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Social Anxiety Treatment – Cognitive Behavior Therapy (CBT)

By docdave on Tuesday, October 6th, 2009 | No Comments

Cognitive Behavior Therapy – Theory

As noted in the introduction, people with SA are able to experience anxiety through their thoughts alone, without being in the actual situation. However, the thoughts themselves may often be distorted. Since there is avoidance of the feared situation, this thinking does not get corrected by reality.

With CBT the therapist helps the client to identify distorted thought patterns and learn to correct them. A thought journal is often used for this process.

There is cumulative evidence that individuals with SA process information differently from people who are not socially anxious. It is found that they place much more importance on making a favorable impression on others, yet, they believe that they will act incompetently in social situations.

As a result of these concerns, people with SA use various processes intended to protect themselves in feared situations, which, unfortunately, often fail to help.

These processes include intensified attention on oneself, including paying attention to one’s internal state; viewing oneself from an observer’s perspective; overuse of safety behaviors. When in social situations, people who are anxious about how they are seen, commonly pay more attention to themselves and ignore useful and necessary social cues from others. This paying attention to oneself is encouraged by the presence of the physiological sensations of anxiety.

Another consequence of this inward attention is that people with SA usually construct a negative image of themselves, based on how they think others see them and how they feel.

Practice

Duration

Usually cognitive therapy is time limited. Commonly 10 to 20 sessions are required. If there is a more specific limited problem it could be dealt with in fewer sessions. Sometimes if there are complex problems more sessions may be required.

Therapeutic Alliance.

The therapist will work with the client to set up a collaborative relationship. It is important that the client be an active participant in the whole process. He or she cannot expect to make any improvement unless they are prepared to follow through and do the homework assignments. However, the client’s opinion and agreement will be sought throughout the process.

Set Agenda for Sessions

The therapist in collaboration with the client will set an agenda for each session. The activities will include giving constructive feedback, and employ cognitive therapy techniques on a regular basis and assign homework to link the sessions together.

Use Cognitive Techniques
Identifying Automatic Thoughts

Many people with SA commonly have thoughts which come into their mind in response to either a situation or to an emotion. They may be aware of the feeling but not recognize the thought. With SA these thoughts are commonly predictive of some disastrous event happening. Examples of these are given in Table II.

The therapist will guide the client in identifying these thoughts and then proceeding to the next step:-

Modifying Automatic Thoughts

Examining the Evidence for These Thoughts

The therapist will collaborate with the client in examining the evidence for these beliefs. This challenge also helps the client to more easily identify automatic thoughts in the here and now. There are common patterns of cognitive distortions which the therapist can help the client to recognize.

De-catastrophizing

Clients typically predict that dire consequences will happen if they engage in the feared social behavior. The therapist helps by challenging these assumptions.

Assign Homework

Homework assignments are routinely given in the course of CBT. Commonly a thought journal is kept in which the client records a triggering event, his or her emotional response to that event and the thoughts that accompany it. He or she is then requested to write down the evidence for this thought or to identify in what way it is distorted.

The therapist will be coaching the client in identifying these distortions. The homework and journal will be used as a basis for a subsequent session.

In addition to the thought journal graded exercises with exposure to the feared situation may be assigned.

Cognitive Therapy coupled with graduated exposure to the feared situation has been demonstrated to be an effective treatment for SA.

What is Social Anxiety?

By docdave on Sunday, September 13th, 2009 | No Comments

Social anxiety is where a person is nervous or uncomfortable in social situations. The fear is often one of doing something embarrassing, making a bad impression, or being judged negatively by others. Social anxiety may be specific or generalized. In the case of specific anxiety it is only triggered by one or two situations. These may be, for example, speaking in public or being interviewed for a job.

In the case or generalized social anxiety, almost any social situation can provoke anxiety. However, in all cases the anxiety does not arise in a vacuum, but is triggered either by being confronted with the situation or by thinking about it and anticipating it. Usually thinking about an upcoming situation is enough to create anxiety.

The response to these situations can include:-

The physiological and bodily changes of anxiety (See Table 1)

e.g. increased heart rate, dry mouth, sweating, gastrointestinal upset etc.

Worrying Thoughts (See Table 2)– these commonly involve a fretful anticipation of some disastrous or embarrassing consequence of engaging in a particular social interaction.

Avoidant Behavior. (See Table 3) Often people who exhibit shyness or social anxiety often avoid situations in which they may become anxious. Sometimes the avoidance is obvious but at other times there may be more subtle forms of avoidance. These include using alcohol or drugs to mask anxiety, staying in the kitchen to help out at the party, wearing a turtleneck or a lot of makeup to hide possible blushing.

Table I – Physical Feelings Associated with Social Anxiety

  • Racing or pounding heart
  • Breathlessness or feelings of being smothered
  • Dizziness or lightheadedness
  • Difficulty swallowing, choking feelings, or a “lump” in the throat
  • Quivering or shakiness (e.g., in the hands, knees, lips, or whole body)
  • Blushing
  • Nausea, diarrhea, or “butterflies” in the stomach
  • Excessive sweating
  • Trembling or quavering voice
  • Tearfulness, crying
  • Nervous laughter, smiling
  • Poor concentration (e.g., forgetting what you are trying to say)
  • Blurred vision
  • Numbness and tingling sensations
  • Feelings of unreality or being detached
  • Tightness or weakness in the muscles (e.g., wobbly legs, sore neck)
  • Chest pain or tightness in chest muscles
  • Dry mouth
  • Hot flushes or chills

Table II – Examples of Distorted Thinking

  • It is important that everybody like me
  • If my boss doesn’t like me, I will be fired
  • If I give a presentation, I will make a fool of myself
  • If I make a mistake, people will become angry with me
  • People are untrustworthy and nasty
  • People should always be interested in what I say
  • People should not look at me the wrong way
  • If I am not liked by a particular person, I am unlikable
  • If someone rejects me, I deserve it
  • It is awful to blush, shake, or sweat in front of others
  • People can tell when I am anxious
  • People find me unattractive
  • If I speak to my boss, I will look incompetent
  • I should be able to hide my anxiety symptoms
  • If my hands shake at work, it will be a disaster
  • Anxiety is a sign of weakness
  • I should not appear anxious
  • If I am too anxious, I will not be able to speak

Table III – Examples of Avoidant Behaviors

Avoidant Behavior Examples
Refusing to Enter the Situation Turning down an invitation to a party
Never answering questions in class
Making an excuse not to have dinner with a friend
Escaping from the Situation Always arriving late for meetings and leaving early to avoid making “small talk”
Offering to help with the dishes at a party to avoid talking to the guests

Making an excuse to get off the telephone with a friend or coworker
Subtle Avoidance Behaviors Distracting yourself from your anxious thoughts
Keeping the room dark during your presentations to keep the audience focused on the slides rather than on you
Filling out a check before arriving at store to avoid writing in front of others
Avoiding eye contact and speaking very softly when conversing with others
Overprotective Behaviors Wearing makeup and a turtleneck sweater to hide your blushing
Always attending the holiday office party with a close friend, spouse, other safe person even though your coworkers tend to attend alone
Always arriving early for meetings to ensure that it will not be necessary to enter the room after everyone else is already seated
Drug or Alcohol Use Having a couple of glasses of wine before meeting another person for a date

Examples of Social Situations

Interpersonal Situations

  • Asking someone out on a date
  • Initiating or maintaining a conversation
  • Going to a party
  • Having friends over for dinner
  • Meeting new people
  • Talking on the telephone
  • Expressing a personal opinion
  • Having a job interview
  • Being assertive (e.g., asking someone else to change their behavior)
  • Returning an item to a store
  • Sending back food in a restaurant
  • Making eye contact

Performance Situations

  • Public speaking
  • Speaking in meetings
  • Playing sports or participating in aerobics
  • Getting married
  • Performing music or acting on a stage
  • Eating or drinking in front of others
  • Using public bathrooms with others in the room
  • Writing with others watching (e.g., filling out a form)
  • Making a mistake in public (e.g., falling down, dropping your keys, etc.)
  • Walking or jogging in a public place (e.g., on a busy street)
  • Introducing yourself (e.g., saying your name) in front of a group
  • Shopping in a busy store

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