Lata McGinn Addresses NJ-ACT on Social Anxiety Disorder
By Lynn Mollick
On September 18, Lata McGinn, Ph.D. addressed 72 NJ-ACT members about “Comprehensive CBT for Social Anxiety Disorder.”
Dr. McGinn began by describing Social Anxiety Disorder (SAD). Its essence is fear of showing symptoms of anxiety and being negatively evaluated. SAD is more intense than normal social anxiety and causes significant social and vocational impairment.
SAD usually begins in childhood or adolescence. It often precedes and then co-exists with other disorders such as depression, alcohol abuse, anxiety and personality disorders.
As always, get specifics about thoughts, feelings, schemas, and behaviors. Find out when, where, and with whom these occur.
Thorough assessment should produce both a hierarchy of feared and avoided situations and a chain analysis of the internal and external events, including the antecedents and consequences of problem behaviors. Use the hierarchy for exposure. Use chain analysis for cognitive interventions.
Psychoeducation creates the patient’s “buy in” for CBT by describing the cognitive behavioral model of SAD.
Dr. McGinn tries to de-stigmatize the problem by explaining that before humans became civilized, anxiety protected us from predators. However, in modern life, the dangers people face are psychological, not physical, and too much anxiety is not adaptive.
3. Relaxation Training
Although some empirically supported treatments do not include relaxation training for SAD, Dr. McGinn recommended beginning treatment with an intervention that reduces anxiety. SAD patients suffer great distress because they are hyper-aroused, and learning to relax provides relief.
Dr. McGinn suggested both deep muscle relaxation and breath control training. Mindfulness-based Stress Reduction and aerobic exercise are newer forms of relaxation training that hold promise for SAD.
Patients should eventually learn to reduce arousal during daily activities by focusing on a specific cue, usually the breath. This strategy helps patients approach, rather than avoid, stressful situations so that they eventually learn that they can cope effectively.
Initially, relaxation procedures may help SAD patients approach social situations they would otherwise avoid. But eventually, SAD patients should approach social situations without this safety behavior.
SAD patients should never require feeling relaxed in order to engage in social situations.
4. Dysfunctional Thinking in SAD
SAD patients exhibit cognitive biases about themselves, others, and social events. These beliefs must be targeted.
Regarding the self. They have unrealistic standards for themselves including negative beliefs about their desirability, their value, and their social competence. They discount their achievements and their positive attributes, and they view people hierarchically, ranking themselves below others.
SAD patients focus excessively on themselves, causing them to miss social cues and feedback. They magnify their errors. They underestimate their ability to tolerate anxiety and cope with negative outcomes. They are excessively sensitive to rejection.
Regarding other people. They overestimate how much others pay attention to them. They also overestimate the likelihood of negative outcomes such as criticism or rejection. They erroneously believe that others judge them harshly.
Regarding social events. They view social events as overwhelming and dangerous. They do not view social events as fun or even as benign. If a situation is ambiguous, they interpret it negatively. They do not notice or they discount positive feedback. Common dysfunctional thoughts in SAD include:
“Everyone can see that I am nervous.”
“He thinks that I am incompetent (or stupid, or ugly).”
“I won’t know what to say and I will look foolish.”
“I know I will sweat/blush/stammer.”
“If I don’t know the answer, everyone will laugh and I will feel humiliated.”
5. Cognitive Therapy
Dr. McGinn emphasized the importance of developing a complete chain analysis before doing cognitive therapy. Patients should identify every automatic thought and feeling that accompanies a specific social interaction. After making a complete list of the patient’s automatic thoughts, arrange them in the order they occurred and rate how strongly the patient believes them. Then identify feelings associated with each thought. Usually there are more than one.
Because SAD is complex, Socratic questioning and guided discovery are essential therapeutic techniques for developing comprehensive chains.
Once assessment is complete, intervene on every thought in the chain. Possible questions to help patients restructure their automatic thoughts include:
“Is there another way to view this situation?“
“What’s the evidence that my view of this situation is correct?”
“What objective information do I have?”
“How would someone else see it?”
“Am I overestimating the threat?”
“What’s the worst that can happen?”
“If the worst occurs, can I cope?”
“What’s happened in the past in similar situations?”
Dr. McGinn emphasized that you want to encourage patients to focus on their successes so that they learn that they can function effectively even if they are anxious.
Behavioral experiments designed to test assumptions uncovered in the chain analysis are a useful technique for correcting dysfunctional cognitions.
6. Skill Training
Before undertaking exposure, address social skills. Some SAD patients have social skills deficits; and others do not. Anxiety often prevents SAD patients from using their social skills. Dr. McGinn outlined a 4-step approach to teaching social skills:
1. Teach patients to initiate and terminate social interactions. What are the nuances of when, where and why?
2. Explain verbal and non-verbal mechanics of social interaction to enhance existing social. Each patient will have unique difficulties.
3. Teach public speaking skills. How do you construct a well-organized speech? Learn to deliver it well.
4. Help patients become more flexible. Prepare them for situations that don’t go according to plan. Provide corrective feedback. (Videotapes are useful.) And always provide positive feedback.
5. “Second Life.” Some evidence suggests that “Second Life,” a free online virtual reality game, helps SAD patients by providing a forum where they can rehearse new social skills.
7. Exposure and Response Prevention
As in other forms of CBT for anxiety disorders, confronting feared situations (exposure) is an integral part of treatment for SAD. Ask SAD patients to approach situations on their hierarchy of feared and avoided situations.
Safety behaviors are activities that temporarily reduce anxiety but strengthen dysfunctional beliefs because they prevent patients’ learning they can tolerate and function with anxiety. Safety behaviors – e.g. holding a hand in a pocket to hide trembling, or glancing away too often – may initially be permitted during exposure, but eventually should be faded out completely.
Focusing on the costs of SAD enhances motivation and eventual treatment success. Imaginal, in vivo, and interoceptive exposure are all useful for treating SAD. However, in vivo exposure can present difficulties because the duration and intensity of anxiety and the eventual outcome of the situation cannot be predicted. Patients may misinterpret in vivo exposure as a failure.
Simulated exposure, i.e. staged social interactions, provide an acceptable alternative. Remember that exposure must be repeated frequently. Perform exposure in different situations and eventually abandon the hierarchy.
Anxiety reduction during exposure is not essential as long as cognitions improve. Always check to be certain patients’ dysfunctional beliefs are disconfirmed. (They aren’t necessarily.) Adding cognitive restructuring to exposure is helpful. Here are some potential homework assignments:
1. Joining ongoing conversations
2. Giving and receiving compliments
3. Making mistakes in public
4. Revealing personal information, especially inadequacies and mistakes
5. Expressing opinions
6. Intentionally stammering
7. Drawing attention to themselves, e.g. by leaving the bathroom with toilet paper attached to their clothing.
Patients must learn that they will survive becoming anxious in public and that even when the worst occurs, it’s seldom as bad as they expected.
8. Attention Re-focusing
SAD patients focus on themselves instead of on the social situation. This impairs their behavior and increases the chances that they will be negatively evaluated. It also prevents their noticing positive outcomes that occur.
Attention re-focusing strategies derived from treatment of ADHD are a promising technique to help SAD patients attend to the social task at hand instead of self-concerns and (mis)perceived negative evaluations by others.
1. Teach patients to sustain attention for increasing periods of time. Read or meditate for increasing periods of time. Then practice in situations with increasing amounts of distractions. Begin with distractions that are not social, and then move on to practice sustaining attention in social situations. When attention is lost, simply return attention to the task at hand instead of engaging in self-criticism.
2. Practice attention strengthening in increasingly complex social situations. Teach patients to refocus on other people without becoming self-critical if their attention wanders.
Many SAD patients take SSRI’s. If they want to stop taking them, Dr. McGinn recommended withdrawing medication before exposure.
Preliminary research suggests that an antibiotic called d-cycloserine may be helpful for SAD by improving memory for what was learned during exposure.