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 Practice, 2(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 disorders, 39, 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 Monographs, 69(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 Assessment, 37(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 disorders, 27(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 medicine, 45(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 therapy, 51(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 development, 40(3), 405-419.
King, N., Murphy, G. C., & Heyne, D. (1997). The nature and treatment of social phobia in youth. Counselling Psychology Quarterly, 10(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 therapy, 51(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 Practice, 19(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.
Rachman, S., Grüter-Andrew, J., & Shafran, R. (2000). Post-event processing in social anxiety. Behaviour Research and Therapy, 38(6), 611-617.
Scaini, S., Belotti, R., & Ogliari, A. (2014). Genetic and environmental contributions to social anxiety across different ages: A meta-analytic approach to twin data. Journal of anxiety disorders, 28(7), 650-656.
Spence, S. H., Donovan, C., & Brechman‐Toussaint, M. (2000). The treatment of childhood social phobia: The effectiveness of a social skills training‐based, cognitive‐behavioural intervention, with and without parental involvement. Journal of Child Psychology and Psychiatry, 41(6), 713-726.
Stangier, U., Heidenreich, T., Peitz, M., Lauterbach, W., & Clark, D. M. (2003). Cognitive therapy for social phobia: individual versus group treatment. Behaviour Research and Therapy, 41(9), 991-1007.
Staugaard, S. R. (2010). Threatening faces and social anxiety: a literature review. Clinical psychology review, 30(6), 669-690.
Tabak, B. A., Vrshek-Schallhorn, S., Zinbarg, R. E., Prenoveau, J. M., Mineka, S., Redei, E. E., … & Craske, M. G. (2015). Interaction of CD38 Variant and Chronic Interpersonal Stress Prospectively Predicts Social Anxiety and Depression Symptoms Over 6 Years. Clinical Psychological Science, 2167702615577470.
Torvik, F. A., Welander-Vatn, A., Ystrom, E., Knudsen, G. P., Czajkowski, N., Kendler, K. S., & Reichborn-Kjennerud, T. (2016). Longitudinal associations between social anxiety disorder and avoidant personality disorder: A twin study. Journal of abnormal psychology, 125(1), 114.
Ziegler, C., Dannlowski, U., Bräuer, D., Stevens, S., Laeger, I., Wittmann, H., … & Lesch, K. P. (2015). Oxytocin receptor gene methylation: converging multilevel evidence for a role in social anxiety. Neuropsychopharmacology,40(6), 1528-1538.
Bandura 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.
