Introduction to Social Anxiety: - PowerPoint Presentation

Introduction to Social Anxiety:Identification and Treatment Options 10 /11/18 Debra Hope, PhD

About This Series: Core Topics for Behavioral Health Providers BHECN's webinar series designed to educate behavioral health trainees and providers about practical topics in behavioral health Expert presenters provide a mixture of principles and case based application All webinars are free of charge

CID 39839October 11, 2018Target Audience:Providers and trainees from the following fields: Physicians, psychologists, advanced practice providers, nurse, licensed mental health therapists, and social workers.Educational Objectives:Discuss the various ways in which social anxiety presents in clinical settingsDescribe primary evidence-based interventions for social anxietyDiscuss culture-specific presentations and potential adaptations for specific cultures and sexual minorities Core Topics for Behavioral Health Providers Introduction to Social Anxiety: Identification and Treatment Options

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The University of Nebraska Medical Center, Center for Continuing Education is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The University of Nebraska Medical Center, Center for Continuing Education designates this live activity for a maximum of 1.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.The University of Nebraska Medical Center College of Nursing Continuing Nursing Education is accredited with distinction as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This activity is provided for 1.5 contact hour under ANCC criteria. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the American Nurses Credentialing Center’s Commission on Accreditation (ANCC) through the joint providership of the University of Nebraska Medical Center College of Nursing Continuing Nursing Education (UNMC CON CNE) (provider), University of Nebraska Medical Center, Center for Continuing Education (UNMC CCE), and Behavioral Health Education Center of Nebraska (BHECN). This program meets the criteria of an approved continuing education program for Licensed Mental Health Providers. This program meets the criteria of an approved continuing education program for Social Work. CREDIT

As a provider accredited by ACCME, the University of Nebraska Medical Center, Center for Continuing Education, the University of Nebraska Medical Center, College of Nursing Continuing Nursing Education, and the American Nurses Credentialing Center’s Commission on Accreditation must ensure balance, objectivity, independence, and scientific rigor in its educational activities. Faculty are encouraged to provide a balanced view of therapeutic options by utilizing either generic names or the trade names of several to ensure impartiality.All speakers, planning committee members and others in a position to control continuing medical education content participating in a University of Nebraska Medical Center, Center for Continuing Education, University of Nebraska Medical Center, College of Nursing Continuing Nursing Education, and American Nurses Credentialing Center’s Commission on Accreditation activity are required to disclose relationships with commercial interests. A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. Disclosure of these commitments and/or relationships is included in these course materials so that participants in the activity may formulate their own judgments in interpreting its content and evaluating its recommendations. This activity may include presentations in which faculty may discuss off-label and/or investigational use of pharmaceuticals or instruments not yet FDA-approved. Participants should note that the use of products outside currently FDA-approved labeling should be considered experimental and are advised to consult current prescribing information for FDA-approved indications. All materials are included with the permission of the authors. The opinions expressed are those of the authors and are not to be construed as those of the University of Nebraska Medical Center, Center for Continuing Education, University of Nebraska Medical Center, College of Nursing Continuing Nursing Education, or American Nurses Credentialing Center’s Commission on Accreditation. DISCLOSURE DECLARATION

Debra Hope PhDProfessorDepartment of PsychologyUniversity of Nebraska Lincoln Heidi Keeler, PhD, RN Assistant Professor College of Nursing-Omaha Division Director, Continuing Nursing Education Director, Office of Community Engagement University of Nebraska Medical Center Howard Liu, MD Associate Professor Department of Psychiatry Director, Behavioral Health Education Center of Nebraska University of Nebraska Medical Center Brenda Ram, CMP, CHCP Interim Director, Educational ProgramsCenter for Continuing EducationUniversity of Nebraska Medical Center FACULTY AND PLANNING COMMITTEE DISCLOSURES All faculty and planning committee members have no financial relationships to disclose.

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Inform Your Practice: An Evidence-Based Approach for Clients with Dual DiagnosisNovember1st 12-2pm Dr. McChargue of UNLNext webinar

Dr. Debra Hope Dr. Hope is the director of the Anxiety Disorders Clinic and the Rainbow Clinic, both specialty services within the Psychological Consultation Center.

Treatment of Social AnxietyDebra A. Hope, Ph.D.Aaron Douglas Professor of PsychologyDirector, Anxiety Disorders Clinic of the Psychological Consultation Center University of Nebraska-Lincoln Licensed Clinical Psychologist

Thank you

No commercial support is being provided for this continuing education activity

32 year old single African American man referred from substance abuse treatment centerSocial Anxiety Disorder, Substance Use (alcohol cannabis) (in partial remission)Past diagnosis of schizophrenia (possible due to self-described “paranoia”“I’ve wasted by life with drugs and jail.” - “Andrew”

At time he sought treatment with us on multiple medications, including antipsychoticsTwo inpatient hospitalizationsOn disability, unemployed, occasionally homelessWithdrew from high school, left jobs, failed substance abuse treatment due to social anxiety Andrew’s History

SituationsCasual conversations, talking to authority figures, interacting in groups, walking down the streetThoughts“I make others uncomfortable by being black.”“I’ll never fit in because I have wasted by life with drugs and jail.” Andrew’s Fears

ExposureSitting in a waiting roomConversation with someone on the busWalking around campusInterview for volunteer jobConversation with agency director at volunteer jobCore belief: “There is no use trying to change because I’ve wasted by life and can never be accepted by others.” Course of Treatment

Outcome Data for Andrew

Hierarchy Data for Andrew

Overview of clinical presentation of social anxiety disorder/social phobiaPrimary psychosocial treatment approachesBrief overview of evidence-based assessmentCore components of evidence-based treatmentCulturally-sensitive practice What we will cover

Fear of negative evaluation by othersHypervigilence for cues of social threatBiased information processingPhysiological arousalBehavioral disruption (sometimes)Behavioral avoidanceFear of positive evaluation Core Features b lue red green stupid embarrass

Formal Speaking and InteractionActing, performing, or giving a talk in front of an audienceSpeaking up at a meetingParticipating in small groups Job interviews Observation by Others Working while being observed Writing while being observed Eating or drinking in public places or with others Commonly Feared Situations

Informal Speaking and InteractionInitiating and maintaining conversationGoing to or giving a partyDating interactions - requesting or accepting a dateMeeting strangers Talking on the telephone Posting on social media Writing emails Commonly Feared Situations

AssertionAsking for favors or saying noAsking others to change their behaviorExpressing disagreement or disapproval Returning goods to a store Miscellaneous Situations Using public restrooms (usually men) Introducing self or shaking hands Entering situations where others are seated (room, bus, etc.) Going forward for communion at church Going to the hairdresser/barber Commonly Feared Situations

Continuum of Social Anxiety   u ----------------------------------- u ---------------------- u ------------------- u no social normal social social avoidant anxiety anxiety anxiety personality disorder disorder public generalized speaking social anxiety anxiety disorder

Lifetime prevalence = 13% in USThird most common after depression and alcoholism (4th if include specific phobia) If include public speaking fears that do not interfere with functioning, lifetime prevalence is about 22 %. Probably about twice as common in women (as with other anxiety disorders) but treatment-seeking samples tend to have more men Prevalence of Social Anxiety Disorder

50% report onset before age 12Treatment seeking samples report duration of social fears an average of 15-25 yearsTypically seek treatment about age 30 Age of Onset

Alcohol abuseDepressionLack of social support networkIncreased health care utilizationIncreased risk of suicidalityIncreased use of public assistanceComplications and Consequences

Diagnostic Interview & Differential DiagnosisPanic Disorder?Depression?Normal reaction to sexual prejudice for gay/lesbian/bisexual clients?Reaction to stigmatization for transgender and gender non-conforming clients. Assessment of Social Anxiety

LSAS Subscales with Standard Administration and “No one is judging you” Instructions ME Time Wilks ’ = .76 F (2,64) = 10.3, p < .001 Gender and Time x Gender ns and not shown

Self-Report Questionnaires*Liebowitz Social Anxiety Scale - Michael Liebowitz24 situations rated separately for fear and avoidance Separates interpersonal and performance situations Brief Fear of Negative Evaluation Scale – Mark Leary 12 items Specifically about evaluation concernsChange predicts long term outcomeSocial Interaction Anxiety Scale – Richard Mattick 20 itemsShorter versions are available*PDF available for free on the web Assessment of Social Anxiety

Steps for Behavioral AssessmentA. Set up role play of moderately-anxiety-provoking situation (3-5 minutes)B. Observe1. Overall anxiety noticeable?2. Any specific anxiety symptoms (e.g., hands shaking) noticeable? 3. Quality of performance despite anxiety? C. Check with client to determine how realistic role play felt D. Ask to list thoughts she/he had before/during/after role play Assessment of Social Anxiety: Checking for Social Skills Deficits

Social skills deficits - not knowing sending and receiving skills in social interactions.Safety behaviors – doing disruptive things to help manage anxietyAvoiding eye contactStick to safe topicsCarrying a safety object like water, phone, medicationMost people with social anxiety have few social skills deficits even though they believe they do. Skills Deficits vs. Safety Behaviors

Fear and Avoidance HierarchyIdeographic assessment of situations feared and/or avoided by the individualHelps guide treatmentConstruction of the FAH aids in case formulation by understanding the dimensions that make a situation more or less anxiety provoking for this individualAssessment of Social Anxiety

Brainstorm 8-10 situations that the client fears, considering dimensions that may make a situation easier or harder. - Gender, attractiveness, formality, etc.Begin to rank-order the situations, making sure to get a range of difficulty. Explain scale and have client rate situations on fear, and avoidance on 0-100 scales. Adjust rank-ordering based on fear if necessary . Steps to Constructing a Fear and Avoidance Hierarchy

Situation Fear Avoid #1 most difficult situation is Meeting ex-husband’s girlfriend at his high school reunion     100   100 #2 most difficult situation is Talking with a student’s parents when the student is failing     100   35 #3 most difficult situation is Speaking in front of the congregation at church     90     50 Top 3 items on Hierarchy Adapted Hope et al. 2012

Behavioral and Cognitive Behavioral InterventionsApplied relaxationSocial Skills TrainingExposure with and without cognitive restructuringPharmacological InterventionsMAOIsAnxiolyticsBeta-BlockersAntidepressants – paroxetine early approval Primary Treatment Strategies

Acceptance and Commitment Therapy (ACT)MindfulnessUse values to guide treatmentTransdiagnostic treatmentsUnified Protocol (Barlow)Transdiagnostic CBT (Norton)Technological innovationsTele mental healthVirtual Reality Video feedback Apps More Recent Treatment Innovations

Both CBT and pharmacotherapy are similarly efficacious in reducing social anxiety in acute treatmentCBT (and perhaps other psychosocial interventions) treatment gains maintain wellTherapeutic exposure is an important ingredient in CBTCBT is more cost effective Conclusions of Various Meta-analyses and Reviews

Psychoeducation- sharing the cognitive-behavioral modelInitial training in cognitive restructuringTherapist-assisted cognitive restructuring and exposures (role played and in vivo)  Client-directed cognitive restructuring and in vivo exposures  Relapse prevention and termination (or shift to other concerns) Heimberg’s Cognitive-Behavioral Approach: Gold-standard

Response Rates for CBGT, Phenelzine, Pill Placebo & ES (psychotherapy placebo) at 12 Weeks Adapted form Heimberg et al. A rchives of General Psychiatry 55: 1133-1141, 1998

Relapse for CBGT & Phenelzine in Maintenance and Untreated Follow-Up Adapted from Liebowitz, et al. Depression and Anxiety 10:89-98, 1999.

Socially anxious individuals overestimate the likelihood of negative outcomes in social situations.I am very likely to stumble over my words and be perceived poorly in this upcoming conversation.the cost of any negative outcomes. Being perceived poorly means being perceived as incompetent or mentally ill and I will be rejected and/or humiliated. What about social skills deficits? Mechanism of Change

CBT Strategies and Pointers

Taking off the amber colored glassesLike “rose colored glasses” only screen for danger.Process information differently in feared situations.Goal of therapy is to change information processing related to the self and the world to be more functional manner (more realistic ?) This will change overestimation of likelihood and cost of negative social outcomes. Goal of CBT for Social Anxiety

Exposure in session provides experiences that can be discussed, generates affect, gives an opportunity to practice new behavior and allows habituation of fear to occurHomework for in vivo exposure allows in session experience to translate to real-lifeKey Treatment Component is Therapeutic Exposure

Assessment, including fear and avoidance hierarchyNext introduce an anxiety management strategy, if you are going to use oneCognitive restructuringDiaphragmatic breathingRelaxation (takes more practice so start concurrently in earlier sessions)If no anxiety management strategy, make sure you have sufficient rapport before starting exposure What to do before exposure

1. Elicit (ATs) regarding social situations and identify emotions they cause.2. Categorize ATs by types of Thinking Errors present.3. Question and dispute assumptions underlying the Thinking Errors.4. Develop Rational Responses (RRs) to answer the questions from #3, thereby addressing the distorted aspects of the ATs. Building Cognitive Restructuring Skills - Overview

First goal is to identify ATs that occur before, during , and after anxiety-provoking situations and link to emotional experienceStrategiesIn session - identify as client describes situationIn session - walk through specific situationsHomework to record thoughtsStep 1: Identifying Thoughts and the Emotions They Cause

PerformanceI won’t know what to say.I’m no good at small talk.I’ll stumble over my words.AnxietyHe/she will see I’m anxious.I’ll blush or my hand will shakeLabelingThey will think I’m boring or mentally ill.I’ll look incompetent or stupid. Most Common ATs Reported in CBT (From Hope, et al., 2007

Basic Beckian classification of thinking errors (cognitive distortions) in thoughtsExamples:All or Nothing ThinkingMind ReadingFortune TellingDisqualifying the PositiveStep 2: Identifying Thinking Errors in ATs

Socratic questioning to try to think about ATs differently (not necessarily “correctly”)Examples:What is the worst that can happen? How bad is that?Is there any other explanation?Are you 100% sure that ___?What evidence do you have that ___? Step 3: Challenging the ATs

ATs about marginalization should not be challengedTranswoman expecting rejecting at a family reunion.Rather than challenging whether it will happen, address what it will mean and how the client can act safely and consistent with their values.It is not my fault if they are uncomfortable with my gender transition. I will be friendly and participate with those who treat me respectfully.Avoid conveying that you question their experience around their identity. Step 3: Challenging the ATs

Summarize result of Disputing Questions and answers with a summary statement that can be used in the situationExamplesI’m only responsible for 50% of the conversation.I don’t know for certain he/she will say no.Feeling anxious does not equal looking anxious.Step 4: Rational Response

Once client has some basic skills with the cognitive restructuring, he or she can begin to use it around situations (2-3 sessions).Do cognitive restructuring before entering a situationUse Rational Response in the situationDo cognitive restructuring after the situation to evaluate what happened and prepare for next time.Moving on to Exposure

Rationale for ExposurePatterns of Anxiety Response Client’s Belief Escapes/Avoids What really will happen Anxiety Time

Goal of exposure is to gradually face feared situations, staying long enough for anxiety to level off or decrease.Use cognitive restructuring to process the experience productivelyStart with easier situations, move to harder onesExposure

Advantages of In Session ExposureControllabilityTherapist can observeFewer consequences than real life situationsOpportunity to practice behaviors and using cognitive skillsDisadvantagesSometimes difficult to make realisticProps In Session Vs. In Vivo Exposure

ConversationsPublic speakingEating/Drinking/Writing in front of othersAssertivenessDatingSituations for In Session Exposure

Therapist as role-playerDistinguishing role-play from therapyOther role-playersAdvantage of group treatmentRole-players

Pre-exposure1. Set up the situation briefly: “Play a movie in your head.”2. Elicit ATs and identify affect. Write them down.3. Identify potential thinking errors present in the ATs and question their rationality.4. Develop one (or sometimes two) RR that rebuts the AT. Write it down for the client to read aloud during the exposure.5. Set appropriate goals: verifiable, realistic, pertinent (absence of anxiety is NOT acceptable) Exposure Procedures

During the exposure1. Stay in assigned roles (Do not allow the client to escape the anxiety-producing role. Adjust role-play behavior as needed to create “tolerable anxiety.”)2. Give anxiety ratings at approximately minute intervals, then have the client read RR aloud.3. Encourage client to use RRs when ATs occur.Exposure Procedures

Post-exposure1. Review goal attainment. Don’t disqualify the positive or let failure on aspects not related to the goals interfere with processing goal attainment.2. Review occurrence of ATs and usefulness of cognitive coping skills (RRs).3. Review pattern of anxiety ratings and relation to ATs, RR, and behavior.Exposure Procedures

Post Exposure continued...4. Were there other unanticipated ATs or spontaneous RRs?5. Summarize what was useful from this experience. What related homework would be helpful?Exposure Procedures

First Exposure - anxiety ratings of 40-50 and confident can successfully stageStay in situation until anxiety levels off or decreases to avoid reinforcing escapeMake as realistic as possible with props, rearrange furniture, etc.Carefully outline the situation and required behavior of role player(s)Eventually need to incorporate feared outcomes Explain to client will ask for anxiety ratings on 0-100 fear scale used in hierarchy construction. Considerations for Designing Exposures

Mirrors in-session exposureTypically slightly easier than in session exposure situationMake sure client agrees to do itMake sure client utilizes cognitive restructuring before, during, and afterBe sure to discuss in subsequent sessionHomework for In Vivo Exposure

Less anxiety-provoking to more anxiety-provoking situationsMore reliance on therapist for cognitive restructuring to more reliance on client for cognitive restructuringMore in-session exposures to more in vivo exposuresLess complex situations to more complex situationsMore reliance on therapist to pick exposure situations to more reliance on client to pick exposure situationsCognitive restructuring focuses on more superficial ATs and anxiety to core beliefs and other emotions (e.g., shame) Over Course of Treatment

Relapse PreventionReview Progress, re-rate Hierarchy, repeat other assessmentPressure from others to return to “old self”Set initial goal for one month post treatmentBooster sessionsEnding Treatment

Social anxiety is a common, often debilitating disorder.Cognitive-behavioral therapy is likely to be effective in reducing symptoms and improving quality of life.Good multicultural practices can be easily incorporated.Compared to medication, gains are more likely to be maintained (or increased) following cessation of treatment. Conclusion

AcknowledgementsRichard Heimberg . Cindy Turk