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2003, 9:258-264.APTDavid VealeTreatment of social phobia

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258 Advances in Psychiatric Treatment (2003), vol. 9. http://apt.rcpsych.org/

Veale A dv ances in Psy chi at ri c Treat ment (2003), v ol . 9, 258264

Treatment of social phobiaDavid Veale

Social phobia (or social anxiety disorder) consistsof a marked and persistent fear of social or

performance situations. Affected individuals fearthat they will be evaluated negatively or that theywill act in a humiliating or embarrassing way.Exposure to social or performance situationsinvariably leads to panic or marked anxiety, andsuch situations therefore tend to be avoided orendured with extreme distress.

Social phobia is the third most common mentaldisorder in adults worldwide, with a lifetimeprevalence of at least 5% (depending on thethreshold for distress and impairment). There isan equal gender ratio in treatment settings, butin catchment area surveys, there is a female pre-ponderance of 3:2. Individuals are more likely to be unmarried and have a lower socio-economicstatus. Although common, social phobia is often notdiagnosed or effectively treated. There have,however, been a number of developments in ourunderstanding and treatment of social phobia overthe past decade, and these are the focus of thisarticle.

Presentation

The onset of social phobia usually takes placeduring adolescence, although a minority of causes

involve a late onset after a significant life event (suchas an episode of failure). The typical course ischronic and life-long. Predisposing factors includea shy or anxious temperament from childhood. Thereis significant comorbidity, especially of depression,

alcohol or substance misuse or body dysmorphicdisorder. In body dysmorphic disorder, patients are

often too ashamed to reveal their preoccupation withtheir appearance, and present with symptoms of social anxiety and depression, fearing that themental health professional will view them as vainor narcissistic. A similar situation exists in patientswith olfactory reference syndrome, who believethat they have body odour that others will findunpleasant, which they may camouflage withperfume. Therefore, all patients with symptoms of social anxiety should be routinely asked whetherthey are very concerned about some aspect of theirappearance or about body odour. It should beemphasised that patients with social phobia do notlack social skills. Most affected individuals will havenormal social skills in a consultation with you, orwith a friend or partner. In social situations, theyare trying too hard and can appear to lack socialskills, because they might interact less, keep theirhead down or not reveal personal information.Patients (for example, those with Asperger syn-drome) who do lack communication skills have adifferent problem.

The presentation of social phobia can depend oncultural contexts. In Western cultures, patients mightpresent to surgeons for cures for complaints of excessive blushing or sweating. In Japan, socialphobia is manifested as an extreme fear of bringingoffence to others, and is referred to as taijin kyofusho.Sufferers of this disorder may fear that makingeye contact, blushing, imagined defects in theirappearance or their body odour would be offensiveto others.

David Veale is an honorary senior lecturer at the Royal Free and University College Medical School and a consultant psychiatristat the Priory Hospital (The Bourne, Southgate, London N14 6RA, UK). He has a special interest in cognitivebehaviouraltherapy and its application to anxiety disorders and body dysmorphic disorder.

Abstract Social phobia (or social anxiety disorder) manifests as a marked and persistent fear of negativeevaluation in social or performance situations.The epidemiology, diagnosis and psychopathology arereviewed, including clinical presentation, cultural aspects and the differences between agoraphobiaand social phobia. Behavioural treatments, including graded self-exposure and cognitive restructuring,are considered. A cognitive model of the maintenance of social phobia is discussed. It is hypothesisedthat attentional shifting towards imagery, safety behaviours and post-mortem analyses play a keyrole in symptom maintenance. The implications of this for treatment are described, and guidelines forpharmacological treatment are summarised.

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Treat ment of social phobia


PsychopathologyThe core psychopathology in social phobia is a fearof negative evaluation in social and performancesituations. It overlaps with the concept of shame,although the two sets of literature have largelyignored one other (Gilbert & Andrews, 1998). Social

anxiety is best described as the fear of feelingashamed (e.g. of the emotions aroused and theirinterference in one s presentation) or the fear of beingshamed (e.g. by the negative evaluation of oneself and potential loss of rank), or both.

Social phobia usually leads to avoidance of situations such as public speaking or talking to agroup, parties, meetings, eating or drinking inpublic, working or writing while being observed,telephone calls, intimacy or dating. Groups arenearly always more anxiety-provoking than is anindividual. Peers of the same age are usually moreanxiety-provoking than older individuals. Forheterosexual individuals, people of the oppositegender are usually more anxiety-provoking thanthose of the same gender. Sometimes individuals inauthority, especially at work, are more anxiety-provoking than individuals at the same level.

There tend to be two sub-types of social phobia generalised and non-generalised. Generalised socialphobia is more disabling and involves a more diverserange of feared stimuli. Those affected by it includesome patients with avoidant personality disorderand it has a worse prognosis. Non-generalisedsocial phobia is associated with avoidance of alimited range of performance situations or inter-actions (such as public speaking), and this overlaps

with performance anxiety in sexual dysfunction.Non-generalised social phobia is easier to treat, witha better prognosis.

A person afraid of speaking in public would notreceive a diagnosis of social phobia if publicspeaking was not routinely encountered and theperson was not particularly distressed about it. It isusually the degree of distress or impairment thatwarrants a diagnosis of social phobia, and thepossible indicators need to be considered in theappropriate context. For example, transient or mildsocial anxiety is especially common in adolescence.The degree of severity in social phobia is veryvariable, ranging from individuals who are virtuallyhousebound and have never had a relationship, toothers who are highly functioning except in certainareas such as making a presentation, which theyfind very distressing and which handicaps them intheir occupation.

Social phobia might be confused with agora-phobia. Individuals with agoraphobia tend to be female and to be anxious about their physicalor mental health. They misinterpret physical

sensations as evidence of an immediate catastropheto their health. Panic attacks in agoraphobia tend to be both situational and spontaneous. Affectedindividuals are concerned with a wider range of autonomic sensations such as palpitations andfeeling dizzy or short of breath. Those with socialphobia, however, are more likely to be concerned

with autonomic sensations of blushing, shaking orstammering (which the person believes may benoticeable to others). Panic attacks in social phobiaoccur almost exclusively in social situations. Some-times, a patient with agoraphobia also has comorbidsymptoms of social anxiety. For example, he might believe that he will collapse or go mad as a result of a panic attack, but in a social situation, he mightalso fear causing a scene and others evaluating himnegatively. Typical beliefs in an individual withsocial phobia focus on the perceived negativeevaluation by others of revealing a flaw or un-acceptable behaviour (for example, the person believes that her hands will shake or she will soundstupid or boring). This is also referred to in theliterature as external shame .

Such individuals tend to have high standards orrules about how they must perform in socialsituations. Their assumption is that failing toachieve these standards might lead others to seethem as inferior, flawed or inadequate and they them-selves also agree with this assessment (referred toas internal shame ). They predict that this failurewill lead to rejection or a further failure to achievean important goal. Individuals with no internalshame may know that others are rejecting them andview them as inferior, but not believe it about

themselves.The emotions in social phobia are predominantlythose of anxiety and shame, and sometimes self-disgust or anger (which will depend on beliefs andsafety behaviours). As in other anxiety disorders,the main coping (or defensive) behaviour is to escapefrom the situation. There is a strong urge not to beseen. Eye gaze is commonly averted and there is behavioural inhibition (discussed in more detail below under safety behaviours ). These behav-iours might be linked to the submissive defensive behaviours used to reduce aggression in anotherperson in response to the threat of rejection.

When the focus is on another person as being badand doing something to expose the individual asinferior, then the main emotion is of humiliation(rather than social anxiety). There is a sense of injustice and unfairness, often leading to anger anda strong desire for revenge against the one who isexposing the self as weak or inferior.

Alcohol and other substances are commonly usedin social phobia, but such usage might result in aself-fulfilling prophecy as patients may indeed make

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Veale

affected individual s own evaluation of his or her behaviour that is crucial in determining the degreeof social anxiety. Such alternative approaches arenot usually recommended, as adherence is likely to be poor unless the therapist is prepared to modelthe behaviour. Self-exposure and variants of cognitive restructuring are effective and valid

treatments, but the treatment gains might only bemodest. For example, Heimberg et al (1990) reportthat only 65% make clinically significant change .

Cognitive therapy

Clark & Wells (1995) and Clark (2001) havedeveloped a cognitive model for the maintenance of social phobia (Fig. 1). Most of the material for therest of this article is derived from their approach.The aim of the model is to answer the question of why the fears of someone with social phobia aremaintained despite frequent exposure to social orpublic situations and the non-occurrence of thefeared catastrophes. Recent research from controlledtrials supports the efficacy of the approach (Clarket al, 2003). The model suggests that when patientsenter a social situation, certain rules (e.g. I mustalways appear witty and intelligent ), assumptions(e.g. If a woman really gets to know me then shewill think I am worthless ) or unconditional beliefs(e.g. Im weird and boring ) are activated. When

fools of themselves after excessive alcohol consump-tion. Although alcohol and substance dependenceneed to be treated first, many such patients willhave difficulty attending self-help groups such asAlcoholics Anonymous. Nevertheless, mental healthpractitioners who treat alcohol and substancemisuse frequently fail to address the comorbid social

anxiety once the patient has stopped misusing andrelapse is therefore common.

Assessment measures

Suitable assessment measures include the Brief Social Phobia Scale (Davidson et al, 1991) and theSocial Anxiety Scale (Liebowitz, 2002), which are both observer-rated. Subjective rating scales includethe Social Phobia and Anxiety Scale (Turner &Beidel, 1989), the Social Phobia Inventory (Connoret al, 2000) and the Fear Questionnaire (Marks& Mathews, 2002).

Graded self-exposure

Learning theory hypothesises that avoidancemaintains the fear in social phobia, as patients aremotivated to avoid punishment by others. Theanticipated punishment the prediction of rejection, deflation and isolation is never dis-confirmed. Graded self-exposure has been thetreatment of choice for social phobia for many years.A detailed hierarchy is made of all the situationsthat the person avoids, with a rating of 0 to 100%

according to the degree of anticipated anxiety. Self-exposure involves repeatedly facing previouslyavoided situations in a graded manner untilhabituation has occurred.

There are problems with exposure alone forexample, tasks might be brief (and not long enoughfor the anxiety to subside) or not susceptible toregular repetition. Furthermore, a significant numberof patients refuse self-exposure or drop out early. Of those who complete treatment, about 50% willovercome their problem. Treatment failures tend to be associated with a depressed mood, avoidantpersonality, intolerance of emotion and markedavoidance behaviour. Alternative approaches haveincluded group cognitive behavioural therapy(Heimberg et al, 1990) or the addition of coping skills,cognitive restructuring or shame-attacking fromrational emotive behaviour therapy. An example of shame-attacking is for the patient to shout out thenames of stations on a railway line. Other passengersmight think that the individual is stupid, but he orshe can learn that performing a stupid act does notmake one stupid through and through . It is the Fig. 1 A model of social phobia.

Socialsituation

Activates assumption

Perceived social danger

Processingof self as a

socialobject

Safety behaviours

Somatic andcognitive

symptoms

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individuals believe that they are in danger of negative evaluation, an attentional shift occurstowards detailed self-observation, and monitoringof sensations and images. Socially anxious indivi-duals thus use internal information to infer howothers are evaluating them (in Fig. 1 this isprocessing of self as a social object ). The internal

information is associated with feeling anxious, andvivid or distorted images are imagined from anobserver perspective (Hackmann et al, 2000). Theseimages are mostly visual, but they might also include bodi ly sensat ions and audi tory or ol factoryperspectives. This is not, of course, what an observeractually sees . Recurrent images can be elicited byasking patients to recall a social situation associatedwith extreme anxiety. The images are usually linkedto early memories. The therapist asks the patientwhen he or she remembers first having the experienceencapsulated in the recurrent image and to recallthe sensory features and meaning that these had.For example, someone who had an image of beingfat remembered being teased during adolescence,which resulted at the time in feelings of humiliationand rejection.

A second factor that maintains symptoms of socialphobia are safety behaviours. These are actions takenin feared situations which are designed to preventfeared catastrophes (Salkovskis, 1991). Safety behaviours in social phobia include: using alcohol;avoiding eye contact; gripping a glass too tightly;excessive rehearsing of a presentation; reluctanceto reveal personal information; and asking manyquestions. Safety behaviours are often problematic:they prevent disconfirmation of the feared catas-

trophe; they can heighten self-focused attention andmonitoring to determine if the behaviour isworking ; they increase the feared symptoms (e.g.,keeping arms close to the body to stop others seeingone sweat will increase sweating); they have aneffect on others (e.g. the individual may appear coldand unfriendly, so that a feared catastrophe becomesa self-fulfilling prophecy); and they can drawattention to feared symptoms (e.g. speaking quietlyand slowly will lead others to focus on the indi-vidual even more).

It is hypothesised that a third factor that main-tains symptoms of social phobia is anticipatory andpost-event processing. Such processing focuses onthe feelings and constructed images of the self in theevent and leads to selective retrieval of past failures.

Stages of therapy

Therapy begins with a detailed assessment andformulation of the problem, which is developedcollaboratively between therapist and patient. The

aim is to understand the development and main-tenance of the disorder and how the patient s current beliefs, emotions and behaviour interact. Sessionsare recorded on audio- or videocassette so that thepatient may listen to a session again and providefeedback at the next session. The therapist also hasan opportunity of reviewing the sessions in

supervision.An idiosyncratic version of the model (Fig. 1) isdrawn up with the patient, based upon a review of recent episodes of social anxiety. First, the therapistidentifies a specific and recent social situation thatwas sufficiently anxiety-provoking. He or she thenattempts to identify the negative automatic thoughts by asking questions such as: What went throughyour mind as you noticed yourself becominganxious , What was the worst you thought couldhappen? and What did you suppose that otherswould notice or think?

The therapist may use a downward arrow technique to try to identify the patients assumptionsand core beliefs. This involves asking the patient toassume the worst and then to assume that thethought is true. The therapist then asks what themost anxiety-provoking thing about the thought isor what it means to the individual. For example:

Therapist: How did you feel you came across?Patient: I felt I appeared very red and sounded

stupid.Therapist: Lets assume that you did appear very red

and sounded stupid, what would that meanabout you?

Patient: I felt that I looked like an idiot and otherswould be secretly laughing at me.

Therapist: Lets assume it s true that everyone in theroom is laughing to themselves, whatwould that mean to you?

Patient: I think no one will really want to know mein the future and I ll be alone.

Next, the therapist identifies the autonomicsensations or symptoms of anxiety by askingquestions such as: When you thought the fearedevent might happen, what did you notice happeningin your body? (e.g. blushing, shaking, sweating).

Safety behaviours are next elicited by askingWhen you thought the feared event might happen,did you do anything to try to prevent it fromhappening? , Is there anything you do to try toensure you come across well? or Do you doanything to stop drawing attention to yourself?

Increased self-consciousness and imagery areelicited by asking questions such as: What happensto your attention when you are most afraid? Doyou become more self-conscious? Do you havedifficulty following what others are saying? Do youhave a picture in your mind of how you feel youare coming across? Further details of the imagery

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M odifyi ng post- int eracti on ruminat ions

Those affected by social phobia often engage in post-mortems . Here, the therapist helps the patient toidentify the content of the event (not the feelings)and review what actually happened by shifting toexternal processing and constructing an alternative

data log of information that is normally disregardedor distorted.Therapy would normally take between 8 and 20

out-patient sessions, depending on the severity andchronicity of the phobia. Patients with very severephobia, who are housebound or dependent onalcohol, might do better on an intensive programmeof CBT as either day-patients or in-patients in theright setting.

Pharmacotherapy

Medication is indicated if it is the patient s first

choice, CBT has failed, there is a long waiting-listfor CBT or there is significant comorbidity of depression. The treatment of choice in social phobiais a selective serotonin reuptake inhibitor (SSRI)(Ballenger et al, 1998). Of the SSRIs, only paroxetineis licensed and marketed in the UK for social phobia,although there is no reason why other SSRIs maynot be as effective. Most affected individuals cantolerate a normal starting dose of an SSRI, as theydo not usually experience an activation syndrome (as in panic disorder). The starting dose is used for24 weeks and then increased as necessary. Theonset of action is usually within 6 weeks and anadequate trial period is 8 weeks. The full responsemay occur after up to 12 weeks.

About 50% of patients relapse on discontinuationof an SSRI and treatment is therefore continued for aminimum of 12 months. Once in remission, the dosemay be reduced slowly (e.g. a 25% reduction every2 months). If a patient fails to respond to an SSRI,then some evidence exists for the efficacy of a mono-amine oxidase inhibitor (MAOI) (e.g. phenelzine,45 90 mg daily) or a reversible monoamine oxidaseinhibitor (RIMA) (e.g. moclobemide, 300 900 mgdaily). Allow 2 weeks between discontinuing anSSRI (5 weeks if fluoxetine) and commencing anMAOI or RIMA. Although there are no evidence- based guidelines on the treatment of patients whohave failed to respond fully to an SSRI or an MAOI,expert opinions suggest the adjunctive use of beta- blockers (e.g. propranolol, starting dose 20 mg daily,gradually increased to 60 mg, or atenolol 50 100 mgdaily) to augment the response. Similarly, clonidinemay augment the response for symptoms of blushingwhen used as an adjunct to an SSRI. The use of benzodiazepines (especially short-acting ones) isnot recommended, because side-effects at a higher

dose can include sedation, forgetfulness, impairedconcentration and disinhibition, especially whenused intermittently. Benzodiazepines are especiallycontraindicated for patients with comorbidity of depression and/or a history of alcohol or substancemisuse.

Which treatment for whom?

Only one trial has compared later versions of CBTwith an SSRI (Clark et al, 2003), and it found CBT to be superior to fluoxetine. No trials have yet com-pared later versions of CBT with a combination of CBT and another SSRI, especially in the long termand after discontinuation of the active treatment.As always, treatment will depend upon patientchoice and availability of therapy, but in commonwith other anxiety disorders, CBT is the initial choiceof treatment for social phobia, as it is usually moreacceptable and has a reduced risk of relapse. Asalways, the main problem is user choice and accessto CBT in a timely manner.

ReferencesArntz, A. & Weertman, A. (1999) Treatment of childhood

memories: theory and practice. Behaviour Research Therapy,37 , 715740.

Ballenger, J. C., Davidson, R. T., Lecrubier, Y. , et al (1998)Consensus statement on social anxiety disorder from theInternational Consensus Group on Depression andAnxiety. Journal of Clinical Psychiat ry, 59, 5460.

Bogels, S. M., Mulkens, S. & De Jong, P. J. (1997) Taskconcentration training and fear of blushing. ClinicalPsychology and Psychotherapy, 4, 251258.

Clark, D. M. (2001) A cognitive perspective on social phobia.In International Handbook of Social Anxiety: Concepts, Researchand Interventions Relating to the Self and Shyness (eds W. R.Crozier & L. E. Alden) . pp. 405 430. Chichester: JohnWiley & Sons.

& Wells, A. (1995) A cognitive model of social phobia . InSocial Phobia Diagnosis, Assessment, and Treatment (eds R.G. Heimberg, M. R. Liebowitz, D. Hope, et al), pp. 69 93.New York: Guilford.

, Ehlers, A., Hackmann, A., et al (2003) Cognitive therapyvs. fluoxetine plus self exposure in the treatment of generalized social phobia (social anxiety disorder): Arandomised placebo controlled trial. Journal of Consultingand Clinical Psychology, in press.

Connor, K. M., Davidson, J. R. T., Churchill, L. E. , et al (2000)Psychometric properties of the Social Phobia Inventory(SPIN). British Journal of Psychiatry, 176 , 379386.

Davidson, J. R. T., Potts, N. L. S., Richichi, E. A., et al (1991)The Brief Social Phobia Scale. Journal of Clinical Psychiatry,52, 4851.

Gilbert, P & Andrews, B. (1998) Shame: Interpersonal Behaviour,Psychopathology, and Culture . New York: Oxford UniversityPress.

Hackmann, A., Clark, D. M. & McManus, F. (2000) Recurrentimages and early memories in social phobia. BehaviourResearch and Therapy, 38, 601610.

Heimberg, R. G, Dodge, C. S., Hope, D. A. , et al (1990)Cognitive behavioral group treatment for social phobia:Comparison with a credible placebo control. CognitiveTherapy and Research, 14, 123.

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