November 14, 2023

Dear Colleagues,

The National Social Anxiety Center (NSAC) provides information about relevant and current research in service of disseminating and promoting evidence-based treatment. This month’s summary is written by Annika Okamoto, PhD, A-CBT, representing NSAC Santa Barbara, and examines the 2023 article by Wolitzky-Taylor & LeBeau: Recent advances in the understanding and psychological treatment of social anxiety disorder.

The Wolitzky-Taylor and LeBeau’s article provides an overview of the current understanding and psychological treatment of social anxiety disorder (SAD). Key takeaways for clinicians include:

How is SAD best treated?

  • The gold standard psychotherapy continues to be CBT in individual or group settings, but comparison studies of ACT and CBT show that they have comparable effects.
  • Pharmacological interventions, particularly SSRIs, may also be helpful.

What other factors that coincide with SAD could be addressed in therapy to improve outcomes?

  • Prior social trauma that involves humiliation and rejection,
  • Envy (individuals with social anxiety experience higher levels of envy that predicts anxiety),
  • Uncontrollable thoughts, rumination and perseverative cognition,
  • Inattention and being more likely to feel distracted,
  • Difficulties with inferring others’ emotional states and feelings, but not beliefs and intentions,
  • Deriving less pleasure from social interactions (but still more than from nonsocial situations),
  • Poor recall of positive social outcomes,
  • Behavioral avoidance and safety behaviors,
  • Intolerance of uncertainty and
  • Delays in shifting attention away from social threats.

What do we know about SAD and other disorders?

  • SAD contributes to worse educational performance across one’s life span.
  • Later onset is associated with higher comorbidity and diminished quality of life.
  • SAD symptom severity is correlated to depression and cannabis use disorder as adults.
  • There is a direct relationship between the severity of negative psychotic symptoms and ideas of reference, and social anxiety. Meanwhile, the SAD in psychosis may be overlooked as less salient.
  • Non-assertiveness seems to be a shared core for SAD and some other disorders, such as avoidant personality disorder.
  • SAD research supports the interpersonal theory of suicide that posits that perceived burdensomeness and thwarted belongingness predict acute suicidal ideation (SI). In individuals with SAD, these factors predict acute SI better than effects of depression, and clinicians should evaluate them as risk factors.

What’s new in the assessment of SAD?

  • There are two new measures that address the gaps left by other measures: 1) The Socially Anxious Rumination Questionnaire (SARQ) assessing rumination, and 2) the Ryerson Social Anxiety Scale (RSAS) measuring distress and impairment level.
  • Machine-learning algorithms have shown promise in differential diagnosis of social difficulties such as SAD, autism spectrum disorder, and prodromal psychosis.

What does research evidence show about the treatment of SAD?

  • “Does changing cognitions change behavior (traditional model), or does changing behavior change cognitions?” Research evidence points to behavior changing cognition. For example, exposure therapy works even without a focus on cognitive strategies.
  • Mindfulness interventions and attention bias modification do not improve treatment outcomes.
  • Decreases in social cost estimates during exposure are associated with better social anxiety outcomes. Targeting shame may contribute to progress.
  • Self-guided digital therapies for SAD work but roughly 2/3rds drop out. People with SAD need individualized engagement strategies.
  • Telehealth-based exposures can be as effective as in vivo exposures for public speaking.
  • For people with SAD who use substances, clinicians should consider integrated treatments (i.e., exposure therapy + motivational interviewing); just targeting SAD alone is less effective.
  • Changes in social anxiety symptoms may lead to improvement in depression if the depression symptoms are not too severe.
  • People who have significant depression and SAD improve from SAD treatment more than non-depressed individuals. Thus, comorbidity does not equal treatment resistance.

Question for clinicians:
Behavior impacts cognition and mood. What would your patient do differently if they were not anxious? Could you get their buy-in for a few weeks to do these things on a trial basis, to see how it affects their thoughts about themselves and the way they feel?

Wolitzky-Taylor, Kate, and LeBeau, Richard. Recent advances in the understanding and psychological treatment of social anxiety disorder. Faculty reviews, vol. 12, issue 8, April 2023.

Annika Okamoto, PhD, A-CBT
Representing NSAC Santa Barbara
(California Counseling Clinics)