Social Phobia, also know as Social Anxiety Disorder, affects between 7 -13% of individuals in western society (Furmark, 2002). It usually presents during adolescences and is typically chronic and lifelong (Veale, 2003). Two theories have been commonly used to explain the development and maintenance of the phobia: learning theory and cognitive theory. Both theories alone do not provide a comprehensive treatment plan, however when used in conjunction are much more effective. Cognitive behaviour therapy (CBT) identifies both behavioural and cognitive aspects of social phobia. By addressing ongoing interaction between thought, feelings, and behaviour, it aims to positively restructure an individual’s response to social interactions.
It successfully combines client education, exposure to fearful situations, and cognitive restructuring to alleviate anxiety and develop a realistic outlook toward social situations. Social Phobia is made up of problematic emotions, behaviours, and automatic thoughts that are interconnected and mutually causal. It manifests as a marked and persistent fear of negative evaluation in social or performance situations (Veale, 2003). There are two subtypes of social phobia: generalized (fear of all social situations) and non-generalized (fear of specific situations, such as public speaking). Diagnostic features of the disorder are addressed in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [APA], 2000). Symptoms include cognitive, behavioural, and somatic symptoms. Meeting criteria for diagnosis must include the extent to which these concerns are interpreted to cause distress in an individuals career, relationships, or daily routines (APA, 2000). Anxiety and its associated behaviours resulting from social or performance situations must interfere significantly with career, relationships, and daily routines. Primary cognitive symptoms include the fear of being exposed to criticism and judgment from others, particularly during social events where there is a demand of performance or interaction with others (APA, 2000).
The individual fears being perceived as weak or stupid and that they will act inappropriately, resulting in humiliation or embarrassment. This may occur in familiar or unfamiliar surroundings, with peers known or unknown to them. They are often self-judging and hyper aware of their own performance, physical sensations, and actions during the event. They dwell on thoughts of awkwardness or embarrassment post-event. The person recognizes their fears as unreasonable, though cannot control their responses.
Clients suffering from social phobia often engage in behaviours such as leaving or avoiding social situations. They use isolated activities (e.g., using their mobile phone) to prevent feared social interactions that will provoke anxiety. They attempt to direct attention away from their social performance and engage in excessive planning or preparation (e.g., practicing what to say or excessively grooming). These behaviours are maladaptive to the client and interfere with daily functioning.
Exposure to the feared situation usually results in anxiety, often in the form of a panic attack. Physiological indicators may include increased heart rate, muscular tension, chest pain, and diarrhea. Other somatic symptoms that may be more obvious include blushing, trembling of hands, intense sweating, a shaky voice, and difficulty making eye contact (APA, 2000). The person often tries to hide these responses, fearing further embarrassment. Commonly symptoms are exhibited with anticipation of the social event, or during the event itself. This often results in choosing to avoid exposure by leaving the event early or not attending.
Learning theory is considered an extension of behaviourism with similar concepts and primary ideas. Learning theory maintains that behavour is the primary focus, and that learning is influenced by factors of reward and punishment. It proposes that fears and behaviours (both rational and irrational) are acquired through associative learning.
Classical conditioning and operant conditioning are the two models used to explain the acquisition and maintenance of social phobia. Classical (or Pavlovian) conditioning associates a neutral stimulus with an unconditional stimulus through paired association. A neutral stimulus is an object or situation that under normal circumstances wouldn’t elicit a fearful response (e.g., meeting with friends). An unconditional stimulus produces an automatic, unconditioned response (e.g., sweating or blushing). If the neutral stimulus is continuously paired with an unconditional stimulus it will elicit the unconditional response without the unconditional stimulus present. The individual has now been conditioned to view the social situation as threatening as opposed to non-threatening. Based on this model, prolonged repetition of the eliciting stimulus without an aversive outcome should result in a progressive reduction of the conditioned response.
This is called extinction, a process of reversal that breaks the association. Learning theory proposes that the treatment to social phobia is exposure, as the client will be exposed to their fear without an adverse outcome, and over time extinction will take place. However, social phobia is very resistant to extinction, as people often engage in avoidance and escape behaviours as defense mechanisms. Avoidance behaviours, thought to maintain social phobia, are a product of operant conditioning. Skinner (1984) proposed that the consequences of actions are an important element to either strengthening (reinforcement) or weakening (punishment) behaviour. This often results in avoidance and escape behaviours, which are maladaptive to the client. As an example, a social phobic decides not to meet with their friends, as this will cause them anxiety. This avoidance behaviour is then reinforced as it takes away an aversive stimulus and relieves the social phobic, strengthening the behaviour and increasing the rate at which it occurs. Likewise, an individual could have a similar result by using escape behaviour.
This would involve meeting friends but leaving early, and would also remove the aversive stimulus. Learning theory proposes that avoidance behaviours and associated symptoms of social phobia will stop through exposure to the feared situation. Repeatedly facing previously avoided situations in a graded manner, coupled with the disconfirmed fear (Veale, 2003) continues till the fear becomes extinct. Cognitive theory debates this by proposing that social phobics are constantly exposed to their fears but due to dysfunctional thoughts, appraise otherwise neutral situations as negative. Cognitive therapy claims that individuals have deep cognitive structures called schemas that influence processing and organisation of incoming information, allowing the person to interpret experiences in a meaningful way (Beck, et al. 1985). Schemas activated by negative experiences often manifest as cognitive distortions whereby the individual misinterprets situations or subjective feelings as negative.
This shift in thinking subsequently affects behavior. Beck found that patients had a systematic negative bias regarding themselves and their prediction of their future (Gottlieb, Kash, & Traill, 2004). Individuals shift their attention toward themselves, self-monitoring their performance and how they appear to others. Individuals with social phobia are characterised by having excessively high standards of social performance, conditional beliefs regarding social performance, and unconditional negative beliefs about the self. Socratic questioning is a form of psychotherapy often used in cognitive therapy. The psychologist guides the client to evaluate and contemplate information that was already available to them, with the aim of reaching rational and logical thoughts. This is done through a series of questions which the individual’s attention is drawn to relevant information. Though much of the information is already known to the client, socratic questioning is designed to organize this information and generate a different perspective or conclusion to an issue. Cognitive theory emphasizes that thoughts and appraisals play a vital role in determining behaviour. Cognitions immediately follow an event, and the interpretation of the event determines behaviour.
Therefore, interpretation of the stimulus is more important than the actual stimulus itself. In the case of a social phobia the social event is interpreted as negative or threatening due to irrational thoughts. These irrational thoughts culminate in symptoms that individual attempts to disguise through safety behaviours. These behaviours contribute to social phobia. Safety behaviours are cognitive based behaviours designed to alleviate the feared outcome of a social event. They include internal mental processes such as analysing past conversations and comparing them to the current conversation, and behavioural, such as wearing a scarf to hide blushing (Clark, 2001). Safety behaviours act to maintain the phobia by creating some of the symptoms the phobic is trying to avoid. They also increase self-monitoring which may make the individual appear less warm and outgoing (Rapee & Lim, 1992).
This often equates to poor social skills, which causes a negative self-image and repeats the cycle. If the catastrophe fails to eventuate, the patient ascribes the non-occurrence of a negative outcome to the safety behaviour, rather than interpreting the situation as less dangerous and adjusting schemas. Both learning theory and cognitive theory show a cyclic pattern of behaviour. When confronting the feared social situation with either behavioural coping mechanisms of avoidance, or cognitive coping mechanisms, both theories prevent disconfirmation of the negative beliefs and appraisals. Beck developed a therapy that focused on changing automatic thoughts, behaviours and schemas. He believed them to be reciprocally causal, and that changes in schemas reduced the intensity of future episodes of illness. Beck (1975) found that by increasing a client’s objectivity regarding their cognitive distortions and negative expectancies, they experience a shift in thinking and subsequently in emotions and behaviour. Changes in schemas are identified by a reduction in number and intensity of future phobic episodes.
He also advocated that patients assume an active role in normalizing their dysfunctions to prevent remission of their psychiatric conditions. These ideas combined both cognitive and behavioural therapy and are the basis the commonly used CBT. CBT is currently intervention of choice for treating social phobia (Radomsky, 2001). Neither cognitive nor behavioural therapy alone provides adequate and long-term relief from social anxiety. CBT addresses this by blending cognitive and behavioural therapies, where behaviour therapy is an extension of learning therapy. This therapy employs three main techniques to treat social anxiety disorder: exposure, cognitive restructuring, and social skills training. Cognitive restructuring and exposure are particularly effective treatment as they address the two core beliefs that maintain social phobia: negative schemas toward self and others, and the processes preventing these beliefs being challenged (Heimberg et al, 2002).
They are usually employed together as exposure and response prevention (ERP), as they are more effective together than as two parts. Intervention programmes employing CBT start with psychoeducation, counselling clients on symptoms, and causative factors regarding social phobia. The link between dysfunctional thoughts and the anxiety experienced in social situations is made apparent. Social skills are addressed, though this is not always a requirement. Social skills can be role played, and may be employed to build confidence. Clients are also instructed in muscle relaxation and breathing exercises to decrease anxiety and physiological responses. Once understanding and relaxation exercises have been practiced, the client is then introduced to exposure and response prevention (ERP). ERP has two components: actual or imagined exposure to the social situation, and response prevention that addresses avoidance or escape behaviours.
The goal is habituation and extinction of responses that contribute to social anxiety. Through exposure to feared stimuli, increasing in hierarchy of intensity, the client is systematically desensitised to the situation and the avoidance response is extinguished. Exposure can occur in-vivo or through imaging the specific performance. Exposure directs attention toward processing the reality of a phobic situation rather than the imagined scenario. Cognitive restructuring is also an important component. It focuses on the cognitive symptoms associated with the self, and the fear of being negatively evaluated by others. In order to modify and restructure negative and incorrect schemas, the client is taught to identify and challenge negative thoughts rationally and objectively. Thoughts are challenged rather than blindly accepted as truth.
This results in more realistic views of self and others, freeing resources devoted to negative dysfunctional thoughts and decreasing physiological symptoms (Turk etal, 2008). Cognitive restructuring causes the client to identify misperceptions of themselves regarding appearance to others, ability, and self-worth. It addresses negative associations from past experiences and accompanying emotions. Through repetition the more realistic schemas become automatic. CBT may be delivered individually, in a group, or internet based. Typically cognitive behavioural group therapy has four to eight people, but all must be suffering social phobia. It has been suggested that individual therapy is superior (Stangier, 2003) as clients can work on an exposure gradient specific to their needs. However other studies show no variance between group and individual (Fedoroff, 2001).
Internet delivered CBT increases the availability of therapy and is proven effective (Titov, et al. 2008) In conclusion, cognitive behavioural therapy draws on the evidence of past theories, particularly learning theory and cognitive theory. It is particularly successful in treating anxiety disorders, including social phobia. CBT addresses ongoing interactions between thoughts, feelings, and behaviours to successfully change schemas that control responses to social situations. It incorporates psychoeducation, gradual desensitization through exposure, and cognitive restructuring to alleviate symptoms of social phobia. With patient cooperation it has been found very effective, and is therapy of choice for treating social phobia.
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