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Exposure therapy

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

Four approaches:


In vivo exposure


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


• 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


• 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

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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


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

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


- 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)

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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)