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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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

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

Core Patterns In Social Phobia Self-focused attention Negative self-evaluation Anxious apprehension Avoidance and escape Behavioral disruption of normal functioning Skills deficits

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

Consequences Of Negative Expectations Vigilance To Perceived Danger “Failure” - Focused Attention (and overestimation of the cost of everyday failures) SymptomsSymptoms ErrorsErrors Negative evaluations by othersNegative evaluations by others Negative Expectations Self-focused attention during performanceSelf-focused attention during performance Perception of anxiety or errorsPerception of anxiety or errors

The Amplification of Anxiety About Symptoms or Minor Errors AnxietyAnxiety FailureFailure ShameShameAnxiety Minor Mistakes

Amplifying Cognitions Being Different = Rejection Anxiety = Failure Errors = Blowing it

Perceived Failure

Next Time I hope I don’t mess up (again)!

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

Common CBT Interventions Information Cognitive restructuring Exposure Social skills training Relaxation training

Cognitive Restructuring Identify truth about cognitions: they don’t 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

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

Heimberg’s 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

I was nervous, but I did OK Maybe I can do this.

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?”)

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 don’t own a DVD player”

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”

Attending to What is Learned – Social Cost 3 group design (90 randomized patients) –CBT –Exposure without cognitive restructuring –Wait-list control CBT = Exposure > Wait-list Estimated social cost mediated treatment changes in both active treatment conditions Hofmann, 2004, JCCP, 72,

Outcome Studies for Social Anxiety

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,

Within-Group Meta-Analysis Of Treatment Elements Taylor S. (1996), J Behav Ther Exp Psychiatry, 27, 1-9.

Treatment Acceptability (dropout rates) Table 1. Treatment Acceptability as assessed by drop-out rates in controlled trials Percent Dropout

CBT for Social Anxiety Disorder Comparisons to Pharmacotherapy

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

Generalized Social Phobia: Comparative Trial CGI Response Rate Davidson et al. Arch Gen Psychiatry. 2004;61,

Social Anxiety Disorder: Week 24 Outcomes LSAS Defined Remission Rate Blanco et al., 2010, Arch Gen Psychiatry, 67:

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

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,

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

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