Academic journal article The Israel Journal of Psychiatry and Related Sciences

Social Phobia: Maintenance Models and Main Components of CBT

Academic journal article The Israel Journal of Psychiatry and Related Sciences

Social Phobia: Maintenance Models and Main Components of CBT

Article excerpt

Abstract: Social phobia (SP, or social anxiety disorder, SAD) is among the most common of all psychiatric disorders. SP typically begins early in life and provokes a great deal of impairment and reduction in quality of life. Despite its high prevalence and associated impact, SP has only recently become the focus of clinical research. We review the current CBT literature on SP, focusing on its main components, such as exposure, safety behaviors, cognitive restructuring, post-event processing, attentional retraining and social skills training. We suggest that although CBT for SP is effective, with effect sizes ranging from .6 to 2.6, much room for improvement remains. We conclude by reviewing some new and promising directions in the development of CBT for SP.

Social phobia (SP), also known as social anxiety disorder (SAD), is a widespread, impairing anxiety disorder. According to some accounts, SP is the fourth most common psychiatric disorder (1), with estimated lifetime prevalence rates of 7-13% in Western countries (2). The DSM-IV-TR (3) distinguishes between generalized (GSP) and non-generalized or specific (SSP) subtypes. GSP is characterized by fear of multiple social situations, whereas SSPs fears are circumscribed to a small number of situations. SP usually starts in childhood or adolescence and is typically comorbid with other Axis-I disorders, particularly anxiety and mood disorders (4). In the absence of treatment, SP is a chronic, lifelong condition with little spontaneous remission (5) which results in substantial impairment in social, educational, and employment functioning. Individuals suffering from SP rate their quality of life as low (6), report feelings of loneliness and suicidal ideation (7), and are at greater risk for suicide attempts (8). These clinical correlates of SP make the disorder severe and impairing.

CBT Model: Maintenance Factors in SP

Several cognitive-behavioral models of SP have been developed in recent years to explain the maintenance of SP (8-10). These models attempt to explain how SP persists despite repeated exposures to interpersonal interactions. As these models contain many similar features, we present an integrated account.

SP is maintained by virtue of two core beliefs: the malevolence of others and in the deficiency of the self and several processes that prevent these beliefs from being challenged. The malevolence assumption states that other people are critical, dominant, competitive, and adhere to high standards. The deficiency assumption holds that one is deficient in terms of personal qualities and abilities, and thus unable to meet strict standards. Combined, those beliefs result in the conjecture that social situations are inherently threatening, and that unless one makes a good impression, one's social destiny is jeopardized. The perception of any social situation as involving an evaluation, combined with the malevolence assumption, generates anxiety, which leads to physical, behavioral and cognitive manifestations. Several processes inhibit the updating of these beliefs: (a) selective attention to one's anxiety symptoms when in social situations; (b) selective attention to evaluative, threatening, or critical cues from others, and negative interpretation of ambiguous cues; (c) enhanced elaboration of one's mental representation in the eyes of others; (d) the use of safety behaviors during stressful social situations; (e) engagement in negative postevent-processing. First, when individuals suffering from SP encounter social situations, their attention tends to focus on how they are coming across to others, rather than on the situation at hand. This self -focused attention prevents them from seeing potentially positive information that would serve to disconfirm their beliefs. The self-focused attention also contributes to focusing on symptoms of anxiety, which, in turn, are taken to support the belief that one is weak or strange, thus enhancing the belief in self's deficiency. …

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