The nature and treatment of social phobia in youth

A small proportion of children and adolescents experience a debilitating level of social anxiety, known as social phobia. Initially, we consider the phenomenology and aetiology of social phobia in children and adolescents. A number of age-sensitive assessment instruments or tools are briefly considered: a diagnostic interview, selj-report instruments, behavioural observations, cognitive assessment, self-monitoring and psychophysiological recording. We explore cognitive-behavioural strategies that have been found to be useful in the management of social phobia. Although there is much research support for the efficacy of cognitive-behavioural strategies for adults with social phobia, it is emphasized that controlled evaluations have yet to be undertaken with socially phobic youngsters.     

Individual response patterns and the effects of different behavioral methods in the treatment of social phobia

The importance of individual response patterns in the treatment of phobic patients was examined in the present study. Forty psychiatric outpatients with social phobia were assessed with a social interaction test which was videotaped. Heart rate was continuously monitored during the test. On the basis of their reactions in the test situation, the patients were divided into two groups showing different response patterns; behavioral and physiological reactors. Within each group half of the patients were randomly assigned to a behaviorally focused method (social skills training) while the other half received a physiologically focused method (applied relaxation). The patients were treated individually in 10 sessions. The within-group comparisons showed that both treatments yielded significant improvements on most measures. The between-group comparisons showed that for the behavioral reactors, social skills training was significantly better than applied relaxation on six out of ten measures, and for the physiological reactors applied relaxation was significantly better than social skills training on three of the measures. The results support the hypothesis that greater effects are achieved when the method used fits the patient's response pattern.     

焦虑中的安全行为及其影响

安全行为是个体用于预防或者减轻恐惧后果的行为, 它被认为是焦虑障碍维持的重要机制之一, 也会对焦虑的暴露治疗产生干扰。安全行为与焦虑水平、焦虑相关的认知偏差存在联系, 错误归因假说、注意资源偏离假说和行为信息假说对这种联系做出了解释。此外, 安全行为的使用会削弱焦虑暴露治疗的效果、提高暴露的接受性。未来研究应对安全行为做出更清晰的界定和准确的测量, 进一步改进研究设计, 借鉴第三代行为治疗的理论解释安全行为与焦虑的关系; 同时还需要考察安全行为的双重作用, 开发聚焦于安全行为的治疗方案并评估其效果。     

Optimizing treatment in social phobia: a review of treatment resistance

Over the last 25 years, there has been a rapid expansion of our knowledge base of social phobia (SP). Although there are a number of well-validated treatment modalities, including pharmacotherapy and cognitive-behavioral therapy, significant gaps remain in our ability to achieve full remission in most patients. Despite advances in the neurobiology of SP, the etiology has yet to be determined. Investigations examining potential predictors of response have provided little guidance in selecting an appropriate treatment modality. These gaps in our knowledge have pushed us to examine issues related to treatment resistance. This paper presents a review of the current literature and issues related to treatment-resistant SP, including a discussion of the functional impairment associated with SP, definitions of treatment response and remission, as well as outcome measures that have been used in clinical investigations of SP. In addition, criteria for a standard treatment trial, predictors of treatment response, a review of treatment resistance studies, and potential directions for future research are examined. The most promising strategies to attain remission, will likely involve augmenting selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors with agents such as anticonvulsants, benzodiazepines, and antipsychotics as well as combining pharmacotherapy with cognitive-behavioral therapy. Our current treatment target of simply attaining a response needs to be refocused, so that an asymptomatic state and high end state functioning become the final goal of treatment.     

Self-focused attention before and after treatment of social phobia

It has been hypothesized that effective psychological treatment for social phobia changes the person's representation of the self in a more positive direction. In order to test this hypothesis, we analyzed 506 thoughts that were endorsed by 23 social phobic individuals while anticipating socially stressful situations before and after exposure therapy. Treatment efficacy was assessed with the Social Phobia and Anxiety Inventory (SPAI) [Turner, S. M., Beidel, D. C., Dancu, C. V., & Stanley M. A. (1989) An empirically derived inventory to measure social fears and anxiety: the Social Phobia and Anxiety Inventory. Psychological Assessment, 1, 35-40)]. Subjects endorsed significantly fewer negative self-focused thoughts after treatment (on average 8.7% of the thoughts) than before treatment (26.5%, p < 0.005). These changes were highly correlated with pre-post difference scores in the social phobia subscale of the SPAI (r = 0.74, p < 0.0001). Implications of the results for the cognitive model of social phobia will be discussed.     

Effectiveness of an empirically supported treatment for social phobia in the field

This study examined the effectiveness of individual exposure combined with cognitive restructuring for social phobia in a clinical setting as well as the influence of sample restriction criteria on the effect size. Participants were 217 unselected patients with a primary diagnosis of social phobia who were treated by 57 therapists in four outpatient clinics of the Christoph-Dornier-Foundation of Clinical Psychology in Germany. Results 6 weeks after the end of therapy showed highly significant reductions in social phobic fears and avoidance as well as in general anxiety and symptoms of depression. However, patients who dropped out during therapy reported a significantly higher degree of depression. Results did not differ between the four outpatient clinics and are comparable with the average effect-sizes reported by meta-analytic studies of controlled efficacy research, using selected patients. Also, restricting the sample according to the selection criteria often applied in research settings did not result in higher effect sizes for the applied outcome measures. We conclude that individual cognitive behavioural therapy for social phobia can be transported from research settings to the field of mental health.     

The interpretation of negative social events in social phobia: changes during treatment and relationship to outcome

Catastrophic interpretations of negative social events are considered to be an important factor underlying social phobia. This study investigated the extent to which these interpretative biases change during cognitive-behavioural treatment for social phobia, and examined whether within-treatment changes in different types of interpretations predict longer-term treatment outcome. Results showed that treatment was associated with decreases in various types of maladaptive interpretations of negative social events, but that social phobia symptoms 3 months after treatment were independently predicted only by within-treatment reductions in the degree to which individuals personally believed that negative social events were indicative of unfavourable self-characteristics. These findings are discussed in relation to cognitive models of the maintenance of social anxiety, and implications for treatment are considered.     

Interpersonal subtypes in social phobia: diagnostic and treatment implications

Interpersonal assessment may provide a clinically useful way to identify subtypes of social phobia. In this study, we examined evidence for interpersonal subtypes in a sample of 77 socially phobic outpatients. A cluster analysis based on the dimensions of dominance and love on the Inventory of Interpersonal Problems-Circumplex Scales (Alden, Wiggins, & Pincus, 1990) found 2 interpersonal subtypes of socially phobic patients. These subtypes did not differ on pretreatment global symptom severity as measured by the Brief Symptom Inventory (Derogatis, 1993) or diagnostic comorbidity but did exhibit differential responses to outpatient psychotherapy. Overall, friendly-submissive social phobia patients had significantly lower scores on measures of social anxiety and significantly higher scores on measures of well-being and satisfaction at posttreatment than cold-submissive social phobia patients. We discuss the results in terms of interpersonal theory and the clinical relevance of assessment of interpersonal functioning prior to beginning psychotherapy with socially phobic patients.     

The effects of group contingencies on first graders' academic and social behaviors

This study describes how a graduate student in counseling and guidance worked with a team of teachers in implementing a group-contingent reinforcement system with first graders. One hundred students in an open-spaced classroom were divided into smaller groups of from 9–12 students. Each group could earn free time by completing its work within a designated period and by minimizing disruptive activity. The group contigencies proved highly effective in increasing the percentage of work completed and reducing disruptive responses. After the study was completed, the teachers voluntarily organized the entire morning's activities around the group contigencies. A check of the same classroom the following year indicated that the teachers were continuing to make extensive use of group-contingent free time.     

Prediction of treatment outcome in social phobia: a cross-validation.

This study was a replication of a study on the prediction of treatment outcome in social phobic patients [Chambless, D. L., Tran, G. Q. Glass, C.R. (1997). Predictors of response to cognitive-behavioral group therapy for social phobia. Journal of Anxiety Disorders, 11 221-240]. Results at the posttest and the 18-months follow-up were analyzed for DSM-III-R social phobic patients, with either a generalized social phobia (n = 50) or a nongeneralized fear, i.e. fear of blushing, trembling or sweating in social situations (n = 26). Predictors were pretreatment depression, personality disorder traits, clinician rated severity of impairment and frequency of negative self-statements during social interactions. The criterium variable was (the residual gain score of) self-reported avoidance of social situations. In line with Chambless et al., pretreatment depression showed some predictive value, but smaller and only at the posttest. Change in the frequency of negative self-statements paralleled, but did not predict, change in social phobia symptoms. In contrast with Chambless et al., clinician rated severity was (slightly) predictive for treatment outcome, whereas avoidant personality traits had reverse correlations with outcome in both subgroups. The results are discussed and directions for further research are given.     

Smoking and social anxiety: the role of false safety behaviors

ABSTRACT

Despite the negative health consequences associated with smoking, most smokers find it difficult to quit. This is especially true for smokers with elevated social anxiety. One factor that may play a role in maintaining smoking with elevated anxiety is false safety behavior (FSB), behaviors geared toward decreasing anxiety short-term but that maintain or increase anxiety long-term. The present study tested whether FSB explained the relation of social anxiety severity with smoking among 71 current smokers. Avoidance-related FSB was the only type of FSB related to cigarettes smoked per day (CPD) and it was robustly related to more CPD. Further, social anxiety was related to CPD indirectly via FSB-Avoidance. Findings suggest that more frequent use of avoidance behaviors to manage anxiety may maintain smoking and may partially explain the high rates of smoking among those with elevated social anxiety. Thus, FSB may be a promising target in smoking cessation interventions, especially among those with elevated social anxiety.     

Exposure in vivo vs social skills training for social phobia: long-term outcome and differential effects

This study examined the long-term effectiveness of specific exposure in vivo (individual IE or group GE) and of office-based social skills training (group SST) in two groups of patients with social inhibition (primary social skills deficits or primary social phobia). Seventy-eight outpatients were divided into these two subgroups according to clinical assessment. Twenty-seven patients received SST which consisted of 25 twice a week 90-min group sessions: 32 patients received GE and 17 IE. Exposure in vivo consisted of 4 weekly (8-hr in the group condition included 2 hr discussion; 3 hr in the individual condition included 1 hr discussion) sessions. Self-rating-assessments were carried out at pre- and post-treatment, at 3 months- and 2.5 yr follow-up. The general results indicate that all three treatment modes led to clinically and statistically-significant improvements in the main problem area (social anxiety, skills deficits), in other neurotic complaints (depression, obsessions, psychosomatic complaints) and in attribution-style. Patients with the diagnosis of primary phobia seemed to get the same profit from either treatment and showed slightly better gains (in all treatment modalities) than patients with skills deficits at long-term follow-up. Within the subgroup with skills deficits there was a tendency for superior outcome of group exposure. These results and recommendations for future research are discussed.     

In‐group representation and social value affect the use of in‐group identification for maintaining and enhancing self‐evaluation

Individuals with independent self‐construals identify with their in‐group in order to buffer threats to self‐esteem to a greater degree than do those with interdependent self‐construals. This study focused on the effect of the in‐group's social value and representation on this identification process among individuals who reported various real‐world threats to their self‐esteem. We conducted a questionnaire survey for university students and we examined how self‐construal, the in‐group social value, and the in‐group representation either moderate or mediate the relationship between threat to self‐esteem and identification with their academic departments. The results of multiple‐group analyses of structural equation modelling showed that independents who reported more threats to their self‐esteem identified with the in‐group when it was high in social value. In contrast, they did not exhibit in‐group identification when it was low in social value. Interdependents showed less in‐group identification regardless of the in‐group's social value. The representation of the in‐group as a common identity group mediated the relationship between threat to self‐esteem and in‐group identification for independents, whereas the representation of a common bond group played the same role for interdependents. These findings suggest the importance of considering the role of self‐construal and the in‐group social value, along with the representation of in‐group, in understanding in‐group identification in situations of threat to self‐esteem.     

Double foot‐in‐the‐door,social representations,and environment: application for energy savings

This study aims to determine the most effective procedure to bring individuals to adopt pro‐environmental behaviors, specifically to make energy savings for several weeks. A link was established between two fields of research traditionally separated in social psychology literature: free will compliance and social representations theories. An experiment was carried out to test the effectiveness of several simple and double foot‐in‐the‐door procedures, activating central or peripheral cognitions of the social representation of energy savings. Basically, the results indicate that the most effective procedure is the double foot‐in‐the‐door, which activates central cognitions. Twice as many participants accepted the target request and three times as many actually performed the expected behavior with this procedure.