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Fenster schliessen

Exposure therapy

More effective than insight-oriented group or individual psychotherapy (Gelder et al. 1967)

Four approaches:

Flooding

In vivo exposure

Modeling

Systematic desensitization (Wolpe 1958)

• Gradual

• Prolongued exposure -> psychoeducation

• Therapist needs to be comfortable with phobic object

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Treatment options

• Eye movement desensitization and Reprocessing

• Hypnotherapy: several studies reported success of hypnosis in phobia treatment

(Bird 1997, Ginsberg 1993, Morgan 2001)

-> group studies no comparison group (Peretz et al. 1996), many dropouts

(Hamarstrand et al. 1995)

• Psychopharmacology:

not treatment of choice for specific phobia (Roy-Byrne and Cowley, 2007)

studies using benzodiazepines showed no evidence of

long-term reductions in anxiety or avoidance (Campos et al. 1984)

based on preliminary studies

• Blood-Injection-Injury phobia: treatment complicated by fainting

applied tension-> tensing various muscle group during exposure

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Epidemiology; Social Anxiety

• One of the most common psychological disorders

• Lifetime prevalence rates for SAD based on large community samples range

from 3 to 13% (Kessler et al., 2005)

• Tends to begin in adolescence (mid / late teens) but also earlier possible

• Mean onset 15.7 years (Brown et al. 2001) -> lower compared to other AD

• Onset later in adulthood are rare and may be secondary to another mental disorder

(social withdrawal MDD, avoidance of eating in public)

• SAD slightly more common in women than men (Fehm et al., 2005)

• Gender differences in presentation of SAD (Turk et al. 1998)

women: talking to people of authority, performing in front of audience, working while

being observed, entering a room where others are already seated, being center

of attention, expressing disagreement, throwing a party

men: returning goods to a store, urinating in a public bathroom

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The cognitive model of Clark and Wells (1995)

• People with SAD are invested in making a positive impression on others, but

are insecure about ability to do so

• They hold negative beliefs about themselves and their ability to perform in social

situations

• When in social situations people with SAD focus on themselves and see

themselves as if they’re watching themselves on television

• Focusing on themselves doesn’t allow people with SAD to fully participate

in the social situation

• People with SAD either avoid situations of use safety behaviors in feared

situations

• Safety behaviors and avoidance do not allow the person to learn that fears

may not actually come true

• Negative thinking about social situations occurs before, during and after

exposure to the situation

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The cognitive behavioral model of Rapee and Heimberg (1997)

• Source of perceived threat for people with SAD is the belief that others hold

unreasonable high expectations of them, “reaction of an audience”

• audience reaction ->mental representation

• Mental representation is influenced by self-image from memory, pictures, physical

symptoms and social feedback

• Mental representation often distorted: people with SAD rate their performance as

poor, even if not objectively true

• Feedback often distorted or twisted to be consistent with fears

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Negative learning experiences in SAD

• People with SAD report a history of childhood teasing more often than people without

SAD (Mc Cabe et al. 2003)

• Severe bullying during childhood related to higher frequency of SAD

(Gladstone et al., 2006)

• Lacking social experiences (socially anxious individuals often raised by socially

isolated parents (Bögels et al. 2001)

• Observational studies: parents of anxious children support more likely desire of

child to be avoidant (Dadds et al. 1996)

• However, negative learning cannot fully explain how SAD develops

Fenster schliessen

Psychological treatment options for SAD

• Studies comparing CBT to other psychotherapies for SAD, CBT superior

(Rodebaugh et al.2004)

• The most frequently studied, evidence based psychological strategies for SAD

include:

- cognitive strategies (identifying anxiety provoking thoughts, replace such thoughts with

more realistic thoughts and predictions, behavioral experiments to test validity of anxious

thoughts)

- exposure-based-strategies

- social skills training (improve social and communication skills, eye contact, body language,

making small talk..)

• Mixed results: combination of exposure plus cognitive therapy works better than

exposure alone. Other studies found exposure alone just as effective (Rodebaugh et al.,2004)

• In addition some studies suggest that applied relaxation (PMR combined with

exposure) is also useful (Rodebaugh et al. 2004)

• Social skills training has been shown to improve effectiveness of CBT, other studies

found no difference between CBT with or without social training (Rodebaugh et al. 2004)

Fenster schliessen

Pharmacological treatment options for SAD

• Considerable evidence supporting SSRIs as first-line pharmacological treatment

for SAD, with proposed length of treatment for 6-12 months

• No consistent evidence that combining CBT and medication leads to better outcomes

than either treatment alone (Davidson et al. 2004)

• Relapse rates higher following discontinuation of pharmacotherapy than

discontinuation CBT (Liebowith et al., 1999)