Psychotherapy for Social Anxiety Disorder

Case vignette

After arriving early for his interview, David impressed the therapist as being calm and competent. He answered questions clearly and articulately. His voice did not quaver or shake, and he kept his hands neatly in his pockets. David made only occasional eye contact, but this made him seem distracted and aloof, rather than fearful. He was seeking treatment for social anxiety now, he explained, because he was on the verge of losing his job. An electrical engineer, David experienced intense and unrelenting anxiety about any interactions with his boss. When his boss stopped by his office unexpectedly, David experienced full-symptom panic attacks and could not give more than 1- or 2-word answers. He avoided almost all other contact with his boss, worrying that he would find fault with David's work. When asked if this ever happened in other situations, David confessed that he was up most of the night before the meeting with the therapist, worrying that the therapist might be critical of him and tell him he did not belong in the study.

One of the challenges to improving recognition for the millions of Americans with social anxiety disorder (SAD) is that its presentation is so varied. Many people with SAD keep the extent of their distress secret, even from family members. While SAD may cause observable signs of anxiety and social awkwardness in some, many others, like David, suffer silently. Social avoidance may be misinterpreted by others as lack of motivation, disinterest, or even arrogance.

Like most individuals with SAD, David's symptoms began when he was a teenager.¹ He was paralyzed by fear at the thought of talking to his teachers. David began experiencing difficulties in high school. His grades suffered because he would never volunteer to speak in class and never clarified information with the teacher. He also avoided handing in some assignments for fear of criticism. Impairment, such as David now experiences at work, is typical of SAD.²

For many people with SAD, fear may be focused on only 1 or a few types of social situations. David's fear is of authority figures, but the most common fear is public speaking. Most individuals who seek treatment for SAD have excessive fear of most social situations, a condition known as generalized SAD.³

The past 2 decades have seen an explosion in research on focused, time-limited psychotherapy treatments for SAD.⁴ This research has focused primarily on behavioral and cognitive therapy or, most commonly, a combined cognitive-behavioral approach.⁴ For simplicity's sake, we will refer to all of these treatments as cognitive-behavioral therapy (CBT), even though some are primarily behavioral, some are primarily cognitive, and others are a balanced integration of the 2 approaches (Table 1).⁵

Habituation/
new learning neutralizes impact of internal anxiety response

Cognitive therapy

Rather than changing behavior, cognitive therapy seeks to get patients to think differently about their social experiences. Cognitive theories of SAD view the way an individual perceives and thinks about social situations as essential to maintaining the disorder.^9,10 The goal of cognitive therapy for patients with SAD is for them to identify distortions in how they anticipate, perceive, interpret, and reflect on their social behavior and other people's responses and to learn to modify these feelings and reactions. The therapist guides the patient through a scientific inquiry in which beliefs are identified and disproved and then replaced with more rational thinking.

Cognitive therapy works on immediate cognitive reactions or automatic thoughts (eg, "everyone noticed my hand shaking"). It also addresses core beliefs--enduring and basic assumptions that the patient makes about social interactions (eg, "it's not OK for some people to disapprove of me").

Social skills training

Cognitive therapy seems ideally suited for patients with SAD who worry unjustifiably that they won't know what to say in a conversation. However, some patients seem to truly lack social proficiency (eg, how to make eye contact, how close to stand). Social skills training (SST) remedies this by identifying gaps in social competency and then teaching patients those skills.

There is mixed evidence regarding SST as a primary treatment. A study showed that when SST is added to CBT, the results were comparable to CBT alone.⁶ Nonetheless, many clinicians believe that SST provides added benefit for a specific subgroup of patients with SAD.

Internal sensations

Relaxation alone has been found to be of limited benefit for SAD patients, but it has been used effectively with exposure exercises.¹¹ In an approach known as applied relaxation, the patient practices invoking muscle relaxation in response to anxiety from graduated exposure to social situations.

Another technique for managing internal sensations is interoceptive exposure. This therapy helps neutralize rather than control internal sensations. The patient is systematically exposed to internal sensations (eg, sweating, palpitations), in a way similar to CBT for those with panic disorder. This is illustrated in the following case vignette.

Case vignette

Sally, aged 42 years, came for treatment of generalized SAD that had increased in severity over the past few years. Her main concern was that she blushed--with a hot sensation and red blotching most visible on her neck. During the winter she always wore a turtleneck or a scarf. However, in the summer people commented on her wearing scarves, which intensified her focus on this symptom.

Behavior exposure began with turning off the air conditioner during the sessions and Sally wearing a wool scarf to induce the hot sensation. Next, Sally began tolerating increasing amounts of time with her neck exposed, first with the therapist, then with friends, and finally with coworkers. Cognitive restructuring helped her identify unrealistic beliefs about how coworkers would react if they saw her blushing.

Limitations of CBT

As with medication treatments for SAD, a substantial minority of patients are not helped by CBT.^3,6,12 Furthermore, many patients who do improve with CBT continue to experience significant residual symptoms. Although not a limitation of CBT itself, the failure of broader dissemination hampers its usefulness and success. In fact, individuals with SAD report receiving unstudied psychotherapies, such as supportive therapy, more often than they received CBT.^13,14 Thus, despite the positive overall picture, there is need for improvement.

New developments and technologic enhancements

A somewhat newer CBT program developed by Clark and colleagues^15,16 shows potential for providing increased benefits relative to some standard CBT treatments. One technique emphasized in this treatment is the systematic manipulation of safety behaviors. "Safety behaviors" are subtle behaviors that the individual uses to help manage anxiety (eg, rehearsing what he will say before a conversation so he will say it correctly). Going through an exposure exercise using safety behaviors is a little like jumping into a pool wearing a life vest. Cognitively, a patient may conclude that the situation is still dangerous. Encouraging the patient to intentionally drop safety behaviors (eg, start a conversation and make sure they have nothing prepared to say) may more clearly disprove exaggerated beliefs about social danger. This is thought to help further reduce social anxiety.

Technology is also being used to help facilitate CBT for SAD patients. The treatment developed by Clark and colleagues¹⁵ makes use of video, with patients viewing videotapes of their exposure exercises. This is thought to help patients correct distorted perceptions about how they present themselves,¹⁷ but it also may add another layer to behavioral exposure. At this stage it is not clear whether videotaped technology reduces anxiety more than exposure alone.¹⁸

Following the successful use of virtual reality for the treatment of some phobias, researchers are now studying the use of virtual reality to simulate various social situations, such as public speaking, for the treatment of SAD. Initial results suggest that this technology may hold promise by helping clinicians to overcome the logistic challenges of planning exposures and by increasing accessibility of initial exposure situations.¹⁹

Finally, the use of interactive computer programs and the Internet is of potential benefit in treating SAD. One study found that a handheld computer helped facilitate exposure and cognitive restructuring during cognitive-behavioral group therapy.²⁰ Turk and colleagues²¹ adapted their widely used CBT approach to a CD-ROM format, and this program may be a useful adjunct to treatment. Not surprisingly, individuals with SAD often communicate through the Internet.²² Many prefer the anonymity and decreased time pressure of communicating through online chat and e-mail. Although not well studied, the Internet presents a potential future avenue for improving access and continuity to treatment for SAD.

Combining psychotherapy and medication

Because CBT and medication are presumed to work through different mechanisms, one would expect that combining these treatments would increase the number of patients who benefit and the degree of benefit for those treated. However, to date, research studies have not demonstrated a clear advantage of the combined treatment for SAD patients compared with CBT or medication alone.^6,23 Because the benefits of CBT tend to be more durable after discontinuation of treatment, it may be helpful to initiate CBT for patients already receiving medication.²⁴

In an intriguing new development, Hofmann and colleagues²⁵ found that an N-methyl d-aspartate receptor agonist, d-cycloserine, may increase the efficacy of behavioral exposure treatment of SAD by biologically enhancing learning effects. In a small randomized placebo-controlled trial, patients receiving d-cycloserine an hour before behavioral exposure to public speaking situations showed greater improvement than those receiving placebo. Although promising, d-cycloserine has not been approved by the FDA for this use.

Other psychotherapy approaches

The psychoanalytic literature is replete with case examples and conceptualizations of shyness, social discomfort, and lack of assertiveness--many cases that would meet current criteria for SAD.^26-28 Unfortunately, there has been limited systematic research regarding the potential benefit of psychodynamic therapy for SAD. In a small randomized trial, Bogels and colleagues²⁹ found that the benefit of 36 sessions of psychodynamic therapy was superior to that of wait-list controls and comparable to that of CBT. In another small trial, 12 sessions of psychodynamic group therapy was found to be superior to 12 sessions of educational supportive therapy.³⁰ Although these early trials are intriguing, further research is needed.

An intuitively appealing psychotherapy approach for SAD is interpersonal therapy (IPT).³¹ With its focus on improving interpersonal problems to achieve symptomatic recovery, IPT has shown efficacy in treating depression in numerous trials.³² Noting SAD's prominent interpersonal features, researchers adapted IPT for SAD patients; this treatment generated positive results in a small open trial.³³

In a subsequent controlled trial comparing IPT with supportive therapy, both treatments showed improvement at endpoint, but IPT failed to show superiority over supportive therapy.³⁴ Two recently completed European studies showed the benefit of IPT in comparison with wait-list controls³⁵ and cognitive therapy.³⁶ Although the author is optimistic about the long-term potential for treating SAD patients with IPT, further research is needed to clearly establish IPT's efficacy. Currently, there is insufficient empirical support to recommend IPT as a first-line SAD treatment.

Conclusion: clinical applications

CBT can be helpful for most patients with SAD. The Association for Behavioral and Cognitive Therapies and the Anxiety Disorders Association of America are potential resources for identifying therapists who use CBT. For patients receiving medication who have poor or partial response, CBT may be helpful, but further research is needed. Because the benefits of CBT tend to be more durable than those of medications, CBT may also be a useful approach for patients with SAD whose symptoms have already improved with medication. Alternative therapies such as psychodynamic therapy and interpersonal therapy may help fill important gaps, but these require further empirical testing.

General implications of work with CBT for the treatment of those with SAD include the importance of gradual steps in approaching large obstacles, the benefit of structure, and a system and/or motivation for continued repetition of social exposures. For patients who have made progress with medication therapy or psychotherapy, a nonprofessional organization, club, or class may help provide such structure. For example, individuals who have already made progress may benefit from a membership in Toastmasters International, a nonprofit organization in which people gain regular practice speaking in public.

Another general implication of experience with psychotherapy is the importance of patience. It is counterproductive for the patient or clinician to expect the patient to be "over it" or even feel comfortable after 1 or even a few exposures to a situation they may have avoided for years. It is essential to persevere and to prepare for setbacks along the way.

Dr Lipsitz is associate professor of clinical psychology in the department of psychiatry at Columbia University College of Physicians and Surgeons and a clinical psychologist in the Anxiety Disorders Clinic of the New York State Psychiatric Institute. He reports that he is a consultant for Eli Lilly.

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