social anxiety and it’s treatment david m clark institute of psychiatry, kings college london
TRANSCRIPT
Social Anxiety and It’s Treatment
David M Clark
Institute of Psychiatry, Kings College London
Anxiety and Anxiety Disorders
• Anxiety is a survival mechanism• Motivator and sometimes life saver with real
dangers• Problematic when danger is imagined• Anxiety Disorder diagnosed when anxiety is
out of proportion to the danger, is persistent, and disabling. One year prevalence: 17%
Cost $42 billion per year (US, 1990s).
Social Phobia(Social Anxiety Disorder)
• Most common anxiety disorder (12 % prevalence)
• Persistent fear of social or performance situations. Individual fears he/she will act in a way which will be humiliating or embarrassing.
• Fear recognised as excessive or unreasonable
• Feared situations are avoided or endured with intense distress
Characteristics and Consequences
• Typically childhood onset (median 13 yrs).
• Low natural recovery rate (Bruce et al 2005: 37% over 12 years).
• Increased risk of suicide, alcohol & drug abuse, depression, other anxiety disorders.
• Marked under-achievement• Low treatment seeking rates
Typical Thoughts
What I say sounds stupid
I’m boring
I will make a fool of myself
They don’t like me
They’ll see I’m anxious
I won’t have anything to say
I’ll blush/shake/lose control
Existing Treatments
Medication• MAOI (phenelzine) • SSRIs (paroxetine, sertraline, fluvoxamine,
fluoxetine) (effective in short-term but problematic relapse )Psychological• Exposure therapy• Group cognitive-behavior therapy(effective in short-term & gains well-maintained )BUT less than 50% recover.
Clark & Wells (1995)SOCIAL PHOBIA PERSISTS DUE TO:
• shift to internal focus of attention
• use of internal information to infer how one appears to others
• safety behaviors
Social Situation
Activates assumptions
Perceived social danger
Processing of Self as a
Social ObjectSafety Behaviours
Somatic & cognitive symptoms
Mansell, Clark & Ehlers (2003)
Do high socially anxious individuals have an internal attentional bias?
High vs Low Socially Anxious Students
Detect external and internal probes
Threat vs No Threat
Source: Behaviour Research & Therapy, 41, 555-572.
External vs Internal Focus of Attention
-10
-5
0
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35
No Threat Social Threat
High SociallyAnxious
Low SociallyAnxious
Hackmann, Surawy & Clark (1998)
Do patients with social phobia experience negative, observer perspective images when anxious in social situations?
Structured interview.
Frequency, content & perspective of spontaneous imagery
% Negative, distorted, observer perspective images
0
10
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70
80
Social Phobics
Non-Patients
Link between date of memory and onset of social phobia
0
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70
- 4 yrs 0nset + 4 yrs + 8 yrs
Wells, Clark, Salkovskis et al (1995)
Do safety behaviours prevent cognitive change?
Exposure with safety behavioursVS
Exposure without safety behaviours
Improvement
05
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Keep SB Drop SB
BeliefsAnxiety
New Cognitive Treatment
• Derive idiosyncratic version of model• Self-focussed attention/safety behaviours
experiment• Video feedback• Shift attention to social situation• Behavioural Experiments• Construct veridical image of social self
“I’ll sound stupid”
Self-ConsciousImage of self
- looking very strange- twisted mouth and rigid- feel different and apart
Safety Behaviours AnxiousDelay asking, take deep breaths uncomfortable,Speak quickly, mumble, hand over sweaty palms,mouth, rehearse what about stiff muscles,to say, check memory for what mind goes blank,I have just said
New Cognitive Treatment
• Derive idiosyncratic model• Self-focussed attention/safety behaviours
experiment• Video feedback• Shift attention to social situation• Behavioural Experiments• Construct veridical image of social self
Attention and Safety Behaviours Experiment
• Difficult social interaction (twice)
Focus on self & safety behavioursversus
Focus externally & no safety behaviours
• Compare subjective anxiety, catastrophes, performance
Video and Audio Feedback
• shows true observable self
• but can continue to process internal information ordiscount accuracy of image
• therefore run “mental” video first and operationalise conspicuousness of negative behaviours
• can help patient drop safety behaviours by showing they are more observable than feared symptoms
New Cognitive Treatment
• Derive idiosyncratic model• Self-focussed attention/safety behaviors
experiment• Video feedback• Shift attention to social situation• Behavioral Experiments• Construct veridical image of social self
SITUATION PREDICTION EXPERIMENT
What exactly did you think would happen? How would you know?
(Rate belief 0-100%)
What did you do to test the prediction?
Coffee break.
Sitting with other
teachers. Trying to
join in the conversation
If I just say things
That come into my mind they’ll think I’m stupid.
50%
Say whatever comes into my mind and watch them like a hawk. Don’t focus on myself. This only gives me misleading information and means I can’t see them.
OUTCOME WHAT I LEARNED
What actually happened?
Was the prediction correct?
Balanced view
(Rate belief 0-100%)?
How likely is what you predicted to happen in future (Rate 0-100%)?
I did it and I watched the others; one of them showed interest and we talked: she seemed to quite enjoy it.
I am probably more acceptable than I think:
70%
Interrogating the Social Environment
1. Behave in “unacceptable” fashion and observe others’ response (WIDEN BANDWIDTH)
- pause in speech, umms and ahs- damp armpits- shake/spill drink- wear blusher- disagree/express opinion- ignore acquaintance
2. Conduct surveys
3. Articulate and discount imaginary critic
Social Phobia Trial 1(Clark, Ehlers et al, J. Consult. Clin. Psychol. 2003, 71, 1058-1067)
-1.4-1.2
-1-0.8-0.6-0.4-0.2
00.20.40.60.8
Pre Post 3mth FU 1 Yr FU
Social Phobia Composite
PLA + SEFLU + SECT
Social Phobia Trial 2 (Clark, Ehlers et al. in press)
-2-1.8-1.6-1.4-1.2
-1-0.8-0.6-0.4-0.2
00.20.40.60.8
Pre Post One Year FU
Social Phobia Composite
WaitEXP + ARCT
Trial 3 (Mortberg, Clark et al. in press)Stockholm
40
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Pre Post
Social Phobia (LSAS)
CTGrp CTSSRI (TAU)