Social Anxiety and It’s Treatment

David M Clark

Institute of Psychiatry, Kings College London

Anxiety and Anxiety Disorders

• Anxiety is a survival mechanism• Motivator and sometimes life saver with real

dangers• Problematic when danger is imagined• Anxiety Disorder diagnosed when anxiety is

out of proportion to the danger, is persistent, and disabling. One year prevalence: 17%

Cost $42 billion per year (US, 1990s).

Social Phobia(Social Anxiety Disorder)

• Most common anxiety disorder (12 % prevalence)

• Persistent fear of social or performance situations. Individual fears he/she will act in a way which will be humiliating or embarrassing.

• Fear recognised as excessive or unreasonable

• Feared situations are avoided or endured with intense distress

Characteristics and Consequences

• Typically childhood onset (median 13 yrs).

• Low natural recovery rate (Bruce et al 2005: 37% over 12 years).

• Increased risk of suicide, alcohol & drug abuse, depression, other anxiety disorders.

• Marked under-achievement• Low treatment seeking rates

Typical Thoughts

What I say sounds stupid

I’m boring

I will make a fool of myself

They don’t like me

They’ll see I’m anxious

I won’t have anything to say

I’ll blush/shake/lose control

Existing Treatments

Medication• MAOI (phenelzine) • SSRIs (paroxetine, sertraline, fluvoxamine,

fluoxetine) (effective in short-term but problematic relapse )Psychological• Exposure therapy• Group cognitive-behavior therapy(effective in short-term & gains well-maintained )BUT less than 50% recover.

Clark & Wells (1995)SOCIAL PHOBIA PERSISTS DUE TO:

• shift to internal focus of attention

• use of internal information to infer how one appears to others

• safety behaviors

Social Situation

Activates assumptions

Perceived social danger

Processing of Self as a

Social ObjectSafety Behaviours

Somatic & cognitive symptoms

Mansell, Clark & Ehlers (2003)

Do high socially anxious individuals have an internal attentional bias?

High vs Low Socially Anxious Students

Detect external and internal probes

Threat vs No Threat

Source: Behaviour Research & Therapy, 41, 555-572.

External vs Internal Focus of Attention

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No Threat Social Threat

High SociallyAnxious

Low SociallyAnxious

Hackmann, Surawy & Clark (1998)

Do patients with social phobia experience negative, observer perspective images when anxious in social situations?

Structured interview.

Frequency, content & perspective of spontaneous imagery

% Negative, distorted, observer perspective images

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Social Phobics

Non-Patients

Link between date of memory and onset of social phobia

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- 4 yrs 0nset + 4 yrs + 8 yrs

Wells, Clark, Salkovskis et al (1995)

Do safety behaviours prevent cognitive change?

Exposure with safety behavioursVS

Exposure without safety behaviours

Improvement

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Keep SB Drop SB

BeliefsAnxiety

New Cognitive Treatment

• Derive idiosyncratic version of model• Self-focussed attention/safety behaviours

experiment• Video feedback• Shift attention to social situation• Behavioural Experiments• Construct veridical image of social self

“I’ll sound stupid”

Self-ConsciousImage of self

- looking very strange- twisted mouth and rigid- feel different and apart

Safety Behaviours AnxiousDelay asking, take deep breaths uncomfortable,Speak quickly, mumble, hand over sweaty palms,mouth, rehearse what about stiff muscles,to say, check memory for what mind goes blank,I have just said

New Cognitive Treatment

• Derive idiosyncratic model• Self-focussed attention/safety behaviours

experiment• Video feedback• Shift attention to social situation• Behavioural Experiments• Construct veridical image of social self

Attention and Safety Behaviours Experiment

• Difficult social interaction (twice)

Focus on self & safety behavioursversus

Focus externally & no safety behaviours

• Compare subjective anxiety, catastrophes, performance

Video and Audio Feedback

• shows true observable self

• but can continue to process internal information ordiscount accuracy of image

• therefore run “mental” video first and operationalise conspicuousness of negative behaviours

• can help patient drop safety behaviours by showing they are more observable than feared symptoms

New Cognitive Treatment

• Derive idiosyncratic model• Self-focussed attention/safety behaviors

experiment• Video feedback• Shift attention to social situation• Behavioral Experiments• Construct veridical image of social self

SITUATION PREDICTION EXPERIMENT

What exactly did you think would happen? How would you know?

(Rate belief 0-100%)

What did you do to test the prediction?

Coffee break.

Sitting with other

teachers. Trying to

join in the conversation

If I just say things

That come into my mind they’ll think I’m stupid.

50%

Say whatever comes into my mind and watch them like a hawk. Don’t focus on myself. This only gives me misleading information and means I can’t see them.

OUTCOME WHAT I LEARNED

What actually happened?

Was the prediction correct?

Balanced view

(Rate belief 0-100%)?

How likely is what you predicted to happen in future (Rate 0-100%)?

I did it and I watched the others; one of them showed interest and we talked: she seemed to quite enjoy it.

I am probably more acceptable than I think:

70%

Interrogating the Social Environment

1. Behave in “unacceptable” fashion and observe others’ response (WIDEN BANDWIDTH)

- pause in speech, umms and ahs- damp armpits- shake/spill drink- wear blusher- disagree/express opinion- ignore acquaintance

2. Conduct surveys

3. Articulate and discount imaginary critic

Social Phobia Trial 1(Clark, Ehlers et al, J. Consult. Clin. Psychol. 2003, 71, 1058-1067)

-1.4-1.2

-1-0.8-0.6-0.4-0.2

00.20.40.60.8

Pre Post 3mth FU 1 Yr FU

Social Phobia Composite

PLA + SEFLU + SECT

Social Phobia Trial 2 (Clark, Ehlers et al. in press)

-2-1.8-1.6-1.4-1.2

-1-0.8-0.6-0.4-0.2

00.20.40.60.8

Pre Post One Year FU

Social Phobia Composite

WaitEXP + ARCT

Trial 3 (Mortberg, Clark et al. in press)Stockholm

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Pre Post

Social Phobia (LSAS)

CTGrp CTSSRI (TAU)