Biochemical Treatment

For social phobic patients, medication is usually prescribed only when the Cognitive Behavioral Therapy has failed (CBT) or is not available at the moment. Also when depression coexists with bipolar medication is provided as well. The kind of medication used to social phobia is a Selective Serotonin Reuptake Inhibitor (SSRI) and most social phobic patients can endure a normal starting does of SSRI. The starting does is usually used for two to four weeks and increased when necessary. The response will start within six weeks and adequate trial will last for eight weeks. The full response to the medication will appear in twelve weeks (Veale).
Approximately 50% of patients stop the intake of SSRI; thus treatment is therefore continued for a minimum of 12 months. Once the patient is in remission, the amount of SSRI may be reduced slowly such as 25% reduction every 2 months. If a patient fails to respond to an SSRI, then alternative medication, a monoamine oxidase inhibitor is prescribed (Veale).
The use of benzodiazepines (especially short-acting ones) is not recommended, because the intake of benzodiazepines at high doses can cause many side-effects such as sedation, forgetfulness, and impaired concentration, especially when used intermittently. Benzodiazepines are especially contraindicated for patients with comorbidity of depression and/or a history of alcohol or substance misuse (Veale).

Individual or Group Treatment

Graded self-exposure

Graded self-exposure has been used most frequently as a treatment for social phobia. The self-exposure treatment makes a detailed hierarchy of the situation that the person is feared of, and then makes the person to face previously avoided situations repeatedly in a graded manner until habituation is established. However, there are some problems with the method since tasks might be not long enough for the anxiety to wane or not possible to make regular repetition. Furthermore, a lot of patients reject to actually participate in self-exposure and thus drop out early. Through complete treatment of self-exposure, about 50% will overcome their problem. Treatment failures are associated with a depressed mood, avoidant personality, intolerance of emotion and marked avoidance behavior (Veale).

Group cognitive therapy

Alternative approaches to self-exposure treatment have included group cognitive–behavioral therapy (Heimberg et al, 1990), restructuring of cognition or shame-attacking method. Shame-attacking means to overcome their anxiety by voluntarily participating in socially embarrass situation. For example, the patient is instructed to shout out the names of stations on a railway line, and then other passengers might think that the person is stupid or weird, but he or she can learn that performing a stupid act does not make oneself stupid. The patients’ own evaluation of their own behaviour that is crucial in determining the degree of social anxiety can be affected through this method; however, such alternative approaches are not usually recommended since the patients are likely to withdraw from the situation unless the therapist is prepared to model the behaviour. Self-exposure and many varied cognitive restructuring treatment are effective and valid; however, the result of the treatment may only be modest. For example, Heimberg et al (1990) report that only 65% make ‘clinically significant change’ after the completion of self-exposure and many varied cognitive restructuring treatment therapy.

Cognitive Therapy

external image social-phobia1.jpg
Image Source: David Clark
Clark (2001) have developed a cognitive model for the maintenance of social phobia as shown above. The model demonstrate that when patients enter a social situation, certain obligation such as being witty and intelligent, assumptions such as other people’s impression on themselves or unconditional beliefs about their weaknesses such as physical appearance are stimulated. When individuals believe that they are subjected to negative evaluation, they shift their attention to detailed self-observation, and monitoring of sensations and images. Hence, socially anxious individuals use internal thoughts to evaluate how others might evaluate them. Their internal information is associated with anxious emotion, and vivid or distorted images are envisioned as an observer perspective. These images are mostly visual, but might also include bodily sensations and auditory or olfactory perspectives. The envisioned images are usually associated with early memories; thus, the therapist asks the patient to remember the first experience that is captured in the recurrent image and to recall the sensory features and meaning that these had. For example, a person who had an self-image of being fat will remember being teased during childhood and adolescence, which resulted in the feelings of humiliation and rejection (Veale).
Another factor that attribute to the social phobic symptoms are safety behaviors; they are the certain actions appear in feared situation that is facilitated to prevent feared catastrophes (Salkovskis, 1991). Safety behaviours in social phobia can include:
  • Dependence on alcohol
  • Avoidance of eye contact
  • Gripping a glass too tightly
  • Excessive rehearsing of a presentation
  • Unwillingness to reveal personal information
  • Asking too many questions.
Safety behaviors often entail many problems; the behaviors can
  • further confirm the feared catastrophe in the patients’ mind,
  • intensify self-focused attention,
  • increase the feared symptoms (for example, keeping arms close to the body to stop others seeing one sweat will increase sweating)
  • influence others (e.g. the individual may appear cold and unfriendly, so that a feared catastrophe becomes a self-fulfilling prophecy)
  • can draw attention to feared symptoms (e.g. Speaking quietly and slowly will lead others to focus on the individual even more).
During the cognitive therapy session, the therapist may use a ‘downward arrow’ technique to determine the patients’ assumptions and core beliefs; the therapist, first of all, try to identify a specific and recent social situation that was sufficiently anxiety-provoking. Then the therapist attempts to identify the negative automatic thoughts by asking questions such as:
  • What went through your mind as you noticed yourself becoming anxious?
  • What was the worst you thought that could happen?
  • ‘What did you suppose that others would notice or think?
Next, the therapist identifies the automatic sensations or symptoms of anxiety by asking questions such as:
  • When you thought the feared event might happen,
  • What you noticed happening in your body? (such as blushing, shaking, sweating)
Safety behaviours are then elicited by asking
  • When you thought the feared event might happen
  • Did you do anything to try to prevent it from happening?
  • Is there anything you do to try to ensure you come across well?
  • Do you do anything to stop drawing attention to yourself?
Also Increased self-consciousness and imagery are elicited by asking questions such as:
  • What happens to your attention when you are most afraid?
  • Do you become more self-conscious?
  • Do you have difficulty following what others are saying?
  • Do you have a picture in your mind of how you feel you are coming across
The model may then be used to determine its potential application to past and present experiences and how each of the components is linked to a feedback loop. It is particularly important to review how increased self-focused attention and using safety behaviours are mutually affecting each other, and attribute to the increased frequency of the thoughts and anxiety (Veale). Once a patient is engaged in the model, then various strategies such as watching themselves in a video, changing negative self-image and self-exposure method (described above) may be used to change the cognitive system (Clark).


Works Cited
Veale, David. "Advances in Psychiatric Treatment." Treatment of Social Phobia 258-264 9.4 (2003). The Royal College of Psychiatrists. Web. 1 Mar. 2012. <http://apt.rcpsych.org/content/9/4/258.full.pdf>.
Clark, David M. "A Cognitive Perspective on Social Phobia." International Handbook of Social Anxiety: Concepts, Research and Interventions Relating to the Self and Shyness. Department of Psychology, The University of Texas at Austin, 2001. Web. 1 Mar. 2012. <http://homepage.psy.utexas.edu/homepage/class/psy394U/Bower/12%20Anxiety%20Disorders%20/CLARK-SOCIAL%20PHOBIA.pdf>.