Transcript Information Processing Biases in Social Phobia

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
Safety
Behaviours
Processing of
Self as a Social
Object
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
35
30
25
20
High Socially
Anxious
Low Socially
Anxious
15
10
5
0
-5
-10
No Threat
Social Threat
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
80
70
60
50
40
30
20
10
0
Social Phobics
Non-Patients
Link between date of memory
and onset of social phobia
70
60
50
40
30
20
10
0
- 4 yrs
0nset
+ 4 yrs
+ 8 yrs
Wells, Clark, Salkovskis et al
(1995)
Do safety behaviours prevent cognitive
change?
Exposure with safety behaviours
VS
Exposure without safety behaviours
Improvement
50
45
40
35
30
25
20
15
10
5
0
Beliefs
Anxiety
Keep SB
Drop SB
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-Conscious
Image of self
- looking very strange
- twisted mouth and rigid
- feel different and apart
Safety Behaviours
Delay asking, take deep breaths
Speak quickly, mumble, hand over
mouth, rehearse what about
to say, check memory for what
I have just said
Anxious
uncomfortable,
sweaty palms,
stiff muscles,
mind goes blank,
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 behaviours
versus
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 or
discount 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 What did you do to test
think would happen? the prediction?
How would you
know?
(Rate belief 0-100%)
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 I am probably more
others; one of them
acceptable than I think:
showed interest and we
70%
talked: she seemed to
quite enjoy it.
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
Social Phobia Composite
(Clark, Ehlers et al, J. Consult. Clin. Psychol. 2003, 71, 1058-1067)
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
-1.4
PLA + SE
FLU + SE
CT
Pre
Post
3mth FU
1 Yr FU
Social Phobia Trial 2
Social Phobia Composite
(Clark, Ehlers et al. in press)
0.8
0.6
0.4
0.2
0
-0.2
-0.4
-0.6
-0.8
-1
-1.2
-1.4
-1.6
-1.8
-2
Wait
EXP + AR
CT
Pre
Post
One Year FU
Trial 3 (Mortberg, Clark et al. in press)
Stockholm
Social Phobia (LSAS)
75
70
65
CT
Grp CT
SSRI (TAU)
60
55
50
45
40
Pre
Post