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)
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.
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
Negative
Expectations
Vigilance To
Perceived
Danger
“Failure” - Focused
Attention (and
overestimation of
the cost of everyday
failures)
• Symptoms
• Self-focused attention
during performance
• Perception of anxiety or
errors
• Errors
• Negative
evaluations by
others
The Amplification of Anxiety About
Symptoms or Minor Errors
Anxiety
Minor Mistakes
Social
Cost
Beliefs
•Anxiety
•Failure
•Shame
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 selffocused 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, 393-399
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, 241-254.
Within-Group Meta-Analysis Of
Treatment Elements
Taylor S. (1996), J Behav Ther Exp Psychiatry, 27, 1-9.
•Percent Dropout
Treatment Acceptability
(dropout rates)
CBT for Social Anxiety Disorder
Comparisons to Pharmacotherapy
Social Phobia: Treatment Effect Sizes
Relative To No Treatment Or Placebo
Meta-Analysis Of 24 Studies
Gould et al., 1997
Generalized Social Phobia:
Comparative Trial
CBT+FLU
80
CBT+PBO
70
•CGI Response Rate
CBT
60
54.2
50.8
51.7
Fluoxetine
50.9
PBO
50
40
31.7
30
20
10
0
End Point
Davidson et al. Arch Gen Psychiatry. 2004;61, 1005-113
Social Anxiety Disorder:
LSAS Defined Remission Rate
Week 24 Outcomes
Blanco et al., 2010, Arch Gen Psychiatry, 67: 286-295.
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, 692-700
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 shortterm outcome for pharmacotherapy
• CBT is associated with maintenance and
extension of treatment gains