The Nappy Cat Chronicles

[This is a paper I wrote for my Abnormal Psychology graduate class. In it, I review the literature regarding cognitive-behavioral therapy (CBT) for social phobia. Social phobia, also known as Social Anxiety Disorder (which has the unfortunate acronym SAD), is a controversial diagnosis. A psychopharmacological treatment, which is often considered the "quick fix" solution by insurance groups, may do more harm than good. So what's left? CBT is the favored alternative. It is a long-term, expensive, and time-consuming treatment. As such, it works and what is invested during CBT makes the difference between feeling better and getting better.

P.S. This review is a bit dense. Proceed with caution.]

Cognitive-Behavioral Therapy for Social Phobic Individuals

“Among normals, the sequence perception-cognition-emotion is dictated largely by the demand character of the stimulus situation. . . [However] the paranoid patient may selectively abstract those aspects of his experience that are consistent with his preconceived idea of persecution, etc. He may make arbitrary judgments that have no factual basis. These are usually manifested by reading hidden significances and meanings into events. He also tends to overgeneralize isolated instances of intrusion, discrimination, etc.”

Aaron Beck (as cited in Minuchin, 1974)

Social phobia is considered by the American Psychiatric Association (2000) to be “a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others” (p. 456). Cognitive-behavioral therapy (CBT) is the most well-documented and well-researched treatment for this debilitating anxiety disorder (Rodebaugh, Holaway, Heimberg, 2004). CBT draws upon two distinct yet inherently coupled theories which produce two types of oft-combined treatments: exposure therapy (ET) and cognitive restructuring (CR). To clarify the terminology, ET refers to exposure treatments-without explicit cognitive interventions-such as imaginal, in virtuo, and in vivo desensitization, relaxation and social skills training, behavioral experiments, and homework assignments (Rodebaugh et al., 2004; Roy et al., 2003). Conversely, CR includes explicit cognitive interventions such as the reduction of self-focused attention, lowered standards of perfection for social performance, the development of positive expectations for social encounters, the development or adjustment of social skills, and the enhancement of overall feelings of self worth (Overholser, 2002).

ET is derived from the classical conditioning paradigm. When paired a sufficient number of times throughout a sufficient amount of time, a neutral stimulus and an unconditioned stimulus will evoke equivalent responsive behaviors separately (Foa, Franklin, & Moser, 2002). This allows for the reduction of the pathological anxiety response through extinction and habituation (Heimberg, 2002). Habituation is associated with a long-term and relatively permanent change in behavior (Leaton & Supple, 1991). According to Foa et al. (2002), there are two conditions that must be met in order for this change in anxiety to be accomplished. First, the individual must be objectively and subjectively experiencing the anxiety response. Second, the information present in the environment must be perceived to be in contrast to the individual’s existing unrealistic and selectively abstracted expectations.

In order for a situational expectation to develop, a previously experienced situation must be subjected to the cognitive processes of perception and reason. When it is formed, the expectation will mediate the thoughts that are had before and throughout any similar situation. This is why a non-threatening social encounter, when preceded by a history of perceived or actual threatening social encounters, may be perceived as threatening and produce anxiety.

This “threatening” perception is reinforced by a socially phobic individual’s tendency, first, to believe that they will behave in an inept and unacceptable manner that will produce unbearable consequences; second, to interpret the symptoms of anxiety as additional sources of danger and anxiety; third, to become preoccupied with their anxiety and negative cognitions within the encounter; fourth, to distort and exaggerate any social cues as being negative; and finally, to interpret these “negative” cues as further evidence of failure (Clark & Wells, 1995). Because of this cyclical process, Stopa & Clark (1993) assert that ET alone does not provide long-term benefits as it is unlikely to change the patient’s negative beliefs and self-defeating cognitions.

In a study conducted by Hoffman (2004), 90 social phobic individuals were assigned to a therapy group in which a modified version of Heimberg’s cognitive-behavioral group therapy (CBGT) was used, an exposure therapy group without explicit cognitive interventions (EGT), or a wait-list control group. The CBGT group was trained in cognitive restructuring and rational thought processing. The EGT group received in vivo exposures, didactic training, and weekly homework assignments. Twenty-one patients prematurely ended treatment. Patients in both group treatments showed significant improvement over the control group on the Social Cost Questionnaire (SCQ) and the Social Phobia and Anxiety Inventory (SPAI) that measure patients’ estimated social cost and symptom severity, respectively. Neither group treatment differed significantly from the other at post-test. However, at the 6-month follow-up, the CBGT group showed more improvement on SPAI than the EGT group.

Mattick and Peters (1988) found that a combination of CBGT and ET is superior to ET alone. In the study, 25 patients diagnosed with social phobia according to DSM-III guidelines were assigned to the combined group, while 26 patients received ET alone. Patients in the ET group were required to stay within repeated exposures until their avoidance desire had fully dissipated. Individualized lists of anxiety-invoking situations ordered from least to most feared were employed within the framework of guided exposure. Patients first engaged in those situations invoking only moderate anxiety and gradually ascended to extremely frightening situations. During each behavioral achievement test session, a therapist was present to conduct an assessment and offer support and praise.

The CBGT-ET group received ET in the same format but was required to use cognitive techniques during the exposures. Patients in the combined group received a combination of systematic rational restructuring and rational-emotive therapy and learned cognitive restructuring techniques which allowed them to assess their anxiety as the product of irrational anticipatory and in-situation processing. Pre- and post-treatments showed that the ability to complete behavioral achievement tests of all patients improved significantly. However, at the 3-month follow-up, only 17% of the ET group could complete 100% of the items listed in their fearful situations hierarchy, whereas 52% of the CBGT-ET could complete 100% of the items. Furthermore, 48% of ET group patients reported continued avoidance of feared situations whereas only 14% of CBGT-ET patients reported avoidance of feared situations.

In continuance of Mattick and Peters (1988), Mattick, Peters, and Clarke (1989) assigned 43 patients diagnosed with social phobia to one of four groups: ET, CR, CR-ET, and a wait-list control group. Results indicated that the ability of participants in the ET, CR, and CR-ET groups to complete behavioral achievement tests improved over time. All three groups improved significantly more than the waitlist control group. At the 3-month follow-up, the CR and CR-ET groups showed continual improvement whereas the gains that had been made by the ET group were reduced. The results of this study combined with the results of Mattick and Peters (1988) and Hoffman (2004) highlight the crucial impact of CBT and uphold the effectiveness of the CR-ET combination in treating individuals who suffer from social phobia.

In a review of five meta-analyses, Rodebaugh et al. (2004) found mixed results. When compared to the wait-list control groups at pre- and post-treatment, all CBT treatments of social phobia, which included ET, CR, CR-ET, and applied relaxation showed moderate to large effect sizes and continued improvement at follow-up. The meta-analyses were inconsistent in reported differences between the effect sizes of the ET and CR-ET treatments. Overall, the effect size of CR-ET was superior to the effect size of ET; however, the different did not reach statistical significance. Rodebaugh et al. concluded that CR and ET are so intrinsically related that both treatments heavily “borrow” from one another and, due to ethical concerns, should not be completely dichotomized for the purpose of a meta-analysis.