Download Child and Adolescent Psychopathology

Chapter 5:
Social Anxiety Disorder
Deborah Roth Ledley
Brigette A. Erwin
Amanda S. Morrison
Richard G. Heimberg
Overview
 Definition
 A marked or persistent fear of social or performance
situations
 Social Anxiety Disorder = SAD; also known as Social
Phobia
• Generalized SAD: Individuals fear a range of situations
• Specific SAD: Individuals have a more limited fear (e.g., public
speaking only)
DSM-5 Criteria for Social Anxiety
Disorder (SAD)
 (A) Fear or anxiety about social situations in which the individual
may be exposed to scrutiny by others
 Examples: Speaking in public, eating around other people, initiating a
conversation
 (B) Fear that one will say or do something or display anxiety, and
that this will illicit a negative reaction from others
 (C) Social situations almost always provoke fear or anxiety
 Children may display clinging behaviors, crying, and/or tantrums
 (D) The individual will avoid the situations or endure them with
extreme anxiety or fear
 6 month duration now for all ages
 Anxiety out of proportion to the actual danger or threat but does
not now have to be recognized by the individual as excessive or
unreasonable
Epidemiology
Epidemiology
• SAD is one of the most prevalent psychiatric disorders in the
United States (Kessler, Berglund et al., 2005; Kessler, Chiu, Demler, Merikangas, &
Walters, 2005)
• Mean age of onset is 13-20 (Hazen & Stein, 1995)
• More common in women than men (Magee, Eaton, Wittchen, McGonagle, &
Kessler, 1996)
•
Although men take longer to seek treatment (Wang et al. 2007),
they outnumber women in clinical samples (Chapman, Mannuzza, &
Fyer, 1995; Stein, 1997)
•
Importance of cultural factors: The cost of not pursuing
treatment may be higher in men
Comorbidity
 Most frequent comorbidity: Other anxiety disorders
 For example, panic disorder, agoraphobia, PTSD
 Depression
 Co-occurrence of depression and SAD is associated with
greater impairment (Erwin, Heimberg, Juster, & Mindlin, 2002)
 Substance abuse
 Research suggests SAD could be a risk factor for alcohol
problems
 Individuals with comorbid SAD and alcohol dependence have
lower rates of treatment seeking (Schneier et al., 2010)
 Avoidant Personality Disorder (APD)
 Those who meet criteria for generalized SAD and APD have
greater impairment
Genetic Underpinnings
 It is unlikely that there is a specific “SAD gene”
 Instead, researchers believe that an underlying
trait like neuroticism is transmitted to an individual,
and that this trait contributes to spectrums of
psychopathology (Stein & Stein, 2008)
Neurobiological Underpinnings
 Serotonin and dopamine are two neurotransmitters
that have been frequently linked to SAD in the
literature
 Imaging studies have shown brain activation
differences in the amygdala, uncus, and
parahippocampal gyrus in response to angry and
contemptuous faces among patients with
generalized SAD compared to healthy controls (Stein
et. al, 2002)
Psychosocial Dysfunction
 Impaired Social Functioning
 Individuals with SAD have strained relationships, and
generally fewer relationships than individuals without the
disorder
 May have difficulty expressing emotions and beliefs in
relationships
Deficits in Interpersonal Style
 Individuals with SAD may engage in a “self-
perpetuating interpersonal style” in which they
enter interpersonal relationships expecting the
worst, and then behave in ways that maintain their
expectations
 May frequently display overt signs of anxiety
 May emotionally distance themselves from their partners
 When they do self-disclose, individuals with SAD have a
difficult time describing emotional experiences
Psychological Deficits
 Attentional Bias
 Some studies show slower color-naming of social threat words
 Social anxiety may be associated with cognitive avoidance of
positive material
 Executive control of attention appears to be impaired among
individuals with excessive anxiety
 Judgment and Interpretation Bias
 Socially anxious individuals judge themselves more negatively
than they judge others and also judge themselves more
negatively than they are judged by others
 Individuals with SAD overestimate the probability of negative
outcomes and the cost of these outcomes
 Imagery and Visual Memory Bias
 Many inconsistent findings in this area
Family Environment
 Infant temperament and early attachment to parents
are important early-life factors; insecure attachment
patterns related to SAD in adulthood
 Studies suggest parents of socially anxious individuals
overemphasized the importance of a “perfect”
impression
 Recent meta-analysis suggests that parenting
accounts for only 4% of the variance in social anxiety
(McLeod, Wood, & Weisz, 2007)
 Other detrimental familial factors: long-lasting
separation from either parent, observing conflict
between parents, and lack of a close relationship with
an adult
Peer Environment
 Children with SAD are more likely than non
anxious children to have negative peer relations
 The relationship between social anxiety and peer
victimization appears to be bidirectional
 Relational aggression is particularly important
 Frequent teasing was associated with negative
outcomes later in adulthood, including less comfort
with intimacy and worry about abandonment
 Important to note that one cannot draw causal
conclusions from a correctional relationship, how teasing
in childhood might play a role well into adulthood
Assessment of SAD: Clinical
Interviews
 Structured Clinical Interview for DSM-IV-TR Axis I
Disorders (SCID) – Patient Edition
 Advantage: Can be completed efficiently
 Disadvantage: Information gathered is not sufficiently
detailed for use in treatment planning
 Anxiety Disorder Interview Schedule for DSM-IV
 Contains a lifetime version and a child/adolescent version
 Advantage: Contains many questions that go beyond
DSM criteria (e.g., triggers for anxiety), which is useful for
treatment planning
 Disadvantage: Can take longer to administer
Assessment of SAD: Clinical
Rating Scales
 Liebowitz Social Anxiety Scale (LSAS)
 Most commonly used clinician-administered measure of
social anxiety
 24 items, 11 pertaining to social interaction situations and
13 pertaining to performance situations
 Very good tool for clinical treatment planning
 Brief Social Phobia Scale (BSPS)
 18-item scale that assesses the symptoms of SAD that
patients experienced in the past week
 Three scales: fear, avoidance, and physiological arousal
 Has been shown to be sensitive to medication-related
changes in social anxiety symptoms
Assessment of SAD:
Self-Report Measures
 Social Anxiety Interaction Scale (SIAS)
 Reliable and has high convergent validity with other
indices of social anxiety and avoidance
 Brief Fear of Negative Evaluation Scale (BFNE)
 Strong psychometric properties in undergraduate and
clinical samples
 Social Phobia Inventory (SPS)
 Reliable and has high-convergent validity with other
indices of social anxiety and avoidance
Assessment of SAD: Self-Report
Measures (cont.)
 Social Phobia Inventory (SPIN)
 Good reliability, significant correlations with related
measures, and the ability to discriminate between clients
with SAD and other anxiety disorders
 Social Phobia and Anxiety Inventory (SPAI)
 Valid, reliable, good test-retest reliability, sensitive to
treatment-related changes
Monitoring Progress in Therapy
 Social Anxiety Session Change Index (SASCI)
 Four-item scale that is completed prior to each treatment
session to assess the progress patient believes he or she
has made since beginning treatment
 Good internal consistency
 Sensitive to symptom improvement
 Brief and easy to score
 Additional measures can be administered
 For example, Beck Depression Inventory-II to monitor
depressive symptoms if depression is comorbid with SAD
Psychological Interventions:
Cognitive Behavioral Therapy
 Cognitive Behavioral Therapy
 Exposure  Helps patients face social and performance
situations in which they experience distress or which they
prefer to avoid
 Cognitive Restructuring  Identify, evaluate, and reframe dysfunctional thoughts so that the client learns to
not expect failure in every social situation
 Homework Assignments  Given to patients so they can
apply what they learn in therapy to real-life situations
Psychological Interventions
 Cognitive Behavioral Group Therapy
 Several studies demonstrate CBGT’s efficacy
 May be logistically difficult to implement
 Meta-analyses suggest that there is no difference
between group and individual treatment for SAD
 Cognitive Therapy (individual treatment)
 Teaches clients to reduce safety behaviors and to shift
attention externally rather than on the self
 Goals: Help patients create more accurate information
about how they are evaluated by others and reevaluate
their distorted self-image
Pharmacological Intervention
 Selective Serotonin Reuptake Inhibitors and Serotonin
Norepinephrine Reuptake Inhibitors
 Moderate effect sizes, mild side effects, low risk of overdose,
most efficacious for the treatment of disorders comorbid with
SAD
 Benzodiazepines frequently prescribed on an as-
needed basis for low frequency high-anxiety situations
 Can be problematic withdrawal effects
 Monoamine Oxidase Inhibitors (MAOIs)
 Due to the side effects, used only as a last-resort treatment
when other medications have proven ineffective
Prevention of SAD
 Norwegian Universal Prevention Program for Social
Anxiety (NUPP-SA)
 Psychoeducation, cognitive restructuring, and a writing
assignment in which participants write about an aspect of
social anxiety
 Intervention group had greater reduction in the incidence of
SAD 1 year later than the control group
 FRIENDS Program
 Teaches skills that are a part of a thoroughly researched
protocol used to treat children with anxiety
 Involves children, parents, therapists, and teachers
 Evaluations done by the protocol designers found the program
to be effective, but external evaluations of the program are not
as positive
Future Clinical and Research
Directions
 It is important to evaluate how the various biases
interact to maintain SAD
 More research on disseminating SAD treatments
 Individuals with generalized SAD are twice as likely to
report not seeking treatment
 The most empirically validated treatment strategies are
not always utilized by clinicians
 Important to publish treatment protocols that are relatively
easy to implement