Chapter 5 : Social Anxiety Disorder

1. Chapter 5: Social Anxiety Disorder Deborah Roth Ledley Brigette A. Erwin Amanda S. Morrison Richard G. Heimberg

2. 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)

3. 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 others • Examples: 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

4. 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

5. Comorbidity • Most frequent comorbidity: Other anxiety disorders • For 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 problems • Individuals 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

6. 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)

7. 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 parahippocampalgyrus in response to angry and contemptuous faces among patients with generalized SAD compared to healthy controls (Steinet. al, 2002)

8. Psychosocial Dysfunction • Impaired Social Functioning • Individuals with SAD have strained relationships, and generally fewer relationships than individuals without the disorder • May have difficulty expressing emotions and beliefs in relationships

9. 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 expectations • May frequently display overt signs of anxiety • May emotionally distance themselves from their partners • When they do self-disclose, individuals with SAD have a difficult time describing emotional experiences

10. Psychological Deficits • Attentional Bias • Some studies show slower color-naming of social threat words • Social anxiety may be associated with cognitive avoidance of positive material • Executive 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 Bias • Many inconsistent findings in this area

11. 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

12. 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 bidirectional • Relational 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

13. 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 version • Advantage: 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

14. 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 situations • Very 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 week • Three scales: fear, avoidance, and physiological arousal • Has been shown to be sensitive to medication-related changes in social anxiety symptoms

15. 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

16. 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

17. 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 consistency • Sensitive 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

18. Psychological Interventions: Cognitive Behavioral Therapy • Cognitive Behavioral Therapy • Exposure  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

19. Psychological Interventions • Cognitive Behavioral Group Therapy • Several studies demonstrate CBGT’s efficacy • May be logistically difficult to implement • Meta-analyses suggest that there is no difference between group and individual treatment for SAD • Cognitive 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

20. 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

21. 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

22. Future Clinical and Research Directions • It is important to evaluate how the various biases interact to maintain SAD • More research on disseminating SAD treatments • Individuals 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