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Social Phobia Lecture Overview

Social Phobia Lecture Overview. Nature and epidemiology Empirically-supported treatments Efficacy data Moderator variables Clinical tips in working with social anxiety clients Class discussion. Epidemiology of Social Phobia. Defining features

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Social Phobia Lecture Overview

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  1. Social PhobiaLecture Overview • Nature and epidemiology • Empirically-supported treatments • Efficacy data • Moderator variables • Clinical tips in working with social anxiety clients • Class discussion Treatment of Social Phobia

  2. Epidemiology of Social Phobia • Defining features • 1. Persistent fear (recognized as excessive or unreasonable) of at least 6 months duration of one or more social situations in which the person is exposed to possible scrutiny by others. The primary fear is one of negative evaluation by others. • 2. Exposure almost always provokes anxiety or panic (situationally-bound or predisposed). • 3. Situations are avoided or endured with significant distress. Treatment of Social Phobia

  3. Epidemiology of Social Phobia • Defining features cont. • 4. Marked impairment; • 5. Not better accounted for by a medical problem or other mental disorder Treatment of Social Phobia

  4. Epidemiology of Social Phobia • Subtypes • Generalized • Specific Treatment of Social Phobia

  5. Epidemiology of Social Phobia • Prevalence Treatment of Social Phobia

  6. Prevalence of Anxiety Disorders Treatment of Social Phobia

  7. Epidemiology of Social Phobia • Onset and course • Early age of Onset (14.8 girls; 16.3 boys) • Chronic unremitting course Treatment of Social Phobia

  8. Epidemiology of Social Phobia • Impairment/disability • Significant interference in work and social functioning (Davidson et al, 1993) • Inability to work, attend school, socialize, or marry are common in clinical samples (Liebowitz, 1985) • Most common co-existing anxiety disorder among alcoholics undergoing detoxification (Chambless et al, 1987) Treatment of Social Phobia

  9. Epidemiology of Social Phobia • Comorbidity • Simple phobia (59.0) • Agoraphobia (44.9) • Alcohol abuse (18.8) • Depression (16.6) Based on: (Schneier et al (1992) Treatment of Social Phobia

  10. Pharmacological Treatments for Social Phobia • Standard MAOIs • Selective reversible MAOIs • Benzodiazepines • SSRIs • Beta Blockers Treatment of Social Phobia

  11. Psychosocial Treatments for Social Phobia • CBGT • Exposure • Cognitive therapy Treatment of Social Phobia

  12. Cognitive-Behavioral Group Treatment (CBGT) • Potential advantages of group treatment • Vicarious learning • Fostering independence • Learning through helping others • Having similar problems • Public commitment • Encouragement through others’ successes Treatment of Social Phobia

  13. Cognitive-Behavioral Group Treatment (CBGT) • Procedural Components • Education • Exposure simulations • Cognitive restructuring • Home-based skill practice • self-monitoring • cognitive-restructuring • in vivo exposure Treatment of Social Phobia

  14. Advantages of Exposure Simulations • Exposure simulations are always available; • Exposure simulations can be scheduled in a graduated fashion; • Exposure simulations are more controllable; • Exposure simulations are moldable to the needs of the patient; • Exposure simulations occur under the observation of the therapist; Treatment of Social Phobia

  15. Advantages of Exposure Simulations • Exposure simulations are easily integrated with cognitive restructuring activities; • Exposure simulations are less easily avoided by patients • Exposure simulations may facilitate compliance with homework assignments. Treatment of Social Phobia

  16. Examples of Common Exposure Simulations • Initiating conversations • Asking for a date • Public speaking • Writing in front of others • Eating or drinking in front of others • Working or playing wall being observed Treatment of Social Phobia

  17. Examples of Common Exposure Simulations • Assertion and interaction with authority figures • Job interviews • Joining ongoing conversations • Making mistakes in front of others • Expressing opinions • Revealing personal information Treatment of Social Phobia

  18. Integrating Cognitive Restructuring and Exposures • Prior to a simulated exposure • Prompted thought recall • Identify experienced or potential AT • Identify cognitive distortion • Dispute AT • Develop rationale response to the AT • Set appropriate goal for performance in the exposure simulation Treatment of Social Phobia

  19. Integrating Cognitive Restructuring and Exposures • During an exposure simulation • Patient gives SUDS ratings at one minute intervals • Patient reads rational responses aloud when giving SUDS rating • Patient uses rational responses as automatic thoughts occur Treatment of Social Phobia

  20. Integrating Cognitive Restructuring and Exposures • After an exposure simulation • Review the patient’s goal and assess goal attainment • Review the occurrence of automatic thoughts listed before the exposure simulation • Review and evaluate the use of rational responses • Examine the occurrence of unexpected automatic thoughts and patients’ attempt to cope with them • Examine the covariation between automatic thoughts, rational responses, and SUDS ratings Treatment of Social Phobia

  21. Summary of Homework Procedures • Before attempting assignment • Imagine yourself in the target situation • Record AT on self-monitoring form • Identify cognitive distortions • Ask yourself which AT is most problematic • Come up with the rational response for each AT Treatment of Social Phobia

  22. Summary of Homework Procedures • While attempting the assignment • Focus on the goals that you have set • Tolerate whatever anxiety you experience to the best of your ability • Use your rational responses to help control your anxiety • Keep your eyes open and try to learn whatever you can from the assignment Treatment of Social Phobia

  23. Summary of Homework Procedures • After attempting the assignment • Set aside a period of cognitive debriefing • Assess whether or not you made your goals • Examined the list of automatic thought you recorded before the assignment • Record automatic thoughts that occurred since you did the assignment • Relax Treatment of Social Phobia

  24. CBGT Efficacy Data • Heimberg et al, (1990) • Heimberg et al. (1993) • Gelernter et al. (1991) • NIMH Multicenter Study Heimberg et al (1998) • Lucas & Telch (unpublished) Treatment of Social Phobia

  25. Heimberg et al (1990) Data from Heimberg et al (1990). Cognitive Therapy and Research, 14, 1-22. Treatment of Social Phobia

  26. Gelernter et al (1991) Data from Gelernter et al (1991). Archives of General Psychiatry, 48, 936-944. Treatment of Social Phobia

  27. NIMH Multicenter StudyPost-Treatment Findings Data from Heimberg et al (1998). Archives of General Psychiatry, 56, 1133-1141. Treatment of Social Phobia

  28. Heimberg et al (1998)Treatment-free Follow-up Treatment of Social Phobia

  29. Heimberg et al (1998)Treatment-free Follow-up Treatment of Social Phobia

  30. Lucas & Telch (Unpublished) Treatment of Social Phobia

  31. Meta Analyses • Fiske & Chambless (1995) • 21 studies (12 involving CBT and 9 involving exposure alone) • CBT was no more effective than exposure • Examined pre- to post effect sizes (uncontrolled) Treatment of Social Phobia

  32. Meta Analyses • Taylor (1997) • 49 studies divided into one of 5 classes of treatment (1) exposure, (2) CT without exposure; (3) CT + Exp; (4) Social skills training; and (5) Wait-list • Trend for CT + Exp to outperform the other treatments • length of treatment predicted outcome and drop-outs • Effects of treatment increased over the follow-up period Treatment of Social Phobia

  33. Moderators of Treatment Outcome • Avoidant personality disorder • Van Velzen et al (1997) -negative findings • Lucas & Telch (unpublished) positive findings • Social Phobia Subtype • Liebowitz et al (unpublished) • Lucas & Telch (unpublished) • Client Expectancies (Safren & Heimberg, 1997) • Safety Behaviors (Wells et al, 1995) Treatment of Social Phobia

  34. Clinical Strategies in Treating Social Phobia • Strategies aimed at correcting exaggerated estimates of social threat occurrence • Education • Downward arrow technique • Pie chart with 100 objective judges • Role reversal strategies • Recorded feedback strategies • Observation/participant modeling techniques • In vivo exposure techniques • Biological challenge techniques • Fade Safety Behaviors as a way of facilitating disconfirmation of social threat Treatment of Social Phobia

  35. Clinical Strategies in Treating Social Phobia • Strategies for correcting exaggerated estimates of social threat severity (Catastrophizing) • Monitoring techniques • Scaling technique • Observation/participant modeling techniques • In vivo techniques aimed at drawing attention to oneself • Feigning Techniques • Biological challenge techniques Treatment of Social Phobia

  36. Clinical Strategies in Treating Social Phobia • Fading of safety behaviors as a way of facilitating disconfirmation of social threat • Avoidance of eye contact • Positioning oneself in an inconspicuous place in social/academic/work gatherings • Alcohol/drugs • Not speaking up in class or in meetings • Making checks out in advance • Keeping hands in pockets • Excessive use of deodorant or A/C Treatment of Social Phobia

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