Does Skunk Cannabis Cause Psychosis: Causes and symptoms from smoking skunk marijuana.

Skunk and Psychosis: Does Strong Cannabis cause psychosis and what are the symptoms?
by: Eleanor Segall

It has been known for quite some time that smoking ‘Weed’, Cannabis can cause all kinds of effects. Whilst many are seen to be positive- calming you, helping you ‘chill out’ there are some more harmful and sinister effects of a particular strain of Cannabis known as ‘Skunk’.

What is ‘Skunk’?

Skunk is a high potency strain of cannabis which is known for both its strength and pungent smell. It has increased in volume on the street over the past few decades and many smoke it due to its strength. Some also smoke it unaware that its side effects are far more dangerous than conventional cannabis.
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If smoked daily or regularly, the Skunk strain of cannabis can cause psychosis in the brain- meaning one may suffer from delusions, hallucinations, extreme anxiety and paranoia, sleeplessness or hear voices and become quite unwell. This is due to the high amount of chemical present in the drug- Skunk contains more THC- the main  psychoactive ingredient than other types.

Hashish (which is cannabis resin) contains substantial qualities of another chemical- Cannabidol (CBD). NHS Research suggests that the CBD acts as an antidote to the THC, counteracting psychotic side effects. In Skunk strain of cannabis there is far less Cannabidol, meaning that the brain can be triggered more easily into a psychotic state. There is also research suggesting that less potent strains of cannabis, if smoked daily, can trigger mental illness although this is less known than Skunk cannabis.

The NHS have stated in their research from 2015, that ‘Skunk like cannabis increases risk of psychosis, study suggests’ (2015, NHS). They also go on to say that ‘the use of high potency cannabis was associated with a far greater increase in risk’.

Due to the increase in psychotic symptoms from those men and women regularly smoking Skunk cannabis, a medical study was undertaken in the UK. As the NHS and BBC reported,

‘The study compared cannabis use patterns among 410 people from South London who attended hospital with a first episode of psychosis and 370 people from the general public without the condition…

It found that the daily use of cannabis was associated with a greater increase in risk of psychosis and use of high potency cannabis associated with a greater increase in risk.  Smoking potent cannabis was linked to 24% of new psychosis cases analysed in a study by Kings College London Institute of Psychiatry, Psychology and Neuroscience …

The research suggests the risk of psychosis is three times higher for users of potent skunk like cannabis than for non users.’

Following on from  this, many former Skunk users have commented on their own psychotic symptoms after smoking it daily or regularly. It is shown that major changes in the brain occur when Skunk is smoked regularly and it can take years for people with skunk induced psychosis to recover fully. The study above was funded by the Maudsley Hospital Charitable fund and published in the medical journal ‘The British Journal of Psychiatry’.

It found that young men were more at risk- the study found most were young between 25- 30 and most were men with a high proportion of unemployment.

So what can you do if you are worried about someone you know who may be presenting with addiction to Skunk or psychotic symptoms?

Firstly, if someone is addicted to Skunk or cannabis and smoking it daily, but wants help to stop, they may need to get some support to stop smoking as much- whether that’s through a specialist Doctor or Rehab unit and initially referred through their GP.

If  they are exhibiting psychotic symptoms and in a crisis situation it is key to get the local Crisis team or psychiatry involved as if they are severely unwell, they may need a short or long hospital stay.

There are many addiction charities and groups out there that can support you and the addict and these are worth exploring. If someone does not want help and you can’t convince them to stop smoking (and they aren’t psychotic), it can be difficult as you may have to wait until crisis point.

If you need to discuss these issues, do speak to Drug addiction charities, doctors/therapists or helplines and make sure you get the support you and your friend/ family member need.

Jessica at Brighton Wellness Centre is a therapist who deals with addiction issues. For more information, please do contact her via the website www.brightonwellnesscentre.co.uk or email jessica@brightonwellnesscentre.co.uk.

Mental Health New Years Resolutions

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It’s that time of year again, tinsel and fairy lights adorn houses and trees, Christmas songs blare from the radio, mulled wine is served and not to mention advent calendars, nativity plays and more. This time of year is a time to be with family and friends, whatever faith you are.  This can mean that the Christmas period can be a challenging time for those suffering from mental ill health- either due to isolation and loneliness or because of the overtly social time frame.

So, if you are feeling like this the best thing to do is to either talk to someone you trust, phone a helpline or charity if you need , speak to a psychotherapist or use other coping mechanisms, eg.  journalling, mindfulness, deep breathing or relaxation CD’s.  Whichever works for you make sure you don’t bottle things up.

Being that it is coming to the end of the year and looking ahead to 2017, I thought I would share some new years resolutions for positive mental health that you can implement in your life.

1) I will make sure to invest in self-care this year.

Self-care means I will actually take time out of my day to check in with myself and decide what I need. This isn’t selfish, it is vital to survival of the bleak winter period in particular.  Each day  I will invest in self care, whether its running a warm bubble bath and soaking for half an hour, journaling out my negative feelings and replacing it with positive ones, colouring for relaxation or just getting some much needed down time in front of the TV in my PJs- make sure I invest every day and you do too, in self-care activities.

2) I will make sure I go outside more.

In the winter, I am definitely more prone to curling up like a doormouse and hibernating inside- in the comfort of my warm home, chatting to friends on my smart phone and computer.  I am also a sucker for my blanket and a warm mug of hot chocolate. While this is good some of the time, I know that I need to push myself out more into the cold and bright mornings.  So, my resolution is to make sure I go out and get enough light and Vitamin D to boost my mood and health and enough exercise to keep my mind and heart healthy.

3) I will make sure to be present.

A friend of mine gave me this tip when she said –‘Stay in the Now and Enjoy the Moment’ .  I definitely need to do this more and not worry myself too much.  Staying present means that the only moment is now- try and focus on something positive in the present and not worry too far ahead.

4) I will try not to worry what others think and don’t beat myself up.

Easier said than done, this resolution had come about due to having people pleasing tendencies.  I hate upsetting anyone.  This means that I will often overthink or worry about others and what they think.  This year I resolve to spend less time fretting and not to beat myself up over small things that turn from a mountain into a molehill!

5) I will have a more positive mind-set.

This means I will not be ashamed of how I am feeling and feel bad because of it.  I will be more accepting of my feelings and needs.  I will know that even if I am at rock bottom, ‘This too shall pass’ and I will find a way to get through adversity and be positive.  I will actively think positive thoughts and push myself to achieve my goals.

If you are suffering from depression, anxiety or any other mental illness please reach out for help.  Contact The Brighton Wellness Centre at http://www.brightonwellnesscentre.co.uk or 07810 744 821.  Phone sessions, online sessions and face-to-face sessions are available.

Looking forward to a happier, healthier 2017 and wishing you a Merry Christmas and Happy Chanukah!

 

Changing habitual behaviour for a happier life – anxiety disorders.

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Do you have behavioural habits that you know you are repeating over and over- and want to learn how to stop them continuing?

Our behaviour is such a challenging thing to change because the mind and our thought patterns and chemistry are so complex- and so individually unique. Once we begin certain behaviours and repeat them over and over, they become automatic and our brain continues to act in the same way, unless we take control and change it. This is to do with the way the brain and an organ called the amygdala processes hormones such as adrenaline and the memory of previous behaviour patterns.

So, how can we change negative or destructive behaviour patterns which perpetuate illnesses such as anxiety disorders? (Please note this is similar in other disorders eg addictions but this article will focus on anxiety disorders, however it can apply to you too.).

The most important thing if you have an anxiety disorder- this can be generalised anxiety disorder, OCD, PTSD, social anxiety and more… is that you can change your habits but it will take work, perseverance and support.

I have suffered from social anxiety in the past, coupled with depression. This made it extremely difficult for me to go out to occasions where there were lots of people, for fear of negative judgement, such as weddings and on public transport. The psychotherapists I worked with taught me that these thoughts were ‘irrational’ and I had various courses of Cognitive Behavioural therapy  to unpack my negative thoughts and limiting beliefs on paper .

However, what really helped me to change my habits around going out and socialising was something I call- exposure therapy. By going out with a few friends and then on the tube, around more people I slowly desensitised my brain to my new surroundings. I then found I actually wanted to go out more and it didn’t feel quite as frightening as when I stayed indoors and cancelled my plans. I didn’t want to hide away.

For those of us with anxiety disorders, we can be triggered by anything in the subconscious and our body chemicals (cortisol and adrenaline). I still have bad days and I know you will too. Yet, you can get better and feel stronger, if you take charge.

If exposure therapy sounds too big an idea- break it down. As mentioned, I had CBT and psychotherapy but there are so many therapies out there that can help too and everyone will have unique symptoms and triggers. Talk with a qualified therapist or your GP to see what therapy plan is best for you.

You may find that Mindfulness CDs work for you to help you stay present and do deep breathing or meditation, art therapy, hypnotherapy or in depth talking therapies. CBT can also be beneficial in changing behaviour patterns but this will depend on the individual.

If you need help changing your negative behavioural patterns, get in touch with Jessica Valentine, therapist at Brighton Wellness Centre.

SELF-EFFICACY: TURNING DOUBT INTO DRIVE

 An efficacious attitude works as a driving force – an individual with a strong sense of efficacy is more likely to become self-motivated, committed and assured in the face of a challenge. With high self-efficacy, one can attempt goals and conquer stress more readily, and as a result, experience better wellbeing. On the contrary, those who have doubts about their own abilities ruminate on personal flaws, slacken efforts and lose faith in the face of failure – a mind-set that in the long run can act as a brake on one’s ambitions and increase proneness to mental illness. But how does one develop self-efficacy? Is it ever as simple as telling yourself, “I can do this” when faced with a challenge? Is self-efficacy something that can be moulded and strengthened to the level we want it to be? Is anyone ever totally self-confident, and if so, is that always a good thing?

Efficacy beliefs shape the course of our lives – what goals we choose to pursue, how much we commit to those goals and how much effort we put into given endeavours. Our everyday realities are filled with obstacles, frustrations and limitations. However, it is not the difficulties we face that influence our strength and wellbeing, but the beliefs we hold about them. Our beliefs determine how much stress we experience when confronting challenges, and how long it takes before we give up altogether. We must, therefore, develop a robust sense of self-worth to sustain the enduring effort needed to flourish.

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Psychologist Albert Bandura, known primarily for his research on behavioural modelling, suggests we can improve our self-efficacy, ironically, through failure. After all, if people only experience straightforward successes, it becomes an expectation that makes them far more vulnerable when things don’t go as planned. Therefore, if one comes to realise their self-worth and capability through sustained effort in overcoming adversity, they can emerge with more resilience rather than disheartenment. He discovered this during his research on fear arousal, where he saw the mediating effect that strong self-efficacy had on phobics, war veterans and hurricane survivors in overcoming incapacitating trauma.

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A second way in which Bandura suggests we can shape our efficacy beliefs is through second-hand experiences provided by social role models. When we see people similar to ourselves accomplish goals, we can foster our own beliefs that we too have it in us to master similar challenges. With this in mind, we can see others’ achievements not as unattainable comparisons, but as an inspirational framework to guide our own aspirations and plans of action we set ourselves. So, instead of becoming envious and measuring our success through triumphs over others, we can do so through focusing on our own self-improvement and sharing encouragement.

Finally, because our self-efficacy can vary as a function of our physical and mental state, it can be difficult to approach a task that arouses a sense of debility or anxiety. Some people experience a nervous state as an added driving force to their motivation, whereas others view it as a sign to remove themselves from the situation as quickly as possible. This can be a particularly tough thought pattern to eradicate in the moment, but through a structured process of identifying, eliminating and replacing maladaptive or irrational thoughts and behaviours (such as through cognitive behavioural therapy), we can transform what holds us back into a force that pushes us forward. For example, we can break down large challenges into smaller, more manageable steps.

Demetri-Martin_tumblr_lo9k5j8SE31qhtggqo1_500.jpgBandura offers some extremely useful suggestions for how we can manage our own levels of self-efficacy – a skill that can motivate us to change ineffective attitudes and behaviours that might be holding us back. However, these are not limited to themselves – there are a range of other methods to be explored if these do not fit for you or every aspect of life. If you have any ideas or have had personal experience trying the above strategies or any others, please comment or message me with your thoughts and suggestions.

 

WORKS CITED

Bandura, A. (1994). Self‐efficacy. John Wiley & Sons, Inc..

Bandura, A., & Adams, N. E. (1977). Analysis of self-efficacy theory of behavioral change. Cognitive therapy and research, 1(4), 287-310.

Bandura, A. (2005). The primacy of self‐regulation in health promotion. Applied Psychology, 54(2), 245-254.

Benight, C.C. & Bandura, A. (2004). Social cognitive theory of post-traumatic recovery: The role of perceived self-efficacy. Behaviour Research and Therapy, 42 (10), 1129–1148

Reactions to illness stigma: living with others judgement

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At Brighton Wellness Centre, we are well aware of the mental health stigma that pervades our society. Even in 2016, with the many pioneering organisations and charities helping those with mental illness, with the rise of good medications that work (such as anti depressants and mood stabilisers) and an awareness of psychotherapy, there is still stigma. People can react negatively, be harsh or not understanding because they do not understand the complexity that is mental ill health and the effects it has on the brain and behaviour.

Common stigmatised reactions may include language such as ‘You aren’t crazy, why do you need to take those pills?’, ‘You should be locked up’,’You are behaving so bipolar‘, ‘Depression means you are weak’ and so on. Mental illness is still sadly associated by some (who have no experience of it) with Doctors white coats, straight jackets, life long hospital stays and never making a full, complete recovery. This is completely ridiculous, however it will take generations to change these attitudes, although we are beginning to turn the tide!

While these perceptions of mental illness may have been the case 60 or more years ago, today the mental health world in the UK and other Western countries has moved on. Since the 1950s, the rise of medications that worked to help illnesses such as bipolar disorder, schizophrenia, psychosis, depressive/anxiety disorders, eating disorders etc have improved drastically. With the rise of SSRI medications- that work on the brain as anti depressants as well as newly developed anti psychotic medications, mental illness sufferers are able, in most cases, to return to their normal lives. This coupled with psychotherapy can truly change lives. The policy also of recovery is a great shift from the past. Psychiatrists, psychologists and psychotherapists don’t just aim to manage symptoms – they aim to set you on the path to recovery.

The feeling of judgement and of someone thinking you are ‘crazy’ is awful, sad and terrifying. For every person that understands and supports, you may get those who can’t and won’t understand you. You can lose friends or loved ones due to this- which is appalling. Support networks are badly needed for those with an illness in particular. So, don’t be stigmatised to those with an illness. Help and love your friend and loved one, give to them, provide a listening ear and a hug.

As someone with experience of mental health, I would say there is still a long way to go in terms of stigma. I talk about and blog about my experiences, raise money for mental health charities and have just started reaching a wider audience. However, I still feel I cannot fully disclose my illness under my real name. This is due to the fact that it is still not hugely understood in society, so to be associated with it could be upsetting. Yet, I hope that within a decade or two, this will change. I blog to change attitudes and highlight awareness which is badly needed.

This is why I support Jessica Valentine at Brighton Wellness Centre. She focuses particularly on womens wellness and provides a therapeutic setting and a listening ear to all her clients. Psychotherapy of any kind is truly beneficial in helping you manage symptoms and difficult emotions. By taking the step to going to psychotherapy, you are battling stigma as well as helping yourself move forward.  Remember, there is nothing wrong or weak in talking to a therapist (whatever you may have been told)- in fact you are being incredibly strong for seeking help and reaching out. Hopefully, any therapy you undergo will also help you to change your life for the better.  Reach out today.

The Importance of talking through therapy or support networks.

When dealing with mental health issues of any kind, it is so important to talk it through with a recognised professional and/or your support network. Talking through difficult and painful emotions (of depression, anxiety for example), with someone you trust is vital for mental wellbeing and balance.

If you are lucky to have a good, stable support network- utilise it. Your friends and/or family are so important at promoting happiness and keeping you well, if they in turn are a calming, stable influence on you. Positive support promotes wellness in all of us.

Whether its one friend, a family member or an extended support network on or offline, talking to those you love and who care for you is vital. If you need further support there are health charities like the Samaritans– who are always on hand to listen on their helpline. Mind charity are also a brilliant support and resource and check out Rethink Mental Illness. All promote a non stigmatised view of mental illness and a listening ear.

Don’t suffer in silence- Tell someone you trust how bad you are feeling. Share your thoughts with a professional who can help you unpack the difficult emotions you are feeling.This is so important too if you are considering psychotherapy. There are various therapies that we offer at the Brighton Wellness Centre that can really help. Whether its one to one talking therapy, CBT (cognitive behavioural therapy to help change behaviour patterns) or in depth psychoanalysis there is something to help you and everyone struggling with mental health issues.

It doesn’t matter what issue, disorder or behaviour pattern you need help with, there will be a therapy to help you back to wellness!  We particularly specialise in womens wellbeing and are here to assist you with any concerns you have.

To contact us further, email Jessica or call her via this website.

Why do I have social phobia? Can social phobia be treated?

Social Phobia – Theories of Causation and Treatment options

Social Phobia is classified as an intense fear or feeling of anxiety over social situations and is surprisingly common in the general population although rarely reported unless severe.

One of the most influential explanations of the onset of social anxiety disorder is the cognitive model. The main theory, presented by Clark and Wells (1995), involves the manifestation of faulty cognitions in the individual during social situations that possess them to believe that they are in danger of being seen as inept, boring or stupid, which could lead to people disliking them or ignoring them. The model begins with the social situation which activates the assumptions of perceived social danger, and in turn, the processing of the self as a social object. These cognitive processes can lead to behavioural symptoms, for example the patients’ avoidance behaviour, or somatic and cognitive symptoms, such as the intrusive thoughts of what others may think. The theory proposes that people don’t initially possess the symptoms of social anxiety disorder, they simply have to believe that they do, and their actions of avoidance help to reinforce these biases, which in effect helps them to manifest (Clark and Wells, 1995).

Early maladaptive schemas affect the way the individual thinks and processes situations, and have been shown to be more commonly present in those with social phobia particularly, in the sense of disconnection or rejection, but also including self-focused attention, anticipatory processing and post event processing (Calvete, Orue & Hankin, 2015; Hedman et al., 2013). Post-event ruminations are suggested to be one of the main cognitive bias in those suffering from social phobia (Penney & Abbott, 2015). It is suggested that socially anxious individuals negatively perceive themselves and the way they have previously behaved in a social situation which takes over their attentional resources causing them to negatively over evaluate (Chen, Rapee & Abbott, 2013). This in turn will influence avoidance of similar situations in the future (Rachman, Grüter-Andrew & Shafran, 2000). In addition, recently the idea of pre-event rumination has been offered, which involves the individual negatively anticipating an event with obsessive faulty thinking, which may influence them to avoid it before anything negative has actually happened. (Penny & Abbott, 2015).

Those with social anxiety disorder also appear to have attentional biases to threatening stimuli, which may account for why they find social situations particularly intimidating (Bantin et al., 2016). If all the focus is on the negative aspects of a situation, the individual will feel a heightened sense of fear. This has been shown in studies where attention is monitored, and individuals with social anxiety disorder pay more attention to relevant negative stimuli, for example threatening faces compared to neutral ones influencing a state of panic (Staugaard, 2010). There is also an overall feeling of low self efficacy, that is suggested to result from childhood relationships, for example peer rejection or overprotective parenting styles. This could potentially arise through acts of conditioning, for example observing others being embarrassed or humiliated in social situations. It has been suggested that because shyness has a negative stigma, this promotes social avoidance (Henderson, Gilbert & Zimbardo, 2014).

Genetics and biological processes are also proposed theories of the manifestation of social anxiety. Evidence has been suggested to support a biological explanation of social anxiety in terms of neuropeptides. Oxytocin is believed to be a peptide linked to social behaviour as it facilitates approach behaviours, and impacts on social bonding and trust, by linking the amygdala to socio-emotional areas of the cortex (Ziegler, 2015). It has been observed that those with social anxiety possess lower levels of oxytocin than controls (Ziegler, 2015), due to a variation in the CD38 gene that regulates its secretion (Tabak, 2015). A-allele carriers on the SNP rs3796863 appear to have higher levels of trait anxiety with particular vulnerabilities to developing social anxiety than the C-C allele (Tabak, 2015).

The function of this neuropeptide is to reduce excessive amygdala activation to threatening stimuli, therefore with a reduced amount, this repression is dampened, increasing the fear that those with social anxiety feel (Ziegler, 2015). In addition, there is also reduced functional communication between these areas of the brain during stress inducing situations, reducing the positive emotional effects that the peptide has on social behaviour (Cremers et al., 2015).

An additional biological perspective is associated with genetics and heritability. Data has shown that direct relatives of those with social phobia manifest higher rates of the same disorder than control patients do (Scaini, Belotti & Ogliari, 2014). For example, it has been found that the phobia is more likely to manifest in children when one or both of their parents suffer from the disorder also (Hughes et al., 2009).

Risk factors for social anxiety have been found to be highly hereditable (.66; Torvik et al., 2016; .65; Beatty et al., 2002), which appear to have higher impact in young people, suggesting that genetic risk factors have higher influence in those who develop social anxiety in their youth. (Scaini, Belotti & Ogliari, 2014).

It is suggested that the overall process is that genetic vulnerabilities make those more susceptible to environmental influences concerning the onset of social anxiety disorder (Scaini, Belotti & Ogliari, 2014), which integrates both explanations of the manifestation of the disorder. There have been significant gene environment interactions found in terms of stress (Tabak, 2015) or attachment types for example (Notzon et al., 2015), suggesting that this interplay between nature and nurture is a solid explanation for the onset of social anxiety disorder.

One of the most common form of treatment of social phobia is cognitive behavioural therapy (CBT; Albano, 1996; Barkowski et al., 2016; Goldin et al., 2016). Patients can attend between 8 to 12 sessions with a therapist in a one on one setting (NICE, 2013). The therapy involves forms of exposing patients to their feared situations with support (Spence, Donovan & Brechman‐Toussaint, 2000), and should aim to help the individual understand the irrationality of their fears. This individual therapy may also involve teaching different types of social skills, either verbal or non verbal. These may involve anything from keeping eye contact and retaining posture, to specific word use, voice, volume and tone, or easy conversation topics (Mesa, Le & Beidel, 2015). Methods of relaxation are also taught, to help diminish feelings of apprehension or the general physical arousal induces from social situations (King, Murphy & Heyne, 1997). What is described as ‘cognitive restructuring’ is another tactic used which aims to correct faulty cognitions within the patient. This works by getting the individual to analyse their own statements or social expectations to understand why they may be irrational, which may in turn aid in reshaping the maladaptive schemas (King, Murphy & Heyne, 1997).

Once someone appears to be making some form of improvement, cognitive behavioural group treatment may be suggested, to help ease them into a welcoming social situation with others who have the same feelings as themselves (Barkowski et al., 2016). This gentle ease may drastically help the treatment process. Sessions may include discussing various social skills techniques with others, and learning interaction techniques with each other. Group members may also find themselves being exposed to anxiety provoking situations in a structured and graded way, starting with minimal exposure which gradually increases once the phobic becomes at ease (Albano, 1996). The efficacy of group therapy for anxiety has been shown by Mychailyszyn, Brodman Read and Kendall (2012) who found that 64% of children who participated in the FRIENDS (a specialized form of CBGT for adolescents) programme no longer met clinical criteria for social phobia after treatment.

An emerging form of group therapy that may also be an option is mindfulness and acceptance based group therapy. In these therapy session mindfulness strategies are used to increase the feelings of acceptance of unwanted physical symptoms, for example trembling, or anxious thoughts, such as feelings of embarrassment. This in turn reduces the feeling of panic that a phobic will experience when they sense their face blushing or their hands shaking. There has been an effect size of 43% observed for the success of this treatment in those with social anxiety (Kocovski, 2013).

Trials have shown group therapies to have a positive effect on the reduction of symptoms in social anxiety, for example decreases in subtle avoidance behaviours, cognitive distortions and attention focusing and rumination (Goldin et al., 2016; Hedman et al., 2013). However, there do appear to be more issues with group therapy as opposed to individual therapy, for example, a group first needs to be formed before therapy can begin therefore potentially taking longer to initiate (Stangier, 2003). It has been suggested that overall individual therapy is more successful for those with social anxiety disorder, as a majority of patients find the group setting too intimidating to handle whilst still going through treatment, which could potentially worsen their feelings of fear (Stangier, 2003). More feelings of self-consciousness may be induced with feelings of scrutiny. In addition, individual therapy allows the therapist to form a more careful and personal assessment of the patient, in turn catering for a more effective treatment system (Stangier, 2003).

Both therapies have their advantages and disadvantages, however the right programme should be based on the patient’s individual progress and preference.

References

Albano, 1996. Treatment of social anxiety in adolescents. Cognitive and Behavioral Practice2(2), 271-298.

Bantin, T., Stevens, S., Gerlach, A. L., & Hermann, C. (2016). What does the facial dot-probe task tell us about attentional processes in social anxiety? A systematic review. Journal of behavior therapy and experimental psychiatry,50, 40-51.

Barkowski, S., Schwartze, D., Strauss, B., Burlingame, G. M., Barth, J., & Rosendahl, J.  (2016). Efficacy of group psychotherapy for social anxiety disorder: A meta-analysis of randomized-controlled trials. Journal of anxiety disorders39, 44-64.

Beatty, M. J., Heisel, A. D., Hall, A. E., Levine, T. R., & La France, B. H. (2002). What can we learn from the study of twins about genetic and environmental influences on interpersonal affiliation, aggressiveness, and social anxiety?: A meta-analytic study. Communication Monographs69(1), 1-18.

Calvete, E., Orue, I., & Hankin, B. L. (2015). A longitudinal test of the vulnerability-stress  model with early maladaptive schemas for depressive and social anxiety symptoms in adolescents. Journal of Psychopathology and Behavioral Assessment37(1), 85-99.

Chen, J., Rapee, R. M., & Abbott, M. J. (2013). Mediators of the relationship between social   anxiety and post-event rumination. Journal of anxiety disorders27(1), 1-8.

Cremers, H. R., Veer, I. M., Spinhoven, P., Rombouts, S. A. R. B., Yarkoni, T., Wager, T. D., & Roelofs, K. (2015). Altered cortical-amygdala coupling in social anxiety disorder during the anticipation of giving a public speech.Psychological medicine45(07), 1521-1529.

Goldin, P. R., Morrison, A., Jazaieri, H., Brozovich, F., Heimberg, R., & Gross, J. J. (2016). Group CBT Versus MBSR for Social Anxiety Disorder: A Randomized Controlled Trial.

Hedman, E., Mörtberg, E., Hesser, H., Clark, D. M., Lekander, M., Andersson, E., &

Ljótsson, B. (2013). Mediators in psychological treatment of social anxiety disorder: Individual cognitive therapy compared to cognitive behavioral group therapy. Behaviour  research and therapy51(10), 696-705.

Henderson, L., Gilbert, P., & Zimbardo, P. (2014). Shyness, social anxiety, and social    phobia. Social Anxiety: Clinical, Developmental, and Social Perspectives, 95.

Hughes, A. A., Furr, J. M., Sood, E. D., Barmish, A. J., & Kendall, P. C. (2009). Anxiety, mood, and substance use disorders in parents of children with anxiety disorders. Child psychiatry and human development40(3), 405-419.

King, N., Murphy, G. C., & Heyne, D. (1997). The nature and treatment of social phobia in youth. Counselling Psychology Quarterly10(4), 377-387.

Kocovski, N. L., Fleming, J. E., Hawley, L. L., Huta, V., & Antony, M. M. (2013). Mindfulness and acceptance-based group therapy versus traditional cognitive behavioral group therapy for social anxiety disorder: A randomized controlled trial. Behaviour research and therapy51(12), 889-898.

Mesa, F., Le, T. A., & Beidel, D. C. (2015). Social skill-based treatment for social anxiety disorder in adolescents. In Social Anxiety and Phobia in Adolescents (pp. 289-299). Springer International Publishing.

Mychailyszyn, M. P., Brodman, D. M., Read, K. L., & Kendall, P. C. (2012). Cognitive‐Behavioral School‐Based Interventions for Anxious and Depressed Youth: A Meta‐Analysis of Outcomes. Clinical Psychology: Science and Practice19(2), 129-153.

National Institute for Health and Clinical Excellence (NICE) (2013) Social Anxiety Disorder: recognition, assessment and treatment. [Online]. Available at: https://www.nice.org.uk/guidance/cg159.

Notzon, S., Domschke, K., Holitschke, K., Ziegler, C., Arolt, V., Pauli, P., … & Zwanzger, P. (2015). Attachment style and oxytocin receptor gene variation interact in influencing social anxiety. The World Journal of Biological Psychiatry, 1-8.

Penney, E. S., & Abbott, M. J. (2015). The impact of perceived standards on state anxiety, appraisal processes, and negative pre-and post-event rumination in Social Anxiety Disorder. Cognitive Therapy and Research,39(2), 162-177.

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