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Social Mishap Exposures for Social Anxiety Disorder: An Important Treatment Ingredient

https://doi.org/10.1016/j.cbpra.2012.05.003Get rights and content

Abstract

Conventional cognitive-behavioral therapy for social anxiety disorder, which is closely based on the treatment for depression, has been shown to be effective in numerous randomized placebo-controlled trials. Although this intervention is more effective than waitlist control group and placebo conditions, a considerable number of clients do not respond to this approach. Newer approaches include techniques specifically tailored to this particular population. One of these techniques, social mishap exposure practice, is associated with significant improvement in treatment gains. We will describe here the theoretical framework for social mishap exposures that addresses the client's exaggerated estimation of social cost. We will then present clinical observations and outcome data of a client who underwent treatment that included such social mishap exposures. Findings are discussed in the context of treatment implications and directions for future research.

Highlights

► Social mishap exposures target patients’ exaggerated social cost by confronting them with the consequences of such mishaps. ► Data suggest that protocols that include social mishap exposures show greater efficacy than traditional CBT protocols. ► The current study provides a case example outlining how social mishap exposures can be incorporated into treatment. ► Social mishap exposures should be specifically tailored to the core fear of the patient.

Section snippets

Theoretical Models of SAD

There is strong empirical evidence supporting a cognitive-behavioral model of SAD (Davidson et al., 2004, Heimberg et al., 1990, Heimberg et al., 1998). The cognitive-behavioral model proposes that SAD develops and is maintained by maladaptive cognitive and behavioral processes, which negatively reinforce avoidance strategies and contribute to a cycle of anxiety and avoidance (Clark and Wells, 1995, Rapee and Heimberg, 1997). The following discussion is based on the maintenance model developed

Method

The Anxiety Disorders Interview Schedule (ADIS-IV; DiNardo, Brown, & Barlow, 1994) was administered at the intake evaluation. The ADIS-IV is a semistructured clinical interview that assesses mood and anxiety disorders according to DSM-IV (American Psychiatric Association, 1994) criteria. The Liebowitz Social Anxiety Scale (LSAS; Liebowitz, 1987) is a 24-item clinician-administered measure that assesses fear and avoidance of social situations (each rated on a 0- to 3-point scale with a range of

Discussion

Although Mary improved in a clinically meaningful way by the end of the treatment, she presented certain challenges to the therapists who led her group. One primary difference in Mary's case compared to the other group members was that Mary had a longer duration of illness (she was the oldest member of the group) and she had a higher baseline severity of symptoms than the other members. She had therefore developed highly evolved and idiosyncratic avoidance strategies. For example, it was not

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