Contemporary Issues in Social Anxiety Disorder

Contemporary Issues in Social Anxiety DisorderEtiology, Diagnosis and Treatment

Conor Mahon BSc.

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OverviewIntroWhat is it?Prevalence

EtiologyBehavioural InhibitionGenetic FactorsConditioning Events

DiagnosisDSMComorbiditiesSAD vs Shyness

TreatmentDrugs vs TherapyCannabidiol ResearchCognitive Behavioural Therapy

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What is it?Principle fears-acting in way thats results in embarrassment, humiliation, or negative evaluation by others (Stein & Stein, 2008)

Avoid interpersonal meetings OR suffer them with great distressMay not show overt distress (e.g., avoiding eye contact)BUT consistently endure emotional and/or physical symptoms (e.g., heart racing, perspiring).

Also known as Social Phobia

The principle fears in an individual with SAD are that they will act in way thats results in embarrassment, humiliation, or negative evaluation by others (Stein & Stein). These fears are so influential that the individual may avoid interpersonal meetings, or suffers such encounters with extreme distress.

During interaction, those with SAD may or may not show overt indicators of distress (e.g., avoiding eye contact) but consistently endure emotional or physical symptoms (e.g., heart racing, perspiring).

SAD is categorised as a phobic disorder, and is often still referred to as social phobia (Stein & Stein, 2008).3

PrevalenceAnxiety disorders most prevalent of all mental disorders (Kessler, Chiu, Demler & Walters 2005). Social Anxiety Disorder (SAD) is most common, with established yearly and lifetime prevalence rates of 7.1% and 12.1% respectively (Stein & Stein).

Most prevalent in females Extremely early onset (appears by age 20 in 80% of cases)

Once widely disregarded, SAD has recently accumulated increased attention due to its persistent nature and comorbidity with other disorders, such as depression and substance abuse (Schneier, 2006).

Of all the classes of mental disorders, anxiety disorders prove to be the most prevalent, with a yearly prevalence in the community of 18% suggested (Kessler, Chiu, Demler & Walters 2005). Within this class, social anxiety disorder (SAD) is the most common, with established yearly and lifetime prevalence rates of 7.1% and 12.1% respectively.

The disorder is most prevalent in females and has an extremely early onset, appearing by the age of 20 in 80% of cases. Once widely disregarded, in recent times SAD has accumulated increased empirical attention due to its persistent nature and comorbidity with other disorders, such as depression and substance abuse (Schneier, 2006).4

Etiology (Causes)

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Behavioural InhibitionDevelopmental risk factor for SAD (Clauss & Blackford, 2012).

Heritable, arises in early childhoodChronic tendency to react to novel stimuli (i.e., people, places, items) with caution or refraining behaviours. Children with BI seven times more likely to develop SAD

Behavioural inhibition (BI) has been extensively identified as a developmental risk factor for developing SAD (Clauss & Blackford, 2012). BI is heritable and arises in early childhood; it is described as the chronic tendency to react to novel stimuli (i.e., people, places, items) with caution or refraining behaviours. In a meta-analytic study, Clauss and Blackford portrayed children with BI as being at seven times more risk to develop SAD later in life. 6

Behavioural Inhibition

Significant association between high BI and maternal over-control (Lewis-Morrarty et al., 2012). Early maternal stress and increased cortisol levels (Essex et al., 2010).

Predicts increased levels of SAD during adolescence years.

Thus parenting styles can maintain BI

A significant association between high BI and maternal over-control has also been established (Lewis-Morrarty et al., 2012). Further re-iterating this point, children exposed to early maternal stress display increased cortisol levels and are more likely to develop chronic high inhibition (Essex, Klein, Slattery, Goldsmith & Kalin, 2010).Called the stress hormone,cortisolinfluences, regulates or modulates many of the changes that occur in thebodyin response to stress

Thus, while BI is heritable, it is evident that environmental factors (i.e., parenting styles) can maintain the propensity, and in turn contribute to the later development of SAD. 7

Behavioural InhibitionIs BI simply a childhood expression of SAD? Both are characterised by social inhibition.Amygdala hyperresponsivity is typified in both conditions (Phan, Fitzgerald, Nathan & Tancer, 2006)Prevalence rates of BI in childhood are comparable to those of SAD in adolescence.

However not all childhood BI evolves into SAD (Claus & Blackford, 2012).Transition in 43% of casesBI children should be subjected to early preventative intervention

Presented with these findings, one would find it difficult to argue against BI being an identifiable causal factor of SAD, nevertheless there remains a debate surrounding this issue. Is BI simply a childhood expression of SAD? For instance both BI and SAD are characterised by social inhibition.On a biological level, amygdala hyperresponsivity is typified in both conditions (Phan, Fitzgerald, Nathan & Tancer, 2006), and prevelance rates of BI in childhood are comparable to those of SAD in adolescence. This means there is an abnormal degree of responsiveness in the amygdala (emotion centre of the brain)

However, empirical evidence suggests not all childhood BI evolves into SAD, Claus and Blackford (2012) showed this transition occurred in 43% of cases. It would appear that children displaying BI can have differing developmental pathways, with many having futures free of SAD. Still, due to its early appearance in life, children displaying BI should be subjected to early preventative intervention.

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Genetic FactorsChildren diagnosed with SAD more likely to have parents with same disorder (Lieb et al., 2000).Elevated chance of children developing SAD when their parents are living with the condition.

Large twin studies: heritability estimates ranging from 0.4-0.65 (Beatty et al., 2002)

A vast body of empirical work proposes that genetic factors play a somewhat modest but significant role in the development of SAD, in both child and adult populations (Rapee & Spence, 2004).Children diagnosed with SAD are more likely to have parents with the same disorder than their non-diagnosed peers and correspondingly there is an elevated chance of children developing SAD when their parents are living with the condition (Lieb et al., 2000; Mancini et al., 1996).Twin studies utilising sizable samples indicate a moderately significant genetic influence in developing SAD, with heritability estimates ranging from 0.4-0.65 (Ollendick & Hirshfeld-Becker, 2002; Beatty, Heisel, Hall, Levine, & La France, 2002).

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Genetic FactorsHeritability not confined to SAD (Kendler et al., 1995)Common genetic component impacting SAD, depression and alcoholism (Nelson et al., 2000).

It is important to note that this heritability is not confined to SAD and may encompass other disorders such as depression, substance abuse and eating disorders (Kendler et al., 1995). For instance Nelson and colleagues (2000) reported a common additive genetic component impacting SAD, depression and alcoholism, with a disorder-specific influence being restricted solely to alcoholism. Acknowledging these genetic commonalities may elucidate the significant levels of comorbidity between SAD and other disorders.

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Conditioning Events

Undesirable experiences with peers in adolescents and adults displaying symptoms of SAD (Gilmartin, 1987; Ollendick & Hirshfeld-Becker 2002). Significantly less likely to have positive interactions with their peers (Spence, Donovan & Brechman-Toussaint, 1999).

For many years studies have demonstrated undesirable experiences with peers in adolescents and adults displaying symptoms of SAD (Gilmartin, 1987; Ollendick & Hirshfeld-Becker 2002). It has been found that socially phobic youth are significantly less likely to have positive interactions with their peers (Spence, Donovan & Brechman-Toussaint, 1999). 11

Conditioning EventsAdolescents with SAD

Experience higher levels of peer victimisation (Siegel, La Greca & Harrison, 2009)Peer victimisation has also been more closely linked to SAD than depression (Ranta et al., 2009)Increased risks of developing the disorder directly associated with peer maltreatment (Gren-Landell, Aho, Andersson & Svedin, 2011).

Similar results are conveyed in adolescent populations with higher levels of peer victimisation experienced by those with social anxiety (Siegel, La Greca & Harrison, 2009). Peer victimisation has also been more closely linked to SAD than depression in teenagers (Ranta et al., 2009); with increased risks of developing the disorder directly associated with peer maltreatment (Gren-Landell, Aho, Andersson & Svedin, 2011). 12

Conditioning EventsAre these conditioning events causal factors? Many characteristics associated with the disorder (e.g., social withdrawal) may elicit peer victimisation (Flanagan, Erath & Bierman, 2008)

Bi-directional relationship appears more probable

However it would appear inaccurate to determine such experiences as solely causal factors of SAD, as many characteristics associated with the disorder (e.g., social withdrawal) may elicit peer victimisation (Flanagan, Erath & Bierman, 2008). Here a bi-directional relationship appears more probable; with poor peer experiences embodying both a cause and outcome of SAD.

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Case StudyChaves et al. (2012) 21 year old maleIn teenage years: no history of shyness or fearing interactions with others, upheld perfectly healthy social life and considered himself rather extroverted. Suffered a brain injury after being hit by a car, but was released from hospital after two days as he was displaying no neurological symptoms.Year after accident: experienced constant anxiety in social situations, particularly when interacting with authority figures and females. Also avoided social situations whenever possible.

Certain presentations of SAD deviate from the more typical etiological factors discussed previously. Chaves and colleagues (2012) illustrated this point through reporting the case of a 21-year old male. As a teenager he had no previous history of shyness nor did he fear or avoid interactions with others. Furthermore he upheld a perfectly healthy social life and considered himself to be rather extroverted. In 2004 he suffered a brain injury after being hit by a car, but was released from hospital after two days as he was displaying no neurological symptoms. However, a year after the accident, he experienced constant anxiety in social situations, particularly when interacting with authority figures and females. He also avoided social situations whenever possible. 14

Case StudyChaves et al. (2012)

Eventually after seeking treatment four years after the incident due to the worsening of his symptoms, he received a diagnosis of SAD with no additional co-morbid mental disorder. MRI scans revealed the SAD symptoms were being caused by compression-induced dysfunction in the left frontal lobe induced by a bony protuberance. This case study highlights that there is much yet to uncover in relation to the neurobiological causal factors of SAD.

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Diagnosis

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The Diagnostic and Statistical Manual of Mental Disorders (DSM)Diagnostic criterion for SAD and its portrayal has seen many alterations across the various editions of the DSM (Heimberg et al., 2014). DSM-III: Social Phobia was infrequent and a condition with minor impairment

What is the DSM? the standard classification of mental disorders used by mental health professionals in the United States. It is intended to be used in all clinical settings by clinicians of different theoretical orientations.

The diagnostic criterion for SAD and its portrayal has seen many alterations across the various editions of the DSM (Heimberg et al., 2014). For instance, DSM-III surmised that social phobia was infrequent and primarily represents a condition with minor impairment. 17

DSMSocially anxious children were principally diagnosed with avoidant personality disorder (APD) as opposed to SAD. Significant level of symptom overlap important diagnostic issue (Marques et al., 2012; Lampe & Sunderland, 2015). APD more severe SAD? (Bgels et al., 2010)Should both conditions be amalgamated into one disorder?

Anxiety Sub-Workgroup of the DSM-V determined there was inadequate evidence to do so (Heimberg et al.)

This is a reflection of how in years previous, socially anxious children were principally diagnosed with avoidant personality disorder (APD) as opposed to SAD. APD similar but broader and more severe. The significant level of symptom overlap and comorbidity between both APD and SAD has been highly recognised as a salient diagnostic issue in recent empirical research (Marques et al., 2012; Lampe & Sunderland, 2015). There has been a suggestion both conditions should be amalgamated into a single disorder, as much empirical work has concluded that APD is simply a more severe version of SAD (Bgels et al., 2010). However, whilst acknowledging their similarities, the Anxiety Sub-Workgroup of the DSM-V determined there was inadequate evidence to do so (Heimberg et al.). Although this deliberation did not result in any diagnostic modifications pertaining to SAD in the DSM-V, many others relevant amendments occurred.

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DSM-VDepiction of SAD fear was notably expanded to include the concept of negative evaluation (Michail & Birchwood, 2013)Fear of offending others and rejection are now represented in the DSM-V (Heimberg et al.)

Traditionally, according to earlier editions of the DSM, the principle fear in an individual with SAD was demonstrating anxiety symptoms that would result in embarrassment or humiliation (Heimberg et al., 2014). Concurring with current research (Michail & Birchwood, 2013); the depiction of this fear was notably expanded to include the concept of negative evaluation. As a result the fears of offending others and rejection are now represented in the DSM-V (Heimberg et al.). This is a salient amendment as these latter fears can be solely responsible for functional impairment in those with SAD, independent of humiliation and embarrassment (Aderka et al., 2012). 19

DSM-VPerformance only sub-typeFears in the individual are confined to performing, speaking or socialising in publicSupported by epidemiological research (Knappe et al., 2007; Stein, Torgrud & Walker, 2000) BUT highly debatable

Extremely low prevalence rates (i.e., 0.3% of lifetime cases; Crome et al., 2015) raises concerns about its clinical utility.

Additionally the DSM-V establishes a performance only sub-type of SAD, whereby fears in the individual are confined to performing, speaking or socialising in public. While this revision is supported by epidemiological research specifying some individuals with SAD present only performance fears (Knappe et al., 2007; Stein, Torgrud & Walker, 2000); it remains highly debatable. Recent empirical studies have revealed extremely low prevalence rates (i.e., 0.3% of lifetime cases; Crome et al., 2015) of the performance-only specifier, raising concerns about its clinical utility.20

Comorbidity RatesMajor Depressive Disorder (MDD) reported in 19.5% (Ohanyon & Schatzberg, 2010)Those diagnosed with SAD have highest likelihood of anyone to develop MDD within two years of the original diagnosis (Reiger, et al., 1998).

Further phobias (59%), panic disorder (49%)Relationship between social phobia and eating disorders (Kaye et al., 2004)Caution must be taken when diagnosing SADDifficult to reach a differential diagnosis

A vital issue to consider when diagnosing SAD is its high association with other disorders. Major depressive disorder (MDD) has been reported in 19.5% of individuals with social phobia (Ohanyon & Schatzberg, 2010). When taking into account the general population, those diagnosed with SAD have the highest likelihood of any to develop MDD within two years of the original diagnosis (Reiger, Rae, Narrow, Kaelber & Schatzberg, 1998).Significant levels of comorbidity have also been demonstrated between SAD and further phobias (59%) and panic disorder (49%; Ohanyon & Schatzberg). In addition, the relationship between social phobia and eating disorders is well documented (Kaye et al., 2004). Here, in the majority of cases, anxiety disorders preceded the development of an eating disorder. The aforementioned findings emphasise the caution that must be taken when diagnosing an individual with SAD. Due to its high level of comorbidity with numerous other psychiatric conditions, establishing a differential diagnosis may often prove difficult, thus the chance that the condition is being underdiagnosed in the general population is quite plausible. 21

Ohanyon & Schatzberg, 2010

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Case Study: Marion Kaufman & Baucom, 201420-year old female studentPresented to a university counselling service with concerns regarding self-esteem, social withdrawal, academic struggles and excessive, irrational guilt.Initial assessment: did not endorse symptoms of anxietycase met seven of the nine criteria for MDD

Diagnostic overshadowing occurredMarion treated solely for MDDTherefore an exposure based intervention was delayed

In order to illustrate the diagnostic difficulties faced due to SADs high comorbidity with other disorders, the case of Marion, a 20-year old female student is considered (Kaufman & Baucom, 2014). The client presented to a university counselling service with concerns regarding self-esteem, social withdrawal, academic struggles and excessive, irrational guilt. The young woman displayed low levels of productivity in relation to course work, showed significant levels of social avoidance and reported suicidal thoughts, yet renounced current suicidal intent. At Marions initial assessment interview she did not endorse symptoms of anxiety; instead she described constant feelings of guilt. Furthermore her case met seven of the nine criteria for MDD. It then seemed apparent that a diagnostic overshadowing of SAD by MDD occurred, thus Marion was treated solely for the latter disorder, and this impeded the application of more suitable approaches. For instance, due to the initial discounting of SAD, an exposure-based intervention was not implemented until late in the clients course of treatment, which may well have prevented improvements in her symptoms (Kaufman & Baucom).23

Case Study: Marion Kaufman & Baucom, 2014Lacking structure in her initial diagnostic assessment

Social orientated role-play exercise that eventually exposed her SAD diagnosis was only utilised several weeks after her initial assessment

Highlights the importance of acknowledging the plausibility of a comorbid diagnosis

This diagnostic overshadowing occurred for several reasons. Firstly Marions portrayal of her problems corresponded to symptoms of MDD and due to a lacking structure in her initial diagnostic assessment, the recognition that many of these problems truly resulted from SAD was delayed (Kaufman & Baucom, 2014). Additionally, a social orientated role-play exercise that eventually exposed her SAD diagnosis was only utilised several weeks after her initial assessment. This case highlights the importance of acknowledging the plausibility of a comorbid diagnosis, as clients with such comorbidities often require longer periods of treatment and tend to have less successful treatment outcomes than those with a single diagnosis of SAD or MDD (Campbell-Sillis et al., 2009). This had very real implications for Marion as at the end of her 12-week treatment, despite reduction in symptoms, she still presented with mild clinical depression and due to time restraints she demonstrated an attenuated SAD treatment response. It is evident due to its high levels of comorbidity, SAD presents clinicians with many diagnostic challenges, and therefore they must be attentive in identifying the disorder throughout the treatment process.

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SAD vs ShynessIs the experience of shyness being over-pathologised? (Dalrymple, 2012)Where do we distinguish those who are merely shy from those who should be diagnosed with a disorder? Many with SAD fit onto a continuum of normal temperamental variations (Wakefield, Horwitz & Schmitz, 2005).SAD has an evolutionary role to avoid negative social relationships.

Another salient concern pertaining to the diagnosis of SAD is that the experience of shyness is being over-pathologised (Dalrymple, 2012). There are evident ambiguities surrounding where to distinguish those who are merely shy from those who should be diagnosed with a disorder. Wakefield, Horwitz and Schmitz (2005) contend that many individuals diagnosed with SAD exhibit shy behaviour that fits onto a continuum of normal temperamental variations. Furthermore, the researchers assert that social anxiety may have an evolutionary role in assisting individuals to avoid social relationships that may produce negative consequences.25

SAD vs Shyness

Campbell-Sims and Stein (2005) malfunctioning of psychological and physical mechanisms advocate the relevance of the disorder.Not beneficial in anyway, leads to ostricization

Contrastingly other researchers proclaim the malfunctioning of both psychological and physical mechanisms (i.e., adverse cognitions, physiological symptoms) clearly advocate the relevance of the disorder (Campbell-Sims & Stein, 2005). They claim such social anxiety does not have a beneficial avoidance role in relationships as it can lead to ostricization in social contexts.26

SAD vs ShynessSAD carries higher levels of comorbidities, social avoidance and impairment (Dalrymple & Zimmerman 2013).Poorer quality of life.

Those who are shy but are undiagnosed with SAD are more similar to non-shy people (Heiser, Turner & Beidel, 2003).

Reflects effect of carrying of a psychiatric label in itself?

Dalrymple and Zimmerman (2013) portray important distinctions between SAD and benign shyness. Being diagnosed with SAD is accompanied by significantly higher levels of comorbidities, social avoidance and impairment. A poorer quality of life is also reported by those carrying a diagnosis. Also, it has been demonstrated individuals who are shy but are undiagnosed with SAD are more similar to non-shy people than to those diagnosed with SAD (Heiser, Turner & Beidel, 2003); with these similarities referring to levels of functional impairment, substance abuse and other behavioural difficulties. While it appears these findings support the concept of SAD as being distinct from shyness, they must be interpreted with caution. One must acknowledge that a certain proportion of the behavioural and functional disparities reported may be due to the carrying of a psychiatric label in itself.27

Treatment

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Drugs vs therapyVarious medications- SSRIs and benzodiazepines are effective as short term treatments (Davidson, 2003).

Medications have been associated with higher rates of relapse than CBT treatments (Stein, Versiani, Hair, & Kumar, 2002).

Lacking research to show combined treatment is more efficacious than either monotherapy (Dalrymple, 2012).

Efficacious treatments for SAD are represented through both pharmacological and psychotherapeutical approaches. Various medications, such as the selective serotonin/serotoninnorepinephrine reuptake inhibitors and benzodiazepines are established as effective short term treatments (Davidson, 2003). In a meta-analysis, Gould and colleagues (1997) displayed that medications and CBT are both effective treatments when considered against a control, however they did not significantly vary from each other. Contrastingly, an additional meta-analysis, accounting for various classes of medications and several CBT approaches showed SSRIs and benzodiazepines to be more reliably effective short term treatments (Fedoroff & Taylor, 2001). With this said, it is salient to acknowledge that medications have been associated with higher rates of relapse than CBT treatments (Stein, Versiani, Hair, & Kumar, 2002). It is also clear from the current body of empirical research, there is a lacking indication that combined treatment (i.e., medication and CBT) is more efficacious than either monotherapy, yet this may merely be due to the paucity of empirical attention toward this issue (Dalrymple, 2012).29

Drug TreatmentPrinciple pharmaceutical interventions are not achieving desirable effects (Bergamaschi et al., 2011).Efficacy confined to short-termLow complete recovery rates

Thus there is evidence of the exploration of novel therapeutic agents emerging in current research.

As emphasised by the low complete recovery rates and their efficacy being confined to the short-term, the principle pharmaceutical interventions for SAD are not achieving desirable effects (Bergamaschi et al., 2011). Thus it is not surprising there is evidence of the exploration of novel therapeutic agents emerging in current research. 30

CannabidiolThose with SAD are particularly susceptible to cannabis use and therefore cannabis-related problems (Buckner, Crosby, Wonderlich & Schmidt, 2012).

Cannabis use is associated with both reducing anxiety and eliciting anxious reactions or panic attacks (Crippa et al., 2009).

However through harnessing cannabidiol, a compound of cannabis, the inhibition of anxiety has been displayed.

It is widely recognised that individuals with SAD are particularly susceptible to cannabis use and therefore cannabis-related problems (Buckner, Crosby, Wonderlich & Schmidt, 2012). Remarkably, within this vulnerability may lie a very promising way forward in terms of pharmaceutical intervention. Cannabis use is associated with both reducing anxiety and eliciting anxious reactions or panic attacks (Crippa et al., 2009). However, through harnessing cannabidiol (CBD), a major non-psychotomimetic compound of cannabis, the inhibition of anxiety has been displayed (Zuardi, Cosme, Graeff & Guimaraes, 1993). Consequently, recent empirical work has explored the potential utility of CBD in the treatment of SAD (Bergamaschi et al.).31

CannabidiolCBD to decrease anxiety, cognitive impairment and distress in relation to simulated public speaking in individuals with SAD (Bergamaschi et al., 2011). Placebo group: increased anxiety, cognitive impairment and distressNo differences between CBD treated SAD subjects and healthy controls.

Bergamaschi and colleagues (2011) demonstrated CBD to decrease anxiety, cognitive impairment and distress in relation to simulated public speaking in individuals with SAD. In comparison a placebo group showed increased levels of anxiety, cognitive impairment and distress when presented with the same task. Placebo-controlled studies are a way of testing a medical therapy in which, in addition to a group of subjects that receives the treatment to be evaluated, a separate control group receives a sham "placebo" treatment which is specifically designed to have no real effect.Encouragingly, no significant differences emerged between SAD subjects treated with CBD and healthy controls on the aforementioned measures. These findings embody the favourable therapeutic effects of CBD in those with SAD, as just a single dose significantly decreased participants anxiety symptoms when faced with a principle fear associated with the disorder (Bergamaschi et al.). While these results are extremely promising, the research related to this compound remains in a period of infancy. Its exact mechanisms and treatment ranges in relation to anxiety disorders is still yet to be uncovered, further empirical research is undoubtedly warranted. 32

Cognitive Behavioural TherapyCBT is the most widely utilised psychotherapy for SAD, with much contemporary research establishing its effectiveness (Wantanabe et al., 2010)A type of psychotherapy in which negative patterns of thought about the self and the world are challenged in order to alter unwanted behaviour patterns or treat mood disorders such as depression.

CBT is the most widely utilised psychotherapy in relation to SAD, with much contemporary research establishing its effectiveness (Wantanabe et al., 2010). a type of psychotherapy in which negative patterns of thought about the self and the world are challenged in order to alter unwanted behaviour patterns or treat mood disorders such as depression.

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CBT- Goldin et al. (2014)Two means by which CBT may alleviate social anxietyHeightening reappraisal success-- application of logic and perspective-taking to adjust the influence of an emotion-inducing cue.Expressive suppression-- is an avoidance or escape orientation distinguished by actively withdrawing from interaction with others. Crucial to decrease as such behaviours are often reinforced in the daily lives of those with SAD due to their desires to conceal physiological symptoms of anxiety (i.e., blushing, shaking).

Goldin and colleagues (2014) highlighted two means by which CBT may alleviate social anxiety. The first is heightening reappraisal success, while the second encompasses a reduction in expressive suppression frequency. In this instance, reappraisal represents the application of logic and perspective-taking to adjust the influence of an emotion-inducing cue. Contrastingly, expressive suppression is an avoidance or escape orientation distinguished by actively withdrawing from interaction with others. Decreasing expressive suppression is crucial as such behaviours are often reinforced in the daily lives of those with SAD due to their desires to conceal physiological symptoms of anxiety (i.e., blushing, shaking). Further emphasising the efficacy of CBT, its ability to improve reappraisal in SAD is evident in cognitive reappraisal associated prefrontal cortex responses (Goldin et al., 2013).

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CBTAppropriate therapeutic approach for reducing maladaptive beliefs in SAD (Boden et al., 2012).

Superior to other therapeutic approaches (i.e., psychodynamic therapy) for remission and decreased interpersonal difficulties (Leichsenring et al., 2013).

CBT is also an appropriate therapeutic approach for reducing maladaptive beliefs in SAD (Boden et al., 2012). This is a key consideration as maladaptive beliefs are identified as a causal factor of SAD. CBT has also proven superior to other therapeutic approaches (i.e., psychodynamic therapy) for remission and decreased interpersonal difficulties (Leichsenring et al., 2013). It appears this approach should be seriously advocated in treating SAD, due to both its effectiveness and accessibility. 35

Internet-based CBTInternet-based CBT has demonstrated sustained reduction in social anxiety, depressive symptoms and general anxiety five years after initial treatment (Hedman et al., 2011).Cost-effective, materials can be re-visited, not as unnerving as visiting a therapist

So many people relying on online services in their lives, it is salient that internet-based CBT can reduce anxiety symptoms in those with SAD. However more empirical attention is needed toward the potential jeopardising effect this may have on the therapeutic relationship.

Internet-based CBT has demonstrated sustained reduction in social anxiety, depressive symptoms and general anxiety five years after initial treatment (Hedman et al., 2011). This online approach holds several advantages including its cost-effectiveness and the fact that materials can be saved and re-visited at any time. Furthermore, it may also see more of those living with SAD seeking initial treatments at higher rates as commencing online treatment may not seem as unnerving as visiting a therapist. Nowadays, with so many people relying on online services in their lives, it is salient that internet-based CBT can reduce anxiety symptoms in those with SAD. However more empirical attention is needed toward the potential jeopardising effect this may have on the therapeutic relationship.

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Case Study: HenryShorey & Stuart (2012)26 year old male studentReferred to University Psychological Clinic for treatment of anxiety.Anxious around women, faced answering a question in class and seriously feared negative evaluation by others.16 1-hour sessions across a 20 week period, with the treatment design consisting of five sections

In order to demonstrate the efficacy of CBT in treating SAD, the case report of Henry a 26 year old male is considered (Shorey & Stuart, 2012). Henry, a full-time student and part-time retail worker, was self-referred to a University Psychological Clinic for treatment of anxiety. His primarily became anxious when around women or faced with answering a question in class and he seriously feared negative social evaluation by others. Henry underwent 16 1-hour sessions across a 20 week period, with the treatment design consisting of five sections. 37

Case Study: HenryPsychoeducation- what represents abnormal anxiety and the underlying components of social anxietyPrimary fears of sharing emotions, speaking in public and being monitored while writing identified

Cognitive Restructuring- learnt about automatic thoughts and rational responsesRational responses to his social anxiety created, one of them being anxiety is not always bad when considering social interactions with women.

Firstly, the client was subjected to psychoeducation on what represents abnormal anxiety and the underlying components of social anxiety. At this stage he was able to identify his primary fears, which included sharing emotions with other people, speaking in public and being monitored while writing. During the cognitive restructuring segment of treatment, Henry learnt about automatic thoughts and rational responses. Here, he created rational responses to his social anxiety, one of them being anxiety is not always bad when considering social interactions with women.

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Case Study: HenryExposure Sessions- applying his cognitive restructuring knowledge to achieve behaviour goals related to his fearsprogressed from writing in the company of his therapist to more challenging behaviours such as asking questions in front of all his college classmates

Advanced Cognitive Restructuring- educational focus transferred from situation-specific automatic thoughts to more general conceptsContested his core beliefs related to social scenarios

Termination Phase- Henry indicated he had learned to interpret his anxiety as a sign to so something rather than partake in avoidance

After six weeks, Henry began exposure sessions, consisting of applying his cognitive restructuring knowledge to achieve behaviour goals related to his fears (Shorey & Stuart, 2012). These progressed from writing in the company of his therapist to more challenging behaviours such as asking questions in front of all his college classmates. Stage four of the treatment entailed advanced cognitive restructuring, whereby the educational focus transferred from situation-specific automatic thoughts to more general concepts applicable to Henrys social life across various contexts. Here, the client was encouraged to contest his core beliefs related to social scenarios. Lastly during the termination phase, Henry indicated he had learned to interpret his anxiety as a sign to so something rather than partake in avoidance. The client demonstrated significantly reduced SAD symptoms, which were maintained at an 8-month follow up. He reported his social anxiety no longer represented a functional impairment in his life. Furthermore, shortly after completion treatment Henry began a romantic relationship for the first time in his life and soon became engaged. This case study highly advocates the use of CBT in cases of SAD, and allows one to appreciate the life changing beneficial effects it can have on a persons life. It is hardly surprising CBT proves to be the most popular therapeutic approach in contemporary treatment of SAD.

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Useful ResourcesButler, G. (2009).Overcoming Social Anxiety and Shyness: A Self-help Guide Using Cognitive Behavioral Techniques. Hachette UK.

www.socialanxietyireland.com

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