After arriving early for his interview, David impressed the therapist as being calm and competent. He answered questions clearly and articulately. His voice did not quaver or shake, and he kept his hands neatly in his pockets. David made only occasional eye contact, but this made him seem distracted and aloof, rather than fearful. He was seeking treatment for social anxiety now, he explained, because he was on the verge of losing his job. An electrical engineer, David experienced intense and unrelenting anxiety about any interactions with his boss. When his boss stopped by his office unexpectedly, David experienced full-symptom panic attacks and could not give more than 1- or 2-word answers. He avoided almost all other contact with his boss, worrying that he would find fault with David's work. When asked if this ever happened in other situations, David confessed that he was up most of the night before the meeting with the therapist, worrying that the therapist might be critical of him and tell him he did not belong in the study.
One of the challenges to improving recognition for the millions of Americans with social anxiety disorder (SAD) is that its presentation is so varied. Many people with SAD keep the extent of their distress secret, even from family members. While SAD may cause observable signs of anxiety and social awkwardness in some, many others, like David, suffer silently. Social avoidance may be misinterpreted by others as lack of motivation, disinterest, or even arrogance.
Like most individuals with SAD, David's symptoms began when he was a teenager.1 He was paralyzed by fear at the thought of talking to his teachers. David began experiencing difficulties in high school. His grades suffered because he would never volunteer to speak in class and never clarified information with the teacher. He also avoided handing in some assignments for fear of criticism. Impairment, such as David now experiences at work, is typical of SAD.2
For many people with SAD, fear may be focused on only 1 or a few types of social situations. David's fear is of authority figures, but the most common fear is public speaking. Most individuals who seek treatment for SAD have excessive fear of most social situations, a condition known as generalized SAD.3
The past 2 decades have seen an explosion in research on focused, time-limited psychotherapy treatments for SAD.4 This research has focused primarily on behavioral and cognitive therapy or, most commonly, a combined cognitive-behavioral approach.4 For simplicity's sake, we will refer to all of these treatments as cognitive-behavioral therapy (CBT), even though some are primarily behavioral, some are primarily cognitive, and others are a balanced integration of the 2 approaches (Table 1).5
Common behavior and cognitive
approaches for treating patients with SAD
|Target||Presumed mode(s) of action||Key techniques|
|Exposure (graduated)||(Learned) fear response;avoidant behavior||Habituation-extinction; new compensatory learning||
In-session exposure, role-play, homework, systematic repetition sufficient duration for habituation/
Distorted processing of social information; maladaptive beliefs
Modification of thoughts that maintain anxiety
|Identify anxious thoughts using diary, test patient’s validity through discussion in therapy and behavioral experiments, practice realistic thoughts|
|Social skills training||
Underdeveloped social skills
Skill acquisition; rehabilitation
|Relaxation used with exposure)||
Internal feelings of anxiety
reduce internal anxiety response
Progressive muscle relaxation
Internal sensations that trigger increased anxiety
Exposure exercises that systematically induce internal sensations
|SAD, social anxiety disorder.|
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