treatment Acceptability as assessed by
  drop-out rates in controlled trials
•  

• Percent Dropout

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CBT for Social Anxiety Disorder

• Comparisons to Pharmacotherapy

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Social Phobia Treatment Effect Sizes Relative
To No Treatment Or Placebo
Meta-Analysis Of 24 Studies
Gould et al., 1997
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Generalized Social PhobiaComparative Trial

• CGI Response Rate

Davidson et al. Arch Gen Psychiatry. 200461,
1005-113
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Social Anxiety DisorderWeek 24 Outcomes
LSAS Defined Remission Rate
Blanco et al., 2010, Arch Gen Psychiatry, 67
286-295.
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Success with a Novel Combination Strategy

• Combination of CBT with the putative memory
  enhancer, d-cycloserine
• Two treatment trials for social anxiety indicate
  that d-cycloserine helps consolidate therapeutic
  learning from exposure, helping speed treatment
  outcome
• Similar benefits for d-cycloserine exposure is
  seen for other anxiety disorders

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CT vs. IPT for Social Anxiety Disorder

• 117 patients were randomized to
• Cognitive therapy
• Interpersonal therapy
• Wait-list control
• 16 regular sessions and 1 booster session
• Post-treatment response rates favor CT
• 65.8 CT
• 42.1 IT
• 7.3 WL
• Stangier et al., 2011, Arch Gen Psychiatry, 68,
  692-700

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Maintenance of Treatment Gains

• Across trials there has been evidence for
  maintained or extended treatment gains for social
  anxiety disorder patients who received CBT
• One of the longest follow-up periods (5 years)
  replicated this finding of maintained gains
  (Mörtberg et al., 2011)
• These results support the general notion that CBT
  teaches patients new patterns of behavior
  (responding to anxiety and social concerns) that
  continue to be rehearsed over time

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Conclusions

• CBT is an effective and tolerable treatment for
  social phobia
• Greatest evidence for efficacy of exposure
  cognitive restructuring
• Approximately equal efficacy for pharmacotherapy
  and CBGT, but limited evidence for superior
  short-term outcome for pharmacotherapy
• CBT is associated with maintenance and extension
  of treatment gains