Social Phobia
Social phobia is a marked and persistent fear of negative evaluation. It is a grossly exaggerated version of the "jitters" many of us get when we perform or think about having to perform under public scrutiny: We worry about not dong well or getting so nervous that people begin to notice. We worry about humiliating or embarrassing ourselves. We worry about other people thinking poorly of us.

Signs and Symptoms
The qualities that distinguish social phobia from normal "jitters" are the duration and intensity of the fear. Unlike "stage fright" and other forms of performance anxiety, the fear with social phobia builds well in advance, continues into the performance, and sometimes persists afterward in anticipation of "next time". Furthermore, it is severe enough that it causes either significant interference with social and occupational functioning, or marked distress. In combination with other problems, it can even lead to increased risk of suicide.

Most of this interference and distress results from the direct and indirect effects of autonomic arousal on our behaviour. Among the more devastating direct effects are the observable signs of anxiety: sweating, twitching, blushing, stammering and dry mouth. Indirect effects of autonomic arousal are the ones that are arise from these observable signs: recognizing our anxiety is spiraling out of control, and worrying that everyone will notice.

Types of Social Anxiety
There appear to be at least two different types of social phobia. In its most narrowly defined form, called the discrete type, the feared situation is relatively circumscribed. The most commonly reported of these situations is public speaking or interacting at formal gatherings.

This is followed by talking one-on-one or in small groups at informal gatherings, and asserting oneself by saying "no" or asking someone to change.

Further down the list is being observed performing an activity such as eating, drinking or writing. Some have argued for including discomfort with using public washrooms or "bashful bladder" with these other activities, however there isn't consensus.

People with discrete social anxiety have the necessary skills to perform adequately in these social situations, but are prevented from doing so by their fear. They anticipate these situations by becoming anxious well in advance. Their symptoms of anxiety become a source of distraction, and they stop noticing or even misinterpret relevant social cues, resulting in temporary lapses in performance. They become further distracted by these lapses, and they begin to pay more attention to doing badly than to the social task at hand. For example, instead of listening to other people in a conversation and trying to think of a response, the person with social phobia is wondering if they will be nervous, if it will be noticed, and what the consequences of this will be.

The more broadly defined form of social phobia is called the generalized type. It involves the fear of most, if not all social situations, and is associated with social skills deficits. These are people who generally report being shy much of their lives, and having relatively limited social contact with other people. Their social difficulties appear to emerge as an ever expanding rift between their development and the development of social skills by their peers. They seem genuinely unaware of socially appropriate behaviour, resulting in a history of failures and disappointments.

Extent of the Problem
Social phobia exacts a heavy toll on the professional and private lives of people who all too often find themselves under-educated, under-employed and lonely. It stops people from interacting and forming relationships by evoking fear and/or avoidance at the prospect of human contact. It even stops them from seeking help or getting married. In fact, people with social phobia tend to avoid treatment longer, and get married less often than people with other anxiety disorders.

Social phobia afflicts approximately two percent of the general population at any particular point in time. It is the most prevalent anxiety disorder, and the third most prevalent psychiatric disorder overall. Its lifetime prevalence of 13.3% follows depression and alcohol dependence at 17.1% and 14.1%, respectively. With a typical age of onset either during the early grade school years or around puberty, it is also one of the earliest of the major psychiatric disorders.

Finally, there is some evidence to suggest that social phobia may contribute to the onset of other major psychiatric disorders such as mood disorders, substance abuse disorders and other anxiety disorders. Sadly, it is often one of these co-existing problems that will bring a person with social phobia in for treatment.

Cognitive Behavioural Therapy
The good news for people with social phobia who are able to seek help for their problem is that there are a myriad of treatment options available. The psychological treatment best supported by the research literature as a treatment for social phobia is cognitive behavioural therapy. Roughly 70% of people with social phobia are substantially improved with cognitive behavioural therapy, and treatment effects have been found to last for up to five years. Some of this improvement occurs post-treatment, suggesting that what is learned in treatment helps people to realize further gains after treatment has been completed.

Exposure
Cognitive behavioural therapy is actually a combination of therapies. Its active therapeutic ingredient is a behavioural technique based on systematic desensitization, called exposure. Exposure is a method of experiencing a feared social situation in a relatively controlled and manageable way.

It is done by rank ordering social situations, from most to least troublesome on a fear and avoidance hierarchy. Then the person is exposed to these situations in a progression from least to most.

FEAR AND AVOIDANCE HIERARCHY

This exposure is done two different ways in session. First the client imagines the social interaction as vividly and in as much detail as possible. This is followed by role playing the social interaction with a therapist or fellow client. Exposure is arguably the single most effective approach to treating many anxiety problems, including social phobia.

Cognitive Restructuring
The second therapeutic component of cognitive behavioural therapy is called cognitive restructuring. According to Beck and Emery, the way we process information is governed by structures called schemata. These schemata cause a person with social phobia to be anxious by explaining incoming information and memories in terms of social threat. Treatment consists of correcting faulty or illogical thinking by repeatedly confronting cognitive schemata with discrepant information from role-playing and homework assignments. The entire procedure is carried out in four steps.

Alone, cognitive restructuring probably doesn't work as well as exposure, and opinion is mixed about whether cognitive restructuring and exposure together work better than exposure alone. In studies where the combination has worked better than exposure alone, the difference has emerged on follow up. That is, people who receive the combined treatment tend to continue making therapeutic gains long after therapy has concluded.

Homework
The last but not least of the three therapeutic components is plain, old-fashioned homework. These homework assignments involve subjective anxiety ratings, and practice with both cognitive restructuring and exposure exercises. Exposure exercises done in actual social situations, are called in-vivo exposures. In-vivo exposures are important to ensure transfer of learning from sessions to the real world.

Sometimes the homework is done on a session-to-session basis, but other times more than the week interval between sessions is required in order for the client to obtain sufficient practice. For example, the self-exposure assignment may be to approach an acquaintance for a date. In these cases, homework is carried over two weeks or more.

Homework assignments are vital to the success of CBT. A clear relationship has been found between completion of homework and success of CBT for social phobia.

Sample Treatment Protocol
Jim is a fictional 25-year-old male with a fear of negative evaluation and rejection from females he would like to approach for a date. The therapeutic contract he negotiated with his therapist was to increase the number of opportunities for meeting women by joining a health club, taking a course, and by participating in some functions of a local singles' club. The three highest (i.e., most challenging) items on his fear and avoidance hierarchy were:

Initiate conversations with women he hasn't met before.

Initiate follow-up conversations with women he met previously.

Ask a woman to join him in a social outing.

Step 1: Elicit Automatic Thoughts
Automatic thoughts are habitual ways of thinking that drive emotions. The automatic thoughts of people with social phobia tend to contain cognitive distortions that make them afraid of certain social interactions. Jim collected his automatic thoughts on thought record forms given to him for homework. His assignment was to record his thoughts any time he experienced anxiety in a social situation.

I won't be able to talk.

She'll see my anxiety, and will think there is something wrong with me.

Step 2: Identify Underlying Irrational Beliefs
Examine the automatic thoughts for any cognitive distortions that may be present. These cognitive distortions usually occur as one of twelve unrealistic or irrational beliefs.

12 Cognitive Distortions

1.   Emotional reasoning

2.   Over generalization

3.   Arbitrary inference

4.   All-or-nothing (black and white) thinking

5.   Should statements

6.   Jumping to conclusions

(b) Mind-reading

7.   Selective negative focus

8.   Disqualifying the positive

9.   Magnification and minimization

10. Catastrophizing

11. Personalization

12. Labeling

These irrational beliefs are all based on flawed or faulty logic, and have the potential to cause negative mood states such as anxiety, depression or anger. Jim's irrational beliefs were:

Fortune telling

Mind reading

Step 3: Challenge the Irrational Beliefs
Once the irrational belief underlying an automatic thought has been identified, it is important to refute these beliefs by examining the evidence for them, and by looking for alternative explanations.

Step 4: Replace the Irrational Beliefs with Suitable Alternatives
Often the replacements for automatic thoughts become evident in the course of refuting the irrational beliefs on which they are based.

Automatic Thoughts
I won't be able to talk.
She'll see my anxiety, and will think there is something wrong with me.

Irrational Beliefs
Fortune telling
Mind reading

Rebuttal
I'm able to talk to men and women for whom I have no attraction.
What are the chances she will notice?
What are the other possible outcomes?
How else might she think?

Alternative Beliefs
I have been able to talk just fine in other situations.
Just because I'm nervous doesn't mean it shows.
If she does see my anxiety, it doesn't mean she'll think the worst about me.

The Group Treatment Option

Why Group?
Why consider doing cognitive behavioural therapy in a group?

There are several advantages to doing therapy in a group compared to doing it individually. First, there is a sense of universality clients get in group from realizing they are not alone in suffering from their problems. Second, the group provides opportunities for vicarious learning from witnessing other people solve similar problems. Third, the client's attendance in group for he first time is like a public declaration of their commitment to change. Other advantages particularly relevant to cognitive behavioural therapy are opportunities for role-play and assistance disputing irrational thoughts. Through role play, realistic yet controlled exposure situations can be tailored to the individual needs of each client. The goal in disputing irrational thoughts is to replace illogical and maladaptive thoughts with more positive and logical ones. Last but not least, although group cognitive behavioural therapy is in many cases as effective as individual therapy, its cost is roughly one third.

The Program
CBGT is a group treatment for social phobia developed by Richard Heimberg at the University of Albany's Centre for Stress and Anxiety Disorders. It is designed to take place in weekly, 2-hour sessions over a 12 week period, and makes use of cognitive restructuring and desensitization (exposure treatment) techniques. A highly structured approach is used to teach these techniques, beginning with an exploration of the link between clients' faulty self-talk or irrational thoughts about social situations, and their anxiety in those situations. Next, clients are given some tools for identifying and disputing their irrational thoughts, and replacing them with healthier ones.

Finally, clients are given imaginal, simulated and actual (real-life) exposures to feared social situations in a graduated progression of experiences known as a fear and avoidance hierarchy. The anxiety provoked by these experiences is countered with cognitive restructuring of the clients' faulty thinking, and an assortment of relaxation techniques. Desensitization is complete when clients' no longer experience significant anxiety when they encounter the feared social situations.

If you or someone you care about is suffering from social anxiety, and would like more information about cognitive behavioural treatment programs, call me at 881-1206. A complimentary, 20-minute consultation with Dr. Cook is available on request. You may also wish to participate in the National Anxiety Disorder Screening Day at Dr. Cook's Broadmead office year round.

What other people think is none of my business
- Ellen Degeneres

Recommended Reading
     Heimberg, R. G. (1991). A manual for conducting cognitive-behavioral group therapy for social phobia (2nd ed.). Unpublished manuscript, State University of New York at Albany.

     Heimberg, R. G., Liebowitz, M. R., Hope, D. A. and Schneier, F. R. (1995). Social phobia. New York: The Guilford Press.

     Roth, W. T. (1997). Treating anxiety disorders. San Francisco: Jossey-Bass Publishers.