Cognitive-behavioral treatment of social anxiety disorder

1. Cognitive-behavioral treatment of social anxiety disorder Maureen L. Whittal, Ph.D. & Adam Chodkiewicz, M.D. UBC Hospital October 19, 2006

2. Basic Social Phobic Beliefs • They will behave in an unacceptable way (and they have strict rules to judge behavior) and it will lead to rejection, loss of worth/status, or failure to achieve important goals

3. Typical Social Phobic Thoughts • What I say sounds stupid • I’m boring • I will made a fool of myself • They don’t like me • The will see I’m anxious • I won’t have anything to say • I’ll blush/shake/lose control

4. Assumptions and Core beliefs Excessively high standards for social performance • “My speech must be perfectly fluent” • “I must always appear intelligent and witty” Conditional beliefs • “If I disagree with someone, they will think I’m stupid/reject me” • “If I appear anxious, people will think badly of me”

5. Assumptions and core beliefs continued More conditional beliefs • “If others want to know me, they will let me know” Unconditional beliefs about the self • “I am uninteresting, different, weird” • “I’m unlikeable”

6. Assessment Measures • Social Phobia and Anxiety Inventory (SPAI) • Fear of Negative Evaluation (FNE) • Social Behaviour Questionnaire

7. Treatment outcome • Heimberg et al. (1990) 65% “clinically significant change • Mattick and Peters (1988) - 38% “high end-state function” Degree of cognitive change is modest Heimberg et al (1990) FNE at Pre - 24.7 and at post 20.7

8. Treatment outcome (2) • Oxford RCT with N=60 Pre FNE Post FNE CT (16 wks) 25 14 Prozac + SE 25 21 Placebo + SE 25 22

9. Oxford Model for Maintenance of Social Phobia Social Situation Activates assumptions Perceived social danger Processing of self as a social object Safety behaviours Somatic and cognitive symptoms

10. Evidence that maintains social anxiety • Distorted mental image • Emotional reasoning (feel anxious so therefore must look anxious) • “felt sense” - sitting close and feeling as if very far away - often involves some feeling of exclusion

11. What maintains social anxiety • Attention shift - to detailed self observation and monitoring (sensations, images, felt sense) • Safety behaviours - intended to prevent feared consequences BUT they prevent disconfirmation and can cause feared symptoms, can make the person appear withdrawn and focus others attention to self

12. Maintenance continued • Avoidance - prevents disconfirmation • Anticipatory and post-event processing - focuses on feelings and constructed images of self after the fact and selective retrievals of past failures

13. Stages of Cognitive Therapy 1. Derive idiosyncratic model 2. Safety behaviour manipulation 3. Video and audio feedback 4. Shift attention to observation of others 5. Behavioral experiment in social setting 6. Dealing with anticipatory anxiety and self image 7. Constructing a veridical social self-image 8. Dealing with remaining assumptions

14. Deriving the model • Review several recent episodes of social anxiety or create an analogue in session • Identify the main automatic thoughts • Divide anxiety response into safety behaviours and other symptom

15. Useful questions for deriving the model For identifying negative thoughts • What went through your mind before/as you entered the situation or as you noticed yourself becoming anxious? • What was the worst you thought could happen? • What did you think others would notice/think? • What would that mean?

16. Questions continued For identifying safety behaviours • When you thought the feared event was/might happen, did you do anything to try to prevent it from happening or prevent others from noticing? • Is there anything that you do to ensure that you come across well? • What do you do to avoid drawing attention to yourself? • Do you do anything to try to control the symptoms?

17. Questions continued For identifying processing of self as a social object • What happens to your attention when you are afraid that the feared event will happen? • Do you become more self-conscious? • Do you have difficulty following what other people are saying/doing? • Are you less aware of others?

18. Questions for self processing continued • As you focus your attention on yourself, what do you notice? • Do you have an image of how you think you appear? • Do you have an impression of how you feel you are coming across? • When you try to conceal your symptoms, how do you feel you look to others?

19. Manipulating the focus of attention • Behavioural experiment that involves 2-five minute conversations. The first conversations the social phobic is engaging in their safety behaviors and the second conversation to not engage in their safety behaviors. • The social phobic predicts extent of anxiety and how well they came across with and w/o safety behaviours

20. Manipulating the focus of attention - continued • Following each conversation the social phobic records (a) degree of self-consciousness (b) subjective anxiety and (c) how well they think they came across • Make ratings on 0-10 scale • Homework is to drop safety behaviours and shift external focus of attention

21. Video and audio feedback • Shows true observable self • Problem in that they can discount accuracy of image (e.g., shaking on the inside, you couldn’t see it)

22. Exposure • Use “record sheet for noting behavioural experiments” • testing predictions not habituation • shift focus of attention and drop other safety behaviours • process situation not self

23. Self monitoring of thoughts • Daily ‘dysfunctional thought record’ • can be useful for unplanned situations

24. Useful questions to challenge thoughts • What is the evidence? Is is feelings and self-image? • Is there any other explanation? Did my safety behaviours make it difficult for others? • Am I mind reading? • How would I think if I was the other person?

25. Interrogating the environment • Behave in an “unacceptable” fashion and observe others’ response (e.g., pause in speech, damp armpits, shake/spill drink, disagree/express opinion, ignore acquaintence) • Manipulate felt sense and observe others’response • Conduct surveys (e.g., why do people stutter? What would you think about someone who stutters. Would you think less of someone for stuttering) • Articulate and discount imaginary critic

26. Anticipatory anxiety • Often involves imagining the worst which in turn produces anxious feelings and self-awareness which are taken as evidence the worst will happen. • Rehearsal of coping responses may be a safety behaviour and may lead to rigid rules about how to behave.

27. Dealing with post-mortem • Identify content of post-mortem (feelings not events) • Review what actually happens and keeping a positive log of what happened • Review advantages and disadvantages of post-mortem and ban it.

28. Constructing a veridical self-image • Use video, surveys, evidence from behavioural experiments to replace spontaneous negative self-image to one that accurately reflects evidence in the environment