Cognitive-behavioral models of social anxiety disorder

In 1985, Liebowitz et al labeled SAD the "neglected anxiety disorder." Clearly, times have changed. Although it took 10 years after this pronouncement for the first cognitive-behavioral model of SAD to be introduced, a great deal of research has been carried out and a great deal has been learned since then. The core features of these models seem to hold a great deal of validity. Perhaps the greatest "learning curve" has been seen in work done on the processing of the self as social object, a component of both cognitive-behavioral models of SAD. A great deal of empiric evidence now suggests that people with SAD see themselves as they believe they are seen by others. Unfortunately, their perception of how they are seen by others is often grossly distorted, likely contributing to the distress they feel about social situations and their concomitant avoidance of them. Recent work by Hirsch and Mathews has gone so far as to suggest that people with the disorder may not attend at all to social information while social events are ongoing but rather may judge them later based on preexisting notions about themselves as social beings. In Rapee and Heimberg's model, preferential allocation of attentional resources is emphasized, and this has been another great area of progress over the past few years. While people with SAD may be hypervigilant to social threat in their environments, once they find it, they tend to divert their attention away from it--as has been most clearly demonstrated in the studies of processing of facial expressions. The data suggest that both angry and happy faces may be perceived as threatening and attention is diverted as a means of avoiding them--again having important implications for social behavior and for maintenance of the disorder over time. Important strides have also been made in understanding judgment biases in SAD. Studies on this issue have suggested that individuals with the disorder see positive social outcomes as unlikely and see negative social outcomes as highly likely. When presented with ambiguous scenarios, people with SAD are more likely to select negative interpretations for them, even when they are given the option of selecting positive interpretations and neutral interpretations that they could find at least somewhat believable. Furthermore, people with SAD see both negative social outcomes and positive social outcomes as coming at a higher emotional cost than do people without the disorder. Hirsch and Mathews suggest that the core of social anxiety may be a failure to (over-)emphasize the positive. However, people with the disorder may not adequately distinguish between positive and negative cues, seeing them as equal in valence. Gilboa-Schechtman et al and Wallace and Alden, using very different approaches, have also suggested that both positive and negative outcomes in social situations come at a great emotional cost for people with SAD. Studies of facial expressions suggest that positive and negative faces are perceived as threatening, leading people with SAD to divert attention away from both. Finally, the studies on the observer perspective suggest, also in line with the research of Hirsch and Mathews, that people with SAD do not pay sufficient attention to what is going on around them in social situations. In effect, they are looking at the wrong thing (or through the wrong eyes) and missing important social cues, both positive and negative. Perhaps, as suggested by Hirsh and Mathews, people with the disorder come away from social situations with very little information at all (this notion is supported by older studies that asked socially anxious people what they remembered from social situations after they had participated in them), forcing them to draw conclusions about their performance based on blanket assumptions about themselves as social beings rather than about what actually occurred during that single event. These conclusions have very important implications for treatment. First, it is clear that clinicians need to help their patients learn to pay attention in social situations and, furthermore, to attend to the "right" things. Studies that have included that manipulations of attention suggest that this is a positive direction to pursue. Furthermore, clinicians have to help their patients to make judgments based on what really occurred in a single situation, rather than drawing blanket conclusions for all situations based on preconceived notions of the self as social being. Again, some very preliminary evidence suggests that this approach (through the use of video feedback and other techniques) could be of great benefit.