The Wiley Blackwell Handbook of Social Anxiety Disorder

Justin W. Weeks

• Publisher: Wiley-Blackwell
• Year: 2014
• Print ISBN: 9781119968603
• eBook ISBN: 9781118653890
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Featuring leading international authors working in clinical psychology and psychiatry, this handbook offer the most in-depth coverage of social anxiety disorder, including personality factors in SAD, and multicultural issues in the diagnosis, case conceptualization, and treatment of SAD.

• A multi-contributed, internationally diverse handbook covering all major elements of social anxiety disorder, offering an invaluable teaching tool
• This unique text contributes significantly to the field by summarizing the current state of research in the area and outlining future directions
• Provides a comprehensive overview of applied, empirically-supported techniques in the conceptualization, assessment, and treatment of SAD

I

Theoretical Overview

Social Anxiety Disorder

1

Cognitive-Behavioral Models of Social Anxiety Disorder

Judy Wong, Elizabeth A. Gordon and Richard G. Heimberg

Adult Anxiety Clinic, Temple University, USA

Cognitive-Behavioral Models of Social Anxiety Disorder

Since its recognition as a mental disorder in the Diagnostic and Statistical Manual of Mental Disorders, third edition (American Psychiatric Association, 1980), social anxiety disorder (SAD, also known as social phobia) has received increasing attention in the field of psychology as a complex, debilitating disorder that, left untreated, is often unremitting. In the last few decades, many theorists have contributed significantly to our understanding of this disorder, subsequently informing approaches to treatment. In this chapter, we review and compare aspects of the two preeminent cognitive behavioral models of SAD, as well as more recently proposed models of SAD.

Clark and Wells (1995): A Cognitive Model of SAD

Clark and Wells (1995) put forth a cognitive1 model of SAD to explain why exposure to feared situations alone was not enough to extinguish fear in socially anxious individuals. According to their model, SAD develops as a result of an interaction between innate behavioral predispositions and life experiences, leading individuals to perceive the social world as a dangerous one which they have little ability to navigate. A core feature of this model, derived from self-presentational models described below, is “a strong desire to convey a particular favorable impression of oneself to others and marked insecurity about one's ability to do so” (p. 69). These beliefs contribute to the sense that the person with SAD is at substantial risk of behaving in an inept and unacceptable fashion and that such behavior will have catastrophic consequences involving loss of status, loss of value, or rejection. The following is a brief overview of the model—a discussion of the empirical support for specific aspects of the model is beyond the scope of this chapter, but interested readers are referred to reviews of research by Clark and Wells (1995) and Clark (2001).

Dysfunctional Processes

Clark and Wells (1995) describe the dysfunctional pattern of social anxiety as being comprised of four interactive processes. The first process begins when people with SAD enter a feared situation and judge that they may be in danger of being negatively evaluated. They then turn their attention inward and use interoceptive information as the main source of feedback about their performance. Often, their internal experiences appear to provide confirmation of their social ineffectiveness, which is believed to be obvious to those around them (e.g., “I feel nervous, therefore everyone must realize I am nervous”). Compounding this negative self-perception, people with SAD often imagine themselves as others see them (the “observer perspective”), though these images are likely to be quite distorted. Clark and Wells refer to this attentional inward bias and distorted images as a processing of the self as a social object, and this is the putative reason why exposure alone to feared situations is insufficient to reduce social anxiety. They write:

Clinically, the importance of this processing bias is that it prevents social phobics from getting maximum benefit from their everyday experience with social situations or from the exposure exercises used in behavior therapy treatment programs. When in feared social situations, social phobics process the negative feelings generated by their fear of the situation, but they do not check out what is really happening. (p. 72)

The second dysfunctional process relates to behaviors that socially anxious individuals engage in to prevent negative evaluation by others. Clark and Wells (1995) refer to these behaviors as safety behaviors. For instance, a person concerned with others noticing his profuse sweating may wear an extra layer of dark clothing. Ironically, safety behaviors often make the feared behavior or outcome more likely to occur: the extra layer of clothing may cause the person to sweat more. Safety behaviors also serve to maintain anxiety because they prevent the person from experiencing unambiguous, disconfirming evidence of their negative beliefs about feared consequences. So, although the feared outcome may not have occurred (e.g., people did not express disgust about the person's sweating), the person with SAD may attribute this to the fact that he or she engaged in this safety behavior.

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The third dysfunctional process described by Clark and Wells (1995) is that individuals with SAD often overestimate how negatively others evaluate their performance and predict the consequences of social failures to be far worse than is realistic. As a result of these cognitive distortions, they are hypervigilant in monitoring their behavior and performance, which may further impair their ability to fully engage in social interactions. Real performance deficits may result, which could lead to others perceiving them to be socially unskilled, aloof, or unfriendly.

The final dysfunctional process delineated by Clark and Wells (1995) occurs either before or after a social situation is encountered. Prior to engaging in a social event, many individuals with SAD frequently experience a period of anticipatory anxiety in which previous negative experiences are recalled, and expectations of failure and images of the self performing poorly are evoked. This can lead to complete avoidance of the situation. However, if the situation is not avoided, anticipatory anxiety can lead the person to enter the situation with a self-focused processing mode and reduced capacity for noticing positive reactions from others. Following a social interaction, people with SAD frequently review their performance in detail (referred to by Clark and Wells, p. 74, as a “postmortem” review or “post-event processing”), often recalling events and their outcomes to have been more negative than they really were, as their perceptions are colored by their attentional biases and cognitive distortions. Ultimately, this helps maintain negative self-schemas and increases the likelihood that the person will avoid feared situations in the future.

Rapee and Heimberg (1997): A Cognitive-Behavioral Model of SAD

Along with Clark and Wells' (1995) and Rapee and Heimberg's (1997) model is the other most widely cited and applied model of SAD in the literature. According to Rapee and Heimberg, social anxiety exists along a continuum, with individuals with SAD representing the higher end of the continuum. Similarly, the degree of dysfunctional patterns can be represented along a continuum. Thus, according to the model, the difference between those with SAD and those without is “the extent to which [individuals with SAD] appraise cues as predictive of threat and the extent of threat predicted by a given cue” (Rapee & Heimberg, 1997, p. 751).

A number of different factors are thought to influence the development of dysfunctional processes, which in turn lead to the development of SAD. A genetic tendency toward preferential attention to threat may be one factor, which interacts with early childhood family environment and/or other experiences (e.g., being teased or bullied) to create a perception of the social world as being dangerous and unforgiving. Consequently, a defining characteristic among those with SAD is the assumption that others are likely to evaluate them negatively. Additionally, individuals with SAD attach fundamental importance to being accepted by others. The result is a set of expectations and goals that the person feels unable to reach, accompanied by predictions of very negative consequences of this failure. The discrepancy between the mental representations of the self as seen by others and others' perceived expectations, according to Rapee and Heimberg (1997), lies at the heart of SAD. Below, we provide an overview of the model, including its recent update (Heimberg, Brozovich, & Rapee, 2010). As with the Clark–Wells model, a discussion of the empirical support for the Rapee–Heimberg model is beyond the scope of this chapter. Interested readers are referred to the original theoretical articles for reviews of empirical research; see also Roth and Heimberg (2001) and Turk, Lerner, Heimberg, and Rapee (2001).

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Dysfunctional Processes

In this model, “social situations” are defined broadly and may include situations in which no social interaction actually occurs, as the presence of a perceived threat may be enough to evoke anxiety. Thus, the stranger walking down the street may become an audience for and potential judge of the socially anxious person's appearance and behavior. For individuals with SAD, the prospect of an audience activates a mental representation of the self as they imagine they are perceived by that audience. This mental representation of the self is a distorted image that is shaped by a number of inputs. Rapee and Heimberg (1997) proposed that individuals form a “baseline image” (p. 745) that may be derived from past experiences and actual images of the self as seen by an audience (e.g., from mirrors or photographs) and which is consistent with negative self-schemas and core beliefs. It is modified in any given situation by internal (i.e., interoceptive) and external feedback. For instance, sensations of warmth may cause the person to imagine herself to be blushing noticeably, or a passing and ambiguous comment by another person in a group interaction may lead the person to think she has said something contrary to group opinion, and she thus imagines that she “looks stupid.”

According to the model, one reason this mental representation of the self as seen by the audience is distorted is that individuals with SAD have a bias toward attending to external cues in the social environment that signal threat or negative evaluation. This orientation to threat is consistent with other anxiety disorders. However, Rapee and Heimberg (1997) also hypothesized that individuals with SAD also preferentially allocate attentional resources to monitoring and adjusting the mental representation of the self as perceived by the audience. This is in addition to the attentional resources needed to engage in the social task at hand. Consequently, social performance suffers as attentional resources are taxed, and the poor performance only serves to confirm negative mental representations of the self (e.g., that one is socially unskilled, awkward, etc.).

The model proposes that a key dysfunctional process is the comparison of the mental representation of the self with the perceived expectations of the audience. Socially anxious individuals typically believe that others hold extremely high standards for their performance, and the greater the perceived failure to live up to this standard, the greater the likelihood of negative evaluation, and the greater the anxiety. Socially anxious individuals anticipate the cost of such failure to be high, and this anticipation activates behavioral, cognitive, and physical symptoms of anxiety, which feed back into the mental representation of the self as seen by the audience in a most deflating way, renewing the vicious cycle, which continues until the situation comes to a natural end or is terminated by the anxious person. It is therefore not surprising that socially anxious individuals often engage in avoidance or escape from feared situations, as it seemingly provides respite from this cycle. However, behavioral avoidance becomes yet another source of shame and frustration and contributes to an increasingly negative mental representation of the self as seen by the audience.

In 2010, Heimberg et al. published an updated version of the model to incorporate knowledge from new findings about the processes that occur in SAD. For instance, a growing body of research has shown that individuals with SAD frequently engage in negative self-imagery (e.g., Hackman, Surawy, & Clark, 1998). In addition, compared with non-anxious individuals, the images of socially anxious individuals are often from the observer's perspective (Hackman et al., 1998). These findings are consistent with the theory that those with SAD formulate a mental representation of the self as seen by the audience. The updated model highlights the role of negative imagery in influencing the mental representation of the self, and ultimately serving to maintain SAD.

A significant change to the model addresses what is thought to be the core fear in SAD, typically characterized as a fear of negative evaluation. However, recent research suggests that socially anxious individuals fear any evaluation, whether it is negat...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Notes on the Contributors
• Part I: Theoretical Overview
• Part II: Variability Within Social Anxiety Disorder
• Part III: Optimizing Assessment Approaches
• Part IV: Symptomological Manifestations
• Part V: Broadening the Scope of Social Anxiety Disorder
• Part VI: Treatment
• Index